Thoracotomy – Patient declining op

Gabrielle Morris

73y/o F for Left thoracotomy and biopsy for para-aortic left node (PET avid). Not EBUS amenable

Recent Admission with proximal myopathy (improved with steroids) and PET AVID lesion noted – ? paraneoplastic syndrome causing weakness.

Background

  • ? Scleroderma/Dermatomyositis (Recent reviews by Rheumatology- still undergoing investigations)
  • AF – apixaban
  • HTN
  • DASI METS < 4
  • CFS 6
  • COPD
    • FEV1 0.94 , FEV1 1.8, DLCO 39%
    • Exacerbation in Feb 23
    • 96% on RA, hyperinflation of chest on examination 

Issues

  • Patient not keen for procedure due to concern about high risks
  • NSQUIP – Risk of death >5%; 12% complications, Readmission 13%
  • Severe COPD, likely not optimizable

Discussion

  • ? natural history of disease once tissue diagnosis is obtained
  • ? options for treatment of presumed cancer without tissue diagnosis
  • ? risk of anaesthesia and procedure outweighs benefit
  • Respecting patient autonomy 
  • Options for less invasive surgery?

Plan

  • To Discuss with Oncology team re ? option for empirical therapy due to the high risks, ? likely natural history without treatment
  • Discuss with rheum/onc – ? myopathy due to dermatomyositis (not cancer), ? other non-cancerous diagnoses possible for the lymph node
  • To discuss with surgical team – is a thoracotomy required for a tissue diagnosis or is there an alternative option