Ikenna C. Okereke

Persistent air-leak following pulmonary resection.

Air leaks are an unavoidable complication of pulmonary resection. The definition of a persistent air leak is arbitrary and may even be irrelevant in solving the problem. Persistent air leaks are more common in patients with severe COPD, and preoperative interventions are ineffective in reducing their prevalence. Meticulous surgical technique and care in handling and resection of the pulmonary parenchyma are essential in preventing persistent air leaks. Buttressing parenchymal staple lines and creating a pleural tent or pneumoperitoneum should be reserved for patients at risk for persistent air leaks. The use of currently available sealants is ineffective for the treatment of this complication. To stop persistent air leaks, early cessation of suction and placing chest tubes to an underwater seal is more effective than continuous suction. The management of persistent air leaks may require provocative chest tube clamping and permissive chest tube removal or patient discharge from the hospital with a chest tube and a Heimlich valve.

Thymic carcinoma: Outcomes after surgical resection

BACKGROUND Thymic carcinoma is a rare malignancy with little information regarding outcomes after therapy with curative intent. We undertook a retrospective analysis of all patients who underwent resection of thymic carcinoma at 2 hospitals. METHODS From 1990 to 2011, 16 patients (9 men, 7 women) underwent surgical resection of thymic carcinoma at a mean age of 52 years. Patient demographics, extent of surgical resection, and outcomes were compiled. RESULTS The distribution of Masaoka stages at presentation was I in 3 (19%), II in 4 (25%), III in 8 (50%), and IV in 1 (6%). Neoadjuvant chemotherapy was administered to 6 patients (38%) whose tumors were deemed to be more locally invasive. Surgical resection included en bloc extrapleural pneumonectomy in 1, lobectomy in 2, and superior vena cava resection and reconstruction in 4. There were no perioperative deaths. Complete resection was achieved in 14 (88%), and of these patients, only 1 experienced local recurrence. At last follow-up, 10 patients were alive and well, 1 patient was alive with disease, and 5 patients had died. Mean survival was 4.2 years. CONCLUSIONS Although considered to have greater malignant potential, long-term survival can be achieved in patients with thymic carcinoma who are amenable to surgical therapy. With increased use of computed tomography imaging, patients with early-stage disease are being identified more frequently, and complete surgical resection appears to have favorable cure rates in these patients. Select patients with locally advanced disease can experience long-term survival with a multimodality approach.

Standard Uptake Value Predicts Survival in Non–Small Cell Lung Cancer

BACKGROUND Integrated [(18)F]fluorodeoxyglucose positron emission tomography-computed tomography (PET-CT) scan is a widely used modality in the evaluation of lung cancer. Our goal was to determine the ability of the standard uptake value (SUV) of the primary tumor (SUV-T) and regional lymph nodes (SUV-N) to predict survival. METHODS From January 2005 through June 2007, 584 consecutive patients undergoing integrated PET-CT scan for suspected lung cancer were studied. Results of integrated PET-CT scans, including the maximum SUV-T and SUV-N, were recorded. A patient was defined as having a positive PET scan if the maximum SUV (T or N) was greater than 2.5. Overall survival was documented from clinical records and the Social Security Death Index. Cox regression analysis was used to evaluate the correlation between SUV and survival. RESULTS Among patients with a positive PET scan (n = 329), both SUV-T and SUV-N were predictors of survival. As maximum SUV of the primary mass increased, survival decreased (hazard ratio, 1.05; p < 0.001). As maximum SUV of locoregional lymph nodes increased, survival also decreased (hazard ratio, 1.06; p < 0.001). Furthermore, among patients with no mediastinal disease identified by PET-CT scan, increased SUV-T continued to predict poor survival (hazard ratio, 1.06; p = 0.001). CONCLUSIONS Local and regional maximum SUVs defined by integrated PET-CT scanning have a strong correlation with survival in patients with non-small cell lung cancer. An elevated SUV is known preoperatively and may assist clinicians in stratifying patients at increased overall risk preoperatively.

Prognostic indicators after surgery for thymoma.

BACKGROUND We undertook a 20-year retrospective institutional study to investigate prognostic indicators after surgery for thymoma. METHODS From 1989 to 2009, 83 patients underwent surgical resection of thymoma or thymic carcinoma at our institution. Twelve of these patients were determined to have either World Health Organization type C disease or Masaoka stage IV-B disease and were excluded from analysis. The remaining 71 patients were reviewed. RESULTS The majority of patients in this series were female 64.7% (n=46) with an overall average age of 51.0 years. The distribution of Masaoka stages I, II, III, and IV-A was 40.8% (n=29), 19.7% (n=14), 18.3% (n=13), and 21.1% (n=15), respectively. Thirteen of the 28 (46.2%) patients who presented with stage III or IV-A disease received preoperative chemotherapy. After a mean follow-up of 66 months (range, 6 to 241 months), 54 (75.3%) patients are alive and well while six are alive with disease. Eleven (16.0%) patients have died, but only 3 (4.3%) of these patients died of thymoma. The overall disease-specific survival was 97% and 89% at 5 and 10 years. Of the variables analyzed, only age was predictive of overall survival (p=0.03). Masaoka stages I to III as compared with stage IV-A was significantly predictive of disease-free survival (p<0.01). CONCLUSIONS Long-term disease-specific survival can be expected not only after surgery for early stage thymoma but also after surgery for advanced disease, including patients with pleural metastases. However, patients who undergo surgery for stage IV-A disease have reduced disease-free survival. Late mortality due to secondary cancers and associated immunologic disorders was more frequent than mortality from thymoma in this series.

A Simple Solution for Complicated Pleural Effusions

Introduction: Complicated pleural effusions are difficult to manage with conventional strategies. In this study, we review the safety, efficacy, and durability of PleurX catheters (Denver Biomedical, Golden, CO) for managing complicated pleural effusions and describe a patient population who might benefit. Patients and Methods: From July 1999 to February 2003, 63 PleurX catheters were placed in 58 symptomatic patients (an additional five had bilateral catheters) to manage complicated pleural effusions. Patients selected for catheter placement tended to have poor performance status (Eastern Cooperative Oncology Group ≤2) or had failed standard therapies. Of the 63 catheters, 52 (83%) were placed because of malignant complicated pleural effusions. A registry of patients was constructed, and data were obtained from review of medical records. Nonparametric estimates of freedom from reintervention and overall survival were obtained by the Kaplan-Meier method. Results: Catheter-related complications were noted in four of 58 patients (7%) and included one each of pneumothorax, seroma, empyema, and pain syndrome. Freedom from reintervention for effusion management was 95%. Of the patients, 86% (50 of 58) experienced dyspnea relief. There were no procedure-related mortalities. Catheters remained functional up to 330 days, and four of 63 (6%) required one-time thrombolysis with tissue plasminogen activator. Conclusions: PleurX catheters are safe, effective, and durable solutions for complicated pleural effusions and seem to provide an attractive alternative for patients who have few other palliative options. We consider the catheters as first-line therapy for these patients.

Support service use and interest in support services among distressed family caregivers of lung cancer patients

This study examined support service use and interest in support services among distressed family caregivers of patients recently entering comprehensive cancer care facilities.

Results of Superior Vena Cava Reconstruction With Externally Stented-Polytetrafluoroethylene Vascular Prostheses

BACKGROUND Resection and reconstruction of the superior vena cava (SVC) is occasionally required in the surgical treatment of intrathoracic neoplasms or symptomatic occlusion secondary to benign causes. We reviewed our institutional experience with SVC reconstruction using externally stented-polytetrafluoroethylene vascular prostheses. METHODS From 1991 to 2009, medical records of 38 patients who underwent SVC resection and reconstruction with externally stented-polytetrafluoroethylene vascular prostheses were reviewed. Indications for surgery were malignancy in 34 (89%) patients (germ cell, 13; thymoma, 10; lung cancer, 9; sarcoma, 2) and benign symptomatic occlusion in 4 (11%) patients. RESULTS Eighteen patients (47%) underwent right innominate vein to SVC interposition graft reconstruction, which became the favored approach during the study interval when resection of the innominate confluence was necessary. Eight patients (21%) had left innominate vein to SVC interposition grafts, earlier in the series or when the right innominate vein was unavailable. Nine patients (24%) received graft interposition of the proximal to distal SVC. The remaining 3 patients had a Y reconstruction. There were 2 perioperative mortalities. Follow-up averaged 15 months (range, 1 to 113 months), including 11 (29%) patients who died of disease. All patients demonstrated minimal to no brachiocephalic swelling at last follow-up. Twenty (53%) patients underwent imaging after an average of 24 months (range, 1 to 113 months) with only two grafts demonstrating complete occlusion. CONCLUSIONS Although several SVC reconstructive techniques have been described, externally stented-polytetrafluoroethylene vascular prostheses are readily available for off-the-shelf use. In our experience, patency rates are high, and patients who do demonstrate graft thrombosis have minimal to no symptoms.

Glomus Tumor of the Trachea

Introduction: We describe a primary glomus tumor of the trachea. Methods: A patient presented to our institution with a mid-tracheal mass. Results: We performed a tracheal resection on this patient. Conclusion: The final pathology was consistent with glomus tumor of the trachea.

The “growing teratoma syndrome” in primary mediastinal nonseminomatous germ cell tumors: Criteria based on current practice

OBJECTIVE Criteria for the growing teratoma syndrome in patients with primary mediastinal nonseminomatous germ cell tumors have not been well established according to current practice. METHODS An institutional database identified 188 patients who underwent postchemotherapy surgery for primary mediastinal nonseminomatous germ cell tumors from 1981 to 2009. We reviewed the subset of patients who underwent urgent surgery for tumor growth resulting in cardiopulmonary deterioration secondary to mediastinal compression precluding safe completion of 4 cisplatin-based chemotherapy cycles with rapidly declining serum tumor markers. RESULTS Five men (2.6%) with an average age of 25.8 years were identified. All patients initially presented with a large symptomatic anterior mediastinal mass and elevated serum tumor markers. Patients received an average of 2.4 chemotherapy cycles of a scheduled 4 courses before cardiopulmonary deterioration. Pathology of the resected specimens demonstrated mature teratoma in all patients; however, it was admixed in 4 patients with foci of immaturity (n=1), malignant transformation of teratoma to sarcoma (n=2), and nonseminomatous germ cell tumor (n=2). There was 1 operative death. Three of the 4 operative survivors subsequently completed a total of 4 cycles of chemotherapy after recovery. Two patients are alive and well after an average of 14 years. Two patients died of metastatic disease. CONCLUSIONS The growing teratoma syndrome should be defined not only as a growing mediastinal mass but also with secondary cardiopulmonary deterioration precluding safe completion of planned chemotherapy in the presence of declining serum tumor markers. Prompt recognition of this syndrome, discontinuation of chemotherapy, and surgical intervention can result in cure.

[18F]Fluorodeoxyglucose positron emission tomography-computerized tomography and lung cancer: a significant referral bias exists

OBJECTIVE [(18)F]Fluorodeoxyglucose positron emission tomography-computerized tomography (PET-CT) scan is a tool widely used in the diagnosis and staging of lung cancer. Referral bias is present when the results of a diagnostic study affect the decision to proceed with definitive testing. This bias artificially increases the sensitivity and decreases the specificity, and may inappropriately alter the decision to undergo definitive testing. The accuracy of PET-CT scan in suspected lung cancer and the role of referral bias were investigated. METHODS From January 2005 through June 2007, 584 consecutive patients undergoing PET-CT scan for suspected lung cancer were studied. Endpoints measured included qualitative and quantitative results of PET-CT scans and pathologic results from patients, who underwent invasive procedures for diagnosis, staging and/or therapy. A positive PET scan was defined as one in which the standard uptake value (SUV) was greater than 2.5. A standard mathematical model, based on overall results of PET-CT scan in all patients, was used to create adjustments to account for the effect of referral bias. RESULTS A total of 414 (71%) of PET-CT scans were reported as positive, while 170 (29%) were negative. Attempt at tissue diagnosis occurred in 417 patients (71%); surgical intervention was performed in 246 (42%). Whereas 86% (355/414) of patients with a positive PET-CT scan underwent tissue sampling, only 36% (62/170) with a negative PET-CT scan had an attempt (p<.001). In patients with a positive study, a higher SUV was associated with an attempt at tissue diagnosis (p<.001). Before adjustment, the sensitivity and specificity of the PET-CT scan for any cancer were 87% and 43%. After adjustment, sensitivity fell to 75%, while specificity rose to 64%. The unadjusted sensitivity of PET-CT scan for detecting mediastinal disease was only 79%. CONCLUSIONS The estimate of the accuracy of PET-CT scan is significantly influenced by referral bias, and a strong reliance is placed on its results. Furthermore, patients with a positive PET-CT scan are more likely to undergo tissue sampling as the SUV increases. Given the relatively low sensitivity of the PET-CT scan in detecting disease and its poor performance in the mediastinum, the PET-CT scan may have too high an impact on the decision to undergo further invasive diagnostic procedures. Patients should not be deferred from tissue sampling based solely on a negative PET-CT scan.