Nicholas P. Rossi

Can FDG-PET reduce the need for mediastinoscopy in potentially resectable nonsmall cell lung cancer?

BACKGROUNDnFew fluoro-deoxy-glucose (FDG)-positron emission tomography (PET) nonsmall cell lung cancer (NSCLC) trials have had sufficient patients to adequately evaluate PET for mediastinal staging. We question whether once PET is performed, is mediastinoscopy necessary?nnnMETHODSnWe performed a 5-year retrospective analysis of operable patients with known or suspicious NSCLC. Standard PET techniques were used. Inclusion criteria were (1) surgical mediastinal nodal sampling by mediastinoscopy within 31 days of the PET and (2) definitive diagnosis.nnnRESULTSnThere were 237 patients who met the evaluation criteria; ninety-nine patients with NSCLC and 138 with suspicious lesions (137 men and 100 women; aged 20 to 88 years). The PETs were performed from 0 to 29 days before mediastinoscopy (median, 7 days). The standardized uptake value for the primary lesion was 0 to 24.6 (7.9+/-5.0). Nine primary lesions had no FDG uptake (1 benign, 8 NSCLCs). Seventy-one patients (31%) had mediastinal PET positive disease, and 44 patients (19%) had histologic positive mediastinal disease; N2 41 patients (17%) and N3 9 patients (4%). In 6 patients (3%), the initial frozen sections were negative, but PET positivity encouraged further biopsies that were positive for cancer. The PET sensitivity was 82%, specificity 82%, accuracy 82%, negative predictive value 95%, and positive predictive value was 51%. All primary lesions with a standardized uptake value less than 2.5 and a negative mediastinal PET were negative histologically (n = 29). Logistic regression analysis resulted in 100% specificity for PET in this group.nnnCONCLUSIONSnIn NSCLC PET may reduce the necessity for mediastinoscopy when the primary lesion standardized uptake value is less than 2.5 and the mediastinum is PET negative. Accepting this approach in our patient population, the need for mediastinoscopy would have been reduced by 12%.

PET, CT, and MRI with Combidex for mediastinal staging in non-small cell lung carcinoma.

BACKGROUNDnTo determine the relative utility of positron emission tomography (PET), computed tomography (CT), and magnetic resonance imaging with Combidex (MRI-C) in the non-invasive staging of non-small cell lung cancer (NSCLC) mediastinal lymph nodes (MLN), we compared the three tests individual performance with surgical mediastinal sampling. In contrast to prior studies, cytology was not used.nnnMETHODSnThe MLN were evaluated using PET and CT in 64 NSCLC patients. MRI-C was performed in 9 of these patients. MLN with a PET standard uptake value greater than or equal to 2.5, or greater than 1 cm in the short axis by CT or lack of MRI-C signal change were considered positive for metastatic disease. All MLN were sampled and subjected to standard pathologic analysis. PET, CT, and MRI-C scans were interpreted blinded to the histopathological results. Sensitivity, specificity, and accuracy for each scan type to appropriately stage MLN was determined using pathologic results as the standard.nnnRESULTSnThirty patients had stage I disease, 8 stage II, 9 stage IIIA, 7 stage IIIB, and 10 stage IV. Two-hundred-and-thirty MLN were sampled. Sixteen patients had metastatic mediastinal disease. Compared to the pathological results, PET, CT, and MRI-C had a sensitivity, specificity, and accuracy of 70%, 86%, 84%; 65%, 79%, 76%; 86%, 82%, and 83%, respectively. PET and MRI-C were statistically more accurate than CT (p<0.001). In cases where PET and CT did not identify MLN involvement with NSCLC, 8% (2/25) were pathologically positive.nnnCONCLUSIONSnPET and MRI-C are statistically more accurate than CT. However, the differences are small and may not be clinically relevant. No technique was sensitive or specific enough to change the current recommendation to perform mediastinoscopy for MLN staging in NSCLC.

Intrapleural bupivacaine ν saline after thoracotomy—effects on pain and lung function—a double-blind study

The effects of intrapleural (IP) bupivacaine on pain, morphine requirement, and pulmonary function were evaluated in 15 patients for 24 hours after thoracotomy. An IP catheter was placed during surgery. Patients were randomized in a double-blind fashion to receive 1.5 mg/kg of 0.5% bupivacaine IP or saline on two occasions, eight hours apart. A standard anesthetic with thiopental, oxygen, isoflurane, and nondepolarizing muscle relaxant was given. Pain was evaluated with a visual analog pain score every hour, and forced vital capacity (FVC), forced expiratory volume one second (FEV1), peak expiratory flow (PF), and forced expiratory flow 25% to 75% (FEF) were measured 1, 2, 4, 8, and 24 hours postoperatively as well as before and 30 minutes after each IP injection. Arterial blood gases were sampled 1, 2, 8, and 24 hours postoperatively. Plasma bupivacaine concentrations were measured in 10 patients 5, 10, 20, 30, 60, 120, and 180 minutes after IP injection. With each IP bupivacaine injection, the pain score and morphine requirement decreased. There was a significant improvement in all pulmonary function tests in the patients receiving bupivacaine, but no change in the saline controls. The analgesic effect was shortlived (two to five hours), possibly because of loss of bupivacaine in the chest drains. No differences were seen between the two groups after the effect of IP bupivacaine had worn off. Plasma bupivacaine levels had a Cmax of 0.44 to 1.50 micrograms/mL, with a Tmax at 5 to 30 minutes with levels well below 2 to 4 micrograms/mL where increasing toxicity is seen.

Reversed Intercostal Arterial Flow in Coarctation of the Aorta: Intraoperative Assessment with the Doppler Ultrasonic Velocity Detector

Abstract The collateral circulation around a coarctation of the aorta was assessed in 11 patients during operative repair of the lesion. A sterile directional Doppler velocity detector probe was applied directly to the intercostal arteries and flow direction was determined. Prior to the repair, flow in the first two intercostals was normal in direction. Flow was reversed in direction (toward the aorta) in from two to six intercostal arteries arising distad to the coarctation. Following repair, flow was in the normal direction in all intercostal arteries. There was no correlation between the number of intercostals with reversed flow and either the pathological severity of the coarctation or the arm-ankle pressure gradient determined preoperatively. This study confirms the simplicity and utility of the Doppler ultrasonic velocity detector for intraoperative assessment of collateral circulation in coarctation of the aorta.

Dilatation for Severe Esophageal Stricture

Abstract A method of retrograde dilatation is described that is safe, easy to perform, and effective even for severe stenosis of the esophagus.