Faculty Bibliography

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.

In contrast to the benign clinical course of a primary spontaneous pneumothorax, secondary pneumothorax in patients who have severe COPD can be a life-threatening event. COPD patients who develop spontaneous pneumothorax require a more aggressive management of their acute respiratory problem and treatment to prevent recurrences. All patients who have secondary spontaneous pneumothorax should be hospitalized and managed with tube thoracostomy and chest roentgenogram. Patients who have a persistent or large air leak or those who lack parietalto-visceral pleural apposition should undergo VATS early in their hospital stay. During VATS, the leaking bulla should be resected if it can be located, and if not, the most apical bleb should be resected. In addition, pleurodesis along with pleurectomy should be considered in those patients who are safe operative candidates. These techniques help prevent future pneumothoraces from bleb rupture in the patients who have COPD.

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.

Air leaks are one of the most common complications after pulmonary resection and they are the most frequent cause of prolonged hospital stay, increased cost and patient dissatisfaction. The management of chest tubes in patients with air leaks is optimized when the air leak is scientifically evaluated. The traditionally used analogue classification system, the Robert David Cerfolio Classification System (or RDC named after my father) has inherent subjectivity to it and may be interpreted differently by different bedside observers. More recently, several companies have developed digital pleural drainage systems that are able to quantify the size of air leaks in ml/min or in ml/breath. This eliminates the subjectivity. This affords better interpretation of chest tube setting changes and of air leak healing. These units also provide recordings of the air leak and of the pleural pressure. In this multimedia chapter, we report the different methods of measuring air leaks.

OBJECTIVES: With the exception of one retrospective survey, there are currently no prospectively published data about the frequency of cervical esophageal perforation at the time of endoscopic ultrasound (CEP-EUS). We prospectively investigated the frequency of CEP-EUS and the outcomes and management of patients sustaining CEP-EUS. METHODS: All patients that underwent upper EUS by a single experienced endosonographer over a 7-year period were enrolled. All indications and immediate complications encountered, the baseline demographics, indication of the procedures, surgical interventions, length of hospital stay, and the final outcomes of the patients were prospectively recorded. RESULTS: A total of 5,225 EUS procedures were performed. Lower gastrointestinal tract EUS procedures (n=331) were excluded from the analysis, and thus 4,894 upper EUSs constitute this study. The mean age of the patients was 59.7 years (s.d. 14.3 years); 54% patients were men and 79% were white. Indications for EUS included pancreaticobiliary (58%), esophageal (14%), mediastinal (14%), gastric (9%), celiac blocks (1%), and other (4%). Of 4,894 patients, 3 (0.06%, exact 95% confidence interval: 0.01-0.18) suffered CEP-EUS. The curvilinear echoendoscope was used in all three patients. All patients were octogenarians and women. All perforations were suspected at the time of intubation. Esophagogram confirmed contained perforation in all patients. All patients were immediately admitted and underwent surgical repair with a neck incision and recovered completely. The length of hospital stay was 6, 11, and 23 days respectively. All patients resumed swallowing without complications. One patient died from progressive pancreatic cancer 6 months after Whipple's procedure. The two other patients remained alive and well 12 and 22 months after the procedure. CONCLUSIONS: CEP-EUS is rare but a potentially devastating event for the patient and the treating physician. Although rare, the incidence is 2- to 3-fold higher than what has been reported in the survey literature. Early recognition and treatment is crucial for prompt intervention and complete recovery from CEP-EUS. These data can be used by endosonographers to counsel their patients about frequency, management, and outcomes of CEP-EUS.