Faculty Bibliography

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.

BACKGROUND: Transesophageal EUS-guided FNA (EUS-FNA) is safe, accurate, and cost effective in staging patients with non-small-cell lung cancer (NSCLC). However, the impact of EUS-FNA on patient survival has not been demonstrated. OBJECTIVE: To determine the impact of metastatic disease in mediastinal lymph nodes as determined by EUS staging on treatment choice and survival in patients with NSCLC. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Tertiary university-based referral center. PATIENTS: Patients with biopsy-proven NSCLC who underwent staging EUS-FNA. The relationship between the EUS nodal status and patient survival was evaluated. Cox proportional hazards models were used to determine the significance of EUS nodal status and patient characteristics on patient survival. MAIN OUTCOMES MEASUREMENTS: Impact of EUS-FNA on therapy and survival in patients with NSCLC. RESULTS: Of 125 patients with NSCLC, EUS-FNA confirmed metastatic disease in 46% of the patients. Patients who were node positive were more likely to receive chemotherapy and/or radiation therapy and were less likely to undergo surgery compared with patients who were node negative (P< .0001). Patients with N2 or N3 disease by EUS-FNA had a shorter survival time than patients who were node negative (P= .004). Adjusting for age, race, and sex, EUS-FNA was the most important predictor of survival of patients with NSCLC in this cohort of patients (hazard ratio 2.34, 95% CI 1.31-4.21). LIMITATIONS: Lack of surgical reference standard in all patients and referral to a tertiary center. CONCLUSIONS: Patients with node-positive NSCLC as detected by EUS-FNA have a shorter survival time compared with patients who were node negative. They are more likely to receive neoadjuvant therapy and less likely to receive surgery. Preoperative EUS-FNA is a minimally invasive technique that provides important prognostic information in patients with NSCLC.

Patients with malignant pleural mesothelioma and negative N2 stage lymph nodes may benefit from extrapleural pneumonectomy with adjuvant therapy. The objective of this study is to describe the use of EUS-FNA to determine N2 stage status in patients with mesothelioma and its impact in the management of such patients. Six patients (mean age, 62 yr; median age, 63 yr; range, 52-70 yr; 5 men; 1 woman) underwent EUS-FNA for staging of N2 lymph nodes from July 2000 to July 2006. Follow-up included operative notes, treatment summaries, and surgical pathology. Eight sites were aspirated: four subcarinal lymph nodes, three aorto-pulmonary window lymph nodes, and one paraesophageal mass. Two of 8 (25%) aspirates were positive for metastatic disease in two different patients. Two false negative EUS-FNAs were observed and were attributed to sampling error not diagnostic error. No complications were observed. EUS-FNA is a safe N2 node staging technique in patients with mesothelioma. A positive N2 lymph node by EUS-FNA may be a contraindication to definitive surgery in patients with malignant mesothelioma.

Recent studies have shown that patients who are down-staged via neoadjuvant therapy and undergo resection have a significant increased 5-year survival rate (as high as 40%-50%) when compared with patients who have residual N2 disease. The identification of patients who are N2 negative after the completion of their neoadjuvant therapy is a critical component of proper patient selection for thoracotomy. Some may even argue that it is a necessary step before resection. In this article we review the best ways to restage patients with N2 disease after they have completed their neoadjuvant therapy.

Fast-tracking protocols or postoperative care computerized algorithms have been shown to reduce hospital LOS and reduce costs for patients. who undergo both open and VATS procedures The ability to fast-track is not governed by the type of procedure (closed versus open), but rather by patient characteristics and the mindset of the operating surgeon and the postoperative care team. While use of protocols enhance the ability of many physicians to fast-track many different types of patients, it is a mistake to force these protocols on all patients because, if not modified, they can lead to increased complications, readmissions, and low patient and family satisfaction. By carefully analyzing surgical results using accurate prospective databases, the types of patients who fail fast-tracking and the reasons they fail can be identified. Specific changes to the postoperative algorithms can be implemented and these alterations can lead to improved outcomes. For example, we 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 use of increased 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 with low FEV1% and DLCO%. 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 by way of preset postoperative algorithms after VATS or thoracotomy procedures. When the typical daily events are communicated each morning and the planned date of discharge is reinforced with the patient and family before surgery and each day in the hospital on rounds, most patients can be safely fast-tracked with high satisfaction and outstanding results.

BACKGROUND: Stage IIIA non-small cell lung (NSCLC) from N2 disease is common, but represents a heterogeneous group of patients. Predictors of who completes their neoadjuvant chemoradiotherapy and undergoes subsequent surgical resection are unknown. METHODS: This retrospective cohort study used a prospective database. Patients who had biopsy-proven, nonbulky N2 disease underwent neoadjuvant chemoradiotherapy and were restaged or resected, or both. RESULTS: There were 402 patients, and 326 (81%) completed their neoadjuvant therapy. Only 198 (50%) returned for definitive pathologic restaging, and 149 (37%) underwent thoracotomy for attempted resection. Predictors of who returned to the surgical arena were age (< 70), multiple node involvement, and response to neoadjuvant therapy. The 5-year survival was 8% for the 253 patients who did not return for restaging but was 47% for the 149 patients who underwent thoracotomy (p < 0.001). The 5-year survival for selected subgroups of patients who underwent complete resection was 42% for the 14 patients who had unsuspected recalcitrant N2 disease, 49% for the 65 patients who had a partial response, and 53% for the 34 patients who had a complete response. CONCLUSIONS: Only 37% of patients with favorable, nonbulky, biopsy-proven N2 disease actually complete their neoadjuvant therapy, undergo restaging, and then return for attempted resection. Only 28% undergo complete resection. However, in this highly selected subset of patients, the 5-year survival is 47% or better if partial or complete pathologic response is achieved. Therefore, surgical resection remains a viable treatment for selected patients with favorable N2 NSCLC.

BACKGROUND: Air leaks remain the most common pulmonary complication after elective pulmonary resection, yet their assessment, unlike other clinical bedside indicators, remains analogue and not digital. METHODS: This prospective randomized study compared a digital air leak system with the current analogue air leak system in 100 patients that underwent elective pulmonary resection. RESULTS: The digital and analogue patient groups each had 50 patients. Pulmonary function, types of pulmonary resection, number of chest tubes, and pathology were not statistically different between the groups. The digital system confirmed the air leak status in 5 patients that were equivocal on the analogue system. The ability to assess the air leak status continuously afforded quicker chest tube removal in the digital group (mean, 3.1 vs 3.9 days, p = 0.034) and reduced hospital stay (mean, 3.3 vs 4.0 days, p = 0.055). Three patients were discharged home with the device, without complications. CONCLUSIONS: The digital and continuous measurement of air leaks instead of the currently used static analogue systems reduces hospital length of stay by more accurately and reproducibly measuring air leaks. This leads to quicker chest tube management decisions because the average size of an air leak during the last several hours can be determined. Intrapleural pressure curves may also help predict the optimal chest tube setting for each patient's air leak and eliminate the need for chest roentgenograms. Further studies on the pleural pressure curves and this device are needed.

BACKGROUND: The objective of this study was to determine the survival of patients who have completely resected, nonsmall-cell, stage IIIA, lung cancer from unsuspected (nonimaged) N2 disease who received adjuvant chemotherapy. METHODS: This is a retrospective cohort study using a prospective database. All patients underwent positron emission tomography scan and computed tomography scan with contrast, R0 resection with complete thoracic lymphadenectomy, and had unsuspected, pathologic N2 NSCLC. RESULTS: Between June 1998 and December 2007, there were 148 patients (89 men). The most common pulmonary resection was right upper lobectomy in 67 patients (48%), and the most common lymph node station for unsuspected N2 diseased was 4R. One hundred and thirty-seven patients (93%) received adjuvant chemotherapy and 13% received postoperative radiation as well. The overall 2- and 5-year survivals were 58% and 35%, respectively. The 5-year survival for the 98 patients with single lymph node disease compared with patients with multiple nodal involvement was 40% versus 25%, respectively (p = 0.028). The number of lymph nodes involved (p = 0.032) was an independent predictors of survival on multivariate analysis. Median follow-up was 54 months. CONCLUSIONS: The 5-year survival of patients with unsuspected N2 disease who undergo complete resection, followed by adjuvant therapy, is 35%. Patients with single station N2 disease fare better. The role for mediastinoscopy, endoscopic esophageal ultrasound with fine-needle aspirate, or endobronchial ultrasound in patients who are negative by positron emission tomography and computed tomography is unknown, since the benefit of neoadjuvant therapy in these patients is also unproven. A randomized study is needed.

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.

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.