weekly_question 15/12/2024

[Admin]

An 11-year-old girl presents with two weeks of progressive orthopnea. A chest radiograph demonstrates a large anterior mediastinal mass and blunting of the right costophrenic angle. Computerized tomography confirms the presence of an anterior mediastinal mass with an associated slit-like narrowing of the distal trachea and right mainstem bronchus, compression of the superior vena cava, a moderate right pleural effusion and enlarged cervical lymph nodes. You are asked to provide a tissue diagnosis. Which of the following is the best approach to initial tissue diagnosis in this patient?

A pleural fluid aspiration

B cervical lymph node biopsy with general anesthetic

C image-guided core needle of primary tumor under sedation

D mediastinoscopy with ketamine anesthesia

E thoracoscopic biopsy of the primary mass under general anesthesia

[Admin]

Correct answer
A pleural fluid aspiration

A safe approach to tissue diagnosis remains paramount. Compressive symptoms and subsequent anatomic information gained from cross sectional imaging can help guide the approach. A multidisciplinary approach including all stakeholders will streamline this process.

Malik performed a single institutional (tertiary referral center) retrospective review of their diagnostic approach to 44 patients presenting with an anterior mediastinal mass between 2011 and 2016. Of those included in the study, 50% were symptomatic and approximately 60% had evidence of airway compression on cross sectional imaging. The authors outline a diagnostic algorithm which minimizes anesthetic exposure and is very similar to that proposed by Perger in a highly cited paper from 2008.

Following this algorithm, pleural fluid, peripheral blood smears or bone marrow aspirate should be the first diagnostic line of approach followed by lymph node biopsy under local anesthesia. Only if these methods fail should tissue be obtained from the primary tumor with sedation. In this study, 25% of patients could be diagnosed on the basis of peripheral blood or pleural fluid, 45% were diagnosed by cervical lymph node biopsy, 23% were diagnosed by core needle and five percent were diagnosed by mediastinoscopy. Eight children (18%) required steroids for severe symptoms prior to biopsy (duration of steroids one to three days) and all were able to have definitive diagnosis made on immunohistochemistry of biopsied tissue. General anesthesia was avoided in 14/44 (32%) of children using the recommended stepwise approach to diagnosis. Of those receiving general anesthesia, spontaneous breathing was maintained in 72% and ketamine was frequently employed to reduce negative inotropic and chronotropic effects associated with other anesthetic agents. There were no observed anesthetic complications.

[Ismailmohamed]

C

[Habeebogundipe]

B

[Safaa]

B

[Anas Fagelnor]

E

[Abd El wahed]

A pleural fluid aspiration

[Mariam Babiker]

A

[Radwan suleiman abukarsh]

B

[Admin]

Correct answer
A pleural fluid aspiration

A safe approach to tissue diagnosis remains paramount. Compressive symptoms and subsequent anatomic information gained from cross sectional imaging can help guide the approach. A multidisciplinary approach including all stakeholders will streamline this process.

Malik performed a single institutional (tertiary referral center) retrospective review of their diagnostic approach to 44 patients presenting with an anterior mediastinal mass between 2011 and 2016. Of those included in the study, 50% were symptomatic and approximately 60% had evidence of airway compression on cross sectional imaging. The authors outline a diagnostic algorithm which minimizes anesthetic exposure and is very similar to that proposed by Perger in a highly cited paper from 2008.

Following this algorithm, pleural fluid, peripheral blood smears or bone marrow aspirate should be the first diagnostic line of approach followed by lymph node biopsy under local anesthesia. Only if these methods fail should tissue be obtained from the primary tumor with sedation. In this study, 25% of patients could be diagnosed on the basis of peripheral blood or pleural fluid, 45% were diagnosed by cervical lymph node biopsy, 23% were diagnosed by core needle and five percent were diagnosed by mediastinoscopy. Eight children (18%) required steroids for severe symptoms prior to biopsy (duration of steroids one to three days) and all were able to have definitive diagnosis made on immunohistochemistry of biopsied tissue. General anesthesia was avoided in 14/44 (32%) of children using the recommended stepwise approach to diagnosis. Of those receiving general anesthesia, spontaneous breathing was maintained in 72% and ketamine was frequently employed to reduce negative inotropic and chronotropic effects associated with other anesthetic agents. There were no observed anesthetic complications.