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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 Cardiothoracic Centre, Liverpool Fri 23rd 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 • Lung volume reduction surgery
Diagnosis • Sputum cytology • Bronchoscopic biopsy • Needle aspiration biopsy • VATS • Thoracotomy
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%
Diagnosis Bronchoscopy • Flexible vs Rigid
Diagnosis Bronchoscopy
Diagnosis Bronchoscopy • Visual inspection of tumor • Biopsy of tumor • Targeted washing & brushing for cytology • Transbronchial biopsy
Diagnosis Needle aspiration cytology / cutting • CT / fluoroscopically • guided • Trans-bronchial • aspiration cytology
Diagnosis VATS • Excision of peripheral • lesion • Biopsy of nodal station
Diagnosis Thoracotomy • Frozen section • Important in pneumonectomy
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)
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
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
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
Staging Small Cell Carcinoma • Localised • Disease limited to ipsilateral hemithorax • TNM system in very localised disease • Extensive • Disease spread beyond ipsilateral hemithorax
Palliative resection Thoracotomy No surgical intervention Prognosis Survival curve of patients with stage III NSCLC Hara N, J Surg Oncol:25;153. 1984
Operability • Stage I • T1N0 and T2N0 • Stage II • T1N1, T2N1 and T3N0 • Excellent and Reasonable chance of cure by surgery alone
Operability • Stage IIIa • T3N1 and T1N2-T3N2 • NOT Surgery alone • Consider Adjuvant therapy
Operability • Stage IIIb and Stage IV • Inoperable • Stage IIIb (T4N0 and T4N1) • ? Role of surgery
Assessment & Staging Mediastinal Lymphadenopathy
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
Assessment & Staging PET (Positron Emission Tomography)
Assessment & Staging Integrated PET / CT scanner
Assessment & Staging Mediastinoscopy
Assessment & Staging Anterior Mediastinotomy
Lung Resection • Wedge Excision • Segmentectomy • Lobectomy • Bilobectomy • Pneumonectomy
Sympathectomy • Palmar hyperhidrosis better response • T2 to T3 but T2 to T5 for axillary • 20 % compensatory hyerhidrosis • Horner’s syndrome if T1 resected
Empyema • Complete drainage of purulent collection • Obliteration of empyema space • Investigation and treatment of the cause