Ethmoid sinus biopsy

84-year-old man with B cell lymphoma and new sinus masses

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  • Diffuse large B cell lymphoma, secondary to mycophenolate
  • R-CHOP chemotherapy
  • New onset headaches and diplopia – PET-avid sinus lesions

Issues

  • Profoundly frail and deconditioned. CFS = 6, DASI 2.9 METS
  • Multiple hospital admissions this year including ICU stay for neutropenic sepsis and 40-dayhospital admission
  • Renal Transplant 2014 – live donor kidney from wife. Native polycystic kidney disease.
  • IDDM – secondary to methylprednisolone for acute transplant rejection
  • Severe MR – Mitraclip in Nov 2020 post chordae rupture.
  • Regular cardiology follow-up until lymphoma diagnosis, current plan to focus on cancertreatment.
  • Recent echo – mild to moderate residual MR, Moderate concentric LVH, low-normal systolicfunction, moderate to severe pulmonary hypertension, and severe LA enlargement.
  • Paroxysmal AF – not currently anticoagulated
  • VRE

Discussion

Reason for procedure

  • Diagnostic vs therapeutic – patient and family believe it may help to resolve his headaches
  • Discussed with ENT – diagnostic procedure only. Requested by oncologist. The Surgeon doesnot think it will add any therapeutic benefit.
  • Surgeon and oncologist to have further discussions

Opportunity for optimisation

  • Discussed with Prof Fletcher, last echo reassuring. Patient on optimal cardiac therapy.
  • Significant level of frailty and deconditioning are concerning
  • High-risk patient and low risk procedure
  • Ascertain if biopsy will significantly affect the management of his malignancy

Advanced care planning

• No documented advanced care directive in notes

Plan

  • Await outcome of discussions between oncologist and ENT surgeon
  • Liaise with patient regarding ACD