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Common Thoracic Procedures

Common Thoracic Procedures. Cardiothoracic Centre, Liverpool Fri 23 rd January 2004 Edwin Woo. Overview. Lung Cancer VATS Disease of the thorax Oesophageal surgery Emergency thoracic procedures. Omission. Transplantation Anterior mediastinal mass Thymoma Retro-sternal goitre

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Common Thoracic Procedures

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  1. Common Thoracic Procedures Cardiothoracic Centre, Liverpool Fri 23rd January 2004 Edwin Woo

  2. Overview • Lung Cancer • VATS • Disease of the thorax • Oesophageal surgery • Emergency thoracic procedures

  3. Omission • Transplantation • Anterior mediastinal mass • Thymoma • Retro-sternal goitre • Lung volume reduction surgery

  4. Diagnosis • Sputum cytology • Bronchoscopic biopsy • Needle aspiration biopsy • VATS • Thoracotomy

  5. Diagnosis Sputum Cytology • Yield proportional to number of samples Oswald NC, Thorax 26:623,1971 • Position of tumor • Cell type • Best in squamous, least with SCLC • Agrees with final histology in 85%

  6. Diagnosis Bronchoscopy • Flexible vs Rigid

  7. Diagnosis Bronchoscopy

  8. Diagnosis Bronchoscopy • Visual inspection of tumor • Biopsy of tumor • Targeted washing & brushing for cytology • Transbronchial biopsy

  9. Diagnosis Needle aspiration cytology / cutting • CT / fluoroscopically • guided • Trans-bronchial • aspiration cytology

  10. Diagnosis VATS • Excision of peripheral • lesion • Biopsy of nodal station

  11. Diagnosis Thoracotomy • Frozen section • Important in pneumonectomy

  12. Diagnosis Tissue diagnosis from metastasis • Cervical lymph node biopsy • Mediastinal lymph nodes • Trans bronchial biopsy • Cervical mediastinoscopy • Anterior mediastinotomy • Cytology of pleural effusion • Pleural biopsy (needle, open & VATS)

  13. Diagnosis Non Small Cell Carcinoma • Squamous Cell Carcinoma • Ademocarcinoma • Large Cell Undifferentiated Carcinoma Small Cell Carcinoma • Oat Cell Carcinoma • Intermediate Cell Type • Mixed Cell Type

  14. Staging • 1966 TNM system adopted by UICC (International Union Against Cancer) Denoix PF: Bull Inst Nat Hyg (Paris) 1:70. 1964 • 1986 International staging system adopted by AJCC (American Joint Committee on Cancer)for NSCLC Mountain CF: Chest89:225S-35S. 1986 • 1997 Updated Mountain CF: Chest111:1711-7. 1997

  15. Staging TNM classification • T Tumor TX, T0, TIS, T1 – T4 • Site, size & local extent • N Node N0 – N3 • Presence & location of regional node involvement • MMetastases M0 or M1 • Presence or absence of distal metastasis

  16. Staging

  17. Prognosis

  18. Staging Small Cell Carcinoma • Localised • Disease limited to ipsilateral hemithorax • TNM system in very localised disease • Extensive • Disease spread beyond ipsilateral hemithorax

  19. Prognosis

  20. Prognosis

  21. Palliative resection Thoracotomy No surgical intervention Prognosis Survival curve of patients with stage III NSCLC Hara N, J Surg Oncol:25;153. 1984

  22. Operability • Stage I • T1N0 and T2N0 • Stage II • T1N1, T2N1 and T3N0 • Excellent and Reasonable chance of cure by surgery alone

  23. Operability • Stage IIIa • T3N1 and T1N2-T3N2 • NOT Surgery alone • Consider Adjuvant therapy

  24. Operability • Stage IIIb and Stage IV • Inoperable • Stage IIIb (T4N0 and T4N1) • ? Role of surgery

  25. Assessment & Staging

  26. Assessment & Staging Mediastinal Lymphadenopathy

  27. Assessment & Staging

  28. Assessment & Staging PET (Positron Emission Tomography) • 18F-fluorodeoxyglucose is used as the tracer molecule. • Preferential metabolism of glucose in tumor cells. • When Phosphorylated, it is trapped within the cell. • Positron releases reacts with an electron, releasing gamma rays. • However, uptake by inflammatory processes, myocardium, and brain

  29. Assessment & Staging PET (Positron Emission Tomography)

  30. Assessment & Staging Integrated PET / CT scanner

  31. Assessment & Staging Mediastinoscopy

  32. Assessment & Staging Anterior Mediastinotomy

  33. Lung Resection • Wedge Excision • Segmentectomy • Lobectomy • Bilobectomy • Pneumonectomy

  34. Lung Resection

  35. Lung Resection

  36. Lung Resection

  37. Lung Resection

  38. Video Assisted Thoracoscopic Surgery

  39. Video Assisted Thoracoscopic Surgery

  40. Video Assisted Thoracoscopic Surgery

  41. Video Assisted Thoracoscopic Surgery

  42. Sympathectomy • Palmar hyperhidrosis better response • T2 to T3 but T2 to T5 for axillary • 20 % compensatory hyerhidrosis • Horner’s syndrome if T1 resected

  43. Sympathectomy

  44. Sympathectomy

  45. Sympathectomy

  46. Empyema

  47. Empyema

  48. Empyema • Complete drainage of purulent collection • Obliteration of empyema space • Investigation and treatment of the cause

  49. Diaphragmatic Rupture

  50. Diaphragmatic Rupture

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