Transcript TBNA Left mediastinal mass - Bronchoscopy International

TBNA Left Mediastinal Mass
► Learning
Objectives
 List at least 6 elements of
informed consent.
 Describe anatomic dangers of
TBNA at the level of the
posterior wall of Left main
bronchus.
 Identify at least 5 elements
essential to formulating a
patient-focused care plan.
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Case description (practical approach # 4)
► DD
is a70 year old female
with severe emphysema
admitted for exacerbation
► Found to have decreased
breath sounds on left with
expiratory wheezing
► CXR revealed large
mediastinal mass
► CT scan showed extrinsic
mass with extrinsic
compression of the distal left
main bronchus
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The Practical Approach
Initial Evaluation
Procedural Strategies
• Examination and,
functional status
• Significant comorbidities
• Support system
• Patient preferences and
expectations
• Indications, contraindications, and
results
• Team experience
• Risk-benefits analysis and
therapeutic alternatives
• Informed Consent
Techniques and Results
Long term Management
• Anesthesia and peri-operative
• Outcome assessment
care
• Follow-up tests and procedures
• Techniques and
• Referrals
instrumentation
• Quality improvement
• Anatomic dangers and other
risks
• Results and procedure-related
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complications
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Initial Evaluation - History
► Severe
emphysema with exacerbation
 What is the FEV1? Home Oxygen requirement?
► Important
to classify the severity of disease and prognosis.
 What is the patient’s functional status?
► Karnofsky
score may be important to make treatment decisions
and for prognosis.
 Other historical information
► Hemoptysis
or other symptoms such has bone pain, SOB
(treatment alternatives may change: radiation treatment, stent
evaluation)
► Patient’s wishes for treatment – respect for autonomy: how
aggressive does she want to be.
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Initial evaluation: Objective findings
► Physical
exam:
 Vital signs and SaO2– is patient stable for a
diagnostic procedure?
 Wheezes, decreased breath sounds on left
►Differential diagnosis includes
 Bronchial obstruction
 Obstructive lung disease
 Pneumothorax
 Foreign body
 Pleural fluid
 Search for signs of metastatic disease
►Including
neurologic exam
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Initial evaluations: Radiology
► Imaging:
chest radiograph and CT scan are
consistent with large mediastinal mass and
extrinsic compression left main bronchus
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Initial evaluations: Bronchoscopy
► Narrowing
of left main bronchus and
tumor infiltration of LC1 and LC2
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Initial Evaluations
► Patient
preferences
 Unknown at this time. Will need to discuss as this may
be important in formulating treatment plan.
► Chemotherapy,
radiation therapy, surgical removal
► Supportive care and palliation
► Family
and support system: patient lives alone
 Need to discuss advanced directives.
 Need to discuss potential treatment alternatives in case
diagnosis is cancer.
 Need to discuss “goals of care”.
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Procedural Strategies
►
Least invasive to most invasive:
 Bronchoscopy with endobronchial biopsy, washings and
brushings. Performing all three increases diagnostic yield
compared to each one alone.
► However,
risk of bleeding and increased airway compromise could
cause respiratory distress in this patient with severe emphysema.
► Preprocedure bronchodilator treatment may be warranted.
 Bronchoscopy with transbronchial and/or endobronchial needle
aspiration with rapid on-site cytology would provide immediate
diagnosis and accelerate referral for treatment, especially in case
of small cell carcinoma.
 Endobronchial ultrasound or esophageal ultrasound needle
aspiration
► Yield
probably 100% in this setting
 Rigid bronchoscopy unlikely to be necessary
 Mediastinoscopy or mediastinotomy unlikely to be necessary
 Open thoracotomy unlikely to be necessary
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Information provided before
obtaining informed consent
► Differential
diagnosis for mediastinal mass
in patients with severe emphysema:
 Malignancies:
►Bronchogenic
CA (small vs. nonsmall) , Lymphoma
,and less likely neurogenic tumor.
 Nonmalignant:
►infectious
disease)
► Diagnosis
(TB), noninfectious (granulomatous
affects treatment choices:
 depends on whether malignancy is diagnosed,
stage and cell type as well as patient’s
functional status.
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Elements of informed consent
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Discussion of the clinical issue
Description of the procedure
Discussion of the risks and potential benefits of the
procedure
Discussion of the therapeutic alternatives, and potential
consequences from choosing those alternatives
Discussion of the implications of refusing procedure or
treatment
Assessment of the patient’s understanding
Discussion of the uncertainties associated with the decision
Discussion of the patient’s preferences
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Procedural techniques and results
► Anesthesia
and perioperative care
 Minimal conscious sedation using One medication
rather than combination so as to avoid respiratory
insufficiency or hypoxemia.
 Good topical anesthesia
 Supplemental oxygen
 Preprocedure nebulizer treatment with bronchodilators.
► Techniques
 Cytology needle for TBNA, with Rapid On-Site Cytology
for immediate diagnosis and in order to decrease length
of procedure.
 Histology needle can also be used.
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Advantages of performing TBNA vs.
brushing and endobronchial biopsy
►
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Increased diagnostic yield in TBNA + conventional bronchoscopy
(wash, brush, forceps biopsy) versus conventional alone for extrinsic
mass lesions (Gullon JA et al Arch Bronconeumol. 2003 Nov; 39(11):496-500)
No difference in TBNA versus TBNA + conventional yield for
submucosal lesions and peripheral lesions (Shure D - Chest - 01-JUL-1985; 88(1): 49-51
 However sensitivity of biopsy obtained by forceps versus TBNA was 55%
versus. 71%
 Possibly because some lesions are covered by normal epithelium or are
firm with only submucosal infiltration
►
In a prospective trial of submucosal / peribronchial
tumors (Kacar et al. Lung Cancer. 2005 Nov;50(2):221-6)
 Highest rate of diagnosis was achieved with needle aspiration
(72.2%), and when compared with forceps biopsy (47.2%), a
significant difference between the two procedures (forceps biopsy
versus needle aspiration)
was observed (P = 0.049)
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Potential dangers of TBNA through posterior
wall of Left main bronchus
► Includes
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all potential complications of TBNA
Fever
Oozing of blood
Bacteremia
Pneumothorax or pneumomediastinum
Perforation of vascular structures
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Anatomic dangers surrounding left
main bronchus
Careful review of the CT scan is
warranted to be sure to avoid entering
vascular structures such as the aorta or
left pulmonary artery.
The left paratracheal mass
appears to be readily accessible using
TBNA through the left lateroposterior
wall of the left main bronchus
approximately 1-2 cm below the carina.
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Left mediastinal mass
From: Mountain CF et al, Chest
1997
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Long Term Management Plan
►
Outcome
 TBNA positive for small cell carcinoma
►
Follow-up results
 No evidence of distal metastases
 Brain MRI and bone scan were negative
►
Referrals
 Immediate referral for chemotherapy and radiation therapy.
 Based on Performance status and conversations with patient
regarding treatment related morbidities, decision was made to
pursue chemotherapy alone.
►
Palliative care plan
 If no response, consider palliative care
 Airway stent insertion not indicated
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Outcomes
► Three
months after beginning systemic
treatment, substantial improvement is noted on
bronchoscopy.
Pretreatment bronchoscopy
To view video, please
see Video Archive PA 4a
3 months post treatment
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To view video, please
see Video Archive PA 4b 17
Identify essential components
essential to elaborating a patientfocused care plan
► Medical
and surgical history
► Prevention of procedure-related adverse
events
► Patient expectations and preferences
► Social history and existing support system
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Initial evaluation: More essential elements
►
Review of medical history
 such as COPD, pulmonary embolus, deep venous thrombosis or
other illnesses effecting respiration.
 such as rheumatoid arthritis, ankylosing spondylitis, trauma,
tracheotomy or intubation effecting neck mobility or airway patency.
 such as infectious lung disease or other illness potentially effecting
the airway. Also, cardiac disease, pacemaker, coronary artery
disease, obstructive sleep apnea, CO2 retention, laryngospasm or
bronchospasm, elevated intracranial pressure, asthma and
 Pregnancy
►
Review of surgical history
 such as neck surgery, lung surgery, spine surgery, as well as
 Dentures or loose teeth, bleeding disorder, allergies to medications
including local anesthetics, antibiotics, or reactions to general
anesthetic drugs,
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Initial evaluation: Essential elements
► Medication
usage including anticoagulation,
antiplatelet agents, inhalers, antibiotics
► Social history
 Such as living situation and family or friend
support system
 proximity to medical center and physician
services
► Advanced
directives and health care decision
making.
► Patient preferences and expectations
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Bronchoscopy International: Practical Approach©, an Electronic OnLine Multimedia Slide Presentation.
http://www.Bronchoscopy.org/PracticalApproach/htm. Published
2009 (Please add “Date Accessed”).
Thank you
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Prepared with the assistance of Larry Tom M.D.
www.bronchoscopy.org
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