Case study: Anterior mediastinal mass

A 17-year-old female was recently diagnosed with Hodgkin’s disease based on a biopsy of a new neck mass. She is scheduled for insertion of a permanent indwelling central venous catheter to facilitate administration of chemotherapy.

Is there anything else you would like to know prior to proceeding with administration of general anesthesia?

Patients with newly diagnosed Hodgkin’s disease are very likely to have an anterior mediastinal mass. I will perform a detailed history and physical exam looking for evidence of extrinsic airway compression, and review all radiological studies of the chest and neck.

The patient states that she has had progressive dyspnea over the past several weeks while lying down, forcing her to sleep in the semi-sitting position. Physical exam reveals mild inspiratory stridor and use of accessory muscles of respiration when upright. Review of the chest CT reveals an anterior mediastinal mass that is compressing the distal trachea.

Should the case be canceled?

Absolutely – this case should be canceled. Insertion of a central venous catheter to facilitate chemotherapy is an elective procedure. The patient can continue to receive chemotherapy through a peripheral IV catheter or temporary percutaneous central venous catheter, and/or radiation until the mediastinal mass has decreased in size and is no longer compressing the trachea.

After 5 days’ prednisone and radiation therapy, the patient is markedly improved. She is now able to sit upright without stridor or dyspnea, but is still unable to lie supine without coughing. The surgeon has rebooked the case. How will you induce general anesthesia in this patient?

Although this patient has responded to initial therapy and is markedly improved, she still has symptoms of airway compression, and is at risk for further airway compression upon induction of general anesthesia. Therefore I will again cancel this case. She can continue to receive IV chemotherapy via an indwelling peripheral line. This elective case should not be performed until the patient is free of any symptoms related to airway compression, which is then confirmed by follow-up CT of the chest.


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