ACTINOMYCES-ASSOCIATED LYMPHADENOPATHY FALSELY UPSTAGING A NON-SCLC

Abstract

SESSION TITLE: Lung Cancer Cases SESSION TYPE: Fellow Case Reports PRESENTED ON: 10/08/2018 11:00 AM - 12:00 PM INTRODUCTION: Accurate staging plays a crucial role in the management of patients diagnosed with lung cancer. We present a case of a squamous cell carcinoma of the lung found to have actinomyces on endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). CASE PRESENTATION: A 58-year-old woman presented to for the management of a lung mass that was discovered after a chest x-ray was performed for evaluation of cough. She denied having constitutional symptoms, shortness of breath or hemoptysis. She had a 40-pack year history of cigarette smoking. The patient had no significant past medical history. On examination she was afebrile, well appearing with normal vital signs, pulmonary, cardiac and abdominal examinations. Laboratory data showed no abnormalities. A chest CT showed a 10 x7.6 cm peripherally enhancing irregular centrally hypodense mass in the posterior segment of the right upper lobe (RUL) and suprahilar and hilar enlarged lymph nodes (figure 1). PET-CT showed a hypermetabolic mass in the right lung apex and multiple fluorodeoxyglucose (FDG) avid right hilar and paratracheal lymph nodes (figure 2). The patient underwent bronchoscopy with transbronchial biopsy of the right upper lobe and EBUS-TBNA of station 4L, 7, 4R and 11R. Pathology showed squamous cell carcinoma of the RUL mass with involvement of 11R and no evidence of malignancy at station 4L, 7, and 4R. Cytology demonstrated Actinomyces at station 4R. The patient was treated with Amoxicillin and was referred to cardiothoracic surgery for further evaluation. Mediastinoscopy was performed and ruled out N2 disease. She underwent right upper lobe lobectomy and right mediastinal lymph node dissection. Her final pathology was T3N1M0 and the patient was treated with adjuvant chemo-radiation. DISCUSSION: The use of EBUS-TBNA for the initial diagnosis and staging of lung cancer has gained significant support and is now recommended by numerous guidelines. Not only is this modality less invasive than previously use staging methods, but it has also shown to have reduction in work-up time (1) and increase survival (2). The case we presented emphasizes the risk of incorrectly upstaging a tumor based on chest CT or PET scan findings. The benefit of accurately staging a tumor translates into better outcomes and every patient should therefore be referred for EBUS-TBNA for pathologic staging, as this is a low risk procedure that could have significant impact on patients’ prognosis. In experienced hands EBUS-TBNA has similar accuracy to that of mediastinoscopy (3) as confirmed here after final pathologic staging via thoracotomy. CONCLUSIONS: Infectious and inflammatory process can mimic malignancy on PET/CT. It is imperative to obtain pathologic staging to avoid a false upstaging that would result in changing therapy for lung cancer. EBUS-TBNA is an excellent expeditious tool for accurate staging with minimal morbidity. Reference #1: Ozturk A, Demirci NY, Aktas Z, Demirag F, Alagoz A, Alici IO, Yilmaz A. EBUS may arise as an initial time saving procedure in patients who are suspected to have small cell lung cancer. Clin Respir J 2018; 12: 517-523. Reference #2: Navani N, Nankivell M, Lawrence DR, Lock S, Makker H, Baldwin DR, Stephens RJ, Parmar MK, Spiro SG, Morris S, Janes SM, Lung Bti. Lung cancer diagnosis and staging with endobronchial ultrasound-guided transbronchial needle aspiration compared with conventional approaches: an open-label, pragmatic, randomised controlled trial. Lancet Respir Med 2015; 3: 282-289. Reference #3: Yasufuku K, Pierre A, Darling G, de Perrot M, Waddell T, Johnston M, da Cunha Santos G, Geddie W, Boerner S, Le LW, Keshavjee S. A prospective controlled trial of endobronchial ultrasound-guided transbronchial needle aspiration compared with mediastinoscopy for mediastinal lymph node staging of lung cancer. J Thorac Cardiovasc Surg 2011; 142: 1393-1400 e1391. DISCLOSURES: no disclosure on file for Sixto Arias; No relevant relationships by Yoslay Perez, source=Web Response No relevant relationships by Rene Rico, source=Web Response Consultant relationship with Trevena,Inc Please note: $1001 - $5000 Added 03/03/2018 by Nestor Villamizar, source=Web Response, value=Consulting fee