Dr. Faisal A Kahn
A 70 year-old female with a history of stage II papillary cancer of the thyroid that previously underwent surgical resection in 2019 presents with new para-aortic isolated lymphadenopathy with significant uptake on PET/CT. (Fig. 1 & 2) Given the location of the lymph node, she was initially sent to thoracic surgery for a mediastinoscopy and a thoracotomy for diagnosis. After additional discussion with the thoracic oncology multi-disciplinary team, that patient was referred to interventional pulmonology for a less invasive approach with Robotic-Assisted Bronchoscopy.
Evaluation of the CT showed a station 6 lymph node located between the aorta and visceral pleura of left upper lobe. Although no definitive bronchus sign was identified, there was an airway in close proximity of the node that was used for pre-procedure planning.
Initial inspection was performed using a regular flexible bronchoscope which revealed a sharp upper lobe take off not traversable into the segmental bronchus. The bronchoscope was replaced with the MONARCH® Platform and once the area in question was accessed, extrinsic compression was visualized (Fig. 3) due to the enlarged node. Fused navigation along with precise control of the MONARCH® Scope, allowed for crucial circumferential alignment into the node. Radial EBUS was used to confirm proper angulation and to identify vascular structures within the area (Fig 4). A 21G flexible biopsy needle(Fig 5) was used while slight adjustments were made with the scope to maintain ideal positioning and allow the needle to make the final turn. Rapid onsite evaluation revealed positive for malignancy consistent withmetastatic papillary thyroid cancer.
MONARCH’s ability to maneuver around tight curves especially in the upper lobes and control the angulation of attack is what made considering a transbronchial approach to access para-aortic nodes possible.
MONARCH’s ability to maneuver around tight curves especially in the upper lobes and control the angulation of attack is what made considering a transbronchial approach to access para-aortic nodes possible. Fine adjustments at the distal end of the scope and visualization provided the tools necessary to target an area with challenging anatomy and facilitated in making a diagnosis with a less invasive technique.
Dr. Khan is based in Indianapolis, IN and has over twenty years of medical experience. He is the Medical Director of Endoscopy, Interventional Pulmonology, Respiratory and Pulmonary Rehabilitation for Franciscan Health. He is board certified in pulmonary, critical care and internal medicine.
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).
This document reflects the techniques, approaches and opinions of the individual physician. This Auris sponsored document is not intended to be used as a training guide. Other physicians may employ different techniques. The steps demonstrated may not be the complete steps of the procedure. Individual physician preference and experience, as well as patient needs, may dictate variation in procedure steps. Before using any medical device, review all relevant package inserts with particular attention to the indications, contraindications, warnings and precautions, and steps for use of the device(s).
Dr. Faisal A. Khan is compensated by and writing on behalf of Auris Health and must present information in accordance with applicable FDA requirements.
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.