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Diagnostic Methods in Solitary Pulmonary Nodules: Diagnostic Surgical Approach

Diagnostic Methods in Solitary Pulmonary Nodules: Diagnostic Surgical Approach. Cengiz GEBİTEKİN, FETCS Uludağ Üniversitesi Tıp Fakültesi Göğüs Cerrahisi ABD, BURSA. SPN. 5-year survival in stage I Lung carcinoma diagnosed as SPN – med.%70 * Stage I symptomatic patients %10 **

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Diagnostic Methods in Solitary Pulmonary Nodules: Diagnostic Surgical Approach

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  1. Diagnostic Methods in Solitary Pulmonary Nodules: Diagnostic Surgical Approach Cengiz GEBİTEKİN, FETCS Uludağ Üniversitesi Tıp Fakültesi Göğüs Cerrahisi ABD, BURSA

  2. SPN • 5-year survival in stage I Lung carcinoma diagnosed as SPN – med.%70* • Stage I symptomatic patients %10** • Stage I according to Chest X-ray %30***, CT -%85**** *Flehinger BJ. Chest 1992;101:1013-1018, **Melamed MR.Chest 1984;86:44-53 ***Fontana RS. J Occuo Med 1986;28:746-750, ****Swensen SJ Am J Respir Crit Care Med 2002;165:508-11111513

  3. Surgery: When, to Whom?Primary Lung Carcinoma • SPNs with spiculary margin • SPNs with irregular margin, %83 malignant, with spiculated margins %90 malignant • PET/CT positive SPNs • ≥1.5cm in size- high malignancy • Increased 5-year survival with early surgery • Low Morbidity and mortality

  4. Surgery: When and to Whom?Primary Malignancy with metachronous/syncronous SPN • Stage of the disease • Neoadjuvant treatment • Chemotherapy • VATS or open surgery for diagnosis and treatment

  5. SPN – History of Malignancy • What is the risk of follow-up?

  6. Primary Squamous Cell Ca. and Primary Lung Adenocarcinoma

  7. Videothoracoscopic Surgery • Finger Palpation • Easy to palpate lesions 2cm away from pleura • Intrathoracic US • Radiologic procedures- ”needle wire”, stains, radiolabelled guiding

  8. SPN- Reassurence of Patient • Surgical approach? • Follow-up? • Complications? • Mortality?

  9. Hamartoma with spiculated margins • Follow-up? • Direct surgery?

  10. History of malignancy: Breast, Colon and malignant melanomas • SPNs less than 1.5 cm • At least 2cm away from the pleura med.2.6±0.5cm • Intrathoracic US (ITUS)+finger palpation (FP) • Radio-guided tracing (RGT)+finger palpaption

  11. ITUS %96 • FP %76 • RGT %80 • Finger Palpation %80 p=NS • Finding with US med.8min., finger palpation med.6min. and radio-guided 21 min. • %40 pneumothorax with RGT • The most reliable method - ITUS

  12. 40 patients • SPN 5-10 mm • Without finger palpation • Thoracic surgical decision according to characterstics and growt rate of the SPN • RTG VATS resection • Lobectomy if malignant

  13. Total 54 patients • Peripheric lesions not visible in fluroscopy med. 2.2±0.7 cm • Intrabronchial EBUS and biopsy • Lesion was found in 48 (%89) patients • Diagnosis in 38 (%70) patients • Avoidance of 9 (%17) thoracotomy • Surgery for 16 patients

  14. %11 patients lesion was not found • Med. procedure time 12 dak. • Median 4.5 biopsies taken • 16 (%30) patients was sent for surgical biopsy

  15. Yatış Süresi

  16. VATS resections in 429 patients • Med. size 1.8cm • %54 smoker • Resection with VATS - %77 • Minithoracotomy %23 • Med. Size for malignant lesions 2.3cm • Median hospital stay 4.6days • %14 malignant lesions

  17. 129 patients with SPN • %76 minithoracotomy, %24 VATS resections, at least 2cm. Healty resection margin • Malignant lesions %63 (%47 primary, %16 secondary malignancy) • Med. Hospital stay 6 days • Mortality %2.3 • 5-year survival %66 for primary lung cancer

  18. Toplam 276 hasta %28 %50 %22

  19. Reasons for Lobectomy • Primer lung cancer • Deep SPN • Technical difficulties

  20. Uludağ University Medical Faculty Thoracic Surgery Department • 1997-2008 Total 62 patients - 24/62 (%39) Malignant - 38/62 (%61) Benign • Metastases 9/24 (%37.5) • History of malignancy in all patients • Carcinoid 2/24 (%8) • Primary Lung Ca. 13/24 (%54.5) • Thoracotmy 21/24 (%87.5) • Lobectomy 7/13 (%54) • Segmentectomy 6/13 (%46)

  21. Benign Lezyonlar 38/62 - %61 • Hamartoma 18 (%47) • Tuberculoma 12 (%31) • Benign 4 (%10) • Organizing Pneumonia 1 (%3) • Leimyoma 1 (%3) • Pseudo inflmatory Tm. 1 (%3) • Alveolar Fibrozis 1 (%3) • Thoracoscopy % 53 • Thoracotomy % 47

  22. Minithoracotomy-Wedge Resection Carcinoid Tm-Wedge

  23. Toracoscopic wedge Hamartoma

  24. Toracoscopic Segmentectomy Bronchioloalveolar carcinoma PET-SUV1.5

  25. Open excision Inf. pseudotümör

  26. VATS Wedge Adeno Ca Lobectomy

  27. Resection with full muscle sparing minithoracotomy Approx. 8-10 cm. incision

  28. Left Pneumonectomy

  29. Conclusion • Surgery in patients with malignancy history • VATS in all patients • Main problem is palpation • Finger palpation is reliable procedure • Minithoracotomy/VATS no difference • Short hospital stay (med.2.3 days) • Diagnostic value 100% • Early return to daily activities

  30. Thank You

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