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The Journal of Thoracic and... Aug 2004Screening for lung cancer with computed tomography may detect cancers at an earlier stage but may also result in overdiagnosis. We reviewed the thoracic surgical...
OBJECTIVE
Screening for lung cancer with computed tomography may detect cancers at an earlier stage but may also result in overdiagnosis. We reviewed the thoracic surgical operations performed on patients enrolled in our computed tomographic screening program.
METHODS
From January 1999 through December 2002, screening computed tomography for lung cancer was performed annually on 1520 participants. All participants were at least 50 years old and smoked more than 20 pack/y. We found 3130 indeterminate pulmonary nodules in 1112 participants (73%). Fifty-five participants (3.6%) underwent 60 thoracic operations for a variety of indications. The medical records of these 55 patients were reviewed.
RESULTS
Indications for operation included suspicious pulmonary nodules, mediastinal adenopathy, and a spontaneous pneumothorax. Operations performed included a lobectomy in 37 cases, wedge resection in 11, segmentectomy in 6, video-assisted thoracoscopic surgical talc pleurodesis in 1, bilobectomy in 2, mediastinoscopy in 2, and anterior mediastinotomy in 1. Benign disease was found in 10 patients (18.1%), and lung cancer was found in 45 (81.9%), 2 of whom had metachronous lung cancers. Cell types were adenocarcinoma in 15 cancers, bronchioloalveolar cell carcinoma in 13, squamous cell in 13, carcinoid in 2, small cell in 2, and large cell and undifferentiated non-small cell in 1 case each. Twenty-eight cancers were classified as stage IA, 4 as IB, 4 as IIA, 1 as IIB, 4 as IIIA, 3 as IIIB, 1 as IV, and 2 as limited small cell carcinoma. Complications occurred in 27% of patients. Operative mortality was 1.7%.
CONCLUSION
Computed tomographic screening finds a large number of indeterminate pulmonary nodules in smokers 50 years old or older, most of which are observed and not operated on. Although 47 cancers were detected thus far in this highly selected group of patients, this represents only 1.5% of the pulmonary nodules identified.
Topics: Aged; Aged, 80 and over; Female; Humans; Lung Diseases; Lung Neoplasms; Male; Mass Screening; Middle Aged; Thoracic Surgical Procedures; Tomography, X-Ray Computed
PubMed: 15282462
DOI: 10.1016/j.jtcvs.2004.02.017 -
Medical Principles and Practice :... 2002To report our experiences of surgical diagnostic procedures in patients with unidentified mediastinal pathology.
OBJECTIVE
To report our experiences of surgical diagnostic procedures in patients with unidentified mediastinal pathology.
METHODS
From July 1995 to July 1999, 72 patients with mediastinal pathology had 73 surgical procedures for the purpose of tissue diagnosis. Of the 72 patients, 39 were female and 33 male, with an average age of 54 years. Mediastinoscopy and anterior mediastinotomy were performed in 54 and 15 patients, respectively (13 left and 2 right). Thoracoscopy was used in 3 cases, and 2 patients were diagnosed via cervical incision. Superior vena cava (SVC) obstruction was noted in 4 patients and four procedures were repeat procedures. Frozen section analysis was performed in 52 cases.
RESULTS
Tissue diagnosis was achieved in all cases, enabling a specific diagnosis in 70 cases (97%). In 2 patients, the final diagnosis was non-specific and in 1 patient repeat biopsy was needed. The diagnoses were lymphoma (n = 32), tuberculosis (n = 20), metastatic disease (n = 11) and other pathology (n = 9). There was no operation-related mortality although 1 patient developed mediastinal haematoma, which was treated conservatively. The 2 in-hospital deaths resulted from causes secondary to the primary disease (invasive aspergilloma or Hodgkin's lymphoma).
CONCLUSION
Mediastinoscopy is a safe surgical procedure with high diagnostic yield. Its routine use with mediastinotomy and thoracoscopy ensures accurate diagnosis. Careful surgical technique is mandatory in repeat procedures and SVC obstruction cases.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Bronchoscopy; Child; Diagnosis, Differential; Female; Humans; Lymphoma; Male; Mediastinal Diseases; Mediastinal Neoplasms; Mediastinoscopy; Middle Aged; Outcome and Process Assessment, Health Care; Safety; Saudi Arabia; Superior Vena Cava Syndrome; Tomography, X-Ray Computed; Tuberculosis, Pulmonary
PubMed: 12424417
DOI: 10.1159/000065808 -
Oncology (Williston Park, N.Y.) May 1999The staging of lung cancer defines the extent of disease. Accurate staging is important to define operability, select treatment regimens, and predict survival....
The staging of lung cancer defines the extent of disease. Accurate staging is important to define operability, select treatment regimens, and predict survival. Nonsurgical and surgical techniques are used to stage patients. The most important nonsurgical techniques used currently are the chest x-ray and computed tomographic (CT) scan of the chest and upper abdomen. In the future, positron emission tomography (PET) may become the single most important nonsurgical investigation. Surgical staging involves histologic assessment of the primary tumor and potential sites of metastases. At present, the standard for surgical staging is cervical mediastinotomy. Other minimally invasive surgical procedures used to stage patients with lung cancer are scalene lymph node biopsy, bronchoscopy with transbronchial biopsy, anterior mediastinoscopy, and video-assisted thoracoscopy. The different surgical staging options and their indications will be discussed in depth.
Topics: Biopsy; Diagnostic Imaging; Humans; Lung Neoplasms; Neoplasm Staging; Pathology, Surgical
PubMed: 10356687
DOI: No ID Found -
The Journal of Thoracic and... Jan 1994Descending necrotizing mediastinitis can occur as a complication of oropharyngeal and cervical infections that spread to the mediastinum via the cervical spaces. Delayed...
Descending necrotizing mediastinitis can occur as a complication of oropharyngeal and cervical infections that spread to the mediastinum via the cervical spaces. Delayed diagnosis and inadequate mediastinal drainage through a cervical or minor thoracic approach are the primary causes of a high published mortality rate (near 40%). Between 1985 and 1992, six men (mean age, 49 years) with descending necrotizing mediastinitis were surgically treated at our institution. The primary oropharyngeal infection was peritonsillar abscess (three cases) and odontogenic abscess (three cases). In all cases, occurrence of respiratory insufficiency associated with serious cervical infection suggested the mediastinitis diagnosis. Computed tomographic scans confirmed the mediastinitis, showing mediastinal abscess and mediastinal emphysema. All patients underwent surgical drainage of the deep neck infection combined with mediastinal drainage through a thoracic approach. The outcome was favorable in five patients who had mediastinal drainage through a thoracotomy; the patient who had mediastinal drainage through a minor thoracic approach (anterior mediastinotomy) died of tracheal fistula on postoperative day 18. In our experience, aggressive mediastinal drainage by a thoracotomy approach regardless of the level of mediastinal involvement led to improvement in survival of these patients, with a 17% mortality rate.
Topics: Adult; Drainage; Focal Infection, Dental; Humans; Male; Mediastinitis; Middle Aged; Necrosis; Peritonsillar Abscess; Thoracotomy
PubMed: 8283919
DOI: No ID Found -
The Journal of Thoracic and... Jan 1994Between 1979 and 1989, 876 patients with non-small-cell lung carcinoma were referred to our unit for surgical treatment. One hundred forty-six patients were judged not...
Between 1979 and 1989, 876 patients with non-small-cell lung carcinoma were referred to our unit for surgical treatment. One hundred forty-six patients were judged not suitable for surgical treatment on clinical, radiologic, or bronchoscopic findings. Cervical mediastinoscopy or anterior mediastinotomy (or both) showed that 151 patients had mediastinal involvement by invasion or metastases into the ipsilateral (N2 disease) or contralateral (N3 disease) superior mediastinal lymph nodes and were therefore deemed inoperable. Except for one patient who had involvement of a single nodal station at mediastinoscopy, all other patients (n = 578) undergoing thoracotomy were thought, on the basis of computed tomographic scan or mediastinal exploration (or both) not to have N2 disease. Despite our efforts to avoid surgery on patients with N2 disease, at thoracotomy routine mediastinal node dissection disclosed that 149 patients had unsuspected N2 disease. Resection was possible in 130 (87.3%) by pneumonectomy (n = 72), bilobectomy (n = 7), lobectomy (n = 49), or lesser resection (n = 2). In three patients the resection was incomplete (2.3%), but in 127 a complete resection was performed (85%). Histologic examination in these 149 patients showed that 72 tumors were squamous cell carcinoma, 54 adenocarcinoma, 14 large-cell carcinoma, and 9 of mixed type. Eight patients died in the hospital after thoracotomy. Adjuvant therapy was not used after complete resection. Complete follow-up was obtained in 134 patients and the mean follow-up period was 27.25 months (1 to 116 months). The actuarial 5-year survival for those having complete resection was 20.1%. There was a statistically significant difference favoring long-term survival in those patients with squamous cell carcinoma (p < 0.01) and those in whom only one nodal station was involved (p < 0.05). Neither the extent of resection nor the involvement of any specific nodal station influenced long-term survival. Despite rigorous preoperative investigations, routine mediastinal node dissection demonstrated mediastinal node metastasis for the first time at thoracotomy in 26% of our patients. We believe resection is justified in these patients, who have already necessarily incurred the morbidity and mortality of thoracotomy, so long as complete resection is possible.
Topics: Carcinoma, Non-Small-Cell Lung; Humans; Lung Neoplasms; Lymphatic Metastasis; Mediastinum; Survival Rate
PubMed: 8283883
DOI: No ID Found -
Journal of the National Medical... Dec 1991Surgical diagnostic procedures were done on 33 Nigerians (20 males and 13 females [mean age 47.0 years +/- 20.5 SD]) who presented with atypical noneffusive...
Surgical diagnostic procedures were done on 33 Nigerians (20 males and 13 females [mean age 47.0 years +/- 20.5 SD]) who presented with atypical noneffusive bronchopulmonary diseases between 1982 and 1988. Rigid bronchoscopy was done 16 times with or without mediastinal biopsy. Mediastinal biopsy was done through scalene, supraclavicular, or suprasternal approach or by anterior mediastinotomy on 23 occasions. Diagnostic yield and clinicopathologic concurrence for the 23 mediastinal biopsies were 91.3% and 95.6%, respectively. No deaths were associated with these biopsy procedures.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Biopsy; Bronchi; Bronchial Diseases; Bronchoscopy; Child; Child, Preschool; Female; Humans; Infant; Lung; Lung Diseases; Male; Mediastinoscopy; Middle Aged; Nigeria; Prospective Studies; Retrospective Studies
PubMed: 1813641
DOI: No ID Found -
Thorax Jan 1983Forty-four patients coming to surgery for carcinoma of the bronchus underwent preoperative staging of the mediastinum by computed tomography (CT scanning) and surgical... (Comparative Study)
Comparative Study
Forty-four patients coming to surgery for carcinoma of the bronchus underwent preoperative staging of the mediastinum by computed tomography (CT scanning) and surgical exploration of the mediastinum by cervical mediastinoscopy or left anterior mediastinotomy or both. Where mediastinal nodes were affected the sensitivity and specificity of computed tomography was inferior to that of mediastinoscopy (57% and 85% versus 71% and 100%). The sensitivity of computed tomography in predicting mediastinal invasion was superior to that of mediastinoscopy (77% v 46%), especially in the case of lower-lobe tumours (67% v 17%). Mediastinoscopy had the considerable advantage of 100% specificity. In the assessment of hilar lymphadenopathy computed tomography had a sensitivity of 38% and a specificity of 64%. In cases where computed tomography showed a normal mediastinum or enlargement of the hilar glands only, mediastinal exploration conferred no additional information and could have been omitted. A computed tomography scan showing mediastinal abnormality is an indication for mediastinoscopy and not a contraindication to surgery. In 23 patients computed tomography showed some abnormality of the mediastinum, confirmed at mediastinoscopy in 12 cases. The remaining 11 patients underwent thoracotomy, resection being carried out in nine. Postsurgical staging showed that six of these tumours were N0 lesions without invasion; in two further N0 cases there was a minor degree of mediastinal invasion which did not prevent resection, and the remaining tumour was N1 without invasion.
Topics: Aged; Carcinoma, Bronchogenic; Female; Humans; Lung Neoplasms; Male; Mediastinoscopy; Mediastinum; Middle Aged; Neoplasm Invasiveness; Neoplasm Staging; Prospective Studies; Tomography, X-Ray Computed
PubMed: 6845256
DOI: 10.1136/thx.38.1.10 -
Annals of Surgery Aug 1977In a series of 112 patients who underwent reoperation for primary hyperparathyroidism at the Massachusetts General Hospital between 1930 and 1975, all but 10 were...
In a series of 112 patients who underwent reoperation for primary hyperparathyroidism at the Massachusetts General Hospital between 1930 and 1975, all but 10 were treated successfully. Seventy-five initial explorations had been performed elsewhere, and 37 in our hospital. A total of 110 diseased parathyroids were uncovered-89 (81%) via re-exploration of the neck and 21 (19%) via mediastinotomy. In operation via the neck, the missing glands were most frequently found in the superior posterior mediastinum at the thoracic inlet (34, or 38%) and in mediastinal exploration, in the upper anterior mediastinum (14, or 67%). There were 66 patients with adenoma, 7 with carcinoma, and 29 with primary hyperplasia. Four had a hyperfunctioning fifth gland. One patient had an intrathyroidal and one, an ectopic gland. Reoperation was unsuccessful in 10 patients. Four died, and 6 are living. Unsuccessful exploration resulted from failure to understand the widespread distribution of normal parathyroids and the way they were displaced when diseased, error in diagnosing the pathologic entity of hyperparathyroidism at surgery, and technical incompetence. Reoperation of the neck was generally performed first. A mediastinotomy was undertaken only if the missing gland was clearly excluded from the neck or if localization studies had demonstrated its presence beyond doubt in the mediastinum. Reoperation was rarely performed simultaneously on the neck and the mediastinum, and it was seldom indicated in asymptomatic cases with a mild degree of the disease.
Topics: Adenoma; Adolescent; Adult; Aged; Carcinoma; Female; Humans; Hyperparathyroidism; Hyperplasia; Male; Middle Aged; Neck; Parathyroid Glands; Parathyroid Neoplasms; Postoperative Complications; Recurrence
PubMed: 889360
DOI: 10.1097/00000658-197708000-00004 -
Thorax Jul 1973The indications and techniques for performing the operation of anterior mediastinotomy are described. In the years 1966-71, 116 anterior mediastinotomies were done. The...
The indications and techniques for performing the operation of anterior mediastinotomy are described. In the years 1966-71, 116 anterior mediastinotomies were done. The results of these are presented. In 36 patients the operation was done to provide a histological diagnosis in benign conditions. In 51 patients, with probable carcinoma but normal bronchoscopy, mediastinotomy was done to establish a diagnosis and assess operability; 43 had involved mediastinal nodes proven on histology. In a further 29 patients, with positive bronchoscopic biopsies, mediastinotomy was done to assess operability alone. In all, 14 patients (17ยท5%) were judged suitable for thoracotomy. Of these, nine had operable disease while five were found to be inoperable. The incidence of complications of the operation was low (11%). These were mostly minor, There were no deaths. Most patients, after anterior mediastinotomy alone, were fit for discharge 48 to 72 hours after the operation. The value of an operation that provides both diagnosis and assessment of mediastinum, lung, and pleura is discussed. The operation of anterior mediastinotomy is compared with mediastinoscopy and, in our opinion, the superiority of the former is demonstrated.
Topics: Biopsy; Bronchial Neoplasms; Bronchoscopy; Humans; Lung Diseases; Lung Neoplasms; Mediastinal Neoplasms; Mediastinum; Methods; Postoperative Complications; Sarcoidosis; Surgical Wound Infection
PubMed: 4741446
DOI: 10.1136/thx.28.4.444