Clark Fuller

Video-Assisted Thoracic Surgery Sleeve Lobectomy: A Case Series

BACKGROUND As thoracic surgery moves towards more minimally invasive procedures, such as video-assisted thoracic surgery (VATS) lobectomy, conversion from a VATS to open thoracotomy has been required for a sleeve resection. This article reports a large experience of VATS sleeve lobectomy. METHODS We reviewed our thoracic surgery database of more than 1500 VATS lobectomies for VATS sleeve resections. Preoperative, operative, and perioperative outcome variables, including morbidity and mortality were examined. RESULTS Identified were 13 patients (median age, 59 years; range, 16 to 82 years) who underwent VATS sleeve lobectomy. There were no conversions to thoracotomy. Diagnoses included non-small cell lung cancer in 8 patients, typical carcinoid in 4, and metastatic sarcoma in 1 patient. Median tumor size was 2.1 cm (range, 0 to 6.6 cm). Median data were operative time, 167 minutes (range, 90 to 300 minutes); blood loss, 250 mL (range, 75 to 800 mL); chest tube drainage, 692 mL (range, 459 to 1590 mL); and chest tube duration, 3 days (range, 2 to 6 days). Median intensive care unit stay was 0 days (range, 0 to 4 days), and median hospital stay was 3 days (range, 2 to 8 days). No complications occurred in 9 patients (69%). Morbidity in the remaining 4 patients included 1 patient each with atrial fibrillation, anastomotic stricture, reintubation, and bronchial tear requiring repair. There were no deaths at 30 days. CONCLUSIONS In experienced centers, VATS sleeve lobectomy is possible with acceptable morbidity and mortality as well as short length of stay.

Wedge Resection and Brachytherapy for Lung Cancer in Patients With Poor Pulmonary Function

BACKGROUND Although lobectomy is the standard for lung cancer because a wedge resection has a 3 to 5 times greater incidence of local recurrence, poor pulmonary function may preclude lobectomy. For these patients, low-dose-rate brachytherapy has recently been used to decrease local recurrence after sublobar resection. Current techniques expose operating room personnel and patient contacts to unnecessary radioactivity risks. We present our technique of sublobar resection combined with afterload catheters for high-dose-rate brachytherapy for patient benefit with minimal risk to others. METHODS Forty-eight patients (25 women, 23 men) underwent wedge resection, node dissection, and brachytherapy. A remote-afterloading high-dose-rate unit for radiation produced a median dose of 2450 cGy (350 cGy per fraction over 7 fractions twice daily for 4 days). The dose was prescribed to 1 cm deep to the stapled line. Biologically, this dose is approximately 5000 cGy and above (180 cGy/d equivalent) at the depth of 5 mm in reference to the resection margin. RESULTS Two patients died. The length of mean stay was 5.5 days (median, 5 days). Complications included prolonged air leak in 5 patients, atrial fibrillation in 5, pneumonia in 3, trapped lung in 2, and 1 each with empyema, bleeding, and recurrent laryngeal nerve injury. Three patients required a blood transfusion. Within the follow-up of 1 to 27 months, there were four recurrences. CONCLUSIONS Wedge resection and brachytherapy appears to be a reasonable treatment for patients with lung cancer and pulmonary function that prohibits a lobectomy.

Reduction of intraoperative air leaks with Progel in pulmonary resection: a comprehensive review

Intraoperative alveolar air leaks (IOALs) occur in 75% of patients during pulmonary resection. Despite routine use of sutures and stapling devices, they remain a significant problem in the daily practice of thoracic surgery. Air leaks that persist beyond postoperative day 5 often result in increased costs and complications. Several large meta-analyses have determined that sealants as a class reduce postoperative air leak duration and time to chest drain removal, but these results did not necessarily correlate with a reduction in length of postoperative hospital stay. These analyses grouped surgical sealants together of necessity, but differences in efficacy may exist due to the differing product characteristics, study protocols, surgical procedures, and study endpoints. Progel, currently the only pleural surgical sealant FDA-approved for use in lung resection, has demonstrated efficacy and safety in two controlled clinical studies and superiority over standard air leak closure methods in reducing IOALs and length of hospital stay. This paper will review these findings and report on real-world experience with this recently approved pleural sealant.

High Prevalence of Lung Cancer in a Surgical Cohort of Lung Cancer Patients A Decade After Smoking Cessation

BackgroundThis study was designed to assess the prevalence of smoking at time of lung cancer diagnosis in a surgical patient cohort referred for cardiothoracic surgery.MethodsRetrospective study of lung cancer patients (n = 626) referred to three cardiothoracic surgeons at a tertiary care medical center in Southern California from January 2006 to December 2008. Relationships among years of smoking cessation, smoking status, and tumor histology were analyzed with Chi-square tests.ResultsSeventy-seven percent (482) had a smoking history while 11.3% (71) were current smokers. The length of smoking cessation to cancer diagnosis was <1 year for 56 (13.6%), 1-10 years for 110 (26.8%), 11-20 years for 87 (21.2%), 21-30 years for 66 (16.1%), 31-40 years for 44 (10.7%), 41-50 years for 40 (9.7%) and 51-60 years for 8 (1.9%). The mean cessation was 18.1 ± 15.7 years (n = 411 former smokers). Fifty-nine percent had stage 1 disease and 68.0% had adenocarcinoma. Squamous cell carcinoma was more prevalent in smokers (15.6% vs. 8.3%, p = 0.028); adenocarcinoma was more prevalent in never-smokers (79.9% versus 64.3%, p = 0.0004). The prevalence of adenocarcinoma varied inversely with pack year (p < 0.0001) and directly with years of smoking cessation (p = 0.0005).ConclusionsIn a surgical lung cancer cohort, the majority of patients were smoking abstinent greater than one decade before the diagnosis of lung cancer.

Swyer-James (MacLeod) syndrome with placental transmogrification of the lung: a case report and review of the literature.

Swyer-James (MacLeod) syndrome is an acquired form of unilateral hyperlucency of the lung and is characterized by the development of severe emphysema, bronchiectasis, and/or bronchiolitis obliterans. It may develop as a complication of repeated episodes of pulmonary infection resulting in bronchiolitis obliterans and obstruction of small airways. Most patients with Swyer-James (MacLeod) syndrome can be managed clinically, and the pathologic features of the syndrome have been described in only a few reports. Placental transmogrification of the lung is a rare histopathologic finding that has been described in patients with severe emphysema associated with cigarette smoking, congenital bullous emphysema, and fibrochondromatous hamartomas of the lung and is characterized by the development of peculiar structures in the pulmonary parenchyma that resemble placental villi. To our knowledge, placental transmogrification of the lung has not been previously described in patients with Swyer-James (MacLeod) syndrome. We encountered a 32-year-old man with a history of childhood asthma who presented with progressively severe exertional dyspnea and had unilateral right lung hyperlucency. The patient underwent a right pneumonectomy. Examination of the lung revealed severe mixed centriacinar-panacinar emphysema in all lobes, bullous emphysema in the upper lobe, bronchiectases, mild interstitial pneumonia with fibrosis, and placental transmogrification of the pulmonary parenchyma of all 3 lobes. Here, we review the pathology of Swyer-James (MacLeod) syndrome and the possible pathogenesis of villous-like changes in the lung tissues.

Photodynamic Therapy Followed by Thoracoscopic Sleeve Lobectomy for Locally Advanced Lung Cancer

Photodynamic therapy is an effective technique for debulking endobronchial tumors over an acceptably short time-course; however, to be effective, numerous treatment cycles may be required to achieve the desired results. We present a case in which photodynamic therapy was used with curative intent to downsize an obstructing endobronchial non-small cell lung cancer in advance of resection via video-assisted thoracoscopic surgery with right upper lobe sleeve lobectomy.

Primary pulmonary myxoid sarcoma, a potential mimic of metastatic extraskeletal myxoid chondrosarcoma

Sir, Primary sarcomas of the lung are very rare with an incidence of approximately one case per 500 pulmonary sarcomas, with the remainder representing metastases. Primary pulmonary sarcomas characteristically involve the distal parenchyma rather than a major bronchus or artery. However, rarely, primary endobronchial sarcomas are encountered. Nascimento et al. described approximately 10% of sarcomas of the lung as having a dominant endobronchial component. In 1999, Nicholson et al. reported two cases histologically reminiscent of extraskeletal myxoid chondrosarcoma (EMC). However, the histogenesis and malignant potential of these tumours were incompletely characterised and only limited clinical follow-up was described. We report a primary endobronchial tumour in a 32-year-old female. It was initially considered to be the translocation of EMC with morphological and immunohistochemical findings. With retrospective molecular genetic analysis and characteristic morphology, the tumour in our case was included in a category of rare but distinctive myxoid neoplasm termed ‘primary pulmonary myxoid sarcoma (PPMS)’ by Thway et al. in 2011. We present our case with detailed description of clinical course and histopathological findings with additional follow-up. The differential diagnosis and similar literature cases are discussed and reviewed with a reassessment of the nomenclature and classification of this group of rare neoplasms. A 32-year-old woman presented to her primary care physician with complaint of non-productive cough. She denied exposure to toxins or infectious agents. There was no fever or chills; however, she reported an approximately 40pound weight loss. The patient was otherwise healthy without any known history of malignancy. The patient was a non-user of alcohol and tobacco related products. Her family history was notable for breast cancer in her greatgrandmother. Physical examination was unremarkable. A chest X-ray revealed round, nodular density in the right lung. A positron emission tomography (PET)-computed tomography (CT) scan showed a 2.6 2.2 cm soft tissue mass in the right mid-lung lateral to the right hilum (Fig. 1). The mass was PET positive with standardised uptake value (SUV) of 4.5. No other areas of uptake were identified. A CT guided needle biopsy was reported as suspicious for an adenoma of salivary gland origin. A thoracoscopic wedge resection was performed. The mass was palpated in the posterior segment of the right upper lobe. There was no thoracoscopic evidence of metastatic disease. A frozen section revealed a tumour of 3.5 cm in the endobronchial region with features of a myxoid neoplasm, the differential diagnosis of which included both salivary gland and other neoplasms. Subsequently, a right upper lobectomy and level 10, 7, 4, 2 lymphadenectomy was performed. Grossly, the tumour was a 3.5 3 3 cm well-delineated lobulated lesion located immediately adjacent to the main