A 80 year old male patient presents at his GP surgery with haemoptysis and shortness of breath. Prior to his retirement the man worked in the building manufacturing industry using asbestos. The patient also has a 30 a day smoking habit for over the past 50 years.
Q1) Based on just the presenting history explain what the GPs most likely thoughts on the patients diagnosis and possible differential diagnosis (10 marks)
Figure 1: H&E Low power
Figure 2: H&E high power
Q2a) Why is H&E the most useful stain for use in this scenario?
Think about what each element of H&E stains for and think about what information is needed from this tissue to make a diagnosis. How does H&E allow this information to be obtained. Think about the urgency of the results and other factors that determine the usefulness of using a particular technique in an NHS lab. Again your answer should be referenced.
Q2b ) Looking at Figure 1 is the lung tissue as you would expect it to appear and if not why not?
Compare the image with an image of normal lung tissue ( you will have to use a histology book for this). Compare the obvious structural features, how do the images differ, is anything missing? Remember tissue is designed for a specific function, can the tissue still meet this function, if not why not?
Q2c) Looking at Figure 2 what nuclear changes can you see and what are they suggestive of? How do the changes differ from what you would expect in normal lung tissue?
Look at colour intensity, size of the nucleaus, number of nuclei. How do they compare with what you would expect in cells that are mature and differentiated? What are the changes suggestive of in terms of activity?
All answers must be referenced.
(25 marks)
Following a confirmation of non-small cell lung carcinoma (NSCLC) a wedge dissection of the lung mass was requested. On review of this material an unexpected foreign body was identified (Figure 3).
Figure 3: H&E foreign body
Q3
)Explain what this figure is and why it is present.
Consult the patient history , the text books and the literature. Remember to explain why this foreign body is present.
b) Critically evaluate what special stains can be used to highlight it.
This should be straight forward but remember the question asks for a ‘critical evaluation’ so do not just describe the stain.
c) Diagnostically, what other lung cancer may this finding support?
This should be obvious but you need to support your explanation using the literature. (25 marks)
Q4
In order to confirm the diagnosis of NSCLC immunohistochemistry was performed. Suggest and evaluate the antibodies that would be used in order to support the diagnosis of NSCLC.
(20 marks)
You must read around NSCLC to begin with. What is the cell type of origin?
Q5
At a subsequent multi- disciplinary team meeting review of the case, discuss and evaluate what options could be considered for this patient’s management and treatment. (20 marks)
You need some understanding of NSCLC and how it can be treated. Factors to consider include the patients age, past history, tumour location, type of tumour. What is feasible for this particular patient what is the likely prognosis? What does the literature say in terms of treatment and survival.
You MUST now create a correctly presented reference list.