Faculty Bibliography

BACKGROUND: EUS-guided FNA of the left and right adrenals has been described, but data are very limited. OBJECTIVES: Our primary objective was to determine the impact of the diagnostic utility of EUS-guided FNA of adrenal glands on patient management. Our secondary objective was to determine predictors of malignant adrenal involvement. STUDY DESIGN: Observational study. SETTING: Tertiary referral center. PATIENTS: Patients with enlarged adrenal(s) on abdominal imaging underwent EUS-guided FNA. The left adrenal (n = 54) was sampled via the transgastric approach and the right adrenal (n = 5) via a transduodenal approach. RESULTS: Fifty-nine patients (63% men, median age 65 years) were evaluated. The median adrenal gland size was 25 x 17 mm. Adrenal tissue adequate for interpretation was obtained in all of the patients. EUS-guided FNA confirmed malignancy in 22 (37%) patients. Based on size (> or =30 mm) alone, EUS had an accuracy of 68%. Patients with malignant cytology had higher standard uptake value scores on positron-emission tomography compared with patients with benign adrenal masses (P < .001). Malignant masses were more likely to have an altered adrenal gland shape compared with benign masses (crude odds ratio [OR] 12.0; P < .001). On multivariable analysis, altered adrenal gland shape was a significant predictor of malignancy (adjusted OR 7.94; P = .015), whereas a size of 30 mm or larger (adjusted OR 1.30; P = .774) and hypoechoic nature (adjusted OR 12.05; P = .148) were not. All patients except 2 with malignant cytology were treated with systemic therapy without the need for additional invasive biopsies or surgery. No immediate complications were encountered. LIMITATIONS: Lack of surgical criterion standard; 1 experienced endosonographer. CONCLUSIONS: EUS-guided FNA of the adrenal glands is a minimally invasive and safe approach that documents or excludes malignant involvement. EUS-guided FNA should be the first next test to evaluate enlarged adrenal glands because it directs therapy and affects patient management.

Prolonged pulmonary parenchymal air leaks are an important clinical problem. Standard treatment of prolonged air leaks include continued chest tube drainage, pleural sclerosis, or surgery. Approaches that are less invasive than bedside sclerosis or surgery are desirable but bronchoscopy approaches tried over the years have had limited success. In 2001, an American College of Chest Physicians (ACCP) consensus statement concluded there was no role for bronchoscopy for the treatment of prolonged air leaks. The development of bronchial valves for treatment of emphysema allowed the use of these devices for air leaks under compassionate use regulations. Multiple reports of successful bronchial valve treatments, along with the US Food and Drug Administration's (FDA) humanitarian use approval of a bronchial valve for certain postsurgical air leaks, provide new evidence that there is likely a role for endobronchial treatment of prolonged air leaks in selected patients.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) affects millions of people and has limited treatment options. Surgical treatments for severe COPD with emphysema are effective for highly selected patients. A minimally invasive method for treating emphysema could decrease morbidity and increase acceptance by patients. OBJECTIVE: To study the safety and effectiveness of the IBV(R) Valve for the treatment of severe emphysema. METHODS: A multicenter study treated 91 patients with severe obstruction, hyperinflation and upper lobe (UL)-predominant emphysema with 609 bronchial valves placed bilaterally into ULs. RESULTS: Valves were placed in desired airways with 99.7% technical success and no migration or erosion. There were no procedure-related deaths and 30-day morbidity and mortality were 5.5 and 1.1%, respectively. Pneumothorax was the most frequent serious device-related complication and primarily occurred when all segments of a lobe, especially the left UL, were occluded. Highly significant health-related quality of life (HRQL) improvement (-8.2 +/- 16.2, mean +/- SD change at 6 months) was observed. HRQL improvement was associated with a decreased volume (mean -294 +/- 427 ml, p = 0.007) in the treated lobes without visible atelectasis. FEV(1), exercise tests, and total lung volume were not changed but there was a proportional shift, a redirection of inspired volume to the untreated lobes. Combined with perfusion scan changes, this suggests that there is improved ventilation and perfusion matching in non-UL lung parenchyma. CONCLUSION: Bronchial valve treatment of emphysema has multiple mechanisms of action and acceptable safety, and significantly improves quality of life for the majority of patients.

This article covers the risk factors, diagnostic tools, staging methods/modalities and treatment for patients with non-small cell lung cancer (NSCLC). Also presented is the new 7th edition American Joint Cancer Committee (AJCC) TNM classification for staging of NSCLC and a recommended treatment algorithm.

BACKGROUND: Neoadjuvant chemotherapy or chemoradiotherapy increases the risk of pulmonary resection. Changes in specific pulmonary function tests may be predictive. METHODS: A retrospective review of a prospective database of patients with non-small cell lung cancer who underwent neoadjuvant therapy, had pulmonary function tests performed both before and after therapy, and then underwent elective pulmonary resection was performed. Final values and change in the pulmonary function tests before and after treatment were entered as independent variables into a multivariate model in which the dependent variable was major or respiratory morbidity. RESULTS: There were 132 patients. The mean duration between pretherapy and posttherapy pulmonary function tests was 4.1 months. The mean change in the percent forced expiratory volume in 1 second, in the percent diffusion capacity of the lung for carbon monoxide, and in the percent diffusion capacity of the lung for carbon monoxide corrected for the alveolar volume was +1.0, -6.4%, and -6.6%, respectively. Fifty-five patients (42%) experienced a postoperative complication, and 39 of those patients experienced a major or respiratory complication. There were 7 (5.3%) operative mortalities (5 were respiratory related). On multivariate analysis the change in the percent diffusion capacity of the lung for carbon monoxide corrected for the alveolar volume was the only factor associated with major or respiratory morbidity (p = 0.028). When the posttherapy percent diffusion capacity of the lung for carbon monoxide corrected for the alveolar volume fell by 8% or more, there was an increased likelihood of major morbidity (p = 0.01). CONCLUSIONS: A decrease in the percent diffusion capacity of the lung for carbon monoxide corrected for the alveolar volume after neoadjuvant chemotherapy or chemoradiotherapy may predict increased risk for pulmonary resection, especially if the decrease is 8% or greater. These results should be considered in the preoperative risk assessment of patients who are to undergo pulmonary resection after induction therapy.

BACKGROUND: Many patients with resected, pathologic (p)stage I non-small cell lung cancer (NSCLC) are not adequately staged preoperatively or intraoperatively. Reported 5-year survival is about 65%. Recently, nonsurgical techniques are being offered to these patients. METHODS: A prospective database was retrospectively reviewed. All patients had an integrated positron-emission tomography/computed tomography (CT) and CT scan, an R0 pulmonary resection with lung palpation, and complete thoracic lymphadenectomy. RESULTS: From August 2002 until July 2008, 2171 patients presented with presumed, resectable NSCLC. Of these, 721 were clinically (c)staged I, and 1450 were (c)staged II, III, or IV. Of the 721 (c)stage I, 405 (56%) had (p)stage I disease; 101 (14%) were clinically over-staged (benign nodules). Of those with NSCLC, 32% were clinically under-staged (stage II or higher on path). The 5-year Kaplan-Meier survival rates were 80% for (p)stage IA, 72% for (p)stage IB (p = 0.026), and 87% for the 721 with (c)stage I disease. The median-follow up was 3.8 years. CONCLUSIONS: When patients with NCSLC are accurately staged preoperatively and undergo complete thoracic lymphadenectomy, the 5-year survival is 80% for (p)stage IA tumors and 87% for (c)stage I disease. About 32% of patients are under-staged (most commonly from nonimaged N2 disease) despite the liberal application of all of the techniques that assess mediastinal lymph nodes preoperatively. Thus surgical intervention offers improved staging with resection of unsuspected nodal or parenchymal disease. If stereotactic radiation and radiofrequency ablation are considered for patients with clinically staged I NSCLC, these results should be considered.

BACKGROUND: The percent predicted diffusing capacity of the lung for carbon monoxide (Dlco%) is an important pulmonary function test (PFT) obtained before elective pulmonary resection. However, there are several Dlco values reported and it is unknown which ones are important predictors of postoperative morbidity. METHODS: This is a retrospective study of a prospective database of patients who underwent PFTs and pulmonary resection by one surgeon. The PFTs evaluated were as follows: forced expiratory volume in one second (FEV(1)%), minute ventilation volume (MVV%), and three types of diffusion capacity of the lung for carbon monoxide values: the diffusion capacity of the lung for carbon monoxide (Dlco%), the Dlco adjusted for hemoglobin (DL adjusted%), and the Dlco adjusted for alveolar volume (Dlco/VA%). RESULTS: There were 906 patients between January 2005 and December 2007, and lobectomy was performed most commonly. Complications occurred in 254 patients (28%) and were respiratory in 115 (13%). On univariate analysis, age (p < 0.001), number of cigarettes smoked (p = 0.008), history of coronary artery disease (p = 0.028), FEV(1)% (p = 0.021), postoperative predicted (ppo) FEV1% (p < 0.001), Dlco% (p = 0.018), ppoDlco% (p = 0.002), and Dlco/VA% (p = 0.004) were significantly different among those who did and did not experience postoperative respiratory morbidity. Multivariate regression analysis identified ppoDlco%, ppoFEV1%, Dlco/VA%, and age as significant independent predictors of respiratory morbidity. Operative mortality was 2% (18 patients). CONCLUSIONS: Although age, FEV(1)%, ppoFEV(1)%, Dlco%, and ppoDlco% are all well-known predictors of operative morbidity after elective pulmonary resection, the Dlco/VA% is another important predictor. This information should be included to help guide patient selection for pulmonary resection and to determine preoperative risk stratification.