Faculty Bibliography

BACKGROUND: Despite the use of integrated positron emission tomography and computed tomography scans in patients with nonsmall-cell lung cancer, N2 disease is often missed. Knowledge of the N2 station most likely to be malignant based on the lobar location of the primary may help guide biopsies. METHODS: A retrospective review of an electronic prospective database of patients with nonsmall-cell lung cancer who underwent positron emission tomography and computed tomography clinical staging and had nodal biopsy or resection with complete lymphadenectomy, or both. RESULTS: The incidence and location of N2 disease of the 954 patients based on the location of the primary tumor was as follows: for right upper lobe cancers, 27% had N2 disease, most commonly in the 4R (23%); right middle lobe, 15%, most commonly in the 4R (8%) and the 7th station (6%); right lower lobe, 30%, most commonly in the 4R (15%) and the 7th station (14%); left upper lobe, 20%, most commonly in the 6 (16%); and left lower lobe, 22%, most commonly in the 7 (8%). Patients with right middle lobe cancer were more likely to have N1 disease (p = 0.014). Skip metastases (no N1, but N2 disease) was most common with left upper lobe lesions. Patients with right-sided cancers were more likely to have N2 disease compared with patients who had left-sided lesions (27% versus 21%, p = 0.02). CONCLUSIONS: There is a distinct predilection for the location of N2 disease based on the lobar location of primary nonsmall-cell lung cancer. We recommend the consideration of video-assisted thoracoscopy for biopsy of the 5 and 6 stations for patients with left upper lobe lesions, mediastinoscopy for right upper lobe lesions, and esophageal ultrasound with fine-needle aspiration for right lower lobe, left lower lobe, and right middle lobe lesions. Right-sided lesions are more likely to have N2 disease.

In conclusion, chylothorax after esophagectomy is a devastating complication with high mortality rates if not corrected. A heightened awareness of this complication with early diagnosis and aggressive reoperation leads to excellent outcome. Reoperation is not indicated only when medical therapy significantly slows the daily loss of chyle and there are no metabolic consequences. The early decision to reoperate avoids the high morbidity of a persistently unchecked chylothorax. Reoperation should be based on the approach initially used for the esophagectomy, the location of the leak, and the side that has the chylothorax. The conduit should be handled carefully at the time of reoperation, the leak identified, the duct or the leaking nodal basin clipped and glued, and a pleurodesis performed. Following these principles minimizes the morbidity of a serious postoperative complication.

OBJECTIVE: The treatment of non-small cell lung cancer depends on the stage, and this is clinically best determined by using fluorodeoxyglucose-positron emission tomography/computed tomography. We evaluated the effect smoking has on the accuracy of this test. METHODS: We performed a prospective cohort study evaluating the accuracy of clinical stage compared with pathologic stage between cigarette smokers and nonsmokers with non-small cell lung cancer. All patients were assigned a clinical TNM stage after fluorodeoxyglucose-positron emission tomographic/computed tomographic scanning and then underwent meticulously pathologic TNM staging. If N2, N3, or M1 negative, patients underwent thoracotomy with complete thoracic lymphadenectomy. The clinical and pathologic stages were compared. RESULTS: There were 246 patients: 52 never smoked (NS group), 112 quit at least 1 month before fluorodeoxyglucose-positron emission tomography/computed tomography (Q group), and 82 were still smokers (S group). The 3 groups were similar for stage and histology. The overall accuracy was 83%, 80%, and 64% for the NS, Q, and S groups, respectively (P = .03). The accuracy for the T status was 88%, 84%, and 86%; accuracy for the N2 lymph nodes was 96%, 75%, and 72%; and accuracy for the N1 lymph nodes was 92%, 78%, and 80%, respectively, favoring the NS group. The greater the pack-year history, the greater the N2 inaccuracy (P = .04). Multivariate analysis showed that status of smoking (P = .026) and maxSUV value (P = .014) were independent predictors of fluorodeoxyglucose-positron emission tomography/computed tomography accuracy. CONCLUSIONS: Patients with non-small cell lung cancer who continue to smoke at the time of their fluorodeoxyglucose-positron emission tomographic/computed tomographic scan have less accurate clinical staging compared with those who stopped 1 month before or who never smoked. As the pack-years increase, the accuracy for the N2 nodes decrease. Nonsmokers have the most accurate clinical staging.

BACKGROUND: Positron emission tomography (PET) is often used for an indeterminate pulmonary nodule. METHODS: This is a prospective study on a consecutive series of patients who had an indeterminate pulmonary nodule that was 2.5 cm or less, underwent integrated positron emission tomography using fluorodeoxyglucose-PET/computed tomographic [FDG-PET/CT] scan with the maximum standardized uptake values (maxSUVs) reported, and who underwent complete resection. RESULTS: There were 585 patients (401 men). A total of 496 patients had a malignant nodule and the median maxSUV was 8.5 (range, 0 to 36). Eighty-nine patients had a benign nodule and the median maxSUV was 4.9 (range, 0 to 28, p < 0.001). If the maxSUV was between 0 and 2.5 there was a 24% chance the nodule was malignant, if between 2.6 and 4.0 it was 80%, and if 4.1 or greater it was 96%. False negative FDG-PET/CT was from bronchoalveolar carcinoma in 11 patients, carcinoid in 4, and renal cell in 2. False positives included fungal infections in 16 patients. Nodal involvement, whether malignant or infectious, was more likely with a pulmonary mass that had a higher maxSUV (8.4 vs 3.8 for nonmalignant lesions, 9.8 vs 4.5 for malignant lesions). CONCLUSIONS: Although integrated FDG-PET/CT is a valuable study for an indeterminate pulmonary nodule, one must be aware of causes of false positives and negatives. There is a 24% chance a suspicious nodule that has a maxSUV of 0 to 2.5 is cancer. The higher the maxSUV of the primary mass the more likely the nodes are to be involved with either malignancy or infection, and this may help direct nodal biopsy instead of pulmonary resection.

BACKGROUND: Patients with recurrent, refractory hepatic hydrothorax from porous diaphragm syndrome represent a therapeutic challenge with few options. METHODS: A retrospective review of an electronic prospective database of patients with cirrhosis and refractory hepatic hydrothorax. Patients underwent video-assisted thoracoscopic surgery (VATS) with talc pleurodesis insufflating 2.5 g of talc. Successful therapy was defined as relief of dyspnea and control of symptomatic hydrothorax for a minimum of 6 months after the procedure. RESULTS: There were 41 patients (21 men, median age 55 years), 25 with Child-Pugh class C and 14 with class B, and 2 liver transplant patients. The etiology of the cirrhosis was hepatitis B in 4, hepatitis C in 20, alcohol in 4, cryptogenic cirrhosis in 11, and other in 2. Definitive openings in the diaphragm were seen in only 2 patients. Seven patients (17%) required bedside talc slurry through the chest tube after the intraoperative talc. Overall success was achieved in 80% (33 of 41). Four patients experienced symptomatic fluid reaccumulation at 45, 61, 62, and 102 days and were treated with a repeat VATS, with success in 2. There was 1 operative death (coagulopathy). CONCLUSIONS: Patients with recurrent effusions from porous diaphragm syndrome have few options. Video-assisted thoracoscopic surgery with talc is safe and successful in about three fourths of patients, but repeat talc slurry through the chest tube or repeat VATS is often needed. Video-assisted thoracoscopic surgery provides an effective alternative to transjugular intrahepatic portosystemic shunt and is a bridge toward liver transplantation in patients with few other options.

BACKGROUND: We assessed the morbidity, mortality, and long-term survival of pulmonary resection for non-small cell lung cancer (NSCLC) in elderly patients in three subgroups: 70 years or greater, 75 years or greater, and 80 years or greater. METHODS: A nested case-control study over a 5-year period using an electronic prospective database (n = 6,450) of patients with NSCLC who underwent complete resection. Patients 70 years or older, 75 years or older, and 80 years or older were matched 1:1 to younger controls for stage, pulmonary function, performance status, and type of pulmonary resection. RESULTS: There were 726 patients: 363 were 70 years of age or older (191 patients were 70 to 74 years old, 121 were 75 to 79, and 51 patients were 80 or older). There were 363 patients younger than 70 years of age. There was no significant difference in length of stay, major morbidity, or operative mortality between any of the elderly groups and the younger controls. However, elderly patients who received neoadjuvant therapy had three times the risk of developing major morbidity (odds ratio [OR] 2.8, 95% confidence interval [CI] 1.14 to 7.41). There was a statistically significant better 5-year survival in elderly patients with stage I NSCLC (78% vs 69%, p = 0.01); however, survival was similar for all other stages. CONCLUSIONS: Elderly patients with NSCLC should not be denied pulmonary resection based on chronologic age. Their short-term risks and long-term survival are similar to younger patients. Additionally, there seems to be no increased risk in selected octogenarians. However, elderly patients had double the risk for developing major morbidity after resection if they underwent neoadjuvant therapy.

BACKGROUND: Positron emission tomography (PET) scans often help direct biopsies of mediastinal lymph nodes in patients with non-small cell lung cancer (NSCLC), but the maximum standard uptake value (maxSUV) of individual nodes has not been evaluated. METHODS: This is a prospective study of consecutive patients with NSCLC, all of whom underwent integrated fluorodeoxyglucose-positron emission-computed tomography (FDG-PET-CT) and had biopsy or resection of their mediastinal lymph nodes. RESULTS: There were 397 patients. One-hundred and forty-three patients had N2 disease and 1,252 N2 nodes were pathologically examined. The median maxSUV of the nodes that had metastatic disease were the following: for the 2R node, 10.4 (range, 0-18.6); for 4R, 8.6 (range, 0-18.3); for 5, 8.9 (range, 0-26.3); for 6, 7.6 (range, 0-19.6); for 7, 7.7 (range, 0-14); for 8 and 9, 5.4 (range, 0-8.9). The median maxSUV for all of the N2 nodes that were benign was 0 (range, 0-18.8) (p < 0.05 for all stations except for nodes 8 and 9). When a maxSUV of 5.3 is used the accuracy of integrated FDG-PET-CT for each N2 nodal station is maximized and is at least 92% for each. CONCLUSIONS: The maxSUV of individual mediastinal lymph nodes is a predictor of malignancy. There is overlap between false and true positives. Definitive biopsies are required to prove cancer irrespective of the maxSUV value. However, when a maxSUV of 5.3 is used instead of the traditional value of 2.5, the accuracy for FDG-PET-CT for each N2 nodal station increases to at least 92%.

BACKGROUND: The stage of esophageal cancer is currently determined by the anatomic TNM classification system as opposed to information about tumor biology. METHODS: A retrospective review was made of a prospective electronic database. Patients had esophageal cancer, dedicated positron emission tomography (PET) using F-18-fluorodeoxyglucose (FDG-PET) and maximum standardized uptake value (maxSUV) measured. Biopsies were obtained from suspicious nodal and systemic locations, and when indicated, resection with complete lymphadenectomy was performed. RESULTS: There were 89 patients (53 men). The median maxSUV for patients with high grade dysplasia, stage I, IIa, IIb, III, and IVa esophageal cancer was 1.7, 2.9, 8.9, 7.7, 9.5, and 12, respectively. Multivariate analysis showed patients with a high maxSUV were more likely to have poorly differentiated tumors (risk ratio 1.89, p = 0.032) and advanced stage (risk ratio 2.6, p < 0.001). The maxSUV correlated better (r(2) = 0.85) than the current TNM staging system for survival (r(2) = 0.68). Receiving operator characteristics curve demonstrated a maxSUV of 6.6 to be the optimal cut-off point. The 4-year survival of patients with a maxSUV of 6.6 or less was 89%, whereas it was only 31% for those patients with values greater than 6.6 (p < 0.001). CONCLUSIONS: The maxSUV of an esophageal cancer on dedicated FDG-PET scan is an independent predictor of stage, tumor characteristics, and survival. It predicts survival better than the current TNM staging system. This information may help guide treatment strategies.

BACKGROUND: The accuracy of restaging in patients with stage IIIa non-small cell lung cancer after neoadjuvant chemoradiotherapy is unknown. METHODS: A prospective trial of patients with biopsy-proven N2 disease who underwent initial clinical staging with mediastinoscopy, integrated positron emission tomography/computed tomography (PET/CT), and CT. Patients then were clinically restaged by the same imaging techniques 4 to 12 weeks after their induction chemoradiation therapy and then underwent definitive pathologic staging. RESULTS: Ninety-three patients had their lymph nodes pathologically restaged. Repeat PET/CT after neoadjuvant therapy missed residual N2 disease in 13/65 (20%) patients and falsely suggested it in 7 of 28 (25%). It was more accurate than repeat CT for restaging at all pathologic stages (stage 0, 92% vs 39%, P = .03; and stage I 89% vs 36%, P = .04). When the maximum standardized uptake value of the primary tumor is decreased by 75% or more, it is highly likely (likelihood ratio, +LR, 6.1) the patient is a complete responder; when it decreased by 55% or more, it is highly likely (+LR, 9.1) the patient is a partial responder. When the maximum standardized uptake value of the N2 node initially involved with metastatic cancer is decreased by more than 50%, it is highly likely (+LR, 7.9) the node is now benign. CONCLUSION: Repeat integrated PET/CT is superior to repeat CT for the restaging of patients with stage IIIa non-small cell lung cancer. The percent decrease in the maximum standardized uptake value of the primary and of the involved lymph node is predictive of pathology; however, nodal biopsies are required since a persistently high maximum standardized uptake value does not equate to residual cancer.