Dr. Lauren Ventola
A 39-year-old female recently diagnosed with cervical cancer status post-surgical resection and currently receiving chemotherapy and radiation. Staging PET showed right hilar lymphadenopathy with SUV 4.8 and a right upper lobe 13 mm x 10 mm lung nodule with SUV 2.1. (Fig. 1 & 2) Of note she has a 20 pack-year smoking history, family history of lung cancer in both parents and is currently employed working on the floor of a plastic factory
Examination of CT revealed no discernable bronchus sign, but a nearby adjacent airway and a large vessel suggested an airway may pass close enough to allow successful biopsy. Pre-procedure planning focused on an airway away from intervening vasculature and parallel to the fissure.
The procedure began with endobronchial ultrasound and staging biopsies of the right paratracheal, subcarinal and right hilar lymphadenopathy, which on rapid onsite cytology showed normal lymph node tissue only. Airways were then cleared, and the procedure transitioned to a robotic-assisted bronchoscopy with the MONARCH® Platform. While maintaining a central position of the MONARCH® scope and using intermittent puffs of air, full visualization was maintained out to the periphery of the lung where the nodule was located. At the position of the nodule, confirmed by fluoroscopy (Fig. 3), a small white foreign body was noted and removed with MONARCH® biopsy forceps. (Fig. 4)
Following removal, biopsies were performed with a 21-gauge FNA needle, biopsy forceps and bronchoalveolar lavage. (Fig. 5 & Fig. 6) Final pathology showed macrophages and inflammation. The procedure was complicated by a pneumothorax requiring chest tube for 24 hours.
This nodule was followed up in 6 weeks with a repeat chest CT showing stability. Due to risk factors and concern for possible metastatic disease, the patient underwent a right upper lobe wedge resection. Final pathology confirmed caseating granulomatous inflammation. Based on bronchoscopic and surgical findings, the nodule was likely related to inhaled plastic fiber from her place of employment.
"As a new user who has never been able to see the periphery of the lung bronchoscopically, the MONARCH® navigation system opened a new world of what I am able to access safely for my patients. This case taught me the value of vision as well as the importance of keeping an open mind regarding the differential for pulmonary nodules."
Although a wedge resection was performed due to underlining risk factors and concern for metastatic disease, not all nodules are malignant. The vast majority of nodules are from benign sources such as previous infections or inflammatory responses
The MONARCH® technology shows visualization to the periphery of the lungs, allowing for better localization of sub-centimeter nodules as well as identifying foreign bodies.
Centennial Medical Center, Nashville, TN
Lauren Ventola, MD received her medical degree from St. George’s University and is affiliated with Tri-Star Centennial Medical Center in Nashville, TN. She completed her internal medicine residency, pulmonary critical care fellowship and interventional pulmonology fellowship at Penn State Health. She is a member of the ACCP, ATS, AABIP and Women in Interventional Pulmonology.
Indications for Use: The MONARCH® Platform and its accessories are intended to provide bronchoscopic visualization of and access to patient airways for diagnostic and therapeutic procedures.
Important Safety Statement: Complications from bronchoscopy are rare and most often minor, but if they occur, may include breathing difficulty, vocal cord spasm, hoarseness, slight fever, vomiting, dizziness, bronchial spasm, infection, low blood oxygen, bleeding from biopsied site, or an allergic reaction to medications. It is uncommon for patients to experience other more serious complications (for example, collapsed lung, respiratory failure, heart attack and/or cardiac arrhythmia).
Complications from bronchoscopy are rare and most often minor, but if they occur, may include breathing difficulty, vocal cord spasm, hoarseness, slight fever, vomiting, dizziness, bronchial spasm, infection, low blood oxygen, bleeding from biopsied site, or an allergic reaction to medications. Only rarely do patients experience other more serious complications (for example, collapsed lung, respiratory failure, heart attack and/or cardiac arrhythmia).
Adverse effects from both Mini-PCNL and Ureteroscopy include pain, urinary tract infection, fever, hematuria (presence of blood in urine), exposure to low levels of radiation, retained or residual stones.
Adverse effects from ureteroscopy may include pain, perforation or injury to the ureter, resulting in extravasation of fluid and urine (urinoma), stricture of the ureter with risk of subsequent obstruction (hydronephrosis needing further repair), rare avulsion of the ureter, urinary blood clots, residual stones.
PCNL access may result in minor and major adverse effects. Minor effects include fever and nephrostomy leak. Major adverse effects may include injuries to pleura, liver, spleen, large vessels with related bleeding, gallbladder, duodenum, jejunum, colon with related cutaneous fistula, fever, pain, ileus, elevated counts.
Major adverse effects related to stone removal may include infection and urosepsis, intravascular fluid overload, extravasation of fluid, and post percutaneous nephrolithotomy bleeding.