Biomedical subjects

Ayesha S Bryant

Publications and source records attributed to Ayesha S Bryant.

At least 19 recordsLinked to original sources

PubMed2006

The clinical stage of non-small cell lung cancer as assessed by means of fluorodeoxyglucose-positron emission tomographic/computed tomographic scanning is less accurate in cigarette smokers.

OBJECTIVE: The treatment of non-small cell lung cancer depends on the stage, and this is clinically best determined by using fluorodeoxyglucose-positron emission tomography/computed tomography. We evaluated the effect smoking has on the accuracy of this test. METHODS: We performed a prospective cohort study evaluating the accuracy of clinical stage compared with pathologic stage between cigarette smokers and nonsmokers with non-small cell lung cancer. All patients were assigned a clinical TNM stage after fluorodeoxyglucose-positron emission tomographic/computed tomographic scanning and then underwent meticulously pathologic TNM staging. If N2, N3, or M1 negative, patients underwent thoracotomy with complete thoracic lymphadenectomy. The clinical and pathologic stages were compared. RESULTS: There were 246 patients: 52 never smoked (NS group), 112 quit at least 1 month before fluorodeoxyglucose-positron emission tomography/computed tomography (Q group), and 82 were still smokers (S group). The 3 groups were similar for stage and histology. The overall accuracy was 83%, 80%, and 64% for the NS, Q, and S groups, respectively (P = .03). The accuracy for the T status was 88%, 84%, and 86%; accuracy for the N2 lymph nodes was 96%, 75%, and 72%; and accuracy for the N1 lymph nodes was 92%, 78%, and 80%, respectively, favoring the NS group. The greater the pack-year history, the greater the N2 inaccuracy (P = .04). Multivariate analysis showed that status of smoking (P = .026) and maxSUV value (P = .014) were independent predictors of fluorodeoxyglucose-positron emission tomography/computed tomography accuracy. CONCLUSIONS: Patients with non-small cell lung cancer who continue to smoke at the time of their fluorodeoxyglucose-positron emission tomographic/computed tomographic scan have less accurate clinical staging compared with those who stopped 1 month before or who never smoked. As the pack-years increase, the accuracy for the N2 nodes decrease. Nonsmokers have the most accurate clinical staging.

Aged↗

PubMed2006

Native aortic valve insufficiency in patients with left ventricular assist devices.

Management of mild to moderate aortic insufficiency in patients with a left ventricular assist device remains controversial. We report 3 patients with aortic insufficiency and pulsatile left ventricular assist devices treated with a central aortic valve coapting suture. Two of the repairs have been durable for more than 1 year and aspirin appears to be sufficient anticoagulation.

Aged↗

PubMed2006

Maximum standard uptake value of mediastinal lymph nodes on integrated FDG-PET-CT predicts pathology in patients with non-small cell lung cancer.

BACKGROUND: Positron emission tomography (PET) scans often help direct biopsies of mediastinal lymph nodes in patients with non-small cell lung cancer (NSCLC), but the maximum standard uptake value (maxSUV) of individual nodes has not been evaluated. METHODS: This is a prospective study of consecutive patients with NSCLC, all of whom underwent integrated fluorodeoxyglucose-positron emission-computed tomography (FDG-PET-CT) and had biopsy or resection of their mediastinal lymph nodes. RESULTS: There were 397 patients. One-hundred and forty-three patients had N2 disease and 1,252 N2 nodes were pathologically examined. The median maxSUV of the nodes that had metastatic disease were the following: for the 2R node, 10.4 (range, 0-18.6); for 4R, 8.6 (range, 0-18.3); for 5, 8.9 (range, 0-26.3); for 6, 7.6 (range, 0-19.6); for 7, 7.7 (range, 0-14); for 8 and 9, 5.4 (range, 0-8.9). The median maxSUV for all of the N2 nodes that were benign was 0 (range, 0-18.8) (p < 0.05 for all stations except for nodes 8 and 9). When a maxSUV of 5.3 is used the accuracy of integrated FDG-PET-CT for each N2 nodal station is maximized and is at least 92% for each. CONCLUSIONS: The maxSUV of individual mediastinal lymph nodes is a predictor of malignancy. There is overlap between false and true positives. Definitive biopsies are required to prove cancer irrespective of the maxSUV value. However, when a maxSUV of 5.3 is used instead of the traditional value of 2.5, the accuracy for FDG-PET-CT for each N2 nodal station increases to at least 92%.

Adult↗

PubMed2006

Distribution and likelihood of lymph node metastasis based on the lobar location of nonsmall-cell lung cancer.

BACKGROUND: Despite the use of integrated positron emission tomography and computed tomography scans in patients with nonsmall-cell lung cancer, N2 disease is often missed. Knowledge of the N2 station most likely to be malignant based on the lobar location of the primary may help guide biopsies. METHODS: A retrospective review of an electronic prospective database of patients with nonsmall-cell lung cancer who underwent positron emission tomography and computed tomography clinical staging and had nodal biopsy or resection with complete lymphadenectomy, or both. RESULTS: The incidence and location of N2 disease of the 954 patients based on the location of the primary tumor was as follows: for right upper lobe cancers, 27% had N2 disease, most commonly in the 4R (23%); right middle lobe, 15%, most commonly in the 4R (8%) and the 7th station (6%); right lower lobe, 30%, most commonly in the 4R (15%) and the 7th station (14%); left upper lobe, 20%, most commonly in the 6 (16%); and left lower lobe, 22%, most commonly in the 7 (8%). Patients with right middle lobe cancer were more likely to have N1 disease (p = 0.014). Skip metastases (no N1, but N2 disease) was most common with left upper lobe lesions. Patients with right-sided cancers were more likely to have N2 disease compared with patients who had left-sided lesions (27% versus 21%, p = 0.02). CONCLUSIONS: There is a distinct predilection for the location of N2 disease based on the lobar location of primary nonsmall-cell lung cancer. We recommend the consideration of video-assisted thoracoscopy for biopsy of the 5 and 6 stations for patients with left upper lobe lesions, mediastinoscopy for right upper lobe lesions, and esophageal ultrasound with fine-needle aspiration for right lower lobe, left lower lobe, and right middle lobe lesions. Right-sided lesions are more likely to have N2 disease.

Adult↗

PubMed2006

Survival and outcomes of pulmonary resection for non-small cell lung cancer in the elderly: a nested case-control study.

BACKGROUND: We assessed the morbidity, mortality, and long-term survival of pulmonary resection for non-small cell lung cancer (NSCLC) in elderly patients in three subgroups: 70 years or greater, 75 years or greater, and 80 years or greater. METHODS: A nested case-control study over a 5-year period using an electronic prospective database (n = 6,450) of patients with NSCLC who underwent complete resection. Patients 70 years or older, 75 years or older, and 80 years or older were matched 1:1 to younger controls for stage, pulmonary function, performance status, and type of pulmonary resection. RESULTS: There were 726 patients: 363 were 70 years of age or older (191 patients were 70 to 74 years old, 121 were 75 to 79, and 51 patients were 80 or older). There were 363 patients younger than 70 years of age. There was no significant difference in length of stay, major morbidity, or operative mortality between any of the elderly groups and the younger controls. However, elderly patients who received neoadjuvant therapy had three times the risk of developing major morbidity (odds ratio [OR] 2.8, 95% confidence interval [CI] 1.14 to 7.41). There was a statistically significant better 5-year survival in elderly patients with stage I NSCLC (78% vs 69%, p = 0.01); however, survival was similar for all other stages. CONCLUSIONS: Elderly patients with NSCLC should not be denied pulmonary resection based on chronologic age. Their short-term risks and long-term survival are similar to younger patients. Additionally, there seems to be no increased risk in selected octogenarians. However, elderly patients had double the risk for developing major morbidity after resection if they underwent neoadjuvant therapy.

Aged↗

PubMed2006

Maximum standardized uptake values on positron emission tomography of esophageal cancer predicts stage, tumor biology, and survival.

BACKGROUND: The stage of esophageal cancer is currently determined by the anatomic TNM classification system as opposed to information about tumor biology. METHODS: A retrospective review was made of a prospective electronic database. Patients had esophageal cancer, dedicated positron emission tomography (PET) using F-18-fluorodeoxyglucose (FDG-PET) and maximum standardized uptake value (maxSUV) measured. Biopsies were obtained from suspicious nodal and systemic locations, and when indicated, resection with complete lymphadenectomy was performed. RESULTS: There were 89 patients (53 men). The median maxSUV for patients with high grade dysplasia, stage I, IIa, IIb, III, and IVa esophageal cancer was 1.7, 2.9, 8.9, 7.7, 9.5, and 12, respectively. Multivariate analysis showed patients with a high maxSUV were more likely to have poorly differentiated tumors (risk ratio 1.89, p = 0.032) and advanced stage (risk ratio 2.6, p < 0.001). The maxSUV correlated better (r(2) = 0.85) than the current TNM staging system for survival (r(2) = 0.68). Receiving operator characteristics curve demonstrated a maxSUV of 6.6 to be the optimal cut-off point. The 4-year survival of patients with a maxSUV of 6.6 or less was 89%, whereas it was only 31% for those patients with values greater than 6.6 (p < 0.001). CONCLUSIONS: The maxSUV of an esophageal cancer on dedicated FDG-PET scan is an independent predictor of stage, tumor characteristics, and survival. It predicts survival better than the current TNM staging system. This information may help guide treatment strategies.

Adult↗

PubMed2006

Efficacy of video-assisted thoracoscopic surgery with talc pleurodesis for porous diaphragm syndrome in patients with refractory hepatic hydrothorax.

BACKGROUND: Patients with recurrent, refractory hepatic hydrothorax from porous diaphragm syndrome represent a therapeutic challenge with few options. METHODS: A retrospective review of an electronic prospective database of patients with cirrhosis and refractory hepatic hydrothorax. Patients underwent video-assisted thoracoscopic surgery (VATS) with talc pleurodesis insufflating 2.5 g of talc. Successful therapy was defined as relief of dyspnea and control of symptomatic hydrothorax for a minimum of 6 months after the procedure. RESULTS: There were 41 patients (21 men, median age 55 years), 25 with Child-Pugh class C and 14 with class B, and 2 liver transplant patients. The etiology of the cirrhosis was hepatitis B in 4, hepatitis C in 20, alcohol in 4, cryptogenic cirrhosis in 11, and other in 2. Definitive openings in the diaphragm were seen in only 2 patients. Seven patients (17%) required bedside talc slurry through the chest tube after the intraoperative talc. Overall success was achieved in 80% (33 of 41). Four patients experienced symptomatic fluid reaccumulation at 45, 61, 62, and 102 days and were treated with a repeat VATS, with success in 2. There was 1 operative death (coagulopathy). CONCLUSIONS: Patients with recurrent effusions from porous diaphragm syndrome have few options. Video-assisted thoracoscopic surgery with talc is safe and successful in about three fourths of patients, but repeat talc slurry through the chest tube or repeat VATS is often needed. Video-assisted thoracoscopic surgery provides an effective alternative to transjugular intrahepatic portosystemic shunt and is a bridge toward liver transplantation in patients with few other options.

Adult↗

PubMed2006

The maximum standardized uptake values on integrated FDG-PET/CT is useful in differentiating benign from malignant pulmonary nodules.

BACKGROUND: Positron emission tomography (PET) is often used for an indeterminate pulmonary nodule. METHODS: This is a prospective study on a consecutive series of patients who had an indeterminate pulmonary nodule that was 2.5 cm or less, underwent integrated positron emission tomography using fluorodeoxyglucose-PET/computed tomographic [FDG-PET/CT] scan with the maximum standardized uptake values (maxSUVs) reported, and who underwent complete resection. RESULTS: There were 585 patients (401 men). A total of 496 patients had a malignant nodule and the median maxSUV was 8.5 (range, 0 to 36). Eighty-nine patients had a benign nodule and the median maxSUV was 4.9 (range, 0 to 28, p < 0.001). If the maxSUV was between 0 and 2.5 there was a 24% chance the nodule was malignant, if between 2.6 and 4.0 it was 80%, and if 4.1 or greater it was 96%. False negative FDG-PET/CT was from bronchoalveolar carcinoma in 11 patients, carcinoid in 4, and renal cell in 2. False positives included fungal infections in 16 patients. Nodal involvement, whether malignant or infectious, was more likely with a pulmonary mass that had a higher maxSUV (8.4 vs 3.8 for nonmalignant lesions, 9.8 vs 4.5 for malignant lesions). CONCLUSIONS: Although integrated FDG-PET/CT is a valuable study for an indeterminate pulmonary nodule, one must be aware of causes of false positives and negatives. There is a 24% chance a suspicious nodule that has a maxSUV of 0 to 2.5 is cancer. The higher the maxSUV of the primary mass the more likely the nodes are to be involved with either malignancy or infection, and this may help direct nodal biopsy instead of pulmonary resection.

Adenocarcinoma, Bronchiolo-Alveolar↗

PubMed2006

Satellite pulmonary nodule in the same lobe (T4N0) should not be staged as IIIB non-small cell lung cancer.

BACKGROUND: Treatment of non-small cell lung cancer depends on stage. Patients with T4 lesions represent a heterogeneous group. METHODS: A case-control study of patients with pathologically proven, node-negative T4 lesions (T4 N0 M0) was conducted. Patients with T4 disease were stratified as T4 from a satellite nodule (T4-satellite) or T4 from local invasion (T4-invasion). T4-satellite patients were matched 1:4 for sex and histology with resected control patients with stage IA, IB, and IIA non-small cell lung cancer and matched 1:3 with stage II non-small cell lung cancer. Survival and the maximal standardized uptake value on F-18 fluorodeoxyglucose-positron emission tomography scans were compared. RESULTS: There were 337 patients, 26 patients with T4-satellite lesions, 25 with T4-invasion lesions, and 286 controls (104 patients with T1 N0 M0, 104 with T2 N0 M0, and 78 with T1 N1 M0 or T2 N1 M0 lesions). The two T4 groups were similar for age, race, sex, and neoadjuvant therapy rates. The 5-year survival was 80% for the T1 N0 M0 patients, 68% for T2 N0 M0, 57% for T4-satellite N0 M0, 45% for T1 N1 M0 or T2 N1 M0, and 30% for the T4-invasion N0 M0 patients (p = 0.016). Multivariate analysis showed that only the type of T4 impacted survival (p = 0.011). The median maximal standardized uptake values of the cancers were 4.2 for T1 N0 M0, 4.8 for T4-satellite, 5.4 for T2 N0 M0, 7.8 for T1 N1 M0 or T2 N1 M0, and 8.8 for the T4-invasion patients. CONCLUSIONS: Larger studies are needed; however, patients with T4-satellite non-small cell lung cancer who undergo complete resection have survival and maximal standardized uptake values similar to patients with stage IB and stage IIA lesions. Their survival is significantly better than those with T4-invasion. Patients with T4-satellite N0 M0 lesions should not be classified as stage IIIB and should not be grouped with patients with T4-invasion, and resection should be considered.

Aged↗

PubMed2006

Restaging patients with N2 (stage IIIa) non-small cell lung cancer after neoadjuvant chemoradiotherapy: a prospective study.

BACKGROUND: The accuracy of restaging in patients with stage IIIa non-small cell lung cancer after neoadjuvant chemoradiotherapy is unknown. METHODS: A prospective trial of patients with biopsy-proven N2 disease who underwent initial clinical staging with mediastinoscopy, integrated positron emission tomography/computed tomography (PET/CT), and CT. Patients then were clinically restaged by the same imaging techniques 4 to 12 weeks after their induction chemoradiation therapy and then underwent definitive pathologic staging. RESULTS: Ninety-three patients had their lymph nodes pathologically restaged. Repeat PET/CT after neoadjuvant therapy missed residual N2 disease in 13/65 (20%) patients and falsely suggested it in 7 of 28 (25%). It was more accurate than repeat CT for restaging at all pathologic stages (stage 0, 92% vs 39%, P = .03; and stage I 89% vs 36%, P = .04). When the maximum standardized uptake value of the primary tumor is decreased by 75% or more, it is highly likely (likelihood ratio, +LR, 6.1) the patient is a complete responder; when it decreased by 55% or more, it is highly likely (+LR, 9.1) the patient is a partial responder. When the maximum standardized uptake value of the N2 node initially involved with metastatic cancer is decreased by more than 50%, it is highly likely (+LR, 7.9) the node is now benign. CONCLUSION: Repeat integrated PET/CT is superior to repeat CT for the restaging of patients with stage IIIa non-small cell lung cancer. The percent decrease in the maximum standardized uptake value of the primary and of the involved lymph node is predictive of pathology; however, nodal biopsies are required since a persistently high maximum standardized uptake value does not equate to residual cancer.

Adult↗

PubMed2006

Routine mediastinoscopy and esophageal ultrasound fine-needle aspiration in patients with non-small cell lung cancer who are clinically N2 negative: a prospective study.

BACKGROUND: Despite normal mediastinal (N2) lymph nodes shown on positron emission tomography (PET) and CT, some physicians routinely perform mediastinoscopy and/or endoscopic ultrasound fine-needle aspiration (EUS-FNA) in patients with non-small cell lung cancer (NSCLC). METHODS: A prospective trial on patients with NSCLC who were clinically staged N2 negative by both integrated PET/CT and CT scan. All underwent mediastinoscopy and EUS-FNA and if N2 negative underwent thoracotomy with thoracic lymphadenectomy. RESULTS: There were 153 patients (107 men). Of these, 136 patients were clinically staged N0 and 17 patients were clinically staged N1. Of the 136 patients who were staged as N0, 5 patients (3.7%) had positive EUS-FNA results (three in the subcarinal node), and 4 patients (2.9%) had positive mediastinoscopy results (all in the #4R node; one was N3). Six of the remaining 127 patients (4.7%) had N2 disease after resection. Seventeen patients were clinically staged as N1 by integrated PET/CT. Four patients (23.5%) had positive EUS-FNA results (two in the subcarinal node), 3 patients (17.6%) had positive mediastinoscopy results (all in #4R node; two were N2 and one was N3), and none of the remaining 10 patients had N2 disease after resection. Patients with unsuspected N2 disease were twice as likely (relative risk, 2.1; 95% confidence interval, 1.24 to 2.51; p = 0.02) to have a maximum standardized uptake value (maxSUV) > 10 and poorly differentiated cancer (relative risk, 2.1; 95% confidence interval, 1.14 to 2.38; p = 0.03). CONCLUSION: We do not recommend routine mediastinoscopy or EUS-FNA in patients who are clinically staged as N0 after both integrated PET/CT and CT. However, these procedures should both be considered in patients clinically staged as N1 after PET/CT, and/or in those with adenocarcinoma, upper-lobe tumors, or tumors with a maxSUV > or = 10.

Adenocarcinoma↗

PubMed2006

Women with pathologic stage I, II, and III non-small cell lung cancer have better survival than men.

OBJECTIVE: Bronchogenic malignancy is the number one cause of cancer deaths in both men and women worldwide. National registry-based studies have shown gender disparity in clinicopathologic characteristics and in survival. This study evaluates the risk factors and trends of lung cancer between genders. METHODS: A prospective cohort of consecutive patients with non-small cell lung cancer (NSCLC) who were carefully clinically (all underwent dedicated positron emission tomography scans) and pathologically staged with stage I, II, or III disease underwent homogenous treatment algorithms and were followed up over a period of 7 years. Primary outcomes were 5-year survival and response to neoadjuvant therapy. RESULTS: There were 1,085 patients (671 men and 414 women). Groups were similar for race, pulmonary function, smoking history, comorbidities, neoadjuvant therapy, histology, and resection rates. Women were younger (p = 0.014), had a higher incidence of adenocarcinoma (p = 0.01), and presented at an earlier pathologic stage (p = 0.01) than men. The overall age-adjusted and stage-adjusted 5-year survival rate favored women (60% vs 50%, respectively; p < 0.001). Women had better stage-specific 5-year survival rates (stage I disease, 69% vs 64%, respectively [p = 0.034]; stage II disease, 60% vs 50%, respectively [p = 0.042]; and stage III disease, 46% vs 37%, respectively [p = 0.024]). Women who received neoadjuvant chemotherapy alone (n = 76) were more likely to be a complete or partial responder than men (n = 142; p = 0.025). CONCLUSIONS: Despite uniform staging and treatment, the 5-year survival rate of women with stage I to III NSCLC was better than men overall and at each stage. Women are more likely to have adenocarcinoma, to present with earlier stage disease, and to be younger. Interestingly, women respond better to neoadjuvant chemotherapy.

Adult↗

PubMed2005

Pulmonary resection after high-dose and low-dose chest irradiation.

BACKGROUND: The purpose of this study is to assess the safety and efficacy of pulmonary resection after low and high dose neoadjuvant radiotherapy with concurrent chemotherapy. PATIENTS AND METHODS: A retrospective cohort study using an electronic prospective database from January 1998 to August 2004. All patients had N2, stage IIIa, nonsmall cell lung cancer, and received neoadjuvant carboplatinum-based chemotherapy with similar doses. In addition, some patients received high-dose chest radiation (HD) equal to or greater than 60 Gy and were compared with those who received low-dose radiation (LD) less than 60 Gy. All bronchial stumps were buttressed with an intercostal muscle. RESULTS: There were 104 patients, 50 in the LD group and 54 patients in the HD group. Median dose of radiation was 45 Gy (range 35-50.4) in the LD group and 60 Gy (range 60-66.7) in the HD group. Complete pathologic response rate was 10% compared to 28% favoring the HD group (p = 0.04). Median length of stay for both groups was 4 days and the ICU was avoided in 74%. Major morbidity and mortality rates were similar: 8% compared to 9% and 2% compared to 3.7% for the low and high dose groups, respectively. Pneumonectomy was a significant risk factor for morbidity (OR = 17.0). CONCLUSIONS: Pulmonary resection after preoperative chest radiation is safe even after 60 Gy or higher. Sixty or higher may afford an increase in complete pathologic response and it does not seem to increase morbidity or mortality. However, if pneumonectomy is known to be required we prefer to avoid neoadjuvant radiotherapy and use chemotherapy alone.

Adult↗

PubMed2005

Intercostal muscle flap to buttress the bronchus at risk and the thoracic esophageal-gastric anastomosis.

BACKGROUND: We assessed our outcomes using an intercostal muscle flap harvested with cautery prior to chest retraction. METHODS: Our retrospective study was conducted using an electronic prospective database. RESULTS: There were 456 patients (348 men) over a six year period. The intercostal muscle flap was used for bronchial coverage in 391 patients. The indications for the flap were neoadjuvant radiochemotherapy in 285 patients, infection or inflammatory disease in 106, to buttress an esophageal-gastric anastomosis in 49, and for esophageal fistula in 16. There were three bronchopleural fistulas (0.7%); one after a right pneumonectomy for tuberculosis, one after a left pneumonectomy, and one after a lobectomy in a heart transplant patient for mucormycosis. The 4-week median postoperative pain score for patients who underwent an intercostal muscle flap was lower compared with historic controls who underwent similar procedures over the same time frame but did not have an intercostal muscle flap (2.4 vs 3.7, p = 0.003). Follow-up was a median of 26 months (range, 1 to 72 months) and no patients had ossification of their flap. CONCLUSIONS: An intercostal muscle flap is a versatile pedicle flap that can reach all bronchi. It is easy to harvest, adds no morbidity, and may protect the bronchi at risk. When harvested devoid of periosteum it does not ossify over time and it may reduce the pain of thoracotomy.

Adult↗

PubMed2005

Improving the inaccuracies of clinical staging of patients with NSCLC: a prospective trial.

BACKGROUND: Clinical stage affects the care of patients with nonsmall cell lung cancer. METHODS: This is a prospective trial on patients with suspected resectable nonsmall cell lung cancer. All patients underwent integrated positron emission tomographic scanning and computed tomographic scanning, and all suspicious metastatic sites were investigated. A, T, N, and M status was assigned. If N2, N3 and M1 were negative, patients underwent thoracotomy and complete thoracic lymphadenectomy. RESULTS: There were 383 patients. The accuracy of clinical staging using positron emission tomographic scanning and computed tomographic scanning was 68% and 66% for stage I, 84% and 82% for stage II, 74% and 69% for stage III, and 93% and 92% for stage IV, respectively. N2 disease was discovered in 115 patients (30%) and was most common in the subcarinal lymph node (30%). Unsuspected N2 disease occurred in 28 patients (14%) and was most common in the posterior mediastinal lymph nodes (subcarinal, 38%; posterior aortopulmonary, 15%). It was found in 9% of patients who were clinically staged I (58% in the posterior mediastinal lymph nodes) and in 26% of patients clinically staged II (86% in posterior mediastinal lymph nodes). CONCLUSIONS: Despite integrated positron emission tomographic scanning and computed tomographic scanning, clinical staging remains relatively inaccurate for patients with nonsmall cell lung cancer. Recent studies suggest adjuvant therapy for stage Ib and II nonsmall cell lung cancer; thus the impact on preoperative care is to find unsuspected N2 disease. Unsuspected N2 disease is most common in posterior mediastinal lymph nodes inaccessible by mediastinoscopy. Thus one should consider endoscopic ultrasound fine-needle aspiration, especially for patients clinically staged as I and II, even if the nodes are negative on positron emission tomographic scanning and computed tomographic scanning.

Adult↗

PubMed2005

The maximum standardized uptake values on positron emission tomography of a non-small cell lung cancer predict stage, recurrence, and survival.

OBJECTIVE: We sought to assess whether the standard uptake value of a pulmonary nodule is an independent predictor of biologic aggressiveness. METHODS: This is a retrospective review of a prospective database of patients with non-small cell lung cancer. Patients had dedicated positron emission tomography scanning with F-18 fluorodeoxyglucose, with the maximum standard uptake value measured. All suspicious nodal and systemic locations on computed tomographic and positron emission tomographic scanning underwent biopsy, and when indicated, resection with complete lymphadenectomy was performed. RESULTS: There were 315 patients. Multivariate analysis showed patients with a high maximum standard uptake value (>/=10) were more likely to have poorly differentiated tumors (risk ratio, 1.5; P = .005) and advanced stage (risk ratio, 1.9; P = .010) and were less likely to have their disease completely resected (risk ratio, 3.7; P = .004). Maximum standard uptake value was the best predictor of disease-free survival (hazard ratio, 2.5; P = .039) and survival (hazard ratio, 2.8; P = .001). Stage-specific analysis showed that patients with stage IB and stage II disease with a maximum standard uptake value of greater than the median for their respective stages had a lower disease-free survival at 4 years ( P = .005 and .044). The actual 4-year survival for patients with stage Ib non-small cell lung cancer was 80% versus 66% ( P = .048), for stage II disease it was 64% versus 32% ( P = .028), and for stage IIIa disease it was 64% versus 16% ( P = .012) for the low and high maximum standard uptake value groups, respectively. CONCLUSIONS: The maximum standard uptake value of a non-small cell lung cancer nodule on dedicated positron emission tomography is an independent predictor of stage and tumor characteristics. It is a more powerful independent predictor than the TNM stage for recurrence and survival for patients with early-stage resected cancer. This information might help guide treatment strategies.

Adult↗

PubMed2005

The accuracy of endoscopic ultrasonography with fine-needle aspiration, integrated positron emission tomography with computed tomography, and computed tomography in restaging patients with esophageal cancer after neoadjuvant chemoradiotherapy.

BACKGROUND: Patients with esophageal cancer who receive neoadjuvant chemoradiotherapy are restaged with computed tomography (CT), endoscopic ultrasound with fine needle aspiration (EUS-FNA), and integrated positron emission computed tomography (FDG-PET/CT), and the results affect treatment. METHODS: This is a prospective trial on a consecutive series of patients who had initial chest, abdomen, and pelvis CT scan; EUS-FNA; and fluoro-2-deoxy- d -glucose (FDG)-integrated PET/CT; neoadjuvant chemoradiotherapy; repeat staging tests; pathologic staging; and, if appropriate, resection with lymphadenectomy. The primary objective was to assess the accuracy of these 3 tests in restaging patients after neoadjuvant therapy. RESULTS: There were 48 patients (41 men), and 41 underwent Ivor Lewis esophagogastrectomy with lymphadenectomy. The accuracy of each test for distinguishing pathologic T4 from T1 to T3 disease is 76%, 80%, and 80% for CT scan, EUS-FNA and FDG-PET/CT, respectively. The accuracy for nodal disease was 78%, 78%, and 93% for CT scan, EUS-FNA and FDG-PET/CT, respectively ( P = .04). FDG-PET/CT correctly identified M1b disease in 4 patients, falsely suggested it in 4 patients, and missed it in 2 patients, whereas for CT, it was 3, 3, and 3 patients. Fifteen (31%) patients were complete responders, and FDG-PET/CT accurately predicted complete response in 89% compared with 67% for EUS-FNA ( P = .045) and 71% for CT ( P = .05). CONCLUSIONS: FDG-PET/CT is more accurate than EUS-FNA and CT scan for predicting nodal status and complete responders after neoadjuvant therapy in patients with esophageal cancer. FDG-PET/CT and CT alone provide targets for biopsy, but results are often falsely positive.

Adenocarcinoma↗

PubMed2005

Intercostal muscle flap reduces the pain of thoracotomy: a prospective randomized trial.

BACKGROUND: Thoracotomy is associated with significant pain and morbidity. METHODS: We performed a prospective randomized trial over 4 months. Patients were randomized to a standard posterior-lateral thoracotomy or an identical procedure, except an intercostal muscle was harvested from the lower rib (to protect the intercostal nerve) before chest retraction. To ensure an equal distribution among both groups, patients were stratified by race, sex, and type of pulmonary resection. All patients received similar pain management. Pain was assessed by using multiple pain scores during hospitalization and after discharge. Outcomes assessed were pain scores, spirometric values, analgesic use, and activity level. RESULTS: There were 114 patients. The median time for intercostal muscle harvesting was 3.7 minutes. The numeric pain scores were lower for the intercostal muscle group on postoperative days 1 and 2 and at weeks 1, 2, 3, 4, 8, and 12 (P < .05 for all). In addition, patients in the intercostal muscle group had a smaller decrease in spirometric values, were less likely to be using analgesics, and were more likely to have returned to normal activity. CONCLUSIONS: The harvesting of an intercostal muscle flap before chest retraction decreases the pain of thoracotomy and leads to a lower decrease in spirometry. In addition, patients have less pain at 1, 2, 3, 4, 8, and 12 weeks postoperatively and are less likely to be using narcotics. Finally, it offers a pedicled muscle flap that takes little time to harvest and is able to buttress all bronchi after lobectomy.

Aged↗