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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. BI 4. TBNA Left mediastinal mass 1 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 BI 4. TBNA Left mediastinal mass 2 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 BI 4. TBNA Left mediastinal mass complications 3 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. BI 4. TBNA Left mediastinal mass 4 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 BI 4. TBNA Left mediastinal mass 5 Initial evaluations: Radiology ► Imaging: chest radiograph and CT scan are consistent with large mediastinal mass and extrinsic compression left main bronchus BI 4. TBNA Left mediastinal mass 6 Initial evaluations: Bronchoscopy ► Narrowing of left main bronchus and tumor infiltration of LC1 and LC2 BI 4. TBNA Left mediastinal mass 7 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”. BI 4. TBNA Left mediastinal mass 8 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 BI 4. TBNA Left mediastinal mass 9 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. BI 4. TBNA Left mediastinal mass 10 Elements of informed consent ► ► ► ► ► ► ► ► 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 BI 4. TBNA Left mediastinal mass 11 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. BI 4. TBNA Left mediastinal mass 12 Advantages of performing TBNA vs. brushing and endobronchial biopsy ► ► 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) BI 4. TBNA Left mediastinal mass 13 Potential dangers of TBNA through posterior wall of Left main bronchus ► Includes all potential complications of TBNA Fever Oozing of blood Bacteremia Pneumothorax or pneumomediastinum Perforation of vascular structures BI 4. TBNA Left mediastinal mass 14 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. BI 4. TBNA Left mediastinal mass From: Mountain CF et al, Chest 1997 15 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 BI 4. TBNA Left mediastinal mass 16 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 BI 4. TBNA Left mediastinal mass 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 BI 4. TBNA Left mediastinal mass 18 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, BI 4. TBNA Left mediastinal mass 19 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 BI 4. TBNA Left mediastinal mass 20 All efforts are made by Bronchoscopy International to maintain currency of online information. All published multimedia slide shows, streaming videos, and essays can be cited for reference as: Bronchoscopy International: Practical Approach©, an Electronic OnLine Multimedia Slide Presentation. http://www.Bronchoscopy.org/PracticalApproach/htm. Published 2009 (Please add “Date Accessed”). Thank you BI 4. TBNA Left mediastinal mass 21 Prepared with the assistance of Larry Tom M.D. www.bronchoscopy.org BI 4. TBNA Left mediastinal mass 22