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ABSTRACT: Patients with suspected lung cancer require tissue diagnosis and accurate staging to determine optimal treatment. In the absence
of distant metastases, mediastinal lymph node staging is an important branch point in deciding therapy. The initial clinical
evaluation of patients with suspected lung cancer includes a contrast CT scan of the chest and upper abdomen that provides
staging information about the T descriptor and usually leads to a presumptive clinical staging of the mediastinal lymph nodes.
Increasingly, this clinical CT assessment is being supplemented or replaced altogether in routine clinical practice with a
CT-PET scan. The CT portion of the CT-PET examination is performed without intravenous contrast and is of lower resolution
than a dedicated CT scan. One often comes across the caveat describing the CT as “not of diagnostic quality” in the radiologic
reports. For the purpose of this discussion, we will assume that the patient has known or suspected lung cancer and has undergone
a CT scan and CT-PET examination.
12/2010: pages 67-75;
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ABSTRACT: Lower respiratory viral infections predispose to bronchiolitis obliterans syndrome (BOS). In addition, there is emerging evidence to support the role of autoimmunity in the pathogenesis of BOS. Because CD4(+)CD25(+)Foxp3(+) regulatory T-cells (Treg) control autoimmunity, we tested the hypothesis that respiratory virus-induced Treg dysfunction leads to BOS.
Treg frequency was monitored using flow cytometry. Apoptosis, cytokines, and antibodies were analyzed using annexin V assay, LUMINEX, and enzyme-linked immunosorbent assay, respectively. Murine studies were performed using the orthotopic tracheal transplant model.
(A) Human studies: Treg troughs (decrease >50% of baseline) were found in 13 (43.3%) of 30 lung transplant recipients. Treg isolated during troughs revealed increased apoptosis (37.8%). Patients with Treg troughs had increased prevalence of antibodies to self-antigens collagen type I (23.1% vs 5.8% pretrough), collagen V (7.7% vs 0%), and k-alpha tubulin (30.7% vs 11.7%, p < 0.01) at 6 months post-trough. Increased number of Treg troughs correlated with more rapid onset of BOS. (B) Murine studies: Infection of tracheal transplant recipients with murine parainfleunza sendai virus led to increased Treg apoptosis (50.5%) in the draining lymph nodes. Vaccination against sendai virus prior to transplant abrogated apoptosis of Treg. In vitro, sendai virus-infected, but not naive, tracheal epithelial cells demonstrated upregulation of FasL (>3.5-fold) and induction of co-cultured Treg apoptosis (5.6-fold increase).
Respiratory viral infections cause Treg apoptosis which leads to the development of de novo autoimmunity that may play a role in the pathogenesis of BOS.
The Annals of thoracic surgery 11/2010; 90(5):1637-44; discussion 1644. · 3.74 Impact Factor
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ABSTRACT: This article addresses several distinct but related pulmonary conditions that are commonly referred to general thoracic surgeons for decision making and management. The management of various types of pneumothorax is reviewed, with particular attention to the selection of the appropriate level of surgical intervention. The related entities of bullous lung disease and diffuse emphysema are discussed, with a focus on the identification of appropriate circumstances for surgical intervention. The summarized work and the treatment recommendations are supported with an extensive bibliography of important work in this area.
Surgical Clinics of North America 10/2010; 90(5):935-53. · 2.14 Impact Factor
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ABSTRACT: Primary graft dysfunction (PGD) is a known risk factor for bronchiolitis obliterans syndrome (BOS) after lung transplantation. Here, we report that preformed antibodies to self-antigens increase PGD risk and promote BOS.
Adult lung transplant recipients (n = 142) were included in the study. Primary graft dysfunction and BOS were diagnosed based on International Society for Heart and Lung Transplantation guidelines. Antibodies to self-antigens k-alpha-1 tubulin, collagen type V, and collagen I were quantitated using standardized enzyme-linked immunosorbent assays, and cytokines were analyzed using Luminex immunoassays (Biosource International, Camirillo, CA). Human leukocyte antigen (HLA) antibodies were measured using Flow-PRA (One Lambda, Canoga Park, CA).
Lung transplant recipients with pretransplant antibodies to self-antigens had increased risk of PGD (odds ratio 3.09, 95% confidence interval: 1.2 to 8.1, p = 0.02) compared with recipients without. Conversely, in patients with PGD, 34.7% were positive for pretransplant antibodies whereas in the PGD negative group, only 14.6% had antibodies (p = 0.03). Antibody positive patients demonstrated high levels of proinflammatory cytokines interleukin (IL)-1β (2.1-fold increase), IL-2 (3.0), IL-12 (2.5), IL-15 (3.0), and chemokines interferon-inducible protein-10 (3.9) and monocyte chemotactic protein-1 (3.1; p < 0.01 for all). On 5-year follow-up, patients without antibodies showed greater freedom from development of HLA antibodies compared with patients who had antibodies (class I: 67% versus 38%, p = 0.001; class II: 71% versus 41%, p < 0.001). Patients with pretransplant antibodies were found to have an independent relative risk of 2.3 (95% confidence interval: 1.7 to 4.5, p = 0.009) for developing BOS.
Presence of antibodies to self-antigens pretransplant increases the risk of PGD immediately after transplant period and BOS on long-term follow-up. Primary graft dysfunction is associated with an inflammatory cascade that augments the alloimmune (anti-HLA) response that predisposes to BOS.
The Annals of thoracic surgery 10/2010; 90(4):1094-101. · 3.74 Impact Factor
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ABSTRACT: Because the development of donor-specific anti-human leukocyte antigen (HLA) antibodies (DSA) after lung transplantation has been associated with acute and chronic rejection, we implemented a clinical protocol to screen all transplant recipients for DSA and preemptively treat those who developed DSA with rituximab and intravenous immune globulin (IVIG), or IVIG alone.
We conducted a prospective observational study of this protocol and used the LABScreen Single Antigen assay to detect DSA after transplantation. We compared the incidence of acute rejection, lymphocytic bronchiolitis, and bronchiolitis obliterans syndrome (BOS) between those who developed DSA and those who did not using Cox proportional hazards models. We used the Kaplan-Meier method to compare freedom from BOS and survival between those who had persistent DSA and those who had successful depletion of DSA.
Among 116 recipients screened, DSA developed in 65 during the study period. Those who developed DSA and received antibody-directed therapy had a similar incidence of acute rejection, lymphocytic bronchiolitis, and BOS as those who did not develop DSA. Furthermore, recipients who had successful depletion of DSA had greater freedom from BOS and better survival than those who had persistent DSA. Finally, those treated for DSA had a similar incidence of infectious complications as those who did not develop DSA.
The development of DSA is surprisingly common after lung transplantation. Antibody-directed therapy may reduce the risk of rejection associated with DSA, but a randomized controlled trial is necessary to critically evaluate the efficacy of this treatment protocol.
The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation 09/2010; 29(9):973-80. · 3.54 Impact Factor
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David S Gierada,
Jason C Woods,
Richard E Jacob,
Andrew J Bierhals,
Cliff K Choong,
Seth T Bartel,
Yulin V Chang,
Nitin A Das,
Cheng Hong,
Barbara A Lutey,
Jon H Ritter,
Thomas K Pilgram,
Joel D Cooper,
G Alexander Patterson,
Richard J Battafarano, Bryan F Meyers,
Dmitriy A Yablonskiy,
Mark S Conradi
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ABSTRACT: To evaluate the use of inflation-fixed lung tissue for emphysema quantification with computed tomography (CT) and He magnetic resonance (MR) diffusion imaging.
Fourteen subjects representing a range of chronic obstructive pulmonary disease severity who underwent complete or lobar lung resection were studied. Computed tomographic measurements of lung attenuation and MR measurements of the hyperpolarized 3He apparent diffusion coefficient (ADC) in resected specimens fixed in inflation with heated formalin vapor were compared with measurements obtained before fixation.
The mean (SD) CT emphysema indices were 56% (17%) before and 58% (19%) after fixation (P = 0.77; R = 0.76). Index differences correlated with differences in lung volume (R = 0.47). The mean (SD) 3He ADCs were 0.40 (0.15) cm/s before and 0.39 (0.14) cm/s after fixation (P = 0.03, R = 0.98). The CT emphysema index and the 3He ADC were correlated before (R = 0.89) and after fixation (R = 0.79).
Concordance of CT and 3He MR imaging measurements in unfixed and inflation-fixed lungs supports the use of inflation-fixed lungs for quantitative imaging studies in emphysema.
Journal of computer assisted tomography 08/2010; 34(5):773-9. · 1.38 Impact Factor
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ABSTRACT: Stereotactic body radiation therapy has been proposed as an alternative local treatment option for high-risk patients with early-stage lung cancer. A direct comparison of outcomes between stereotactic body radiation therapy and surgical resection has not been reported. This study compares short-term outcomes between stereotactic body radiation therapy and surgical treatment of non-small cell lung cancer.
We compared all patients treated with surgery (January 2000-December 2006) or stereotactic body radiation therapy (February 2004-May 2007) with clinical stage IA/B non-small cell lung cancer staged by computed tomography and positron emission tomography. Comorbidity scores were recorded prospectively using the Adult Co-Morbidity Evaluation scoring system. Charts were reviewed to determine local tumor recurrence, disease-specific survival, and overall survival. A propensity score matching analysis was used to adjust estimated treatment hazard ratios for confounding effects of patient age, comorbidity index, and clinical stage.
A total of 462 patients underwent surgery and 76 received stereotactic body radiation therapy. Overall, surgical patients were younger (P < .001), had lower comorbidity scores (P < .001), and better pulmonary function (forced expiratory volume in 1 second and carbon monoxide diffusion in the lung) (P < .001). Among the surgical and stereotactic body radiation therapy groups, 62.6% (291/462) and 78.9% (60/76) were in clinical stage IA, respectively. Final pathology upstaged 35% (161/462) of the surgery patients. In an unmatched comparison, overall 5-year survival was 55% with surgery, and the 3-year survival was 32% with radiation therapy. Among patients with clinical stage IA disease, 3-year local tumor control was 89% with radiation therapy and 96% with surgery (P = .04). There was no difference in local tumor control in stage IB disease (P = .89). No disease-specific survival differences were found in patients with 1A (P = .33) or IB disease (P = .69). Propensity analysis matched 57 high-risk surgical patients to 57 patients undergoing stereotactic body radiation therapy. In the matched comparison of this subgroup, there was no difference in freedom from local recurrence (88% vs 90%), disease-free survival (77% vs 86%), and overall survival (54% vs 38%) at 3 years.
In an unmatched comparison of clinical stage IA disease, surgical patients were healthier and had better local tumor control compared with those receiving stereotactic body radiation therapy. Propensity analysis in clinical stage IA/B non-small cell lung cancer revealed similar rates of local recurrence and disease-specific survival in patients treated with surgery compared with stereotactic body radiation therapy.
The Journal of thoracic and cardiovascular surgery 08/2010; 140(2):377-86. · 3.41 Impact Factor
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ABSTRACT: With the emergence of video-assisted thoracic surgery (VATS) lobectomy, concern remains regarding the adequacy of nodal assessment versus thoracotomy.
All clinical stage I non-small cell lung cancer patients treated with VATS or open lobectomy were retrospectively evaluated. Total nodes, N2 nodes, and nodes at each station were evaluated for associations with surgery type and location of involved lobe.
There were 79 VATS and 464 open lobectomy or segmental resections for stage I tumors. Overall, fewer lymph nodes were sampled with VATS compared with thoracotomy (7.4 +/- 0.6 vs 8.9 +/- 0.2, respectively; p = 0.029), and fewer N2 nodes were sampled with VATS versus thoracotomy as well (2.5 +/- 3.0 vs 3.7 +/- 3.3, p = 0.004). There were no differences in N1 node sampling between the two groups (5.2 +/- 3.6 vs 4.9 +/- 4.2, p = 0.592). Furthermore, there were more station 7 nodes with thoracotomy versus VATS (1.2 +/- 0.1 vs 0.6 +/- 0.1, p = 0.002). Among right-sided lesions, there was no difference in 4R nodes between groups (1.4 +/- 0.4 vs 1.6 +/- 0.2, p = 0.7) although there was a trend toward more level 7 nodes with thoracotomy (1.0 +/- 0.2 vs 1.4 +/- 0.2, p < 0.08). Among left-sided resections there were more station 7 nodes with thoracotomy versus VATS (1.0 +/- 0.1 vs 0.4 +/- 0.1, p < 0.001) and more station 5/6 nodes (1.1 +/- 0.1 vs 0.5 +/- 0.1, p < 0.04). For upper lobe resections, the total nodes (8.9 +/- 0.3 vs 7.4 +/- 0.7, p = 0.05) and station 7 nodes (1.0 +/- 0.1 vs 0.6 +/- 0.1, p < 0.01) were higher with thoracotomy than VATS. There was no difference in 2-year survival between groups (81% vs 83%, p = 0.4).
Our early experience with VATS has been associated with fewer lymph nodes sampled compared with open lobectomy although there was no survival difference. Analysis of these differences has directed us toward a more focused lymph node sampling with VATS lobectomy.
The Annals of thoracic surgery 06/2010; 89(6):1730-5; discussion 1736. · 3.74 Impact Factor
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ABSTRACT: Conventional thoracic surgical teaching suggests a worse outcome for lower lobe lung cancers. It is unclear whether this is due to stage migration or whether lobar location is an independent negative prognostic factor.
We performed a retrospective review of our institutional database of patients undergoing resection for pathologic stage I or stage II lung cancer between Jan 2000 and December 2006. Survival analysis was used to compare outcomes in various groups using the log-rank test. Logistic regression analysis was used to compare the primary dependent variables; age, size, and location of tumor (both laterality and lobe), histology (adenocarcinoma, squamous, large cell, or neuroendocrine and others) and type of resection (wedge, lobectomy or segmentectomy, and pneumonectomy).
A total of 841 patients met the inclusion criteria. The mean age of patients was 64.9 years, mean tumor size 3.3 cm, and, 144 patients had N1 disease. The three-year and five-year survivals for stage I tumors were 346 of 478 (72.4%) and 277 of 497 (55.7%), respectively. There was no difference in survival based upon lobar location. The three-year and five-year survivals for stage II tumors were 81 of 175 (46.3%) and 39 of 150 (26%), respectively, and lobar location did not influence survival. Logistic regression analysis showed that for stage I tumors increasing age and having undergone a pneumonectomy were associated with worse survival, and for stage II tumors increasing age and adenocarcinoma histology were associated with worse survival.
Tumor location within the lung does not predict survival in pathologic stage I/II non-small cell lung carcinoma. Increasing age, adenocarcinoma histology, and pneumonectomy as the resection may lead to worse long-term survival.
The Annals of thoracic surgery 04/2010; 89(4):1053-9. · 3.74 Impact Factor
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ABSTRACT: Surgical resection remains the favored option of treatment for stage I lung cancer patients. Co-existing obstructive lung disease can reduce lung function and increase the risk of surgery. Severe emphysema may preclude resection of lung cancer due to concerns about low values of postoperative lung function. However, many patients will experience stable or improved lung function simply by resecting hyper-expanded and relatively functionless lung. This so-called "lung volume reduction effect" may occur after standard resection or after rare instances of formal lung volume reduction surgery concurrent with pulmonary resection of the tumor. This review explores these possibilities and informs the readers of pioneering work in this area.
Seminars in Thoracic and Cardiovascular Surgery 01/2010; 22(1):38-43.
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David S Gierada,
Andrew J Bierhals,
Cliff K Choong,
Seth T Bartel,
Jon H Ritter,
Nitin A Das,
Cheng Hong,
Thomas K Pilgram,
Kyongtae T Bae,
Bruce R Whiting,
Jason C Woods,
James C Hogg,
Barbara A Lutey,
Richard J Battafarano,
Joel D Cooper, Bryan F Meyers,
G Alexander Patterson
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ABSTRACT: Computed tomography (CT) section thickness and reconstruction kernel each influence CT measurements of emphysema. This study was performed to assess whether their effects are related to the magnitude of the measurement.
Low-radiation-dose multidetector CT was performed in 21 subjects representing a wide range of emphysema severity. Images were reconstructed using 20 different combinations of section thickness and reconstruction kernel. Emphysema index values were determined as the percentage of lung pixels having attenuation lower than multiple thresholds ranging from -960 HU to -890 HU. The index values obtained from the different thickness-kernel combinations were compared by repeated measures analysis of variance and Bland-Altman plots of mean versus difference in all subjects, and correlated with quantitative histology (mean linear intercept, Lm) in a subset of resected lung specimens.
The effects of section thickness and reconstruction kernel on the emphysema index were significant (P < .001) and diminished as the index attenuation threshold was raised. The changes in index values from changing the thickness-kernel combination were largest for subjects with intermediate index values (10%-30%), and became progressively smaller for those with lower and higher index values. This pattern was consistent regardless of the thickness-kernel combinations compared and the HU threshold used. Correlations between the emphysema index values obtained with each thickness-kernel combination and Lm ranged from r = 0.55-0.68 (P = .007-.03).
The effects of CT section thickness and kernel on emphysema index values varied systematically with the magnitude of the emphysema index. All reconstruction techniques provided significant correlations with quantitative histology.
Academic radiology 11/2009; 17(2):146-56. · 2.09 Impact Factor
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ABSTRACT: Lung donation after cardiac death (DCD) can enlarge the donor pool. Single-center reports have shown comparable outcomes after lung transplantation using conventional donors versus DCD in small numbers of patients.
We performed a retrospective review of DCD experience at a single lung transplant program using a prospective database.
Between January 2003 and April 2008, 293 lung transplantations were performed, including 11 bilateral transplantations (3.7%) using DCD lungs. Similar criteria were used to assess donor quality. The hospital mortality for DCD recipients was 2 of 11 (18%) and overall mortality was 4 of 11 (36%) by 18 months of follow-up. Seven DCD patients (64%) are alive with a median follow-up of 32 months. The DCD group was comparable to the control group in age and ischemic times. The 4 deaths, when compared with 7 DCD survivors, had longer ischemic time (293 minutes versus 232 minutes) and a higher incidence of nonlocal donors (3 of 4 versus 1 of 7).
At our center, early outcomes after DCD lung transplantations are somewhat inferior to those of series from other centers but approach national averages for conventional lung transplantation. Thus, DCD lung transplantation has the potential to increase the donor pool but must be offered cautiously.
The Annals of thoracic surgery 11/2009; 88(5):1609-14; discussion 1614-5. · 3.74 Impact Factor
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David S Gierada,
Jason C Woods,
Andrew J Bierhals,
Seth T Bartel,
Jon H Ritter,
Cliff K Choong,
Nitin A Das,
Cheng Hong,
Thomas K Pilgram,
Yulin V Chang,
Richard E Jacob,
James C Hogg,
Richard J Battafarano,
Joel D Cooper, Bryan F Meyers,
G Alexander Patterson,
Dmitriy A Yablonskiy,
Mark S Conradi
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ABSTRACT: To characterize the effect of diffusion time on short-range hyperpolarized (3)He magnetic resonance imaging (MRI) diffusion measurements across a wide range of emphysema severity.
(3)He diffusion MRI was performed on 19 lungs or lobes resected from 18 subjects with varying degrees of emphysema using three diffusion times (1.6 msec, 5 msec, and 10 msec) at constant b value. Emphysema severity was quantified as the mean apparent diffusion coefficient (ADC) and as the percentage of pixels with ADC higher than multiple thresholds from 0.30-0.55 cm(2)/sec (ADC index). Quantitative histology (mean linear intercept) was obtained in 10 of the lung specimens from 10 of the subjects.
The mean ADCs with diffusion times of 1.6, 5.0, and 10.0 msec were 0.46, 0.40, and 0.37 cm(2)/sec, respectively (P < 0.0001, analysis of variance [ANOVA]). There was no relationship between the ADC magnitude and the effect of diffusion time on ADC values. The mean linear intercept correlated with ADC (r = 0.91-0.94, P < 0.001) and ADC index (r = 0.78-0.92, P < 0.01) at all diffusion times.
Decreases in ADC with longer diffusion time were unrelated to emphysema severity. The strong correlations between the ADC at all diffusion times tested and quantitative histology demonstrate that ADC is a robust measure of emphysema.
Journal of Magnetic Resonance Imaging 10/2009; 30(4):801-8. · 2.70 Impact Factor
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David S. Gierada MD,
Jason C. Woods PhD,
Andrew J. Bierhals MD,
Seth T. Bartel MS,
Jon H. Ritter MD,
Cliff K. Choong MBBS,
Nitin A. Das MD,
Cheng Hong MD,
Thomas K. Pilgram PhD,
Yulin V. Chang PhD,
Richard E. Jacob PhD,
PhD James C. Hogg MD,
PhD Richard J. Battafarano MD,
Joel D. Cooper MD, Bryan F. Meyers MD,
G. Alexander Patterson MD,
Dmitriy A. Yablonskiy PhD,
Mark S. Conradi PhD
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ABSTRACT: PurposeTo characterize the effect of diffusion time on short-range hyperpolarized 3He magnetic resonance imaging (MRI) diffusion measurements across a wide range of emphysema severity.Materials and Methods3He diffusion MRI was performed on 19 lungs or lobes resected from 18 subjects with varying degrees of emphysema using three diffusion times (1.6 msec, 5 msec, and 10 msec) at constant b value. Emphysema severity was quantified as the mean apparent diffusion coefficient (ADC) and as the percentage of pixels with ADC higher than multiple thresholds from 0.30–0.55 cm2/sec (ADC index). Quantitative histology (mean linear intercept) was obtained in 10 of the lung specimens from 10 of the subjects.ResultsThe mean ADCs with diffusion times of 1.6, 5.0, and 10.0 msec were 0.46, 0.40, and 0.37 cm2/sec, respectively (P < 0.0001, analysis of variance [ANOVA]). There was no relationship between the ADC magnitude and the effect of diffusion time on ADC values. The mean linear intercept correlated with ADC (r = 0.91–0.94, P < 0.001) and ADC index (r = 0.78–0.92, P < 0.01) at all diffusion times.Conclusion
Decreases in ADC with longer diffusion time were unrelated to emphysema severity. The strong correlations between the ADC at all diffusion times tested and quantitative histology demonstrate that ADC is a robust measure of emphysema. J. Magn. Reson. Imaging 2009;30:801–808. © 2009 Wiley-Liss, Inc.
Journal of Magnetic Resonance Imaging 09/2009; 30(4):801 - 808. · 2.70 Impact Factor
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ABSTRACT: Lung transplantation in the modern era remains an evolving field and a viable option for patients suffering from end-stage emphysema. Recent modifications for recipient prioritization has resulted in a modest decrease in the number of patients with emphysema receiving transplants. More time will be required to determine what impact, if any, these modifications will have on the overall survival of patients with end-stage emphysema. Ongoing research will address persistent issues with lung transplantation, most notably, primary graft dysfunction and chronic BOS.
Thoracic Surgery Clinics 06/2009; 19(2):275-83.
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ABSTRACT: PET and PET-CT are rapidly evolving as modalities of thoracic imaging. In the mediastinum, PET can provide information to distinguish thymic hyperplasia from neoplasia, although the use of this imaging for this purpose is not accepted uniformly as necessary. PET is the standard of care in staging and follow-up of mediastinal lymphoma and in follow-up of metastatic seminomas after chemotherapy. Mycobacterial/fungal infections, sarcoidosis, and brown fat can mimic malignant findings on PET in the mediastinum.
Thoracic Surgery Clinics 03/2009; 19(1):7-15.
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ABSTRACT: Widespread application of computed tomographic scans has increased detection of asymptomatic pulmonary nodules. A dedicated clinic was established to encourage referral and manage large numbers of patients with such nodules.
Patients were evaluated periodically by a nurse practitioner with surgeon oversight, and follow-up imaging was centralized. Patients were rescanned at intervals on the basis of radiologist recommendation.
A total of 414 patients, 189 male and 225 female with a median age of 60.2 years (20.7-84.1 years), were evaluated since April 2000. Median follow-up was 1.51 years (0-6.65 years). Thirty-seven percent (153/414) were older than 60 years with at least 10 pack-years of tobacco use, whereas 30% (123/414) had never smoked. A total of 286 patients completed at least 2 years of follow-up computed tomographic evaluation. After 2 years, 24.2% (69/286) were deemed in stable condition and were discharged from further follow-up, whereas 22.4% (64/286) of patients were followed up longer than 2 years owing to the development of new nodules. Forty-five percent (127/286) of patients did not complete their recommended follow-up at our clinic. Overall, 3% (13/414) of our patients have been shown to have a malignant tumor. Only 5 patients underwent curative resection of a primary lung cancer.
In a population of patients with indeterminate nodules in routine clinical practice, few patients required intervention and few cancers were detected. Although the benefits of a "nodule" clinic may include patient reassurance and convenience to referring physicians, a significant number of patients did not complete their follow-up in our clinic.
The Journal of thoracic and cardiovascular surgery 02/2009; 137(1):30-5. · 3.41 Impact Factor
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ABSTRACT: Although EUS-guided FNA (EUS-FNA) and 18F-fluorodeoxyglucose-positron emission tomography (FDG-PET) are both used in the staging of esophageal cancer, the utility of routinely performing both tests is unclear.
The primary aim of the study was to determine the benefit of routine FDG-PET for esophageal cancer nodal staging in patients undergoing EUS-FNA. The secondary objective was to determine EUS criteria that selectively identify patients in whom PET yields additional information.
Retrospective chart review.
Tertiary-care academic medical center.
All patients who underwent both EUS and PET for initial staging of esophageal cancer between April 2003 and August 2007.
EUS and PET detection of malignant lymph nodes and distant metastases.
Of 242 patients who underwent esophageal EUS for a malignant indication, 148 also underwent PET within 30 days. EUS detected locoregional-node disease by EUS criteria or cytology in 92 patients, and PET was positive in a minority of these patients (n = 41 [45%]). For celiac-node staging, PET was positive in 2 of 17 patients (12%) with celiac-node involvement detected by EUS. EUS was also significantly more sensitive than PET in the detection of nodal disease confirmed by cytology or histology (86% vs 44%). PET did not alter nodal staging in any patient with complete EUS-FNA. PET identified distant metastases only in those patients with incomplete EUS or nodal disease detected by EUS.
Single institution, retrospective analysis.
The addition of PET to a complete EUS examination did not alter regional-node or celiac-node staging. PET performance in overall staging is strongly associated with EUS assessment of lymph nodes.
Gastrointestinal endoscopy 12/2008; 69(7):1210-7. · 6.71 Impact Factor
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ABSTRACT: For patients with end-stage emphysema undergoing lung volume reduction surgery (LVRS), we have preferred a bilateral (BLVRS) approach to achieve maximum benefit with a single procedure. A unilateral (ULVRS) approach has been used in certain patients in whom BLVRS is contraindicated.
Between January 1993 and December 2006, 43 consecutive patients underwent ULVRS. The study excluded patients undergoing giant bullectomy. Relative contraindications for BLVRS were unilateral emphysema, 21; unilateral emphysema plus other factors, 2; and other factors alone, 10. Preoperative pulmonary rehabilitation was required. Postrehabilitation data were used as the baseline for analyses. Outcome measurements for ULVRS were compared with BLVRS results.
After ULVRS, the mean increase in forced expiratory volume in 1 second (FEV(1)) from postrehabilitation values was 32% at 6 months (p <or= 0.001) and 28% at 3 years (p = 0.036). The FEV(1) was not significantly improved at 5 years. The mean reduction in residual volume after ULVRS was 23% at 6 months (p <or= 0.001) and 38% at 5 years (p = 0.001). Supplemental oxygen requirements declined initially postoperatively. One patient (2%) died in the hospital. The 90-day mortality was 0%. Kaplan-Meier survival after ULVRS was 97.7%, 80.9%, and 45.5%, at 1, 3, and 5 years.
ULVRS produces improvements in pulmonary function, exercise capacity, and quality of life with an acceptable morbidity and mortality in patients for whom BLVRS is contraindicated, but the benefits are of lower magnitude than those achieved with BLVRS.
The Annals of thoracic surgery 08/2008; 86(1):204-11; discussion 211-2. · 3.74 Impact Factor
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ABSTRACT: Primary graft dysfunction (PGD) in the immediate post-lung transplant period strongly increases the risk of chronic rejection (broncholitis obliterans syndrome). Here, we hypothesized that PGD-induced inflammation augments alloimmunity, thereby predisposing to broncholitis obliterans syndrome.
Primary graft dysfunction and broncholitis obliterans syndrome were diagnosed according to the established International Society for Heart and Lung Transplantation criteria. Anti-human leukocyte antigen (HLA) alloantibodies were analyzed using Flow-PRA. Donor HLA class II-specific T cells were analyzed using interferon (IFN)-gamma ELISPOT. Serum levels of 25 cytokines and chemokines were measured using LUMINEX.
Of the 127 subjects, 29 (22.8%) had no PGD (grade 0), 42 (33.2%) had PGD-1, 36 (28.3%) had PGD-2, and 20 (15.7%) had PGD-3. Patients with PGD grades 1 to 3 (PGD(1-3)) had elevated proinflammatory mediators MCP-1, IP-10, interleukin (IL)-1 beta, IL-2, IFN-gamma, and IL-12 in the sera during the early posttransplant period compared with patients with PGD grade 0 (PGD(0)). On serial analysis, PGD(1-3) patients revealed increased development of de novo anti-HLA-II (5 years: 52.2% versus PGD(0) 13.5%, p = 0.008). However, no difference was found in anti-HLA-I alloantibody development (PGD(1-3) patients 48% versus PGD(0) 39.6%, p = 0.6). Furthermore, PGD(1-3) patients had increased frequency of donor HLA class II-specific CD4(+) T cells [(91.4 +/- 19.37) x 10(-6) versus (23.6 +/- 15.93) x 10(-6), p = 0.003].
Primary graft dysfunction induces proinflammatory cytokines that can upregulate donor HLA-II antigens on the allograft. Increased donor HLA-II expression along with PGD-induced allograft inflammation promotes the development of donor specific alloimmunity. This provides an important mechanistic link between early posttransplant lung allograft injury and reported association with broncholitis obliterans syndrome.
The Annals of thoracic surgery 08/2008; 86(1):189-95; discussion 196-7. · 3.74 Impact Factor
