A 52-year-old man with a 30-pack-year smoking history presents with persistent cough and haemoptysis for 3 weeks. Chest X-ray shows a left lower lobe opacity. Bronchoscopy reveals a nodular lesion in the left lower lobe bronchus, and multiple biopsies are taken. Histopathology shows intestinal-type metaplasia of the bronchial epithelium with focal areas of dysplasia (CIN 2). The patient is asymptomatic apart from cough and has no dyspnoea or stridor. What is the most appropriate next step in management?

Explanation

## Clinical Context This patient has **Barrett's metaplasia of the bronchus** (intestinal-type metaplasia) with **CIN 2 (cervical intraepithelial neoplasia grade 2)** dysplasia. This is a precancerous lesion with significant risk of progression to invasive carcinoma. ## Key Point: **Dysplasia is a reversible lesion if the causative stimulus (smoking) is removed early, but requires surveillance.** CIN 2 dysplasia carries a 30–40% risk of progression to invasive cancer within 5 years if untreated. ## Management Algorithm for Bronchial Dysplasia ```mermaid flowchart TD A[Bronchial biopsy shows dysplasia]:::outcome --> B{Grade of dysplasia?}:::decision B -->|CIN 1 Low-grade| C[Smoking cessation + repeat bronchoscopy in 6 months]:::action B -->|CIN 2 Moderate| D[Smoking cessation + repeat bronchoscopy in 3 months]:::action B -->|CIN 3 High-grade| E[Consider photodynamic therapy or surgical resection]:::action B -->|Invasive carcinoma| F[Staging + definitive treatment]:::urgent C --> G{Regression?}:::decision D --> G G -->|Yes| H[Continue surveillance]:::action G -->|No/Progression| I[Escalate intervention]:::urgent ``` ## High-Yield: **CIN 2 dysplasia management:** Aggressive smoking cessation + close endoscopic surveillance every 3 months. If dysplasia persists or progresses to CIN 3, consider photodynamic therapy (PDT) or surgical resection. ## Clinical Pearl: Metaplasia itself (intestinal-type epithelium) is **not cancer**—it is an adaptive response to chronic irritation. However, dysplasia superimposed on metaplasia is a **precancerous state** requiring active surveillance and intervention. ## Why Option 0 is Correct - Repeat bronchoscopy in 3 months allows assessment of dysplasia grade progression and guides escalation to PDT or surgery if needed. - Smoking cessation is mandatory but must be paired with surveillance because dysplasia may not fully regress. - This follows the standard surveillance protocol for CIN 2 in the respiratory tract. ## Distinction from Other Scenarios | Dysplasia Grade | Next Step | Rationale | |---|---|---| | **CIN 1 (Low-grade)** | Smoking cessation + repeat in 6 months | Often regresses with cessation alone | | **CIN 2 (Moderate)** | Smoking cessation + repeat in 3 months | Higher progression risk; closer surveillance | | **CIN 3 (High-grade)** | PDT or surgical resection | ~90% risk of progression to invasive cancer | | **Invasive carcinoma** | Staging + curative surgery/chemo/RT | No longer a precancerous lesion |