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Case : Tumor in the right upper lobe

Kei Morikawa, MD

Division of Respiratory and Infectious Diseases,
Department of Internal Medicine

St. Marianna University School of Medicine

 

Disclaimer:

  • TXI™, NBI™,  and RDI™ Technologies are not intended to replace histopathological sampling as a means of diagnosis
  • The positions and statements made herein by Dr. Morikawa are based on Dr. Morikawa’s experiences, thoughts and opinions. As with any product, results may vary, and the techniques, instruments, and settings can vary from facility to facility. The content hereof should not be considered as a substitute for carefully reading all applicable labeling, including the Instructions for Use. Please thoroughly review the relevant user manual(s) for instructions, risks, warnings, and cautions. Techniques, instruments, and setting can vary from facility to facility. It is the clinician’s decision and responsibility in each clinical situation to decide which products, modes, medications, applications, and settings to use.
  • The BF-1TH1200 used in this case is not available in the US market at this time nor is there an established time for its release. The safety and effectiveness of this product and or the use of these products has not yet been established in the United States market.
  • The EVIS X1™ endoscopy system is not designed for cardiac applications. Other combinations of equipment may cause ventricular fibrillation or seriously affect the cardiac function of the patient. Improper use of endoscopes may result in patient injury, infection, bleeding, and/or perforation. Complete indications, contraindications, warnings, and cautions are available in the Instructions for Use (IFU)
  • Dr Morikawa, the authoring physician(s) of this presentation, are/ is a paid consultant(s) to Olympus Corporation.
Procedure information

Scope: BF-1TH1200
Location: Right upper lobe
Patient information: Male, 66 years old
Medical history: Angina pectoris (treated with PCI), stroke, and heavy smoking (40 cigarettes per day). For past 3 months, he has experienced swelling in the right upper limb and increased difficulty in breathing during exertion. Two weeks ago, he coughed up blood and went to a nearby clinic, where a chest X-ray revealed a mass shadow in the right upper lung field. He was then referred to our institution for further examination.

 

 

1-1 Right upper bronchus
(WLI)
The segmental bronchus of the right upper lobe is almost entirely occupied by the tumor. The B2 lumen is visible beyond the opening on the side of the bronchus with vascular patterns . Although the epithelium adjacent to the tumor is edematous and the lumen is narrowed throughout, there is no continuity with the tumor. The lesion protrudes from B1 and B3 in a polypoid fashion, with a depression around the B1/3 spur.

1-2 Right upper bronchus
(TXI™ Technology - 1)
In the TXI™ technology mode, the tumor and the surrounding tracheal epithelium are clearly distinguishable. We can infer that the internal structure of the tumor is mottled, and includes bleeding and necrosis. It can also be understood that the visible part is the proximal end of the tumor, which has grown in a polypoid fashion in the longitudinal axis direction of the bronchus and toward the center of the bronchus.

1-3 Right upper bronchus
(TXI™ Technology - 2)
In the TXI™ technology mode2, observation is possible as the similar color tone with WLI.

1-4 Right upper bronchus
(WLI)
The proximal end of the tumor exhibits whitish necrosis in a twisted string-like shape .

1-5 Right upper bronchus
(NBI™ Technology)
The NBI™ technology mode highlights the areas of bleeding and necrosis, making it difficult to assess vascular characteristics.

1-6 Right upper bronchus
(RDI™ Technology - 1)
In the RDI™ technology mode, there appear to be few superficial vessels, and no obvious bleeding point can be recognized. It seems likely that the difference of blood flow volumes within the tumor may be reflected in the color tones.

1-7 Right upper bronchus
(RDI™ Technology - 3)
In the RDI™ technology mode 3, it is easy to confirm that there are no conspicuous vessels in deeper parts, making it possible to proceed to biopsy.

Case Video

Using a spray catheter, the vocal cords are anesthetized under direct observation with the endoscope while the scope is advanced. The right upper lobe branch, which is the target of this examination, has a tumor growing in a polypoid fashion and protruding accompanied by distal necrosis. Although the subepithelial vessels of the tumor are unclear, the localization of the tumor blood flow can be estimated in NBI™ and RDI™ technologies observation — which leads to the removal of necrotic tissue and subsequent collection of samples from the main body of the tumor.

Pathological Findings

  • Figure A (HE staining): Dense proliferation of small, round tumor cells can be observed. The cells have bare nuclei and sparse cytoplasm with delicate nuclear chromatin and indistinct nucleoli.
  • Figure B (chromogranin A immunostaining): Tumor cells show expression of chromogranin A, which is a neuroendocrine marker.
  • Final diagnosis: Primary lung cancer (small cell lung carcinoma)

     

Overall Comment

Dense proliferation of tumor cells made it difficult to observe subepithelial vessels. However, it was possible to evaluate the local blood flow of the tumor in NBI™ and RDI™ technologies observation in addition to white light observation. This facilitated removal of necrotic tissue and subsequent biopsy. When a biopsy is performed, selection of an optimal site is important from a safety standpoint when using ROSE in combination. Thus, it may be useful to evaluate a site of particular interest in a multifaceted manner using various modes with different characteristics and then check for consistency between the findings produced by each mode.

Co-editor:

Dr. Nobuyuki Ohike

Department of Pathology, St. Marianna University School of Medicine

 

Case 4: LUL and its more distal branches Case 9 : Right lung tumor
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