Michael D. Zervos

Malignant mesothelioma 2008.

Purpose of review Mesothelioma is an aggressive malignancy of the pleura with poor survival. There will be approximately 3000 cases of mesothelioma in the United States annually. Multimodality treatment including neoadjuvant chemotherapy in selected individuals followed by extrapleural pneumonectomy and radiation has been studied in recent trials for its effects on disease free and overall survival This review provides a general overview of malignant mesothelioma with a summary of the most significant articles from within the past year as well as from the past. Recent findings Areas of recent interest include the evaluation of osteopontin and mesothelin as new tumor markers for mesothelioma. New phase III trials have been performed to evaluate the use of combined chemotherapy regimens. Summary Malignant mesothelioma is a very difficult malignancy to treat. Patients with the disease usually have an occupational asbestos exposure, and in some, viral exposure with SV40. There have been many historical treatments including combinations of local control with surgery and radiation as well as attempts to prevent systemic failure with chemotherapy. Novel therapies including intrapleural chemotherapy, photodynamic therapy and hyperthermic perfusion have also been used with some success. Finally there are several attempts at immunomodulating and targeted treatments, which are in phase I/II trials.

Severe mediastinal infection with abscess formation after endobronchial ultrasound-guided transbrochial needle aspiration.

Endobronchial, ultrasound-guided, transbronchial needle aspiration has recently been introduced as an alternative to mediastinoscopy for lymph node staging of lung cancer and the diagnosis of respiratory diseases. This procedure is less invasive and more cost-effective, and multiple large studies have reported no associated complications. In this case, an individual presented with descending mediastinitis after having this minimally invasive procedure for mediastinal lymphadenopathy.

The diagnostic value of endobronchial ultrasound‐guided needle biopsy in lung cancer and mediastinal adenopathy

Endobronchial ultrasonography (EBUS) has emerged as a new diagnostic tool that allows the bronchoscopist to see beyond the airway, including pulmonary and mediastinal lesion. The real time EBUS‐guided transbronchial needle aspiration (TBNA) has advanced the diagnostic yield in primary lung pathology and mediastinal lymph node staging of lung carcinoma. Sixty‐four patients (36 males, 28 females, ages ranging from 16 to 86 years) with peribronchial lung lesions and mediastinal and/or hilar lymph node lesions underwent EBUS‐TBNA. All patients had intraoperative cytological assessment by smears on aspiration samples or touch preparation on needle core biopsies.

Initial experience with endobronchial ultrasound in an academic thoracic surgery program.

BACKGROUND Mediastinoscopy is considered the gold standard for evaluating mediastinal lymph nodes. However, endobronchial ultrasound-guided transbronchial needle aspiration has lately offered a less invasive alternative, with the ability to obtain nodal samples under direct visualization. Recent literature found an early learning curve for this technique. We present the initial experience of 4 thoracic surgeons with the procedure. MATERIALS AND METHODS A retrospective chart review was performed on the first 51 patients on whom an endobronchial ultrasound-guided transbronchial needle aspiration was performed from January 5, 2007, to July 24, 2008. This group included 43 patients with a history or known diagnosis of malignancy as well as 8 patients with a presumed sarcoidosis diagnosis. All negative results were confirmed with mediastinoscopy. The techniques sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were assessed. RESULTS A total of 73 lymph nodes underwent biopsy in 51 patients. These individuals included 34 men and 17 women, with an average age of 62 years (range, 21-89 years). No surgical or postoperative complications were noted. Overall, a correct diagnosis was established in 88% of the patients (45 of 51). After the first 25 cases (a mean of 6 cases per surgeon), a technique modification was adapted to increase diagnostic yield. The first 25 cases had a 72.22% sensitivity and 80% accuracy, whereas the last 26 cases had a 95.45% sensitivity and 96.15% accuracy (P = .07). CONCLUSION Endobronchial ultrasound-guided transbronchial needle aspiration is a quickly mastered technique that offers a safe, minimally invasive, and accurate means to evaluate mediastinal lymph nodes.

Post-thoracotomy Horner syndrome associated with extrapleural infusion of local anesthetic

Continuous incisional infusion of local anesthetic through an extrapleural catheter to achieve an intercostal nerve block is a safe and effective adjunct to control postoperative pain after thoracotomy. Local and systemic complications are rare. Here we present a case of an acute, reversible, post-thoracotomy Horner syndrome associated with the use of local anesthetic infusion via an intraoperatively placed extrapleural catheter.

Separation from Cardiopulmonary Bypass with a Rigid Bronchoscope Airway After Hemoptysis and Bronchial Impaction with Clot

Hemoptysis after cardiopulmonary bypass (CPB) occasionally occurs, and has varying clinical significance based upon amount of bleeding. Hemoptysis resulting in a clot and airway obstruction is an extremely rare event found almost exclusively in the intensive care unit. We describe a unique case of hemoptysis resulting in bronchial impaction from a clot requiring an emergent return to CPB during valve replacement surgery. We used a rigid bronchoscope, without an endotracheal tube, to facilitate airway patency in a patient with diffuse airway bleeding after bronchial disimpaction to separate from CPB.

Video-Assisted Thoracoscopic Lobectomy for Pulmonary Aspergilloma After Life-Threatening Hemoptysis in a Patient With Lupus

Open thoracotomy procedures serve as the mainstay for surgical resection of pulmonary aspergilloma. These procedures are considered among the most challenging for thoracic surgeons, and postoperative morbidity and mortality rates are high. Here, we present patient who underwent video-assisted thoracoscopic lobectomy for aspergilloma. Based on the success of the operation, we suggest that video-assisted thoracoscopic surgical resection be considered as an option for pulmonary aspergilloma.

A Review of the Use of Stents for Palliation of Esophageal and Lung Cancer

According to the American Cancer Society, there will be an estimated 14,520 new cases of esophageal cancer and 174,470 new cases of lung cancer in 2005 (1). Close to 60% of these patients with esophageal cancer will present at an advanced stage not amenable to cure, but still will require palliation of their dysphagia (2). Conventional plastic stents (CPS) were used initially, and with continuous improvement in technology, insertion of self- expanding metal stents (SEMS) has become the palliative treatment of choice in the majority of these patients (3-7). SEMS are effective in palliating malignant dysphagia in 85%-100% of patients (7-9). More recently, a new self- expanding plastic stent (SEPS) has been designed which in early studies has been very effective in palliating dysphagia (10-13). Similarly, the majority of patients with lung cancer will present at an advanced stage and approximately 20% of these pa- tients will have an endobronchial component requiring some form of palliation for relief of airway obstruction (14). Currently airway stents are either made of self-expanding metal for more permanent use, or silicone if a more temporary solution is needed. Complications similar to the esophageal stents may arise. The purpose of this article is to provide an evidence based review of stents in the palliative setting for esophageal and lung cancer and briefly explore their potential use and expanding indications in the neoadjuvant setting.