PIG Meeting: 11th March 2021

83 year old lady with left lower lobe lesion for thoracotomy and wedge resection

Background

• Incidental finding of LLL lesion on CTPA. Under surveillance for one year, increasing in size. Asymptomatic.
• Cardiothoracic surgeon strongly suspicious of malignancy
• Long-standing dyspnoea – previous PE. Investigated but no cause identified. Intermittent in nature.
• DASI 5 METS
• Spirometry: reduced FEV1 (63%) DLCO and FVC normal
• PAF. Normal echo and Holter

Issues

• Elderly patient without confirmed diagnosis of cancer. Should we proceed or discuss less invasive options with surgical team?
• Dyspnoea concerning as no identified cause. Excluded significant issues such as valvular heart disease and pulmonary hypertension. Would non-invasive stress test change management – likely need expedited surgery due to cancer possibility.
• Anticoagulation – high risk for VTE. CHADSVASC = 6

Discussion

• Thought to be little benefit in delaying to biopsy as surgeon suspicious of cancer. Will likely need to have surgery regardless.
• Dyspnoea in patients with no respiratory cause and structurally normally heart could be caused by Atrial Fibrillation. Rate well-controlled, no need to increase dose of beta-blocker preoperatively
• Consensus was to bridge given high risk from CHADSVASC score

Plan

• Proceed to surgery without further investigations
• Clexane bridging

Post-operative ICU given age, open procedure, and co-morbidities