Faculty Bibliography

BACKGROUND: The treatment of patients with nonsmall cell lung cancer (NSCLC) is determined by the stage. We evaluated the accuracy of staging using integrated positron emission tomography (PET) and computed tomography (CT) and compared it with dedicated PET visually correlated with CT scan. METHODS: A prospective blinded trial was performed on a consecutive series of patients with NSCLC. Patients underwent integrated PET-CT scanning with 2-[18F]-fluoro-2-deoxy-D-glucose (FDG-18). A radiologist assigned the T, N and M status. No sooner than 2 weeks the same radiologist read the dedicated PET alone, without the integrated CT images and a T, N and M status was assigned again. The most recent CT scan was available and visually correlated with both studies. All patients underwent biopsies of suspicious N2 or N3 lymph node or distant metastases and if negative, pulmonary resection with lymphadenectomy was performed. RESULTS: There were 129 patients. Integrated PET-CT is a better predictor than PET for all stages of cancer and achieved statistical significance for stage I (52% versus 33%, p = 0.03) and for stage II (70% versus 36%, p = 0.04). It also is a better overall predictor for T status (70% versus 47%, p = 0.001) and the N status (78% versus 56%, p = 0.008). Nodal analysis shows that integrated PET-CT was more accurate for the total N2 nodes (96% versus 93%, p = 0.01) and for the total N1 nodes (90% versus 80%, p = 0.001). It was also more sensitive, specific, and had a higher positive predictive value for both N2 and N1 nodes (p < 0.05 for all). Integrated PET-CT is significantly more sensitive at the 4R, 5, 7, 10 L and 11 stations and more accurate at the 7 and 11 lymph nodes stations than dedicated PET. CONCLUSIONS: Integrated PET-CT using FDG-18 better predicts stage I and II disease as well as the T and N status of patients with NSCLC when compared with dedicated PET alone. It is more accurate at some nodal stations but still only achieves an accuracy of 96% and 90% for the N2 and N1 nodes, respectively.

BACKGROUND: The management of foregut duplication cysts is controversial, especially in asymptomatic patients. The safety and accuracy of endoscopic ultrasound (EUS) and EUS-fine-needle aspiration EUS-FNA) in confirming the nature of cysts by using electron microscopy (EM) has not been reported. In this study, the authors describe the utility of demonstrating detached ciliary tufts (DCTs) in the diagnosis of foregut duplication cysts with EUS-FNA. METHODS: Consecutive patients with suspected mediastinal masses or mediastinal cysts on imaging studies were evaluated prospectively by EUS and EUS-FNA. Cyst fluid was examined by routine cytologic techniques. In two patients, EM was performed to confirm the nature of DCTs. RESULTS: Ten consecutive patients were evaluated with EUS and EUS-FNA. Seventy percent of the cysts were characterized by computed tomography (CT) scans as solid masses. The mean greatest cyst dimension measured 34 mm x 48 mm by EUS. Microscopic examination of the cyst content revealed mucinous material, cellular debris, and DCTs. The latter were seen in routine cytologic preparations and by EM. Patients were followed up to a median of 321 days. Due to EUS-FNA confirmatory diagnoses of foregut duplication cysts, none of the patients except 1 underwent surgical resection after developing pneumonia 6 months later. Histologic sections of the resected specimen confirmed the presence of (foregut cyst, bronchogenic type). All other patients were asymptomatic. Cysts size and nature did not change on repeated imaging studies. CONCLUSIONS: EUS was superior compared with CT scanning in characterizing foregut duplication cysts. EUS-FNA is safe and accurate in the diagnosis of foregut duplication cysts. The demonstration of DCTs in cyst fluid and the absence of malignant cells confirmed the benign nature of these lesions, allowing conservative and expectant management for these patients.

BACKGROUND: Most general thoracic surgeons use double-lumen endotracheal tube (DLET) anesthesia for all video-assisted thoracoscopic surgery (VATS). We evaluated a single-lumen endotracheal tube (SLET) for VATS for drainage of pleural effusions and pleural biopsies. METHODS: A consecutive series of patients with recurrent pleural effusions underwent VATS using an SLET and only one incision. Operations were accomplished via one 2-cm incision using a 5-mm rigid thoracoscope and mediastinoscopic biopsy forceps for directed pleural biopsies. A working area was accomplished with low tidal volumes. RESULTS: There were 376 patients (191 women). The indications for VATS were a nondiagnosed or benign pleural effusion in 294 patients, and a malignant effusion in 82 patients. Two hundred eight patients underwent biopsy of the parietal pleura, and mean operative time was 17 min. Adequate visibility was obtained in all. When compared to preoperative cytology, VATS was more sensitive (45% compared to 99%, p < 0.001), had a higher negative predictive value (56% compared to 99%, p < 0.001), and was more accurate (67% compared to 99%, p < 0.001). Forty-seven percent of patients with a history of cancer had false-negative preoperative cytology results. Complications occurred in seven patients (2%), and there were three operative deaths (none related to the operative procedure). CONCLUSION: VATS using SLET and only one incision is possible, and it affords excellent visualization of the pleural space, allowing pleural biopsies and talc insufflation. It avoids the risk, time, and cost of a DLET. It is significantly more sensitive and accurate than preoperative cytology, and it should be considered as the diagnostic and therapeutic procedure of choice in patients with recurrent pleural effusions.

BACKGROUND: The diagnostic yield and safety of trans-gastric EUS-guided FNA of the left adrenal gland are not well defined. METHODS: All patients with an enlarged left adrenal gland on abdominal imaging and known or suspected malignancy referred to two EUS centers over a 3-year period were included in this study. EUS-guided FNA was performed on an outpatient basis by one of 4 experienced endosonographers. RESULTS: Thirty-one consecutive patients (21 men, 10 women; mean age 64.8 years) were evaluated. Tissue adequate for interpretation was obtained in all patients; no attempt to obtain tissue was unsuccessful. The median number of needle passes was 4.5 (range 1-8). No immediate complications were encountered. EUS-guided FNA confirmed malignant left adrenal involvement in 42% (13/31) of the patients. Patients with malignant left adrenal masses were more likely to have known cancer at another site (OR 12.0: 95% CI[1.6, 87.9]). Patients with benign masses were more likely to have preservation of the normal sonographic appearance of the adrenal gland ("seagull" configuration) compared with those with malignant masses (OR 9.8: 95% CI[1.9, 51.0]). The accuracy of EUS imaging based on size (> or =3 cm) alone was 81%: 95% CI[63, 93]). Of the patients with malignant adrenal masses, 85% (11/13) died or their clinical condition deteriorated during follow-up, while 15% (2/13) were being treated and were stable clinically. CONCLUSIONS: EUS-guided FNA of the left adrenal gland is a minimally invasive, safe, and highly accurate method that confirms or excludes malignant adrenal involvement in patients with thoracic or GI malignancies.

BACKGROUND: Postpneumonectomy pulmonary edema and pneumonia are life threatening and seemingly unavoidable complications after pneumonectomy. We theorized that an intraoperative dose of intravenous steroids (as a prophylactic measure to reduce pulmonary injury to the remaining lung) just before pulmonary artery ligation might decrease this problem. METHODS: Seventy-two patients (52 men) who had pneumonectomy during two time periods were studied prospectively. Thirty-five patients received 250 mg of methylprednisolone sodium succinate (Solumedrol; Upjohn, Kalamazoo, MI) just before pulmonary artery ligation (S group) and 37 did not (non-S group). Groups were matched for known or suspected preoperative, intraoperative, and postoperative risk factors for postpneumonectomy pulmonary edema. RESULTS: The incidence of postpneumonectomy pulmonary edema or adult respiratory distress syndrome was less in the S group (0 of 35, 0% versus 5 of 37, 13.5%, p = 0.049), the overall major complication rate was less in the S group (7 of 35, 20% versus 16 of 37, 43%, p = 0.04), and the length of hospital stay was shorter in the S group (6.1 days versus 11.9 days, p = 0.02). In addition, there were no bronchopleural fistulas in the S group compared with two (both right-sided) in the non-S group. CONCLUSIONS: The intraoperative intravenous administration of 250 mg of methylprednisolone sodium succinate just before pulmonary artery ligation during pneumonectomy may reduce the incidence of postpneumonectomy pulmonary edema and adult respiratory distress syndrome as well as decrease other major complications and shorten the hospital stay. It does not seem to increase the incidence of bronchopleural fistula. Further randomized trials are needed.

BACKGROUND: Thoracic surgeons spend a lot of time treating the pain of thoracotomy. METHODS: A total of 119 consecutive patients underwent elective thoracotomy. They were prospectively randomized into two groups. One group received an injection of 1% lidocaine with epinephrine in the planned skin incision just before thoracotomy, and the other group received an equal amount of saline and epinephrine. All patients had a functioning preoperative epidural; a skin incision the width of their latissimus dorsi muscle, which was cut; sparing of the serratus anterior muscle; undercutting of the sixth rib; intercostal nerve blocks before rib spreading; a similar number of chest tubes and pulmonary resections; and comparable postoperative pain management. Pain was objectified by a numeric pain score, a visual pain score, and by the Modified McGill pain questionnaire each day in the hospital, and at 3, 6, and 12 months postoperatively. RESULTS: There were 66 patients in the lidocaine group (L group) and 53 patients in the saline group (S group). Although a trend was noted toward less pain in the L group during the first 3 postoperative days (on the numeric pain scale only) the difference was not statistically significant in overall pain in the hospital or at 3, 6, and 12 months after the operation. Other pain scores and descriptors were similar throughout. CONCLUSIONS: The injection of lidocaine and epinephrine in the skin just before thoracotomy does not decrease the amount or type of pain during the hospital stay or at 3, 6, and 12 months after surgery.

BACKGROUND: To assess the role of flourodeoxyglucose-positron-emission tomography (FDG-PET) scan in staging patients with nonsmall cell lung cancer (NSCLC). METHODS: We prospectively studied 400 patients with NSCLC. Each patient underwent a computed tomography (CT) scan of the chest and upper abdomen, other conventional staging studies and had a FDG-PET scan within 1 month before surgery. All suspicious N2 lymph nodes by either chest CT or by FDG-PET scan were biopsied. Patients that were N2 and M1 negative underwent pulmonary resection and complete thoracic lymphadenectomy. RESULTS: The FDG-PET had a higher sensitivity (71% vs 43%, p < 0.001), positive predictive value (44% vs 31%, p < 0.001), negative predictive value (91% vs 84%, p = 0.006), and accuracy (76% vs 68%, p = 0.037) than CT scan for N2 lymph nodes. Similarly, FDG-PET had a higher sensitivity (67% vs 41%, p < 0.001), but lower specificity (78% vs 88%, p = 0.009) than CT scan for N1 lymph nodes. FDG-PET led to unnecessary mediastinoscopy in 38 patients. FDG-PET was most commonly falsely negative in the subcarinal (#7) station and the aortopulmonary window lymph node (#5, #6) stations. It accurately upstaged 28 patients (7%) with unsuspected metastasis and it accurately downstaged 23 patients (6%). CONCLUSIONS: The FDG-PET scan allows for improved patient selection. It more accurately stages the mediastinum, however there are many false positives lymph nodes and it may be more likely to miss N2 disease in the #5, #6, and #7 stations. A positive FDG-PET scan means a tissue biopsy is indicated in that location.

BACKGROUND: General thoracic surgeons spend much time dealing and treating patients' pain after thoracotomy. METHODS: Two hundred eighty consecutive patients underwent elective thoracotomy for pulmonary resection. Patients with a history of chronic pain were excluded. One general thoracic surgeon performed all procedures. All patients had a functioning preoperative epidural, a skin incision the width of their latissimus dorsi muscle which was cut, sparing of the serratus anterior muscle, undercutting of the rib, preemptive analgesia of the intercostal nerve before rib spreading, and similar number of chest tubes and postoperative pain management. The first 140 patients had their chests closed with pericostal sutures (stitches placed on top of the fifth rib and on top of the seventh rib), and the next 140 patients had their chest closed with intracostal sutures (stitches placed on top of the fifth rib and through the small holes drilled in the bed of the sixth rib). Pain was objectified by a numeric pain score and by the McGill pain questionnaire at 2 weeks, and 1, 2, and 3 months postoperatively. RESULTS: There were 140 patients in each group, and the groups were matched for age, gender, race, types of pulmonary resections, number of chest tubes, number of broken ribs, length of chest tube duration, and length of hospital stay (p > 0.05 for all). The mean pain score for the pericostal group (P group) at 2 weeks, 1 month, 2 months, and 3 months postoperatively was 5.5, 3.8, 2.3, and 1.6, respectively. For the intracostal group it was 3.3, 1.7, 1.1, and 0.6, respectively (p = 0.004, p = 0.0001, p < 0.0001, and p < 0.0001, respectively). Descriptors of pain in the P group were more likely to be, hot/burning, shooting or stabbing (p < 0.003). CONCLUSIONS: Intracostal sutures seem to be less painful than pericostal sutures at 2 weeks, 1 month, 2 months, and 3 months after thoracotomy. The pain is less likely to be described as burning or shooting.