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Surgery_Schwartz_4802 | Surgery_Schwartz | patients commonly have candidal pneumonia, pulmonary abscess, esophagitis, and mediastinitis. Pulmonary candidal infections typically result in an acute or chronic granulomatous reaction. Because Candida can invade blood vessel walls and a variety of tissues, systemic or disseminated infections can occur, but are less common.Treatment for candidal infection includes both fungicidal and fungistatic agents. The fungicidal medications include poly-enes (amphotericin B deoxycholate [AmB-D] and various lipid-associated amphotericin B preparations) and the echinocandins (caspofungin, micafungin, and anidulafungin). Fungistatic drugs include the triazoles (fluconazole, itraconazole, voricon-azole, and posaconazole). The availability of multiple effective therapies allows for specific tailoring of treatment, including combination regimens, based on the patient’s ability to toler-ate associated toxicities, the microbiologic information for the specific candidal species, and the route of | Surgery_Schwartz. patients commonly have candidal pneumonia, pulmonary abscess, esophagitis, and mediastinitis. Pulmonary candidal infections typically result in an acute or chronic granulomatous reaction. Because Candida can invade blood vessel walls and a variety of tissues, systemic or disseminated infections can occur, but are less common.Treatment for candidal infection includes both fungicidal and fungistatic agents. The fungicidal medications include poly-enes (amphotericin B deoxycholate [AmB-D] and various lipid-associated amphotericin B preparations) and the echinocandins (caspofungin, micafungin, and anidulafungin). Fungistatic drugs include the triazoles (fluconazole, itraconazole, voricon-azole, and posaconazole). The availability of multiple effective therapies allows for specific tailoring of treatment, including combination regimens, based on the patient’s ability to toler-ate associated toxicities, the microbiologic information for the specific candidal species, and the route of |
Surgery_Schwartz_4803 | Surgery_Schwartz | of treatment, including combination regimens, based on the patient’s ability to toler-ate associated toxicities, the microbiologic information for the specific candidal species, and the route of administration. While demonstrated efficacy is similar, the triazoles and echinocan-dins appear to have fewer side effects and are better tolerated than the other classes of antifungal drugs. The current initial recommended regimen for adults with invasive candidiasis is an echinocandin.107In addition to prompt institution of antifungal therapy, it is advisable to remove all central venous catheters as soon as can be safely achieved. For fungemia, an eye examination should be performed. Treatment should continue for at least 2 weeks after the last positive blood culture. For patients with Candida medi-astinitis (which has a mortality rate of >50%), surgical inter-vention to debride all infected tissues is required, in addition to prolonged administration of antifungal drugs.Mucormycosis The | Surgery_Schwartz. of treatment, including combination regimens, based on the patient’s ability to toler-ate associated toxicities, the microbiologic information for the specific candidal species, and the route of administration. While demonstrated efficacy is similar, the triazoles and echinocan-dins appear to have fewer side effects and are better tolerated than the other classes of antifungal drugs. The current initial recommended regimen for adults with invasive candidiasis is an echinocandin.107In addition to prompt institution of antifungal therapy, it is advisable to remove all central venous catheters as soon as can be safely achieved. For fungemia, an eye examination should be performed. Treatment should continue for at least 2 weeks after the last positive blood culture. For patients with Candida medi-astinitis (which has a mortality rate of >50%), surgical inter-vention to debride all infected tissues is required, in addition to prolonged administration of antifungal drugs.Mucormycosis The |
Surgery_Schwartz_4804 | Surgery_Schwartz | medi-astinitis (which has a mortality rate of >50%), surgical inter-vention to debride all infected tissues is required, in addition to prolonged administration of antifungal drugs.Mucormycosis The Mucor species, rare members of the class Zygomycetes, are responsible for rapidly fatal disease in immunocompromised patients. Other disease-causing spe-cies of the class Zygomycetes include Absidia, Rhizopus, and Mortierella.109 Characteristic of these fungi are nonsep-tate, branching hyphae that are difficult to culture. Infec-tion occurs via inhalation of spores. Immunocompromised patients, including patients with neutropenia, acidosis, dia-betes, and hematologic malignancy all predispose to clinical susceptibility. In the lungs, disease consists of blood vessel invasion, thrombosis, and infarction of infected organs.Tissue destruction is significant, along with cavitation and abscess formation. Initial treatment is to correct underly-ing risk factors and administer antifungal therapies, | Surgery_Schwartz. medi-astinitis (which has a mortality rate of >50%), surgical inter-vention to debride all infected tissues is required, in addition to prolonged administration of antifungal drugs.Mucormycosis The Mucor species, rare members of the class Zygomycetes, are responsible for rapidly fatal disease in immunocompromised patients. Other disease-causing spe-cies of the class Zygomycetes include Absidia, Rhizopus, and Mortierella.109 Characteristic of these fungi are nonsep-tate, branching hyphae that are difficult to culture. Infec-tion occurs via inhalation of spores. Immunocompromised patients, including patients with neutropenia, acidosis, dia-betes, and hematologic malignancy all predispose to clinical susceptibility. In the lungs, disease consists of blood vessel invasion, thrombosis, and infarction of infected organs.Tissue destruction is significant, along with cavitation and abscess formation. Initial treatment is to correct underly-ing risk factors and administer antifungal therapies, |
Surgery_Schwartz_4805 | Surgery_Schwartz | of infected organs.Tissue destruction is significant, along with cavitation and abscess formation. Initial treatment is to correct underly-ing risk factors and administer antifungal therapies, although Brunicardi_Ch19_p0661-p0750.indd 71401/03/19 7:01 PM | Surgery_Schwartz. of infected organs.Tissue destruction is significant, along with cavitation and abscess formation. Initial treatment is to correct underly-ing risk factors and administer antifungal therapies, although Brunicardi_Ch19_p0661-p0750.indd 71401/03/19 7:01 PM |
Surgery_Schwartz_4806 | Surgery_Schwartz | CHAPTER 19715CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAthe optimal duration and optimal total dose are unknown. Lipid formulations of amphotericin B are recommended at this time. Surgical resection of any localized disease should be performed after initial medical treatment attempts fail.Primary Fungal Pathogens Histoplasma capsulatum Histoplasma capsulatum is a dimor-phic fungus existing in mycelial form in soil contaminated by fowl or bat excreta and in yeast form in human hosts. The most common of all fungal pulmonary infections, histoplasmosis, primarily affects the respiratory system after spores are inhaled. It is endemic in the Midwest and Mississippi River Valley of the United States, where about 500,000 new cases arise each year. In immunocompromised patients, the infection becomes systemic and more virulent; because cell-mediated immunity is impaired, uninhibited fungal proliferation occurs within pulmo-nary macrophages and then spreads. Acute forms of the disease present as | Surgery_Schwartz. CHAPTER 19715CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAthe optimal duration and optimal total dose are unknown. Lipid formulations of amphotericin B are recommended at this time. Surgical resection of any localized disease should be performed after initial medical treatment attempts fail.Primary Fungal Pathogens Histoplasma capsulatum Histoplasma capsulatum is a dimor-phic fungus existing in mycelial form in soil contaminated by fowl or bat excreta and in yeast form in human hosts. The most common of all fungal pulmonary infections, histoplasmosis, primarily affects the respiratory system after spores are inhaled. It is endemic in the Midwest and Mississippi River Valley of the United States, where about 500,000 new cases arise each year. In immunocompromised patients, the infection becomes systemic and more virulent; because cell-mediated immunity is impaired, uninhibited fungal proliferation occurs within pulmo-nary macrophages and then spreads. Acute forms of the disease present as |
Surgery_Schwartz_4807 | Surgery_Schwartz | systemic and more virulent; because cell-mediated immunity is impaired, uninhibited fungal proliferation occurs within pulmo-nary macrophages and then spreads. Acute forms of the disease present as primary or disseminated pulmonary histoplasmosis; chronic forms present as pulmonary granulomas (histoplasmo-mas), chronic cavitary histoplasmosis, mediastinal granulomas, fibrosing mediastinitis, or bronchiolithiasis. Histoplasmosis is definitively diagnosed by fungal smear, culture, direct biopsy of infected tissues, or serologic testing.The clinical presentation depends on the inoculum size and on host factors.Symptoms of acute pulmonary histoplasmosis are fever, chills, headache, chest pain, musculoskeletal pain, and nonpro-ductive cough. CXRs may be normal or may show mediastinal lymphadenopathy and patchy parenchymal infiltrates. Most patients improve in a few weeks; mild to moderate disease can be treated with itraconazole. Amphotericin B is the treatment of choice if moderate | Surgery_Schwartz. systemic and more virulent; because cell-mediated immunity is impaired, uninhibited fungal proliferation occurs within pulmo-nary macrophages and then spreads. Acute forms of the disease present as primary or disseminated pulmonary histoplasmosis; chronic forms present as pulmonary granulomas (histoplasmo-mas), chronic cavitary histoplasmosis, mediastinal granulomas, fibrosing mediastinitis, or bronchiolithiasis. Histoplasmosis is definitively diagnosed by fungal smear, culture, direct biopsy of infected tissues, or serologic testing.The clinical presentation depends on the inoculum size and on host factors.Symptoms of acute pulmonary histoplasmosis are fever, chills, headache, chest pain, musculoskeletal pain, and nonpro-ductive cough. CXRs may be normal or may show mediastinal lymphadenopathy and patchy parenchymal infiltrates. Most patients improve in a few weeks; mild to moderate disease can be treated with itraconazole. Amphotericin B is the treatment of choice if moderate |
Surgery_Schwartz_4808 | Surgery_Schwartz | and patchy parenchymal infiltrates. Most patients improve in a few weeks; mild to moderate disease can be treated with itraconazole. Amphotericin B is the treatment of choice if moderate symptoms persist for 2 to 4 weeks or if the illness is extensive, including dyspnea and hypoxia, and if patients are immunosuppressed.110As the pulmonary infiltrates from acute histoplasmosis heal, consolidation into an asymptomatic solitary nodule or histoplasmoma may occur and is usually seen incidentally on radiographs as a coin-shaped lesion. Central and concentric calcification may occur; if so, no further treatment is required. Noncalcification of the lesion requires further diagnostic workup including chest CT scan, needle biopsy, or surgical excision to rule out a malignancy. Figure 19-34 demonstrates the differ-ences in pathologic findings between infections in normal and immunocompromised hosts.111When lymph nodes and pulmonary granulomas calcify over time, pressure atrophy on the bronchial | Surgery_Schwartz. and patchy parenchymal infiltrates. Most patients improve in a few weeks; mild to moderate disease can be treated with itraconazole. Amphotericin B is the treatment of choice if moderate symptoms persist for 2 to 4 weeks or if the illness is extensive, including dyspnea and hypoxia, and if patients are immunosuppressed.110As the pulmonary infiltrates from acute histoplasmosis heal, consolidation into an asymptomatic solitary nodule or histoplasmoma may occur and is usually seen incidentally on radiographs as a coin-shaped lesion. Central and concentric calcification may occur; if so, no further treatment is required. Noncalcification of the lesion requires further diagnostic workup including chest CT scan, needle biopsy, or surgical excision to rule out a malignancy. Figure 19-34 demonstrates the differ-ences in pathologic findings between infections in normal and immunocompromised hosts.111When lymph nodes and pulmonary granulomas calcify over time, pressure atrophy on the bronchial |
Surgery_Schwartz_4809 | Surgery_Schwartz | the differ-ences in pathologic findings between infections in normal and immunocompromised hosts.111When lymph nodes and pulmonary granulomas calcify over time, pressure atrophy on the bronchial wall may result in erosion and migration of the granulomatous mass into the bronchus, causing bronchiolithiasis. Typical symptoms include cough, hemoptysis, and dyspnea. Life-threatening complica-tions include massive hemoptysis or bronchoesophageal fistula. In addition to radiography, bronchoscopy should be performed to aid in diagnosis. Definitive treatment requires surgical exci-sion of the bronchial mass and repair of the airway and contigu-ous structures. Endobronchial debridement is not advised as this can result in massive, fatal bleeding.Fibrosing mediastinitis is an uncommon manifestation of histoplasmosis but can be fatal due to progressive distortion and compression of the major vessels and central airways.Diagnosis can be difficult, and symptoms may be present for extended periods, | Surgery_Schwartz. the differ-ences in pathologic findings between infections in normal and immunocompromised hosts.111When lymph nodes and pulmonary granulomas calcify over time, pressure atrophy on the bronchial wall may result in erosion and migration of the granulomatous mass into the bronchus, causing bronchiolithiasis. Typical symptoms include cough, hemoptysis, and dyspnea. Life-threatening complica-tions include massive hemoptysis or bronchoesophageal fistula. In addition to radiography, bronchoscopy should be performed to aid in diagnosis. Definitive treatment requires surgical exci-sion of the bronchial mass and repair of the airway and contigu-ous structures. Endobronchial debridement is not advised as this can result in massive, fatal bleeding.Fibrosing mediastinitis is an uncommon manifestation of histoplasmosis but can be fatal due to progressive distortion and compression of the major vessels and central airways.Diagnosis can be difficult, and symptoms may be present for extended periods, |
Surgery_Schwartz_4810 | Surgery_Schwartz | of histoplasmosis but can be fatal due to progressive distortion and compression of the major vessels and central airways.Diagnosis can be difficult, and symptoms may be present for extended periods, even years, before the diagnosis is made. The differential diagnosis for the disease process includes granu-lomatous mediastinitis related to recent infection, malignancy, and chronic pulmonary thromboembolism. A trial of itracon-azole is worthwhile, although it is not proven to be effective. In cases where radiographic or physiologic improvement is achieved after a trial of 12 week of therapy, continuation of therapy is con-sidered for a full 12 months. In the majority of patients, how-ever, antifungal therapy has not been proven. There is no role for corticosteroids at this time or for antifibrotics. Occasionally, intravascular stents have been helpful for severe vascular compro-mise. Balloon dilatation and endobronchial silicone stents may be needed for airway compromise, although this | Surgery_Schwartz. of histoplasmosis but can be fatal due to progressive distortion and compression of the major vessels and central airways.Diagnosis can be difficult, and symptoms may be present for extended periods, even years, before the diagnosis is made. The differential diagnosis for the disease process includes granu-lomatous mediastinitis related to recent infection, malignancy, and chronic pulmonary thromboembolism. A trial of itracon-azole is worthwhile, although it is not proven to be effective. In cases where radiographic or physiologic improvement is achieved after a trial of 12 week of therapy, continuation of therapy is con-sidered for a full 12 months. In the majority of patients, how-ever, antifungal therapy has not been proven. There is no role for corticosteroids at this time or for antifibrotics. Occasionally, intravascular stents have been helpful for severe vascular compro-mise. Balloon dilatation and endobronchial silicone stents may be needed for airway compromise, although this |
Surgery_Schwartz_4811 | Surgery_Schwartz | Occasionally, intravascular stents have been helpful for severe vascular compro-mise. Balloon dilatation and endobronchial silicone stents may be needed for airway compromise, although this should be directed by a surgeon with expertise in mediastinal and airway disease management.Chronic pulmonary histoplasmosis occurs in about 10% of patients who become symptomatic after infection. Most such patients have preexisting lung pathology, particularly emphy-sema, which becomes colonized, and subsequent pneumonitis and necrosis, cavity enlargement, new cavity formation, and pulmonary dissemination occur. Nonspecific symptoms, such as cough, sputum production, fever, weight loss, weakness, and hemoptysis are common. Chest radiography may reveal intrapulmonary cavitation and scarring. Occasionally, par-tial resolution of the inflammatory changes may be observed. Itraconazole provides effective therapy, but must be given for 12 to 24 months. It is superior to ketoconazole and fluconazole; | Surgery_Schwartz. Occasionally, intravascular stents have been helpful for severe vascular compro-mise. Balloon dilatation and endobronchial silicone stents may be needed for airway compromise, although this should be directed by a surgeon with expertise in mediastinal and airway disease management.Chronic pulmonary histoplasmosis occurs in about 10% of patients who become symptomatic after infection. Most such patients have preexisting lung pathology, particularly emphy-sema, which becomes colonized, and subsequent pneumonitis and necrosis, cavity enlargement, new cavity formation, and pulmonary dissemination occur. Nonspecific symptoms, such as cough, sputum production, fever, weight loss, weakness, and hemoptysis are common. Chest radiography may reveal intrapulmonary cavitation and scarring. Occasionally, par-tial resolution of the inflammatory changes may be observed. Itraconazole provides effective therapy, but must be given for 12 to 24 months. It is superior to ketoconazole and fluconazole; |
Surgery_Schwartz_4812 | Surgery_Schwartz | par-tial resolution of the inflammatory changes may be observed. Itraconazole provides effective therapy, but must be given for 12 to 24 months. It is superior to ketoconazole and fluconazole; these should only be used if itraconazole is not tolerated. Vori-conazole and posaconazole have been found to be useful for salvage therapy. Serum itraconazole levels should be monitored to ensure that the drug is being absorbed. Occasionally, lipid-associated amphotericin B is necessary for more severe infec-tions. Surgical excision should be considered in patients with adequate pulmonary reserve and localized, thick-walled cavities that have been unresponsive to antifungal therapy.Disseminated histoplasmosis occurs most frequently in patients who are severely immunocompromised, such as post-transplantation patients, patients with HIV, and patients using immunosuppressive medications. Presentation ranges from non-specific signs of fever, weight loss, and malaise, to shock, respi-ratory | Surgery_Schwartz. par-tial resolution of the inflammatory changes may be observed. Itraconazole provides effective therapy, but must be given for 12 to 24 months. It is superior to ketoconazole and fluconazole; these should only be used if itraconazole is not tolerated. Vori-conazole and posaconazole have been found to be useful for salvage therapy. Serum itraconazole levels should be monitored to ensure that the drug is being absorbed. Occasionally, lipid-associated amphotericin B is necessary for more severe infec-tions. Surgical excision should be considered in patients with adequate pulmonary reserve and localized, thick-walled cavities that have been unresponsive to antifungal therapy.Disseminated histoplasmosis occurs most frequently in patients who are severely immunocompromised, such as post-transplantation patients, patients with HIV, and patients using immunosuppressive medications. Presentation ranges from non-specific signs of fever, weight loss, and malaise, to shock, respi-ratory |
Surgery_Schwartz_4813 | Surgery_Schwartz | patients, patients with HIV, and patients using immunosuppressive medications. Presentation ranges from non-specific signs of fever, weight loss, and malaise, to shock, respi-ratory distress, and multiorgan failure. Diagnosis can be made with a combination of Histoplasma urine antigen, serologic assay, and fungal culture and should be suspected in patients with the above symptoms in any endemic area, particularly if the patient is immunosuppressed.112 Any of the antifungal thera-pies can be used in treatment of disseminated histoplasmosis. Use of amphotericin B has decreased the mortality rate to less than 25% in this type of serious infection.Coccidioides immitis Coccidioides immitis is an endemic fun-gus found in soil and dust of the southwestern United States. Agricultural workers, military personnel, and other occupa-tions with extensive exposure to soil, especially in areas of endemic growth, are at highest risk, as are immunocompro-mised individuals.113 Spores (arthroconidia) | Surgery_Schwartz. patients, patients with HIV, and patients using immunosuppressive medications. Presentation ranges from non-specific signs of fever, weight loss, and malaise, to shock, respi-ratory distress, and multiorgan failure. Diagnosis can be made with a combination of Histoplasma urine antigen, serologic assay, and fungal culture and should be suspected in patients with the above symptoms in any endemic area, particularly if the patient is immunosuppressed.112 Any of the antifungal thera-pies can be used in treatment of disseminated histoplasmosis. Use of amphotericin B has decreased the mortality rate to less than 25% in this type of serious infection.Coccidioides immitis Coccidioides immitis is an endemic fun-gus found in soil and dust of the southwestern United States. Agricultural workers, military personnel, and other occupa-tions with extensive exposure to soil, especially in areas of endemic growth, are at highest risk, as are immunocompro-mised individuals.113 Spores (arthroconidia) |
Surgery_Schwartz_4814 | Surgery_Schwartz | personnel, and other occupa-tions with extensive exposure to soil, especially in areas of endemic growth, are at highest risk, as are immunocompro-mised individuals.113 Spores (arthroconidia) are inhaled, swell into spherules, and subdivide into endospores, and subsequent infection develops. Diagnosis can be achieved through serum analysis for anticoccidioidal antibody, spherule identification in tissue, or by isolating the fungus in cultures from sputum, other body fluid, or tissue.Inhalation of the fungus causes pulmonary involvement in 95% of patients with symptomatic disease. Three main cat-egories of pulmonary involvement, based on the associated signs and symptoms, are possible: primary, complicated, and residual pulmonary coccidioidomycosis. Primary pulmonary Brunicardi_Ch19_p0661-p0750.indd 71501/03/19 7:01 PM 716SPECIFIC CONSIDERATIONSPART IIABCDEFFigure 19-34. Pathologic findings of infection in normal and immunocompromised hosts. Histopathologic preparations are shown | Surgery_Schwartz. personnel, and other occupa-tions with extensive exposure to soil, especially in areas of endemic growth, are at highest risk, as are immunocompro-mised individuals.113 Spores (arthroconidia) are inhaled, swell into spherules, and subdivide into endospores, and subsequent infection develops. Diagnosis can be achieved through serum analysis for anticoccidioidal antibody, spherule identification in tissue, or by isolating the fungus in cultures from sputum, other body fluid, or tissue.Inhalation of the fungus causes pulmonary involvement in 95% of patients with symptomatic disease. Three main cat-egories of pulmonary involvement, based on the associated signs and symptoms, are possible: primary, complicated, and residual pulmonary coccidioidomycosis. Primary pulmonary Brunicardi_Ch19_p0661-p0750.indd 71501/03/19 7:01 PM 716SPECIFIC CONSIDERATIONSPART IIABCDEFFigure 19-34. Pathologic findings of infection in normal and immunocompromised hosts. Histopathologic preparations are shown |
Surgery_Schwartz_4815 | Surgery_Schwartz | 71501/03/19 7:01 PM 716SPECIFIC CONSIDERATIONSPART IIABCDEFFigure 19-34. Pathologic findings of infection in normal and immunocompromised hosts. Histopathologic preparations are shown contrast-ing acute diffuse pulmonary involvement in a lung segment of a normal host with a probable primary infection (A through D) with pulmonary granulomas from an immunocompromised patient who had an opportunistic reinfection with Histoplasma capsulatum (E, F). A. Diffuse interstitial pneumonitis in an adult (normal host) with recent heavy environmental exposure and subsequent development of progressive pulmonary disease. There is an inflammatory cell infiltrate primarily involving the interalveolar interstitial spaces but present within many alveolar spaces as well. The exudate consists mostly of mononuclear phagocytes, lymphocytes, and occasional plasma cells. Many of the alveolar walls are markedly thickened (hematoxylin and eosin stain [H&E], ×50). B. Another area from the same lung as in A | Surgery_Schwartz. 71501/03/19 7:01 PM 716SPECIFIC CONSIDERATIONSPART IIABCDEFFigure 19-34. Pathologic findings of infection in normal and immunocompromised hosts. Histopathologic preparations are shown contrast-ing acute diffuse pulmonary involvement in a lung segment of a normal host with a probable primary infection (A through D) with pulmonary granulomas from an immunocompromised patient who had an opportunistic reinfection with Histoplasma capsulatum (E, F). A. Diffuse interstitial pneumonitis in an adult (normal host) with recent heavy environmental exposure and subsequent development of progressive pulmonary disease. There is an inflammatory cell infiltrate primarily involving the interalveolar interstitial spaces but present within many alveolar spaces as well. The exudate consists mostly of mononuclear phagocytes, lymphocytes, and occasional plasma cells. Many of the alveolar walls are markedly thickened (hematoxylin and eosin stain [H&E], ×50). B. Another area from the same lung as in A |
Surgery_Schwartz_4816 | Surgery_Schwartz | phagocytes, lymphocytes, and occasional plasma cells. Many of the alveolar walls are markedly thickened (hematoxylin and eosin stain [H&E], ×50). B. Another area from the same lung as in A showing focal vasculitis with an infiltrate of lymphocytes and macrophages (H&E, ×25). C. Relatively large alveolar macrophages packed with single and budding yeasts 2 to 4 µm in diameter (same lung as in A and B). The basophilic cytoplasm of these yeasts is retracted from their thin outer cell walls, leaving halo-like clear areas that can be confused with capsules (H&E, ×500). D. Intracellular and extracellular yeasts, 2 to 4 µm in diameter, some of which are single, budding, or in short chains (Gomori methenamine silver stain, ×500). E. Nonnecrotizing (sometimes called epithelioid cell or noncaseating) granuloma from a patient who had recently received chemotherapy for a germ cell tumor (different patient than in A through D). This lesion consists of a focal collection of macrophages (sometimes | Surgery_Schwartz. phagocytes, lymphocytes, and occasional plasma cells. Many of the alveolar walls are markedly thickened (hematoxylin and eosin stain [H&E], ×50). B. Another area from the same lung as in A showing focal vasculitis with an infiltrate of lymphocytes and macrophages (H&E, ×25). C. Relatively large alveolar macrophages packed with single and budding yeasts 2 to 4 µm in diameter (same lung as in A and B). The basophilic cytoplasm of these yeasts is retracted from their thin outer cell walls, leaving halo-like clear areas that can be confused with capsules (H&E, ×500). D. Intracellular and extracellular yeasts, 2 to 4 µm in diameter, some of which are single, budding, or in short chains (Gomori methenamine silver stain, ×500). E. Nonnecrotizing (sometimes called epithelioid cell or noncaseating) granuloma from a patient who had recently received chemotherapy for a germ cell tumor (different patient than in A through D). This lesion consists of a focal collection of macrophages (sometimes |
Surgery_Schwartz_4817 | Surgery_Schwartz | granuloma from a patient who had recently received chemotherapy for a germ cell tumor (different patient than in A through D). This lesion consists of a focal collection of macrophages (sometimes referred to as histiocytes or epithelioid cells) plus lymphocytes and occasional plasma cells. A few multinucleated macrophages are present. A thin layer of fibroblasts circumscribes the lesion. Yeasts of H capsulatum, probably present within macrophages of this lesion at an earlier stage, were not identified in this granuloma or in any of several other nonnecrotizing granulomas within the specimen. Lesions of this type often undergo necrosis to become necrotiz-ing granulomas (H&E, ×50). F. Necrotizing (sometimes referred to as caseating) granuloma from the same lung as in E. This lesion has a necrotic center surrounded by macrophages, encapsulating fibroblasts, fibrous connective tissue in the periphery, and scattered lymphocytes. A prominent giant cell is present in the lower left of the | Surgery_Schwartz. granuloma from a patient who had recently received chemotherapy for a germ cell tumor (different patient than in A through D). This lesion consists of a focal collection of macrophages (sometimes referred to as histiocytes or epithelioid cells) plus lymphocytes and occasional plasma cells. A few multinucleated macrophages are present. A thin layer of fibroblasts circumscribes the lesion. Yeasts of H capsulatum, probably present within macrophages of this lesion at an earlier stage, were not identified in this granuloma or in any of several other nonnecrotizing granulomas within the specimen. Lesions of this type often undergo necrosis to become necrotiz-ing granulomas (H&E, ×50). F. Necrotizing (sometimes referred to as caseating) granuloma from the same lung as in E. This lesion has a necrotic center surrounded by macrophages, encapsulating fibroblasts, fibrous connective tissue in the periphery, and scattered lymphocytes. A prominent giant cell is present in the lower left of the |
Surgery_Schwartz_4818 | Surgery_Schwartz | necrotic center surrounded by macrophages, encapsulating fibroblasts, fibrous connective tissue in the periphery, and scattered lymphocytes. A prominent giant cell is present in the lower left of the granuloma (at approximately 8 o’clock). Microorganisms are usually present only in relatively small numbers in these types of lesions. They are most frequently detected within the most central necrotic material in these granulomas (H&E, ×25). (Reproduced with permission from Hage CA, Wheat LJ, Loyd J, et al: Pulmonary histoplasmosis, Semin Respir Crit Care Med. 2008 Apr;29(2):151-165.)Brunicardi_Ch19_p0661-p0750.indd 71601/03/19 7:01 PM | Surgery_Schwartz. necrotic center surrounded by macrophages, encapsulating fibroblasts, fibrous connective tissue in the periphery, and scattered lymphocytes. A prominent giant cell is present in the lower left of the granuloma (at approximately 8 o’clock). Microorganisms are usually present only in relatively small numbers in these types of lesions. They are most frequently detected within the most central necrotic material in these granulomas (H&E, ×25). (Reproduced with permission from Hage CA, Wheat LJ, Loyd J, et al: Pulmonary histoplasmosis, Semin Respir Crit Care Med. 2008 Apr;29(2):151-165.)Brunicardi_Ch19_p0661-p0750.indd 71601/03/19 7:01 PM |
Surgery_Schwartz_4819 | Surgery_Schwartz | CHAPTER 19717CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAcoccidioidomycosis occurs in about 40% of people who inhale spores. The other 60% will remain asymptomatic and develop life-long immunity. The constellation of symptoms of “valley fever,” including fever, chills, headache, erythema multiforme, erythema nodosum, polyarthralgias, nonproductive cough, and chest pain, and a CXR showing hilar and paratracheal adenopa-thy are highly suggestive of pulmonary coccidioidomycosis. In many patients, initial diagnosis is community-acquired pneumo-nia, and it is only when the patient fails to respond to appropriate antibiotic therapy that pulmonary coccidioidomycosis is consid-ered. The disease is self-limited in the majority of patients, and treatment is not required in these cases.Therapy should be considered for (a) patients with impaired cellular immunity; (b) comorbid illnesses that are adversely impacted by the infection, including chronic pulmo-nary dysfunction, renal failure, and | Surgery_Schwartz. CHAPTER 19717CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAcoccidioidomycosis occurs in about 40% of people who inhale spores. The other 60% will remain asymptomatic and develop life-long immunity. The constellation of symptoms of “valley fever,” including fever, chills, headache, erythema multiforme, erythema nodosum, polyarthralgias, nonproductive cough, and chest pain, and a CXR showing hilar and paratracheal adenopa-thy are highly suggestive of pulmonary coccidioidomycosis. In many patients, initial diagnosis is community-acquired pneumo-nia, and it is only when the patient fails to respond to appropriate antibiotic therapy that pulmonary coccidioidomycosis is consid-ered. The disease is self-limited in the majority of patients, and treatment is not required in these cases.Therapy should be considered for (a) patients with impaired cellular immunity; (b) comorbid illnesses that are adversely impacted by the infection, including chronic pulmo-nary dysfunction, renal failure, and |
Surgery_Schwartz_4820 | Surgery_Schwartz | be considered for (a) patients with impaired cellular immunity; (b) comorbid illnesses that are adversely impacted by the infection, including chronic pulmo-nary dysfunction, renal failure, and congestive heart failure; and (c) when symptoms and radiographic findings persist for more than 6 to 8 weeks, at which time the disease is considered to be persistent coccidioidal pneumonia and occurs in approximately 1% of patients. Progression to caseous nodules, cavities, and calcified, fibrotic, or ossified lesions indicates complicated or residual stages of coccidioidomycosis.There are several relative indications for surgery in pulmo-nary coccidioidomycosis. A rapidly expanding (>4 cm) cavity that is close to the visceral pleura is a high risk for rupture into the pleural space and subsequent empyema. Other indications for operative intervention include life-threatening hemoptysis; hemoptysis that is persistent despite medical therapy; symptom-atic fungus ball; bronchopleural fistula; | Surgery_Schwartz. be considered for (a) patients with impaired cellular immunity; (b) comorbid illnesses that are adversely impacted by the infection, including chronic pulmo-nary dysfunction, renal failure, and congestive heart failure; and (c) when symptoms and radiographic findings persist for more than 6 to 8 weeks, at which time the disease is considered to be persistent coccidioidal pneumonia and occurs in approximately 1% of patients. Progression to caseous nodules, cavities, and calcified, fibrotic, or ossified lesions indicates complicated or residual stages of coccidioidomycosis.There are several relative indications for surgery in pulmo-nary coccidioidomycosis. A rapidly expanding (>4 cm) cavity that is close to the visceral pleura is a high risk for rupture into the pleural space and subsequent empyema. Other indications for operative intervention include life-threatening hemoptysis; hemoptysis that is persistent despite medical therapy; symptom-atic fungus ball; bronchopleural fistula; |
Surgery_Schwartz_4821 | Surgery_Schwartz | empyema. Other indications for operative intervention include life-threatening hemoptysis; hemoptysis that is persistent despite medical therapy; symptom-atic fungus ball; bronchopleural fistula; cavitary lesions with persistent positive sputum; and pulmonary nodules that degen-erate over time. Finally, any nodule with signs that are concern-ing for malignancy should undergo further evaluation, including biopsy or resection, to determine the underlying etiology.Diagnosis of coccidioidomycosis is confirmed by histo-pathologic, mycologic, and serologic evaluation. Extrapulmo-nary disease may develop in approximately 0.5% of infected patients, with involvement of meninges, bones, joints, skin, or soft tissues. Immunocompromised patients are especially sus-ceptible to disseminated coccidioidomycosis, which carries a mortality rate over 40%. Treatment options for this disease vary depending on the severity of the disease as well as the stage. Amphotericin B deoxycholate or the triazoles | Surgery_Schwartz. empyema. Other indications for operative intervention include life-threatening hemoptysis; hemoptysis that is persistent despite medical therapy; symptom-atic fungus ball; bronchopleural fistula; cavitary lesions with persistent positive sputum; and pulmonary nodules that degen-erate over time. Finally, any nodule with signs that are concern-ing for malignancy should undergo further evaluation, including biopsy or resection, to determine the underlying etiology.Diagnosis of coccidioidomycosis is confirmed by histo-pathologic, mycologic, and serologic evaluation. Extrapulmo-nary disease may develop in approximately 0.5% of infected patients, with involvement of meninges, bones, joints, skin, or soft tissues. Immunocompromised patients are especially sus-ceptible to disseminated coccidioidomycosis, which carries a mortality rate over 40%. Treatment options for this disease vary depending on the severity of the disease as well as the stage. Amphotericin B deoxycholate or the triazoles |
Surgery_Schwartz_4822 | Surgery_Schwartz | which carries a mortality rate over 40%. Treatment options for this disease vary depending on the severity of the disease as well as the stage. Amphotericin B deoxycholate or the triazoles continue to be the primary antifungal medications. If meningeal involvement is identified, fluconazole or itraconazole therapy is required for the remainder of the patient’s life. Intrathecal amphotericin B can also be administered in some cases.Blastomyces dermatitidis Blastomyces dermatitidis is a round, single-budding yeast with a characteristic thick, refrac-tile cell wall. It resides in the soil as a nonmotile spore called conidia. Exposure occurs when contaminated soil is disturbed and the conidia are aerosolized. The spore is inhaled and trans-forms into a yeast phase at body temperature.114 Infection is typically self-limited. A small minority of patients will develop chronic pulmonary infection or disseminated disease, includ-ing cutaneous, osteoarticular, and genitourinary involvement. B | Surgery_Schwartz. which carries a mortality rate over 40%. Treatment options for this disease vary depending on the severity of the disease as well as the stage. Amphotericin B deoxycholate or the triazoles continue to be the primary antifungal medications. If meningeal involvement is identified, fluconazole or itraconazole therapy is required for the remainder of the patient’s life. Intrathecal amphotericin B can also be administered in some cases.Blastomyces dermatitidis Blastomyces dermatitidis is a round, single-budding yeast with a characteristic thick, refrac-tile cell wall. It resides in the soil as a nonmotile spore called conidia. Exposure occurs when contaminated soil is disturbed and the conidia are aerosolized. The spore is inhaled and trans-forms into a yeast phase at body temperature.114 Infection is typically self-limited. A small minority of patients will develop chronic pulmonary infection or disseminated disease, includ-ing cutaneous, osteoarticular, and genitourinary involvement. B |
Surgery_Schwartz_4823 | Surgery_Schwartz | is typically self-limited. A small minority of patients will develop chronic pulmonary infection or disseminated disease, includ-ing cutaneous, osteoarticular, and genitourinary involvement. B dermatitidis has a worldwide distribution; in the United States, it is endemic in the central states.115 With chronic infec-tion, the organism induces a granulomatous and pyogenic reac-tion with microabscesses and giant cells; caseation, cavitation, and fibrosis may also occur. Symptoms are nonspecific and con-sistent with chronic pneumonia in 60% to 90% of patients. They include cough, mucoid sputum production, chest pain, fever, malaise, weight loss, and, uncommonly, hemoptysis. In acute disease, radiographs are either completely negative or have nonspecific findings; in chronic disease, fibronodular lesions (with or without cavitation) similar to tuberculosis are noted. Pulmonary parenchymal abnormalities in the upper lobe(s) may be noted. Mass lesions similar to carcinoma are frequent, and | Surgery_Schwartz. is typically self-limited. A small minority of patients will develop chronic pulmonary infection or disseminated disease, includ-ing cutaneous, osteoarticular, and genitourinary involvement. B dermatitidis has a worldwide distribution; in the United States, it is endemic in the central states.115 With chronic infec-tion, the organism induces a granulomatous and pyogenic reac-tion with microabscesses and giant cells; caseation, cavitation, and fibrosis may also occur. Symptoms are nonspecific and con-sistent with chronic pneumonia in 60% to 90% of patients. They include cough, mucoid sputum production, chest pain, fever, malaise, weight loss, and, uncommonly, hemoptysis. In acute disease, radiographs are either completely negative or have nonspecific findings; in chronic disease, fibronodular lesions (with or without cavitation) similar to tuberculosis are noted. Pulmonary parenchymal abnormalities in the upper lobe(s) may be noted. Mass lesions similar to carcinoma are frequent, and |
Surgery_Schwartz_4824 | Surgery_Schwartz | lesions (with or without cavitation) similar to tuberculosis are noted. Pulmonary parenchymal abnormalities in the upper lobe(s) may be noted. Mass lesions similar to carcinoma are frequent, and lung biopsy is frequently used. Over 50% of patients with chronic blastomycosis also have extrapulmonary manifesta-tions, but less than 10% of patients present with severe clinical manifestation.114Once a patient manifests symptoms of chronic blastomy-cosis, antifungal treatment is required to achieve resolution. Mortality approaches 60% if untreated.114 While controversial, a short course of triazole therapy (oral itraconazole 200 mg daily) for 6 months is the treatment of choice for most patients with mild to moderate forms of the disease. Because itraconazole has poor CNS penetration, the most common site of recurrence after apparently successful therapy is in the CNS. In the absence of therapy, close follow-up is warranted for evidence of progres-sion to chronic or extrapulmonary disease. | Surgery_Schwartz. lesions (with or without cavitation) similar to tuberculosis are noted. Pulmonary parenchymal abnormalities in the upper lobe(s) may be noted. Mass lesions similar to carcinoma are frequent, and lung biopsy is frequently used. Over 50% of patients with chronic blastomycosis also have extrapulmonary manifesta-tions, but less than 10% of patients present with severe clinical manifestation.114Once a patient manifests symptoms of chronic blastomy-cosis, antifungal treatment is required to achieve resolution. Mortality approaches 60% if untreated.114 While controversial, a short course of triazole therapy (oral itraconazole 200 mg daily) for 6 months is the treatment of choice for most patients with mild to moderate forms of the disease. Because itraconazole has poor CNS penetration, the most common site of recurrence after apparently successful therapy is in the CNS. In the absence of therapy, close follow-up is warranted for evidence of progres-sion to chronic or extrapulmonary disease. |
Surgery_Schwartz_4825 | Surgery_Schwartz | common site of recurrence after apparently successful therapy is in the CNS. In the absence of therapy, close follow-up is warranted for evidence of progres-sion to chronic or extrapulmonary disease. Amphotericin B is warranted for patients with severe or life-threatening disease, CNS involvement, disseminated disease, or extensive lung involvement and in immunocompromised patients. After ade-quate drug therapy, surgical resection of known cavitary lesions should be considered because viable organisms are known to persist in such lesions.Massive HemoptysisMassive hemoptysis is generally defined as expectoration of over 600 mL of blood within a 24-hour period. It is a medi-cal emergency associated with a mortality rate of 30% to 50%. Most clinicians would agree that losing over a liter of blood via the airway within 1 day is significant, yet use of an abso-lute volume criterion presents difficulties. First, it is difficult for the patient or caregivers to quantify the volume of blood | Surgery_Schwartz. common site of recurrence after apparently successful therapy is in the CNS. In the absence of therapy, close follow-up is warranted for evidence of progres-sion to chronic or extrapulmonary disease. Amphotericin B is warranted for patients with severe or life-threatening disease, CNS involvement, disseminated disease, or extensive lung involvement and in immunocompromised patients. After ade-quate drug therapy, surgical resection of known cavitary lesions should be considered because viable organisms are known to persist in such lesions.Massive HemoptysisMassive hemoptysis is generally defined as expectoration of over 600 mL of blood within a 24-hour period. It is a medi-cal emergency associated with a mortality rate of 30% to 50%. Most clinicians would agree that losing over a liter of blood via the airway within 1 day is significant, yet use of an abso-lute volume criterion presents difficulties. First, it is difficult for the patient or caregivers to quantify the volume of blood |
Surgery_Schwartz_4826 | Surgery_Schwartz | blood via the airway within 1 day is significant, yet use of an abso-lute volume criterion presents difficulties. First, it is difficult for the patient or caregivers to quantify the volume of blood being lost. Second, and most relevant, the rate of bleeding nec-essary to incite respiratory compromise is highly dependent on the individual’s prior respiratory status. For example, the loss of 100 mL of blood over 24 hours in a 40-year-old male with normal pulmonary function would be of little immediate con-sequence, because his normal cough would ensure his ability to clear the blood and secretions. In contrast, the same amount of bleeding in a 69-year-old male with severe COPD, chronic bronchitis, and an FEV1 of 1.1 L may be life-threatening.Anatomy. The lungs have two sources of blood supply: the pulmonary and bronchial arterial systems. The pulmonary sys-tem is a high-compliance, low-pressure system, and the walls of the pulmonary arteries are very thin and delicate. The bronchial | Surgery_Schwartz. blood via the airway within 1 day is significant, yet use of an abso-lute volume criterion presents difficulties. First, it is difficult for the patient or caregivers to quantify the volume of blood being lost. Second, and most relevant, the rate of bleeding nec-essary to incite respiratory compromise is highly dependent on the individual’s prior respiratory status. For example, the loss of 100 mL of blood over 24 hours in a 40-year-old male with normal pulmonary function would be of little immediate con-sequence, because his normal cough would ensure his ability to clear the blood and secretions. In contrast, the same amount of bleeding in a 69-year-old male with severe COPD, chronic bronchitis, and an FEV1 of 1.1 L may be life-threatening.Anatomy. The lungs have two sources of blood supply: the pulmonary and bronchial arterial systems. The pulmonary sys-tem is a high-compliance, low-pressure system, and the walls of the pulmonary arteries are very thin and delicate. The bronchial |
Surgery_Schwartz_4827 | Surgery_Schwartz | the pulmonary and bronchial arterial systems. The pulmonary sys-tem is a high-compliance, low-pressure system, and the walls of the pulmonary arteries are very thin and delicate. The bronchial arteries, part of the systemic circulation, have systemic pres-sures and thick walls; most branches originate from the proxi-mal thoracic aorta. Most cases of massive hemoptysis involve bleeding from the bronchial artery circulation or from the pul-monary circulation pathologically exposed to the high pres-sures of the bronchial circulation. In many cases of hemoptysis, particularly those due to inflammatory disorders, the bronchial arterial tree becomes hyperplastic and tortuous. The systemic pressures within these arteries, combined with a disease process within the airway and erosion, lead to bleeding.Causes. Significant hemoptysis has many causes, most com-monly including pulmonary, extrapulmonary, and iatrogenic. Table 19-20 summarizes the most common causes of hemopty-sis. Most are | Surgery_Schwartz. the pulmonary and bronchial arterial systems. The pulmonary sys-tem is a high-compliance, low-pressure system, and the walls of the pulmonary arteries are very thin and delicate. The bronchial arteries, part of the systemic circulation, have systemic pres-sures and thick walls; most branches originate from the proxi-mal thoracic aorta. Most cases of massive hemoptysis involve bleeding from the bronchial artery circulation or from the pul-monary circulation pathologically exposed to the high pres-sures of the bronchial circulation. In many cases of hemoptysis, particularly those due to inflammatory disorders, the bronchial arterial tree becomes hyperplastic and tortuous. The systemic pressures within these arteries, combined with a disease process within the airway and erosion, lead to bleeding.Causes. Significant hemoptysis has many causes, most com-monly including pulmonary, extrapulmonary, and iatrogenic. Table 19-20 summarizes the most common causes of hemopty-sis. Most are |
Surgery_Schwartz_4828 | Surgery_Schwartz | to bleeding.Causes. Significant hemoptysis has many causes, most com-monly including pulmonary, extrapulmonary, and iatrogenic. Table 19-20 summarizes the most common causes of hemopty-sis. Most are secondary to inflammatory processes. Aneurysms Brunicardi_Ch19_p0661-p0750.indd 71701/03/19 7:01 PM 718SPECIFIC CONSIDERATIONSPART IITable 19-20Pulmonary and extrapulmonary causes of massive hemoptysisPULMONARYEXTRAPULMONARYIATROGENICPulmonary parenchymal diseaseBronchitisBronchiectasisTuberculosisLung abscessPneumoniaCavitary fungal infection (e.g., aspergilloma)Lung parasitic infection (ascariasis, schistosomiasis, paragonimiasis)Pulmonary neoplasmPulmonary infarction or embolismTraumaArteriovenous malformationPulmonary vasculitisPulmonary endometriosisWegener’s granulomatosisCystic fibrosisPulmonary hemosiderosisCongestive heart failureCoagulopathyMitral stenosisMedicationsIntrapulmonary catheterTable 19-21Treatment priorities in the management of massive hemoptysis 1. Achieve | Surgery_Schwartz. to bleeding.Causes. Significant hemoptysis has many causes, most com-monly including pulmonary, extrapulmonary, and iatrogenic. Table 19-20 summarizes the most common causes of hemopty-sis. Most are secondary to inflammatory processes. Aneurysms Brunicardi_Ch19_p0661-p0750.indd 71701/03/19 7:01 PM 718SPECIFIC CONSIDERATIONSPART IITable 19-20Pulmonary and extrapulmonary causes of massive hemoptysisPULMONARYEXTRAPULMONARYIATROGENICPulmonary parenchymal diseaseBronchitisBronchiectasisTuberculosisLung abscessPneumoniaCavitary fungal infection (e.g., aspergilloma)Lung parasitic infection (ascariasis, schistosomiasis, paragonimiasis)Pulmonary neoplasmPulmonary infarction or embolismTraumaArteriovenous malformationPulmonary vasculitisPulmonary endometriosisWegener’s granulomatosisCystic fibrosisPulmonary hemosiderosisCongestive heart failureCoagulopathyMitral stenosisMedicationsIntrapulmonary catheterTable 19-21Treatment priorities in the management of massive hemoptysis 1. Achieve |
Surgery_Schwartz_4829 | Surgery_Schwartz | fibrosisPulmonary hemosiderosisCongestive heart failureCoagulopathyMitral stenosisMedicationsIntrapulmonary catheterTable 19-21Treatment priorities in the management of massive hemoptysis 1. Achieve respiratory stabilization and prevent asphyxiation. 2. Localize the bleeding site. 3. Control the hemorrhage. 4. Determine the cause. 5. Definitively prevent recurrence.of the pulmonary artery (referred to as Rasmussen’s aneurysm) can develop within pulmonary cavities and can result in massive bleeding. Hemoptysis due to lung cancer is usually mild, result-ing in blood-streaked sputum. Massive hemoptysis in patients with lung cancer is typically caused by malignant invasion of pulmonary artery vessels by large central tumors. Although rare, it is often a terminal event.Management. Life-threatening hemoptysis is best managed by a multidisciplinary team of intensive care physicians, interven-tional radiologists, and thoracic surgeons. Treatment priorities begin with respiratory | Surgery_Schwartz. fibrosisPulmonary hemosiderosisCongestive heart failureCoagulopathyMitral stenosisMedicationsIntrapulmonary catheterTable 19-21Treatment priorities in the management of massive hemoptysis 1. Achieve respiratory stabilization and prevent asphyxiation. 2. Localize the bleeding site. 3. Control the hemorrhage. 4. Determine the cause. 5. Definitively prevent recurrence.of the pulmonary artery (referred to as Rasmussen’s aneurysm) can develop within pulmonary cavities and can result in massive bleeding. Hemoptysis due to lung cancer is usually mild, result-ing in blood-streaked sputum. Massive hemoptysis in patients with lung cancer is typically caused by malignant invasion of pulmonary artery vessels by large central tumors. Although rare, it is often a terminal event.Management. Life-threatening hemoptysis is best managed by a multidisciplinary team of intensive care physicians, interven-tional radiologists, and thoracic surgeons. Treatment priorities begin with respiratory |
Surgery_Schwartz_4830 | Surgery_Schwartz | hemoptysis is best managed by a multidisciplinary team of intensive care physicians, interven-tional radiologists, and thoracic surgeons. Treatment priorities begin with respiratory stabilization; intubation with isolation of the bleeding lung may be required to prevent asphyxiation. This can be done with main-stem intubation into the nonbleeding lung, endobronchial blockers into the bleeding lung, or double-lumen endotracheal intubation, depending on the urgency of the situation and the expertise of the providers. Once adequate ven-tilation has been achieved, the bleeding site should be localized; bronchoscopy can often provide direct visualization of blood coming from a specific area of the tracheobronchial anatomy. Control of the hemorrhage is then achieved endobronchially with laser or bronchial occlusion, endovascularly with bronchial and/or pulmonary artery embolization, or surgically with resec-tion of the involved area.116 The order of priorities in manage-ment is detailed in | Surgery_Schwartz. hemoptysis is best managed by a multidisciplinary team of intensive care physicians, interven-tional radiologists, and thoracic surgeons. Treatment priorities begin with respiratory stabilization; intubation with isolation of the bleeding lung may be required to prevent asphyxiation. This can be done with main-stem intubation into the nonbleeding lung, endobronchial blockers into the bleeding lung, or double-lumen endotracheal intubation, depending on the urgency of the situation and the expertise of the providers. Once adequate ven-tilation has been achieved, the bleeding site should be localized; bronchoscopy can often provide direct visualization of blood coming from a specific area of the tracheobronchial anatomy. Control of the hemorrhage is then achieved endobronchially with laser or bronchial occlusion, endovascularly with bronchial and/or pulmonary artery embolization, or surgically with resec-tion of the involved area.116 The order of priorities in manage-ment is detailed in |
Surgery_Schwartz_4831 | Surgery_Schwartz | bronchial occlusion, endovascularly with bronchial and/or pulmonary artery embolization, or surgically with resec-tion of the involved area.116 The order of priorities in manage-ment is detailed in Table 19-21.The clinically pragmatic definition of massive hemoptysis is a degree of bleeding that threatens respiratory stability. There-fore, clinical judgment of respiratory compromise is the first step in evaluating a patient.117,118 Two scenarios are possible: (a) bleeding is significant and persistent, but its rate allows a rapid but sequential diagnostic and therapeutic approach, and (b) bleeding is so rapid that emergency airway control and ther-apy are necessary.Scenario 1: Significant, Persistent, but Nonmassive Bleeding Although bleeding is brisk in scenario 1, the patient may be able to maintain clearance of the blood and secretions with his or her own respiratory reflexes. Immediate measures are admission to an intensive care unit; strict bed rest; Trendelenburg position-ing | Surgery_Schwartz. bronchial occlusion, endovascularly with bronchial and/or pulmonary artery embolization, or surgically with resec-tion of the involved area.116 The order of priorities in manage-ment is detailed in Table 19-21.The clinically pragmatic definition of massive hemoptysis is a degree of bleeding that threatens respiratory stability. There-fore, clinical judgment of respiratory compromise is the first step in evaluating a patient.117,118 Two scenarios are possible: (a) bleeding is significant and persistent, but its rate allows a rapid but sequential diagnostic and therapeutic approach, and (b) bleeding is so rapid that emergency airway control and ther-apy are necessary.Scenario 1: Significant, Persistent, but Nonmassive Bleeding Although bleeding is brisk in scenario 1, the patient may be able to maintain clearance of the blood and secretions with his or her own respiratory reflexes. Immediate measures are admission to an intensive care unit; strict bed rest; Trendelenburg position-ing |
Surgery_Schwartz_4832 | Surgery_Schwartz | to maintain clearance of the blood and secretions with his or her own respiratory reflexes. Immediate measures are admission to an intensive care unit; strict bed rest; Trendelenburg position-ing with the affected side down (if known); administration of humidified oxygen; cough suppression; monitoring of oxygen saturation and arterial blood gases; and insertion of large-bore intravenous catheters. Strict bed rest with sedation may lead to slowing or cessation of bleeding, and the judicious use of intravenous narcotics or other relaxants to mildly sedate the patient and diminish some of the reflexive airway activity is often necessary. Also recommended are administration of aero-solized adrenaline, intravenous antibiotic therapy if needed, and correction of abnormal blood coagulation study results. Finally, unless contraindicated, intravenous vasopressin (20 U over 15 minutes, followed by an infusion of 0.2 U/min) can be given.A CXR is the first test and often proves to be the most | Surgery_Schwartz. to maintain clearance of the blood and secretions with his or her own respiratory reflexes. Immediate measures are admission to an intensive care unit; strict bed rest; Trendelenburg position-ing with the affected side down (if known); administration of humidified oxygen; cough suppression; monitoring of oxygen saturation and arterial blood gases; and insertion of large-bore intravenous catheters. Strict bed rest with sedation may lead to slowing or cessation of bleeding, and the judicious use of intravenous narcotics or other relaxants to mildly sedate the patient and diminish some of the reflexive airway activity is often necessary. Also recommended are administration of aero-solized adrenaline, intravenous antibiotic therapy if needed, and correction of abnormal blood coagulation study results. Finally, unless contraindicated, intravenous vasopressin (20 U over 15 minutes, followed by an infusion of 0.2 U/min) can be given.A CXR is the first test and often proves to be the most |
Surgery_Schwartz_4833 | Surgery_Schwartz | results. Finally, unless contraindicated, intravenous vasopressin (20 U over 15 minutes, followed by an infusion of 0.2 U/min) can be given.A CXR is the first test and often proves to be the most revealing. Localized lesions may be seen, but the effects of blood soiling of other areas of the lungs may predominate, obscuring the area of pathology. Chest CT scan provides more detail and is nearly always performed if the patient is stable. Pathologic areas may be obscured by blood soiling.Flexible bronchoscopy is the next step in evaluating the patient’s condition. Some clinicians argue that rigid bronchos-copy should always be performed. However, if the patient is clinically stable and the ongoing bleeding is not imminently threatening, flexible bronchoscopy is appropriate. It allows diagnosis of airway abnormalities and will usually permit Brunicardi_Ch19_p0661-p0750.indd 71801/03/19 7:01 PM | Surgery_Schwartz. results. Finally, unless contraindicated, intravenous vasopressin (20 U over 15 minutes, followed by an infusion of 0.2 U/min) can be given.A CXR is the first test and often proves to be the most revealing. Localized lesions may be seen, but the effects of blood soiling of other areas of the lungs may predominate, obscuring the area of pathology. Chest CT scan provides more detail and is nearly always performed if the patient is stable. Pathologic areas may be obscured by blood soiling.Flexible bronchoscopy is the next step in evaluating the patient’s condition. Some clinicians argue that rigid bronchos-copy should always be performed. However, if the patient is clinically stable and the ongoing bleeding is not imminently threatening, flexible bronchoscopy is appropriate. It allows diagnosis of airway abnormalities and will usually permit Brunicardi_Ch19_p0661-p0750.indd 71801/03/19 7:01 PM |
Surgery_Schwartz_4834 | Surgery_Schwartz | CHAPTER 19719CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAlocalization of the bleeding site to either a lobe or even a seg-ment. The person performing the bronchoscopy must be pre-pared with excellent suction and must be able to perform saline lavage with a dilute solution of epinephrine.Most cases of massive hemoptysis arise from the bron-chial arterial tree; therefore, the next therapeutic option fre-quently is selective bronchial arteriography and embolization. Prearteriogram bronchoscopy is extremely useful to direct the angiographer. However, if bronchoscopy fails to localize the bleeding site, then bilateral bronchial arterio-grams can be performed. More recently, use of multidetec-tor CT angiography in patients with hemoptysis that is not immediately life-threatening has been shown to facilitate endovascular intervention; reformatting of the images in mul-tiple projections allows clear delineation of the pulmonary vascular anatomy.105 With this approach, abnormal bronchial and | Surgery_Schwartz. CHAPTER 19719CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAlocalization of the bleeding site to either a lobe or even a seg-ment. The person performing the bronchoscopy must be pre-pared with excellent suction and must be able to perform saline lavage with a dilute solution of epinephrine.Most cases of massive hemoptysis arise from the bron-chial arterial tree; therefore, the next therapeutic option fre-quently is selective bronchial arteriography and embolization. Prearteriogram bronchoscopy is extremely useful to direct the angiographer. However, if bronchoscopy fails to localize the bleeding site, then bilateral bronchial arterio-grams can be performed. More recently, use of multidetec-tor CT angiography in patients with hemoptysis that is not immediately life-threatening has been shown to facilitate endovascular intervention; reformatting of the images in mul-tiple projections allows clear delineation of the pulmonary vascular anatomy.105 With this approach, abnormal bronchial and |
Surgery_Schwartz_4835 | Surgery_Schwartz | to facilitate endovascular intervention; reformatting of the images in mul-tiple projections allows clear delineation of the pulmonary vascular anatomy.105 With this approach, abnormal bronchial and nonbronchial arteries can be visualized and subsequently targeted for therapeutic arterial embolization.119 Once the tar-geted arterial system has been embolized, immediate control and cessation of the hemoptysis is achieved in more than 80% of patients. If bleeding persists after bronchial artery emboli-zation, a pulmonary artery source should be suspected and a pulmonary angiogram performed at the same setting.Recurrence is seen in 30% to 60% of cases and is very common in the setting of invasive fungal infections such as aspergilloma. Recurrence after bronchial artery embolization is less common in the setting of malignancy and active tuberculo-sis but does occur and can ultimately result in patient death.120 Repeat embolization can be effective and is warranted for ini-tial management | Surgery_Schwartz. to facilitate endovascular intervention; reformatting of the images in mul-tiple projections allows clear delineation of the pulmonary vascular anatomy.105 With this approach, abnormal bronchial and nonbronchial arteries can be visualized and subsequently targeted for therapeutic arterial embolization.119 Once the tar-geted arterial system has been embolized, immediate control and cessation of the hemoptysis is achieved in more than 80% of patients. If bleeding persists after bronchial artery emboli-zation, a pulmonary artery source should be suspected and a pulmonary angiogram performed at the same setting.Recurrence is seen in 30% to 60% of cases and is very common in the setting of invasive fungal infections such as aspergilloma. Recurrence after bronchial artery embolization is less common in the setting of malignancy and active tuberculo-sis but does occur and can ultimately result in patient death.120 Repeat embolization can be effective and is warranted for ini-tial management |
Surgery_Schwartz_4836 | Surgery_Schwartz | in the setting of malignancy and active tuberculo-sis but does occur and can ultimately result in patient death.120 Repeat embolization can be effective and is warranted for ini-tial management of recurrent hemoptysis, but early surgical intervention should be considered, particularly in the setting of aspergilloma or other cavitary lesions.105If respiratory compromise is impending, orotracheal intu-bation should be performed. After intubation, flexible bronchos-copy should be performed to clear blood and secretions and to attempt localization of the bleeding site. Depending on the pos-sible causes of the bleeding, bronchial artery embolization or (if appropriate) surgery can be considered.Scenario 2: Significant, Persistent, and Massive Bleeding Life-threatening bleeding requires emergency airway control and preparation for potential surgery. Such patients are best cared for in an operating room equipped with rigid bronchos-copy. Immediate orotracheal intubation may be necessary to | Surgery_Schwartz. in the setting of malignancy and active tuberculo-sis but does occur and can ultimately result in patient death.120 Repeat embolization can be effective and is warranted for ini-tial management of recurrent hemoptysis, but early surgical intervention should be considered, particularly in the setting of aspergilloma or other cavitary lesions.105If respiratory compromise is impending, orotracheal intu-bation should be performed. After intubation, flexible bronchos-copy should be performed to clear blood and secretions and to attempt localization of the bleeding site. Depending on the pos-sible causes of the bleeding, bronchial artery embolization or (if appropriate) surgery can be considered.Scenario 2: Significant, Persistent, and Massive Bleeding Life-threatening bleeding requires emergency airway control and preparation for potential surgery. Such patients are best cared for in an operating room equipped with rigid bronchos-copy. Immediate orotracheal intubation may be necessary to |
Surgery_Schwartz_4837 | Surgery_Schwartz | airway control and preparation for potential surgery. Such patients are best cared for in an operating room equipped with rigid bronchos-copy. Immediate orotracheal intubation may be necessary to gain control of ventilation and suctioning. However, rapid trans-port to the operating room with rigid bronchoscopy should be facilitated. Rigid bronchoscopy allows adequate suctioning of bleeding with visualization of the bleeding site; the nonbleed-ing side can be cannulated with the rigid scope and the patient ventilated. After stabilization, ice-saline lavage of the bleeding site can then be performed (up to 1 L in 50-mL aliquots); bleed-ing stops in up to 90% of patients.121Alternatively, blockade of the main stem bronchus of the affected side can be accomplished with a double-lumen endo-tracheal tube, with a bronchial blocker, or by intubation of the nonaffected side by an uncut standard endotracheal tube. Place-ment of a double-lumen endotracheal tube is challenging in these | Surgery_Schwartz. airway control and preparation for potential surgery. Such patients are best cared for in an operating room equipped with rigid bronchos-copy. Immediate orotracheal intubation may be necessary to gain control of ventilation and suctioning. However, rapid trans-port to the operating room with rigid bronchoscopy should be facilitated. Rigid bronchoscopy allows adequate suctioning of bleeding with visualization of the bleeding site; the nonbleed-ing side can be cannulated with the rigid scope and the patient ventilated. After stabilization, ice-saline lavage of the bleeding site can then be performed (up to 1 L in 50-mL aliquots); bleed-ing stops in up to 90% of patients.121Alternatively, blockade of the main stem bronchus of the affected side can be accomplished with a double-lumen endo-tracheal tube, with a bronchial blocker, or by intubation of the nonaffected side by an uncut standard endotracheal tube. Place-ment of a double-lumen endotracheal tube is challenging in these |
Surgery_Schwartz_4838 | Surgery_Schwartz | endo-tracheal tube, with a bronchial blocker, or by intubation of the nonaffected side by an uncut standard endotracheal tube. Place-ment of a double-lumen endotracheal tube is challenging in these circumstances, given the bleeding and secretions. Proper placement and suctioning may be difficult, and attempts could compromise the patient’s ventilation. The best option is to place a bronchial blocker in the affected bronchus with inflation. Endovascular embolization can be performed to stop the bleeding after control has been achieved with the bronchial blocker. The blocker is left in place for 24 hours; after 24 hours, the area is reexamined bronchoscopically.Surgical Intervention. In most patients, bleeding can be stopped, recovery can occur, and plans to definitively treat the underlying cause can be made. In scenario 1 (significant, persis-tent, but nonmassive bleeding), the patient may undergo further evaluation as an inpatient or outpatient. A chest CT scan and pulmonary function | Surgery_Schwartz. endo-tracheal tube, with a bronchial blocker, or by intubation of the nonaffected side by an uncut standard endotracheal tube. Place-ment of a double-lumen endotracheal tube is challenging in these circumstances, given the bleeding and secretions. Proper placement and suctioning may be difficult, and attempts could compromise the patient’s ventilation. The best option is to place a bronchial blocker in the affected bronchus with inflation. Endovascular embolization can be performed to stop the bleeding after control has been achieved with the bronchial blocker. The blocker is left in place for 24 hours; after 24 hours, the area is reexamined bronchoscopically.Surgical Intervention. In most patients, bleeding can be stopped, recovery can occur, and plans to definitively treat the underlying cause can be made. In scenario 1 (significant, persis-tent, but nonmassive bleeding), the patient may undergo further evaluation as an inpatient or outpatient. A chest CT scan and pulmonary function |
Surgery_Schwartz_4839 | Surgery_Schwartz | cause can be made. In scenario 1 (significant, persis-tent, but nonmassive bleeding), the patient may undergo further evaluation as an inpatient or outpatient. A chest CT scan and pulmonary function studies should be obtained preoperatively. In scenario 2 (patients with significant, persistent, and massive bleeding), surgery, if appropriate, will usually be performed during the same hospitalization as the rigid bronchoscopy or main stem bronchus blockade. In a small number of patients (<10%), immediate surgery will be necessary due to the extent of bleeding. The bleeding site in these patients is localized using rigid bronchoscopy with immediate thoracotomy or sternotomy to follow.Surgical treatment is individualized according to the source of bleeding and the patient’s medical condition, prog-nosis, and pulmonary reserve. General indications for urgent surgery are presented in Table 19-22. In patients with significant cavitary disease or with fungus balls, the walls of the cavities | Surgery_Schwartz. cause can be made. In scenario 1 (significant, persis-tent, but nonmassive bleeding), the patient may undergo further evaluation as an inpatient or outpatient. A chest CT scan and pulmonary function studies should be obtained preoperatively. In scenario 2 (patients with significant, persistent, and massive bleeding), surgery, if appropriate, will usually be performed during the same hospitalization as the rigid bronchoscopy or main stem bronchus blockade. In a small number of patients (<10%), immediate surgery will be necessary due to the extent of bleeding. The bleeding site in these patients is localized using rigid bronchoscopy with immediate thoracotomy or sternotomy to follow.Surgical treatment is individualized according to the source of bleeding and the patient’s medical condition, prog-nosis, and pulmonary reserve. General indications for urgent surgery are presented in Table 19-22. In patients with significant cavitary disease or with fungus balls, the walls of the cavities |
Surgery_Schwartz_4840 | Surgery_Schwartz | prog-nosis, and pulmonary reserve. General indications for urgent surgery are presented in Table 19-22. In patients with significant cavitary disease or with fungus balls, the walls of the cavities are eroded and necrotic; rebleeding will likely ensue. In addi-tion, bleeding from cavitary lesions may be due to pulmonary artery erosion, which requires surgery for control.End-Stage Lung DiseaseLung Volume Reduction Surgery. The ideal patient for lung volume reduction surgery (LVRS) has heterogeneous emphy-sema with apical predominance, meaning the worst emphyse-matous changes are in the apex (seen on chest CT scan) of the lungs. The physiologic lack of function of these areas is dem-onstrated by quantitative perfusion scan, which shows minimal or no perfusion. By surgically excising these nonfunctional areas, the volume of the lung is reduced, theoretically restor-ing respiratory mechanics. Diaphragm position and function are improved, and there may be an improvement in the dynamic | Surgery_Schwartz. prog-nosis, and pulmonary reserve. General indications for urgent surgery are presented in Table 19-22. In patients with significant cavitary disease or with fungus balls, the walls of the cavities are eroded and necrotic; rebleeding will likely ensue. In addi-tion, bleeding from cavitary lesions may be due to pulmonary artery erosion, which requires surgery for control.End-Stage Lung DiseaseLung Volume Reduction Surgery. The ideal patient for lung volume reduction surgery (LVRS) has heterogeneous emphy-sema with apical predominance, meaning the worst emphyse-matous changes are in the apex (seen on chest CT scan) of the lungs. The physiologic lack of function of these areas is dem-onstrated by quantitative perfusion scan, which shows minimal or no perfusion. By surgically excising these nonfunctional areas, the volume of the lung is reduced, theoretically restor-ing respiratory mechanics. Diaphragm position and function are improved, and there may be an improvement in the dynamic |
Surgery_Schwartz_4841 | Surgery_Schwartz | nonfunctional areas, the volume of the lung is reduced, theoretically restor-ing respiratory mechanics. Diaphragm position and function are improved, and there may be an improvement in the dynamic small airway collapse in the remaining lung.Operative mortality in the initial experience was 16.9%, with a 1-year mortality of 23%. In response, the National Emphysema Treatment Trial (NETT) performed a randomized trial of 1218 patients in a noncrossover design to medical versus surgical management after a 10-week pretreatment pulmonary rehabilitation program. Subgroup analysis demonstrated that in patients with the anatomic changes delineated by Cooper and colleagues, LVRS significantly improved exercise capacity, lung function, quality of life, and dyspnea compared to medi-cal therapy. After 2 years, functional improvements began to decline toward baseline. Similar parameters in medically treated patients steadily decline below baseline. LVRS was associated with increased short-term | Surgery_Schwartz. nonfunctional areas, the volume of the lung is reduced, theoretically restor-ing respiratory mechanics. Diaphragm position and function are improved, and there may be an improvement in the dynamic small airway collapse in the remaining lung.Operative mortality in the initial experience was 16.9%, with a 1-year mortality of 23%. In response, the National Emphysema Treatment Trial (NETT) performed a randomized trial of 1218 patients in a noncrossover design to medical versus surgical management after a 10-week pretreatment pulmonary rehabilitation program. Subgroup analysis demonstrated that in patients with the anatomic changes delineated by Cooper and colleagues, LVRS significantly improved exercise capacity, lung function, quality of life, and dyspnea compared to medi-cal therapy. After 2 years, functional improvements began to decline toward baseline. Similar parameters in medically treated patients steadily decline below baseline. LVRS was associated with increased short-term |
Surgery_Schwartz_4842 | Surgery_Schwartz | 2 years, functional improvements began to decline toward baseline. Similar parameters in medically treated patients steadily decline below baseline. LVRS was associated with increased short-term morbidity and mortality and did not confer a survival benefit over medical therapy.122Table 19-22General indications for urgent operative intervention for massive hemoptysis 1. Presence of a fungus ball 2. Presence of a lung abscess 3. Presence of significant cavitary disease 4. Failure to control the bleedingBrunicardi_Ch19_p0661-p0750.indd 71901/03/19 7:01 PM 720SPECIFIC CONSIDERATIONSPART IISurvival123BOS-free survival1.00.80.60.40.2Years posttransplantFigure 19-36. The survival rate after lung transplantation in the absence of bronchiolitis obliterans syndrome (BOS) at the University of Minnesota.Survival123Primary graft failure1.00.80.60.40.2No PGFPGFYears posttransplantFigure 19-37. The survival rate after lung transplantation at the University of Minnesota as a function of primary | Surgery_Schwartz. 2 years, functional improvements began to decline toward baseline. Similar parameters in medically treated patients steadily decline below baseline. LVRS was associated with increased short-term morbidity and mortality and did not confer a survival benefit over medical therapy.122Table 19-22General indications for urgent operative intervention for massive hemoptysis 1. Presence of a fungus ball 2. Presence of a lung abscess 3. Presence of significant cavitary disease 4. Failure to control the bleedingBrunicardi_Ch19_p0661-p0750.indd 71901/03/19 7:01 PM 720SPECIFIC CONSIDERATIONSPART IISurvival123BOS-free survival1.00.80.60.40.2Years posttransplantFigure 19-36. The survival rate after lung transplantation in the absence of bronchiolitis obliterans syndrome (BOS) at the University of Minnesota.Survival123Primary graft failure1.00.80.60.40.2No PGFPGFYears posttransplantFigure 19-37. The survival rate after lung transplantation at the University of Minnesota as a function of primary |
Surgery_Schwartz_4843 | Surgery_Schwartz | graft failure1.00.80.60.40.2No PGFPGFYears posttransplantFigure 19-37. The survival rate after lung transplantation at the University of Minnesota as a function of primary graft failure (PGF).Lung Transplantation. The most common indications for lung transplant are COPD and idiopathic pulmonary fibrosis (IPF). Most patients with IPF and older patients with COPD are offered a single-lung transplant. Younger COPD patients and patients with α1-antitrypsin deficiency and severe hyperinflation of the native lungs are offered a bilateral-lung transplant. Most patients with primary pulmonary hypertension and almost all patients with cystic fibrosis are treated with a bilateral-lung transplant. A heart-lung transplant is reserved for patients with irreversible ventricular failure or uncorrectable congenital cardiac disease.Patients with COPD are considered for placement on the transplant waiting list when their FEV1 has fallen to below 25% of its predicted value. Patients with significant | Surgery_Schwartz. graft failure1.00.80.60.40.2No PGFPGFYears posttransplantFigure 19-37. The survival rate after lung transplantation at the University of Minnesota as a function of primary graft failure (PGF).Lung Transplantation. The most common indications for lung transplant are COPD and idiopathic pulmonary fibrosis (IPF). Most patients with IPF and older patients with COPD are offered a single-lung transplant. Younger COPD patients and patients with α1-antitrypsin deficiency and severe hyperinflation of the native lungs are offered a bilateral-lung transplant. Most patients with primary pulmonary hypertension and almost all patients with cystic fibrosis are treated with a bilateral-lung transplant. A heart-lung transplant is reserved for patients with irreversible ventricular failure or uncorrectable congenital cardiac disease.Patients with COPD are considered for placement on the transplant waiting list when their FEV1 has fallen to below 25% of its predicted value. Patients with significant |
Surgery_Schwartz_4844 | Surgery_Schwartz | congenital cardiac disease.Patients with COPD are considered for placement on the transplant waiting list when their FEV1 has fallen to below 25% of its predicted value. Patients with significant pulmonary hyper-tension should be listed earlier. IPF patients should be referred when their forced vital capacity has fallen to less than 60% or their Dlco has fallen to less than 50% of their predicted values.In the past, patients with primary pulmonary hypertension and New York Heart Association (NYHA) class III or IV symp-toms were listed for a lung transplant. However, treatment of such patients with intravenous prostacyclin and other pulmonary vasodilators has now markedly altered that strategy. Virtually all patients with primary pulmonary hypertension are now treated with intravenous epoprostenol. Several of these patients have experienced a marked improvement in their symptoms associ-ated with a decrease in their pulmonary arterial pressures and an increase in exercise capacity. | Surgery_Schwartz. congenital cardiac disease.Patients with COPD are considered for placement on the transplant waiting list when their FEV1 has fallen to below 25% of its predicted value. Patients with significant pulmonary hyper-tension should be listed earlier. IPF patients should be referred when their forced vital capacity has fallen to less than 60% or their Dlco has fallen to less than 50% of their predicted values.In the past, patients with primary pulmonary hypertension and New York Heart Association (NYHA) class III or IV symp-toms were listed for a lung transplant. However, treatment of such patients with intravenous prostacyclin and other pulmonary vasodilators has now markedly altered that strategy. Virtually all patients with primary pulmonary hypertension are now treated with intravenous epoprostenol. Several of these patients have experienced a marked improvement in their symptoms associ-ated with a decrease in their pulmonary arterial pressures and an increase in exercise capacity. |
Surgery_Schwartz_4845 | Surgery_Schwartz | epoprostenol. Several of these patients have experienced a marked improvement in their symptoms associ-ated with a decrease in their pulmonary arterial pressures and an increase in exercise capacity. Listing of these patients is deferred until they develop NYHA class III or IV symptoms or until their mean pulmonary artery pressure rises above 75 mmHg.Medium-term and bronchiolitis obliterans syndrome (BOS)–free survival rates of patients who underwent a lung transplant at the University of Minnesota are shown in Figs. 19-35 and 19-36. The mortality of patients while waiting for transplants is about 10%. In an effort to expand the number of lung donors, many transplant groups have liberalized their criteria for donor selection. Still, the partial pressure of arterial oxygen (Pao2) should be greater than 300 mmHg on a fraction of inspired oxygen (Fio2) of 100%. In special circumstances, lungs may be used from donors with a smoking history; from donors older than 50 years of age; and from | Surgery_Schwartz. epoprostenol. Several of these patients have experienced a marked improvement in their symptoms associ-ated with a decrease in their pulmonary arterial pressures and an increase in exercise capacity. Listing of these patients is deferred until they develop NYHA class III or IV symptoms or until their mean pulmonary artery pressure rises above 75 mmHg.Medium-term and bronchiolitis obliterans syndrome (BOS)–free survival rates of patients who underwent a lung transplant at the University of Minnesota are shown in Figs. 19-35 and 19-36. The mortality of patients while waiting for transplants is about 10%. In an effort to expand the number of lung donors, many transplant groups have liberalized their criteria for donor selection. Still, the partial pressure of arterial oxygen (Pao2) should be greater than 300 mmHg on a fraction of inspired oxygen (Fio2) of 100%. In special circumstances, lungs may be used from donors with a smoking history; from donors older than 50 years of age; and from |
Surgery_Schwartz_4846 | Surgery_Schwartz | greater than 300 mmHg on a fraction of inspired oxygen (Fio2) of 100%. In special circumstances, lungs may be used from donors with a smoking history; from donors older than 50 years of age; and from donors with positive Gram stains or infiltrates on CXR.123,124 The use of two living donors, each donating a single lower lobe, is another strategy for increasing the donor pool. Recipient outcomes are similar to those with cadaver donors in carefully selected patients.Survival123Overall survival1.00.80.60.40.2Years posttransplantFigure 19-35. The overall survival rate after lung transplantation at the University of Minnesota.Most of the early mortality after lung transplant is related to primary graft failure resulting from a severe ischemia-reper-fusion injury to the lung(s) (Fig. 19-37). Reperfusion injury is characterized radiographically by interstitial and alveolar edema and clinically by hypoxia and ventilation-perfusion mismatch. Donor neutrophils and recipient lymphocytes | Surgery_Schwartz. greater than 300 mmHg on a fraction of inspired oxygen (Fio2) of 100%. In special circumstances, lungs may be used from donors with a smoking history; from donors older than 50 years of age; and from donors with positive Gram stains or infiltrates on CXR.123,124 The use of two living donors, each donating a single lower lobe, is another strategy for increasing the donor pool. Recipient outcomes are similar to those with cadaver donors in carefully selected patients.Survival123Overall survival1.00.80.60.40.2Years posttransplantFigure 19-35. The overall survival rate after lung transplantation at the University of Minnesota.Most of the early mortality after lung transplant is related to primary graft failure resulting from a severe ischemia-reper-fusion injury to the lung(s) (Fig. 19-37). Reperfusion injury is characterized radiographically by interstitial and alveolar edema and clinically by hypoxia and ventilation-perfusion mismatch. Donor neutrophils and recipient lymphocytes |
Surgery_Schwartz_4847 | Surgery_Schwartz | Reperfusion injury is characterized radiographically by interstitial and alveolar edema and clinically by hypoxia and ventilation-perfusion mismatch. Donor neutrophils and recipient lymphocytes prob-ably play an important role in the pathogenesis of reperfu-sion injury. The most important impediment to longer-term survival after a lung transplant is the development of BOS, a manifestation of chronic rejection. Episodes of acute rejection are the major risk factors for developing BOS. Other injuries to the lung (including early reperfusion injury and chronic gas-troesophageal reflux disease) may also adversely affect long-term outcomes of patients.125,126CHEST WALLChest Wall MassClinical Approach. Surgeons confronted with a patient with a chest wall mass must be cognizant that their approach to diagno-sis and treatment has significant impact on the patient’s chances Brunicardi_Ch19_p0661-p0750.indd 72001/03/19 7:01 PM | Surgery_Schwartz. Reperfusion injury is characterized radiographically by interstitial and alveolar edema and clinically by hypoxia and ventilation-perfusion mismatch. Donor neutrophils and recipient lymphocytes prob-ably play an important role in the pathogenesis of reperfu-sion injury. The most important impediment to longer-term survival after a lung transplant is the development of BOS, a manifestation of chronic rejection. Episodes of acute rejection are the major risk factors for developing BOS. Other injuries to the lung (including early reperfusion injury and chronic gas-troesophageal reflux disease) may also adversely affect long-term outcomes of patients.125,126CHEST WALLChest Wall MassClinical Approach. Surgeons confronted with a patient with a chest wall mass must be cognizant that their approach to diagno-sis and treatment has significant impact on the patient’s chances Brunicardi_Ch19_p0661-p0750.indd 72001/03/19 7:01 PM |
Surgery_Schwartz_4848 | Surgery_Schwartz | CHAPTER 19721CHEST WALL, LUNG, MEDIASTINUM, AND PLEURADiagnosis is clear;a surgical resection is theprimary treatmentLesion <2.0 cmBenign Tumors Fibrous dysplasia Chondroma Osteochondroma Eosinophilic granulomaMalignant Tumors ChondrosarcomaWide surgical excisionCT or MRI or bothChest wall massFigure 19-38. Systematic approach for evaluating a chest wall mass when the clinical scenario is uncomplicated and initial imag-ing studies suggest a clear diagnosis. CT = computed tomography; MRI = magnetic resonance imaging.for long-term survival. All chest wall tumors should be consid-ered malignant until proven otherwise. It is critically important that the surgeon(s) be mindful of this tenet and well versed in the diagnostic and treatment principles for chest wall malignan-cies. These tenets must be applied from the initial biopsy, as the placement of the incision can impact significantly on the successful complete resection and reconstruction of the chest wall. Complete resection is | Surgery_Schwartz. CHAPTER 19721CHEST WALL, LUNG, MEDIASTINUM, AND PLEURADiagnosis is clear;a surgical resection is theprimary treatmentLesion <2.0 cmBenign Tumors Fibrous dysplasia Chondroma Osteochondroma Eosinophilic granulomaMalignant Tumors ChondrosarcomaWide surgical excisionCT or MRI or bothChest wall massFigure 19-38. Systematic approach for evaluating a chest wall mass when the clinical scenario is uncomplicated and initial imag-ing studies suggest a clear diagnosis. CT = computed tomography; MRI = magnetic resonance imaging.for long-term survival. All chest wall tumors should be consid-ered malignant until proven otherwise. It is critically important that the surgeon(s) be mindful of this tenet and well versed in the diagnostic and treatment principles for chest wall malignan-cies. These tenets must be applied from the initial biopsy, as the placement of the incision can impact significantly on the successful complete resection and reconstruction of the chest wall. Complete resection is |
Surgery_Schwartz_4849 | Surgery_Schwartz | must be applied from the initial biopsy, as the placement of the incision can impact significantly on the successful complete resection and reconstruction of the chest wall. Complete resection is imperative if there is any hope for cure and/or long-term survival. A general approach is outlined in Figs. 19-38 and 19-39.Patients with chest wall tumors, regardless of etiology, typically complain of a slowly enlarging palpable mass (50% to 70%), chest wall pain (25% to 50%), or both. Interestingly, growing masses are often not noticed by the patient until they suffer a trauma to the area. Pain from a chest wall mass is typi-cally localized to the area of the tumor; it occurs more often and more intensely with malignant tumors, but it can also be present in up to one-third of patients with benign tumors. With Ewing’s sarcoma, fever and malaise may also be present. Benign chest wall tumors tend to occur in younger patients (average age 26 years), whereas malignant tumors tend to be found | Surgery_Schwartz. must be applied from the initial biopsy, as the placement of the incision can impact significantly on the successful complete resection and reconstruction of the chest wall. Complete resection is imperative if there is any hope for cure and/or long-term survival. A general approach is outlined in Figs. 19-38 and 19-39.Patients with chest wall tumors, regardless of etiology, typically complain of a slowly enlarging palpable mass (50% to 70%), chest wall pain (25% to 50%), or both. Interestingly, growing masses are often not noticed by the patient until they suffer a trauma to the area. Pain from a chest wall mass is typi-cally localized to the area of the tumor; it occurs more often and more intensely with malignant tumors, but it can also be present in up to one-third of patients with benign tumors. With Ewing’s sarcoma, fever and malaise may also be present. Benign chest wall tumors tend to occur in younger patients (average age 26 years), whereas malignant tumors tend to be found |
Surgery_Schwartz_4850 | Surgery_Schwartz | tumors. With Ewing’s sarcoma, fever and malaise may also be present. Benign chest wall tumors tend to occur in younger patients (average age 26 years), whereas malignant tumors tend to be found in older patients (average age 40 years). Overall, between 50% and 80% of chest wall tumors are malignant.Evaluation and Management. Laboratory evaluations are useful in assessing chest wall masses for the following:1. Plasmacytoma. Serum protein electrophoresis demon-strates a single monoclonal spike, which is measuring the overproduction of one immunoglobulin from the malignant plasma cell clone.Chest wall massCT or MRI or bothDiagnosis is NOT clearPreoperative chemotherapyWide surgical excisionOsteosarcomaRhabdomyosarcomaNonrhabdomyosarcomaPNET/Ewing’s sarcomaNonrhabdosarcoma Fibrosarcoma Malignant fibrous histiocytoma Liposarcoma Synovial cell sarcoma DesmoidNeedle biopsyor incisional biopsyFigure 19-39. Systematic approach for evaluating a chest wall mass for which the diagnosis is | Surgery_Schwartz. tumors. With Ewing’s sarcoma, fever and malaise may also be present. Benign chest wall tumors tend to occur in younger patients (average age 26 years), whereas malignant tumors tend to be found in older patients (average age 40 years). Overall, between 50% and 80% of chest wall tumors are malignant.Evaluation and Management. Laboratory evaluations are useful in assessing chest wall masses for the following:1. Plasmacytoma. Serum protein electrophoresis demon-strates a single monoclonal spike, which is measuring the overproduction of one immunoglobulin from the malignant plasma cell clone.Chest wall massCT or MRI or bothDiagnosis is NOT clearPreoperative chemotherapyWide surgical excisionOsteosarcomaRhabdomyosarcomaNonrhabdomyosarcomaPNET/Ewing’s sarcomaNonrhabdosarcoma Fibrosarcoma Malignant fibrous histiocytoma Liposarcoma Synovial cell sarcoma DesmoidNeedle biopsyor incisional biopsyFigure 19-39. Systematic approach for evaluating a chest wall mass for which the diagnosis is |
Surgery_Schwartz_4851 | Surgery_Schwartz | fibrous histiocytoma Liposarcoma Synovial cell sarcoma DesmoidNeedle biopsyor incisional biopsyFigure 19-39. Systematic approach for evaluating a chest wall mass for which the diagnosis is not unequivocal. A tissue diagnosis is critical for effective management of chest wall masses. CT = computed tomography; MRI = magnetic resonance imaging; PNET = primitive neuroectodermal tumor.2. Osteosarcoma. Alkaline phosphatase levels may be elevated.3. Ewing’s sarcoma. Erythrocyte sedimentation rates may be elevated.Radiography CXR may reveal rib destruction, calcification within the lesion, and if old films are available, a clue to growth rate. CT scanning, however, is necessary to determine the rela-tionship of the chest wall mass to contiguous structures (e.g., mediastinum, lung, soft tissues, and other skeletal elements), evaluate for pulmonary metastases, and assess for extraosseous bone formation and bone destruction, both typically seen with osteosarcoma.Because MRI provides | Surgery_Schwartz. fibrous histiocytoma Liposarcoma Synovial cell sarcoma DesmoidNeedle biopsyor incisional biopsyFigure 19-39. Systematic approach for evaluating a chest wall mass for which the diagnosis is not unequivocal. A tissue diagnosis is critical for effective management of chest wall masses. CT = computed tomography; MRI = magnetic resonance imaging; PNET = primitive neuroectodermal tumor.2. Osteosarcoma. Alkaline phosphatase levels may be elevated.3. Ewing’s sarcoma. Erythrocyte sedimentation rates may be elevated.Radiography CXR may reveal rib destruction, calcification within the lesion, and if old films are available, a clue to growth rate. CT scanning, however, is necessary to determine the rela-tionship of the chest wall mass to contiguous structures (e.g., mediastinum, lung, soft tissues, and other skeletal elements), evaluate for pulmonary metastases, and assess for extraosseous bone formation and bone destruction, both typically seen with osteosarcoma.Because MRI provides |
Surgery_Schwartz_4852 | Surgery_Schwartz | tissues, and other skeletal elements), evaluate for pulmonary metastases, and assess for extraosseous bone formation and bone destruction, both typically seen with osteosarcoma.Because MRI provides multiple planes of imaging (coronal, sagittal, and oblique), better definition of the relationship between tumor and muscle, and tumor and contiguous or nearby neurovascular structures or the spine, it is an important radio-graphic adjunct for preoperative planning. Compared to CT scan alone, MRI may further delineate tissue abnormalities, poten-tially enhancing the ability to distinguish benign from malignant sarcoma.Biopsy The first step in the management of all chest wall tumors is to obtain a tissue diagnosis. Inappropriate or mis-guided attempts at tissue diagnosis through casual open biopsy techniques have the potential (if the lesion is a sarcoma) to seed surrounding tissues and contiguous body cavities (e.g., the pleural space) with tumor cells, potentially compromising local | Surgery_Schwartz. tissues, and other skeletal elements), evaluate for pulmonary metastases, and assess for extraosseous bone formation and bone destruction, both typically seen with osteosarcoma.Because MRI provides multiple planes of imaging (coronal, sagittal, and oblique), better definition of the relationship between tumor and muscle, and tumor and contiguous or nearby neurovascular structures or the spine, it is an important radio-graphic adjunct for preoperative planning. Compared to CT scan alone, MRI may further delineate tissue abnormalities, poten-tially enhancing the ability to distinguish benign from malignant sarcoma.Biopsy The first step in the management of all chest wall tumors is to obtain a tissue diagnosis. Inappropriate or mis-guided attempts at tissue diagnosis through casual open biopsy techniques have the potential (if the lesion is a sarcoma) to seed surrounding tissues and contiguous body cavities (e.g., the pleural space) with tumor cells, potentially compromising local |
Surgery_Schwartz_4853 | Surgery_Schwartz | biopsy techniques have the potential (if the lesion is a sarcoma) to seed surrounding tissues and contiguous body cavities (e.g., the pleural space) with tumor cells, potentially compromising local Brunicardi_Ch19_p0661-p0750.indd 72101/03/19 7:01 PM 722SPECIFIC CONSIDERATIONSPART IItumor control and patient survival. Tissue diagnosis is accom-plished using one of three methods: needle biopsy (typically CT-guided, FNA, or a core biopsy), incisional biopsy, or exci-sional biopsy in limited and specific situations.1. Needle biopsy. Pathologists experienced with sarcomas can accurately diagnose approximately 90% of patients using FNA cytology. A needle biopsy (FNA or core) has the advantage of avoiding wound and body cavity contami-nation (a potential complication with an incisional biopsy).2. Incisional biopsy. If a needle biopsy is nondiagnostic, an incisional biopsy may be performed, with caveats. First, the skin incision must be placed directly over the mass and ori-ented to | Surgery_Schwartz. biopsy techniques have the potential (if the lesion is a sarcoma) to seed surrounding tissues and contiguous body cavities (e.g., the pleural space) with tumor cells, potentially compromising local Brunicardi_Ch19_p0661-p0750.indd 72101/03/19 7:01 PM 722SPECIFIC CONSIDERATIONSPART IItumor control and patient survival. Tissue diagnosis is accom-plished using one of three methods: needle biopsy (typically CT-guided, FNA, or a core biopsy), incisional biopsy, or exci-sional biopsy in limited and specific situations.1. Needle biopsy. Pathologists experienced with sarcomas can accurately diagnose approximately 90% of patients using FNA cytology. A needle biopsy (FNA or core) has the advantage of avoiding wound and body cavity contami-nation (a potential complication with an incisional biopsy).2. Incisional biopsy. If a needle biopsy is nondiagnostic, an incisional biopsy may be performed, with caveats. First, the skin incision must be placed directly over the mass and ori-ented to |
Surgery_Schwartz_4854 | Surgery_Schwartz | biopsy).2. Incisional biopsy. If a needle biopsy is nondiagnostic, an incisional biopsy may be performed, with caveats. First, the skin incision must be placed directly over the mass and ori-ented to allow subsequent scar excision and skin flaps, and drains should be avoided. If the surgeon believes a hema-toma is likely to develop, a drain is useful for limiting soft tissue contamination by tumor cells. At the time of definitive surgical resection, the en bloc resection includes the biopsy scar and the drain tract along with the tumor.3. Excisional biopsy. Any lesion less than 2.0 cm can be excised as long as the resulting wound is small enough to close primarily. Otherwise, excisional biopsy is per-formed only when the initial diagnosis (based on radio-graphic evaluation) indicates that the lesion is benign or when the lesion has the classic appearance of a chondro-sarcoma (in which case, definitive surgical resection can be undertaken).Benign Chest Wall Neoplasms1. Chondroma. | Surgery_Schwartz. biopsy).2. Incisional biopsy. If a needle biopsy is nondiagnostic, an incisional biopsy may be performed, with caveats. First, the skin incision must be placed directly over the mass and ori-ented to allow subsequent scar excision and skin flaps, and drains should be avoided. If the surgeon believes a hema-toma is likely to develop, a drain is useful for limiting soft tissue contamination by tumor cells. At the time of definitive surgical resection, the en bloc resection includes the biopsy scar and the drain tract along with the tumor.3. Excisional biopsy. Any lesion less than 2.0 cm can be excised as long as the resulting wound is small enough to close primarily. Otherwise, excisional biopsy is per-formed only when the initial diagnosis (based on radio-graphic evaluation) indicates that the lesion is benign or when the lesion has the classic appearance of a chondro-sarcoma (in which case, definitive surgical resection can be undertaken).Benign Chest Wall Neoplasms1. Chondroma. |
Surgery_Schwartz_4855 | Surgery_Schwartz | that the lesion is benign or when the lesion has the classic appearance of a chondro-sarcoma (in which case, definitive surgical resection can be undertaken).Benign Chest Wall Neoplasms1. Chondroma. Chondromas, seen primarily in children and young adults, are one of the more common benign tumors of the chest wall. They usually occur at the costochondral junction anteriorly and may be confused with costochondri-tis, except that a painless mass is present. Radiographically, the lesion is lobulated and radiodense; it may have diffuse or focal calcifications; and it may displace the bony cortex without penetration. Chondromas may grow to huge sizes if left untreated. Treatment is surgical resection with a 2-cm margin. Large chondromas may harbor well-differentiated chondrosarcoma and should be managed with a 4-cm mar-gin to prevent local recurrence.1272. Fibrous dysplasia. As with chondromas, fibrous dysplasia most frequently occurs in young adults and may be associ-ated with trauma. Pain | Surgery_Schwartz. that the lesion is benign or when the lesion has the classic appearance of a chondro-sarcoma (in which case, definitive surgical resection can be undertaken).Benign Chest Wall Neoplasms1. Chondroma. Chondromas, seen primarily in children and young adults, are one of the more common benign tumors of the chest wall. They usually occur at the costochondral junction anteriorly and may be confused with costochondri-tis, except that a painless mass is present. Radiographically, the lesion is lobulated and radiodense; it may have diffuse or focal calcifications; and it may displace the bony cortex without penetration. Chondromas may grow to huge sizes if left untreated. Treatment is surgical resection with a 2-cm margin. Large chondromas may harbor well-differentiated chondrosarcoma and should be managed with a 4-cm mar-gin to prevent local recurrence.1272. Fibrous dysplasia. As with chondromas, fibrous dysplasia most frequently occurs in young adults and may be associ-ated with trauma. Pain |
Surgery_Schwartz_4856 | Surgery_Schwartz | managed with a 4-cm mar-gin to prevent local recurrence.1272. Fibrous dysplasia. As with chondromas, fibrous dysplasia most frequently occurs in young adults and may be associ-ated with trauma. Pain is an infrequent complaint, and the lesion is typically located in the posterolateral aspect of the rib cage. Radiographically, an expansile mass is present, with cortical thinning and no calcification. Local excision with a 2-cm margin is curative.3. Osteochondroma. Osteochondromas, often found inciden-tally as a solitary lesion on radiograph, are the most common benign bone tumor. Osteochondromas occur in the first two decades of life, and they arise at or near the growth plate of bones. Osteochondromas in the thorax arise from the rib cortex. They are one of several components to the autosomal dominant syndrome, hereditary multiple exostoses. When part of this syndrome, osteochondromas have a high rate of degeneration into chondrosarcomas. Any patient with heredi-tary multiple exostoses | Surgery_Schwartz. managed with a 4-cm mar-gin to prevent local recurrence.1272. Fibrous dysplasia. As with chondromas, fibrous dysplasia most frequently occurs in young adults and may be associ-ated with trauma. Pain is an infrequent complaint, and the lesion is typically located in the posterolateral aspect of the rib cage. Radiographically, an expansile mass is present, with cortical thinning and no calcification. Local excision with a 2-cm margin is curative.3. Osteochondroma. Osteochondromas, often found inciden-tally as a solitary lesion on radiograph, are the most common benign bone tumor. Osteochondromas occur in the first two decades of life, and they arise at or near the growth plate of bones. Osteochondromas in the thorax arise from the rib cortex. They are one of several components to the autosomal dominant syndrome, hereditary multiple exostoses. When part of this syndrome, osteochondromas have a high rate of degeneration into chondrosarcomas. Any patient with heredi-tary multiple exostoses |
Surgery_Schwartz_4857 | Surgery_Schwartz | dominant syndrome, hereditary multiple exostoses. When part of this syndrome, osteochondromas have a high rate of degeneration into chondrosarcomas. Any patient with heredi-tary multiple exostoses syndrome who develops new pain at the site of an osteochondroma or who notes gradual growth in the mass over time should be carefully evaluated for osteosarcoma. Local excision of a benign osteochondroma is sufficient. If malignancy is determined, wide excision is performed with a 4-cm margin.4. Eosinophilic granuloma. Eosinophilic granulomas are benign osteolytic lesions. Eosinophilic granulomas of the ribs can occur as solitary lesions or as part of a more gener-alized disease process of the lymphoreticular system termed Langerhans cell histiocytosis (LCH). In LCH, the involved tissue is infiltrated with large numbers of histiocytes (similar to Langerhans cells seen in skin and other epithelia), which are often organized as granulomas. The cause is unknown. Of all LCH bone lesions, 79% are | Surgery_Schwartz. dominant syndrome, hereditary multiple exostoses. When part of this syndrome, osteochondromas have a high rate of degeneration into chondrosarcomas. Any patient with heredi-tary multiple exostoses syndrome who develops new pain at the site of an osteochondroma or who notes gradual growth in the mass over time should be carefully evaluated for osteosarcoma. Local excision of a benign osteochondroma is sufficient. If malignancy is determined, wide excision is performed with a 4-cm margin.4. Eosinophilic granuloma. Eosinophilic granulomas are benign osteolytic lesions. Eosinophilic granulomas of the ribs can occur as solitary lesions or as part of a more gener-alized disease process of the lymphoreticular system termed Langerhans cell histiocytosis (LCH). In LCH, the involved tissue is infiltrated with large numbers of histiocytes (similar to Langerhans cells seen in skin and other epithelia), which are often organized as granulomas. The cause is unknown. Of all LCH bone lesions, 79% are |
Surgery_Schwartz_4858 | Surgery_Schwartz | with large numbers of histiocytes (similar to Langerhans cells seen in skin and other epithelia), which are often organized as granulomas. The cause is unknown. Of all LCH bone lesions, 79% are solitary eosinophilic granulomas, 7% involve multiple eosinophilic granulomas, and 14% belong to other forms of more systemic LCH. Iso-lated single eosinophilic granulomas can occur in the ribs or skull, pelvis, mandible, humerus, and other sites. They are diagnosed primarily in children between the ages of 5 and 15 years. Because of the associated pain and tenderness, they may be confused with Ewing’s sarcoma or with an inflammatory process such as osteomyelitis. Healing may occur spontaneously, but the typical treatment is limited sur-gical resection with a 2-cm margin.5. Desmoid tumors. Soft tissue neoplasms arising from fas-cial or musculoaponeurotic structures, desmoid tumors con-sist of proliferations of benign-appearing fibroblastic cells, abundant collagen, and few mitoses. Desmoid | Surgery_Schwartz. with large numbers of histiocytes (similar to Langerhans cells seen in skin and other epithelia), which are often organized as granulomas. The cause is unknown. Of all LCH bone lesions, 79% are solitary eosinophilic granulomas, 7% involve multiple eosinophilic granulomas, and 14% belong to other forms of more systemic LCH. Iso-lated single eosinophilic granulomas can occur in the ribs or skull, pelvis, mandible, humerus, and other sites. They are diagnosed primarily in children between the ages of 5 and 15 years. Because of the associated pain and tenderness, they may be confused with Ewing’s sarcoma or with an inflammatory process such as osteomyelitis. Healing may occur spontaneously, but the typical treatment is limited sur-gical resection with a 2-cm margin.5. Desmoid tumors. Soft tissue neoplasms arising from fas-cial or musculoaponeurotic structures, desmoid tumors con-sist of proliferations of benign-appearing fibroblastic cells, abundant collagen, and few mitoses. Desmoid |
Surgery_Schwartz_4859 | Surgery_Schwartz | tissue neoplasms arising from fas-cial or musculoaponeurotic structures, desmoid tumors con-sist of proliferations of benign-appearing fibroblastic cells, abundant collagen, and few mitoses. Desmoid tumors pos-sess alterations in the adenomatous polyposis coli (APC)/β-catenin pathway. Cyclin D1 dysregulation is thought to play a significant role in their pathogenesis.128 Associations with other diseases and conditions are well documented, espe-cially those with similar alterations in the APC pathway, such as familial adenomatous polyposis (Gardner’s syn-drome). Other conditions with increased risk of desmoid tumor formation include increased estrogen states (preg-nancy) and trauma. Surgical incisions (abdominal and tho-rax) have been the site of desmoid development, either in or near the scar. Clinically, patients are usually in the third to fourth decade of life and have pain, a chest wall mass, or both. The tumor is usually fixed to the chest wall, but not to the over-lying skin. | Surgery_Schwartz. tissue neoplasms arising from fas-cial or musculoaponeurotic structures, desmoid tumors con-sist of proliferations of benign-appearing fibroblastic cells, abundant collagen, and few mitoses. Desmoid tumors pos-sess alterations in the adenomatous polyposis coli (APC)/β-catenin pathway. Cyclin D1 dysregulation is thought to play a significant role in their pathogenesis.128 Associations with other diseases and conditions are well documented, espe-cially those with similar alterations in the APC pathway, such as familial adenomatous polyposis (Gardner’s syn-drome). Other conditions with increased risk of desmoid tumor formation include increased estrogen states (preg-nancy) and trauma. Surgical incisions (abdominal and tho-rax) have been the site of desmoid development, either in or near the scar. Clinically, patients are usually in the third to fourth decade of life and have pain, a chest wall mass, or both. The tumor is usually fixed to the chest wall, but not to the over-lying skin. |
Surgery_Schwartz_4860 | Surgery_Schwartz | scar. Clinically, patients are usually in the third to fourth decade of life and have pain, a chest wall mass, or both. The tumor is usually fixed to the chest wall, but not to the over-lying skin. There are no typical radiographic findings, but MRI may delineate muscle or soft tissue infiltration. Des-moid tumors do not metastasize, but they have a significant propensity to recur locally, with rates as high as 5% to 50%, sometimes despite complete initial resection with histologi-cally negative margins.129 Such locally aggressive behavior is secondary to microscopic tumor infiltration of muscle and surrounding soft tissues and prompts some to consider them a low-grade form of fibrosarcoma. Because the lesions have low cellularity and poor yield with FNA, an open incisional biopsy for lesions over 3 to 4 cm is often necessary, following the caveats listed ear-lier (see biopsy section). Surgery consists of wide local excision with a 2to 4-cm margin and intraoperative fro-zen section | Surgery_Schwartz. scar. Clinically, patients are usually in the third to fourth decade of life and have pain, a chest wall mass, or both. The tumor is usually fixed to the chest wall, but not to the over-lying skin. There are no typical radiographic findings, but MRI may delineate muscle or soft tissue infiltration. Des-moid tumors do not metastasize, but they have a significant propensity to recur locally, with rates as high as 5% to 50%, sometimes despite complete initial resection with histologi-cally negative margins.129 Such locally aggressive behavior is secondary to microscopic tumor infiltration of muscle and surrounding soft tissues and prompts some to consider them a low-grade form of fibrosarcoma. Because the lesions have low cellularity and poor yield with FNA, an open incisional biopsy for lesions over 3 to 4 cm is often necessary, following the caveats listed ear-lier (see biopsy section). Surgery consists of wide local excision with a 2to 4-cm margin and intraoperative fro-zen section |
Surgery_Schwartz_4861 | Surgery_Schwartz | over 3 to 4 cm is often necessary, following the caveats listed ear-lier (see biopsy section). Surgery consists of wide local excision with a 2to 4-cm margin and intraoperative fro-zen section assessment of resection margins. Typically, chest wall resection, including the involved rib(s) and one rib above and below the tumor with a 4to 5-cm margin of rib, is required. A margin of less than 1 cm results in much higher local recurrence rates. If a major neurovascu-lar structure would have to be sacrificed, leading to high morbidity, then a margin of less than 1 cm would have to suffice. Survival after wide local excision with negative margins is 90% at 10 years.130Brunicardi_Ch19_p0661-p0750.indd 72201/03/19 7:01 PM | Surgery_Schwartz. over 3 to 4 cm is often necessary, following the caveats listed ear-lier (see biopsy section). Surgery consists of wide local excision with a 2to 4-cm margin and intraoperative fro-zen section assessment of resection margins. Typically, chest wall resection, including the involved rib(s) and one rib above and below the tumor with a 4to 5-cm margin of rib, is required. A margin of less than 1 cm results in much higher local recurrence rates. If a major neurovascu-lar structure would have to be sacrificed, leading to high morbidity, then a margin of less than 1 cm would have to suffice. Survival after wide local excision with negative margins is 90% at 10 years.130Brunicardi_Ch19_p0661-p0750.indd 72201/03/19 7:01 PM |
Surgery_Schwartz_4862 | Surgery_Schwartz | CHAPTER 19723CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAPrimary Malignant Chest Wall TumorsMalignant tumors of the chest wall are either metastatic lesions from another primary tumor or sarcoma. Soft tissue sarcomas of the chest wall include fibrosarcomas, liposarcomas, malignant fibrous histiocytomas (MFHs), rhabdomyosarcomas, angiosar-comas, and other extremely rare lesions (Fig. 19-40). Despite the prevalence of localized disease, soft tissue sarcomas of the chest wall have significantly worse survival than similar tumors located on the extremities or the head and neck region. The fac-tors impacting on risk of death from soft tissue sarcomas of the chest wall are presented in Table 19-23. All sarcomas have a propensity to spread to the lungs.While many varieties of sarcoma exist, the primary features affecting prognosis are histologic grade and respon-siveness to chemotherapy (Table 19-24). Preoperative (neo-adjuvant) chemotherapy offers the ability to (a) assess tumor | Surgery_Schwartz. CHAPTER 19723CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAPrimary Malignant Chest Wall TumorsMalignant tumors of the chest wall are either metastatic lesions from another primary tumor or sarcoma. Soft tissue sarcomas of the chest wall include fibrosarcomas, liposarcomas, malignant fibrous histiocytomas (MFHs), rhabdomyosarcomas, angiosar-comas, and other extremely rare lesions (Fig. 19-40). Despite the prevalence of localized disease, soft tissue sarcomas of the chest wall have significantly worse survival than similar tumors located on the extremities or the head and neck region. The fac-tors impacting on risk of death from soft tissue sarcomas of the chest wall are presented in Table 19-23. All sarcomas have a propensity to spread to the lungs.While many varieties of sarcoma exist, the primary features affecting prognosis are histologic grade and respon-siveness to chemotherapy (Table 19-24). Preoperative (neo-adjuvant) chemotherapy offers the ability to (a) assess tumor |
Surgery_Schwartz_4863 | Surgery_Schwartz | exist, the primary features affecting prognosis are histologic grade and respon-siveness to chemotherapy (Table 19-24). Preoperative (neo-adjuvant) chemotherapy offers the ability to (a) assess tumor chemosensitivity by the degree of tumor size reduction and microscopic necrosis; (b) determine tumor sensitivity to spe-cific chemotherapeutic agents; and (c) improve resectability by reducing tumor size. Patients whose tumors are responsive to preoperative chemotherapy have a much better prognosis than those with a poor response. Information about tumor response to chemotherapy, the patient’s physiologic state and capacity to receive treatment, and metastatic disease status is used to determine optimal therapy. The initial treatment is either (a) preoperative chemotherapy (for patients with osteosarcoma, rhabdomyosarcoma, primitive neuroectoder-mal tumor, or Ewing’s sarcoma) followed by surgery and postoperative chemotherapy; (b) primary surgical resection and reconstruction (for | Surgery_Schwartz. exist, the primary features affecting prognosis are histologic grade and respon-siveness to chemotherapy (Table 19-24). Preoperative (neo-adjuvant) chemotherapy offers the ability to (a) assess tumor chemosensitivity by the degree of tumor size reduction and microscopic necrosis; (b) determine tumor sensitivity to spe-cific chemotherapeutic agents; and (c) improve resectability by reducing tumor size. Patients whose tumors are responsive to preoperative chemotherapy have a much better prognosis than those with a poor response. Information about tumor response to chemotherapy, the patient’s physiologic state and capacity to receive treatment, and metastatic disease status is used to determine optimal therapy. The initial treatment is either (a) preoperative chemotherapy (for patients with osteosarcoma, rhabdomyosarcoma, primitive neuroectoder-mal tumor, or Ewing’s sarcoma) followed by surgery and postoperative chemotherapy; (b) primary surgical resection and reconstruction (for |
Surgery_Schwartz_4864 | Surgery_Schwartz | with osteosarcoma, rhabdomyosarcoma, primitive neuroectoder-mal tumor, or Ewing’s sarcoma) followed by surgery and postoperative chemotherapy; (b) primary surgical resection and reconstruction (for patients with nonmetastatic MFH, fibrosarcoma, liposarcoma, or synovial sarcoma); or (c) preoperative chemotherapy followed by surgical resection if indicated in patients presenting with metastatic soft tis-sue sarcomas. Contiguous involvement of underlying lung or other soft tissues or the presence of pulmonary metasta-ses does not preclude successful surgery. In fact, patients receiving surgical intervention have significantly better overall survival. Median survival with surgical resection is 25 months compared to 8 months without resection. Addi-tional prognostic variables that are important for long-term survival include tumor size, grade, stage, and negative re-resection margin.131 With the exception of rhabdomyosar-comas, the primary treatment of these lesions is wide surgical | Surgery_Schwartz. with osteosarcoma, rhabdomyosarcoma, primitive neuroectoder-mal tumor, or Ewing’s sarcoma) followed by surgery and postoperative chemotherapy; (b) primary surgical resection and reconstruction (for patients with nonmetastatic MFH, fibrosarcoma, liposarcoma, or synovial sarcoma); or (c) preoperative chemotherapy followed by surgical resection if indicated in patients presenting with metastatic soft tis-sue sarcomas. Contiguous involvement of underlying lung or other soft tissues or the presence of pulmonary metasta-ses does not preclude successful surgery. In fact, patients receiving surgical intervention have significantly better overall survival. Median survival with surgical resection is 25 months compared to 8 months without resection. Addi-tional prognostic variables that are important for long-term survival include tumor size, grade, stage, and negative re-resection margin.131 With the exception of rhabdomyosar-comas, the primary treatment of these lesions is wide surgical |
Surgery_Schwartz_4865 | Surgery_Schwartz | for long-term survival include tumor size, grade, stage, and negative re-resection margin.131 With the exception of rhabdomyosar-comas, the primary treatment of these lesions is wide surgical resection with 4-cm margins and reconstruction.132The following is an overview of several chest wall sarcomas.1. Chondrosarcoma. Chondrosarcomas are the most common primary chest wall malignancy. As with chondromas, they usually arise anteriorly from the costochondral arches. CT scan shows a radiolucent lesion often with stippled calcifica-tions pathognomonic for chondrosarcomas (Fig. 19-41). The involved bony structures are also destroyed. Most chondro-sarcomas are slow-growing, low-grade tumors; these often painful masses can reach massive proportions.127 For this reason, any lesion in the anterior chest wall likely to be a low-grade chondrosarcoma should be treated with wide (4-cm) resection after metastatic disease to the lungs or bones is ruled out. Chondrosarcomas are not sensitive to | Surgery_Schwartz. for long-term survival include tumor size, grade, stage, and negative re-resection margin.131 With the exception of rhabdomyosar-comas, the primary treatment of these lesions is wide surgical resection with 4-cm margins and reconstruction.132The following is an overview of several chest wall sarcomas.1. Chondrosarcoma. Chondrosarcomas are the most common primary chest wall malignancy. As with chondromas, they usually arise anteriorly from the costochondral arches. CT scan shows a radiolucent lesion often with stippled calcifica-tions pathognomonic for chondrosarcomas (Fig. 19-41). The involved bony structures are also destroyed. Most chondro-sarcomas are slow-growing, low-grade tumors; these often painful masses can reach massive proportions.127 For this reason, any lesion in the anterior chest wall likely to be a low-grade chondrosarcoma should be treated with wide (4-cm) resection after metastatic disease to the lungs or bones is ruled out. Chondrosarcomas are not sensitive to |
Surgery_Schwartz_4866 | Surgery_Schwartz | chest wall likely to be a low-grade chondrosarcoma should be treated with wide (4-cm) resection after metastatic disease to the lungs or bones is ruled out. Chondrosarcomas are not sensitive to radiation or chemo-therapy. Prognosis is determined by tumor grade and extent of resection. With a low-grade tumor and wide resection, patient survival at 5 to 10 years can be as high as 60% to 80%.2. Osteosarcoma. While osteosarcomas are the most com-mon bone malignancy, they represent only 10% to 15% of all malignant chest wall tumors.133,134 They primarily occur in young adults as rapidly enlarging, painful masses; how-ever, osteosarcomas can occur in older patients as well, Figure 19-40. Chest computed tomography scan showing a right chest wall tumor (arrow). Tissue diagnosis revealed that this mass was a leiomyosarcoma.Brunicardi_Ch19_p0661-p0750.indd 72301/03/19 7:01 PM 724SPECIFIC CONSIDERATIONSPART IITable 19-23Cox proportional hazards model for risk of death from soft tissue | Surgery_Schwartz. chest wall likely to be a low-grade chondrosarcoma should be treated with wide (4-cm) resection after metastatic disease to the lungs or bones is ruled out. Chondrosarcomas are not sensitive to radiation or chemo-therapy. Prognosis is determined by tumor grade and extent of resection. With a low-grade tumor and wide resection, patient survival at 5 to 10 years can be as high as 60% to 80%.2. Osteosarcoma. While osteosarcomas are the most com-mon bone malignancy, they represent only 10% to 15% of all malignant chest wall tumors.133,134 They primarily occur in young adults as rapidly enlarging, painful masses; how-ever, osteosarcomas can occur in older patients as well, Figure 19-40. Chest computed tomography scan showing a right chest wall tumor (arrow). Tissue diagnosis revealed that this mass was a leiomyosarcoma.Brunicardi_Ch19_p0661-p0750.indd 72301/03/19 7:01 PM 724SPECIFIC CONSIDERATIONSPART IITable 19-23Cox proportional hazards model for risk of death from soft tissue |
Surgery_Schwartz_4867 | Surgery_Schwartz | this mass was a leiomyosarcoma.Brunicardi_Ch19_p0661-p0750.indd 72301/03/19 7:01 PM 724SPECIFIC CONSIDERATIONSPART IITable 19-23Cox proportional hazards model for risk of death from soft tissue sarcomaNHAZARD RATIO95% CIP VALUEGender Male Female39374113Reference group0.897Reference group0.843–0.955Reference group.001Age 50 years 51–70 years >70 years183730993114Reference group1.1311.538Reference group1.026–1.2471.395–1.697Reference group.013<.001Race Caucasian Non-Caucasian7152898Reference group1.212Reference group1.093–1.344Reference group<.001Histologic type Fibrosarcoma MFH Liposarcoma LMS/GIST489252915343498Reference group1.2810.8941.204Reference group1.097–1.4950.759–1.0541.033–1.403Reference group.002.182.018Location Head and neck Trunk Extremity Retroperitoneum57640542474946Reference group1.2551.0031.276Reference group1.096–1.4380.875–1.1511.093–1.489Reference group.001.960.002Stage Localized Regional Distant500617241320Reference group1.5752.897Reference | Surgery_Schwartz. this mass was a leiomyosarcoma.Brunicardi_Ch19_p0661-p0750.indd 72301/03/19 7:01 PM 724SPECIFIC CONSIDERATIONSPART IITable 19-23Cox proportional hazards model for risk of death from soft tissue sarcomaNHAZARD RATIO95% CIP VALUEGender Male Female39374113Reference group0.897Reference group0.843–0.955Reference group.001Age 50 years 51–70 years >70 years183730993114Reference group1.1311.538Reference group1.026–1.2471.395–1.697Reference group.013<.001Race Caucasian Non-Caucasian7152898Reference group1.212Reference group1.093–1.344Reference group<.001Histologic type Fibrosarcoma MFH Liposarcoma LMS/GIST489252915343498Reference group1.2810.8941.204Reference group1.097–1.4950.759–1.0541.033–1.403Reference group.002.182.018Location Head and neck Trunk Extremity Retroperitoneum57640542474946Reference group1.2551.0031.276Reference group1.096–1.4380.875–1.1511.093–1.489Reference group.001.960.002Stage Localized Regional Distant500617241320Reference group1.5752.897Reference |
Surgery_Schwartz_4868 | Surgery_Schwartz | group1.2551.0031.276Reference group1.096–1.4380.875–1.1511.093–1.489Reference group.001.960.002Stage Localized Regional Distant500617241320Reference group1.5752.897Reference group1.458–1.7022.660–3.155Reference group<.001<.001Surgical treatment Yes No67541296Reference group1.562Reference group1.443–1.691Reference group<.001Radiation therapy Yes No21755875Reference group1.151Reference group1.070–1.239Reference group<.001Chemotherapy Yes No10626988Reference group0.909Reference group0.829–0.996Reference group.041Abbreviations: CI = confidence interval; GIST = gastrointestinal stromal tumor; LMS = leiomyosarcoma; MFH = malignant fibrous histiocytoma.Reproduced with permission from Gutierrez JC, Perez EA, Franceschi D, et al: Outcomes for soft-tissue sarcoma in 8249 cases from a large state cancer registry, J Surg Res. 2007;141(1):105-114.Table 19-24Classification of sarcomas by therapeutic responseTUMOR TYPECHEMOTHERAPY SENSITIVITYOsteosarcoma+Rhabdomyosarcoma+Primitive neuroectodermal | Surgery_Schwartz. group1.2551.0031.276Reference group1.096–1.4380.875–1.1511.093–1.489Reference group.001.960.002Stage Localized Regional Distant500617241320Reference group1.5752.897Reference group1.458–1.7022.660–3.155Reference group<.001<.001Surgical treatment Yes No67541296Reference group1.562Reference group1.443–1.691Reference group<.001Radiation therapy Yes No21755875Reference group1.151Reference group1.070–1.239Reference group<.001Chemotherapy Yes No10626988Reference group0.909Reference group0.829–0.996Reference group.041Abbreviations: CI = confidence interval; GIST = gastrointestinal stromal tumor; LMS = leiomyosarcoma; MFH = malignant fibrous histiocytoma.Reproduced with permission from Gutierrez JC, Perez EA, Franceschi D, et al: Outcomes for soft-tissue sarcoma in 8249 cases from a large state cancer registry, J Surg Res. 2007;141(1):105-114.Table 19-24Classification of sarcomas by therapeutic responseTUMOR TYPECHEMOTHERAPY SENSITIVITYOsteosarcoma+Rhabdomyosarcoma+Primitive neuroectodermal |
Surgery_Schwartz_4869 | Surgery_Schwartz | registry, J Surg Res. 2007;141(1):105-114.Table 19-24Classification of sarcomas by therapeutic responseTUMOR TYPECHEMOTHERAPY SENSITIVITYOsteosarcoma+Rhabdomyosarcoma+Primitive neuroectodermal tumor+Ewing’s sarcoma+Malignant fibrous histiocytoma±Fibrosarcoma±Liposarcoma±Synovial sarcoma±sometimes in association with previous radiation, Paget’s disease, or chemotherapy. Radiographically, the typical appearance consists of spicules of new periosteal bone formation producing a sunburst appearance. Osteosarcomas have a propensity to spread to the lungs, and up to one-third of patients present with metastatic disease. Osteosarcomas are potentially sensitive to chemotherapy. Currently, pre-operative chemotherapy is common. After chemotherapy, complete resection is performed with wide (4-cm) margins, followed by reconstruction. In patients presenting with lung metastases that are potentially amenable to surgical resection, induction chemotherapy may be given, followed by surgical resection | Surgery_Schwartz. registry, J Surg Res. 2007;141(1):105-114.Table 19-24Classification of sarcomas by therapeutic responseTUMOR TYPECHEMOTHERAPY SENSITIVITYOsteosarcoma+Rhabdomyosarcoma+Primitive neuroectodermal tumor+Ewing’s sarcoma+Malignant fibrous histiocytoma±Fibrosarcoma±Liposarcoma±Synovial sarcoma±sometimes in association with previous radiation, Paget’s disease, or chemotherapy. Radiographically, the typical appearance consists of spicules of new periosteal bone formation producing a sunburst appearance. Osteosarcomas have a propensity to spread to the lungs, and up to one-third of patients present with metastatic disease. Osteosarcomas are potentially sensitive to chemotherapy. Currently, pre-operative chemotherapy is common. After chemotherapy, complete resection is performed with wide (4-cm) margins, followed by reconstruction. In patients presenting with lung metastases that are potentially amenable to surgical resection, induction chemotherapy may be given, followed by surgical resection |
Surgery_Schwartz_4870 | Surgery_Schwartz | followed by reconstruction. In patients presenting with lung metastases that are potentially amenable to surgical resection, induction chemotherapy may be given, followed by surgical resection of the primary tumor and of the pul-monary metastases. Following surgical treatment of known disease, additional maintenance chemotherapy is usually recommended.Brunicardi_Ch19_p0661-p0750.indd 72401/03/19 7:01 PM | Surgery_Schwartz. followed by reconstruction. In patients presenting with lung metastases that are potentially amenable to surgical resection, induction chemotherapy may be given, followed by surgical resection of the primary tumor and of the pul-monary metastases. Following surgical treatment of known disease, additional maintenance chemotherapy is usually recommended.Brunicardi_Ch19_p0661-p0750.indd 72401/03/19 7:01 PM |
Surgery_Schwartz_4871 | Surgery_Schwartz | CHAPTER 19725CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAFigure 19-41. Chest computed tomography scan showing a right posterior lung tumor. In the appropriate clinical setting, stippled calcifica-tions (white streaks in right lung mass) are highly indicative of chondrosarcomas.3. Malignant fibrous histiocytoma. Originally thought to derive from histiocytes because of the microscopic appear-ance of cultured tumor cells, these tumors likely originate from the fibroblast. MFHs are generally the most common soft tissue sarcoma of late adult life, although they are rare on the chest wall. The typical age at presentation is between age 50 and 70 years. Presentation is pain, with or without a palpable mass. Radiographically, a mass is usually evident, with destruction of surrounding tissue and bone. Treatment is wide resection with a margin of 4 cm or more and recon-struction. Over two-thirds of patients suffer from distant metastasis or local recurrence.4. Liposarcoma. Liposarcomas make up 15% | Surgery_Schwartz. CHAPTER 19725CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAFigure 19-41. Chest computed tomography scan showing a right posterior lung tumor. In the appropriate clinical setting, stippled calcifica-tions (white streaks in right lung mass) are highly indicative of chondrosarcomas.3. Malignant fibrous histiocytoma. Originally thought to derive from histiocytes because of the microscopic appear-ance of cultured tumor cells, these tumors likely originate from the fibroblast. MFHs are generally the most common soft tissue sarcoma of late adult life, although they are rare on the chest wall. The typical age at presentation is between age 50 and 70 years. Presentation is pain, with or without a palpable mass. Radiographically, a mass is usually evident, with destruction of surrounding tissue and bone. Treatment is wide resection with a margin of 4 cm or more and recon-struction. Over two-thirds of patients suffer from distant metastasis or local recurrence.4. Liposarcoma. Liposarcomas make up 15% |
Surgery_Schwartz_4872 | Surgery_Schwartz | Treatment is wide resection with a margin of 4 cm or more and recon-struction. Over two-thirds of patients suffer from distant metastasis or local recurrence.4. Liposarcoma. Liposarcomas make up 15% of chest wall sarcomas. Most liposarcomas are low-grade tumors that have a propensity to recur locally, given their infiltrative nature. They typically present as a painless mass. Treatment is wide resection and reconstruction. Intraoperative mar-gins should be evaluated (as with all sarcomas) and resec-tion continued, if feasible, until margins are negative. Local recurrence can be treated with reexcision, with occasional use of radiotherapy.5. Fibrosarcoma. Often presenting as a large, painful mass, these lesions are visible on plain radiograph or CT, with sur-rounding tissue destruction. Treatment is wide local excision with intraoperative frozen-section analysis of margins, fol-lowed by reconstruction. Local and systemic recurrence is frequent. Patient survival at 5 years is about 50% | Surgery_Schwartz. Treatment is wide resection with a margin of 4 cm or more and recon-struction. Over two-thirds of patients suffer from distant metastasis or local recurrence.4. Liposarcoma. Liposarcomas make up 15% of chest wall sarcomas. Most liposarcomas are low-grade tumors that have a propensity to recur locally, given their infiltrative nature. They typically present as a painless mass. Treatment is wide resection and reconstruction. Intraoperative mar-gins should be evaluated (as with all sarcomas) and resec-tion continued, if feasible, until margins are negative. Local recurrence can be treated with reexcision, with occasional use of radiotherapy.5. Fibrosarcoma. Often presenting as a large, painful mass, these lesions are visible on plain radiograph or CT, with sur-rounding tissue destruction. Treatment is wide local excision with intraoperative frozen-section analysis of margins, fol-lowed by reconstruction. Local and systemic recurrence is frequent. Patient survival at 5 years is about 50% |
Surgery_Schwartz_4873 | Surgery_Schwartz | is wide local excision with intraoperative frozen-section analysis of margins, fol-lowed by reconstruction. Local and systemic recurrence is frequent. Patient survival at 5 years is about 50% to 60%.6. Rhabdomyosarcoma. Rhabdomyosarcomas are rare tumors of the chest wall. Microscopically, they are a spindle cell tumor. The diagnosis often depends on immunohistochemi-cal staining for muscle markers. Rhabdomyosarcomas are sensitive to chemotherapy. Treatment consists of preopera-tive chemotherapy with subsequent surgical resection.Other Tumors of the Chest Wall1. Primitive neuroectodermal tumors (PNETs) and Ewing’s sarcoma. PNETs (neuroblastomas, ganglioneuroblastomas, and ganglioneuromas) derive from primordial neural crest cells that migrate from the mantle layer of the developing spinal cord. Histologically, PNETs and Ewing’s sarcomas are small, round cell tumors; both possess a translocation between the long arms of chromosomes 11 and 22 within their genetic makeup. They also share | Surgery_Schwartz. is wide local excision with intraoperative frozen-section analysis of margins, fol-lowed by reconstruction. Local and systemic recurrence is frequent. Patient survival at 5 years is about 50% to 60%.6. Rhabdomyosarcoma. Rhabdomyosarcomas are rare tumors of the chest wall. Microscopically, they are a spindle cell tumor. The diagnosis often depends on immunohistochemi-cal staining for muscle markers. Rhabdomyosarcomas are sensitive to chemotherapy. Treatment consists of preopera-tive chemotherapy with subsequent surgical resection.Other Tumors of the Chest Wall1. Primitive neuroectodermal tumors (PNETs) and Ewing’s sarcoma. PNETs (neuroblastomas, ganglioneuroblastomas, and ganglioneuromas) derive from primordial neural crest cells that migrate from the mantle layer of the developing spinal cord. Histologically, PNETs and Ewing’s sarcomas are small, round cell tumors; both possess a translocation between the long arms of chromosomes 11 and 22 within their genetic makeup. They also share |
Surgery_Schwartz_4874 | Surgery_Schwartz | cord. Histologically, PNETs and Ewing’s sarcomas are small, round cell tumors; both possess a translocation between the long arms of chromosomes 11 and 22 within their genetic makeup. They also share a consistent pattern of proto-oncogene expression and have been found to express the product of the MIC2 gene. Ewing’s sarcoma occurs in adolescents and young adults who present with progressive chest wall pain, but without the presence of a mass. Systemic symptoms of malaise and fever are often present. Laboratory studies reveal an ele-vated erythrocyte sedimentation rate and mild white blood cell elevation. Radiographically, the characteristic onion peel appearance is produced by multiple layers of perios-teum in the bone formation. Evidence of bony destruction is also common. The diagnosis can be made by a percutaneous needle biopsy or an incisional biopsy. These tumors have a strong propensity to metastasize to the lungs and skeleton; patient survival rates are thus only 50% or less | Surgery_Schwartz. cord. Histologically, PNETs and Ewing’s sarcomas are small, round cell tumors; both possess a translocation between the long arms of chromosomes 11 and 22 within their genetic makeup. They also share a consistent pattern of proto-oncogene expression and have been found to express the product of the MIC2 gene. Ewing’s sarcoma occurs in adolescents and young adults who present with progressive chest wall pain, but without the presence of a mass. Systemic symptoms of malaise and fever are often present. Laboratory studies reveal an ele-vated erythrocyte sedimentation rate and mild white blood cell elevation. Radiographically, the characteristic onion peel appearance is produced by multiple layers of perios-teum in the bone formation. Evidence of bony destruction is also common. The diagnosis can be made by a percutaneous needle biopsy or an incisional biopsy. These tumors have a strong propensity to metastasize to the lungs and skeleton; patient survival rates are thus only 50% or less |
Surgery_Schwartz_4875 | Surgery_Schwartz | can be made by a percutaneous needle biopsy or an incisional biopsy. These tumors have a strong propensity to metastasize to the lungs and skeleton; patient survival rates are thus only 50% or less at 3 years. Increasing tumor size is associated with decreasing survival. Treatment has improved sig-nificantly and now consists of multiagent chemotherapy, radiation therapy, and surgery. Patients are typically treated preoperatively with chemotherapy and reevaluated with radiologic imaging. When residual disease is identified, sur-gical resection and reconstruction are performed followed by maintenance chemotherapy.2. Plasmacytoma. Solitary plasmacytomas of the chest wall are very rare, with approximately 25 to 30 cases per year in the United States.133 The typical presentation is pain with-out a palpable mass. Plain radiographs show an osteolytic lesion in the region of the pain. As with other chest wall tumors, a needle biopsy under CT guidance is performed for diagnosis. | Surgery_Schwartz. can be made by a percutaneous needle biopsy or an incisional biopsy. These tumors have a strong propensity to metastasize to the lungs and skeleton; patient survival rates are thus only 50% or less at 3 years. Increasing tumor size is associated with decreasing survival. Treatment has improved sig-nificantly and now consists of multiagent chemotherapy, radiation therapy, and surgery. Patients are typically treated preoperatively with chemotherapy and reevaluated with radiologic imaging. When residual disease is identified, sur-gical resection and reconstruction are performed followed by maintenance chemotherapy.2. Plasmacytoma. Solitary plasmacytomas of the chest wall are very rare, with approximately 25 to 30 cases per year in the United States.133 The typical presentation is pain with-out a palpable mass. Plain radiographs show an osteolytic lesion in the region of the pain. As with other chest wall tumors, a needle biopsy under CT guidance is performed for diagnosis. |
Surgery_Schwartz_4876 | Surgery_Schwartz | is pain with-out a palpable mass. Plain radiographs show an osteolytic lesion in the region of the pain. As with other chest wall tumors, a needle biopsy under CT guidance is performed for diagnosis. Histologically, the lesion is identical to multiple myeloma, with sheets of plasma cells. It occurs at an aver-age age of 55 years. Evaluation for systemic myeloma is performed with bone marrow aspiration, testing of calcium levels, and measurement of urinary Bence Jones proteins. If the results of these studies are negative, then a solitary Brunicardi_Ch19_p0661-p0750.indd 72501/03/19 7:01 PM 726SPECIFIC CONSIDERATIONSPART IIplasmacytoma is diagnosed. Surgery is usually limited to a biopsy only, which may be excisional.134 Treatment consists of radiation with doses of 4000 to 5000 cGy. Up to 75% of patients develop systemic multiple myeloma with 10-year survival of approximately 20%.Chest Wall ReconstructionThe primary determinant of long-term freedom from recurrence and overall | Surgery_Schwartz. is pain with-out a palpable mass. Plain radiographs show an osteolytic lesion in the region of the pain. As with other chest wall tumors, a needle biopsy under CT guidance is performed for diagnosis. Histologically, the lesion is identical to multiple myeloma, with sheets of plasma cells. It occurs at an aver-age age of 55 years. Evaluation for systemic myeloma is performed with bone marrow aspiration, testing of calcium levels, and measurement of urinary Bence Jones proteins. If the results of these studies are negative, then a solitary Brunicardi_Ch19_p0661-p0750.indd 72501/03/19 7:01 PM 726SPECIFIC CONSIDERATIONSPART IIplasmacytoma is diagnosed. Surgery is usually limited to a biopsy only, which may be excisional.134 Treatment consists of radiation with doses of 4000 to 5000 cGy. Up to 75% of patients develop systemic multiple myeloma with 10-year survival of approximately 20%.Chest Wall ReconstructionThe primary determinant of long-term freedom from recurrence and overall |
Surgery_Schwartz_4877 | Surgery_Schwartz | Up to 75% of patients develop systemic multiple myeloma with 10-year survival of approximately 20%.Chest Wall ReconstructionThe primary determinant of long-term freedom from recurrence and overall survival is margin status; therefore, adequate mar-gins of normal tissue must be included in the en bloc resec-tion. En bloc resection should include involved ribs, sternum, superior sulcus, or spine if necessary; invasion of these struc-tures should not be considered a contraindication to surgery in an otherwise fit patient. The resection should include at least one normal adjacent rib above and below the tumor, with all intervening intercostal muscles and pleura. In addition, an en bloc resection of overlying chest wall muscles is often neces-sary, such as of the pectoralis minor or major, serratus anterior, or latissimus dorsi. When the periphery of the lung is involved with the neoplasm, it is appropriate to resect the adjacent part of the pulmonary lobe in continuity (Fig. 19-42). | Surgery_Schwartz. Up to 75% of patients develop systemic multiple myeloma with 10-year survival of approximately 20%.Chest Wall ReconstructionThe primary determinant of long-term freedom from recurrence and overall survival is margin status; therefore, adequate mar-gins of normal tissue must be included in the en bloc resec-tion. En bloc resection should include involved ribs, sternum, superior sulcus, or spine if necessary; invasion of these struc-tures should not be considered a contraindication to surgery in an otherwise fit patient. The resection should include at least one normal adjacent rib above and below the tumor, with all intervening intercostal muscles and pleura. In addition, an en bloc resection of overlying chest wall muscles is often neces-sary, such as of the pectoralis minor or major, serratus anterior, or latissimus dorsi. When the periphery of the lung is involved with the neoplasm, it is appropriate to resect the adjacent part of the pulmonary lobe in continuity (Fig. 19-42). |
Surgery_Schwartz_4878 | Surgery_Schwartz | serratus anterior, or latissimus dorsi. When the periphery of the lung is involved with the neoplasm, it is appropriate to resect the adjacent part of the pulmonary lobe in continuity (Fig. 19-42). Involvement of the sternum by a malignant tumor requires total resection of the sternum with the adjacent cartilage. Techniques for postop-erative respiratory support are now good enough that resection should not be compromised because of any concern about the patient’s ability to be adequately ventilated in the early postop-erative period.The extent of resection depends on the tumor’s location and on any involvement of contiguous structures. Laterally based lesions often require simple wide excision, with resec-tion of any contiguously involved lung, pleura, muscle, or skin. Anteriorly based lesions contiguous with the sternum require partial sternectomy. Primary malignant tumors of the sternum may require complete sternectomy. Posterior lesions involving the rib heads over their | Surgery_Schwartz. serratus anterior, or latissimus dorsi. When the periphery of the lung is involved with the neoplasm, it is appropriate to resect the adjacent part of the pulmonary lobe in continuity (Fig. 19-42). Involvement of the sternum by a malignant tumor requires total resection of the sternum with the adjacent cartilage. Techniques for postop-erative respiratory support are now good enough that resection should not be compromised because of any concern about the patient’s ability to be adequately ventilated in the early postop-erative period.The extent of resection depends on the tumor’s location and on any involvement of contiguous structures. Laterally based lesions often require simple wide excision, with resec-tion of any contiguously involved lung, pleura, muscle, or skin. Anteriorly based lesions contiguous with the sternum require partial sternectomy. Primary malignant tumors of the sternum may require complete sternectomy. Posterior lesions involving the rib heads over their |
Surgery_Schwartz_4879 | Surgery_Schwartz | based lesions contiguous with the sternum require partial sternectomy. Primary malignant tumors of the sternum may require complete sternectomy. Posterior lesions involving the rib heads over their articulations with the vertebral bodies may, depending on the extent of rib involvement, require partial en bloc vertebrectomy.Optimal management of larger tumors includes care-ful preoperative planning and execution of the surgery by the thoracic surgeon and an experienced plastic surgeon in order to ensure optimal physiologic and cosmetic results. With these measures, reconstruction at the same operation can be accomplished.135 Reconstruction of a large defect in the chest wall requires the use of some type of material to prevent lung herniation and to provide stability for the chest wall (see Fig. 19-42). Mild degrees of paradoxical motion are often well tolerated if the area of instability is relatively small. Historically, a wide variety of materials have been used to reestablish chest | Surgery_Schwartz. based lesions contiguous with the sternum require partial sternectomy. Primary malignant tumors of the sternum may require complete sternectomy. Posterior lesions involving the rib heads over their articulations with the vertebral bodies may, depending on the extent of rib involvement, require partial en bloc vertebrectomy.Optimal management of larger tumors includes care-ful preoperative planning and execution of the surgery by the thoracic surgeon and an experienced plastic surgeon in order to ensure optimal physiologic and cosmetic results. With these measures, reconstruction at the same operation can be accomplished.135 Reconstruction of a large defect in the chest wall requires the use of some type of material to prevent lung herniation and to provide stability for the chest wall (see Fig. 19-42). Mild degrees of paradoxical motion are often well tolerated if the area of instability is relatively small. Historically, a wide variety of materials have been used to reestablish chest |
Surgery_Schwartz_4880 | Surgery_Schwartz | Fig. 19-42). Mild degrees of paradoxical motion are often well tolerated if the area of instability is relatively small. Historically, a wide variety of materials have been used to reestablish chest wall stability, including rib autografts, steel struts, acrylic plates, and numerous synthetic meshes. The current preference is either a 2-mm polytetrafluoroethylene (Gore-Tex) patch or a double-layer polypropylene (Marlex) mesh sandwiched with methylmethacrylate. There are sev-eral properties that make Gore-Tex an excellent material for use in chest wall reconstruction: (a) it is impervious to fluid, which prevents pleural fluid from entering the chest wall and minimizes the formation of seromas, which can compromise the myocutaneous flap viability and provide a nidus for infec-tion; and (b) it provides excellent rigidity and stability when secured taut to the surrounding bony structure and, as a result, provides a firm platform for myocutaneous flap reconstruc-tion. Except for smaller | Surgery_Schwartz. Fig. 19-42). Mild degrees of paradoxical motion are often well tolerated if the area of instability is relatively small. Historically, a wide variety of materials have been used to reestablish chest wall stability, including rib autografts, steel struts, acrylic plates, and numerous synthetic meshes. The current preference is either a 2-mm polytetrafluoroethylene (Gore-Tex) patch or a double-layer polypropylene (Marlex) mesh sandwiched with methylmethacrylate. There are sev-eral properties that make Gore-Tex an excellent material for use in chest wall reconstruction: (a) it is impervious to fluid, which prevents pleural fluid from entering the chest wall and minimizes the formation of seromas, which can compromise the myocutaneous flap viability and provide a nidus for infec-tion; and (b) it provides excellent rigidity and stability when secured taut to the surrounding bony structure and, as a result, provides a firm platform for myocutaneous flap reconstruc-tion. Except for smaller |
Surgery_Schwartz_4881 | Surgery_Schwartz | it provides excellent rigidity and stability when secured taut to the surrounding bony structure and, as a result, provides a firm platform for myocutaneous flap reconstruc-tion. Except for smaller lesions, tissue coverage requires the use of myocutaneous flaps (latissimus dorsi, serratus anterior, rectus abdominis, or pectoralis major muscles).136,137MEDIASTINUMAnatomy and Pathologic EntitiesThe mediastinum can be divided into compartments for classi-fication of anatomic components and disease processes, which, despite substantial overlap, facilitates understanding of general concepts of surgical interest. Several classification schemes exist, but for the purposes of this chapter, the three-compart-ment model is used (Fig. 19-43). The anterior compartment lies between the sternum and the anterior surface of the heart and great vessels. The visceral or middle compartment is located between the great vessels and the trachea. As the name implies, the posterior compartment lies posterior | Surgery_Schwartz. it provides excellent rigidity and stability when secured taut to the surrounding bony structure and, as a result, provides a firm platform for myocutaneous flap reconstruc-tion. Except for smaller lesions, tissue coverage requires the use of myocutaneous flaps (latissimus dorsi, serratus anterior, rectus abdominis, or pectoralis major muscles).136,137MEDIASTINUMAnatomy and Pathologic EntitiesThe mediastinum can be divided into compartments for classi-fication of anatomic components and disease processes, which, despite substantial overlap, facilitates understanding of general concepts of surgical interest. Several classification schemes exist, but for the purposes of this chapter, the three-compart-ment model is used (Fig. 19-43). The anterior compartment lies between the sternum and the anterior surface of the heart and great vessels. The visceral or middle compartment is located between the great vessels and the trachea. As the name implies, the posterior compartment lies posterior |
Surgery_Schwartz_4882 | Surgery_Schwartz | anterior surface of the heart and great vessels. The visceral or middle compartment is located between the great vessels and the trachea. As the name implies, the posterior compartment lies posterior and includes the para-vertebral sulci, bilaterally, and the paraesophageal area.ABFigure 19-42. Principles of recon-struction after resection of a chest wall tumor (osteogenic sarcoma) are shown. A. En bloc resection of the involved chest wall, including nor-mal ribs above and below the tumor as well as pulmonary parenchyma, must be performed. The resected specimen is shown. B. A prosthesis has been sewn in place. In the lower third of the prosthesis, the line of diaphragm reattachment is seen. The skin defect was closed with a myo-cutaneous flap from the ipsilateral rectus muscle.Brunicardi_Ch19_p0661-p0750.indd 72601/03/19 7:01 PM | Surgery_Schwartz. anterior surface of the heart and great vessels. The visceral or middle compartment is located between the great vessels and the trachea. As the name implies, the posterior compartment lies posterior and includes the para-vertebral sulci, bilaterally, and the paraesophageal area.ABFigure 19-42. Principles of recon-struction after resection of a chest wall tumor (osteogenic sarcoma) are shown. A. En bloc resection of the involved chest wall, including nor-mal ribs above and below the tumor as well as pulmonary parenchyma, must be performed. The resected specimen is shown. B. A prosthesis has been sewn in place. In the lower third of the prosthesis, the line of diaphragm reattachment is seen. The skin defect was closed with a myo-cutaneous flap from the ipsilateral rectus muscle.Brunicardi_Ch19_p0661-p0750.indd 72601/03/19 7:01 PM |
Surgery_Schwartz_4883 | Surgery_Schwartz | CHAPTER 19727CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAPosteriormediastinumAnterosuperiormediastinumMiddlemediastinumFigure 19-43. Anatomic division of the mediastinum.ThymusFigure 19-44. Normal appearance of the thymus gland in childhood. Ao = aorta; PA = pulmonary artery; VC = vena cava.The normal content of the anterior compartment includes the thymus gland or its remnant, the internal mammary artery and vein, lymph nodes, and fat. The thymus gland is large during childhood, occupying the entire anterior mediastinum (Fig. 19-44) but decreases in both thickness and length after adolescence and takes on a more fatty content, with only resid-ual islands of thymic cellular components (Fig. 19-45). The middle mediastinal compartment contains the pericardium and its contents, the ascending and transverse aorta, the superior and inferior venae cavae, the brachiocephalic artery and vein, the phrenic and upper vagus nerves, the trachea and main bronchi and corresponding lymph nodes, and the | Surgery_Schwartz. CHAPTER 19727CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAPosteriormediastinumAnterosuperiormediastinumMiddlemediastinumFigure 19-43. Anatomic division of the mediastinum.ThymusFigure 19-44. Normal appearance of the thymus gland in childhood. Ao = aorta; PA = pulmonary artery; VC = vena cava.The normal content of the anterior compartment includes the thymus gland or its remnant, the internal mammary artery and vein, lymph nodes, and fat. The thymus gland is large during childhood, occupying the entire anterior mediastinum (Fig. 19-44) but decreases in both thickness and length after adolescence and takes on a more fatty content, with only resid-ual islands of thymic cellular components (Fig. 19-45). The middle mediastinal compartment contains the pericardium and its contents, the ascending and transverse aorta, the superior and inferior venae cavae, the brachiocephalic artery and vein, the phrenic and upper vagus nerves, the trachea and main bronchi and corresponding lymph nodes, and the |
Surgery_Schwartz_4884 | Surgery_Schwartz | transverse aorta, the superior and inferior venae cavae, the brachiocephalic artery and vein, the phrenic and upper vagus nerves, the trachea and main bronchi and corresponding lymph nodes, and the central portions of the pulmonary arteries and veins. The posterior compartment contains the descending aorta, esophagus, thoracic duct, azygos and hemiazygos veins, and lymph nodes. Numerous pathologic variants may be present in the various compartments, with much overlap. Table 19-25 includes the most common pathologic entities listed by compartment.138,139History and Physical ExaminationMediastinal pathology varies significantly by patient age. In children, neurogenic tumors of the posterior mediastinum are most common, followed by lymphoma, which is usually located in the anterior or middle compartment. Thymoma in child-hood is rare (Table 19-26). In adults, the most common tumors include neurogenic tumors of the posterior compartment, benign cysts occurring in any compartment, and | Surgery_Schwartz. transverse aorta, the superior and inferior venae cavae, the brachiocephalic artery and vein, the phrenic and upper vagus nerves, the trachea and main bronchi and corresponding lymph nodes, and the central portions of the pulmonary arteries and veins. The posterior compartment contains the descending aorta, esophagus, thoracic duct, azygos and hemiazygos veins, and lymph nodes. Numerous pathologic variants may be present in the various compartments, with much overlap. Table 19-25 includes the most common pathologic entities listed by compartment.138,139History and Physical ExaminationMediastinal pathology varies significantly by patient age. In children, neurogenic tumors of the posterior mediastinum are most common, followed by lymphoma, which is usually located in the anterior or middle compartment. Thymoma in child-hood is rare (Table 19-26). In adults, the most common tumors include neurogenic tumors of the posterior compartment, benign cysts occurring in any compartment, and |
Surgery_Schwartz_4885 | Surgery_Schwartz | compartment. Thymoma in child-hood is rare (Table 19-26). In adults, the most common tumors include neurogenic tumors of the posterior compartment, benign cysts occurring in any compartment, and thymomas of the ante-rior mediastinum (Table 19-27). In both age groups, about 25% of mediastinal tumors are malignant. Pediatric tumors will be discussed in Chapter 39.Up to two-thirds of mediastinal tumors in adults are dis-covered as asymptomatic abnormalities on radiologic studies ordered for other problems, particularly now that screening CT examinations are more prevalent. When symptomatic, these tumors are significantly more likely to be malignant. Charac-teristics such as size, location, rate of growth, and associated inflammation are important factors that correlate with symp-toms. Large, bulky tumors, expanding cysts, and teratomas can cause compression of mediastinal structures, in particular the trachea, and lead to cough, dyspnea on exertion, or stridor. Chest pain or dyspnea may | Surgery_Schwartz. compartment. Thymoma in child-hood is rare (Table 19-26). In adults, the most common tumors include neurogenic tumors of the posterior compartment, benign cysts occurring in any compartment, and thymomas of the ante-rior mediastinum (Table 19-27). In both age groups, about 25% of mediastinal tumors are malignant. Pediatric tumors will be discussed in Chapter 39.Up to two-thirds of mediastinal tumors in adults are dis-covered as asymptomatic abnormalities on radiologic studies ordered for other problems, particularly now that screening CT examinations are more prevalent. When symptomatic, these tumors are significantly more likely to be malignant. Charac-teristics such as size, location, rate of growth, and associated inflammation are important factors that correlate with symp-toms. Large, bulky tumors, expanding cysts, and teratomas can cause compression of mediastinal structures, in particular the trachea, and lead to cough, dyspnea on exertion, or stridor. Chest pain or dyspnea may |
Surgery_Schwartz_4886 | Surgery_Schwartz | bulky tumors, expanding cysts, and teratomas can cause compression of mediastinal structures, in particular the trachea, and lead to cough, dyspnea on exertion, or stridor. Chest pain or dyspnea may be reported secondary to associated pleural effusions, cardiac tamponade, or phrenic nerve involve-ment. Occasionally, a mediastinal mass near the aortopulmonary window may be identified in a workup for hoarseness because of left recurrent laryngeal nerve involvement. The patient in Fig. 19-46 presented with hoarseness due to nodal compression of the left recurrent laryngeal nerve from a primary lung cancer with metastases to the level 5 and 6 lymph nodes in the region of the aortopulmonary window.The history and physical examination in conjunction with the imaging findings may suggest a specific diagnosis (Table 19-28). In one series, systemic symptoms were present in 50% of patients with a mediastinal mass and a lymphoproliferative dis-order, as compared with only 29% of patients with | Surgery_Schwartz. bulky tumors, expanding cysts, and teratomas can cause compression of mediastinal structures, in particular the trachea, and lead to cough, dyspnea on exertion, or stridor. Chest pain or dyspnea may be reported secondary to associated pleural effusions, cardiac tamponade, or phrenic nerve involve-ment. Occasionally, a mediastinal mass near the aortopulmonary window may be identified in a workup for hoarseness because of left recurrent laryngeal nerve involvement. The patient in Fig. 19-46 presented with hoarseness due to nodal compression of the left recurrent laryngeal nerve from a primary lung cancer with metastases to the level 5 and 6 lymph nodes in the region of the aortopulmonary window.The history and physical examination in conjunction with the imaging findings may suggest a specific diagnosis (Table 19-28). In one series, systemic symptoms were present in 50% of patients with a mediastinal mass and a lymphoproliferative dis-order, as compared with only 29% of patients with |
Surgery_Schwartz_4887 | Surgery_Schwartz | diagnosis (Table 19-28). In one series, systemic symptoms were present in 50% of patients with a mediastinal mass and a lymphoproliferative dis-order, as compared with only 29% of patients with other masses (such as thymic or neurogenic). Laboratory signs of inflamma-tion were also noted; the erythrocyte sedimentation rate and C-reactive protein levels were elevated and leukocytosis was present in 86% of patients with a lymphoproliferative disorder, as compared with only 58% of patients with other types of medi-astinal masses.Imaging and Serum MarkersChest CT or MRI is required to fully delineate the anatomy.140 A contrast-enhanced CT scan enables clear delineation of the Brunicardi_Ch19_p0661-p0750.indd 72701/03/19 7:01 PM 728SPECIFIC CONSIDERATIONSPART IITable 19-25Usual location of the common primary tumors and cysts of the mediastinumANTERIOR COMPARTMENTVISCERAL COMPARTMENTPARAVERTEBRAL SULCIThymomaEnterogenous cystNeurilemoma-schwannomaGerm cell | Surgery_Schwartz. diagnosis (Table 19-28). In one series, systemic symptoms were present in 50% of patients with a mediastinal mass and a lymphoproliferative dis-order, as compared with only 29% of patients with other masses (such as thymic or neurogenic). Laboratory signs of inflamma-tion were also noted; the erythrocyte sedimentation rate and C-reactive protein levels were elevated and leukocytosis was present in 86% of patients with a lymphoproliferative disorder, as compared with only 58% of patients with other types of medi-astinal masses.Imaging and Serum MarkersChest CT or MRI is required to fully delineate the anatomy.140 A contrast-enhanced CT scan enables clear delineation of the Brunicardi_Ch19_p0661-p0750.indd 72701/03/19 7:01 PM 728SPECIFIC CONSIDERATIONSPART IITable 19-25Usual location of the common primary tumors and cysts of the mediastinumANTERIOR COMPARTMENTVISCERAL COMPARTMENTPARAVERTEBRAL SULCIThymomaEnterogenous cystNeurilemoma-schwannomaGerm cell |
Surgery_Schwartz_4888 | Surgery_Schwartz | 19-25Usual location of the common primary tumors and cysts of the mediastinumANTERIOR COMPARTMENTVISCERAL COMPARTMENTPARAVERTEBRAL SULCIThymomaEnterogenous cystNeurilemoma-schwannomaGerm cell tumorLymphomaNeurofibromaLymphomaPleuropericardial cystMalignant schwannomaLymphangiomaMediastinal granulomaGanglioneuromaHemangiomaLymphoid hamartomaGanglioneuroblastomaLipomaMesothelial cystNeuroblastomaFibromaNeuroenteric cystParagangliomaFibrosarcomaParagangliomaPheochromocytomaThymic cystPheochromocytomaFibrosarcomaParathyroid adenomaThoracic duct cystLymphomaReproduced with permission from Shields TW: Mediastinal Surgery. Philadelphia, PA: Lea & Febiger; 1991.Table 19-26Mediastinal tumors in childrenTUMOR TYPEPERCENTAGE OF TOTALLOCATIONNeurogenic tumors40PosteriorLymphomas18Anterior/middleCysts18AllGerm cell tumors11AnteriorMesenchymal tumors9AllThymomasRareAnteriorReproduced with permission from Silverman NA, Sabiston DC: Mediastinal masses, Surg Clin North Am. 1980 | Surgery_Schwartz. 19-25Usual location of the common primary tumors and cysts of the mediastinumANTERIOR COMPARTMENTVISCERAL COMPARTMENTPARAVERTEBRAL SULCIThymomaEnterogenous cystNeurilemoma-schwannomaGerm cell tumorLymphomaNeurofibromaLymphomaPleuropericardial cystMalignant schwannomaLymphangiomaMediastinal granulomaGanglioneuromaHemangiomaLymphoid hamartomaGanglioneuroblastomaLipomaMesothelial cystNeuroblastomaFibromaNeuroenteric cystParagangliomaFibrosarcomaParagangliomaPheochromocytomaThymic cystPheochromocytomaFibrosarcomaParathyroid adenomaThoracic duct cystLymphomaReproduced with permission from Shields TW: Mediastinal Surgery. Philadelphia, PA: Lea & Febiger; 1991.Table 19-26Mediastinal tumors in childrenTUMOR TYPEPERCENTAGE OF TOTALLOCATIONNeurogenic tumors40PosteriorLymphomas18Anterior/middleCysts18AllGerm cell tumors11AnteriorMesenchymal tumors9AllThymomasRareAnteriorReproduced with permission from Silverman NA, Sabiston DC: Mediastinal masses, Surg Clin North Am. 1980 |
Surgery_Schwartz_4889 | Surgery_Schwartz | cell tumors11AnteriorMesenchymal tumors9AllThymomasRareAnteriorReproduced with permission from Silverman NA, Sabiston DC: Mediastinal masses, Surg Clin North Am. 1980 Aug;60(4):757-777.Figure 19-45. Computed tomography scan showing the normal appearance of an involuted thymus gland in an adult. Note the near-total fatty appearance of the gland with only tiny islands of soft tissue scattered within it (small arrows).soft tissue structures from the vasculature and is preferred over noncontrast studies. If there is concern for invasion of vas-cular structures or spinal involvement, MRI is more accurate than CT scan and provides important information regarding respectability.If an endocrine origin is suspected, several other imaging modalities are available (Table 19-29). Single-photon emission CT (SPECT) technology may be used to improve image contrast and give information on three-dimensional localization, largely replacing conventional two-dimensional nuclear imaging studies. If a | Surgery_Schwartz. cell tumors11AnteriorMesenchymal tumors9AllThymomasRareAnteriorReproduced with permission from Silverman NA, Sabiston DC: Mediastinal masses, Surg Clin North Am. 1980 Aug;60(4):757-777.Figure 19-45. Computed tomography scan showing the normal appearance of an involuted thymus gland in an adult. Note the near-total fatty appearance of the gland with only tiny islands of soft tissue scattered within it (small arrows).soft tissue structures from the vasculature and is preferred over noncontrast studies. If there is concern for invasion of vas-cular structures or spinal involvement, MRI is more accurate than CT scan and provides important information regarding respectability.If an endocrine origin is suspected, several other imaging modalities are available (Table 19-29). Single-photon emission CT (SPECT) technology may be used to improve image contrast and give information on three-dimensional localization, largely replacing conventional two-dimensional nuclear imaging studies. If a |
Surgery_Schwartz_4890 | Surgery_Schwartz | CT (SPECT) technology may be used to improve image contrast and give information on three-dimensional localization, largely replacing conventional two-dimensional nuclear imaging studies. If a thyroid origin is suspected, a thyroid scan using 131I or 123I can identify most intrathoracic goiters and identify the extent of functioning thyroid tissue. If indicated, the thyroid scan should precede other scans requiring iodine-containing contrast agents because they would subsequently interfere with iodine tracer uptake by thyroid tissue. If a pheochromo-cytoma or neuroblastoma is suspected, the octreotide scan or 123I-metaiodobenzylguanidine (MIBG) scans are helpful in diag-nosis and localization. The sestamibi scan may be useful for diagnosing and localizing a mediastinal parathyroid gland. PET is useful for distinguishing malignant from benign tumors and may help detect distant metastases in some patients. However, the role of routine PET imaging for staging surgically resectable | Surgery_Schwartz. CT (SPECT) technology may be used to improve image contrast and give information on three-dimensional localization, largely replacing conventional two-dimensional nuclear imaging studies. If a thyroid origin is suspected, a thyroid scan using 131I or 123I can identify most intrathoracic goiters and identify the extent of functioning thyroid tissue. If indicated, the thyroid scan should precede other scans requiring iodine-containing contrast agents because they would subsequently interfere with iodine tracer uptake by thyroid tissue. If a pheochromo-cytoma or neuroblastoma is suspected, the octreotide scan or 123I-metaiodobenzylguanidine (MIBG) scans are helpful in diag-nosis and localization. The sestamibi scan may be useful for diagnosing and localizing a mediastinal parathyroid gland. PET is useful for distinguishing malignant from benign tumors and may help detect distant metastases in some patients. However, the role of routine PET imaging for staging surgically resectable |
Surgery_Schwartz_4891 | Surgery_Schwartz | PET is useful for distinguishing malignant from benign tumors and may help detect distant metastases in some patients. However, the role of routine PET imaging for staging surgically resectable lesions of the mediastinum has not been established.The use of serum markers to evaluate a mediastinal mass can be invaluable in some patients. For example, nonsemino-matous and seminomatous germ cell tumors can frequently be diagnosed and often distinguished from one another by the lev-els of α-fetoprotein (AFP) and human chorionic gonadotropin (hCG). In over 90% of nonseminomatous germ cell tumors, either the AFP or the hCG level will be elevated. Results are close to 100% specific if the level of either AFP or hCG is greater than 500 ng/mL. Some centers institute chemotherapy based on this result alone, without biopsy confirmation of the diagnosis. In contrast, the AFP level in patients with mediastinal seminoma is always normal; only 10% will have elevated hCG, which is usually less than | Surgery_Schwartz. PET is useful for distinguishing malignant from benign tumors and may help detect distant metastases in some patients. However, the role of routine PET imaging for staging surgically resectable lesions of the mediastinum has not been established.The use of serum markers to evaluate a mediastinal mass can be invaluable in some patients. For example, nonsemino-matous and seminomatous germ cell tumors can frequently be diagnosed and often distinguished from one another by the lev-els of α-fetoprotein (AFP) and human chorionic gonadotropin (hCG). In over 90% of nonseminomatous germ cell tumors, either the AFP or the hCG level will be elevated. Results are close to 100% specific if the level of either AFP or hCG is greater than 500 ng/mL. Some centers institute chemotherapy based on this result alone, without biopsy confirmation of the diagnosis. In contrast, the AFP level in patients with mediastinal seminoma is always normal; only 10% will have elevated hCG, which is usually less than |
Surgery_Schwartz_4892 | Surgery_Schwartz | alone, without biopsy confirmation of the diagnosis. In contrast, the AFP level in patients with mediastinal seminoma is always normal; only 10% will have elevated hCG, which is usually less than 100 ng/mL. Other serum markers, such as intact parathyroid hormone level for ectopic parathyroid Brunicardi_Ch19_p0661-p0750.indd 72801/03/19 7:01 PM | Surgery_Schwartz. alone, without biopsy confirmation of the diagnosis. In contrast, the AFP level in patients with mediastinal seminoma is always normal; only 10% will have elevated hCG, which is usually less than 100 ng/mL. Other serum markers, such as intact parathyroid hormone level for ectopic parathyroid Brunicardi_Ch19_p0661-p0750.indd 72801/03/19 7:01 PM |
Surgery_Schwartz_4893 | Surgery_Schwartz | CHAPTER 19729CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAFigure 19-46. Computed tomography scan of a patient who pre-sented with hoarseness due to compression of the left recurrent laryngeal nerve caused by mediastinal lymph node metastases to the aortopulmonary window area (arrow) from a primary lung cancer.adenomas, may be useful for diagnosing and also for intraopera-tively confirming complete resection. After successful resection of a parathyroid adenoma, this hormone level should rapidly normalize.Diagnostic Nonsurgical Biopsies of the MediastinumThe treatment of up to 60% of patients with anterior mediastinal masses is ultimately nonsurgical, so it is essential to understand all options for obtaining adequate tissue for a definitive diagno-sis using the least invasive approach. CT-guided needle biopsy, EBUSand EUS-guided FNA, and even core-needle biopsy (either CT-guided and EUS-guided) have proven most useful for cytologic and tissue diagnosis of mediastinal masses and | Surgery_Schwartz. CHAPTER 19729CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAFigure 19-46. Computed tomography scan of a patient who pre-sented with hoarseness due to compression of the left recurrent laryngeal nerve caused by mediastinal lymph node metastases to the aortopulmonary window area (arrow) from a primary lung cancer.adenomas, may be useful for diagnosing and also for intraopera-tively confirming complete resection. After successful resection of a parathyroid adenoma, this hormone level should rapidly normalize.Diagnostic Nonsurgical Biopsies of the MediastinumThe treatment of up to 60% of patients with anterior mediastinal masses is ultimately nonsurgical, so it is essential to understand all options for obtaining adequate tissue for a definitive diagno-sis using the least invasive approach. CT-guided needle biopsy, EBUSand EUS-guided FNA, and even core-needle biopsy (either CT-guided and EUS-guided) have proven most useful for cytologic and tissue diagnosis of mediastinal masses and |
Surgery_Schwartz_4894 | Surgery_Schwartz | CT-guided needle biopsy, EBUSand EUS-guided FNA, and even core-needle biopsy (either CT-guided and EUS-guided) have proven most useful for cytologic and tissue diagnosis of mediastinal masses and lymphadenopathy.When FNA and core-needle biopsy were combined, the accuracy was 98%, compared to 79% for each modality inde-pendently. In addition, core-needle biopsy changed the diagno-sis in nine cases that had been missed by FNA due to inadequate specimens. Finally, core-needle biopsy was better at diagnosis for benign diseases compared to FNA. Accessible nodal stations Table 19-27Mediastinal tumors in adultsTUMOR TYPEPERCENTAGE OF TOTALLOCATIONNeurogenic tumors21PosteriorCysts20AllThymomas19AnteriorLymphomas13Anterior/middleGerm cell tumors11AnteriorMesenchymal tumors7AllEndocrine tumors6Anterior/middleData from Shields TW: General Thoracic Surgery, 4th ed. Baltimore, MD: Lippincott Williams & Wilkins; 1994.include subcarinal (level 7), aortopulmonary (level 5), parae-sophageal (level 8), | Surgery_Schwartz. CT-guided needle biopsy, EBUSand EUS-guided FNA, and even core-needle biopsy (either CT-guided and EUS-guided) have proven most useful for cytologic and tissue diagnosis of mediastinal masses and lymphadenopathy.When FNA and core-needle biopsy were combined, the accuracy was 98%, compared to 79% for each modality inde-pendently. In addition, core-needle biopsy changed the diagno-sis in nine cases that had been missed by FNA due to inadequate specimens. Finally, core-needle biopsy was better at diagnosis for benign diseases compared to FNA. Accessible nodal stations Table 19-27Mediastinal tumors in adultsTUMOR TYPEPERCENTAGE OF TOTALLOCATIONNeurogenic tumors21PosteriorCysts20AllThymomas19AnteriorLymphomas13Anterior/middleGerm cell tumors11AnteriorMesenchymal tumors7AllEndocrine tumors6Anterior/middleData from Shields TW: General Thoracic Surgery, 4th ed. Baltimore, MD: Lippincott Williams & Wilkins; 1994.include subcarinal (level 7), aortopulmonary (level 5), parae-sophageal (level 8), |
Surgery_Schwartz_4895 | Surgery_Schwartz | from Shields TW: General Thoracic Surgery, 4th ed. Baltimore, MD: Lippincott Williams & Wilkins; 1994.include subcarinal (level 7), aortopulmonary (level 5), parae-sophageal (level 8), and inferior pulmonary ligament (level 9) as well as paratracheal (level 4).141 Technical expertise in these modalities should be pursued by thoracic and general surgeons.Historically, needle biopsies of anterior mediastinal masses were reportedly sensitive and specific for most carcinomatous tumors, but there were questions regarding accuracy for diagnos-ing lymphomas.142 However, advances in cytopathology as well as needle biopsy technology have substantially improved diag-nostic accuracy such that most centers are reporting yields rang-ing from 75% to 80% for the diagnosis of lymphoma as well. To achieve maximal diagnostic yield for mediastinal masses sug-gestive of a lymphoma, it is necessary to obtain multiple fine-needle aspirates, preferably with immediate onsite rapid cytologic analysis to | Surgery_Schwartz. from Shields TW: General Thoracic Surgery, 4th ed. Baltimore, MD: Lippincott Williams & Wilkins; 1994.include subcarinal (level 7), aortopulmonary (level 5), parae-sophageal (level 8), and inferior pulmonary ligament (level 9) as well as paratracheal (level 4).141 Technical expertise in these modalities should be pursued by thoracic and general surgeons.Historically, needle biopsies of anterior mediastinal masses were reportedly sensitive and specific for most carcinomatous tumors, but there were questions regarding accuracy for diagnos-ing lymphomas.142 However, advances in cytopathology as well as needle biopsy technology have substantially improved diag-nostic accuracy such that most centers are reporting yields rang-ing from 75% to 80% for the diagnosis of lymphoma as well. To achieve maximal diagnostic yield for mediastinal masses sug-gestive of a lymphoma, it is necessary to obtain multiple fine-needle aspirates, preferably with immediate onsite rapid cytologic analysis to |
Surgery_Schwartz_4896 | Surgery_Schwartz | maximal diagnostic yield for mediastinal masses sug-gestive of a lymphoma, it is necessary to obtain multiple fine-needle aspirates, preferably with immediate onsite rapid cytologic analysis to confirm sampling of the target tissue and adequate cellularity. This also facilitates processing of the sample to ensure that proper studies for lymphoma, including flow cytometry, are obtained. If the needle biopsy is inconclusive, surgical biopsy can be performed.143,144 If the lesion is accessible by CT-guided or EUS-guided core-needle biopsy, intraoperative frozen section or immediate cytologic smear of a core biopsy can also be per-formed. Currently, core-needle biopsy with EBUS is not possible. The authors perform their own endobronchial, endoscopic, and CT-guided transbronchial and transthoracic biopsies, and in our experience, lack of cellularity in the aspirate is readily apparent. In general, plans to proceed with surgical biopsy are made in combination with the image-guided | Surgery_Schwartz. maximal diagnostic yield for mediastinal masses sug-gestive of a lymphoma, it is necessary to obtain multiple fine-needle aspirates, preferably with immediate onsite rapid cytologic analysis to confirm sampling of the target tissue and adequate cellularity. This also facilitates processing of the sample to ensure that proper studies for lymphoma, including flow cytometry, are obtained. If the needle biopsy is inconclusive, surgical biopsy can be performed.143,144 If the lesion is accessible by CT-guided or EUS-guided core-needle biopsy, intraoperative frozen section or immediate cytologic smear of a core biopsy can also be per-formed. Currently, core-needle biopsy with EBUS is not possible. The authors perform their own endobronchial, endoscopic, and CT-guided transbronchial and transthoracic biopsies, and in our experience, lack of cellularity in the aspirate is readily apparent. In general, plans to proceed with surgical biopsy are made in combination with the image-guided |
Surgery_Schwartz_4897 | Surgery_Schwartz | transthoracic biopsies, and in our experience, lack of cellularity in the aspirate is readily apparent. In general, plans to proceed with surgical biopsy are made in combination with the image-guided aspiration and, as such, are performed in the same setting. This enables the authors to avoid a more invasive surgical procedure when FNA or core-needle biopsy is sufficient without contributing to delays in diagnosis by having multiple attempts from multiple providers (such as inter-ventional radiology and pulmonology) before involvement of the surgeon in the diagnostic workup.Table 19-28Signs and symptoms suggestive of various diagnoses in the setting of a mediastinal massDIAGNOSISHISTORY AND PHYSICAL FINDINGSCOMPARTMENT LOCATION OF MASSLymphomaNight sweats, weight loss, fatigue, extrathoracic adenopathy, elevated erythrocyte sedimentation rate or C-reactive protein level, leukocytosisAny compartmentThymoma with myasthenia gravisFluctuating weakness, early fatigue, ptosis, | Surgery_Schwartz. transthoracic biopsies, and in our experience, lack of cellularity in the aspirate is readily apparent. In general, plans to proceed with surgical biopsy are made in combination with the image-guided aspiration and, as such, are performed in the same setting. This enables the authors to avoid a more invasive surgical procedure when FNA or core-needle biopsy is sufficient without contributing to delays in diagnosis by having multiple attempts from multiple providers (such as inter-ventional radiology and pulmonology) before involvement of the surgeon in the diagnostic workup.Table 19-28Signs and symptoms suggestive of various diagnoses in the setting of a mediastinal massDIAGNOSISHISTORY AND PHYSICAL FINDINGSCOMPARTMENT LOCATION OF MASSLymphomaNight sweats, weight loss, fatigue, extrathoracic adenopathy, elevated erythrocyte sedimentation rate or C-reactive protein level, leukocytosisAny compartmentThymoma with myasthenia gravisFluctuating weakness, early fatigue, ptosis, |
Surgery_Schwartz_4898 | Surgery_Schwartz | extrathoracic adenopathy, elevated erythrocyte sedimentation rate or C-reactive protein level, leukocytosisAny compartmentThymoma with myasthenia gravisFluctuating weakness, early fatigue, ptosis, diplopiaAnteriorMediastinal granulomaDyspnea, wheezing, hemoptysisVisceral (middle)Germ cell tumorMale gender, young age, testicular mass, elevated levels of human chorionic gonadotropin and/or α-fetoproteinAnteriorBrunicardi_Ch19_p0661-p0750.indd 72901/03/19 7:01 PM 730SPECIFIC CONSIDERATIONSPART IITable 19-29Nuclear imaging relevant to the mediastinumRADIOPHARMACEUTICAL, RADIONUCLIDE, OR RADIOCHEMICALLABELDISEASE OF INTERESTIodine131I, 123IRetrosternal goiter, thyroid cancerMonoclonal antibodies111In, 99mTcNSCLC, colon and breast cancer, prostate cancer metastasesOctreotide111InAmine precursor uptake decarboxylation tumors: carcinoid, gastrinoma, insulinoma, small cell lung cancer, pheochromocytoma, glucagonoma, medullary thyroid carcinoma, paragangliomaGallium67GaLymphoma, NSCLC, | Surgery_Schwartz. extrathoracic adenopathy, elevated erythrocyte sedimentation rate or C-reactive protein level, leukocytosisAny compartmentThymoma with myasthenia gravisFluctuating weakness, early fatigue, ptosis, diplopiaAnteriorMediastinal granulomaDyspnea, wheezing, hemoptysisVisceral (middle)Germ cell tumorMale gender, young age, testicular mass, elevated levels of human chorionic gonadotropin and/or α-fetoproteinAnteriorBrunicardi_Ch19_p0661-p0750.indd 72901/03/19 7:01 PM 730SPECIFIC CONSIDERATIONSPART IITable 19-29Nuclear imaging relevant to the mediastinumRADIOPHARMACEUTICAL, RADIONUCLIDE, OR RADIOCHEMICALLABELDISEASE OF INTERESTIodine131I, 123IRetrosternal goiter, thyroid cancerMonoclonal antibodies111In, 99mTcNSCLC, colon and breast cancer, prostate cancer metastasesOctreotide111InAmine precursor uptake decarboxylation tumors: carcinoid, gastrinoma, insulinoma, small cell lung cancer, pheochromocytoma, glucagonoma, medullary thyroid carcinoma, paragangliomaGallium67GaLymphoma, NSCLC, |
Surgery_Schwartz_4899 | Surgery_Schwartz | uptake decarboxylation tumors: carcinoid, gastrinoma, insulinoma, small cell lung cancer, pheochromocytoma, glucagonoma, medullary thyroid carcinoma, paragangliomaGallium67GaLymphoma, NSCLC, melanomaSestamibi99mTcMedullary thyroid carcinoma, nonfunctional papillary or follicular thyroid carcinoma, Hürthle cell thyroid carcinoma, parathyroid adenoma or carcinomaThallium201TlSee sestamibiMIBG131I, 123IPheochromocytoma, neuroblastoma; see also octreotideFluorodeoxyglucose18FGeneral oncologic imaging, breast and colon cancer, melanomaAbbreviations: MIGB = metaiodobenzylguanidine; NSCLC = non–small cell lung cancer.Reproduced with permission from Pearson FG, Cooper JD, Deslauriers J, et al: Thoracic Surgery, 2nd ed. New York, NY: Elsevier/Churchill Livingstone; 2002.Surgical Biopsies and Resection of Mediastinal MassesFor tumors of the mediastinum that are not amenable to an endo-scopic or CT-guided needle biopsy or that do not yield sufficient tissue for diagnosis, a surgical biopsy is | Surgery_Schwartz. uptake decarboxylation tumors: carcinoid, gastrinoma, insulinoma, small cell lung cancer, pheochromocytoma, glucagonoma, medullary thyroid carcinoma, paragangliomaGallium67GaLymphoma, NSCLC, melanomaSestamibi99mTcMedullary thyroid carcinoma, nonfunctional papillary or follicular thyroid carcinoma, Hürthle cell thyroid carcinoma, parathyroid adenoma or carcinomaThallium201TlSee sestamibiMIBG131I, 123IPheochromocytoma, neuroblastoma; see also octreotideFluorodeoxyglucose18FGeneral oncologic imaging, breast and colon cancer, melanomaAbbreviations: MIGB = metaiodobenzylguanidine; NSCLC = non–small cell lung cancer.Reproduced with permission from Pearson FG, Cooper JD, Deslauriers J, et al: Thoracic Surgery, 2nd ed. New York, NY: Elsevier/Churchill Livingstone; 2002.Surgical Biopsies and Resection of Mediastinal MassesFor tumors of the mediastinum that are not amenable to an endo-scopic or CT-guided needle biopsy or that do not yield sufficient tissue for diagnosis, a surgical biopsy is |
Surgery_Schwartz_4900 | Surgery_Schwartz | of Mediastinal MassesFor tumors of the mediastinum that are not amenable to an endo-scopic or CT-guided needle biopsy or that do not yield sufficient tissue for diagnosis, a surgical biopsy is indicated. The defini-tive approach to a surgical biopsy of the anterior mediastinum is through a median sternotomy. At the time of sternotomy, if the lesion is easily resectable, it should be completely removed. Given the invasiveness of the procedure and the inability in some patients to obtain a definitive diagnosis by frozen section, less invasive procedures are preferable if the lesion is large or if the CT scan or history suggests that surgery is not the best definitive treatment.Masses in the paratracheal region are easily biopsied by mediastinoscopy. For tumors of the anterior or posterior medi-astinum, a left or right VATS approach often allows safe and adequate surgical biopsies. In some patients, an anterior medi-astinotomy (i.e., Chamberlain procedure) may be ideal for an anterior | Surgery_Schwartz. of Mediastinal MassesFor tumors of the mediastinum that are not amenable to an endo-scopic or CT-guided needle biopsy or that do not yield sufficient tissue for diagnosis, a surgical biopsy is indicated. The defini-tive approach to a surgical biopsy of the anterior mediastinum is through a median sternotomy. At the time of sternotomy, if the lesion is easily resectable, it should be completely removed. Given the invasiveness of the procedure and the inability in some patients to obtain a definitive diagnosis by frozen section, less invasive procedures are preferable if the lesion is large or if the CT scan or history suggests that surgery is not the best definitive treatment.Masses in the paratracheal region are easily biopsied by mediastinoscopy. For tumors of the anterior or posterior medi-astinum, a left or right VATS approach often allows safe and adequate surgical biopsies. In some patients, an anterior medi-astinotomy (i.e., Chamberlain procedure) may be ideal for an anterior |
Surgery_Schwartz_4901 | Surgery_Schwartz | medi-astinum, a left or right VATS approach often allows safe and adequate surgical biopsies. In some patients, an anterior medi-astinotomy (i.e., Chamberlain procedure) may be ideal for an anterior tumor or a tumor with significant parasternal extension. Before a surgical biopsy is pursued, a discussion should be held with the pathologist regarding routine histologic assessment, spe-cial stains and markers, and requirements for lymphoma workup.Surgical resection using minimally invasive approaches, including video-assisted and robotic thoracoscopic surgery and transcervical, are now routine for the vast majority of middle and posterior tumors and for moderate sized (<5 to 6 cm) anterior mediastinal tumors.145-148 Outcomes comparing VATS to open thymectomy in patients with myasthenia gravis without thymoma were prospectively evaluated by Chang and colleagues in 2005, and no differences were seen in terms of response to therapy and recurrence of symptoms. Pain scores were | Surgery_Schwartz. medi-astinum, a left or right VATS approach often allows safe and adequate surgical biopsies. In some patients, an anterior medi-astinotomy (i.e., Chamberlain procedure) may be ideal for an anterior tumor or a tumor with significant parasternal extension. Before a surgical biopsy is pursued, a discussion should be held with the pathologist regarding routine histologic assessment, spe-cial stains and markers, and requirements for lymphoma workup.Surgical resection using minimally invasive approaches, including video-assisted and robotic thoracoscopic surgery and transcervical, are now routine for the vast majority of middle and posterior tumors and for moderate sized (<5 to 6 cm) anterior mediastinal tumors.145-148 Outcomes comparing VATS to open thymectomy in patients with myasthenia gravis without thymoma were prospectively evaluated by Chang and colleagues in 2005, and no differences were seen in terms of response to therapy and recurrence of symptoms. Pain scores were |
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