Faculty Bibliography

BACKGROUND: Mediastinoscopy and endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNA) are complementary for staging non-small cell lung cancer (NSCLC) patients. We assessed (1) the yield of EUS-FNA of malignant lymph nodes in NSCLC patients with combined anterior and posterior lymph nodes that had already undergone mediastinoscopy and (2) the cost implications associated with alternative initial strategies. METHODS: All patients underwent chest computed tomography (CT) and/or positron emission tomography (PET), and mediastinoscopy. Then, the posterior mediastinal stations (7, 8, and 9) or station 5 were targeted with EUS-FNA. The reference standard included thoracotomy with complete thoracic lymphadenectomy, repeat clinical imaging, or long-term clinical follow-up. A Monte Carlo cost-analysis model evaluated the expected costs and outcomes associated with staging of NSCLC. RESULTS: Thirty-five NSCLC patients met inclusion criteria (median age 65 years; 80% men). Endoscopic ultrasound-guided FNA was performed in 53 lymph nodes in various stations, the subcarinal station (7) being the most common (47.3%). Of the 35 patients who had a prior negative mediastinoscopy, 13 patients (37.1%) had malignant N2 or N3 lymph nodes. Accuracy of EUS-FNA (98.1%) was significantly higher than that of CT (41.5%; p < 0.001) and PET (40%; p < 0.001). Initial EUS-FNA resulted in average costs per patient of 1,867 dollars (SD +/- 4,308 dollars) while initial mediastinoscopy cost 12,900 dollars (SD +/- 4,164.40 dollars). If initial EUS-FNA is utilized rather than initial mediastinoscopy, an average cost saving of 11,033 dollars per patient would result. CONCLUSIONS: In patients with NSCLC and combined anterior and posterior lymph nodes, starting with EUS-FNA would preclude mediastinoscopy in more than one third of the patients. Endoscopic ultrasound-guided FNA is a safe outpatient procedure that is less invasive and less costly than mediastinoscopy.

BACKGROUND: The purpose of this study is to assess the safety and efficacy of pulmonary resection after low and high dose neoadjuvant radiotherapy with concurrent chemotherapy. PATIENTS AND METHODS: A retrospective cohort study using an electronic prospective database from January 1998 to August 2004. All patients had N2, stage IIIa, nonsmall cell lung cancer, and received neoadjuvant carboplatinum-based chemotherapy with similar doses. In addition, some patients received high-dose chest radiation (HD) equal to or greater than 60 Gy and were compared with those who received low-dose radiation (LD) less than 60 Gy. All bronchial stumps were buttressed with an intercostal muscle. RESULTS: There were 104 patients, 50 in the LD group and 54 patients in the HD group. Median dose of radiation was 45 Gy (range 35-50.4) in the LD group and 60 Gy (range 60-66.7) in the HD group. Complete pathologic response rate was 10% compared to 28% favoring the HD group (p = 0.04). Median length of stay for both groups was 4 days and the ICU was avoided in 74%. Major morbidity and mortality rates were similar: 8% compared to 9% and 2% compared to 3.7% for the low and high dose groups, respectively. Pneumonectomy was a significant risk factor for morbidity (OR = 17.0). CONCLUSIONS: Pulmonary resection after preoperative chest radiation is safe even after 60 Gy or higher. Sixty or higher may afford an increase in complete pathologic response and it does not seem to increase morbidity or mortality. However, if pneumonectomy is known to be required we prefer to avoid neoadjuvant radiotherapy and use chemotherapy alone.

BACKGROUND: Clinical stage affects the care of patients with nonsmall cell lung cancer. METHODS: This is a prospective trial on patients with suspected resectable nonsmall cell lung cancer. All patients underwent integrated positron emission tomographic scanning and computed tomographic scanning, and all suspicious metastatic sites were investigated. A, T, N, and M status was assigned. If N2, N3 and M1 were negative, patients underwent thoracotomy and complete thoracic lymphadenectomy. RESULTS: There were 383 patients. The accuracy of clinical staging using positron emission tomographic scanning and computed tomographic scanning was 68% and 66% for stage I, 84% and 82% for stage II, 74% and 69% for stage III, and 93% and 92% for stage IV, respectively. N2 disease was discovered in 115 patients (30%) and was most common in the subcarinal lymph node (30%). Unsuspected N2 disease occurred in 28 patients (14%) and was most common in the posterior mediastinal lymph nodes (subcarinal, 38%; posterior aortopulmonary, 15%). It was found in 9% of patients who were clinically staged I (58% in the posterior mediastinal lymph nodes) and in 26% of patients clinically staged II (86% in posterior mediastinal lymph nodes). CONCLUSIONS: Despite integrated positron emission tomographic scanning and computed tomographic scanning, clinical staging remains relatively inaccurate for patients with nonsmall cell lung cancer. Recent studies suggest adjuvant therapy for stage Ib and II nonsmall cell lung cancer; thus the impact on preoperative care is to find unsuspected N2 disease. Unsuspected N2 disease is most common in posterior mediastinal lymph nodes inaccessible by mediastinoscopy. Thus one should consider endoscopic ultrasound fine-needle aspiration, especially for patients clinically staged as I and II, even if the nodes are negative on positron emission tomographic scanning and computed tomographic scanning.

BACKGROUND: We assessed our outcomes using an intercostal muscle flap harvested with cautery prior to chest retraction. METHODS: Our retrospective study was conducted using an electronic prospective database. RESULTS: There were 456 patients (348 men) over a six year period. The intercostal muscle flap was used for bronchial coverage in 391 patients. The indications for the flap were neoadjuvant radiochemotherapy in 285 patients, infection or inflammatory disease in 106, to buttress an esophageal-gastric anastomosis in 49, and for esophageal fistula in 16. There were three bronchopleural fistulas (0.7%); one after a right pneumonectomy for tuberculosis, one after a left pneumonectomy, and one after a lobectomy in a heart transplant patient for mucormycosis. The 4-week median postoperative pain score for patients who underwent an intercostal muscle flap was lower compared with historic controls who underwent similar procedures over the same time frame but did not have an intercostal muscle flap (2.4 vs 3.7, p = 0.003). Follow-up was a median of 26 months (range, 1 to 72 months) and no patients had ossification of their flap. CONCLUSIONS: An intercostal muscle flap is a versatile pedicle flap that can reach all bronchi. It is easy to harvest, adds no morbidity, and may protect the bronchi at risk. When harvested devoid of periosteum it does not ossify over time and it may reduce the pain of thoracotomy.

BACKGROUND: Placing chest tubes to water seal is superior for patients with an air leak, but when a patient has a pneumothorax and an air leak the best chest tube setting is unknown. METHODS: This is a retrospective analysis of a prospective database on a consecutive series of patients who had a pneumothorax and air leak on the same day. Patients underwent elective pulmonary resection by one surgeon and had their chest tubes placed to water seal on postoperative day 1. Daily chest radiographs were obtained, and the size of the pneumothorax and air leak were measured. Tubes were left on seal unless there was a symptomatic enlarging pneumothorax or subcutaneous emphysema (defined as failing water seal). The primary objective was to evaluate the efficacy of water seal. We also wanted to identify risk factors that predicted failure of water seal. RESULTS: There were 838 patients > or = 21 years old who underwent elective pulmonary resection, and 86 patients (10%) had an air leak and a concomitant pneumothorax on the same day. Fourteen patients (16%) failed water seal. Multivariate analysis showed that a large air leak (greater than or equal to expiratory 3 in our classification system; odds ratio [OR], 16.5; p < 0.001) and a pneumothorax > 8 cm in size (OR, 4.9; p < 0.005) were predictors of failing water seal. CONCLUSIONS: Keeping chest tubes on water seal is safe for most patients with an air leak and a pneumothorax. However, if the leak or pneumothorax is large, then subcutaneous emphysema or an expanding symptomatic pneumothorax is more likely. A prospective randomized trial is needed to compare water seal to suction in these patients.

OBJECTIVE: We sought to assess whether the standard uptake value of a pulmonary nodule is an independent predictor of biologic aggressiveness. METHODS: This is a retrospective review of a prospective database of patients with non-small cell lung cancer. Patients had dedicated positron emission tomography scanning with F-18 fluorodeoxyglucose, with the maximum standard uptake value measured. All suspicious nodal and systemic locations on computed tomographic and positron emission tomographic scanning underwent biopsy, and when indicated, resection with complete lymphadenectomy was performed. RESULTS: There were 315 patients. Multivariate analysis showed patients with a high maximum standard uptake value (>/=10) were more likely to have poorly differentiated tumors (risk ratio, 1.5; P = .005) and advanced stage (risk ratio, 1.9; P = .010) and were less likely to have their disease completely resected (risk ratio, 3.7; P = .004). Maximum standard uptake value was the best predictor of disease-free survival (hazard ratio, 2.5; P = .039) and survival (hazard ratio, 2.8; P = .001). Stage-specific analysis showed that patients with stage IB and stage II disease with a maximum standard uptake value of greater than the median for their respective stages had a lower disease-free survival at 4 years ( P = .005 and .044). The actual 4-year survival for patients with stage Ib non-small cell lung cancer was 80% versus 66% ( P = .048), for stage II disease it was 64% versus 32% ( P = .028), and for stage IIIa disease it was 64% versus 16% ( P = .012) for the low and high maximum standard uptake value groups, respectively. CONCLUSIONS: The maximum standard uptake value of a non-small cell lung cancer nodule on dedicated positron emission tomography is an independent predictor of stage and tumor characteristics. It is a more powerful independent predictor than the TNM stage for recurrence and survival for patients with early-stage resected cancer. This information might help guide treatment strategies.

PURPOSE OF REVIEW: Alveolar-pleural fistulas (air leaks) are an extremely common clinical problem and remain the most common complication after elective pulmonary resection and video-assisted procedures. The decision making process used to manage air leaks and chest tubes that control them has been, until very recently, based on opinions and training preferences as opposed to facts derived from randomized clinical trials. RECENT FINDINGS: Recently, several prospective randomized trials have studied air leaks. An objective, reproducible classification system has also been designed and clinically validated to help study air leaks. This system and these studies have shown that water seal is superior to wall suction to help stop most leaks. Even in patients with a pneumothorax and an air leak, water seal is safe and best; however, if a patient has a large leak (greater than an expiratory 3 on the classification system) or experiences subcutaneous emphysema or an expanding pneumothorax that causes hypoxia, then some suction (-10 cm of water) should be applied to the chest tubes. SUMMARY: Air leaks were a poorly understood yet extremely common clinical problem that had never been scientifically studied. Over the past 5 years, prospective randomized studies have shown that water seal is the best setting for chest tubes and that a pneumothorax is not a contraindication to leaving tubes on seal. Further studies are needed to investigate the ideal management of alveolar-pleural fistulas (air leaks) in different clinical scenarios besides those that occur postoperatively.

We report the first case of a posterior mediastinal granular cell tumor initially diagnosed on cytologic material obtained via endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in a 51-year-old male with a prior history of colon cancer. Aspirates obtained were cellular and composed of polygonal cells with abundant granular cytoplasm and small, round dark nuclei. An immunoperoxidase stain performed on the cell block for antibodies to S-100 protein showed strong, diffuse staining of the cytoplasmic granules. Electron microscopy performed on the cell block revealed numerous cytoplasmic lysosomes. This is the first case report in the English literature of a definitive preoperative diagnosis of a mediastinal granular cell tumor utilizing material obtained via EUS-FNA.

BACKGROUND: Patients with esophageal cancer who receive neoadjuvant chemoradiotherapy are restaged with computed tomography (CT), endoscopic ultrasound with fine needle aspiration (EUS-FNA), and integrated positron emission computed tomography (FDG-PET/CT), and the results affect treatment. METHODS: This is a prospective trial on a consecutive series of patients who had initial chest, abdomen, and pelvis CT scan; EUS-FNA; and fluoro-2-deoxy- d -glucose (FDG)-integrated PET/CT; neoadjuvant chemoradiotherapy; repeat staging tests; pathologic staging; and, if appropriate, resection with lymphadenectomy. The primary objective was to assess the accuracy of these 3 tests in restaging patients after neoadjuvant therapy. RESULTS: There were 48 patients (41 men), and 41 underwent Ivor Lewis esophagogastrectomy with lymphadenectomy. The accuracy of each test for distinguishing pathologic T4 from T1 to T3 disease is 76%, 80%, and 80% for CT scan, EUS-FNA and FDG-PET/CT, respectively. The accuracy for nodal disease was 78%, 78%, and 93% for CT scan, EUS-FNA and FDG-PET/CT, respectively ( P = .04). FDG-PET/CT correctly identified M1b disease in 4 patients, falsely suggested it in 4 patients, and missed it in 2 patients, whereas for CT, it was 3, 3, and 3 patients. Fifteen (31%) patients were complete responders, and FDG-PET/CT accurately predicted complete response in 89% compared with 67% for EUS-FNA ( P = .045) and 71% for CT ( P = .05). CONCLUSIONS: FDG-PET/CT is more accurate than EUS-FNA and CT scan for predicting nodal status and complete responders after neoadjuvant therapy in patients with esophageal cancer. FDG-PET/CT and CT alone provide targets for biopsy, but results are often falsely positive.