Surgeons Role in Symptom Management. A/Prof Cliff K. C. Choong Consultant Thoracic Surgeon Latrobe Regional Hospital GIPPSLAND

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1 Surgeons Role in Symptom Management A/Prof Cliff K. C. Choong Consultant Thoracic Surgeon Latrobe Regional Hospital GIPPSLAND

2 Conditions PLEURAL Pleural effusion Pneumothorax ENDOBRONCHIAL Haemoptysis Airway narrowing or obstruction CHEST WALL Chest pain from local chest wall invasion Etc

3 INTRODUCTION Common clinical problem 40% of all exudative pleural effusion Indicator of metastatic / disseminated malignancy (eg adenocarcinoma) Locally advanced tumour (eg malignant mesothelioma)

4 Anatomy of Thorax

5 NORMAL PLEURAL PHYSIOLOLOGY NORMAL Dynamic equilibrium between production and absorption of 1-2 litres every 24 hours 20 mls of normal pleural fluid at any time point Lubrication

6 PATHOPHYSIOLOGY PLEURAL MALIGNANCY Excessive fluid production Impairs fluid absorption Resulting in accumulation of malignant pleural effusion The pleural fluid is outside the lung in the pleural space causes compression and collapse of the lung Dyspnoea

7

8 Malignant Pleural Effusion MECHANISM PLEURAL MALIGNANCY 1. Haematogenous spread to the pleura 2. Lymphatic implantation on the pleura 3. Direct extension of tumour cells from adjacent organs such as lung, breast, chest wall or pleura

9 AETIOLOGY Metastatic adenocarcinoma (commonest) Men: lung cancer Women: breast cancer 50 65% of all malignant pleural effusion Others: ovarian ca, lymphoma etc Gippsland Region: Malignant pleural mesothelioma due to previous asbestos exposure

10 Timing of Presentation Synchronously Eg CT showing a lung cancer mass and a large pleural effusion Recurrence following completion of treatment of primary cancer Eg: Completed treatment of breast cancer 3 years ago (considered curative) and presents with a large pleural effusion

11 CLINICAL PRESENTATION Symptoms Shortness of breath Cough, Chest pain Signs Air entry, dullness to percussion etc Radiology CXR CT chest

12 MANAGEMENT Initial drainage by aspiration or a small 14F pigtail chest drain Decompress (symptomatic relief) Fluid cytology analysis (diagnostic)

13 FLUID CYTOLOGY ONLY 50% of malignant pleural effusion have POSITIVE CYTOLOGICAL Malignant cells on fluid aspirated

14 FLUID CYTOLOGY EXUDATIVE or HAEMOSEROUS pleural effusion fluid in general should be considered as potential malignant pleural effusion until proven otherwise

15 Advantage MALIGNANT PLEURAL EFFUSION Thoracentesis = Aspiration Quick temporary relief Disadvantages Temporary measure only Re-accumulation in majority of cases (80%) with some studies stating: % of cases Complications: iatrogenic pneumothorax, bleeding, loculated collection, trapped lung, contamination and infection (empyema)

16 MANAGEMENT EARLY REFERRAL for thoracic consultation Important Highly encouraged Avoids delay in treatment Avoids unnecessary repeated aspiration of pleural effusion fluid and complications

17 VATS Treatment VATS (video-assisted thoracic surgery) Best treatment for pleural effusion Diagnostic (pleural biopsies) Therapeutic (talc pleurodesis)

18 VATS Treatment FOUR IMPORTANT AIMS 1. Completely drain the fluid 2. Pleural biopsies 3. Re-expand the lung completely 4. Pleurodesis

19 VATS Treatment HOW DO WE DO IT? 1. Small / tiny keyhole cuts 2. 5mm camera 3. VATS equipments 4. Talc powder for peurodesis

20 INNOVATIVE INSTRUMENTS

21 RESULTS RESULTS of VATS 1. High success rate 95% Marked improvement in breathing Improved quality of life To undergo and tolerate oncology treatment better 2. Low operative mortality rate (lees than 1%) - Safe procedure

22 PROGNOSIS 1. Type of cancer / Organ of origin Ovarian and breast cancer: better Lung cancer: worse Indeterminate cancer: in between 2. Cell Type Adenocarcinoma (EGFR +ve): Better Squamous cell carcinoma: In between Small cell carcinoma: Worse

23 PROGNOSIS 3. Staging 4. Performance level of patient 5. Response to oncology treatment Duration of Life Median duration 6 to 24 months

24 TREATMENT GOALS 1. Relief or elimination of dyspnoea 2. Restoration of normal activity and function 3. Minimisation or elimination of hospitalisation 4. Efficient use of medical resources

25 SUMMARY 1. Debilitating condition causing shortness of breath 2. Common in advanced malignancy 3. Initial aspiration is useful HOWEVER Recurrence is high EARLY REFERRAL 50% of fluid cytology in malignant pleural effusion is negative 4. Moderate to large effusion which is exudative or haemoserous in colour should be considered malignant until proven otherwise

26 SUMMARY 1. Early referral To avoid unnecessary repeated aspirations Avoid trapped lung 2. VATs Safe (minimal morbidity and mortality) Effective treatment

27

28 THANK YOU A/Prof Cliff K. C. Choong Consultant Thoracic Surgeon Latrobe Regional Hospital GIPPSLAND

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