Methods for Staging Non-small Cell Lung Cancer: Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

Definition and classification of chyle leak after pancreatic operation: A consensus statement by the International Study Group on Pancreatic Surgery

Malignant pleural effusions (MPE) are a common pathology, treated by respiratory physicians and thoracic surgeons alike. In recent years, several well-designed randomised clinical trials have been published that have changed the landscape of MPE management. The European Respiratory Society (ERS) and the European Association for Cardio-Thoracic Surgery (EACTS) established a multidisciplinary collaboration of clinicians with expertise in the management of MPE with the aim of producing a comprehensive review of the scientific literature.Six areas of interest were identified, including the optimum management of symptomatic MPE, management of trapped lung in MPE, management of loculated MPE, prognostic factors in MPE, whether there is a role for oncological therapies prior to intervention for MPE and whether a histological diagnosis is always required in MPE.The literature revealed that talc pleurodesis and indwelling pleural catheters effectively manage the symptoms of MPE. There was limited evidence regarding the management of trapped lung or loculated MPE. The LENT score was identified as a validated tool for predicting survival in MPE, with Brims' prognostic score demonstrating utility in mesothelioma prognostication. There was no evidence to support the use of oncological therapies as an alternative to MPE drainage, and the literature supported the use of tissue biopsy as the gold standard for diagnosis and treatment planning.

/pdf/ers-eacts-statement-on-the-management-of-malignant-pleural-5fjkmy2g74.pdf

ERS/EACTS statement on the management of malignant pleural effusions.

Chylothorax is by definition a collection of chyle in the pleural cavity resulting from leakage from the lymphatic vessels, usually from the thoracic duct. The symptoms of chylothorax can occur in patients of any age; the condition has multiple possible causes, and may therefore be encountered in many fields of medicine. Incidence data are available for only postoperative chylothorax, which can occur after almost any surgical operation in the chest. It is most often observed after esophagectomy (about 3% of cases), or after heart surgery in children (up to about 6% of cases) (1, 2). Treatment options for chylothorax today range from the conservative to surgical and—more recently—interventional radiological procedures. Because of the rarity of the condition, no prospective studies have been carried out on how best to treat it, or for how long. For guidance, therefore, we describe the current state of the art of the diagnosis and treatment of this interdisciplinary disease entity.

/pdf/treatment-options-in-patients-with-chylothorax-4mt1q9brcs.pdf

Treatment Options in Patients With Chylothorax

Airway injuries are life threatening conditions. A very little number of patients suffering air injuries are transferred live at the hospital. The diagnosis requires a high index of suspicion based on the presence of non-specific for these injuries symptoms and signs and a thorough knowledge of the mechanisms of injury. Bronchoscopy and chest computed tomography with MPR and 3D reconstruction of the airway represent the procedures of choice for the definitive diagnosis. Endotracheal intubation under bronchoscopic guidance is the key point to gain airway control and appropriate ventilation. Primary repair with direct suture or resection and an end to end anastomosis is the treatment of choice for patients suffering from tracheobronchial injuries (TBI). The surgical approach to the injured airway depends on its location. Selected patients, mainly with iatrogenic injuries, can be treated conservatively as long as the injury is small (<2 cm), a secure and patent airway and adequate ventilation are achieved, and there are no signs of sepsis. Patients with delayed presentation airway injuries should be referred for surgical treatment. Intraoperative evaluation of the viability of the lung parenchyma beyond the site of stenosis/obstruction is mandatory to avoid unnecessary lung resection.

/pdf/airway-trauma-a-review-on-epidemiology-mechanisms-of-injury-ndeutc9yut.pdf

Airway trauma: a review on epidemiology, mechanisms of injury, diagnosis and treatment

Objective: Positron emission tomography (PET) is used increasingly in staging of non-small cell lung cancer (NSCLC) as a non-invasive tool. The role of the PET in mediastinal lymphatic staging of NSCLC is not clear. We aimed to demonstrate the efficacy of PET in determining mediastinal lymphatic metastasis by comparing the results of PETwith mediastinoscopy. Patients and methods: We performed PET preoperatively in 170 patients with clinically operable NSCLC between 2004 and 2006. Stations defined as metastasis by PET (SUVmax >2.5) were recorded. Mediastinoscopy was performed initially in all patients and a total of 687 stations which can be reached with mediastinoscope were sampled (mean 4.04). Forty-three patients with mediastinal metastasis were referred to the oncology clinic for chemotherapy while lung resection and complete mediastinal lymphatic dissection through thoracotomywas performed in the remaining127 patients. Involvement of mediastinal lymph nodes was verified to compare the sensitivity and specificity of mediastinoscopy and the related PET results. Results: Histopathologic classification of the tumors revealed 79 squamous carcinomas and 58 adenocarcinomas. False positivity rate of PET was 26% (95% CI: 14—38), false negativity was 25% (95% CI: 18—33), sensitivity was 74% (95% CI: 63—86), specificity was 73% (95% CI: 66—82) and accuracy was 74% in mediastinal staging. Negative predictive value of mediastinoscopy was 94% (95% CI: 89—98), positive predictive value 100%, sensitivity 84% (95% CI: 74—94), specificity 100% and accuracy was 95%. Conclusion: PETresults do not provide acceptable accuracy rates. Mediastinoscopy still remains the gold standard for mediastinal staging of NSCLC, although it cannot reach to all the mediastinal stations. # 2007 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

/pdf/role-of-positron-emission-tomography-in-mediastinal-2yrhgy7byp.pdf

Role of positron emission tomography in mediastinal lymphatic staging of non-small cell lung cancer.

Surgical management of childhood bronchiectasis due to infectious disease.

The need and outcome of surgical intervention in patients with pulmonary tuberculosis were assessed retrospectively. Between 1993 and 2003, 72 major surgical procedures were performed in 57 patients with pulmonary tuberculosis. There were 44 males and 13 females with a mean age of 34 years. Indications for surgery were: trapped lung in 18 (31.6%), multidrug-resistant tuberculosis in 10 (17.5%), aspergilloma in 10 (17.5%), destroyed lung in 5 (8.8%), massive hemoptysis in 4 (7%), bronchopleural fistula in 3 (5.3%), persistent cavity in 2 (3.5%), and undiagnosed nodule in 5 (8.8%) patients. The most common procedure was lobectomy (31.9%). Other procedures included decortication, wedge resection, pneumonectomy, segmentectomy, and myoplasty. There were 28 complications in 18 patients, including prolonged air leak in 12 (21.1%), residual space in 7 (12.3%), empyema in 5 (8.8%), hematoma in 2 (3.5%), chylothorax and bronchopleural fistula in 1 (1.8%) each. There was no operative death, but one patient died from sepsis late in the follow-up period (mortality, 1.8%). As morbidity and mortality rates are acceptable, surgical intervention can be considered safe and effective in patients with pulmonary tuberculosis.

Role and Outcome of Surgery for Pulmonary Tuberculosis

Resumen Introduccion En algunos pacientes no es posible establecer la causa del derrame pleural exudativo. Se han analizado los resultados del seguimiento a largo plazo de pacientes con derrame pleural no diagnosticado. Metodos Se evaluo retrospectivamente a pacientes con derrame pleural exudativo a los que se les habia realizado una biopsia pleural mediante cirugia toracoscopica videoasistida (VATS) entre 2008 y 2012 como parte de los procedimientos diagnosticos. En el estudio se incluyo a 53 pacientes con diagnostico de pleuritis inespecifica y con datos de seguimiento disponibles. Resultados Se incluyo a 40 varones y 13 mujeres (promedio de edad, 53,9 ± 13,9 anos). La mediana de tiempo de seguimiento fue de 24 meses. Durante el seguimiento no se llego a un diagnostico en 27 pacientes (51%) y se alcanzo diagnostico clinico en los 26 pacientes restantes (49%). A 2 pacientes (3,7%) se les diagnostico neoplasia maligna (mesotelioma maligno). Otras enfermedades diagnosticadas fueron derrame paraneumonico en 12 casos, insuficiencia cardiaca congestiva en 8 casos y otras afecciones en 4 pacientes. El volumen del derrame en la exploracion inicial y la reacumulacion de fluido tras VATS se asociaron a neoplasia maligna (p = 0,004 y 0,0001, respectivamente). Conclusion Aunque la probabilidad es baja, los pacientes con derrame pleural exudativo y sin diagnostico tras una biopsia pleural mediante VATS pueden tener neoplasia maligna. Es necesario controlar cuidadosamente a los pacientes con un volumen de derrame inicial alto que reaparece tras la exploracion.

Resultados del seguimiento a largo plazo de pacientes con derrame pleural no diagnosticado

Introduction The cause of exudative pleural effusion cannot be determined in some patients. The long-term outcomes of patients with undiagnosed pleural effusion were analyzed. Methods Patients with exudative pleural effusion whose diagnostic procedures included pleural biopsy using video-assisted thoracoscopic surgery carried out between 2008 and 2012 were evaluated retrospectively. Patients diagnosed with nonspecific pleuritis were included. Fifty-three patients with available follow-up data were included in the study. Results Forty men and 13 women (mean age 53.9 ± 13.9 years) were included. Median follow-up time was 24 months. No diagnosis was given in 27 patients (51%), and a clinical diagnosis was given in 26 patients (49%) during the follow-up period. Malignant disease (malignant mesothelioma) was diagnosed in 2 (3.7%) patients. Other diseases were parapneumonic effusion in 12, congestive heart failure in 8, and miscellaneous in 4 patients. Volume of effusion at the time of initial examination and re-accumulation of fluid after video-assisted thoracoscopic surgery were associated with malignant disease (P=.004 and .0001, respectively). Conclusion Although the probability is low, some patients with exudative pleural effusion undiagnosed after pleural biopsy via video-assisted thoracoscopic surgery may have malignant disease. Patients with an initially large volume of effusion that re-accumulates after examination should be closely monitored.

Long-term Outcome of Patients With Undiagnosed Pleural Effusion.

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