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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

Common Thoracic Procedures

Cardiothoracic Centre, Liverpool

Fri 23rd January 2004

Edwin Woo

overview
Overview
  • Lung Cancer
  • VATS
  • Disease of the thorax
  • Oesophageal surgery
  • Emergency thoracic procedures
omission
Omission
  • Transplantation
  • Anterior mediastinal mass
    • Thymoma
    • Retro-sternal goitre
  • Lung volume reduction surgery
diagnosis
Diagnosis
  • Sputum cytology
  • Bronchoscopic biopsy
  • Needle aspiration biopsy
  • VATS
  • Thoracotomy
diagnosis5
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%
diagnosis6
Diagnosis

Bronchoscopy

  • Flexible vs Rigid
diagnosis7
Diagnosis

Bronchoscopy

diagnosis8
Diagnosis

Bronchoscopy

  • Visual inspection of tumor
  • Biopsy of tumor
  • Targeted washing & brushing for cytology
  • Transbronchial biopsy
diagnosis9
Diagnosis

Needle aspiration cytology / cutting

  • CT / fluoroscopically
  • guided
  • Trans-bronchial
  • aspiration cytology
diagnosis10
Diagnosis

VATS

  • Excision of peripheral
  • lesion
  • Biopsy of nodal station
diagnosis11
Diagnosis

Thoracotomy

  • Frozen section
    • Important in pneumonectomy
diagnosis12
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)
diagnosis13
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
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

staging15
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
staging18
Staging

Small Cell Carcinoma

  • Localised
    • Disease limited to ipsilateral hemithorax
    • TNM system in very localised disease
  • Extensive
    • Disease spread beyond ipsilateral hemithorax
prognosis21

Palliative resection

Thoracotomy

No surgical intervention

Prognosis

Survival curve of patients with stage III NSCLC

Hara N, J Surg Oncol:25;153. 1984

operability
Operability
  • Stage I
    • T1N0 and T2N0
  • Stage II
    • T1N1, T2N1 and T3N0
  • Excellent and Reasonable chance of cure by surgery alone
operability23
Operability
  • Stage IIIa
    • T3N1 and T1N2-T3N2
  • NOT Surgery alone
  • Consider Adjuvant therapy
operability24
Operability
  • Stage IIIb and Stage IV
  • Inoperable
  • Stage IIIb (T4N0 and T4N1)
    • ? Role of surgery
assessment staging26
Assessment & Staging

Mediastinal Lymphadenopathy

assessment staging28
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 staging29
Assessment & Staging

PET (Positron Emission Tomography)

assessment staging30
Assessment & Staging

Integrated PET / CT scanner

assessment staging31
Assessment & Staging

Mediastinoscopy

assessment staging32
Assessment & Staging

Anterior Mediastinotomy

lung resection
Lung Resection
  • Wedge Excision
  • Segmentectomy
  • Lobectomy
  • Bilobectomy
  • Pneumonectomy
sympathectomy
Sympathectomy
  • Palmar hyperhidrosis better response
  • T2 to T3 but T2 to T5 for axillary
  • 20 % compensatory hyerhidrosis
  • Horner’s syndrome if T1 resected
empyema48
Empyema
  • Complete drainage of purulent collection
  • Obliteration of empyema space
  • Investigation and treatment of the cause
emergency procedures62
Emergency Procedures

Emergency thoracotomy

  • Penetrating chest trauma
  • Recently dead
  • Anterior lateral