NSCLC and TB

[kdaru]

Probably just missed you oncodoc, but here's a question for when you get back.

My Dad is 82, former smoker. Incidental CXR showed RUL lesion -> CT/PET -> one solid nodule RUL, two smaller cavitated nodules in RUL and LLL, and one lymph node in the aorto-pulmonary window. The solid nodule in the RUL was biopsied -> NSCLC. Because of the CT appearance, Dad was diagnosed as stage IV.

Dad got one cycle chemo (carbo/Taxol), repeat CT six weeks after first -> slight shrinkage RUL nodule, but significant growth LLL lesion with interstitial pattern and another small cavity forming. Sputum sample is now growing out TB.

My question is, how does this affect his staging and treatment?

[john]

Oncdoc will have to give the definitive answer when he gets back, but here are a few thoughts.

The PET scan could have showed a false positive in the lymph nodes due to the TB.

Interstitial pattern: Some disease processes can cause the alveolar:interstitial ratio to shift towards the interstitial, causing the lung tissue to appear more opaque. As this occurs, the vessels become indistinct. In the normal lung, the pulmonary vessels are visible to the third order branches.

Air can still be seen in the lung field because the alveoli are still air-filled. The main cause of an interstitial pattern on a radiograph is a film incorrectly taken during expiration (expiratory film). This causes alveolar compression and so, the intersitium forms a larger component of the lung volume (artefact).

Pathological causes of interstitial pattern include interstitial fibrosis, interstitial (viral) pneumonia, atelectasis, allergic conditions, and the presence of parasites. A nodular interstitial pattern shows focal masses diffusely distributed and usually means neoplasia.

significant growth in the LLL with a slight shinkage in the RUL, seems to me the LLL *might* be an infection or maybe another primary, probably an infection??

I don't know if your dad had TB before but having TB will increase the risk of lung cancer.

I am not a Dr, but I would ask your Dad's doc if the lymph nodes lit up on the PET scan because of the TB and not cancer. Sometimes a medianoscopy is used to check the lymph nodes, but it can not reach all the lymph nodes.

I wonder if your dad is stage I? Maybe even with the TB a wedge resection could be done. A test of how well his lungs function would determine if he is a candidate for surgery.

Again, I am not a Dr and not 100% sure on this, but you could ask your dad's Dr these questions

[kimblanchard]

Wow, one of the few times I'd have to say great news your Dad has TB!

First of all, I'd make absolutely sure that the RUL nodule is cancer. I had a case that I posted about with a patient with a similar story, had two lesions, one cavitary and one not, biopsy revealed squamous cell cancer. Patient underwent surgery to have lung resected and pathology showed the whole thing was TB. No cancer. Reviewed the path and in retrospect it was funny looking cells reacting to the TB.

I agree with John, your Dad may very well have Stage 1 lung cancer and that lymph node could definitely be reactive. AP window nodes are tough to get at with mediastinoscopy, generally need to be biopsied via paramedian sternotomy (i.e. open biopsy).

I'm assuming he is going to have surgery now? The TB is going to complicate matters a bit, he will need to be on anti-TB meds to get that under control and they will want negative sputums before surgery. Usually after about a month of antibiotics people are not contagious. I personally wouldn't be real excited about giving any further chemotherapy, at least not right now.