Juan A. Muñoz-Largacha

Electromagnetic navigational bronchoscopy with dye marking for identification of small peripheral lung nodules during minimally invasive surgical resection

BACKGROUND Identification of small peripheral lung nodules during minimally invasive resection can be challenging. Electromagnetic navigational bronchoscopy (ENB) with injection of dye to identify nodules can be performed by the surgeon immediately prior to resection. We evaluated the effectiveness of ENB with dye marking to aid minimally invasive resection. METHODS Patients with peripheral pulmonary nodules underwent ENB before planned thoracoscopic or robotic-assisted thoracoscopic resection. Methylene blue was injected directly into the lesion for pleural-based lesions or peripherally for lesions deep to the pleural surface. Surgical resection was then immediately performed. Technical success was defined as identification of the dye marking within/close to the lesion with pathological confirmation after minimally invasive surgical resection. RESULTS Seventeen patients (19 nodules) underwent ENB with dye marking followed by minimally invasive resection. Median lesion size was 9 mm (4-32 mm) and the median distance from the pleura was 9.5 mm (1-40 mm). Overall success rate was 79% (15/19). In two cases the dye was not visualized and in the remaining two there was extravasation of dye into the pleural space. There were trends favoring technical success for nodules that were larger or closer to the pleural surface. Five patients required adhesiolysis to visualize the target lesion and all were successful. There were no significant adverse events and a definitive diagnosis was ultimately accomplished in all patients. CONCLUSIONS ENB with dye marking is useful for guiding minimally invasive resection of small peripheral lung nodules. ENB can be undertaken immediately before performing resection in the operating room. This improves workflow and avoids the need for a separate localization procedure.

Navigation bronchoscopy for diagnosis and small nodule location

Lung cancer continues to be the most common cause of cancer death. Screening programs for high risk patients with the use of low-dose computed tomography (CT) has led to the identification of small lung lesions that were difficult to identify using previous imaging modalities. Electromagnetic navigational bronchoscopy (ENB) is a novel technique that has shown to be of great utility during the evaluation of small, peripheral lesions, that would otherwise be challenging to evaluate with conventional bronchoscopy. The diagnostic yield of navigational bronchoscopy however is highly variable, with reports ranging from 59% to 94%. This variability suggests that well-defined selection criteria and standardized protocols for the use of ENB are lacking. Despite this variability, we believe that this technique is a useful tool evaluating small peripheral lung lesions when patients are properly selected.

miRNA profiling of primary lung and head and neck squamous cell carcinomas: Addressing a diagnostic dilemma

Objective To determine whether microRNA (miRNA) profiling of primary lung and head and neck squamous cell carcinomas could be useful to identify a specific miRNA signature that can be used to further discriminate between primary lung squamous carcinomas and metastatic lesions in patients with a history of head and neck squamous cell cancer. Methods Specimens of resected primary head and neck and lung squamous cell carcinomas were obtained from formalin‐fixed, paraffin‐embedded blocks. Paraffin blocks were sectioned and deparaffinized, and total RNA was isolated and profiled. Quantitative polymerase chain reaction was performed to verify array results. Results Twelve head and neck and 16 lung squamous cell carcinoma samples met quality control metrics and were included for analysis. Forty‐eight miRNAs were differentially expressed (P < .05) between the 2 groups. Of these, 30 were also significantly associated (q < .25) with tumor type in 2 independent sets of primary head and neck and lung squamous carcinomas profiled by The Cancer Genome Atlas consortium, including miR‐34a and miR‐10a. The ratio of miR‐10a and miR‐10b was especially predictive of primary cancer site in all 3 data sets, with area under the (receiver operating characteristics) curve values ranging from 0.922 to 0.982. Quantitative polymerase chain reaction confirmed the association of miR‐34a expression and the miR‐10:miR‐10b ratio with tumor type. Conclusions MicroRNA expression may be useful for discriminating between head and neck and lung squamous cell carcinomas, including miR‐34a and the miR‐10a:miR‐10b ratio. This differentiation has clinical importance because it could help determine the appropriate therapeutic approach.

Initial surgical experience following implementation of lung cancer screening at an urban safety net hospital

Background: Safety net hospitals provide care mostly to low‐income, uninsured, and vulnerable populations, in whom delays in cancer screening are established barriers. Socioeconomic barriers might pose important challenges to the success of a lung cancer screening program at a safety net hospital. We aimed to determine screening follow‐up compliance, rates of diagnostic and treatment procedures, and the rate of cancer diagnosis in patients classified as category 4 by the Lung CT Screening Reporting and Data System (Lung‐RADS 4). Methods: We conducted a retrospective review of all patients enrolled in our multidisciplinary lung cancer screening program between March 2015 and July 2016. Demographics, smoking status, Lung‐RADS score, and number of diagnostic and therapeutic interventions and cancer diagnoses were captured. Results: A total of 554 patients were screened over a 16‐month period. The mean patient age was 63 years (range, 47–85 years), and 60% were male. The majority (92%; 512 of 554) were classified as Lung‐RADS 1 to 3, and 8% (42 of 554) were classified as Lung‐RADS 4. Among the Lung‐RADS 4 patients, 98% (41 of 42) completed their recommended follow‐up; 29% (12 of 42) underwent a diagnostic procedure, for an overall diagnostic intervention rate of 2% (12 of 554). Eleven of these 12 patients had cancer, and 1 patient had sarcoidosis. The overall rate of surgical resection was 0.9% (5 of 554), and the rate of diagnostic intervention for noncancer diagnosis was 0.1% (1 of 554). Conclusions: Implementation of a multidisciplinary lung cancer screening program at a safety net hospital is feasible. Compliance with follow‐up and interventional recommendations in Lung‐RADS 4 patients was high despite anticipated social challenges. Overall diagnostic and surgical resection rates and interventions for noncancer diagnosis were low in our initial experience.

Lower Esophageal Magnetic Sphincter Augmentation for Persistent Reflux After Roux-en-Y Gastric Bypass

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a good option for the treatment of gastroesophageal reflux disease (GERD) in the obese population. However, some patients have significant reflux despite this procedure, and their treatment might be challenging. Laparoscopic lower esophageal magnetic sphincter augmentation (MSA) has been introduced into clinical practice with encouraging results. Currently, MSA is only approved for patients with hiatal hernias that are less than 3 cm and without history of antireflux procedures. We present two cases of MSA for the treatment of persistent GERD after LRYGB. Since this is an off-label use of this procedure, both patients underwent extensive evaluation before proceeding with surgery. Excellent results were obtained with a significant improvement in symptoms as well as their GERD Health-Related Quality of Life scores.

Subcutaneous metastases from early stage esophageal adenocarcinoma case report

Highlights • Subcutaneous metastases from esophageal adenocarcinoma are rare.• Associated risk factors have not been clearly elucidated and prognosis is poor.• We present three cases of subcutaneous metastases from esophageal adenocarcinoma.• These metastases can occur even after resection of early stage disease.• They can occur at various intervals of time and various locations.

Approach to resection of sternoclavicular tumor abutting the common carotid artery in irradiated field

Head and neck cancer recurrence at the sternoclavicular junction (SCJ) in irradiated field poses a special challenge in terms of surgical planning. We herein present a case of tonsillar squamous cell cancer recurrence at the SCJ in a patient with history of tracheostomy and head and neck radiation. We describe our preoperative planning for vascular control and possible reconstruction as well as our approach for safe resection.

Endoscopic mucosal ablation and resection of Barrett’s esophagus and related diseases

The prevalence of gastroesophageal reflux disease as well as the incidence of Barretts esophagus (BE) has increased in the Western world over the last decades. The chronic reflux of gastric secretions injuries the esophageal mucosa and triggers cellular and molecular changes inducing the transformation of the normal squamous mucosa into columnar metaplastic epithelium. BE is a premalignant condition that can progress to low-grade dysplasia, high-grade dysplasia and ultimately esophageal adenocarcinoma. An early diagnosis of dysplastic changes and the adoption of appropriate therapeutic approaches are essential to improve patient outcomes and survival. Endoscopic therapies such as radiofrequency ablation (RFA) and endoscopic mucosal resection (EMR) have been developed to treat dysplastic changes and mucosal abnormalities suspicious of malignancy. RFA has shown to be safe and effective for the treatment of low and high-grade dysplasia. EMR is diagnostic for mucosal lesions and potentially therapeutic for high-grade dysplasia or intramucosal adenocarcinoma. Proficient endoscopic skills and frequent practice are essential elements for a successful result. Here, we describe patient selection, the pre- and post-operative management, and the surgical technique for RFA and EMR in patients with the diagnosis of dysplastic BE and intramucosal esophageal adenocarcinoma.

Optimizing the diagnosis and therapy of Barrett’s esophagus

The incidence of Barretts esophagus (BE) in the Western world has increased over the last decades. BE is considered a premalignant lesion that can progress to esophageal adenocarcinoma (EAC), a highly aggressive malignancy with poor survival rates. The close association between BE and EAC highlights the need for an early diagnosis in order to improve survival and outcomes in this group of patients. Although the evidence for BE screening with conventional endoscopy is controversial and limited by cost-effectiveness studies, screening can be suggested in patients with chronic gastroesophageal reflux disease (GERD) and two or more risk factors for EAC. Less invasive techniques with lower costs and higher acceptability by the patients may be useful for screening in the general population. Several novel techniques have been described to aid in the early diagnosis and management of BE and dysplasia. However, these techniques have shown variable results with higher costs, the need of specific training, and variable inter-observer imaging interpretation, making its widespread implementation problematic. High-definition/high-resolution white-light endoscopy (WLE) continues to be a well-accepted technique for the evaluation and surveillance of patients with BE. Further studies are required in order to establish the efficacy of less invasive methods that can be performed in an outpatient setting for BE screening in higher risk individuals.

Incidental posterior mediastinal paraganglioma: The safe approach to management, case report

Highlights • Mediastinal paragangliomas are extremely rare and their diagnosis and management can be challenging.• These tumors are classified as functional or non-functional according to their ability to produce and release catecholamines.• Appropriate laboratory studies should be done prior to biopsy or surgical resection to avoid complications.• Complete surgical resection continues to be the standard of care for patients diagnosed with mediastinal paraganglioma.• Surgeons must consider catecholamine-secreting tumors as a differential diagnosis of mediastinal lesions.