Faculty Bibliography

Angiomyolipoma is a benign tumor composed of varying proportions of smooth muscle cells, blood vessels, and adipose tissue that most commonly occurs in the kidney. Sporadic lesions and lesions arising in the setting of the tuberous sclerosis complex have been reported in extrarenal sites. We present the case of an incidentally discovered angiomyolipoma in the anterior mediastinum. Thymoma was suspected clinically, and the lesion was composed mainly of spindled-to-epithelioid cells arranged in a histologic pattern reminiscent of hemangiopericytoma, a pattern that has been described in thymoma. Immunohistochemical stains revealed positivity for smooth muscle actin and HMB-45, revealing the expression of smooth muscle and melanocytic markers characteristic of angiomyolipoma and other lesions in the PEComa family.

OBJECTIVE: Examination of factors that may contribute to racial disparity among those with lung cancer has been thwarted by heterogeneous treatment and staging strategies, limited national registry and socioeconomic and follow-up data. This study examines a decades worth of data to better elucidate these factors in a cohort staged or treated using homogeneous algorithms. METHODS: A nested case-control study of patients with non-small cell lung cancer (NSCLC). White patients were matched 4:1 to African American patients on age, gender, comorbidities, performance status, and stage. All patients underwent clinical and pathologic staging by one physician using similar staged-based treatment algorithms. Socioeconomic status was assessed by annual income per capita, insurance status, and education level. The primary outcome was survival rate. RESULTS: Among the 930 patients in this series, African Americans were more likely to be smokers (p < 0.001), have a lower per-capita annual income (p = 0.016), greater delay to treatment (p = 0.023), and less likely to agree to neo-adjuvant therapy (p < 0.001). Whites had better 5-year overall survival than African Americans for stage I (84% versus 78%, p = 0.037), stage II (52% versus 44%, p = 0.041), and stage III (32% versus 20%, p = 0.008) NSCLC. However, this survival advantage disappeared for earlier stages of NSCLC (I and II) when adjusted for socioeconomic status and smoking status. The survival advantage for stage IIIa was lost when adjusted for neo-adjuvant chemoradiotherapy. African American men had the worst survival of all subgroups independent of socioeconomic status. CONCLUSIONS: Given uniform staging, treatment, and socioeconomic status the overall survival rates for African American and White patients with NSLC are similar.

BACKGROUND: Patients with calcified mediastinal lymph nodes who have hemoptysis or lithoptysis represent a challenging therapeutic dilemma. METHODS: We performed a retrospective review of a prospective clinic and operative database between January 1998 and December 2006. All patients had calcified mediastinal lymph nodes, symptoms or complications from these nodes, or both. RESULTS: There were 50 patients (23 men). Thirty-eight (76%) were symptomatic, which included hemoptysis in 11, persistent cough in 8, and recurrent pneumonia in 5, and all underwent rigid bronchoscopy. Thirty-four (89%) of the 38 symptomatic patients had stones eroding into the airway (broncholiths), and 2 had an airway esophageal fistula. The most common location of the broncholith was in the bronchus intermedius (n = 19). Endoscopic removal of the broncholith was performed in 29 patients and was successful in all. Elective thoracotomy with lymph node curettage, removal, or both was performed in 5 patients. These 5 patients had no significant morbidity and no operative mortality. Patients remained symptom free (median follow-up, 2.3 years; range, 8-42 months). Twelve asymptomatic patients with calcified lymph nodes were followed with serial computed tomographic scans and remain asymptomatic (median follow-up, 3.1 years). CONCLUSIONS: Broncholiths that are not fixed to the airway can be safely removed with rigid and flexible bronchoscopic equipment. Thoracotomy with broncholithectomy is also safe and effective and is reserved for symptomatic lesions that cannot be removed bronchoscopically or for lesions that cause airway esophageal fistulas. Calcified nodes in asymptomatic patients are not an indication for intervention.

BACKGROUND: The pain of thoracotomy may be related to trauma to the intercostal nerves. METHODS: This was a prospective randomized study of 160 patients. All patients had a functioning epidural, similar type and size thoracotomy, an intercostal muscle flap (ICM) harvested before rib spreading, inferior rib drilling, and postoperative pain management. In one group, the ICM was left intact distally and it dangled (D group); the ICM in the other was cut distally (C group). Pain was assessed using multiple pain scores. Outcomes assessed were qualitative and quantitative pain scores, number of ribs broken, spirometric values, analgesic use, and return to baseline activity for postoperative days 1 to 5 and weeks 2, 3, 4, 8, and 12. RESULTS: The D group had 85 patients and the C group, 75. The groups had similar demographics, types of procedures, and histology. Intrahospital pain scores were similar; however, at postoperative weeks 3, 4, 8, and 12, the D group had significantly lower mean numeric pain scores and was using fewer analgesics (p < 0.05 for all). At 12 weeks, patients in the D group were more likely to have returned to baseline activity (p = 0.002). CONCLUSIONS: An ICM flap reduces pain. Harvesting and then leaving the ICM flap intact instead of cutting it before rib spreading further reduced thoracotomy pain. This technique, when added to rib drilling, leads to reduced pain on postoperative weeks 3 to 12, to quicker return to baseline activity, and lessens the need for analgesics.

BACKGROUND: Subcutaneous emphysema (SE) after pulmonary resection is troublesome and has been poorly studied. METHODS: A retrospective review was made of a prospective database. Patients who underwent pulmonary resection and in whom clinically detected SE were studied. RESULTS: Of 4,023 patients between January 1999 and June 2006, 255 patients (6.3%) had clinically apparent SE. Predictors of developing SE by multivariate analysis were preoperative forced expiratory volume of air in 1 second (FEV(1)%) less than 50%, having an air leak, and having had a previous thoracotomy. Despite maximizing chest tube suction, 85 patients (33%) had recalcitrant SE. These patients with recalcitrant SE were more likely to have a lower median FEV(1)% (p = 0.037), a previous ipsilateral thoracotomy, and have undergone a lobectomy (p < 0.001). Recently, 64 of the 85 patients underwent single-incision, video-assisted thorascopic surgery with pneumolysis and chest tube placement, which successfully resolved the SE within 24 hours in all patients except 1. These 64 patients had a significantly shorter hospital stay (6 versus 9 days, p = 0.02) and less time with recalcitrant SE than the other 21 patients. CONCLUSIONS: Subcutaneous emphysema is more likely in patients who have an FEV(1)% less than 50% and who undergo a redo thoracotomy. Recalcitrant SE emphysema (SE that persists despite increasing chest tube suction) is more likely in patients who undergo lobectomy and is best treated by video-assisted thorascopic surgery with pneumolysis between the leaking lung, which is usually partially adhered to the previously opened intercostal space. This directs the air leak back into the pleural space and out of the subcutaneous space. This procedure shortens the duration of SE and hospital stay.

BACKGROUND: The purpose of this study was to investigate differences in epidemiology, types of presentation, time between diagnosis and treatment, tumor characteristics, and survival in patients 45 years or younger with non-small cell lung cancer. METHODS: A nested case-control study was conducted during 7 years using a prospective database of patients with non-small cell lung cancer. Younger patients (<45 years of age) were matched 1:2 with older patients for stage, sex, performance status, and type of resection. RESULTS: There were 762 patients (254 were <45 years old, 508 controls were older). The median time from initial symptom to thoracic surgical consultation was significantly longer for those younger than 45 years (6.5 versus 2.8 weeks; p < 0.001). Younger patients were more likely to be symptomatic at the time of diagnosis (89% versus 68%; p < 0.001) and less likely to be smokers (45% versus 78%; p < 0.001). Kaplan-Meier analysis showed the time between diagnosis and treatment, symptoms, maximum standardized uptake value on positron emission tomography, and smoking status impacted survival. Only symptoms and smoking status impacted survival on Cox proportional hazards survival analysis among completely resected patients; 5-year survival was lower in the younger group compared with the older group (51% versus 62%; p = 0.037). CONCLUSIONS: Despite similar stages and tumor characteristics patients younger than 45 years of age with non-small cell lung cancer have a significantly worse prognosis than older patients. Although they are more likely to be symptomatic, younger patients have a greater delay in seeking thoracic surgical care. These data should be considered in the treatment strategy offered to younger patients with non-small cell lung cancer.

BACKGROUND: EUS-guided FNA is commonly performed to sample peri-intestinal targets such as the pancreas, lymph nodes, and the left adrenal gland. To our knowledge, EUS-guided FNA of the right adrenal gland has not been reported. OBJECTIVE: Our purpose was to determine the feasibility and success in sampling an enlarged right adrenal gland. STUDY DESIGN: Observational study. SETTING: Tertiary referral center. PATIENTS: Consecutive patients that underwent EUS-guided FNA of the right adrenal gland. RESULTS: Over a span of 3.5 years, 4 patients underwent transduodenal EUS-guided FNA of the right adrenal gland with a curvilinear echoendoscope. Four passes were performed in all cases, and the diagnosis was rendered on the first pass. The posterior wall of the descending duodenum was the port of entry of the needle. Three of the patients had metastatic lung cancer to the right adrenal gland; one was proven by surgical histopathologic examination. One patient had a benign aspirate consistent with angiomyolipoma. None of the patients had any minor or major complications. LIMITATIONS: Observational study, small sample size. CONCLUSIONS: Transduodenal EUS-guided FNA of the right adrenal gland is feasible and safe. Future large-scale studies are needed to replicate our findings and to determine the rate of successful identification and sampling of the right adrenal gland with the curvilinear echoendoscope.

Fast-tracking protocols or postoperative care computerized algorithms have been shown to reduce hospital length of stay and reduce costs; however, not all patients can be fast-tracked. Certain patient characteristics may put patients at increased risk to fail fast-tracking. Additionally some patients have multiple risk factors that have an additive effect that puts them at an even increased risk to fail fast-tracking, and more importantly, to significant morbidity. It is a mistake to force these protocols on all patients because it can lead to increased complications, readmissions, and low patient and family satisfaction. By carefully analyzing surgical results via accurate prospective databases, the types of patients who fail fast-tracking and the reasons they fail can be identified. Once these characteristics are pinpointed, specific changes to the postoperative algorithm can be implemented, and these alterations can lead to improved outcomes. The authors have shown that by using pain pumps instead of epidurals in elderly patients we can improve outcomes and still fast-track octogenarians with minimal morbidity and high-patient satisfaction. We have also shown that the increased use of physical therapy and respiratory treatments (important parts of the care of all patients after pulmonary resection, but a limited resource in most hospitals) may also lead to improved surgical results for those who have low FEV1% and DLco%. Further studies are needed. Although fast-tracking protocols cannot be applied to all, the vast majority of patients who undergo elective pulmonary resection, even those at high risk, can undergo safe, efficient, and cost-saving care via preset postoperative algorithms. When the typical daily events are convened each morning and the planned date of discharge is frequently communicated with the patient and family before surgery and each day in the hospital, most patients can be safely fast-tracked with high satisfaction and outstanding results.

OBJECTIVE: Many patients have their hospital discharge delayed because their chest tube drainage is too high, despite the fact that there are no data to support the commonly used 250 mL/day threshold. METHODS: A retrospective cohort study was conducted with a prospective database and prospective algorithm from one surgeon. All patients underwent elective pulmonary resection. The last chest tube was removed if there was no air leak and nonchylous drainage of 450 mL/day or less. RESULTS: The study comprised 8608 operations and 2077 patients who underwent an elective (nonpneumonectomy) pulmonary resection via thoracotomy by one general thoracic surgeon over a 10-year period. Eighty-nine patients went home with a chest tube owing to air leak. The remaining 1988 patients were discharged without a chest tube. Types of pulmonary resection were wedge resection in 729 patients, segmentectomy in 214, lobectomy in 1104, and bilobectomy in 30. The median day of discharge was postoperative day 4. One hundred one (5%) were readmitted to the hospital within 60 days of discharge. The most common reason for readmission was dehydration and fatigue. Only 11 (0.55%) had readmissions owing to recurrent symptomatic effusion and most were treated with video-assisted thoracoscopy. Follow-up was 100% at 4 weeks and 93% at 8 weeks. CONCLUSIONS: Chest tubes can be removed with up to 450 mL/day of nonchylous drainage after pulmonary resection, and perhaps a higher volume could be accepted. Readmission owing to a recurrent effusion is exceedingly uncommon, and the practice of leaving the tube in longer for drainage less than 450 mL/day is unsupported in the literature.