Photodynamic therapy is a nonthermal laser used for obstructive, bloody lesions in the airway.
A retrospective cohort study of a prospective database was conducted. All patients underwent rigid and ...flexible bronchoscopy under general anesthesia using jet ventilation.
There were 529 operations performed on 133 patients between January 1996 and December 2008. The mean preoperative Modified Medical Research Council Dyspnea Scale grade was 3 of 4. Indications for intervention were non-small cell lung cancer in 89 patients, metastatic airway lesions in 31 patients, small cell disease in 4 patients, benign disease in 7 patients, other or unknown in 2 patients. Tumors were most commonly located in the main stem bronchi (71 patients). A 2.5-cm diffuser was used in 87% of patients, and 300 J (range, 50 to 300 J) was most frequently selected at first treatment. Most patients received two treatments during a 3-day hospitalization and returned in 2 weeks for two more photodynamic therapy treatments. The mean postoperative Modified Medical Research Council Dyspnea Scale grade was 2.7 of 4 and improved in 94 patients (74%). There were 12 operative mortalities (none treatment related). Morbidity occurred in 20 patients (reintubation in 4 patients and respiratory distress leading to an emergent evacuation of debris in 2 patients). Only 4 patients had a photosensitivity reaction.
Photodynamic therapy is a safe and effective treatment. It is best used for bloody tumors that block the tracheobronchial tree, even in severely debilitated patients with profound shortness of breath from advanced malignancy who fail conventional core-out or laser treatments. Photosensitivity reactions are rare with proper education, and dyspnea is improved in properly selected patients.
The annual incidence of a small indeterminate pulmonary nodule (IPN) on computed tomography (CT) scan remains high. While traditional paradigms exist, the integration of new technologies into these ...diagnostic and treatment algorithms can result in alternative, potentially more efficient methods of managing these findings.
We report on an alternative diagnostic and therapeutic strategy for the management of an IPN. This approach combines electromagnetic navigational bronchoscopy (ENB) with an updated approach to placement of a pleural dye marker. This technique lends itself to a minimally invasive wedge resection via either video-assisted thoracoscopic surgery (VATS) or a robotic approach.
Subsequent to alterations in the procedure, a cohort of 22 patients with an IPN was reviewed. Navigation was possible in 21 out of 22 patients with one patient excluded based on airway anatomy. The remaining 21 patients underwent ENB with pleural dye marking followed by minimally invasive wedge resection. The median size of the nodules was 13.4 mm (range: 7-29). There were no complications from the ENB procedure. Indigo carmine dye was used in ten patients. Methylene blue was used in the remaining 11 patients. In 81% of cases, the visceral pleural marker was visible at the time of surgery. In one patient, there was diffuse staining of the parietal pleura. In three additional patients, no dye was identified within the hemithorax. In all cases where dye marker was present on the visceral pleural surface, it was in proximity to the IPN and part of the excised specimen.
ENB with pleural dye marking can provide a safe and effective method to localize an IPN and can allow for subsequent minimally invasive resection. Depending on the characteristics and location of the nodule, this method may allow more rapid identification intraoperatively.
Management of thoracic esophageal perforations Minnich, Douglas J; Yu, Patrick; Bryant, Ayesha S ...
European journal of cardio-thoracic surgery,
10/2011, Letnik:
40, Številka:
4
Journal Article
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Odprti dostop
Abstract
Objective: To assess our results of a prospective algorithm applied to patients with thoracic esophageal perforation. Methods: A retrospective review of a prospective algorithm. Patients ...with esophageal perforation underwent an esophagram. If there was a contained esophageal perforation they were admitted, kept nothing by mouth, and restudied in 3-5 days. If the leak was not contained, they underwent operative repair. Results: From 1/1998 to 6/2009 there were 81 patients. The gastrograffin swallow showed 56 patients had contained perforations and 25 did not. Twenty-two of the 25 patients with noncontained perforation underwent immediate operative repair (one patient refused surgery, two were not stable enough for the operating room); their morbidity was 68% and there were six (24%) operative mortalities. Median hospital length of stay (LOS) was 11 days (range, 2-120). Of the 56 patients with contained perforations, 26 were managed successfully without surgery. However, 30 of the patients initially treated nonoperatively eventually required operations due to new pleural effusion, mediastinal abscess, or conversion to noncontained perforation. Their morbidity was 41% and there were three operative mortalities (5%). On univariate analysis, these patients were more likely to have undergone previous esophageal procedures (surgical or dilation) (p = 0.03), had new or increased pleural effusion (p = 0.04), and had greater than 24 h between diagnosis and treatment (p = 0.02). Only greater than 24 h between diagnosis and treatment remained a significant predictor on multivariate analysis. Their median hospital LOS was 21 days (range, 7-77). Conclusion: Contained thoracic esophageal perforations can usually be safely managed nonoperatively without significant morbidity or mortality. However, careful in-hospital monitoring is needed if surgery is not chosen.
Flattening filter-free (FFF) linear accelerators (linacs) are capable of delivering dose rates more than 4-times higher than conventional linacs during SBRT treatments, causing some to speculate ...whether the higher dose rate leads to increased toxicity owing to radiobiological dose rate effects. Despite wide clinical use of this emerging technology, clinical toxicity data for FFF SBRT are lacking. In this retrospective study, we report the acute and late toxicities observed in our lung radiosurgery experience using a FFF linac operating at 2400 MU/min.
We reviewed all flattening filter-free (FFF) lung SBRT cases treated at our institution from August 2010 through July 2012. Patients were eligible for inclusion if they had at least one clinical assessment at least 30 days following SBRT. Pulmonary, cardiac, dermatologic, neurologic, and gastrointestinal treatment related toxicities were scored according to CTCAE version 4.0. Toxicity observed within 90 days of SBRT was categorized as acute, whereas toxicity observed more than 90 days from SBRT was categorized as late. Factors thought to influence risk of toxicity were examined to assess relationship to grade > =2 toxicity.
Sixty-four patients with >30 day follow up were eligible for inclusion. All patients were treated using 10 MV unflattened photons beams with intensity modulated radiation therapy (IMRT) inverse planning. Median SBRT dose was 48 Gy in 4 fractions (range: 30-60 Gy in 3-5 fractions). Six patients (9%) experienced > = grade 2 acute pulmonary toxicity; no non-pulmonary acute toxicities were observed. In a subset of 49 patients with greater than 90 day follow up (median 11.5 months), 11 pulmonary and three nerve related grade > =2 late toxicities were recorded. Pulmonary toxicities comprised six grade 2, three grade 3, and one each grade 4 and 5 events. Nerve related events were rare and included two cases of grade 2 chest wall pain and one grade 3 brachial plexopathy which spontaneously resolved. No grade > =2 late gastrointestinal, skin, or cardiac toxicities were observed. Tumor size, biologically effective dose (BED10, assuming α/β of 10), and tumor location (central vs peripheral) were not significantly associated with grade > =2 toxicity.
In this early clinical experience, lung SBRT using a FFF linac operating at 2400 MU/min yields minimal acute toxicity. Preliminary results of late treatment related toxicity suggest reasonable rates of grade > =2 toxicities. Further assessment of late effects and confirmation of the clinical efficacy of FFF SBRT is warranted.
Dendritic cells (DCs) play a key role in critical illness and are depleted in spleens from septic patients and mice. To date, few studies have characterized the systemic effect of sepsis on DC ...populations in lymphoid tissues. We analyzed the phenotype of DCs and Th cells present in the local (mesenteric) and distant (inguinal and popliteal) lymph nodes of mice with induced polymicrobial sepsis (cecal ligation and puncture). Flow cytometry and immunohistochemical staining demonstrated that there was a significant local (mesenteric nodes) and partial systemic (inguinal, but not popliteal nodes) loss of DCs from lymph nodes in septic mice, and that this process was associated with increased apoptosis. This sepsis-induced loss of DCs occurred after CD3(+)CD4(+) T cell activation and loss in the lymph nodes, and the loss of DCs was not preceded by any sustained increase in their maturation status. In addition, there was no preferential loss of either mature/activated (MHCII(high)/CD86(high)) or immature (MHCII(low)/CD86(low)) DCs during sepsis. However, there was a preferential loss of CD8(+) DCs in the local and distant lymph nodes. The loss of DCs in lymphoid tissue, particularly CD8(+) lymphoid-derived DCs, may contribute to the alterations in acquired immune status that frequently accompany sepsis.
Understanding the anatomy of the lymphatic channels and lymph nodes in the mediastinum is relevant to many disease processes as well as therapeutic interventions for thoracic malignancies. A brief ...review of the anatomy of the mediastinal lymph nodes is presented and the indications for mediastinal lymph node dissection are discussed, followed by a more detailed description of the technical aspects of thoracoscopic and robotic mediastinal lymph node dissection.
Surgical management of scimitar syndrome: An alternative approach Brown, John W.; Ruzmetov, Mark; Minnich, Douglas J. ...
The Journal of thoracic and cardiovascular surgery,
February 2003, 20030201, 2003-Feb, 2003-02-00, Letnik:
125, Številka:
2
Journal Article
Recenzirano
Odprti dostop
Objective: The scimitar syndrome is a congenital anomaly that consists in part of total or partial anomalous venous drainage of the right lung to the inferior vena cava. Surgical approaches to the ...scimitar syndrome have varied according to the anatomic and pathologic features presented in each case. The aim of this study was to present an alternative approach to the surgical correction of scimitar syndrome. Methods: Nine patients with the scimitar syndrome were operated on between 1990 and 2000. They comprised 1 male and 8 female patients (mean age 11.5 ± 17.6 years). All patients had symptoms, with recurrent pneumonia or respiratory tract infections and pulmonary/systemic flow ratios greater than 1.5:1.0. None of the patients had pulmonary hypertension or an atrial septal defect. All patients underwent repair of the anomalous scimitar vein by direct reimplantation into the left atrium without cardiopulmonary bypass. Two patients underwent concomitant resection of a right lower lobe sequestration. Follow-up was complete in all cases. Results: There were no operative or late deaths, and no patients have required reoperation. At the time of follow-up (mean 55 ± 46 months), echocardiography demonstrated a patent anastomosis in all patients without any evidence of restenosis. Conclusion: This clinical experience indicates that an alternative surgical approach to scimitar syndrome is direct anastomosis of the scimitar vein to the posterior aspect of the left atrium using a right thoracotomy without cardiopulmonary bypass. This procedure is safe and effective and obviates the need for long intra-atrial baffles and the use of the extracorporeal circuit.
J Thorac Cardiovasc Surg 2003;125:238-45
The medical care of patients with sepsis or severe inflammatory response syndromes has seen tremendous technological advancements in recent years; yet, several clinical studies with anti-cytokine ...therapies targetted to this population have met with disappointing results. Four primary factors have been identified that represent potential pitfalls involving the use of biological response modifiers in critically-ill patients. First, the physiological response in the stressed patient is complex. Redundancy within this system may not allow a single intervention to produce a clinical response. Second, the critically-ill patient population is heterogenous and important factors including the age of the patient, associated co-morbidities, the nature of the original injury and the presence or absence of an ongoing injury can modulate the effectiveness of a specific therapy. Third, the timing of the therapeutic intervention can be difficult to standardize among patients and can often produce differing results. A greater understanding of the physiological response to injury has shown that there are both proinflammatory and anti-inflammatory processes ongoing simultaneously. Determining the optimal time to intervene within this framework can be problematic. Fourth, the presence of genetic polymorphisms within the general population has identified subsets of individuals who may have different physiological responses to similar stresses. The relative proportions of patients with these polymorphisms within clinical trials may affect outcome and data analysis. Thus, a better understanding of these issues will result in improvement of the experimental design of clinical trials involving anti-cytokine therapies and critically-ill patients. Avoidance of these pitfalls will enhance the quality and utility of outcomes research in this subset of patients.
Activation of nuclear factor-κB (NF-κB) inhibits chemotherapy-induced apoptosis in some cancer cell lines. Inhibition of NF-κB by adenoviral delivery of an IκBα superrepressor (Ad.IκBα-SR) should ...potentiate 5-fluorouracil (5-FU) and irinotecan chemotherapy in gastric cancer cells.
NCI-N87 and AGS human gastric cancer cells were studied. Chemotherapy-induced NF-κB activation was assessed using a luciferase reporter assay. Inhibition of NF-κB was assessed by luciferase reporter assay and by electrophoretic mobility shift assay. Cells were pretreated for 1 hour with Ad.IκBα (25 MOI) and incubated with 5-FU or the active metabolite of irinotecan (SN-38). Cell growth was assessed by cell proliferation assay and induction of apoptosis was determined by flow cytometry and caspase 3/7 assay.
5-FU and SN-38 significantly induced NF-κB activation as measured by luciferase reporter assay (p < 0.001). Ad.IκBα-SR treatment inhibited NF-κB binding as demonstrated by electrophoretic mobility shift assay and by luciferase reporter assay. In AGS cells, pretreatment with Ad.IκBα-SR followed by 5-FU (0.005 mmol/L) or SN-38 (10 ng/mL) led to increased growth inhibition of 13% and 59%, respectively (p < 0.001). Similarly, growth inhibition in NCI cells was significantly increased by pretreatment with Ad.IκBα followed by 5-FU (0.001 mmol/L) or SN-38 (0.5 ng/mL) (p < 0.001). In both cell lines, Ad.IκBα-SR enhanced apoptosis by both flow cytometry and caspase 3/7 assay as compared with chemotherapy alone.
NF-κB is activated in human gastric cancer in response to chemotherapy and may result in inducible chemoresistance. Inhibition of NF-κB by Ad.IκBα-SR enhances the antitumor effects of chemotherapy and has potential as a novel antineoplastic strategy.
OBJECTIVE
Our objective is to assess the safety of a surgical technique applied to the difficult left upper lobectomy. The inflow-outflow occlusion technique features: dividing the superior pulmonary ...vein first, then proximal control by clamping the main pulmonary artery (PA), and then distal control by clamping the inferior pulmonary vein.
METHODS
A retrospective cohort study of a prospective database was carried out. Patients who underwent left upper lobectomy and required clamping of the vessels were compared to those that did not.
RESULTS
Between January 1999 and March 2010,1796 lobectomies were performed and 360 (23%) of these were left upper lobectomies. Of these, 84 (23%) required the inflow-outflow occlusion technique. There were 70 (83%) men (median age 65 years). Fifty-one patients (61%) required resection of the PA and 33 did not. Heparin was not used in the last 17 patients. These 84 patients were compared to the remaining 276 patients who underwent standard left upper lobectomy. Although the median operative time was longer (150 vs 105 min, p < 0.001) and the median blood loss was greater (120 vs 87 ml, p = 0.03) for the inflow-outflow technique, there were no significant differences in hospital length of stay, morbidity, or mortality between the two groups.
CONCLUSION
In our experience, clamping of the inferior pulmonary vein instead of the distal PA achieves safe distal vascular control. It affords greater PA mobility and assessment of the tumor and easier PA repair. This technique can be used even when PA resection is not required.
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