Biomedical subjects

F C Detterbeck

Publications and source records attributed to F C Detterbeck.

At least 19 recordsLinked to original sources

PubMed2000

Beliefs among pulmonologists and thoracic surgeons in the therapeutic approach to non-small cell lung cancer.

STUDY OBJECTIVES: The physicians who initially evaluate patients with non-small cell lung cancer (NSCLC) strongly impact the course of therapy. Their beliefs in treatment and prognosis may contribute to practices of variable quality and appropriateness. We sought to better describe beliefs among pulmonologists and thoracic surgeons who were selected for guiding early therapy and referrals in patients with NSCLC. DESIGN: Mail questionnaire focusing on survival estimates, treatment perceptions, and referral patterns. PARTICIPANTS: Twelve hundred pulmonologists and 800 thoracic surgeons who were clinically active members of the American College of Chest Physicians. MEASUREMENTS AND RESULTS: Response rates of 50% for pulmonologists and 52% for thoracic surgeons were obtained after two mailings. Five-year survival estimates for patients with resected stage I NSCLC revealed that 30% of respondents overestimated survival rates and 18% underestimated survival rates. The underestimation of survival rate was found among more respondents who are practicing pulmonology than thoracic surgery (22% vs 10% [corrected], respectively), who were trained before 1980 than after 1980 (29% vs 10% [corrected], respectively), and who were seeing < 10 lung cancer patients annually than those who were seeing > 25 (31% vs 0.14%, respectively). Beliefs in the survival benefit of adjuvant chemotherapy or of radiation in stage I-IIIA disease divided respondents within both specialties. Chemotherapy plus radiation vs radiation alone in unresectable stage IIIA-B NSCLC was viewed as benefiting survival less often by physicians seeing < 10 lung cancer patients annually rather than > 25 (57% vs 77% [corrected], respectively) and by physicians underestimating rather than correctly estimating survival in early-stage disease (58% vs 72% [corrected], respectively). Chemotherapy was believed to confer survival benefits in patients with stage IV disease by one third of respondents. CONCLUSIONS: Certain physician characteristics, particularly the length of time since training and NSCLC patient volume, are associated with beliefs not conclusively supported in the medical literature or with opinions inconsistent within and between specialties.

Adult↗

PubMed1999

Inadequacy of computed tomography in assessing patients with esophageal carcinoma after induction chemoradiotherapy.

BACKGROUND: Induction chemoradiotherapy followed by surgery may improve survival of patients with esophageal carcinoma. Computed tomography (CT) has been used to evaluate the tumor response after completing induction chemoradiotherapy. The authors examined the ability of CT to evaluate the pathologic tumor response to induction therapy and to stage the tumor correctly. METHODS: Preinduction and postinduction chemoradiotherapy CT scans were reviewed retrospectively for 50 patients enrolled in a protocol of induction chemoradiotherapy followed by surgery. All studies were performed on third-generation or fourth-generation scanners. Radiographic response was determined using Eastern Cooperative Oncology Group solid tumor response criteria for bidimensional measurable disease. This was compared with the pathologic tumor response. CT-tumor (T) classification using the modified Tio scale was compared with the pathologic T classification. RESULTS: CT-T classification did not correlate with the pathologic stage (P = 0.09) or the pathologic tumor response (P = 0.22). The postinduction chemoradiotherapy CT accurately staged the T classification in 42% of patients but overstaged 36% of patients and understaged 20% of patients. CT had a sensitivity of 65%, a specificity of 33%, a positive predictive value of 58%, and a negative predictive value of 41% in evaluating the pathologic tumor response. CONCLUSIONS: CT is a poor diagnostic study tool for determining the pathologic tumor response or the pathologic disease stage after induction chemoradiotherapy in patients with esophageal carcinoma.

Adult↗

PubMed1998

Multicenter VATS experience with mediastinal tumors.

BACKGROUND: The use of video-assisted thoracic surgery for diagnosis and treatment of mediastinal tumors in a multiinstitution patient population is not well understood. METHODS: We studied 48 cases from Cancer and Leukemia Group B thoracic surgeons. Of 21 men and 27 women, aged 41 +/- 16 years, 22 patients were asymptomatic. In the others, 92% of tumor-related symptoms improved or resolved after treatment. Five tumors involved the anterior compartment, 19 the middle, and 24 the posterior compartment. Diagnoses were typical for each compartment but also included uncommon problems such as superior vena cava hemangioma and a histoplasmosis cyst causing hoarseness. Of the lesions, a biopsy of 12 was done without excision and the rest were excised completely. Fifteen were cystic and 10 were malignant (8 biopsy only). Maximal dimensions were 5.2 +/- 3.3 cm. RESULTS: Operations were briefer for 24 posterior (93 +/- 41 min) than 5 anterior (195 +/- 46 min, p < 0.01) or 19 middle mediastinal tumors (170 +/- 78 min, p < 0.01). Although 96% had vital mediastinal relations, only six open conversions were performed because of bleeding (n = 3), large size, impaired exposure, or rib attachments, and no patient had morbidity beyond that expected for the thoracotomy. Postoperative stay was shorter for the nonconversion group (3.2 +/- 2.8 versus 5.5 +/- 2.1 days, p = 0.05), as was chest tube duration (1.7 +/- 1.4 days versus 3.2 +/- 1.9 days, p = 0.03). There were no postoperative deaths or major complications, but 7 patients had minor complications. During a mean of 20 months of surveillance (range, 1 to 52 months), one cyst recurred (asymptomatic) as did one sarcoma that was excised. CONCLUSIONS: Video-assisted thoracic surgery is a safe technique for benign mediastinal tumors, typically those in the middle and posterior mediastinum.

Adult↗

PubMed1998

Lung transplantation for cystic fibrosis: effective and durable therapy in a high-risk group.

BACKGROUND: The purpose of this study was to review our experience with lung transplantation in patients with end-stage cystic fibrosis. METHODS: Eight-two patients with cystic fibrosis have undergone bilateral lung transplantation (n=76) or bilateral lower lobe transplantation (n=6) since October 1990. RESULTS: Actuarial survival for the entire cohort is 79% at 1 year and 57% at 5 years. The development of bronchiolitis obliterans syndrome is the leading cause of death after the first year. Freedom from bronchiolitis obliterans syndrome is 84% at 1 year and 51% at 3 years. Pulmonary function tests improve dramatically in recipients. There was no association between death within 1 year and recipient age, weight, graft ischemic time, cytomegalovirus seronegativity, or the presence of pan-resistant organisms. Similarly, there was no association between the development of bronchiolitis obliterans syndrome within 2 years and ischemic time, number of rejection episodes, cytomegalovirus seronegativity, or the presence of panresistant organisms. CONCLUSIONS: Despite their poor nutritional status and the presence of multiply resistant organisms, patients with cystic fibrosis can undergo bilateral lung transplantation with acceptable morbidity and mortality.

Adolescent↗

PubMed1998

Pancoast tumors of the lung.

Pancoast or superior pulmonary sulcus tumors are uncommon primary bronchogenic carcinomas that produce a characteristic clinical syndrome of upper extremity pain and Horner's syndrome. Treatment of patients with this malignancy has traditionally involved irradiation alone or preoperative irradiation followed by resection. Recent advances in the management of Pancoast tumors include the importance of mediastinoscopy in staging the tumor before treatment begins. A complete resection should be accomplished including a lobectomy whenever possible. The current treatment protocol involves induction chemoradiotherapy followed by surgery.

Carcinoma, Bronchogenic↗

PubMed1997

Invasive carcinoid tumor of the heart.

Carcinoid tumors have been described in almost every organ and may affect virtually every body system. Cardiac involvement manifesting as right-sided valvular disease is characteristic of the carcinoid syndrome; however, direct myocardial involvement is unusual. We present a case of an invasive carcinoid tumor whose primary manifestation was myocardial invasion.

Adult↗

PubMed1997

Pancoast (superior sulcus) tumors.

Primary carcinomas arising in the apex of the lung (Pancoast tumors) have attracted attention because of the characteristic syndrome that is produced by local extension into the chest wall and the brachial plexus. This article reviews the history of the treatment of this disease, the natural history of untreated patients, and the diagnosis of Pancoast tumors. The published data on results, prognostic factors, and technical aspects of treatment with combined irradiation and operation are examined, as well as those pertaining to treatment with irradiation alone.

Combined Modality Therapy↗

PubMed1997

Induction chemoradiotherapy followed by esophagectomy in patients with carcinoma of the esophagus.

BACKGROUND: Induction chemoradiotherapy followed by esophagectomy may provide results superior to those of single-modality treatment in patients with esophageal cancer. The purpose of this study was to review our experience with this approach for esophageal cancer. METHODS: From 1988 to 1996, 166 consecutive patients with esophageal cancer were evaluated; 66 entered a protocol of chemotherapy (5-fluorouracil, cisplatin) concurrent with radiation (45 Gy) followed by esophagectomy. Fifty-four patients completed the protocol. RESULTS: Toxicity associated with induction chemoradiotherapy was minimal. The actuarial survival at 12, 24, and 36 months was 59%, 42%, and 32%, respectively. The pathologic complete response (pCR) rate was 41%, with 12-, 24-, and 36-month survivals of 77%, 50%, and 45%, whereas non-pCR patients had survivals of 46%, 35%, and 23%. The difference in survival between pCR and non-pCR patients was not significant (p = 0.13), but the difference in recurrence-free survival was significant (p = 0.007). CONCLUSIONS: This well-tolerated protocol resulted in a high pCR. Trimodality treatment for esophageal cancer may provide long-term survival in some patients regardless of their pCR status.

Adenocarcinoma↗

PubMed1997

IIB or not IIB: the current question in staging non-small cell lung cancer.

It has been suggested that T3/N0-1/M0 non-small cell lung cancer should be classified as stage IIB rather than IIIA. This is the result of a widespread perception that the survival of patients with T3/N0-1 lung cancers greatly exceeds that of patients with stage IIIA (N2) lung cancers. This perception is based primarily on the survival of T3/N0-1 patients who have chest wall involvement. However, the T3 classification also includes tumors that involve mediastinal structures, the main stem bronchus <2 cm from the carina, and the brachial plexus as seen in Pancoast tumors. Survival for each of these T3 categories is examined in this articles and found to be somewhat different. The available data show that patients with T3/N0-1 tumors involving the chest wall have a good prognosis after resection, whereas patients with central T3/N0-1 tumors (mediastinal or main stem bronchial involvement) have a prognosis similar to that of patients with resected IIIA (N2) tumors. If a new classification of T3/N0-1 tumors as stage IIB is to be adopted, it will be important for future studies to document which type of T3 tumor is being discussed.

Carcinoma, Non-Small-Cell Lung↗

PubMed1996

One hundred consecutive thymectomies for myasthenia gravis.

BACKGROUND: Between June 1997 and November 1993, 100 consecutive thymectomies for myasthenia gravis were performed at University of North Carolina Hospitals in Chapel Hill. METHODS: A consistent, planned protocol involving preoperative, intraoperative, and postoperative care was followed. All thymectomies were performed through a median sternotomy with removal of all visible thymus and perithymic fat in the anterior mediastinum. RESULTS: There was no perioperative mortality or longterm morbidity. Mean postoperative hospital stay was 6.3 days (range, 3 to 18 days). Ninety-six percent of the patients were extubated the day of the operation, and all patients were extubated within 24 hours. Mean postoperative intensive care unit stay was 1.2 days (range, 1 to 4 days). After a mean follow-up of 65 months (range, 1 to 199 months), 78% of all patients are improved by at least one modified Osserman classification when their current status is compared with their worst preoperative disease severity. In fact, 69% of patients with mild disease preoperatively (class I, II, or III maximal severity) are in pharmacologic remission (asymptomatic without regular medication), whereas 29% of patients with severe disease (class IV or V) are in remission (p = 0.0001). CONCLUSIONS: Our programmatic approach to thymectomy through a sternotomy has shown minimal morbidity and mortality. It is beneficial to myasthenics at both ends of the age and severity spectrum.

Adult↗

PubMed1996

Single-stage replacement of the entire thoracic aorta via transverse thoracosternotomy.

The transverse thoracosternotomy provides excellent exposure for repair of lesions involving the entire thoracic aorta. This approach has been made more feasible by other recent technical advances, such as retrograde perfusion of the brain during circulatory arrest, allowing single-stage replacement of the ascending and descending aorta and aortic arch. The two cases presented here illustrate the use of these advancements in the treatment of extensive aneurysms of the thoracic aorta.

Aged↗

PubMed1996

Wegener's granulomatosis mimicking a sternal abscess.

Bone destruction as a manifestation of Wegener's granulomatosis has been reported, but these cases were limited to the head and face. We present a case in which a sternal abscess was the initial manifestation of Wegener's granulomatosis. We believe this is the first reported case of bone destruction due to Wegener's occurring in a location other than the head and face.

Abscess↗

PubMed1996

Concurrent radiation therapy and chemotherapy followed by esophagectomy for localized esophageal carcinoma.

PURPOSE: A prospective study was performed to determine the outcome of patients with esophageal cancer who received preoperative radiation therapy and chemotherapy followed by esophagectomy, and to determine the role of preresection esophagogastroduodenoscopy (EGD) in predicting the patients in whom surgery could possibly be omitted, and the impact of surgery on survival. MATERIALS AND METHODS: Thirty-five patients with localized carcinoma of the esophagus received concurrent external-beam radiotherapy and chemotherapy followed by esophagectomy. Patients received 45 Gy in 25 fractions. Chemotherapy consisted of continuous infusion fluorouracil (5-FU; 1,000 mg/m2/d) on days 1 through 4 and 29 through 32 and cisplatin (100 mg/m2) on day 1. Patients underwent an Ivor-Lewis esophagectomy 18 to 33 days after completion of radiotherapy. RESULTS: Eighty percent of the patients had squamous cell carcinoma and 20% had adenocarcinoma. In addition, 51% had a pathologic complete response (CR). Twenty-two of the 35 underwent a preresection EGD before resection. Seventeen of the 22 (77%) had negative pathology from the preresection EGD, but seven of the 17 (41%) had residual tumor at surgery. The median survival and disease-free survival rates for all patients were 25.8 months and 32.8 months, respectively. Eighteen patients (51%) had no tumor at resection. The median survival for these patients was 36.8 months; the median disease-free survival time has not been reached. The median survival and disease-free survival rate for the patients with residual tumor in the surgical specimen were 12.9 months and 10.8 months, respectively. CONCLUSION: Preresection EGD is not reliable for determining the presence of residual disease or the patients in whom surgery could be omitted. Twenty-five percent of the patients with residual tumor in the resected surgical specimen were long-term survivors; this suggests a benefit from esophagectomy after concurrent radiotherapy and chemotherapy.

Adenocarcinoma↗

PubMed1995

Effect of size (mis)matching in clinical double-lung transplantation.

Current United Network for Organ Sharing policy requires listing lung transplant recipients with an acceptable donor weight range, but lung size is a function of height, age, sex, and race. Frequently, lung transplant recipients are underweight, which results in a large discrepancy between donor and recipient weights. We reviewed our experience with size discrepancy between donors (D) and recipients (R) of 49 double-lung transplant (DLTX) procedures since July 1990. Pneumoreduction procedures were performed in 11 recipients of lungs judged to be too large at the time of DLTX (right middle lobectomy, 2; lingulectomy, 2; both, 6; right middle lobectomy and bilateral apical resections, 1). Predicted forced vital capacity (FVC) and total lung capacity (TLC) of donors and recipients were calculated. Donors were larger than recipients in general (D:R height = 1.02; D:R weight = 1.46), and, as a result, recipient-predicted lung volumes were smaller than donor-predicted lung volumes (D:R FVC = 1.1; D:R TLC = 1.1). Recipients undergoing pneumoreduction procedures had a significantly greater size discrepancy between donors and recipients; thus, both the ratio of D:R and the difference between D and R predicted FVC and TLC were significantly greater among recipients who underwent pneumoreduction, compared with nonreduced recipients. For recipients in the pneumoreduction group, predicted FVC and TLC were recalculated, with a proportionate amount subtracted based on the number of pulmonary segments removed. When the "corrected" FVC and TLC of the donors were compared with recipient-predicted FVC and TLC, there was no longer any significant difference between reduced and non-reduced groups, which implies that visual estimate of size mismatch at surgery is an accurate measure of size discrepancy. Post-DLTX spirometry showed identical improvement in FVC in patients who had pneumoreduction and those who did not, and survival at 6 months was identical in both groups. We conclude that pneumoreduction had no adverse effect on survival or post-DLTX spirometry, allowing safe use of larger donors in small recipients. Also, because lung size is more a function of height than weight, this study challenges the United Network for Organ Sharing practice of listing recipients with an acceptable donor weight range.

Adolescent↗

PubMed1995

Innominate artery and tracheal compression due to aberrant position of the thymus.

A 3-month-old infant with failure to thrive was found on bronchoscopy to have tracheal obstruction thought to be secondary to innominate artery compression. Subsequent diagnostic evaluation with magnetic resonance imaging revealed superior and posterior extension of the thymus with resultant compression of the innominate artery and trachea within the narrow confines of the thoracic inlet. Resection of the aberrantly positioned and enlarged thymus and aortopexy resulted in relief of tracheal compression.

Brachiocephalic Trunk↗

PubMed1995

Improved results of lung transplantation for patients with cystic fibrosis.

Patients with cystic fibrosis pose particular challenges for lung transplant surgeons. Earlier reports from North American centers suggested that patients with cystic fibrosis were at greater risk for heart-lung or isolated lung transplantation than other patients with end-stage pulmonary disease. During a 3 1/2 year period, 44 patients with end-stage lung disease resulting from cystic fibrosis underwent double lung transplantation at this institution. During the same interval, 18 patients with cystic fibrosis died while waiting for lung transplantation. The ages of the recipients ranged from 8 to 45 years, and mean forced expiratory volume in 1 second was 21% predicted. Seven patients had Pseudomonas cepacia bacteria before transplantation. Bilateral sequential implantation with omentopexy was used in all patients. There were no operative deaths, although two patients required urgent retransplantation because of graft failure. Cardiopulmonary bypass was necessary in six procedures in five patients and was associated with an increased blood transfusion requirement, longer postoperative ventilation, and longer hospital stay. Actuarial survival was 85% at 1 year and 67% at 2 years. Infection was the most common cause of death within 6 months of transplantation (Pseudomonas cepacia pneumonia was the cause of death in two patients), and bronchiolitis obliterans was the most common cause of death after 6 months. Actuarial freedom from development of clinically significant bronchiolitis obliterans was 59% at 2 years. Results of pulmonary function tests improved substantially in survivors, with forced expiratory volume in 1 second averaging 78% predicted 2 years after transplantation. Double lung transplantation can be accomplished with acceptable morbidity and mortality in patients with cystic fibrosis.

Actuarial Analysis↗

PubMed1995

Analysis of cystic fibrosis referrals for lung transplantation.

Patients with cystic fibrosis (CF) are being considered in increasing numbers as candidates for lung transplantation, despite earlier concerns that their nutritional status and the infective nature of their lung disease would contribute to increased morbidity and mortality. We undertook a retrospective analysis of patients with CF referred for consideration of lung transplant to identify factors that helped to select suitable transplant candidates and to identify characteristics that predicted death while on the waiting list. Analysis of 95 referred patients with CF demonstrated a high rate of suitability (78%) by our criteria. The mean weight of listed patients with CF was 77% predicted, and the mean FEV1 was 20% predicted. Sixteen percent of listed patients with CF died awaiting transplant. The FEV1 of these patients was significantly lower than that of patients who survived to transplant. This study implies that patients with CF are being referred for transplant late in the course of their disease. Earlier referral may lead to an increase in the number of patients with CF undergoing successful lung transplantation.

Adolescent↗

PubMed1995

Lung transplantation after previous thoracic surgical procedures.

BACKGROUND: This study examined results of lung transplantation after previous thoracic surgical procedures. METHODS: Twenty percent of the 69 isolated lung transplantations performed at the University of North Carolina between January 1990 and June 1993 were in patients who had undergone a previous thoracic surgical procedure, and an additional 10% had undergone a previous chest tube placement. RESULTS: No statistically significant increase in morbidity or mortality was observed between those having undergone a previous procedure or chest tube placement and all other patients. Specifically, the length of intubation, length of hospital stay, hospital mortality, or the number of patients who experienced major early complications was not significantly different between these groups. A statistically significant increase in the number of blood products used was observed in the patients with previous thoracic surgical procedures but not with patient having had previous chest tube placements. However, when the data were reanalyzed with respect to the use of cardiopulmonary bypass, those patients requiring bypass had a markedly poorer outcome that reached statistical significance in all of the parameters studied: hospital death, incidence of major complications, length of intubation, hospital stay, incidence of bleeding, and number of blood products used. CONCLUSIONS: We conclude that although increased bleeding may be encountered, lung transplantation can be performed successfully in patients who have had previous thoracic surgical procedures without increased major morbidity or mortality; however, the use of cardiopulmonary bypass has been associated with significantly increased morbidity and mortality in our patient population.

Blood Transfusion↗