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Surgery_Schwartz_4902 | Surgery_Schwartz | 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 significantly better in the VATS approach.149 These reports and others support application of VATS for the majority of ante-rior mediastinal masses.Other minimally invasive approaches are under study. For example, good results have been reported using a cervical incision with a sternal retractor for thymus removal. The upward lift allows the surgeon reasonable access to the anterior medi-astinum and has proven adequate in some centers for definitive resection of the thymus gland for myasthenia gravis.150For larger anterior mediastinal masses or in centers where expertise in thoracoscopy is not available, median sternotomy and thoracotomy remain excellent options for resection of ante-rior mediastinal masses. Occasionally, a lateral thoracotomy with sternal extension (hemi-clamshell) provides | Surgery_Schwartz. 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 significantly better in the VATS approach.149 These reports and others support application of VATS for the majority of ante-rior mediastinal masses.Other minimally invasive approaches are under study. For example, good results have been reported using a cervical incision with a sternal retractor for thymus removal. The upward lift allows the surgeon reasonable access to the anterior medi-astinum and has proven adequate in some centers for definitive resection of the thymus gland for myasthenia gravis.150For larger anterior mediastinal masses or in centers where expertise in thoracoscopy is not available, median sternotomy and thoracotomy remain excellent options for resection of ante-rior mediastinal masses. Occasionally, a lateral thoracotomy with sternal extension (hemi-clamshell) provides |
Surgery_Schwartz_4903 | Surgery_Schwartz | median sternotomy and thoracotomy remain excellent options for resection of ante-rior mediastinal masses. Occasionally, a lateral thoracotomy with sternal extension (hemi-clamshell) provides excellent exposure for extensive mediastinal tumors that have a lateral component.Most surgeons would agree that if a larger anterior medi-astinal tumor is seen or malignancy is suspected, a median ster-notomy with a more radical resection should be performed.Mediastinal NeoplasmsThymic Hyperplasia. Diffuse thymic hyperplasia was first described in children after successful chemotherapy for lym-phoma. It has now been described in adults and is referred to as “rebound thymic hyperplasia.”151 It is most frequently reported after chemotherapy for lymphoma or germ cell tumors. Ini-tially, atrophy of the thymic gland is seen with subsequent thymic gland enlargement, which can be dramatic. The usual time course for thymic hyperplasia is about 9 months after ces-sation of chemotherapy (range 2 weeks to | Surgery_Schwartz. median sternotomy and thoracotomy remain excellent options for resection of ante-rior mediastinal masses. Occasionally, a lateral thoracotomy with sternal extension (hemi-clamshell) provides excellent exposure for extensive mediastinal tumors that have a lateral component.Most surgeons would agree that if a larger anterior medi-astinal tumor is seen or malignancy is suspected, a median ster-notomy with a more radical resection should be performed.Mediastinal NeoplasmsThymic Hyperplasia. Diffuse thymic hyperplasia was first described in children after successful chemotherapy for lym-phoma. It has now been described in adults and is referred to as “rebound thymic hyperplasia.”151 It is most frequently reported after chemotherapy for lymphoma or germ cell tumors. Ini-tially, atrophy of the thymic gland is seen with subsequent thymic gland enlargement, which can be dramatic. The usual time course for thymic hyperplasia is about 9 months after ces-sation of chemotherapy (range 2 weeks to |
Surgery_Schwartz_4904 | Surgery_Schwartz | thymic gland is seen with subsequent thymic gland enlargement, which can be dramatic. The usual time course for thymic hyperplasia is about 9 months after ces-sation of chemotherapy (range 2 weeks to 12 months). Benign hyperplasia must be clearly distinguished from recurrent lym-phoma or germ cell tumors, which may be difficult since thymic hyperplasia is dramatic in some patients; careful follow-up with serial CT scans is the minimum requirement. The role of PET scanning is unclear. Thymic hyperplasia is a known cause of false-positive PET scans; in many patients, CT scan will show a triangular soft tissue density in the retrosternal space that has a characteristic bilobed anatomic appearance consistent with thymus gland.152 In addition, a low standardized uptake value of tracer on PET scan suggests a benign tumor.153 Biopsies may be required if the clinical index of suspicion is high.Brunicardi_Ch19_p0661-p0750.indd 73001/03/19 7:01 PM | Surgery_Schwartz. thymic gland is seen with subsequent thymic gland enlargement, which can be dramatic. The usual time course for thymic hyperplasia is about 9 months after ces-sation of chemotherapy (range 2 weeks to 12 months). Benign hyperplasia must be clearly distinguished from recurrent lym-phoma or germ cell tumors, which may be difficult since thymic hyperplasia is dramatic in some patients; careful follow-up with serial CT scans is the minimum requirement. The role of PET scanning is unclear. Thymic hyperplasia is a known cause of false-positive PET scans; in many patients, CT scan will show a triangular soft tissue density in the retrosternal space that has a characteristic bilobed anatomic appearance consistent with thymus gland.152 In addition, a low standardized uptake value of tracer on PET scan suggests a benign tumor.153 Biopsies may be required if the clinical index of suspicion is high.Brunicardi_Ch19_p0661-p0750.indd 73001/03/19 7:01 PM |
Surgery_Schwartz_4905 | Surgery_Schwartz | CHAPTER 19731CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAThymoma. While it is the most frequently encountered neo-plasm of the anterior mediastinum in adults (seen most fre-quently between 40 and 60 years of age), thymoma is rare in children. Between 10% and 50% of patients with thymoma will have symptoms suggestive of myasthenia gravis or have circulating antibodies to acetylcholine receptor, but less than 10% of patients with myasthenia gravis have a thymoma. Most patients with thymoma are asymptomatic. Thymectomy leads to improvement or resolution of symptoms of myasthe-nia gravis in only about 25% of patients with thymomas. In contrast, in patients with myasthenia gravis and no thymoma, thymectomy results are superior: up to 50% of patients have a complete remission, and 90% improve. In 5% of patients with thymomas, other paraneoplastic syndromes, including red cell aplasia, hypogammaglobulinemia, systemic lupus erythema-tosus, Cushing’s syndrome, or SIADH, may be present. Large | Surgery_Schwartz. CHAPTER 19731CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAThymoma. While it is the most frequently encountered neo-plasm of the anterior mediastinum in adults (seen most fre-quently between 40 and 60 years of age), thymoma is rare in children. Between 10% and 50% of patients with thymoma will have symptoms suggestive of myasthenia gravis or have circulating antibodies to acetylcholine receptor, but less than 10% of patients with myasthenia gravis have a thymoma. Most patients with thymoma are asymptomatic. Thymectomy leads to improvement or resolution of symptoms of myasthe-nia gravis in only about 25% of patients with thymomas. In contrast, in patients with myasthenia gravis and no thymoma, thymectomy results are superior: up to 50% of patients have a complete remission, and 90% improve. In 5% of patients with thymomas, other paraneoplastic syndromes, including red cell aplasia, hypogammaglobulinemia, systemic lupus erythema-tosus, Cushing’s syndrome, or SIADH, may be present. Large |
Surgery_Schwartz_4906 | Surgery_Schwartz | In 5% of patients with thymomas, other paraneoplastic syndromes, including red cell aplasia, hypogammaglobulinemia, systemic lupus erythema-tosus, Cushing’s syndrome, or SIADH, may be present. Large thymic tumors may present with symptoms related to a mass effect, which may include cough, chest pain, dyspnea, or SVC syndrome.The diagnosis may be suspected based on CT scan and history, but imaging alone is not diagnostic. In most centers, the diagnosis is made after surgical resection because of the rela-tive difficulty of obtaining a needle biopsy and the likelihood that removal will ultimately be recommended. Biopsy should be avoided in cases where imaging is highly suggestive of thy-moma. In most patients, the distinction between lymphomas and thymomas can be made on CT scan since most lymphomas have marked lymphadenopathy and thymomas most frequently appear as a solitary encapsulated mass. PET scan may have a role in differentiating thymic cancer from thymoma, as thymic cancer | Surgery_Schwartz. In 5% of patients with thymomas, other paraneoplastic syndromes, including red cell aplasia, hypogammaglobulinemia, systemic lupus erythema-tosus, Cushing’s syndrome, or SIADH, may be present. Large thymic tumors may present with symptoms related to a mass effect, which may include cough, chest pain, dyspnea, or SVC syndrome.The diagnosis may be suspected based on CT scan and history, but imaging alone is not diagnostic. In most centers, the diagnosis is made after surgical resection because of the rela-tive difficulty of obtaining a needle biopsy and the likelihood that removal will ultimately be recommended. Biopsy should be avoided in cases where imaging is highly suggestive of thy-moma. In most patients, the distinction between lymphomas and thymomas can be made on CT scan since most lymphomas have marked lymphadenopathy and thymomas most frequently appear as a solitary encapsulated mass. PET scan may have a role in differentiating thymic cancer from thymoma, as thymic cancer |
Surgery_Schwartz_4907 | Surgery_Schwartz | lymphomas have marked lymphadenopathy and thymomas most frequently appear as a solitary encapsulated mass. PET scan may have a role in differentiating thymic cancer from thymoma, as thymic cancer tends to be very FDG avid.153 In addition, PET scan may facilitate identification of low-risk and minimally invasive thy-moma; a standardized uptake value (SUV) <5 was associated with Masaoka stage I or II thymoma, whereas invasive thymoma and mediastinal lymphoma were more likely when the SUV was >5.154 In cases where the diagnosis is unclear, transmediastinal, not transpleural, CT-guided FNA biopsy has a diagnostic sen-sitivity of 87% and a specificity of 95% in specialized centers.The most commonly accepted staging system for thymoma is that of Masaoka.155 It is based on the presence or absence of gross or microscopic invasion of the capsule and of surrounding structures, as well as on the presence or absence of metastases (Table 19-30). Histologically, thymomas are characterized by a | Surgery_Schwartz. lymphomas have marked lymphadenopathy and thymomas most frequently appear as a solitary encapsulated mass. PET scan may have a role in differentiating thymic cancer from thymoma, as thymic cancer tends to be very FDG avid.153 In addition, PET scan may facilitate identification of low-risk and minimally invasive thy-moma; a standardized uptake value (SUV) <5 was associated with Masaoka stage I or II thymoma, whereas invasive thymoma and mediastinal lymphoma were more likely when the SUV was >5.154 In cases where the diagnosis is unclear, transmediastinal, not transpleural, CT-guided FNA biopsy has a diagnostic sen-sitivity of 87% and a specificity of 95% in specialized centers.The most commonly accepted staging system for thymoma is that of Masaoka.155 It is based on the presence or absence of gross or microscopic invasion of the capsule and of surrounding structures, as well as on the presence or absence of metastases (Table 19-30). Histologically, thymomas are characterized by a |
Surgery_Schwartz_4908 | Surgery_Schwartz | of gross or microscopic invasion of the capsule and of surrounding structures, as well as on the presence or absence of metastases (Table 19-30). Histologically, thymomas are characterized by a mixture of epithelial cells and mature lymphocytes. Grossly, many thymomas remain well encapsulated. Even those with capsular invasion often lack histologic features of malignancy; they appear cytologically benign and identical to early-stage tumors. This lack of classic cellular features of malignancy is why most pathologists use the term “thymoma” or “invasive thymoma” rather than “malignant thymoma.” Thymic tumors with malignant cytologic features are classified separately and referred to as “thymic carcinoma.”The definitive treatment for thymoma is complete surgical removal; local recurrence rates and survival vary according to stage (Fig. 19-47). In centers with significant experience with VATS procedures, thymoma is not a contraindication to VATS approach, provided the principles of | Surgery_Schwartz. of gross or microscopic invasion of the capsule and of surrounding structures, as well as on the presence or absence of metastases (Table 19-30). Histologically, thymomas are characterized by a mixture of epithelial cells and mature lymphocytes. Grossly, many thymomas remain well encapsulated. Even those with capsular invasion often lack histologic features of malignancy; they appear cytologically benign and identical to early-stage tumors. This lack of classic cellular features of malignancy is why most pathologists use the term “thymoma” or “invasive thymoma” rather than “malignant thymoma.” Thymic tumors with malignant cytologic features are classified separately and referred to as “thymic carcinoma.”The definitive treatment for thymoma is complete surgical removal; local recurrence rates and survival vary according to stage (Fig. 19-47). In centers with significant experience with VATS procedures, thymoma is not a contraindication to VATS approach, provided the principles of |
Surgery_Schwartz_4909 | Surgery_Schwartz | rates and survival vary according to stage (Fig. 19-47). In centers with significant experience with VATS procedures, thymoma is not a contraindication to VATS approach, provided the principles of resection are adhered to, such as a complete resection without disrupting the capsule.156 Otherwise, resection is generally accomplished by median ster-notomy with extension to hemi-clamshell in more advanced cases. Even advanced tumors with local invasion of resectable structures such as the pericardium, SVC, or innominate vessels should be considered for resection with reconstruction.A multidisciplinary approach to nonresectable and more advanced lesions (stage ≥II) is mandatory to optimize patient care. The goal for surgical resection should be complete exci-sion of the mass with total thymectomy. All contiguous and noncontiguous disease is removed at the same setting; this may include resection of the pericardium or pleura, adjacent adher-ent lung, phrenic nerve, major vascular | Surgery_Schwartz. rates and survival vary according to stage (Fig. 19-47). In centers with significant experience with VATS procedures, thymoma is not a contraindication to VATS approach, provided the principles of resection are adhered to, such as a complete resection without disrupting the capsule.156 Otherwise, resection is generally accomplished by median ster-notomy with extension to hemi-clamshell in more advanced cases. Even advanced tumors with local invasion of resectable structures such as the pericardium, SVC, or innominate vessels should be considered for resection with reconstruction.A multidisciplinary approach to nonresectable and more advanced lesions (stage ≥II) is mandatory to optimize patient care. The goal for surgical resection should be complete exci-sion of the mass with total thymectomy. All contiguous and noncontiguous disease is removed at the same setting; this may include resection of the pericardium or pleura, adjacent adher-ent lung, phrenic nerve, major vascular |
Surgery_Schwartz_4910 | Surgery_Schwartz | thymectomy. All contiguous and noncontiguous disease is removed at the same setting; this may include resection of the pericardium or pleura, adjacent adher-ent lung, phrenic nerve, major vascular structures, and pleural metastasis. Bilateral phrenic nerve resection should be avoided, however, due to the major respiratory morbidity associated with bilateral paralyzed hemidiaphragms.The role of adjuvant or neoadjuvant therapies for advanced-stage tumors remains unclear. Traditionally, stage II thymomas have been treated by complete surgical resection fol-lowed by mediastinal radiation, but randomized trials have not been done. A recent retrospective review of a single-institution series of stage II thymoma patients showed no difference in survival or local recurrence after complete surgical resection alone, as compared with surgical resection with radiotherapy. Advanced thymomas have been shown to respond to platinum-based chemotherapy and to corticosteroids.157 One summary of | Surgery_Schwartz. thymectomy. All contiguous and noncontiguous disease is removed at the same setting; this may include resection of the pericardium or pleura, adjacent adher-ent lung, phrenic nerve, major vascular structures, and pleural metastasis. Bilateral phrenic nerve resection should be avoided, however, due to the major respiratory morbidity associated with bilateral paralyzed hemidiaphragms.The role of adjuvant or neoadjuvant therapies for advanced-stage tumors remains unclear. Traditionally, stage II thymomas have been treated by complete surgical resection fol-lowed by mediastinal radiation, but randomized trials have not been done. A recent retrospective review of a single-institution series of stage II thymoma patients showed no difference in survival or local recurrence after complete surgical resection alone, as compared with surgical resection with radiotherapy. Advanced thymomas have been shown to respond to platinum-based chemotherapy and to corticosteroids.157 One summary of |
Surgery_Schwartz_4911 | Surgery_Schwartz | surgical resection alone, as compared with surgical resection with radiotherapy. Advanced thymomas have been shown to respond to platinum-based chemotherapy and to corticosteroids.157 One summary of chemotherapy trials showed an overall response rate of about 70%. Cisplatin/doxorubicin-based regimens appear to yield the best results. The combination radiotherapy and chemotherapy for local progression appears to prolong survival in some small series.158 Radiation therapy in surgically resected stage III thy-moma is likely beneficial in extending disease-specific survival; an analysis of the Surveillance, Epidemiology, and End Results (SEER) database identified 476 patients with stage III thymoma treated with primary surgery. Postoperative radiation was given Table 19-30Masaoka staging system for thymomaStage IEncapsulated tumor with no gross or microscopic evidence of capsular invasionStage IIGross capsular invasion or invasion into the mediastinal fat or pleura or microscopic capsular | Surgery_Schwartz. surgical resection alone, as compared with surgical resection with radiotherapy. Advanced thymomas have been shown to respond to platinum-based chemotherapy and to corticosteroids.157 One summary of chemotherapy trials showed an overall response rate of about 70%. Cisplatin/doxorubicin-based regimens appear to yield the best results. The combination radiotherapy and chemotherapy for local progression appears to prolong survival in some small series.158 Radiation therapy in surgically resected stage III thy-moma is likely beneficial in extending disease-specific survival; an analysis of the Surveillance, Epidemiology, and End Results (SEER) database identified 476 patients with stage III thymoma treated with primary surgery. Postoperative radiation was given Table 19-30Masaoka staging system for thymomaStage IEncapsulated tumor with no gross or microscopic evidence of capsular invasionStage IIGross capsular invasion or invasion into the mediastinal fat or pleura or microscopic capsular |
Surgery_Schwartz_4912 | Surgery_Schwartz | for thymomaStage IEncapsulated tumor with no gross or microscopic evidence of capsular invasionStage IIGross capsular invasion or invasion into the mediastinal fat or pleura or microscopic capsular invasionStage IIIGross invasion into the pericardium, great vessels, or lungStage IVAPleural or pericardial disseminationStage IVBLymphogenous or hematogenous metastasis1.0.8.6.4.20Proportion surviving02010YearsP=.002Stage IStage IVStage IIIStage IIFigure 19-47. Stage-specific survival for thymomas.Brunicardi_Ch19_p0661-p0750.indd 73101/03/19 7:01 PM 732SPECIFIC CONSIDERATIONSPART IIFigure 19-48. Massive thymolipoma that was asymptomatic in an 18-year-old female.to 322 patients with a significant improvement in survival (127 months compared to 105 months, P = .038) despite the fact that these patients were more likely to have had debulking rather than curative resection. In multivariate analysis, disease-specific survival was better in the adjuvant radiation group.159 There-fore, it is | Surgery_Schwartz. for thymomaStage IEncapsulated tumor with no gross or microscopic evidence of capsular invasionStage IIGross capsular invasion or invasion into the mediastinal fat or pleura or microscopic capsular invasionStage IIIGross invasion into the pericardium, great vessels, or lungStage IVAPleural or pericardial disseminationStage IVBLymphogenous or hematogenous metastasis1.0.8.6.4.20Proportion surviving02010YearsP=.002Stage IStage IVStage IIIStage IIFigure 19-47. Stage-specific survival for thymomas.Brunicardi_Ch19_p0661-p0750.indd 73101/03/19 7:01 PM 732SPECIFIC CONSIDERATIONSPART IIFigure 19-48. Massive thymolipoma that was asymptomatic in an 18-year-old female.to 322 patients with a significant improvement in survival (127 months compared to 105 months, P = .038) despite the fact that these patients were more likely to have had debulking rather than curative resection. In multivariate analysis, disease-specific survival was better in the adjuvant radiation group.159 There-fore, it is |
Surgery_Schwartz_4913 | Surgery_Schwartz | patients were more likely to have had debulking rather than curative resection. In multivariate analysis, disease-specific survival was better in the adjuvant radiation group.159 There-fore, it is imperative that all patients with thymomas undergo a thorough evaluation for potential resection. Current guidelines recommend radiation for patients with unresectable thymoma who have failed induction chemotherapy or for patients with incompletely resected invasive thymoma or thymic cancer. Planning the radiation ports requires input from the surgeon; it is important for the surgeon to carefully document areas of adherence between the thymoma and adjacent structures during the operation, with clips or other radiopaque markers placed to guide radiation therapy postoperatively. Extracapsular extension and positive surgical margins should be noted by the pathologist and correlated anatomically so that the surgeon and radiation oncologist can ensure appropriate radiation treatment.Thymic | Surgery_Schwartz. patients were more likely to have had debulking rather than curative resection. In multivariate analysis, disease-specific survival was better in the adjuvant radiation group.159 There-fore, it is imperative that all patients with thymomas undergo a thorough evaluation for potential resection. Current guidelines recommend radiation for patients with unresectable thymoma who have failed induction chemotherapy or for patients with incompletely resected invasive thymoma or thymic cancer. Planning the radiation ports requires input from the surgeon; it is important for the surgeon to carefully document areas of adherence between the thymoma and adjacent structures during the operation, with clips or other radiopaque markers placed to guide radiation therapy postoperatively. Extracapsular extension and positive surgical margins should be noted by the pathologist and correlated anatomically so that the surgeon and radiation oncologist can ensure appropriate radiation treatment.Thymic |
Surgery_Schwartz_4914 | Surgery_Schwartz | extension and positive surgical margins should be noted by the pathologist and correlated anatomically so that the surgeon and radiation oncologist can ensure appropriate radiation treatment.Thymic Carcinoma. Thymic carcinomas are unequivocally malignant at the microscopic level. Suster and Rosai classified thymic carcinomas into low-grade and high-grade tumors.160 Low-grade tumors are well differentiated with squamous cell, mucoepidermoid, or basaloid features. High-grade thymic car-cinomas include those with lymphoepithelial, small cell neu-roendocrine, sarcomatoid, clear cell, and undifferentiated or anaplastic features. Care must be taken to differentiate thymic carcinoma from lung cancer metastatic to the thymus gland as the histologic features can be similar between the two. Com-pared with thymomas, they are a more heterogeneous group of malignancies with a propensity for early local invasion and widespread metastases. Malignant pleural and pericardial effu-sions occur | Surgery_Schwartz. extension and positive surgical margins should be noted by the pathologist and correlated anatomically so that the surgeon and radiation oncologist can ensure appropriate radiation treatment.Thymic Carcinoma. Thymic carcinomas are unequivocally malignant at the microscopic level. Suster and Rosai classified thymic carcinomas into low-grade and high-grade tumors.160 Low-grade tumors are well differentiated with squamous cell, mucoepidermoid, or basaloid features. High-grade thymic car-cinomas include those with lymphoepithelial, small cell neu-roendocrine, sarcomatoid, clear cell, and undifferentiated or anaplastic features. Care must be taken to differentiate thymic carcinoma from lung cancer metastatic to the thymus gland as the histologic features can be similar between the two. Com-pared with thymomas, they are a more heterogeneous group of malignancies with a propensity for early local invasion and widespread metastases. Malignant pleural and pericardial effu-sions occur |
Surgery_Schwartz_4915 | Surgery_Schwartz | Com-pared with thymomas, they are a more heterogeneous group of malignancies with a propensity for early local invasion and widespread metastases. Malignant pleural and pericardial effu-sions occur frequently.Five-year survival rates are between 30% and 50%. Com-plete resection is occasionally curative and leads to improved survival, but most thymic carcinomas will recur and are refractory to chemotherapy.157 Management, therefore, depends on the completeness of the resection. Postoperative care includes radiation therapy, guided by residual gross disease or microscopically positive margins from the resection specimen. Chemotherapy may also be given, with carboplatin/paclitaxel recommended based on the best response rates with the least toxicity in clinical trials. The prognosis of patients with thymic cancer remains poor.Thymolipoma. Thymolipomas are rare benign tumors that may grow to a very large size prior to diagnosis. On CT scan, their appearance can be dramatic, with a | Surgery_Schwartz. Com-pared with thymomas, they are a more heterogeneous group of malignancies with a propensity for early local invasion and widespread metastases. Malignant pleural and pericardial effu-sions occur frequently.Five-year survival rates are between 30% and 50%. Com-plete resection is occasionally curative and leads to improved survival, but most thymic carcinomas will recur and are refractory to chemotherapy.157 Management, therefore, depends on the completeness of the resection. Postoperative care includes radiation therapy, guided by residual gross disease or microscopically positive margins from the resection specimen. Chemotherapy may also be given, with carboplatin/paclitaxel recommended based on the best response rates with the least toxicity in clinical trials. The prognosis of patients with thymic cancer remains poor.Thymolipoma. Thymolipomas are rare benign tumors that may grow to a very large size prior to diagnosis. On CT scan, their appearance can be dramatic, with a |
Surgery_Schwartz_4916 | Surgery_Schwartz | patients with thymic cancer remains poor.Thymolipoma. Thymolipomas are rare benign tumors that may grow to a very large size prior to diagnosis. On CT scan, their appearance can be dramatic, with a characteristic fat den-sity dotted by islands of soft tissue density representing islands of thymic tissue (Fig. 19-48). Thymolipomas are generally well-encapsulated, soft, and pliable masses that do not invade surrounding structures. Resection is recommended for large masses.Neurogenic Tumors. Most neurogenic tumors of the medi-astinum arise from the cells of the nerve sheath, from ganglion cells, or from the paraganglionic system (Table 19-31). The incidence, cell types, and risk of malignancy strongly correlate with patient age. Tumors of nerve sheath origin predominate in adults. Most present as asymptomatic incidental findings, and most are benign. In children and young adults, tumors of the autonomic ganglia predominate, with up to two-thirds being malignant.161Nerve Sheath | Surgery_Schwartz. patients with thymic cancer remains poor.Thymolipoma. Thymolipomas are rare benign tumors that may grow to a very large size prior to diagnosis. On CT scan, their appearance can be dramatic, with a characteristic fat den-sity dotted by islands of soft tissue density representing islands of thymic tissue (Fig. 19-48). Thymolipomas are generally well-encapsulated, soft, and pliable masses that do not invade surrounding structures. Resection is recommended for large masses.Neurogenic Tumors. Most neurogenic tumors of the medi-astinum arise from the cells of the nerve sheath, from ganglion cells, or from the paraganglionic system (Table 19-31). The incidence, cell types, and risk of malignancy strongly correlate with patient age. Tumors of nerve sheath origin predominate in adults. Most present as asymptomatic incidental findings, and most are benign. In children and young adults, tumors of the autonomic ganglia predominate, with up to two-thirds being malignant.161Nerve Sheath |
Surgery_Schwartz_4917 | Surgery_Schwartz | Most present as asymptomatic incidental findings, and most are benign. In children and young adults, tumors of the autonomic ganglia predominate, with up to two-thirds being malignant.161Nerve Sheath Tumors. Nerve sheath tumors account for 20% of all mediastinal tumors. More than 95% of nerve sheath tumors are benign neurilemomas or neurofibromas. Malignant neurosarcomas are much less common.Neurilemoma. Neurilemomas, also called schwannomas, arise from Schwann cells in intercostal nerves. They are firm, well encapsulated, and generally benign. Two characteristic histo-logic components are referred to as Antoni type A and Antoni type B regions. Antoni type A regions contain compact spindle Brunicardi_Ch19_p0661-p0750.indd 73201/03/19 7:01 PM | Surgery_Schwartz. Most present as asymptomatic incidental findings, and most are benign. In children and young adults, tumors of the autonomic ganglia predominate, with up to two-thirds being malignant.161Nerve Sheath Tumors. Nerve sheath tumors account for 20% of all mediastinal tumors. More than 95% of nerve sheath tumors are benign neurilemomas or neurofibromas. Malignant neurosarcomas are much less common.Neurilemoma. Neurilemomas, also called schwannomas, arise from Schwann cells in intercostal nerves. They are firm, well encapsulated, and generally benign. Two characteristic histo-logic components are referred to as Antoni type A and Antoni type B regions. Antoni type A regions contain compact spindle Brunicardi_Ch19_p0661-p0750.indd 73201/03/19 7:01 PM |
Surgery_Schwartz_4918 | Surgery_Schwartz | CHAPTER 19733CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAFigure 19-49. Magnetic resonance image of a neurogenic tumor with extension into the spinal canal via the foramen, giving a typical dumbbell appearance.Table 19-31Classification of neurogenic tumors of the mediastinumTUMOR ORIGINBENIGNMALIGNANTNerve sheathNeurilemoma, neurofibroma, melanotic schwannoma, granular cell tumorNeurofibrosarcomaGanglion cellGanglioneuromaGanglioneuroblastoma, neuroblastomaParaganglionic cellChemodectoma, pheochromocytomaMalignant chemodectoma, malignant pheochromocytomaReproduced with permission from Pearson FG, Cooper JD, Deslauriers J, et al: Thoracic Surgery, 2nd ed. New York, NY: Elsevier/Churchill Livingstone; 2002.cells with twisted nuclei and nuclear palisading. Antoni type B regions contain loose and myxoid connective tissue with hap-hazard cellular arrangement. These characteristics distinguish neurilemoma from malignant fibrosarcomatous tumors, which lack encapsulation and have no Antoni | Surgery_Schwartz. CHAPTER 19733CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAFigure 19-49. Magnetic resonance image of a neurogenic tumor with extension into the spinal canal via the foramen, giving a typical dumbbell appearance.Table 19-31Classification of neurogenic tumors of the mediastinumTUMOR ORIGINBENIGNMALIGNANTNerve sheathNeurilemoma, neurofibroma, melanotic schwannoma, granular cell tumorNeurofibrosarcomaGanglion cellGanglioneuromaGanglioneuroblastoma, neuroblastomaParaganglionic cellChemodectoma, pheochromocytomaMalignant chemodectoma, malignant pheochromocytomaReproduced with permission from Pearson FG, Cooper JD, Deslauriers J, et al: Thoracic Surgery, 2nd ed. New York, NY: Elsevier/Churchill Livingstone; 2002.cells with twisted nuclei and nuclear palisading. Antoni type B regions contain loose and myxoid connective tissue with hap-hazard cellular arrangement. These characteristics distinguish neurilemoma from malignant fibrosarcomatous tumors, which lack encapsulation and have no Antoni |
Surgery_Schwartz_4919 | Surgery_Schwartz | and myxoid connective tissue with hap-hazard cellular arrangement. These characteristics distinguish neurilemoma from malignant fibrosarcomatous tumors, which lack encapsulation and have no Antoni features. If routine CT scan suggests extension of a neurilemoma into the intervertebral foramen, MRI is used to evaluate the extent of this “dumbbell” configuration (Fig. 19-49). Such a configuration may lead to cord compression and paralysis and requires a more complex surgical approach. Resection is recommended; VATS has been established as safe and effective for simple and, in experienced centers, even the more complex operations.162 It is reasonable to follow small, asymptomatic paravertebral tumors in older patients or in patients at high risk for surgery. In children, ganglioneuroblastomas or neuroblastomas are more common; therefore, all neurogenic tumors should be completely resected.Neurofibroma. Neurofibromas consist of both nerve sheath and nerve cells and account for up to 25% | Surgery_Schwartz. and myxoid connective tissue with hap-hazard cellular arrangement. These characteristics distinguish neurilemoma from malignant fibrosarcomatous tumors, which lack encapsulation and have no Antoni features. If routine CT scan suggests extension of a neurilemoma into the intervertebral foramen, MRI is used to evaluate the extent of this “dumbbell” configuration (Fig. 19-49). Such a configuration may lead to cord compression and paralysis and requires a more complex surgical approach. Resection is recommended; VATS has been established as safe and effective for simple and, in experienced centers, even the more complex operations.162 It is reasonable to follow small, asymptomatic paravertebral tumors in older patients or in patients at high risk for surgery. In children, ganglioneuroblastomas or neuroblastomas are more common; therefore, all neurogenic tumors should be completely resected.Neurofibroma. Neurofibromas consist of both nerve sheath and nerve cells and account for up to 25% |
Surgery_Schwartz_4920 | Surgery_Schwartz | or neuroblastomas are more common; therefore, all neurogenic tumors should be completely resected.Neurofibroma. Neurofibromas consist of both nerve sheath and nerve cells and account for up to 25% of nerve sheath tumors. Up to 40% of patients with mediastinal fibromas have general-ized neurofibromatosis (von Recklinghausen’s disease). About 70% of neurofibromas are benign, but malignant degeneration to neurofibrosarcoma occurs in 25% to 30% of patients.163 The risk of malignant degeneration increases with advancing age, von Recklinghausen’s disease, and exposure to previous radia-tion. Neurofibrosarcomas carry a poor prognosis because of rapid growth and aggressive local invasion along nerve bun-dles. Complete surgical resection is the mainstay of treatment. Adjuvant radiotherapy or chemotherapy does not confer a sig-nificant benefit, but may be added if complete resection is not possible.164 The 5-year survival rate is 53%, but it drops to 16% in patients with neurofibromatosis or | Surgery_Schwartz. or neuroblastomas are more common; therefore, all neurogenic tumors should be completely resected.Neurofibroma. Neurofibromas consist of both nerve sheath and nerve cells and account for up to 25% of nerve sheath tumors. Up to 40% of patients with mediastinal fibromas have general-ized neurofibromatosis (von Recklinghausen’s disease). About 70% of neurofibromas are benign, but malignant degeneration to neurofibrosarcoma occurs in 25% to 30% of patients.163 The risk of malignant degeneration increases with advancing age, von Recklinghausen’s disease, and exposure to previous radia-tion. Neurofibrosarcomas carry a poor prognosis because of rapid growth and aggressive local invasion along nerve bun-dles. Complete surgical resection is the mainstay of treatment. Adjuvant radiotherapy or chemotherapy does not confer a sig-nificant benefit, but may be added if complete resection is not possible.164 The 5-year survival rate is 53%, but it drops to 16% in patients with neurofibromatosis or |
Surgery_Schwartz_4921 | Surgery_Schwartz | does not confer a sig-nificant benefit, but may be added if complete resection is not possible.164 The 5-year survival rate is 53%, but it drops to 16% in patients with neurofibromatosis or with large tumors (>5 cm).Ganglion Cell Tumors Ganglion cell tumors (ganglioneuro-mas, ganglioneuroblastomas, and neuroblastomas) arise from the sympathetic chain or from the adrenal medulla.1. Ganglioneuroma. Well-differentiated, benign tumors char-acterized histologically by well-differentiated ganglion cells with a background of Schwann cells, these are most often found incidentally in asymptomatic young adults. Diarrhea related to secretion of a vasoactive intestinal peptide has been described in some patients. These tumors have a pro-pensity for intraspinal canal extension, although they remain well-encapsulated; complete resection is curative, with a low risk of local recurrence.Brunicardi_Ch19_p0661-p0750.indd 73301/03/19 7:01 PM 734SPECIFIC CONSIDERATIONSPART II2. Ganglioneuroblastoma. | Surgery_Schwartz. does not confer a sig-nificant benefit, but may be added if complete resection is not possible.164 The 5-year survival rate is 53%, but it drops to 16% in patients with neurofibromatosis or with large tumors (>5 cm).Ganglion Cell Tumors Ganglion cell tumors (ganglioneuro-mas, ganglioneuroblastomas, and neuroblastomas) arise from the sympathetic chain or from the adrenal medulla.1. Ganglioneuroma. Well-differentiated, benign tumors char-acterized histologically by well-differentiated ganglion cells with a background of Schwann cells, these are most often found incidentally in asymptomatic young adults. Diarrhea related to secretion of a vasoactive intestinal peptide has been described in some patients. These tumors have a pro-pensity for intraspinal canal extension, although they remain well-encapsulated; complete resection is curative, with a low risk of local recurrence.Brunicardi_Ch19_p0661-p0750.indd 73301/03/19 7:01 PM 734SPECIFIC CONSIDERATIONSPART II2. Ganglioneuroblastoma. |
Surgery_Schwartz_4922 | Surgery_Schwartz | complete resection is curative, with a low risk of local recurrence.Brunicardi_Ch19_p0661-p0750.indd 73301/03/19 7:01 PM 734SPECIFIC CONSIDERATIONSPART II2. Ganglioneuroblastoma. Ganglioneuroblastomas contain a mixture of benign ganglion cells and malignant neuro-blasts. The distribution of these cells within the tumor is predictive of the clinical course. The nodular pattern has a high incidence of metastatic disease, whereas the diffuse pattern rarely metastasizes. Gross examination typically reveals encapsulated tumor; histologically, there are focal calcifications around regions of neuroblasts. Ganglioneu-roblastomas arise most frequently in infants and children <3 years old. The majority are resectable, with 80% 5-year survival.3. Neuroblastoma. Highly malignant, neuroblastomas are the most common extracranial solid malignancy of childhood. The primary site is intrathoracic malignancy in 14%; exten-sion into the spinal canal and osseous invasion commonly present. These | Surgery_Schwartz. complete resection is curative, with a low risk of local recurrence.Brunicardi_Ch19_p0661-p0750.indd 73301/03/19 7:01 PM 734SPECIFIC CONSIDERATIONSPART II2. Ganglioneuroblastoma. Ganglioneuroblastomas contain a mixture of benign ganglion cells and malignant neuro-blasts. The distribution of these cells within the tumor is predictive of the clinical course. The nodular pattern has a high incidence of metastatic disease, whereas the diffuse pattern rarely metastasizes. Gross examination typically reveals encapsulated tumor; histologically, there are focal calcifications around regions of neuroblasts. Ganglioneu-roblastomas arise most frequently in infants and children <3 years old. The majority are resectable, with 80% 5-year survival.3. Neuroblastoma. Highly malignant, neuroblastomas are the most common extracranial solid malignancy of childhood. The primary site is intrathoracic malignancy in 14%; exten-sion into the spinal canal and osseous invasion commonly present. These |
Surgery_Schwartz_4923 | Surgery_Schwartz | are the most common extracranial solid malignancy of childhood. The primary site is intrathoracic malignancy in 14%; exten-sion into the spinal canal and osseous invasion commonly present. These thoracic tumors are not as recalcitrant to chemotherapy and surgical resection as other chest malig-nancies; they are more likely to be resectable, with less inva-sion of surrounding organs. More than half occur in children under 2 years old; 90% arise within the first decade of life, and thus, these malignancies are discussed in more detail in Chapter 39.Paraganglionic Tumors. Paraganglionic tumors arising in the thoracic cavity include chemodectomas and pheochromo-cytomas. Only 10% of all pheochromocytomas are located in an extra-adrenal site. Intrathoracic pheochromocytomas are one of the rarest tumors.Approximately 10% of thoracic pheochromocytomas are malignant, a rate similar to that of adrenal tumors. The most common thoracic location is within the costovertebral sulcus, but | Surgery_Schwartz. are the most common extracranial solid malignancy of childhood. The primary site is intrathoracic malignancy in 14%; exten-sion into the spinal canal and osseous invasion commonly present. These thoracic tumors are not as recalcitrant to chemotherapy and surgical resection as other chest malig-nancies; they are more likely to be resectable, with less inva-sion of surrounding organs. More than half occur in children under 2 years old; 90% arise within the first decade of life, and thus, these malignancies are discussed in more detail in Chapter 39.Paraganglionic Tumors. Paraganglionic tumors arising in the thoracic cavity include chemodectomas and pheochromo-cytomas. Only 10% of all pheochromocytomas are located in an extra-adrenal site. Intrathoracic pheochromocytomas are one of the rarest tumors.Approximately 10% of thoracic pheochromocytomas are malignant, a rate similar to that of adrenal tumors. The most common thoracic location is within the costovertebral sulcus, but |
Surgery_Schwartz_4924 | Surgery_Schwartz | the rarest tumors.Approximately 10% of thoracic pheochromocytomas are malignant, a rate similar to that of adrenal tumors. The most common thoracic location is within the costovertebral sulcus, but paraganglionic tumors also arise within the visceral com-partment of the mediastinum. These catecholamine-producing lesions can lead to life-threatening hemodynamic problems, so complete removal is important. Diagnosis is generally confirmed by measuring elevated levels of urinary catecholamines and their metabolites. Localization is by CT scan, aided by MIBG scintigraphy. Preoperative care includes αand β-adrenergic blockade to prevent intraoperative malignant hypertension and arrhythmias. These tumors tend to be highly vascular and should be approached with care. Chemodectomas are rare tumors that may be located around the aortic arch, vagus nerves, or aor-ticosympathetics. They rarely secrete catecholamines and are malignant in up to 30% of patients.Lymphoma. Overall, lymphomas are the | Surgery_Schwartz. the rarest tumors.Approximately 10% of thoracic pheochromocytomas are malignant, a rate similar to that of adrenal tumors. The most common thoracic location is within the costovertebral sulcus, but paraganglionic tumors also arise within the visceral com-partment of the mediastinum. These catecholamine-producing lesions can lead to life-threatening hemodynamic problems, so complete removal is important. Diagnosis is generally confirmed by measuring elevated levels of urinary catecholamines and their metabolites. Localization is by CT scan, aided by MIBG scintigraphy. Preoperative care includes αand β-adrenergic blockade to prevent intraoperative malignant hypertension and arrhythmias. These tumors tend to be highly vascular and should be approached with care. Chemodectomas are rare tumors that may be located around the aortic arch, vagus nerves, or aor-ticosympathetics. They rarely secrete catecholamines and are malignant in up to 30% of patients.Lymphoma. Overall, lymphomas are the |
Surgery_Schwartz_4925 | Surgery_Schwartz | that may be located around the aortic arch, vagus nerves, or aor-ticosympathetics. They rarely secrete catecholamines and are malignant in up to 30% of patients.Lymphoma. Overall, lymphomas are the most common malig-nancy of the mediastinum. In about 50% of patients who have both Hodgkin’s and non-Hodgkin’s lymphoma, the mediasti-num may be the primary site. The anterior compartment is most commonly involved, with occasional involvement of the mid-dle compartment and hilar nodes. The posterior compartment is rarely involved. Chemotherapy and/or radiation results in a cure rate of up to 90% for patients with early-stage Hodgkin’s disease and up to 60% with more advanced stages.Mediastinal Germ Cell Tumors. Germ cell tumors are uncom-mon neoplasms, but they are the most common malignancy in young men 15 to 35 years of age. Most germ cell tumors are gonadal in origin; primary mediastinal germ cell tumors com-prise less than 5% of all germ cell tumors and less than 1% of all mediastinal | Surgery_Schwartz. that may be located around the aortic arch, vagus nerves, or aor-ticosympathetics. They rarely secrete catecholamines and are malignant in up to 30% of patients.Lymphoma. Overall, lymphomas are the most common malig-nancy of the mediastinum. In about 50% of patients who have both Hodgkin’s and non-Hodgkin’s lymphoma, the mediasti-num may be the primary site. The anterior compartment is most commonly involved, with occasional involvement of the mid-dle compartment and hilar nodes. The posterior compartment is rarely involved. Chemotherapy and/or radiation results in a cure rate of up to 90% for patients with early-stage Hodgkin’s disease and up to 60% with more advanced stages.Mediastinal Germ Cell Tumors. Germ cell tumors are uncom-mon neoplasms, but they are the most common malignancy in young men 15 to 35 years of age. Most germ cell tumors are gonadal in origin; primary mediastinal germ cell tumors com-prise less than 5% of all germ cell tumors and less than 1% of all mediastinal |
Surgery_Schwartz_4926 | Surgery_Schwartz | young men 15 to 35 years of age. Most germ cell tumors are gonadal in origin; primary mediastinal germ cell tumors com-prise less than 5% of all germ cell tumors and less than 1% of all mediastinal tumors (usually occurring in the anterior com-partment). If a malignant mediastinal germ cell tumor is found, it is important to exclude a gonadal primary tumor. Primary mediastinal germ cell tumors (including teratomas, seminomas, and nonseminomatous malignant germ cell tumors) are a het-erogeneous group of benign and malignant neoplasms thought to originate from primitive pluripotent germ cells “misplaced” in the mediastinum during embryonic development. Previ-ously, most mediastinal germ cell tumors were thought to be metastatic. However, two lines of evidence suggest that many mediastinal germ cell tumors are primary, developing from plu-ripotent primordial germ cells in the mediastinum: (a) several autopsy series showed that patients with extragonadal sites of germ cell tumors, | Surgery_Schwartz. young men 15 to 35 years of age. Most germ cell tumors are gonadal in origin; primary mediastinal germ cell tumors com-prise less than 5% of all germ cell tumors and less than 1% of all mediastinal tumors (usually occurring in the anterior com-partment). If a malignant mediastinal germ cell tumor is found, it is important to exclude a gonadal primary tumor. Primary mediastinal germ cell tumors (including teratomas, seminomas, and nonseminomatous malignant germ cell tumors) are a het-erogeneous group of benign and malignant neoplasms thought to originate from primitive pluripotent germ cells “misplaced” in the mediastinum during embryonic development. Previ-ously, most mediastinal germ cell tumors were thought to be metastatic. However, two lines of evidence suggest that many mediastinal germ cell tumors are primary, developing from plu-ripotent primordial germ cells in the mediastinum: (a) several autopsy series showed that patients with extragonadal sites of germ cell tumors, |
Surgery_Schwartz_4927 | Surgery_Schwartz | germ cell tumors are primary, developing from plu-ripotent primordial germ cells in the mediastinum: (a) several autopsy series showed that patients with extragonadal sites of germ cell tumors, presumed previously to have originated from the gonads, had no evidence of an occult primary tumor or of any residual scar of the gonads, even after an exhaustive search; and (b) patients treated by surgery or radiation for their medi-astinal germ cell tumors had long-term survival with no late testicular recurrences.165About one-third of all primary mediastinal germ cell tumors are seminomatous. Two-thirds are nonseminomatous tumors or teratomas. Treatment and prognosis vary consider-ably within these two groups. Mature teratomas are benign and can generally be diagnosed by the characteristic CT findings of multilocular cystic tumors, encapsulated with combinations of fluid, soft tissue, calcium, and/or fat attenuation in the anterior compartment. FNA biopsy alone may be diagnostic for | Surgery_Schwartz. germ cell tumors are primary, developing from plu-ripotent primordial germ cells in the mediastinum: (a) several autopsy series showed that patients with extragonadal sites of germ cell tumors, presumed previously to have originated from the gonads, had no evidence of an occult primary tumor or of any residual scar of the gonads, even after an exhaustive search; and (b) patients treated by surgery or radiation for their medi-astinal germ cell tumors had long-term survival with no late testicular recurrences.165About one-third of all primary mediastinal germ cell tumors are seminomatous. Two-thirds are nonseminomatous tumors or teratomas. Treatment and prognosis vary consider-ably within these two groups. Mature teratomas are benign and can generally be diagnosed by the characteristic CT findings of multilocular cystic tumors, encapsulated with combinations of fluid, soft tissue, calcium, and/or fat attenuation in the anterior compartment. FNA biopsy alone may be diagnostic for |
Surgery_Schwartz_4928 | Surgery_Schwartz | CT findings of multilocular cystic tumors, encapsulated with combinations of fluid, soft tissue, calcium, and/or fat attenuation in the anterior compartment. FNA biopsy alone may be diagnostic for semi-nomas, usually with normal serum markers, including hCG and AFP. In 10% of seminomas, hCG levels may be slightly ele-vated. FNA findings, along with high hCG and AFP levels, can accurately diagnose nonseminomatous tumors. If the diagnosis remains uncertain after assessment of FNA findings and serum marker levels, then core-needle biopsies or surgical biopsies may be required. Thoracoscopy is the most frequent diagnostic surgical approach.1. Seminoma. Most patients with seminomas have advanced disease at the time of diagnosis and present with symptoms of local compression, including SVC syndrome, dyspnea, or chest discomfort. With advanced disease, the preferred treatment is combination cisplatin-based chemotherapy regimens with bleomycin and either etoposide or vinblas-tine. Complete | Surgery_Schwartz. CT findings of multilocular cystic tumors, encapsulated with combinations of fluid, soft tissue, calcium, and/or fat attenuation in the anterior compartment. FNA biopsy alone may be diagnostic for semi-nomas, usually with normal serum markers, including hCG and AFP. In 10% of seminomas, hCG levels may be slightly ele-vated. FNA findings, along with high hCG and AFP levels, can accurately diagnose nonseminomatous tumors. If the diagnosis remains uncertain after assessment of FNA findings and serum marker levels, then core-needle biopsies or surgical biopsies may be required. Thoracoscopy is the most frequent diagnostic surgical approach.1. Seminoma. Most patients with seminomas have advanced disease at the time of diagnosis and present with symptoms of local compression, including SVC syndrome, dyspnea, or chest discomfort. With advanced disease, the preferred treatment is combination cisplatin-based chemotherapy regimens with bleomycin and either etoposide or vinblas-tine. Complete |
Surgery_Schwartz_4929 | Surgery_Schwartz | dyspnea, or chest discomfort. With advanced disease, the preferred treatment is combination cisplatin-based chemotherapy regimens with bleomycin and either etoposide or vinblas-tine. Complete responses have been reported in over 75% of patients treated with these regimens. Surgical resection may be curative for small asymptomatic seminomas that are found incidentally with screening CT scans. Surgical resection of residual masses after chemotherapy may be indicated.2. Nonseminomatous germ cell tumors. Nonseminomatous germ cell tumors include embryonal cell carcinomas, cho-riocarcinomas, endodermal sinus tumors, and mixed types. They are often bulky, irregular tumors of the anterior medi-astinum with areas of low attenuation on CT scan because of necrosis, hemorrhage, or cyst formation. Frequently, adjacent structures have been involved, with metastases to regional lymph nodes, pleura, and lungs. Lactate dehy-drogenase (LDH), AFP, and hCG levels are frequently elevated. Chemotherapy is | Surgery_Schwartz. dyspnea, or chest discomfort. With advanced disease, the preferred treatment is combination cisplatin-based chemotherapy regimens with bleomycin and either etoposide or vinblas-tine. Complete responses have been reported in over 75% of patients treated with these regimens. Surgical resection may be curative for small asymptomatic seminomas that are found incidentally with screening CT scans. Surgical resection of residual masses after chemotherapy may be indicated.2. Nonseminomatous germ cell tumors. Nonseminomatous germ cell tumors include embryonal cell carcinomas, cho-riocarcinomas, endodermal sinus tumors, and mixed types. They are often bulky, irregular tumors of the anterior medi-astinum with areas of low attenuation on CT scan because of necrosis, hemorrhage, or cyst formation. Frequently, adjacent structures have been involved, with metastases to regional lymph nodes, pleura, and lungs. Lactate dehy-drogenase (LDH), AFP, and hCG levels are frequently elevated. Chemotherapy is |
Surgery_Schwartz_4930 | Surgery_Schwartz | adjacent structures have been involved, with metastases to regional lymph nodes, pleura, and lungs. Lactate dehy-drogenase (LDH), AFP, and hCG levels are frequently elevated. Chemotherapy is the preferred treatment and includes combination therapy with cisplatin, bleomycin, and etoposide, followed by surgical resection of residual disease. With this regimen, survival is 67% at 2 years and 60% at 5 years. Surgical resection of residual masses is indicated, as it may guide further therapy. Up to 20% of residual masses contain additional tumors; in another 40%, mature teratomas; and the remaining 40%, fibrotic tissue. Brunicardi_Ch19_p0661-p0750.indd 73401/03/19 7:01 PM | Surgery_Schwartz. adjacent structures have been involved, with metastases to regional lymph nodes, pleura, and lungs. Lactate dehy-drogenase (LDH), AFP, and hCG levels are frequently elevated. Chemotherapy is the preferred treatment and includes combination therapy with cisplatin, bleomycin, and etoposide, followed by surgical resection of residual disease. With this regimen, survival is 67% at 2 years and 60% at 5 years. Surgical resection of residual masses is indicated, as it may guide further therapy. Up to 20% of residual masses contain additional tumors; in another 40%, mature teratomas; and the remaining 40%, fibrotic tissue. Brunicardi_Ch19_p0661-p0750.indd 73401/03/19 7:01 PM |
Surgery_Schwartz_4931 | Surgery_Schwartz | CHAPTER 19735CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAIt is important to note that oxygen toxicity can occur in patients who have been exposed to bleomycin; high lev-els of oxygen supplementation in the perioperative setting should be avoided in these patients as respiratory failure and death can ensue.166 Factors independently predictive of survival after induction chemotherapy followed by resec-tion are elevated serum tumor markers after resection, postchemotherapy pathologic findings (complete necrosis vs. teratoma), and persistent germ cell or non–germ cell cancer in the pathologic specimen.1663. Teratoma. Teratomas are the most common type of medi-astinal germ cell tumors, accounting for 60% to 70% of mediastinal germ cell tumors. They contain two or three embryonic layers that may include teeth, skin, and hair (ectodermal), cartilage and bone (mesodermal), or bron-chial, intestinal, or pancreatic tissue (endodermal). Ther-apy for mature, benign teratomas is surgical resection, | Surgery_Schwartz. CHAPTER 19735CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAIt is important to note that oxygen toxicity can occur in patients who have been exposed to bleomycin; high lev-els of oxygen supplementation in the perioperative setting should be avoided in these patients as respiratory failure and death can ensue.166 Factors independently predictive of survival after induction chemotherapy followed by resec-tion are elevated serum tumor markers after resection, postchemotherapy pathologic findings (complete necrosis vs. teratoma), and persistent germ cell or non–germ cell cancer in the pathologic specimen.1663. Teratoma. Teratomas are the most common type of medi-astinal germ cell tumors, accounting for 60% to 70% of mediastinal germ cell tumors. They contain two or three embryonic layers that may include teeth, skin, and hair (ectodermal), cartilage and bone (mesodermal), or bron-chial, intestinal, or pancreatic tissue (endodermal). Ther-apy for mature, benign teratomas is surgical resection, |
Surgery_Schwartz_4932 | Surgery_Schwartz | include teeth, skin, and hair (ectodermal), cartilage and bone (mesodermal), or bron-chial, intestinal, or pancreatic tissue (endodermal). Ther-apy for mature, benign teratomas is surgical resection, which confers an excellent prognosis. Rarely, teratomas may contain a focus of carcinoma; these malignant tera-tomas (or teratocarcinomas) are locally aggressive. Often diagnosed at an unresectable stage, they respond poorly to chemotherapy and in a limited manner to radiotherapy; prognosis is uniformly poor.Mediastinal CystsBenign cysts account for up to 25% of mediastinal masses and are the most frequently occurring mass in the middle medias-tinal compartment. A CT scan showing characteristic features of near water density in a typical location is virtually 100% diagnostic.1671. Pericardial cyst. Usually asymptomatic and detected inci-dentally in the right costophrenic angle, pericardial cysts typically contain a clear fluid and are lined with a single layer of mesothelial cells. For | Surgery_Schwartz. include teeth, skin, and hair (ectodermal), cartilage and bone (mesodermal), or bron-chial, intestinal, or pancreatic tissue (endodermal). Ther-apy for mature, benign teratomas is surgical resection, which confers an excellent prognosis. Rarely, teratomas may contain a focus of carcinoma; these malignant tera-tomas (or teratocarcinomas) are locally aggressive. Often diagnosed at an unresectable stage, they respond poorly to chemotherapy and in a limited manner to radiotherapy; prognosis is uniformly poor.Mediastinal CystsBenign cysts account for up to 25% of mediastinal masses and are the most frequently occurring mass in the middle medias-tinal compartment. A CT scan showing characteristic features of near water density in a typical location is virtually 100% diagnostic.1671. Pericardial cyst. Usually asymptomatic and detected inci-dentally in the right costophrenic angle, pericardial cysts typically contain a clear fluid and are lined with a single layer of mesothelial cells. For |
Surgery_Schwartz_4933 | Surgery_Schwartz | cyst. Usually asymptomatic and detected inci-dentally in the right costophrenic angle, pericardial cysts typically contain a clear fluid and are lined with a single layer of mesothelial cells. For most simple, asymptomatic pericardial cysts, observation alone is recommended. Sur-gical resection or aspiration may be indicated for complex cysts or large symptomatic cysts.2. Bronchogenic cyst. Developmental anomalies that occur during embryogenesis and occur as an abnormal budding of the foregut or tracheobronchial tree, bronchogenic cysts arise most often in the mediastinum just posterior to the carina or main stem bronchus. Approximately 15% occur within the pulmonary parenchyma. Thin-walled and lined with respiratory epithelium, they contain a protein-rich mucoid material and varying amounts of seromucous glands, smooth muscle, and cartilage. They may commu-nicate with the tracheobronchial tree. In adults, over half of all bronchogenic cysts are found incidentally during workup for an | Surgery_Schwartz. cyst. Usually asymptomatic and detected inci-dentally in the right costophrenic angle, pericardial cysts typically contain a clear fluid and are lined with a single layer of mesothelial cells. For most simple, asymptomatic pericardial cysts, observation alone is recommended. Sur-gical resection or aspiration may be indicated for complex cysts or large symptomatic cysts.2. Bronchogenic cyst. Developmental anomalies that occur during embryogenesis and occur as an abnormal budding of the foregut or tracheobronchial tree, bronchogenic cysts arise most often in the mediastinum just posterior to the carina or main stem bronchus. Approximately 15% occur within the pulmonary parenchyma. Thin-walled and lined with respiratory epithelium, they contain a protein-rich mucoid material and varying amounts of seromucous glands, smooth muscle, and cartilage. They may commu-nicate with the tracheobronchial tree. In adults, over half of all bronchogenic cysts are found incidentally during workup for an |
Surgery_Schwartz_4934 | Surgery_Schwartz | of seromucous glands, smooth muscle, and cartilage. They may commu-nicate with the tracheobronchial tree. In adults, over half of all bronchogenic cysts are found incidentally during workup for an unrelated problem or during screening. The natural history of an incidentally diagnosed, asymptomatic bronchogenic cyst is unknown, but it is clear that many such cysts do not lead to clinical problems. In one study of young military personnel, 78% of all bronchogenic cysts found on routine CXRs were asymptomatic. However, in other reports with more comprehensive follow-up, up to 67% of adults with incidentally found bronchogenic cysts eventu-ally became symptomatic. Symptoms include chest pain, cough, dyspnea, and fever. If large (>6 cm) or symptomatic, resection is generally recommended since serious compli-cations may occur if the cyst becomes larger or infected. Complications include airway obstruction, infection, rup-ture, and, rarely, malignant transformation.168,169 Traditionally, | Surgery_Schwartz. of seromucous glands, smooth muscle, and cartilage. They may commu-nicate with the tracheobronchial tree. In adults, over half of all bronchogenic cysts are found incidentally during workup for an unrelated problem or during screening. The natural history of an incidentally diagnosed, asymptomatic bronchogenic cyst is unknown, but it is clear that many such cysts do not lead to clinical problems. In one study of young military personnel, 78% of all bronchogenic cysts found on routine CXRs were asymptomatic. However, in other reports with more comprehensive follow-up, up to 67% of adults with incidentally found bronchogenic cysts eventu-ally became symptomatic. Symptoms include chest pain, cough, dyspnea, and fever. If large (>6 cm) or symptomatic, resection is generally recommended since serious compli-cations may occur if the cyst becomes larger or infected. Complications include airway obstruction, infection, rup-ture, and, rarely, malignant transformation.168,169 Traditionally, |
Surgery_Schwartz_4935 | Surgery_Schwartz | serious compli-cations may occur if the cyst becomes larger or infected. Complications include airway obstruction, infection, rup-ture, and, rarely, malignant transformation.168,169 Traditionally, complete removal of the cyst wall has been via posterolateral thoracotomy.170 Resection of infected cysts may be quite difficult because of dense adhesions; elective removal is often recommended before infection has a chance to occur. Thoracoscopic exploration and resec-tion are possible for small cysts with minimal adhesions. With increasing experience using video-assisted or robotic-assisted thoracoscopy, a greater proportion of these lesions are amenable to minimally invasive resection.3. Enteric cyst. Most clinicians agree that in contrast to bronchogenic cysts, esophageal cysts should be removed, regardless of the presence or absence of symptoms. Esopha-geal cysts have a propensity for serious complications sec-ondary to enlargement, leading to hemorrhage, infection, or perforation. | Surgery_Schwartz. serious compli-cations may occur if the cyst becomes larger or infected. Complications include airway obstruction, infection, rup-ture, and, rarely, malignant transformation.168,169 Traditionally, complete removal of the cyst wall has been via posterolateral thoracotomy.170 Resection of infected cysts may be quite difficult because of dense adhesions; elective removal is often recommended before infection has a chance to occur. Thoracoscopic exploration and resec-tion are possible for small cysts with minimal adhesions. With increasing experience using video-assisted or robotic-assisted thoracoscopy, a greater proportion of these lesions are amenable to minimally invasive resection.3. Enteric cyst. Most clinicians agree that in contrast to bronchogenic cysts, esophageal cysts should be removed, regardless of the presence or absence of symptoms. Esopha-geal cysts have a propensity for serious complications sec-ondary to enlargement, leading to hemorrhage, infection, or perforation. |
Surgery_Schwartz_4936 | Surgery_Schwartz | removed, regardless of the presence or absence of symptoms. Esopha-geal cysts have a propensity for serious complications sec-ondary to enlargement, leading to hemorrhage, infection, or perforation. Thus, surgical resection is the treatment of choice in both adults and children. As with bronchogenic cysts, experienced surgeons are approaching enteric cyst resections using minimally invasive techniques with great success.4. Thymic cyst. Generally asymptomatic, thymic cysts are often discovered incidentally. Simple cysts are of no con-sequence; however, the occasional cystic neoplasm must be ruled out. Cystic components occasionally are seen in patients with thymoma and Hodgkin’s disease.5. Ectopic endocrine glands. Up to 5% of all mediastinal masses are of thyroid origin; most are simple extensions of thyroid masses. Usually nontoxic, over 95% can be com-pletely resected through a cervical approach. True ectopic thyroid tissue of the mediastinum is rare. About 10% to 20% of abnormal | Surgery_Schwartz. removed, regardless of the presence or absence of symptoms. Esopha-geal cysts have a propensity for serious complications sec-ondary to enlargement, leading to hemorrhage, infection, or perforation. Thus, surgical resection is the treatment of choice in both adults and children. As with bronchogenic cysts, experienced surgeons are approaching enteric cyst resections using minimally invasive techniques with great success.4. Thymic cyst. Generally asymptomatic, thymic cysts are often discovered incidentally. Simple cysts are of no con-sequence; however, the occasional cystic neoplasm must be ruled out. Cystic components occasionally are seen in patients with thymoma and Hodgkin’s disease.5. Ectopic endocrine glands. Up to 5% of all mediastinal masses are of thyroid origin; most are simple extensions of thyroid masses. Usually nontoxic, over 95% can be com-pletely resected through a cervical approach. True ectopic thyroid tissue of the mediastinum is rare. About 10% to 20% of abnormal |
Surgery_Schwartz_4937 | Surgery_Schwartz | extensions of thyroid masses. Usually nontoxic, over 95% can be com-pletely resected through a cervical approach. True ectopic thyroid tissue of the mediastinum is rare. About 10% to 20% of abnormal parathyroid glands are found in the mediasti-num; most can be removed during exploration from a cervi-cal incision. In cases of true mediastinal parathyroid glands, thoracoscopic or open resection may be indicated. Location can generally be pinpointed by a combination of CT scan and Sestamibi scans.MediastinitisAcute Mediastinitis. Acute mediastinitis is a fulminant infec-tious process that spreads rapidly along the continuous fascial planes connecting the cervical and mediastinal compartments. Infections originate most commonly from esophageal perfora-tions, sternal infections, and oropharyngeal or neck infections, but a number of less common etiologic factors can lead to this deadly process (Table 19-32). Clinical signs and symptoms include fever, chest pain, dysphagia, respiratory | Surgery_Schwartz. extensions of thyroid masses. Usually nontoxic, over 95% can be com-pletely resected through a cervical approach. True ectopic thyroid tissue of the mediastinum is rare. About 10% to 20% of abnormal parathyroid glands are found in the mediasti-num; most can be removed during exploration from a cervi-cal incision. In cases of true mediastinal parathyroid glands, thoracoscopic or open resection may be indicated. Location can generally be pinpointed by a combination of CT scan and Sestamibi scans.MediastinitisAcute Mediastinitis. Acute mediastinitis is a fulminant infec-tious process that spreads rapidly along the continuous fascial planes connecting the cervical and mediastinal compartments. Infections originate most commonly from esophageal perfora-tions, sternal infections, and oropharyngeal or neck infections, but a number of less common etiologic factors can lead to this deadly process (Table 19-32). Clinical signs and symptoms include fever, chest pain, dysphagia, respiratory |
Surgery_Schwartz_4938 | Surgery_Schwartz | or neck infections, but a number of less common etiologic factors can lead to this deadly process (Table 19-32). Clinical signs and symptoms include fever, chest pain, dysphagia, respiratory distress, and cervical and upper thoracic subcutaneous crepitus. In severe cases, the clinical course can rapidly deteriorate to florid sepsis, hemodynamic instability, and death. Thus, a high index of sus-picion is required in the context of any infection with access to the mediastinal compartments.A chest CT scan illuminates the extent of spread and guides selection of the best approach to surgical drainage. Acute mediastinitis is a true surgical emergency; treatment must be instituted immediately and aimed at correcting the primary problem, such as the esophageal perforation or oro-pharyngeal abscess, and debridement and drainage of the spreading infectious process within the mediastinum, neck, pleura, and other tissue planes. Antibiotics, fluid resusci-tation, and other supportive measures are | Surgery_Schwartz. or neck infections, but a number of less common etiologic factors can lead to this deadly process (Table 19-32). Clinical signs and symptoms include fever, chest pain, dysphagia, respiratory distress, and cervical and upper thoracic subcutaneous crepitus. In severe cases, the clinical course can rapidly deteriorate to florid sepsis, hemodynamic instability, and death. Thus, a high index of sus-picion is required in the context of any infection with access to the mediastinal compartments.A chest CT scan illuminates the extent of spread and guides selection of the best approach to surgical drainage. Acute mediastinitis is a true surgical emergency; treatment must be instituted immediately and aimed at correcting the primary problem, such as the esophageal perforation or oro-pharyngeal abscess, and debridement and drainage of the spreading infectious process within the mediastinum, neck, pleura, and other tissue planes. Antibiotics, fluid resusci-tation, and other supportive measures are |
Surgery_Schwartz_4939 | Surgery_Schwartz | and debridement and drainage of the spreading infectious process within the mediastinum, neck, pleura, and other tissue planes. Antibiotics, fluid resusci-tation, and other supportive measures are also important. Brunicardi_Ch19_p0661-p0750.indd 73501/03/19 7:01 PM 736SPECIFIC CONSIDERATIONSPART IITable 19-32Etiologic factors in acute mediastinitisEsophageal perforation Iatrogenic Balloon dilatation (for achalasia) Bougienage (for peptic stricture) Esophagoscopy Sclerotherapy (for variceal bleeding) Spontaneous Postemetic (Boerhaave’s syndrome) Straining during: Elimination Weight lifting Seizure Pregnancy Childbirth Ingestion of foreign bodies Trauma Blunt Penetrating Postsurgical Infection Anastomotic leak Erosion by cancerDeep sternotomy wound infectionOropharynx and neck infectionsLudwig’s anginaQuinsyRetropharyngeal abscessCellulitis and suppurative lymphadenitis of the neckInfections of the lung and pleuraSubphrenic abscessRib or vertebral | Surgery_Schwartz. and debridement and drainage of the spreading infectious process within the mediastinum, neck, pleura, and other tissue planes. Antibiotics, fluid resusci-tation, and other supportive measures are also important. Brunicardi_Ch19_p0661-p0750.indd 73501/03/19 7:01 PM 736SPECIFIC CONSIDERATIONSPART IITable 19-32Etiologic factors in acute mediastinitisEsophageal perforation Iatrogenic Balloon dilatation (for achalasia) Bougienage (for peptic stricture) Esophagoscopy Sclerotherapy (for variceal bleeding) Spontaneous Postemetic (Boerhaave’s syndrome) Straining during: Elimination Weight lifting Seizure Pregnancy Childbirth Ingestion of foreign bodies Trauma Blunt Penetrating Postsurgical Infection Anastomotic leak Erosion by cancerDeep sternotomy wound infectionOropharynx and neck infectionsLudwig’s anginaQuinsyRetropharyngeal abscessCellulitis and suppurative lymphadenitis of the neckInfections of the lung and pleuraSubphrenic abscessRib or vertebral |
Surgery_Schwartz_4940 | Surgery_Schwartz | and neck infectionsLudwig’s anginaQuinsyRetropharyngeal abscessCellulitis and suppurative lymphadenitis of the neckInfections of the lung and pleuraSubphrenic abscessRib or vertebral osteomyelitisHematogenous or metastatic abscessReproduced with permission from Pearson FG, Cooper JD, Deslauriers J, et al: Thoracic Surgery, 2nd ed. New York, NY: Elsevier/Churchill Livingstone; 2002.Debridement may need to be repeated and other planes and cavities explored depending on the patient’s clinical status. Blood cell counts and serial CT scans may also be required. Persistent sepsis or collections on CT scan may require further radical surgical debridement.Chronic Mediastinitis. Sclerosing or fibrosing mediastinitis results from chronic mediastinal inflammation that originates in the lymph nodes, most frequently from granulomatous infec-tions such as histoplasmosis or tuberculosis. Chronic, low-grade inflammation leads to fibrosis and scarring, which can, in some patients, result in entrapment | Surgery_Schwartz. and neck infectionsLudwig’s anginaQuinsyRetropharyngeal abscessCellulitis and suppurative lymphadenitis of the neckInfections of the lung and pleuraSubphrenic abscessRib or vertebral osteomyelitisHematogenous or metastatic abscessReproduced with permission from Pearson FG, Cooper JD, Deslauriers J, et al: Thoracic Surgery, 2nd ed. New York, NY: Elsevier/Churchill Livingstone; 2002.Debridement may need to be repeated and other planes and cavities explored depending on the patient’s clinical status. Blood cell counts and serial CT scans may also be required. Persistent sepsis or collections on CT scan may require further radical surgical debridement.Chronic Mediastinitis. Sclerosing or fibrosing mediastinitis results from chronic mediastinal inflammation that originates in the lymph nodes, most frequently from granulomatous infec-tions such as histoplasmosis or tuberculosis. Chronic, low-grade inflammation leads to fibrosis and scarring, which can, in some patients, result in entrapment |
Surgery_Schwartz_4941 | Surgery_Schwartz | frequently from granulomatous infec-tions such as histoplasmosis or tuberculosis. Chronic, low-grade inflammation leads to fibrosis and scarring, which can, in some patients, result in entrapment and compression of the low-pressure veins (including the SVC and innominate and azy-gos veins), the esophagus, and pulmonary arteries. There is no definitive treatment. Surgery is indicated only for diagnosis or in specific patients to relieve airway or esophageal obstruction or to achieve vascular reconstruction. Reports of palliative suc-cess with less invasive procedures (such as dilation and stenting of airways, the esophagus, or the SVC) are promising. In one series of 22 patients, ketoconazole was effective in controlling progression. In another series of 71 patients, 30% died from disease-associated complications during long-term follow-up. Chronic mediastinitis is similar to retroperitoneal fibrosis, scle-rosing cholangitis, and Riedel’s thyroiditis.PLEURA AND PLEURAL SPACEAnatomyEach | Surgery_Schwartz. frequently from granulomatous infec-tions such as histoplasmosis or tuberculosis. Chronic, low-grade inflammation leads to fibrosis and scarring, which can, in some patients, result in entrapment and compression of the low-pressure veins (including the SVC and innominate and azy-gos veins), the esophagus, and pulmonary arteries. There is no definitive treatment. Surgery is indicated only for diagnosis or in specific patients to relieve airway or esophageal obstruction or to achieve vascular reconstruction. Reports of palliative suc-cess with less invasive procedures (such as dilation and stenting of airways, the esophagus, or the SVC) are promising. In one series of 22 patients, ketoconazole was effective in controlling progression. In another series of 71 patients, 30% died from disease-associated complications during long-term follow-up. Chronic mediastinitis is similar to retroperitoneal fibrosis, scle-rosing cholangitis, and Riedel’s thyroiditis.PLEURA AND PLEURAL SPACEAnatomyEach |
Surgery_Schwartz_4942 | Surgery_Schwartz | complications during long-term follow-up. Chronic mediastinitis is similar to retroperitoneal fibrosis, scle-rosing cholangitis, and Riedel’s thyroiditis.PLEURA AND PLEURAL SPACEAnatomyEach hemithorax has a mesothelial lining that invaginates at the hilum of each lung and continues on to cover each lung. The portion lining the bony rib cage, mediastinum, and dia-phragm is called the parietal pleura, whereas the portion encas-ing the lung is known as the visceral pleura. Between these two surfaces is the potential pleural space, which is normally occupied by a thin layer of lubricating pleural fluid. A network of somatic, sympathetic, and parasympathetic fibers innervates the parietal pleura. Irritation of the parietal surface by inflam-mation, tumor invasion, trauma, and other processes can lead to a sensation of chest wall pain. The visceral pleura have no somatic innervation.171,172Pleural EffusionPleural effusion refers to any significant collection of fluid within the pleural | Surgery_Schwartz. complications during long-term follow-up. Chronic mediastinitis is similar to retroperitoneal fibrosis, scle-rosing cholangitis, and Riedel’s thyroiditis.PLEURA AND PLEURAL SPACEAnatomyEach hemithorax has a mesothelial lining that invaginates at the hilum of each lung and continues on to cover each lung. The portion lining the bony rib cage, mediastinum, and dia-phragm is called the parietal pleura, whereas the portion encas-ing the lung is known as the visceral pleura. Between these two surfaces is the potential pleural space, which is normally occupied by a thin layer of lubricating pleural fluid. A network of somatic, sympathetic, and parasympathetic fibers innervates the parietal pleura. Irritation of the parietal surface by inflam-mation, tumor invasion, trauma, and other processes can lead to a sensation of chest wall pain. The visceral pleura have no somatic innervation.171,172Pleural EffusionPleural effusion refers to any significant collection of fluid within the pleural |
Surgery_Schwartz_4943 | Surgery_Schwartz | can lead to a sensation of chest wall pain. The visceral pleura have no somatic innervation.171,172Pleural EffusionPleural effusion refers to any significant collection of fluid within the pleural space. Normally, between 5 and 10 L of fluid enters the pleural space each day by filtration through microves-sels supplying the parietal pleura (located mainly in the less dependent regions of the cavity). The net balance of pressures in these capillaries leads to fluid flow from the parietal pleural surface into the pleural space, and the net balance of forces in the pulmonary circulation leads to absorption through the vis-ceral pleura. Normally, 15 to 20 mL of pleural fluid is present at any given time. Any disturbance in these forces can lead to imbalance and accumulation of pleural fluid. Common patho-logic conditions in North America that lead to pleural effusion include congestive heart failure, bacterial pneumonia, malig-nancy, and pulmonary emboli (Table 19-33).173Access and | Surgery_Schwartz. can lead to a sensation of chest wall pain. The visceral pleura have no somatic innervation.171,172Pleural EffusionPleural effusion refers to any significant collection of fluid within the pleural space. Normally, between 5 and 10 L of fluid enters the pleural space each day by filtration through microves-sels supplying the parietal pleura (located mainly in the less dependent regions of the cavity). The net balance of pressures in these capillaries leads to fluid flow from the parietal pleural surface into the pleural space, and the net balance of forces in the pulmonary circulation leads to absorption through the vis-ceral pleura. Normally, 15 to 20 mL of pleural fluid is present at any given time. Any disturbance in these forces can lead to imbalance and accumulation of pleural fluid. Common patho-logic conditions in North America that lead to pleural effusion include congestive heart failure, bacterial pneumonia, malig-nancy, and pulmonary emboli (Table 19-33).173Access and |
Surgery_Schwartz_4944 | Surgery_Schwartz | Common patho-logic conditions in North America that lead to pleural effusion include congestive heart failure, bacterial pneumonia, malig-nancy, and pulmonary emboli (Table 19-33).173Access and Drainage of Pleural Fluid CollectionsMost patients with pleural effusions of unknown cause should undergo thoracentesis with the following exceptions: effusions in the setting of congestive heart failure, hepatic failure or renal fail-ure, or small effusions associated with an improving pneumonia. If the clinical history suggests congestive heart failure as a cause, particularly in the setting of bilateral effusions, a trial of diuresis may be indicated (rather than thoracentesis). Up to 75% of effu-sions due to congestive heart failure resolve within 48 hours with diuresis alone. Similarly, thoracentesis can be avoided in patients with small effusions associated with resolving pneumonia. These patients typically present with cough, fever, leukocytosis, and uni-lateral infiltrate, and the | Surgery_Schwartz. Common patho-logic conditions in North America that lead to pleural effusion include congestive heart failure, bacterial pneumonia, malig-nancy, and pulmonary emboli (Table 19-33).173Access and Drainage of Pleural Fluid CollectionsMost patients with pleural effusions of unknown cause should undergo thoracentesis with the following exceptions: effusions in the setting of congestive heart failure, hepatic failure or renal fail-ure, or small effusions associated with an improving pneumonia. If the clinical history suggests congestive heart failure as a cause, particularly in the setting of bilateral effusions, a trial of diuresis may be indicated (rather than thoracentesis). Up to 75% of effu-sions due to congestive heart failure resolve within 48 hours with diuresis alone. Similarly, thoracentesis can be avoided in patients with small effusions associated with resolving pneumonia. These patients typically present with cough, fever, leukocytosis, and uni-lateral infiltrate, and the |
Surgery_Schwartz_4945 | Surgery_Schwartz | can be avoided in patients with small effusions associated with resolving pneumonia. These patients typically present with cough, fever, leukocytosis, and uni-lateral infiltrate, and the effusion is usually a result of a reactive, parapneumonic process. If the effusion is small and the patient responds to antibiotics, a diagnostic thoracentesis may be unneces-sary. If the effusion is large and compromising respiratory efforts, or if the patient has a persistent white blood cell count despite improving signs of pneumonia, an empyema of the pleural space must be considered. In these patients, early and aggressive drainage with chest tubes is required, possibly with surgical intervention.Once the decision is made to access a pleural effusion, the next step is to determine if a sample of the fluid or complete drainage of the pleural space is desired. This step is influenced by the clinical history, the type and amount of fluid present, the Brunicardi_Ch19_p0661-p0750.indd 73601/03/19 | Surgery_Schwartz. can be avoided in patients with small effusions associated with resolving pneumonia. These patients typically present with cough, fever, leukocytosis, and uni-lateral infiltrate, and the effusion is usually a result of a reactive, parapneumonic process. If the effusion is small and the patient responds to antibiotics, a diagnostic thoracentesis may be unneces-sary. If the effusion is large and compromising respiratory efforts, or if the patient has a persistent white blood cell count despite improving signs of pneumonia, an empyema of the pleural space must be considered. In these patients, early and aggressive drainage with chest tubes is required, possibly with surgical intervention.Once the decision is made to access a pleural effusion, the next step is to determine if a sample of the fluid or complete drainage of the pleural space is desired. This step is influenced by the clinical history, the type and amount of fluid present, the Brunicardi_Ch19_p0661-p0750.indd 73601/03/19 |
Surgery_Schwartz_4946 | Surgery_Schwartz | fluid or complete drainage of the pleural space is desired. This step is influenced by the clinical history, the type and amount of fluid present, the Brunicardi_Ch19_p0661-p0750.indd 73601/03/19 7:01 PM | Surgery_Schwartz. fluid or complete drainage of the pleural space is desired. This step is influenced by the clinical history, the type and amount of fluid present, the Brunicardi_Ch19_p0661-p0750.indd 73601/03/19 7:01 PM |
Surgery_Schwartz_4947 | Surgery_Schwartz | CHAPTER 19737CHEST WALL, LUNG, MEDIASTINUM, AND PLEURATable 19-33Leading causes of pleural effusion in the United States, based on data from patients undergoing thoracentesisCAUSEANNUAL INCIDENCETRANSUDATEEXUDATECongestive heart failure500,000YesNoPneumonia300,000NoYesCancer200,000NoYesPulmonary embolus150,000SometimesSometimesViral disease100,000NoYesCoronary artery bypass surgery60,000NoYesCirrhosis with ascites50,000YesNoData from Light RW: Pleural diseases, 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001.nature of the collection (such as free-flowing or loculated), the cause, and the likelihood of recurrence. For small, free-flowing effusions, an outpatient diagnostic and/or therapeutic thora-centesis with a relatively small-bore needle or catheter (14to 16-gauge) can be performed (Fig. 19-50). The appearance of the fluid is informative: clear straw-colored fluid is often transuda-tive; turbid or bloody fluid is often exudative.The site of entry for drainage of a | Surgery_Schwartz. CHAPTER 19737CHEST WALL, LUNG, MEDIASTINUM, AND PLEURATable 19-33Leading causes of pleural effusion in the United States, based on data from patients undergoing thoracentesisCAUSEANNUAL INCIDENCETRANSUDATEEXUDATECongestive heart failure500,000YesNoPneumonia300,000NoYesCancer200,000NoYesPulmonary embolus150,000SometimesSometimesViral disease100,000NoYesCoronary artery bypass surgery60,000NoYesCirrhosis with ascites50,000YesNoData from Light RW: Pleural diseases, 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001.nature of the collection (such as free-flowing or loculated), the cause, and the likelihood of recurrence. For small, free-flowing effusions, an outpatient diagnostic and/or therapeutic thora-centesis with a relatively small-bore needle or catheter (14to 16-gauge) can be performed (Fig. 19-50). The appearance of the fluid is informative: clear straw-colored fluid is often transuda-tive; turbid or bloody fluid is often exudative.The site of entry for drainage of a |
Surgery_Schwartz_4948 | Surgery_Schwartz | be performed (Fig. 19-50). The appearance of the fluid is informative: clear straw-colored fluid is often transuda-tive; turbid or bloody fluid is often exudative.The site of entry for drainage of a pleural effusion or pneumothorax may be based on the CXR alone if the effu-sion is demonstrated to be free-flowing. For free-flowing effu-sions, a low approach at the eighth or ninth intercostal space in the posterior midclavicular line facilitates complete drainage. If the effusion is loculated, CTor ultrasound-guided drainage may be indicated. If the goal is complete drainage, a small-bore pigtail catheter is inserted and connected to a closed drainage system with applied suction (typically –20 cm H2O). In general, the smallest-bore drainage catheter that will effec-tively drain the pleural space should be chosen. Smaller-diam-eter catheters significantly decrease the pain associated with the placement of chest tubes but are more prone to clogging and twisting.174,175 For clinical | Surgery_Schwartz. be performed (Fig. 19-50). The appearance of the fluid is informative: clear straw-colored fluid is often transuda-tive; turbid or bloody fluid is often exudative.The site of entry for drainage of a pleural effusion or pneumothorax may be based on the CXR alone if the effu-sion is demonstrated to be free-flowing. For free-flowing effu-sions, a low approach at the eighth or ninth intercostal space in the posterior midclavicular line facilitates complete drainage. If the effusion is loculated, CTor ultrasound-guided drainage may be indicated. If the goal is complete drainage, a small-bore pigtail catheter is inserted and connected to a closed drainage system with applied suction (typically –20 cm H2O). In general, the smallest-bore drainage catheter that will effec-tively drain the pleural space should be chosen. Smaller-diam-eter catheters significantly decrease the pain associated with the placement of chest tubes but are more prone to clogging and twisting.174,175 For clinical |
Surgery_Schwartz_4949 | Surgery_Schwartz | space should be chosen. Smaller-diam-eter catheters significantly decrease the pain associated with the placement of chest tubes but are more prone to clogging and twisting.174,175 For clinical situations requiring biopsy or for potential interventions such as adhesiolysis or pleurodesis, minimally invasive surgery may be indicated, using a VATS approach.Figure 19-50. Techniques for aspiration and drainage of a pleural effusion. A. Needle aspiration. With careful appraisal of the x-ray findings, the best interspace is selected, and fluid is aspirated with a needle and syringe. Large volumes of fluid can be removed with a little patience and a large-bore needle. B. Chest tube insertion. After careful skin preparation, draping, and administration of local anesthesia, a short skin incision is made over the correct interspace. The incision is deepened into the intercostal muscles, and the pleura is penetrated (usually with a clamp). When any doubt exists about the status of the pleural | Surgery_Schwartz. space should be chosen. Smaller-diam-eter catheters significantly decrease the pain associated with the placement of chest tubes but are more prone to clogging and twisting.174,175 For clinical situations requiring biopsy or for potential interventions such as adhesiolysis or pleurodesis, minimally invasive surgery may be indicated, using a VATS approach.Figure 19-50. Techniques for aspiration and drainage of a pleural effusion. A. Needle aspiration. With careful appraisal of the x-ray findings, the best interspace is selected, and fluid is aspirated with a needle and syringe. Large volumes of fluid can be removed with a little patience and a large-bore needle. B. Chest tube insertion. After careful skin preparation, draping, and administration of local anesthesia, a short skin incision is made over the correct interspace. The incision is deepened into the intercostal muscles, and the pleura is penetrated (usually with a clamp). When any doubt exists about the status of the pleural |
Surgery_Schwartz_4950 | Surgery_Schwartz | is made over the correct interspace. The incision is deepened into the intercostal muscles, and the pleura is penetrated (usually with a clamp). When any doubt exists about the status of the pleural space at the site of puncture, the wound is enlarged bluntly to admit a finger, which can be swept around the immediately adjacent pleural space to assess the situation and break down any adhesions. The tube is inserted, with the tip directed toward the optimal position suggested by the chest X-rays. In general, a high anterior tube is best for air (pneumothorax), and a low posterior tube is best for fluid. A 28F to 32F tube is adequate for most situations. A 36F tube is preferred for hemothorax or for a viscous empyema. Many surgeons prefer a very small tube (16F to 20F) for drainage of simple pneumothorax. C. The tube is connected to a water-seal drainage system. Suction is added, if necessary, to expand the lung; it usually will be required in a patient with a substantial air leak | Surgery_Schwartz. is made over the correct interspace. The incision is deepened into the intercostal muscles, and the pleura is penetrated (usually with a clamp). When any doubt exists about the status of the pleural space at the site of puncture, the wound is enlarged bluntly to admit a finger, which can be swept around the immediately adjacent pleural space to assess the situation and break down any adhesions. The tube is inserted, with the tip directed toward the optimal position suggested by the chest X-rays. In general, a high anterior tube is best for air (pneumothorax), and a low posterior tube is best for fluid. A 28F to 32F tube is adequate for most situations. A 36F tube is preferred for hemothorax or for a viscous empyema. Many surgeons prefer a very small tube (16F to 20F) for drainage of simple pneumothorax. C. The tube is connected to a water-seal drainage system. Suction is added, if necessary, to expand the lung; it usually will be required in a patient with a substantial air leak |
Surgery_Schwartz_4951 | Surgery_Schwartz | simple pneumothorax. C. The tube is connected to a water-seal drainage system. Suction is added, if necessary, to expand the lung; it usually will be required in a patient with a substantial air leak (bronchopleural fistula).Brunicardi_Ch19_p0661-p0750.indd 73701/03/19 7:01 PM 738SPECIFIC CONSIDERATIONSPART IITable 19-34Differential diagnosis of pleural effusions I. Transudative pleural effusions A. Congestive heart failure B. Cirrhosis C. Nephrotic syndrome D. Superior vena caval obstruction E. Fontan procedure F. Urinothorax G. Peritoneal dialysis H. Glomerulonephritis I. Myxedema J. Cerebrospinal fluid leaks to pleura K. Hypoalbuminemia L. Pulmonary emboli M. Sarcoidosis II. Exudative pleural effusions A. Neoplastic diseases 1. Metastatic disease 2. Mesothelioma 3. Body cavity lymphoma 4. Pyothorax-associated lymphoma B. Infectious diseases 1. Tuberculosis 2. Other bacterial infections 3. Fungal infections 4. Parasitic infections 5. Viral infections C. Pulmonary | Surgery_Schwartz. simple pneumothorax. C. The tube is connected to a water-seal drainage system. Suction is added, if necessary, to expand the lung; it usually will be required in a patient with a substantial air leak (bronchopleural fistula).Brunicardi_Ch19_p0661-p0750.indd 73701/03/19 7:01 PM 738SPECIFIC CONSIDERATIONSPART IITable 19-34Differential diagnosis of pleural effusions I. Transudative pleural effusions A. Congestive heart failure B. Cirrhosis C. Nephrotic syndrome D. Superior vena caval obstruction E. Fontan procedure F. Urinothorax G. Peritoneal dialysis H. Glomerulonephritis I. Myxedema J. Cerebrospinal fluid leaks to pleura K. Hypoalbuminemia L. Pulmonary emboli M. Sarcoidosis II. Exudative pleural effusions A. Neoplastic diseases 1. Metastatic disease 2. Mesothelioma 3. Body cavity lymphoma 4. Pyothorax-associated lymphoma B. Infectious diseases 1. Tuberculosis 2. Other bacterial infections 3. Fungal infections 4. Parasitic infections 5. Viral infections C. Pulmonary |
Surgery_Schwartz_4952 | Surgery_Schwartz | cavity lymphoma 4. Pyothorax-associated lymphoma B. Infectious diseases 1. Tuberculosis 2. Other bacterial infections 3. Fungal infections 4. Parasitic infections 5. Viral infections C. Pulmonary embolization D. Gastrointestinal disease 1. Pancreatic disease 2. Subphrenic abscess 3. Intrahepatic abscess 4. Intrasplenic abscess 5. Esophageal perforation 6. After abdominal surgery 7. Diaphragmatic hernia 8. Endoscopic variceal sclerosis 9. After liver transplantation E. Heart diseases 1. After coronary artery bypass graft surgery 2. Post-cardiac injury (Dressler’s) syndrome 3. Pericardial disease F. Obstetric and gynecologic diseases 1. Ovarian hyperstimulation syndrome 2. Fetal pleural effusion 3. Postpartum pleural effusion 4. Megis’ syndrome 5. Endometriosis G. Collagen vascular diseases 1. Rheumatoid pleuritis 2. Systemic lupus erythematosus 3. Drug-induced lupus 4. Immunoblastic lymphadenopathy 5. Sjögren’s syndrome 6. Familial Mediterranean fever 7. Churg-Strauss | Surgery_Schwartz. cavity lymphoma 4. Pyothorax-associated lymphoma B. Infectious diseases 1. Tuberculosis 2. Other bacterial infections 3. Fungal infections 4. Parasitic infections 5. Viral infections C. Pulmonary embolization D. Gastrointestinal disease 1. Pancreatic disease 2. Subphrenic abscess 3. Intrahepatic abscess 4. Intrasplenic abscess 5. Esophageal perforation 6. After abdominal surgery 7. Diaphragmatic hernia 8. Endoscopic variceal sclerosis 9. After liver transplantation E. Heart diseases 1. After coronary artery bypass graft surgery 2. Post-cardiac injury (Dressler’s) syndrome 3. Pericardial disease F. Obstetric and gynecologic diseases 1. Ovarian hyperstimulation syndrome 2. Fetal pleural effusion 3. Postpartum pleural effusion 4. Megis’ syndrome 5. Endometriosis G. Collagen vascular diseases 1. Rheumatoid pleuritis 2. Systemic lupus erythematosus 3. Drug-induced lupus 4. Immunoblastic lymphadenopathy 5. Sjögren’s syndrome 6. Familial Mediterranean fever 7. Churg-Strauss |
Surgery_Schwartz_4953 | Surgery_Schwartz | vascular diseases 1. Rheumatoid pleuritis 2. Systemic lupus erythematosus 3. Drug-induced lupus 4. Immunoblastic lymphadenopathy 5. Sjögren’s syndrome 6. Familial Mediterranean fever 7. Churg-Strauss syndrome 8. Wegener’s granulomatosis H. Drug-induced pleural disease 1. Nitrofurantoin 2. Dantrolene 3. Methysergide 4. Ergot alkaloids 5. Amiodarone 6. Interleukin-2 7. Procarbazine 8. Methotrexate 9. Clozapine I. Miscellaneous diseases and conditions 1. Asbestos exposure 2. After lung transplantation 3. After bone marrow transplantation 4. Yellow nail syndrome 5. Sarcoidosis 6. Uremia 7. Trapped lung 8. Therapeutic radiation exposure 9. Drowning 10. Amyloidosis 11. Milk of calcium pleural effusion 12. Electrical burns 13. Extramedullary hematopoiesis 14. Rupture of mediastinal cyst 15. Acute respiratory distress syndrome 16. Whipple’s disease 17. Iatrogenic pleural effusions J. Hemothorax K. ChylothoraxReproduced with permission from Light RW: Pleural diseases, 5th ed. Philadelphia, PA: | Surgery_Schwartz. vascular diseases 1. Rheumatoid pleuritis 2. Systemic lupus erythematosus 3. Drug-induced lupus 4. Immunoblastic lymphadenopathy 5. Sjögren’s syndrome 6. Familial Mediterranean fever 7. Churg-Strauss syndrome 8. Wegener’s granulomatosis H. Drug-induced pleural disease 1. Nitrofurantoin 2. Dantrolene 3. Methysergide 4. Ergot alkaloids 5. Amiodarone 6. Interleukin-2 7. Procarbazine 8. Methotrexate 9. Clozapine I. Miscellaneous diseases and conditions 1. Asbestos exposure 2. After lung transplantation 3. After bone marrow transplantation 4. Yellow nail syndrome 5. Sarcoidosis 6. Uremia 7. Trapped lung 8. Therapeutic radiation exposure 9. Drowning 10. Amyloidosis 11. Milk of calcium pleural effusion 12. Electrical burns 13. Extramedullary hematopoiesis 14. Rupture of mediastinal cyst 15. Acute respiratory distress syndrome 16. Whipple’s disease 17. Iatrogenic pleural effusions J. Hemothorax K. ChylothoraxReproduced with permission from Light RW: Pleural diseases, 5th ed. Philadelphia, PA: |
Surgery_Schwartz_4954 | Surgery_Schwartz | respiratory distress syndrome 16. Whipple’s disease 17. Iatrogenic pleural effusions J. Hemothorax K. ChylothoraxReproduced with permission from Light RW: Pleural diseases, 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007.Complications of Pleural Drainage. The most common complications of invasive pleural procedures are inadvertent injury to adjacent organs, including lung, with air leakage and pneumothorax; subdiaphragmatic entry and damage to the liver, spleen, or other intra-abdominal viscera; intercostal ves-sel injury with subsequent bleeding or larger vessel injury; and even cardiac puncture. Sometimes, bleeding may be the result of an underlying coagulopathy or anticoagulant therapy. Other technical complications include loss of a catheter, guidewire, or fragment in the pleural space and infections. Occasionally, rapid drainage of a large effusion can be followed by shortness of breath, clinical instability, and a phenomenon referred to as postexpansion pulmonary | Surgery_Schwartz. respiratory distress syndrome 16. Whipple’s disease 17. Iatrogenic pleural effusions J. Hemothorax K. ChylothoraxReproduced with permission from Light RW: Pleural diseases, 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007.Complications of Pleural Drainage. The most common complications of invasive pleural procedures are inadvertent injury to adjacent organs, including lung, with air leakage and pneumothorax; subdiaphragmatic entry and damage to the liver, spleen, or other intra-abdominal viscera; intercostal ves-sel injury with subsequent bleeding or larger vessel injury; and even cardiac puncture. Sometimes, bleeding may be the result of an underlying coagulopathy or anticoagulant therapy. Other technical complications include loss of a catheter, guidewire, or fragment in the pleural space and infections. Occasionally, rapid drainage of a large effusion can be followed by shortness of breath, clinical instability, and a phenomenon referred to as postexpansion pulmonary |
Surgery_Schwartz_4955 | Surgery_Schwartz | pleural space and infections. Occasionally, rapid drainage of a large effusion can be followed by shortness of breath, clinical instability, and a phenomenon referred to as postexpansion pulmonary edema. For this reason, it is recom-mended to drain only up to 1500 mL initially. Most complica-tions can be avoided by consulting with a clinician experienced in pleural drainage techniques.Pleural Fluid Analysis. Pleural fluid collections are generally classified as transudates and exudates (Table 19-34). Transu-dates are protein-poor ultrafiltrates of plasma that result from alterations in the systemic hydrostatic pressures or colloid Brunicardi_Ch19_p0661-p0750.indd 73801/03/19 7:01 PM | Surgery_Schwartz. pleural space and infections. Occasionally, rapid drainage of a large effusion can be followed by shortness of breath, clinical instability, and a phenomenon referred to as postexpansion pulmonary edema. For this reason, it is recom-mended to drain only up to 1500 mL initially. Most complica-tions can be avoided by consulting with a clinician experienced in pleural drainage techniques.Pleural Fluid Analysis. Pleural fluid collections are generally classified as transudates and exudates (Table 19-34). Transu-dates are protein-poor ultrafiltrates of plasma that result from alterations in the systemic hydrostatic pressures or colloid Brunicardi_Ch19_p0661-p0750.indd 73801/03/19 7:01 PM |
Surgery_Schwartz_4956 | Surgery_Schwartz | CHAPTER 19739CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAosmotic pressures (for example, with congestive heart failure or cirrhosis). On gross visual inspection, a transudative effusion is generally clear or straw-colored. Exudates are protein-rich pleural fluid collections that generally result from inflamma-tion or pleural invasion by tumor. Grossly, they are often turbid, bloody, or purulent. Absent trauma, grossly bloody effusions are frequently malignant, but they may also occur in the setting of a pulmonary embolism or pneumonia.Transudates and exudates can be differentiated using Light’s criteria. An effusion is exudative if the pleural fluid-to-serum ratio of protein is greater than 0.5 and the LDH ratio is greater than 0.6 or the absolute pleural LDH level is greater than two-thirds of the normal upper limit for serum. If criteria suggest a transudate, a careful evaluation for congestive heart failure, cirrhosis, or conditions associated with transudates is under-taken. If | Surgery_Schwartz. CHAPTER 19739CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAosmotic pressures (for example, with congestive heart failure or cirrhosis). On gross visual inspection, a transudative effusion is generally clear or straw-colored. Exudates are protein-rich pleural fluid collections that generally result from inflamma-tion or pleural invasion by tumor. Grossly, they are often turbid, bloody, or purulent. Absent trauma, grossly bloody effusions are frequently malignant, but they may also occur in the setting of a pulmonary embolism or pneumonia.Transudates and exudates can be differentiated using Light’s criteria. An effusion is exudative if the pleural fluid-to-serum ratio of protein is greater than 0.5 and the LDH ratio is greater than 0.6 or the absolute pleural LDH level is greater than two-thirds of the normal upper limit for serum. If criteria suggest a transudate, a careful evaluation for congestive heart failure, cirrhosis, or conditions associated with transudates is under-taken. If |
Surgery_Schwartz_4957 | Surgery_Schwartz | of the normal upper limit for serum. If criteria suggest a transudate, a careful evaluation for congestive heart failure, cirrhosis, or conditions associated with transudates is under-taken. If criteria suggest an exudate, further diagnostic studies may be helpful. If total and differential cell counts reveal a pre-dominance of neutrophils (>50% of cells), the effusion is likely associated with an acute inflammatory process (such as a para-pneumonic effusion or empyema, pulmonary embolus, or pan-creatitis). A predominance of mononuclear cells suggests a more chronic inflammatory process (such as cancer or tuberculosis). Gram stains and cultures should be obtained if possible, with inoculation into culture bottles at the bedside. Pleural fluid glu-cose levels are frequently decreased (<60 mg/dL) with complex parapneumonic effusions or malignant effusions. It is important to note that while the distinction between transudate and exudate can be diagnostically useful, the ultimate | Surgery_Schwartz. of the normal upper limit for serum. If criteria suggest a transudate, a careful evaluation for congestive heart failure, cirrhosis, or conditions associated with transudates is under-taken. If criteria suggest an exudate, further diagnostic studies may be helpful. If total and differential cell counts reveal a pre-dominance of neutrophils (>50% of cells), the effusion is likely associated with an acute inflammatory process (such as a para-pneumonic effusion or empyema, pulmonary embolus, or pan-creatitis). A predominance of mononuclear cells suggests a more chronic inflammatory process (such as cancer or tuberculosis). Gram stains and cultures should be obtained if possible, with inoculation into culture bottles at the bedside. Pleural fluid glu-cose levels are frequently decreased (<60 mg/dL) with complex parapneumonic effusions or malignant effusions. It is important to note that while the distinction between transudate and exudate can be diagnostically useful, the ultimate |
Surgery_Schwartz_4958 | Surgery_Schwartz | (<60 mg/dL) with complex parapneumonic effusions or malignant effusions. It is important to note that while the distinction between transudate and exudate can be diagnostically useful, the ultimate decision for prolonged chest tube drainage or surgery depends on the effusion size and adequacy of drainage, presence of loculations, adequacy of lung reexpansion after drainage, and recurrence after initial drainage.A pleural effusion occurring in association with pleuritic chest pain, hemoptysis, or dyspnea out of proportion to the size of the effusion should raise concern for pulmonary embolism. These effusions may be transudative, but if an associated infarct near the pleural surface occurs, an exudate may be seen. If a pulmonary embolism is suspected in a postoperative patient, most clinicians would obtain a spiral CT scan. Alternatively, duplex ultrasonography of the lower extremities may yield a diagnosis of deep vein thrombosis, thereby indicating antico-agulant therapy and | Surgery_Schwartz. (<60 mg/dL) with complex parapneumonic effusions or malignant effusions. It is important to note that while the distinction between transudate and exudate can be diagnostically useful, the ultimate decision for prolonged chest tube drainage or surgery depends on the effusion size and adequacy of drainage, presence of loculations, adequacy of lung reexpansion after drainage, and recurrence after initial drainage.A pleural effusion occurring in association with pleuritic chest pain, hemoptysis, or dyspnea out of proportion to the size of the effusion should raise concern for pulmonary embolism. These effusions may be transudative, but if an associated infarct near the pleural surface occurs, an exudate may be seen. If a pulmonary embolism is suspected in a postoperative patient, most clinicians would obtain a spiral CT scan. Alternatively, duplex ultrasonography of the lower extremities may yield a diagnosis of deep vein thrombosis, thereby indicating antico-agulant therapy and |
Surgery_Schwartz_4959 | Surgery_Schwartz | clinicians would obtain a spiral CT scan. Alternatively, duplex ultrasonography of the lower extremities may yield a diagnosis of deep vein thrombosis, thereby indicating antico-agulant therapy and precluding the need for a specific diagnosis of pulmonary embolism. In some patients, a blood test for levels of d-dimer may be helpful; if a sensitive d-dimer blood test is negative, pulmonary embolism may be ruled out.Malignant Pleural EffusionMalignant pleural effusions may occur in association with a number of different malignancies, most commonly lung can-cer, breast cancer, and lymphomas, depending on the patient’s age and gender (Tables 19-35 and 19-36).176 Cytologic testing should be done on exudative effusions to rule out an associated malignancy; accuracy is 70% when associated with adenocarci-nomas, but it is less sensitive for mesotheliomas (<10%), squa-mous cell carcinomas (20%), or lymphomas (25% to 50%). If the diagnosis remains uncertain after drainage and fluid analy-sis, | Surgery_Schwartz. clinicians would obtain a spiral CT scan. Alternatively, duplex ultrasonography of the lower extremities may yield a diagnosis of deep vein thrombosis, thereby indicating antico-agulant therapy and precluding the need for a specific diagnosis of pulmonary embolism. In some patients, a blood test for levels of d-dimer may be helpful; if a sensitive d-dimer blood test is negative, pulmonary embolism may be ruled out.Malignant Pleural EffusionMalignant pleural effusions may occur in association with a number of different malignancies, most commonly lung can-cer, breast cancer, and lymphomas, depending on the patient’s age and gender (Tables 19-35 and 19-36).176 Cytologic testing should be done on exudative effusions to rule out an associated malignancy; accuracy is 70% when associated with adenocarci-nomas, but it is less sensitive for mesotheliomas (<10%), squa-mous cell carcinomas (20%), or lymphomas (25% to 50%). If the diagnosis remains uncertain after drainage and fluid analy-sis, |
Surgery_Schwartz_4960 | Surgery_Schwartz | adenocarci-nomas, but it is less sensitive for mesotheliomas (<10%), squa-mous cell carcinomas (20%), or lymphomas (25% to 50%). If the diagnosis remains uncertain after drainage and fluid analy-sis, thoracoscopy and direct biopsies are indicated.177,178 Malig-nant effusions are exudative and often tinged with blood. An effusion in the setting of a malignancy means a more advanced stage; mean survival ranges from 3 to 11 months, depending on the primary tumor location.Occasionally, effusions associated with a bronchogenic NSCLC are benign, and surgical resection may still be indicated.Table 19-35Primary organ site or neoplasm type in male patients with malignant pleural effusionsPRIMARY SITE OR TUMOR TYPENO. OF MALE PATIENTSPERCENTAGE OF MALE PATIENTSLung14049.1Lymphoma/leukemia6021.1Gastrointestinal tract207.0Genitourinary tract176.0Melanoma41.4Miscellaneous less common tumors103.5Primary site unknown3110.9Total285100.0Reproduced with permission from Johnston WW. The malignant | Surgery_Schwartz. adenocarci-nomas, but it is less sensitive for mesotheliomas (<10%), squa-mous cell carcinomas (20%), or lymphomas (25% to 50%). If the diagnosis remains uncertain after drainage and fluid analy-sis, thoracoscopy and direct biopsies are indicated.177,178 Malig-nant effusions are exudative and often tinged with blood. An effusion in the setting of a malignancy means a more advanced stage; mean survival ranges from 3 to 11 months, depending on the primary tumor location.Occasionally, effusions associated with a bronchogenic NSCLC are benign, and surgical resection may still be indicated.Table 19-35Primary organ site or neoplasm type in male patients with malignant pleural effusionsPRIMARY SITE OR TUMOR TYPENO. OF MALE PATIENTSPERCENTAGE OF MALE PATIENTSLung14049.1Lymphoma/leukemia6021.1Gastrointestinal tract207.0Genitourinary tract176.0Melanoma41.4Miscellaneous less common tumors103.5Primary site unknown3110.9Total285100.0Reproduced with permission from Johnston WW. The malignant |
Surgery_Schwartz_4961 | Surgery_Schwartz | tract207.0Genitourinary tract176.0Melanoma41.4Miscellaneous less common tumors103.5Primary site unknown3110.9Total285100.0Reproduced with permission from Johnston WW. The malignant pleural effusion: a review of cytopathologic diagnoses of 584 specimens from 472 consecutive patients, Cancer. 1985 Aug 15;56(4):905-909.Table 19-36Primary organ site or neoplasm type in female patients with malignant pleural effusionsPRIMARY SITE OR TUMOR TYPENO. OF FEMALE PATIENTSPERCENTAGE OF FEMALE PATIENTSBreast7037.4Female genital tract3820.3Lung2815.0Lymphoma148.0Gastrointestinal tract84.3Melanoma63.2Urinary tract21.1Miscellaneous less common tumors31.6Primary site unknown179.1Total187100.0Reproduced with permission from Johnston WW. The malignant pleural effusion: a review of cytopathologic diagnoses of 584 specimens from 472 consecutive patients, Cancer. 1985 Aug 15;56(4):905-909.Effusion size and degree of associated dyspnea influence management. Symptomatic, moderate to large effusions should be | Surgery_Schwartz. tract207.0Genitourinary tract176.0Melanoma41.4Miscellaneous less common tumors103.5Primary site unknown3110.9Total285100.0Reproduced with permission from Johnston WW. The malignant pleural effusion: a review of cytopathologic diagnoses of 584 specimens from 472 consecutive patients, Cancer. 1985 Aug 15;56(4):905-909.Table 19-36Primary organ site or neoplasm type in female patients with malignant pleural effusionsPRIMARY SITE OR TUMOR TYPENO. OF FEMALE PATIENTSPERCENTAGE OF FEMALE PATIENTSBreast7037.4Female genital tract3820.3Lung2815.0Lymphoma148.0Gastrointestinal tract84.3Melanoma63.2Urinary tract21.1Miscellaneous less common tumors31.6Primary site unknown179.1Total187100.0Reproduced with permission from Johnston WW. The malignant pleural effusion: a review of cytopathologic diagnoses of 584 specimens from 472 consecutive patients, Cancer. 1985 Aug 15;56(4):905-909.Effusion size and degree of associated dyspnea influence management. Symptomatic, moderate to large effusions should be |
Surgery_Schwartz_4962 | Surgery_Schwartz | 584 specimens from 472 consecutive patients, Cancer. 1985 Aug 15;56(4):905-909.Effusion size and degree of associated dyspnea influence management. Symptomatic, moderate to large effusions should be drained by tunneled indwelling pleural catheter, tube thora-costomy (chest tube or pigtail catheter) with subsequent instilla-tion of a sclerosing agent, or VATS with talc instillation. Management is based on patient preference, degree of known or anticipated lung reexpansion, and patient tolerance for operative intervention. Lung entrapment by tumor or adhesions limits reexpansion and generally predicts a poor result with pleurode-sis; it is the primary indication for placement of indwelling pleu-ral catheters. Patient preference is also considered, as is their life expectancy. Tunneled indwelling pleural catheters have dramati-cally changed the management of end-stage cancer treatment Brunicardi_Ch19_p0661-p0750.indd 73901/03/19 7:01 PM 740SPECIFIC CONSIDERATIONSPART IITable | Surgery_Schwartz. 584 specimens from 472 consecutive patients, Cancer. 1985 Aug 15;56(4):905-909.Effusion size and degree of associated dyspnea influence management. Symptomatic, moderate to large effusions should be drained by tunneled indwelling pleural catheter, tube thora-costomy (chest tube or pigtail catheter) with subsequent instilla-tion of a sclerosing agent, or VATS with talc instillation. Management is based on patient preference, degree of known or anticipated lung reexpansion, and patient tolerance for operative intervention. Lung entrapment by tumor or adhesions limits reexpansion and generally predicts a poor result with pleurode-sis; it is the primary indication for placement of indwelling pleu-ral catheters. Patient preference is also considered, as is their life expectancy. Tunneled indwelling pleural catheters have dramati-cally changed the management of end-stage cancer treatment Brunicardi_Ch19_p0661-p0750.indd 73901/03/19 7:01 PM 740SPECIFIC CONSIDERATIONSPART IITable |
Surgery_Schwartz_4963 | Surgery_Schwartz | indwelling pleural catheters have dramati-cally changed the management of end-stage cancer treatment Brunicardi_Ch19_p0661-p0750.indd 73901/03/19 7:01 PM 740SPECIFIC CONSIDERATIONSPART IITable 19-37Pathogenesis of empyemaContamination from a source contiguous to the pleural space (50%–60%) Lung Mediastinum Deep cervical area Chest wall and spine Subphrenic areaDirect inoculation of the pleural space (30%–40%) Minor thoracic interventions Postoperative infections Penetrating chest injuriesHematogenous infection of the pleural space from a distant site (<1%)Reproduced with permission from Pearson FG, Cooper JD, Deslauriers J, et al: Thoracic Surgery, 2nd ed. New York, NY: Elsevier/Churchill Livingstone; 2002.Outpatient referral for management of MPEPlacement ofindwelling pleuralcatheterLoculatedfluid/trapped lungFree-flowing with fulllung expansion Excellent performancestatus/long life expectancyVATS pleurodesisPoor performancestatus/short life expectancyPlacement of | Surgery_Schwartz. indwelling pleural catheters have dramati-cally changed the management of end-stage cancer treatment Brunicardi_Ch19_p0661-p0750.indd 73901/03/19 7:01 PM 740SPECIFIC CONSIDERATIONSPART IITable 19-37Pathogenesis of empyemaContamination from a source contiguous to the pleural space (50%–60%) Lung Mediastinum Deep cervical area Chest wall and spine Subphrenic areaDirect inoculation of the pleural space (30%–40%) Minor thoracic interventions Postoperative infections Penetrating chest injuriesHematogenous infection of the pleural space from a distant site (<1%)Reproduced with permission from Pearson FG, Cooper JD, Deslauriers J, et al: Thoracic Surgery, 2nd ed. New York, NY: Elsevier/Churchill Livingstone; 2002.Outpatient referral for management of MPEPlacement ofindwelling pleuralcatheterLoculatedfluid/trapped lungFree-flowing with fulllung expansion Excellent performancestatus/long life expectancyVATS pleurodesisPoor performancestatus/short life expectancyPlacement of |
Surgery_Schwartz_4964 | Surgery_Schwartz | pleuralcatheterLoculatedfluid/trapped lungFree-flowing with fulllung expansion Excellent performancestatus/long life expectancyVATS pleurodesisPoor performancestatus/short life expectancyPlacement of indwellingpleural catheterDecubitus films and/or CT scan Figure 19-51. Treatment decision algorithm for the management of malignant pleural effusion (MPE). CT = computed tomography; VATS = video-assisted tho-racic surgery.because they substantially shorten the amount of time patients spend in the hospital during their final weeks of life.179 If the lung is expected to fully expand and the patient has a longer life expectancy (e.g., malignant effusions in the setting of breast cancer), drainage with sclerosis is the preferred option. The choice of sclerosant includes mechanical pleurodesis or pleurectomy, talc, bleomycin, or doxycycline. Success rates range from 60% to 90% and are highest with talc. Typically, talc is administered as an aerosolized powder during video-assisted | Surgery_Schwartz. pleuralcatheterLoculatedfluid/trapped lungFree-flowing with fulllung expansion Excellent performancestatus/long life expectancyVATS pleurodesisPoor performancestatus/short life expectancyPlacement of indwellingpleural catheterDecubitus films and/or CT scan Figure 19-51. Treatment decision algorithm for the management of malignant pleural effusion (MPE). CT = computed tomography; VATS = video-assisted tho-racic surgery.because they substantially shorten the amount of time patients spend in the hospital during their final weeks of life.179 If the lung is expected to fully expand and the patient has a longer life expectancy (e.g., malignant effusions in the setting of breast cancer), drainage with sclerosis is the preferred option. The choice of sclerosant includes mechanical pleurodesis or pleurectomy, talc, bleomycin, or doxycycline. Success rates range from 60% to 90% and are highest with talc. Typically, talc is administered as an aerosolized powder during video-assisted |
Surgery_Schwartz_4965 | Surgery_Schwartz | or pleurectomy, talc, bleomycin, or doxycycline. Success rates range from 60% to 90% and are highest with talc. Typically, talc is administered as an aerosolized powder during video-assisted thoracoscopy, whereas doxycycline or a talc slurry is infused at the bedside through a previously placed pigtail catheter or larger bore chest tube. Figure 19-51 presents a decision algorithm for the management of malignant pleural effusion.EmpyemaThoracic empyema is defined by a purulent pleural effusion. Patients of all ages can develop empyema, but the frequency is increased in older or debilitated patients. Common associ-ated conditions include a pneumonic process in patients with pulmonary disorders and neoplasms, cardiac problems, diabe-tes mellitus, drug and alcohol abuse, neurologic impairments, postthoracotomy problems, and immunologic impairments. The mortality of empyema frequently depends on the degree of severity of the comorbidity; it may range from as low as 1% to over 40% in | Surgery_Schwartz. or pleurectomy, talc, bleomycin, or doxycycline. Success rates range from 60% to 90% and are highest with talc. Typically, talc is administered as an aerosolized powder during video-assisted thoracoscopy, whereas doxycycline or a talc slurry is infused at the bedside through a previously placed pigtail catheter or larger bore chest tube. Figure 19-51 presents a decision algorithm for the management of malignant pleural effusion.EmpyemaThoracic empyema is defined by a purulent pleural effusion. Patients of all ages can develop empyema, but the frequency is increased in older or debilitated patients. Common associ-ated conditions include a pneumonic process in patients with pulmonary disorders and neoplasms, cardiac problems, diabe-tes mellitus, drug and alcohol abuse, neurologic impairments, postthoracotomy problems, and immunologic impairments. The mortality of empyema frequently depends on the degree of severity of the comorbidity; it may range from as low as 1% to over 40% in |
Surgery_Schwartz_4966 | Surgery_Schwartz | postthoracotomy problems, and immunologic impairments. The mortality of empyema frequently depends on the degree of severity of the comorbidity; it may range from as low as 1% to over 40% in immunocompromised patients.Pathophysiology. The most common causes are parapneu-monic, but postsurgical, posttraumatic, and GI-associated (e.g., subphrenic or hepatic abscess, perforation of esophagus or other viscus) empyema is also common (Table 19-37). The spectrum of organisms involved in pneumonic processes that progress to empyema is changing. Pneumococci and staphylococci continue to be the most common, but gram-negative aerobic bacteria and anaerobes are becoming more prevalent. Cases involving myco-bacteria or fungi are rare. Multiple organisms may be found in up to 50% of patients. Cultures may be sterile, however, if antibiotics were initiated before the culture or if the culture pro-cess was not efficient. It is also fairly common for Pneumococ-cus to grow in blood cultures but not to | Surgery_Schwartz. postthoracotomy problems, and immunologic impairments. The mortality of empyema frequently depends on the degree of severity of the comorbidity; it may range from as low as 1% to over 40% in immunocompromised patients.Pathophysiology. The most common causes are parapneu-monic, but postsurgical, posttraumatic, and GI-associated (e.g., subphrenic or hepatic abscess, perforation of esophagus or other viscus) empyema is also common (Table 19-37). The spectrum of organisms involved in pneumonic processes that progress to empyema is changing. Pneumococci and staphylococci continue to be the most common, but gram-negative aerobic bacteria and anaerobes are becoming more prevalent. Cases involving myco-bacteria or fungi are rare. Multiple organisms may be found in up to 50% of patients. Cultures may be sterile, however, if antibiotics were initiated before the culture or if the culture pro-cess was not efficient. It is also fairly common for Pneumococ-cus to grow in blood cultures but not to |
Surgery_Schwartz_4967 | Surgery_Schwartz | may be sterile, however, if antibiotics were initiated before the culture or if the culture pro-cess was not efficient. It is also fairly common for Pneumococ-cus to grow in blood cultures but not to grow in the pleural fluid cultures. The choice of antibiotics, therefore, is guided 11by the clinical scenario and not just the organisms found on culture. Broad-spectrum coverage may be required even when cultures do not grow out an organism or if a single organism is grown when the clinical picture is more consistent with a mul-tiorganism process. For example, a polymicrobial gram stain, particularly including yeast, is strongly suggestive of esopha-geal perforation. Common gram-negative organisms include Escherichia coli, Klebsiella, Pseudomonas, and Enterobacte-riaceae. Anaerobic organisms may be fastidious and difficult to document by culture and are associated with periodontal dis-eases (especially Streptococcus species), aspiration syndromes, alcoholism, general anesthesia, drug | Surgery_Schwartz. may be sterile, however, if antibiotics were initiated before the culture or if the culture pro-cess was not efficient. It is also fairly common for Pneumococ-cus to grow in blood cultures but not to grow in the pleural fluid cultures. The choice of antibiotics, therefore, is guided 11by the clinical scenario and not just the organisms found on culture. Broad-spectrum coverage may be required even when cultures do not grow out an organism or if a single organism is grown when the clinical picture is more consistent with a mul-tiorganism process. For example, a polymicrobial gram stain, particularly including yeast, is strongly suggestive of esopha-geal perforation. Common gram-negative organisms include Escherichia coli, Klebsiella, Pseudomonas, and Enterobacte-riaceae. Anaerobic organisms may be fastidious and difficult to document by culture and are associated with periodontal dis-eases (especially Streptococcus species), aspiration syndromes, alcoholism, general anesthesia, drug |
Surgery_Schwartz_4968 | Surgery_Schwartz | may be fastidious and difficult to document by culture and are associated with periodontal dis-eases (especially Streptococcus species), aspiration syndromes, alcoholism, general anesthesia, drug abuse, or other functional associations with gastroesophageal reflux.Organisms gain entry into the pleural cavity through con-tiguous spread from pneumonia, lung abscess, liver abscess, or another, adjacent infectious processes. Organisms may also enter the pleural cavity by direct contamination from thora-centesis, thoracic surgical procedures, esophageal injuries, Brunicardi_Ch19_p0661-p0750.indd 74001/03/19 7:01 PM | Surgery_Schwartz. may be fastidious and difficult to document by culture and are associated with periodontal dis-eases (especially Streptococcus species), aspiration syndromes, alcoholism, general anesthesia, drug abuse, or other functional associations with gastroesophageal reflux.Organisms gain entry into the pleural cavity through con-tiguous spread from pneumonia, lung abscess, liver abscess, or another, adjacent infectious processes. Organisms may also enter the pleural cavity by direct contamination from thora-centesis, thoracic surgical procedures, esophageal injuries, Brunicardi_Ch19_p0661-p0750.indd 74001/03/19 7:01 PM |
Surgery_Schwartz_4969 | Surgery_Schwartz | CHAPTER 19741CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAor trauma. As organisms enter the pleural space, an influx of polymorphonuclear cells and fluid occurs, with subsequent release of inflammatory mediators and toxic oxygen radi-cals. These mechanisms lead to variable degrees of endothe-lial injury and capillary instability. This process overwhelms the normal pleural lymphatic drainage. This early effusion is watery and free-flowing in the pleural cavity. Thoracentesis at this stage yields fluid with a pH typically above 7.3, a glucose level greater than 60 mg/dL, and a low LDH level (<500 U/L). At this stage, the decision to use antibiotics alone or perform a repeat thoracentesis, chest tube drainage, thoracoscopy, or open thoracotomy depends on the amount of pleural fluid, its consis-tency, the clinical status of the patient, the degree of expansion of the lung after drainage, and the presence of loculated fluid in the pleural space (vs. free-flowing purulent fluid). Early in the | Surgery_Schwartz. CHAPTER 19741CHEST WALL, LUNG, MEDIASTINUM, AND PLEURAor trauma. As organisms enter the pleural space, an influx of polymorphonuclear cells and fluid occurs, with subsequent release of inflammatory mediators and toxic oxygen radi-cals. These mechanisms lead to variable degrees of endothe-lial injury and capillary instability. This process overwhelms the normal pleural lymphatic drainage. This early effusion is watery and free-flowing in the pleural cavity. Thoracentesis at this stage yields fluid with a pH typically above 7.3, a glucose level greater than 60 mg/dL, and a low LDH level (<500 U/L). At this stage, the decision to use antibiotics alone or perform a repeat thoracentesis, chest tube drainage, thoracoscopy, or open thoracotomy depends on the amount of pleural fluid, its consis-tency, the clinical status of the patient, the degree of expansion of the lung after drainage, and the presence of loculated fluid in the pleural space (vs. free-flowing purulent fluid). Early in the |
Surgery_Schwartz_4970 | Surgery_Schwartz | the clinical status of the patient, the degree of expansion of the lung after drainage, and the presence of loculated fluid in the pleural space (vs. free-flowing purulent fluid). Early in the parapneumonic process, when the purulent fluid is relatively thin, complete drainage with simple large-bore thoracentesis is possible. If complete lung expansion is obtained and the pneu-monic process is responding to antibiotics, no further drainage may be necessary. Pleural fluid with a pH lower than 7.2 and with a glucose level of less than 40 mg/dL means that a more aggressive approach to drainage should be pursued.The pleural fluid may become thick and loculated over the course of hours to days and may be associated with fibrinous adhesions (the fibrinopurulent stage). At this stage, chest tube insertion with closed-system drainage or drainage with thora-coscopy may be necessary to remove the fluid and adhesions and facilitate complete lung expansion.180 Further progression of the | Surgery_Schwartz. the clinical status of the patient, the degree of expansion of the lung after drainage, and the presence of loculated fluid in the pleural space (vs. free-flowing purulent fluid). Early in the parapneumonic process, when the purulent fluid is relatively thin, complete drainage with simple large-bore thoracentesis is possible. If complete lung expansion is obtained and the pneu-monic process is responding to antibiotics, no further drainage may be necessary. Pleural fluid with a pH lower than 7.2 and with a glucose level of less than 40 mg/dL means that a more aggressive approach to drainage should be pursued.The pleural fluid may become thick and loculated over the course of hours to days and may be associated with fibrinous adhesions (the fibrinopurulent stage). At this stage, chest tube insertion with closed-system drainage or drainage with thora-coscopy may be necessary to remove the fluid and adhesions and facilitate complete lung expansion.180 Further progression of the |
Surgery_Schwartz_4971 | Surgery_Schwartz | tube insertion with closed-system drainage or drainage with thora-coscopy may be necessary to remove the fluid and adhesions and facilitate complete lung expansion.180 Further progression of the inflammatory process leads to the formation of a pleu-ral peel, which may be flimsy and easy to remove early on. However, as the process progresses, a thick pleural rind may develop, leaving a trapped lung; complete lung decortication by either thoracoscopy or thoracotomy would then be necessary.The use of intrapleural fibrinolytic therapy for manage-ment of empyema has been investigated in several large pro-spective trials. Intrapleural infusion of tissue plasminogen activator (t-PA) alone did not improve outcomes, whereas combined intrapleural t-PA and DNase was associated with a reduction in hospital stay of nearly 7 days, 77% fewer refer-rals for surgical intervention at 3 months, and more than double the reduction in the infected pleural fluid collection by CXR imaging.181 In this trial, | Surgery_Schwartz. tube insertion with closed-system drainage or drainage with thora-coscopy may be necessary to remove the fluid and adhesions and facilitate complete lung expansion.180 Further progression of the inflammatory process leads to the formation of a pleu-ral peel, which may be flimsy and easy to remove early on. However, as the process progresses, a thick pleural rind may develop, leaving a trapped lung; complete lung decortication by either thoracoscopy or thoracotomy would then be necessary.The use of intrapleural fibrinolytic therapy for manage-ment of empyema has been investigated in several large pro-spective trials. Intrapleural infusion of tissue plasminogen activator (t-PA) alone did not improve outcomes, whereas combined intrapleural t-PA and DNase was associated with a reduction in hospital stay of nearly 7 days, 77% fewer refer-rals for surgical intervention at 3 months, and more than double the reduction in the infected pleural fluid collection by CXR imaging.181 In this trial, |
Surgery_Schwartz_4972 | Surgery_Schwartz | stay of nearly 7 days, 77% fewer refer-rals for surgical intervention at 3 months, and more than double the reduction in the infected pleural fluid collection by CXR imaging.181 In this trial, the medications were given twice daily by intrapleural injection; the dose was 5 mg for the DNase and 10 mg for t-PA. The chest drain was clamped for 1 hour after injection and released. This study suggests that the combination of fibrinolysis (t-PA) and cleavage of uncoiled DNA by DNase reduces fluid viscosity and facilitates pleural clearance.Management. If there is a residual space, persistent pleural infection is likely to occur. A persistent pleural space may be secondary to contracted, but intact, underlying lung; or it may be secondary to surgical lung resection. If the space is small and well drained by a chest tube, a conservative approach may be possible. This requires leaving the chest tubes in place and attached to closed-system drainage until symphysis of the vis-ceral and parietal | Surgery_Schwartz. stay of nearly 7 days, 77% fewer refer-rals for surgical intervention at 3 months, and more than double the reduction in the infected pleural fluid collection by CXR imaging.181 In this trial, the medications were given twice daily by intrapleural injection; the dose was 5 mg for the DNase and 10 mg for t-PA. The chest drain was clamped for 1 hour after injection and released. This study suggests that the combination of fibrinolysis (t-PA) and cleavage of uncoiled DNA by DNase reduces fluid viscosity and facilitates pleural clearance.Management. If there is a residual space, persistent pleural infection is likely to occur. A persistent pleural space may be secondary to contracted, but intact, underlying lung; or it may be secondary to surgical lung resection. If the space is small and well drained by a chest tube, a conservative approach may be possible. This requires leaving the chest tubes in place and attached to closed-system drainage until symphysis of the vis-ceral and parietal |
Surgery_Schwartz_4973 | Surgery_Schwartz | drained by a chest tube, a conservative approach may be possible. This requires leaving the chest tubes in place and attached to closed-system drainage until symphysis of the vis-ceral and parietal surfaces takes place. At this point, the chest tubes can be removed from suction; if the residual pleural space remains stable, the tubes can be cut and advanced out of the chest over the course of several weeks. If the patient is stable, tube removal can frequently be done in the outpatient setting, guided by the degree of drainage and the size of the residual space visualized on serial CT scans. Larger spaces may require open thoracotomy and decortication in an attempt to reexpand the lung to fill this residual space. If reexpansion has failed or appears too high risk, then open drainage, rib resection, and prolonged packing may be required, with delayed closure with muscle flaps or thoracoplasty.182 Most chronic pleural space problems can be avoided by early specialized thoracic | Surgery_Schwartz. drained by a chest tube, a conservative approach may be possible. This requires leaving the chest tubes in place and attached to closed-system drainage until symphysis of the vis-ceral and parietal surfaces takes place. At this point, the chest tubes can be removed from suction; if the residual pleural space remains stable, the tubes can be cut and advanced out of the chest over the course of several weeks. If the patient is stable, tube removal can frequently be done in the outpatient setting, guided by the degree of drainage and the size of the residual space visualized on serial CT scans. Larger spaces may require open thoracotomy and decortication in an attempt to reexpand the lung to fill this residual space. If reexpansion has failed or appears too high risk, then open drainage, rib resection, and prolonged packing may be required, with delayed closure with muscle flaps or thoracoplasty.182 Most chronic pleural space problems can be avoided by early specialized thoracic |
Surgery_Schwartz_4974 | Surgery_Schwartz | rib resection, and prolonged packing may be required, with delayed closure with muscle flaps or thoracoplasty.182 Most chronic pleural space problems can be avoided by early specialized thoracic surgi-cal consultation and complete drainage of empyema, allowing space obliteration by the reinflated lung.ChylothoraxChylothorax develops most commonly after surgical trauma to the thoracic duct or a major branch, but may be also associ-ated with a number of other conditions (Table 19-38).183 It is generally unilateral; for example, it may occur after dissection of the distal esophagus where the duct lies in close proximity to the esophagus as it enters the right chest from its origin in the Table 19-38Etiology of chylothoraxCongenital Atresia of thoracic duct Thoracic duct-pleural space fistula Birth traumaTraumatic and/or iatrogenic Blunt injury Penetrating injury Surgery Cervical Excision of lymph nodes Radical neck dissection Thoracic Correction of patent ductus | Surgery_Schwartz. rib resection, and prolonged packing may be required, with delayed closure with muscle flaps or thoracoplasty.182 Most chronic pleural space problems can be avoided by early specialized thoracic surgi-cal consultation and complete drainage of empyema, allowing space obliteration by the reinflated lung.ChylothoraxChylothorax develops most commonly after surgical trauma to the thoracic duct or a major branch, but may be also associ-ated with a number of other conditions (Table 19-38).183 It is generally unilateral; for example, it may occur after dissection of the distal esophagus where the duct lies in close proximity to the esophagus as it enters the right chest from its origin in the Table 19-38Etiology of chylothoraxCongenital Atresia of thoracic duct Thoracic duct-pleural space fistula Birth traumaTraumatic and/or iatrogenic Blunt injury Penetrating injury Surgery Cervical Excision of lymph nodes Radical neck dissection Thoracic Correction of patent ductus |
Surgery_Schwartz_4975 | Surgery_Schwartz | space fistula Birth traumaTraumatic and/or iatrogenic Blunt injury Penetrating injury Surgery Cervical Excision of lymph nodes Radical neck dissection Thoracic Correction of patent ductus arteriosus Correction of coarctation of the aorta Vascular procedure involving the origin of the left subclavian artery Esophagectomy Sympathectomy Resection of thoracic aneurysm Resection of mediastinal tumors Left pneumonectomy Abdominal Sympathectomy Radical lymph node dissection Diagnostic procedures Translumbar arteriography Subclavian vein catheterization Left-sided heart catheterizationNeoplasmsInfections Tuberculous lymphadenitis Nonspecific mediastinitis Ascending lymphangitis FilariasisMiscellaneous Venous thrombosis Left subclavian-jugular vein Superior vena cava Pulmonary lymphangiomatosisReproduced with permission from Sabiston DC, Spencer FC: Surgery of the Chest, 6th ed. Philadelphia, PA: Elsevier; 1995.Brunicardi_Ch19_p0661-p0750.indd 74101/03/19 | Surgery_Schwartz. space fistula Birth traumaTraumatic and/or iatrogenic Blunt injury Penetrating injury Surgery Cervical Excision of lymph nodes Radical neck dissection Thoracic Correction of patent ductus arteriosus Correction of coarctation of the aorta Vascular procedure involving the origin of the left subclavian artery Esophagectomy Sympathectomy Resection of thoracic aneurysm Resection of mediastinal tumors Left pneumonectomy Abdominal Sympathectomy Radical lymph node dissection Diagnostic procedures Translumbar arteriography Subclavian vein catheterization Left-sided heart catheterizationNeoplasmsInfections Tuberculous lymphadenitis Nonspecific mediastinitis Ascending lymphangitis FilariasisMiscellaneous Venous thrombosis Left subclavian-jugular vein Superior vena cava Pulmonary lymphangiomatosisReproduced with permission from Sabiston DC, Spencer FC: Surgery of the Chest, 6th ed. Philadelphia, PA: Elsevier; 1995.Brunicardi_Ch19_p0661-p0750.indd 74101/03/19 |
Surgery_Schwartz_4976 | Surgery_Schwartz | cava Pulmonary lymphangiomatosisReproduced with permission from Sabiston DC, Spencer FC: Surgery of the Chest, 6th ed. Philadelphia, PA: Elsevier; 1995.Brunicardi_Ch19_p0661-p0750.indd 74101/03/19 7:01 PM 742SPECIFIC CONSIDERATIONSPART IIabdomen at the cisterna chyli (Fig. 19-52). If the mediastinal pleura are disrupted on both sides, bilateral chylothoraces may occur. Left-sided chylothoraces may develop after a left-sided neck dissection, especially in the region of the confluence of the subclavian and internal jugular veins. Chylothorax may also follow nonsurgical trauma, including penetrating or blunt inju-ries to the chest or neck area, central line placements, and other surgical misadventures. It may be seen in association with a variety of benign and malignant diseases that generally involve the lymphatic system of the mediastinum or neck.Pathophysiology. Most commonly, the thoracic duct origi-nates in the abdomen from the cisterna chyli, which is located in the midline, | Surgery_Schwartz. cava Pulmonary lymphangiomatosisReproduced with permission from Sabiston DC, Spencer FC: Surgery of the Chest, 6th ed. Philadelphia, PA: Elsevier; 1995.Brunicardi_Ch19_p0661-p0750.indd 74101/03/19 7:01 PM 742SPECIFIC CONSIDERATIONSPART IIabdomen at the cisterna chyli (Fig. 19-52). If the mediastinal pleura are disrupted on both sides, bilateral chylothoraces may occur. Left-sided chylothoraces may develop after a left-sided neck dissection, especially in the region of the confluence of the subclavian and internal jugular veins. Chylothorax may also follow nonsurgical trauma, including penetrating or blunt inju-ries to the chest or neck area, central line placements, and other surgical misadventures. It may be seen in association with a variety of benign and malignant diseases that generally involve the lymphatic system of the mediastinum or neck.Pathophysiology. Most commonly, the thoracic duct origi-nates in the abdomen from the cisterna chyli, which is located in the midline, |
Surgery_Schwartz_4977 | Surgery_Schwartz | involve the lymphatic system of the mediastinum or neck.Pathophysiology. Most commonly, the thoracic duct origi-nates in the abdomen from the cisterna chyli, which is located in the midline, near the level of the second lumbar vertebra. From this origin, the thoracic duct ascends into the chest through the aortic hiatus at the level of T10 to T12, and courses just to the right of the aorta (see Fig. 19-52). As the thoracic duct courses cephalad above the diaphragm, it most commonly remains in the right chest, lying just behind the esophagus, between the aorta and azygos vein. The duct continues superiorly, lying just to the right of the vertebral column. Then, at the fourth thoracic ver-tebra, it crosses behind the aorta and the aortic arch into the left posterior mediastinum and travels superiorly, staying near the esophagus and mediastinal pleura as it exits the thoracic inlet. As it exits the thoracic inlet, it passes to the left, just behind the carotid sheath and anterior to the | Surgery_Schwartz. involve the lymphatic system of the mediastinum or neck.Pathophysiology. Most commonly, the thoracic duct origi-nates in the abdomen from the cisterna chyli, which is located in the midline, near the level of the second lumbar vertebra. From this origin, the thoracic duct ascends into the chest through the aortic hiatus at the level of T10 to T12, and courses just to the right of the aorta (see Fig. 19-52). As the thoracic duct courses cephalad above the diaphragm, it most commonly remains in the right chest, lying just behind the esophagus, between the aorta and azygos vein. The duct continues superiorly, lying just to the right of the vertebral column. Then, at the fourth thoracic ver-tebra, it crosses behind the aorta and the aortic arch into the left posterior mediastinum and travels superiorly, staying near the esophagus and mediastinal pleura as it exits the thoracic inlet. As it exits the thoracic inlet, it passes to the left, just behind the carotid sheath and anterior to the |
Surgery_Schwartz_4978 | Surgery_Schwartz | superiorly, staying near the esophagus and mediastinal pleura as it exits the thoracic inlet. As it exits the thoracic inlet, it passes to the left, just behind the carotid sheath and anterior to the inferior thyroid and vertebral bodies. Just medial to the anterior scalene muscle, it courses inferiorly and drains into the union of the internal jugular and subclavian veins. Given the extreme variability in the main duct and its branches, accumulation of chyle in the chest or flow from penetrating wounds may be seen after a variety of trau-matic and medical conditions.184The main function of the duct is to transport fat absorbed from the digestive system along with variable amounts of protein and lymphatic material (Table 19-39). Given the high volume of chyle that flows through the thoracic duct, signifi-cant injuries can cause leaks in excess of 2 L per day; if left untreated, protein, lymphocyte, and volume depletion can lead to serious metabolic effects and death. Thoracentesis is | Surgery_Schwartz. superiorly, staying near the esophagus and mediastinal pleura as it exits the thoracic inlet. As it exits the thoracic inlet, it passes to the left, just behind the carotid sheath and anterior to the inferior thyroid and vertebral bodies. Just medial to the anterior scalene muscle, it courses inferiorly and drains into the union of the internal jugular and subclavian veins. Given the extreme variability in the main duct and its branches, accumulation of chyle in the chest or flow from penetrating wounds may be seen after a variety of trau-matic and medical conditions.184The main function of the duct is to transport fat absorbed from the digestive system along with variable amounts of protein and lymphatic material (Table 19-39). Given the high volume of chyle that flows through the thoracic duct, signifi-cant injuries can cause leaks in excess of 2 L per day; if left untreated, protein, lymphocyte, and volume depletion can lead to serious metabolic effects and death. Thoracentesis is |
Surgery_Schwartz_4979 | Surgery_Schwartz | duct, signifi-cant injuries can cause leaks in excess of 2 L per day; if left untreated, protein, lymphocyte, and volume depletion can lead to serious metabolic effects and death. Thoracentesis is usually grossly suggestive, revealing milky, nonpurulent pleural fluid. However, if the patient is taking nothing by mouth, the pleural fluid may not be grossly abnormal. Laboratory analysis of the pleural fluid shows the presence of chylomicrons, a high lym-phocyte count and high triglyceride levels. If the triglyceride level is greater than 110 mg/100 mL, a chylothorax is almost certainly present (a 99% accuracy rate). If the triglyceride level is less than 50 mg/mL, there is only a 5% chance of chylothorax. In many clinical situations, the accumulation of chyle may be slow because of minimal digestive fat flowing through the gas-trointestinal tract after major trauma or surgery, so the diagnosis may be more difficult to establish.Management. The treatment plan for any chylothorax depends | Surgery_Schwartz. duct, signifi-cant injuries can cause leaks in excess of 2 L per day; if left untreated, protein, lymphocyte, and volume depletion can lead to serious metabolic effects and death. Thoracentesis is usually grossly suggestive, revealing milky, nonpurulent pleural fluid. However, if the patient is taking nothing by mouth, the pleural fluid may not be grossly abnormal. Laboratory analysis of the pleural fluid shows the presence of chylomicrons, a high lym-phocyte count and high triglyceride levels. If the triglyceride level is greater than 110 mg/100 mL, a chylothorax is almost certainly present (a 99% accuracy rate). If the triglyceride level is less than 50 mg/mL, there is only a 5% chance of chylothorax. In many clinical situations, the accumulation of chyle may be slow because of minimal digestive fat flowing through the gas-trointestinal tract after major trauma or surgery, so the diagnosis may be more difficult to establish.Management. The treatment plan for any chylothorax depends |
Surgery_Schwartz_4980 | Surgery_Schwartz | digestive fat flowing through the gas-trointestinal tract after major trauma or surgery, so the diagnosis may be more difficult to establish.Management. The treatment plan for any chylothorax depends on its cause, the amount of drainage, and the patient’s clinical status (Fig. 19-53). In general, most patients are treated with a short period of chest tube drainage, nothing by mouth (NPO) orders, total parenteral nutrition (TPN), and observation. In cen-ters with interventional radiology expertise, thoracic duct embo-lization as soon as possible after diagnosis should be considered. Thoracic d.Cisterna chyliFigure 19-52. Normal thoracic duct anatomy. The esophagus comes into close proximity with the thoracic duct as it enters the chest from its origin in the abdomen at the cisterna chyli.Table 19-39Composition of chyleCOMPONENTAMOUNT (PER 100 ML)Total fat0.4–5 g Total cholesterol65–220 mgTotal protein2.21–5.9 g Albumin1.1–4.1 g Globulin1.1–3.1 g Fibrinogen16–24 gSugars48–200 | Surgery_Schwartz. digestive fat flowing through the gas-trointestinal tract after major trauma or surgery, so the diagnosis may be more difficult to establish.Management. The treatment plan for any chylothorax depends on its cause, the amount of drainage, and the patient’s clinical status (Fig. 19-53). In general, most patients are treated with a short period of chest tube drainage, nothing by mouth (NPO) orders, total parenteral nutrition (TPN), and observation. In cen-ters with interventional radiology expertise, thoracic duct embo-lization as soon as possible after diagnosis should be considered. Thoracic d.Cisterna chyliFigure 19-52. Normal thoracic duct anatomy. The esophagus comes into close proximity with the thoracic duct as it enters the chest from its origin in the abdomen at the cisterna chyli.Table 19-39Composition of chyleCOMPONENTAMOUNT (PER 100 ML)Total fat0.4–5 g Total cholesterol65–220 mgTotal protein2.21–5.9 g Albumin1.1–4.1 g Globulin1.1–3.1 g Fibrinogen16–24 gSugars48–200 |
Surgery_Schwartz_4981 | Surgery_Schwartz | chyli.Table 19-39Composition of chyleCOMPONENTAMOUNT (PER 100 ML)Total fat0.4–5 g Total cholesterol65–220 mgTotal protein2.21–5.9 g Albumin1.1–4.1 g Globulin1.1–3.1 g Fibrinogen16–24 gSugars48–200 gElectrolytesSimilar to levels in plasmaCellular elements Lymphocytes400–6800/mm3 Erythrocytes50–600/mm3Antithrombin globulin>25% of plasma concentrationProthrombin>25% of plasma concentrationFibrinogen>25% of plasma concentrationReproduced with permission from Miller JI: Diagnosis and management of chylothorax, Chest Surg Clin N Am. 1996 Feb;6(1):139-148.Brunicardi_Ch19_p0661-p0750.indd 74201/03/19 7:02 PM | Surgery_Schwartz. chyli.Table 19-39Composition of chyleCOMPONENTAMOUNT (PER 100 ML)Total fat0.4–5 g Total cholesterol65–220 mgTotal protein2.21–5.9 g Albumin1.1–4.1 g Globulin1.1–3.1 g Fibrinogen16–24 gSugars48–200 gElectrolytesSimilar to levels in plasmaCellular elements Lymphocytes400–6800/mm3 Erythrocytes50–600/mm3Antithrombin globulin>25% of plasma concentrationProthrombin>25% of plasma concentrationFibrinogen>25% of plasma concentrationReproduced with permission from Miller JI: Diagnosis and management of chylothorax, Chest Surg Clin N Am. 1996 Feb;6(1):139-148.Brunicardi_Ch19_p0661-p0750.indd 74201/03/19 7:02 PM |
Surgery_Schwartz_4982 | Surgery_Schwartz | CHAPTER 19743CHEST WALL, LUNG, MEDIASTINUM, AND PLEURARadiationtherapyMedicallyunstablePleuralperitonealshuntDrainagepersists(Nonmalignant)Drainage persists(>500 mL/d)MalignantchylothoraxThoracentesisConfirm diagnosisMedicallystableThoracotomyChest tubeConservative management NPOChest tube to suctionCentral hyperalimentationWait 2 weeks*Drainage decrease(<250 mL/d)Continue1 weekThoracotomyDuct ligationMass ligationDecorticationPleurectomyDrainagestopsRemovechest tube Figure 19-53. Algorithm for the management of chylothorax. *If high output persists (>50 mL/d), early surgical ligation of the thoracic duct may be considered. NPO = nothing by mouth.Chest cavity drainage must be adequate to allow complete lung reexpansion. Somatostatin has been advocated by some authors, with variable results. If significant chyle drainage (>500 mL per day in an adult, >100 mL in an infant) continues despite TPN and good lung expansion, early surgical duct ligation or embo-lization is recommended (within | Surgery_Schwartz. CHAPTER 19743CHEST WALL, LUNG, MEDIASTINUM, AND PLEURARadiationtherapyMedicallyunstablePleuralperitonealshuntDrainagepersists(Nonmalignant)Drainage persists(>500 mL/d)MalignantchylothoraxThoracentesisConfirm diagnosisMedicallystableThoracotomyChest tubeConservative management NPOChest tube to suctionCentral hyperalimentationWait 2 weeks*Drainage decrease(<250 mL/d)Continue1 weekThoracotomyDuct ligationMass ligationDecorticationPleurectomyDrainagestopsRemovechest tube Figure 19-53. Algorithm for the management of chylothorax. *If high output persists (>50 mL/d), early surgical ligation of the thoracic duct may be considered. NPO = nothing by mouth.Chest cavity drainage must be adequate to allow complete lung reexpansion. Somatostatin has been advocated by some authors, with variable results. If significant chyle drainage (>500 mL per day in an adult, >100 mL in an infant) continues despite TPN and good lung expansion, early surgical duct ligation or embo-lization is recommended (within |
Surgery_Schwartz_4983 | Surgery_Schwartz | If significant chyle drainage (>500 mL per day in an adult, >100 mL in an infant) continues despite TPN and good lung expansion, early surgical duct ligation or embo-lization is recommended (within 4–7 days following diagnosis). Ligation can be approached best by right thoracotomy, and in some experienced centers, by right thoracoscopy. Chylothoraces due to malignant conditions often respond to radiation and/or chemotherapy and less commonly require surgical ligation. Significant nutritional and immunologic depletion results from untreated chylothorax; associated mortality is in excess of 50%. With early recognition and aggressive medical management as well as early surgical ligation or embolization for persistent leaks, the mortality rate of chylothorax is now less than 10%.Tumors of the PleuraMalignant mesothelioma is the most common type of primary tumor of the pleura, with approximately 3000 cases per year in the United States. Other, less common tumors include benign and | Surgery_Schwartz. If significant chyle drainage (>500 mL per day in an adult, >100 mL in an infant) continues despite TPN and good lung expansion, early surgical duct ligation or embo-lization is recommended (within 4–7 days following diagnosis). Ligation can be approached best by right thoracotomy, and in some experienced centers, by right thoracoscopy. Chylothoraces due to malignant conditions often respond to radiation and/or chemotherapy and less commonly require surgical ligation. Significant nutritional and immunologic depletion results from untreated chylothorax; associated mortality is in excess of 50%. With early recognition and aggressive medical management as well as early surgical ligation or embolization for persistent leaks, the mortality rate of chylothorax is now less than 10%.Tumors of the PleuraMalignant mesothelioma is the most common type of primary tumor of the pleura, with approximately 3000 cases per year in the United States. Other, less common tumors include benign and |
Surgery_Schwartz_4984 | Surgery_Schwartz | of the PleuraMalignant mesothelioma is the most common type of primary tumor of the pleura, with approximately 3000 cases per year in the United States. Other, less common tumors include benign and malignant fibrous tumors of the pleura, lipomas, and cysts.Malignant Mesothelioma. The only known risk factor for mesothelioma is exposure to asbestos, identified in over 50% of cases. Exposure is typically work-related in industries using asbestos in the manufacturing process, such as shipbuilding and brake pad linings. The risk extends to family members who are Brunicardi_Ch19_p0661-p0750.indd 74301/03/19 7:02 PM 744SPECIFIC CONSIDERATIONSPART IIexposed to the dust of the clothing or to the work environment. Asbestos exposure and smoking synergistically increase the risk for lung cancer, but smoking does not increase risk for malig-nant mesotheliomas. Male predominance is 2:1, and it occurs most commonly after the age of 40.Risk of developing mesothelioma after asbestos exposure | Surgery_Schwartz. of the PleuraMalignant mesothelioma is the most common type of primary tumor of the pleura, with approximately 3000 cases per year in the United States. Other, less common tumors include benign and malignant fibrous tumors of the pleura, lipomas, and cysts.Malignant Mesothelioma. The only known risk factor for mesothelioma is exposure to asbestos, identified in over 50% of cases. Exposure is typically work-related in industries using asbestos in the manufacturing process, such as shipbuilding and brake pad linings. The risk extends to family members who are Brunicardi_Ch19_p0661-p0750.indd 74301/03/19 7:02 PM 744SPECIFIC CONSIDERATIONSPART IIexposed to the dust of the clothing or to the work environment. Asbestos exposure and smoking synergistically increase the risk for lung cancer, but smoking does not increase risk for malig-nant mesotheliomas. Male predominance is 2:1, and it occurs most commonly after the age of 40.Risk of developing mesothelioma after asbestos exposure |
Surgery_Schwartz_4985 | Surgery_Schwartz | but smoking does not increase risk for malig-nant mesotheliomas. Male predominance is 2:1, and it occurs most commonly after the age of 40.Risk of developing mesothelioma after asbestos exposure differs depending on the physical characteristics of the asbestos and similar fibers (either serpentine or amphibole). The serpen-tine fibers are large and curly and are generally not able to travel beyond larger airways. However, the narrow, straight amphibole fibers, in particular the crocidolite fibers, may navigate distally into the pulmonary parenchyma and are most clearly associated with mesotheliomas. Like many carcinogens, the latency period between asbestos exposure and the development of mesothe-lioma is at least 20 years. The tumor generally is multicentric, with multiple pleural-based nodules coalescing to form sheets of tumor. This process initially involves the parietal pleura, gener-ally with early spread to the visceral surfaces and with a variable degree of invasion of | Surgery_Schwartz. but smoking does not increase risk for malig-nant mesotheliomas. Male predominance is 2:1, and it occurs most commonly after the age of 40.Risk of developing mesothelioma after asbestos exposure differs depending on the physical characteristics of the asbestos and similar fibers (either serpentine or amphibole). The serpen-tine fibers are large and curly and are generally not able to travel beyond larger airways. However, the narrow, straight amphibole fibers, in particular the crocidolite fibers, may navigate distally into the pulmonary parenchyma and are most clearly associated with mesotheliomas. Like many carcinogens, the latency period between asbestos exposure and the development of mesothe-lioma is at least 20 years. The tumor generally is multicentric, with multiple pleural-based nodules coalescing to form sheets of tumor. This process initially involves the parietal pleura, gener-ally with early spread to the visceral surfaces and with a variable degree of invasion of |
Surgery_Schwartz_4986 | Surgery_Schwartz | nodules coalescing to form sheets of tumor. This process initially involves the parietal pleura, gener-ally with early spread to the visceral surfaces and with a variable degree of invasion of surrounding structures. Autopsy studies have shown that most patients have distant metastases, but the natural history of the disease in untreated patients culminates in death due to local extension and effective strangulation of the lung.Clinical Presentation Most patients present with dyspnea and chest pain. Over 90% have a pleural effusion, but thora-centesis is diagnostic in less than 10% of patients. Frequently, a thoracoscopy or open pleural biopsy with special stains is required to differentiate mesotheliomas from adenocarcinomas (Table 19-40). Epithelial subtypes are associated with a more favorable prognosis, and long-term survival may be seen in rare patients with no treatment. Sarcomatous and mixed tumors share a more aggressive course.Management The treatment of malignant | Surgery_Schwartz. nodules coalescing to form sheets of tumor. This process initially involves the parietal pleura, gener-ally with early spread to the visceral surfaces and with a variable degree of invasion of surrounding structures. Autopsy studies have shown that most patients have distant metastases, but the natural history of the disease in untreated patients culminates in death due to local extension and effective strangulation of the lung.Clinical Presentation Most patients present with dyspnea and chest pain. Over 90% have a pleural effusion, but thora-centesis is diagnostic in less than 10% of patients. Frequently, a thoracoscopy or open pleural biopsy with special stains is required to differentiate mesotheliomas from adenocarcinomas (Table 19-40). Epithelial subtypes are associated with a more favorable prognosis, and long-term survival may be seen in rare patients with no treatment. Sarcomatous and mixed tumors share a more aggressive course.Management The treatment of malignant |
Surgery_Schwartz_4987 | Surgery_Schwartz | a more favorable prognosis, and long-term survival may be seen in rare patients with no treatment. Sarcomatous and mixed tumors share a more aggressive course.Management The treatment of malignant mesotheliomas remains controversial. Treatment options include supportive care only, surgical resection, and multimodality approaches (using a combination of surgery, chemotherapy, and radia-tion therapy).186 Surgical approaches range from extrapleural pneumonectomy (removal of the lung, entire parietal pleural, ipsilateral pericardium, and hemidiaphragm with patch recon-struction), pleurectomy and decortication (removal of the vis-ceral and parietal pleura only), and palliative procedures such as talc pleurodesis and insertion of long-term tunneled indwelling pleural catheters.Table 19-40Differentiation of mesothelioma from adenocarcinoma MESOTHELIOMAADENOCARCINOMAImmunohistochemical results Carcinoembryonic antigenNegativePositive VimentinPositiveNegative Low molecular weight | Surgery_Schwartz. a more favorable prognosis, and long-term survival may be seen in rare patients with no treatment. Sarcomatous and mixed tumors share a more aggressive course.Management The treatment of malignant mesotheliomas remains controversial. Treatment options include supportive care only, surgical resection, and multimodality approaches (using a combination of surgery, chemotherapy, and radia-tion therapy).186 Surgical approaches range from extrapleural pneumonectomy (removal of the lung, entire parietal pleural, ipsilateral pericardium, and hemidiaphragm with patch recon-struction), pleurectomy and decortication (removal of the vis-ceral and parietal pleura only), and palliative procedures such as talc pleurodesis and insertion of long-term tunneled indwelling pleural catheters.Table 19-40Differentiation of mesothelioma from adenocarcinoma MESOTHELIOMAADENOCARCINOMAImmunohistochemical results Carcinoembryonic antigenNegativePositive VimentinPositiveNegative Low molecular weight |
Surgery_Schwartz_4988 | Surgery_Schwartz | 19-40Differentiation of mesothelioma from adenocarcinoma MESOTHELIOMAADENOCARCINOMAImmunohistochemical results Carcinoembryonic antigenNegativePositive VimentinPositiveNegative Low molecular weight cytokeratinsPositiveNegativeElectron microscopic featuresLong, sinuous villiShort, straight villi with fuzzy glycocalyxFibrous Tumors of the Pleura. Fibrous tumors of the pleura are unrelated to asbestos exposure or malignant mesotheliomas. They generally occur as a single pedunculated mass arising from the visceral pleura but can occasionally arise from the parietal pleura. They can grow to be quite large, with most ranging from 5 to 10 cm and 100 to 400 g in size by the time they are dis-covered. Architecturally, the most common microscopic feature is the “patternless pattern.” This is characterized by randomly situated areas of hypercellularity, containing spindle cells with bland, vesicular, ovoidal nuclei and scarce cytoplasm, and hypo-cellularity, with fibrous connective tissue, | Surgery_Schwartz. 19-40Differentiation of mesothelioma from adenocarcinoma MESOTHELIOMAADENOCARCINOMAImmunohistochemical results Carcinoembryonic antigenNegativePositive VimentinPositiveNegative Low molecular weight cytokeratinsPositiveNegativeElectron microscopic featuresLong, sinuous villiShort, straight villi with fuzzy glycocalyxFibrous Tumors of the Pleura. Fibrous tumors of the pleura are unrelated to asbestos exposure or malignant mesotheliomas. They generally occur as a single pedunculated mass arising from the visceral pleura but can occasionally arise from the parietal pleura. They can grow to be quite large, with most ranging from 5 to 10 cm and 100 to 400 g in size by the time they are dis-covered. Architecturally, the most common microscopic feature is the “patternless pattern.” This is characterized by randomly situated areas of hypercellularity, containing spindle cells with bland, vesicular, ovoidal nuclei and scarce cytoplasm, and hypo-cellularity, with fibrous connective tissue, |
Surgery_Schwartz_4989 | Surgery_Schwartz | by randomly situated areas of hypercellularity, containing spindle cells with bland, vesicular, ovoidal nuclei and scarce cytoplasm, and hypo-cellularity, with fibrous connective tissue, hemorrhage, myxoid, or necrosis. They can also have an hemangiopericytoma-like appearance. The neoplastic cells are immunoreactive for CD34 and CD99 but negative for cytokeratins and desmin. Immuno-reactivity for Bcl-2 is variably positive.187They are frequently discovered incidentally on routine CXRs, without an associated pleural effusion. They occur with equal frequency in males and females and are most common in the sixth to seventh decade of life. Fibrous tumors of the pleura may be benign or malignant.188 Symptoms such as cough, chest pain, and dyspnea occur in 30% to 40% of patients but are found in 75% of patients with malignant tumors. Malignant tumors are differentiated from benign tumors based on high cellularity, more than four mitotic figures per 10 high-power fields, nuclear | Surgery_Schwartz. by randomly situated areas of hypercellularity, containing spindle cells with bland, vesicular, ovoidal nuclei and scarce cytoplasm, and hypo-cellularity, with fibrous connective tissue, hemorrhage, myxoid, or necrosis. They can also have an hemangiopericytoma-like appearance. The neoplastic cells are immunoreactive for CD34 and CD99 but negative for cytokeratins and desmin. Immuno-reactivity for Bcl-2 is variably positive.187They are frequently discovered incidentally on routine CXRs, without an associated pleural effusion. They occur with equal frequency in males and females and are most common in the sixth to seventh decade of life. Fibrous tumors of the pleura may be benign or malignant.188 Symptoms such as cough, chest pain, and dyspnea occur in 30% to 40% of patients but are found in 75% of patients with malignant tumors. Malignant tumors are differentiated from benign tumors based on high cellularity, more than four mitotic figures per 10 high-power fields, nuclear |
Surgery_Schwartz_4990 | Surgery_Schwartz | are found in 75% of patients with malignant tumors. Malignant tumors are differentiated from benign tumors based on high cellularity, more than four mitotic figures per 10 high-power fields, nuclear pleomorphism, tumor necrosis, and hemorrhage. They are more likely to arise from the parietal pleura of the chest wall, dia-phragm, or mediastinum, or in the fissures or invaginating into the lung parenchyma. Hypoglycemia, associated pleural effu-sion, and hypertrophic pulmonary osteoarthropathy (clubbed digits, long bone ossifying periostitis, and arthritis) are associ-ated with these lesions in approximately 25% of patients. Less common are fever and hemoptysis.Symptoms resolve with surgical resection. Given the well-circumscribed and often pedunculated nature of fibrous tumors of the pleura, all benign lesions and approximately 50% of malignant lesions are cured by complete surgical resection.188 Incompletely resected malignant tumors may recur locally or metastasize, and more than 50% | Surgery_Schwartz. are found in 75% of patients with malignant tumors. Malignant tumors are differentiated from benign tumors based on high cellularity, more than four mitotic figures per 10 high-power fields, nuclear pleomorphism, tumor necrosis, and hemorrhage. They are more likely to arise from the parietal pleura of the chest wall, dia-phragm, or mediastinum, or in the fissures or invaginating into the lung parenchyma. Hypoglycemia, associated pleural effu-sion, and hypertrophic pulmonary osteoarthropathy (clubbed digits, long bone ossifying periostitis, and arthritis) are associ-ated with these lesions in approximately 25% of patients. Less common are fever and hemoptysis.Symptoms resolve with surgical resection. Given the well-circumscribed and often pedunculated nature of fibrous tumors of the pleura, all benign lesions and approximately 50% of malignant lesions are cured by complete surgical resection.188 Incompletely resected malignant tumors may recur locally or metastasize, and more than 50% |
Surgery_Schwartz_4991 | Surgery_Schwartz | all benign lesions and approximately 50% of malignant lesions are cured by complete surgical resection.188 Incompletely resected malignant tumors may recur locally or metastasize, and more than 50% of patients with malignant tumors will die from the disease; frequently, they are fatal within 2 to 5 years.REFERENCESEntries highlighted in bright blue are key references. 1. Cusimano RJ, Pearson FG. Anatomy, physiology, and embry-ology of the upper airway. In: Pearson FG, Cooper JD, Deslauriers J, et al, eds. Thoracic Surgery. 2nd ed. New York: Churchill Livingstone; 2002:215. 2. Grillo HC. Surgical treatment of postintubation tracheal inju-ries. J Thorac Cardiovasc Surg. 1979;78(6):860-875. 3. Nouraei SA, Ma E, Patel A, et al. Estimating the population incidence of adult post-intubation laryngotracheal stenosis. Clin Otolaryngol. 2007;32(5):411-412. 4. Couraud L, Ballester MJ, Delaisement C. Acquired tracheo-esophageal fistula and its management. Semin Thorac Cardio-vasc Surg. | Surgery_Schwartz. all benign lesions and approximately 50% of malignant lesions are cured by complete surgical resection.188 Incompletely resected malignant tumors may recur locally or metastasize, and more than 50% of patients with malignant tumors will die from the disease; frequently, they are fatal within 2 to 5 years.REFERENCESEntries highlighted in bright blue are key references. 1. Cusimano RJ, Pearson FG. Anatomy, physiology, and embry-ology of the upper airway. In: Pearson FG, Cooper JD, Deslauriers J, et al, eds. Thoracic Surgery. 2nd ed. New York: Churchill Livingstone; 2002:215. 2. Grillo HC. Surgical treatment of postintubation tracheal inju-ries. J Thorac Cardiovasc Surg. 1979;78(6):860-875. 3. Nouraei SA, Ma E, Patel A, et al. Estimating the population incidence of adult post-intubation laryngotracheal stenosis. Clin Otolaryngol. 2007;32(5):411-412. 4. Couraud L, Ballester MJ, Delaisement C. Acquired tracheo-esophageal fistula and its management. Semin Thorac Cardio-vasc Surg. |
Surgery_Schwartz_4992 | Surgery_Schwartz | laryngotracheal stenosis. Clin Otolaryngol. 2007;32(5):411-412. 4. Couraud L, Ballester MJ, Delaisement C. Acquired tracheo-esophageal fistula and its management. Semin Thorac Cardio-vasc Surg. 1996;8(4):392-399. 5. Mathisen DJ, Grillo HC, Wain JC, Hilgenberg AD. Manage-ment of acquired nonmalignant tracheoesophageal fistula. Ann Thorac Surg. 1991;52(4):759-765. 6. Bhattacharyya N. Contemporary staging and prognosis for primary tracheal malignancies: a population-based analysis. Otolaryngol Head Neck Surg. 2004;131:639-642.Brunicardi_Ch19_p0661-p0750.indd 74401/03/19 7:02 PM | Surgery_Schwartz. laryngotracheal stenosis. Clin Otolaryngol. 2007;32(5):411-412. 4. Couraud L, Ballester MJ, Delaisement C. Acquired tracheo-esophageal fistula and its management. Semin Thorac Cardio-vasc Surg. 1996;8(4):392-399. 5. Mathisen DJ, Grillo HC, Wain JC, Hilgenberg AD. Manage-ment of acquired nonmalignant tracheoesophageal fistula. Ann Thorac Surg. 1991;52(4):759-765. 6. Bhattacharyya N. Contemporary staging and prognosis for primary tracheal malignancies: a population-based analysis. Otolaryngol Head Neck Surg. 2004;131:639-642.Brunicardi_Ch19_p0661-p0750.indd 74401/03/19 7:02 PM |
Surgery_Schwartz_4993 | Surgery_Schwartz | CHAPTER 19745CHEST WALL, LUNG, MEDIASTINUM, AND PLEURA 7. Gaissert HA, Grillo HC, Shadmehr MB, et al. Uncommon primary tracheal tumors. Ann Thorac Surg. 2006;82(1): 268-272. 8. Regnard JF, Fourquier P, Levasseur P. Results and prognostic factors in resections of primary tracheal tumors: a multicenter retrospective study. The French Society of Cardiovascular Surgery. J Thorac Cardiovasc Surg. 1996;111:808-813; discussion 813. 9. Chow DC, Komaki R, Libshitz HI, Mountain CF, Ellerbroek N. Treatment of primary neoplasms of the trachea. The role of radiation therapy. Cancer. 1993;71(10):2946-2952. 10. Rice TW. Anatomy of the lung. In: Pearson FG, Cooper JD, Deslauriers J, et al, eds. Thoracic Surgery. 2nd ed. New York: Churchill Livingstone; 2002:427. 11. Jeremy George P, Banerjee AK, Rea CA, et al. Surveillance for the detection of early lung cancer in patients with bronchial dysplasia. Thorax. 2007;62(1):43-50. 12. Wang GF, Lai MD, Yang RR, et al. Histological types and significance | Surgery_Schwartz. CHAPTER 19745CHEST WALL, LUNG, MEDIASTINUM, AND PLEURA 7. Gaissert HA, Grillo HC, Shadmehr MB, et al. Uncommon primary tracheal tumors. Ann Thorac Surg. 2006;82(1): 268-272. 8. Regnard JF, Fourquier P, Levasseur P. Results and prognostic factors in resections of primary tracheal tumors: a multicenter retrospective study. The French Society of Cardiovascular Surgery. J Thorac Cardiovasc Surg. 1996;111:808-813; discussion 813. 9. Chow DC, Komaki R, Libshitz HI, Mountain CF, Ellerbroek N. Treatment of primary neoplasms of the trachea. The role of radiation therapy. Cancer. 1993;71(10):2946-2952. 10. Rice TW. Anatomy of the lung. In: Pearson FG, Cooper JD, Deslauriers J, et al, eds. Thoracic Surgery. 2nd ed. New York: Churchill Livingstone; 2002:427. 11. Jeremy George P, Banerjee AK, Rea CA, et al. Surveillance for the detection of early lung cancer in patients with bronchial dysplasia. Thorax. 2007;62(1):43-50. 12. Wang GF, Lai MD, Yang RR, et al. Histological types and significance |
Surgery_Schwartz_4994 | Surgery_Schwartz | CA, et al. Surveillance for the detection of early lung cancer in patients with bronchial dysplasia. Thorax. 2007;62(1):43-50. 12. Wang GF, Lai MD, Yang RR, et al. Histological types and significance of bronchial epithelial dysplasia. Mod Pathol. 2006;19:429-437. 13. Gould VE, Warren WH. Epithelial tumors of the lung. Chest Surg Clin N Am. 2000;10(4):709-728. 14. Fu JB, Kau TY, Severson RK, Kalemkerian GP. Lung cancer in women: analysis of the national Surveillance, Epidemiology, and End Results database. Chest. 2005;127(3):768-777. 15. Travis WD, Brambilla E, Noguchi M, et al. International Association for the Study of Lung Cancer/American Tho-racic Society/European Respiratory Society international multidisciplinary classification of lung adenocarcinoma. J Thorac Oncol. 2011;6(2):244-285. 16. Schmidt L, Myers J. Bronchioloalveolar carcinoma and the significance of invasion: predicting biologic behavior. Arch Pathol Lab Med. 2010;134:1450-1454. 17. Cerilli LA, Ritter JH, Mills SE, | Surgery_Schwartz. CA, et al. Surveillance for the detection of early lung cancer in patients with bronchial dysplasia. Thorax. 2007;62(1):43-50. 12. Wang GF, Lai MD, Yang RR, et al. Histological types and significance of bronchial epithelial dysplasia. Mod Pathol. 2006;19:429-437. 13. Gould VE, Warren WH. Epithelial tumors of the lung. Chest Surg Clin N Am. 2000;10(4):709-728. 14. Fu JB, Kau TY, Severson RK, Kalemkerian GP. Lung cancer in women: analysis of the national Surveillance, Epidemiology, and End Results database. Chest. 2005;127(3):768-777. 15. Travis WD, Brambilla E, Noguchi M, et al. International Association for the Study of Lung Cancer/American Tho-racic Society/European Respiratory Society international multidisciplinary classification of lung adenocarcinoma. J Thorac Oncol. 2011;6(2):244-285. 16. Schmidt L, Myers J. Bronchioloalveolar carcinoma and the significance of invasion: predicting biologic behavior. Arch Pathol Lab Med. 2010;134:1450-1454. 17. Cerilli LA, Ritter JH, Mills SE, |
Surgery_Schwartz_4995 | Surgery_Schwartz | L, Myers J. Bronchioloalveolar carcinoma and the significance of invasion: predicting biologic behavior. Arch Pathol Lab Med. 2010;134:1450-1454. 17. Cerilli LA, Ritter JH, Mills SE, Wick MR. Neuro-endocrine neoplasms of the lung. Am J Clin Pathol. 2001;116(suppl):S65-S96. 18. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2017. CA Cancer J Clin. 2017;67:7-30. 19. Mulligan CR, Meram AD, Proctor CD, Wu H, Zhu K, Marrogi AJ. Unlimited access to care: effect on racial disparity and prog-nostic factors in lung cancer. Cancer Epidemiol Biomarkers Prev. 2006;15(1):25-31. 20. Samet JM. Health benefits of smoking cessation. Clin Chest Med. 1991;12(4):669-679. 21. Sun S, Schiller JH, Gazdar AF. Lung cancer in never smokers—a different disease. Nat Rev Cancer. 2007;7(10):778-790. 22. Hackshaw AK, Law MR, Wald NJ. The accumulated evidence on lung cancer and environmental tobacco smoke. BMJ. 1997;315(7114):980-988. 23. Aberle DR, Adams AM, Berg CD, et al. Reduced lung-cancer mortality with | Surgery_Schwartz. L, Myers J. Bronchioloalveolar carcinoma and the significance of invasion: predicting biologic behavior. Arch Pathol Lab Med. 2010;134:1450-1454. 17. Cerilli LA, Ritter JH, Mills SE, Wick MR. Neuro-endocrine neoplasms of the lung. Am J Clin Pathol. 2001;116(suppl):S65-S96. 18. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2017. CA Cancer J Clin. 2017;67:7-30. 19. Mulligan CR, Meram AD, Proctor CD, Wu H, Zhu K, Marrogi AJ. Unlimited access to care: effect on racial disparity and prog-nostic factors in lung cancer. Cancer Epidemiol Biomarkers Prev. 2006;15(1):25-31. 20. Samet JM. Health benefits of smoking cessation. Clin Chest Med. 1991;12(4):669-679. 21. Sun S, Schiller JH, Gazdar AF. Lung cancer in never smokers—a different disease. Nat Rev Cancer. 2007;7(10):778-790. 22. Hackshaw AK, Law MR, Wald NJ. The accumulated evidence on lung cancer and environmental tobacco smoke. BMJ. 1997;315(7114):980-988. 23. Aberle DR, Adams AM, Berg CD, et al. Reduced lung-cancer mortality with |
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Surgery_Schwartz_4997 | Surgery_Schwartz | DP. Helical computed tomography of the thorax: clinical applications. Radiol Clin North Am. 1994;32(4): 759-774. 28. Stroobants S, Verschakelen J, Vansteenkiste J. Value of FDG-PET in the management of non-small cell lung cancer. Eur J Radiol. 2003;45(1):49-59. 29. Cahan WG, Shah JP, Castro EB. Benign solitary lung lesions in patients with cancer. Ann Surg. 1978;187(3):241-244. 30. Davidson RS, Nwogu CE, Brentjens MJ, Anderson TM. The surgical management of pulmonary metastasis: current con-cepts. Surg Oncol. 2001;10(1-2):35-42. 31. Pastorino U, Buyse M, Friedel G, et al. Long-term results of lung metastasectomy: prognostic analyses based on 5206 cases. J Thorac Cardiovasc Surg. 1997;113(1):37-49. 32. McCormack PM, Bains MS, Begg CB, et al. Role of vid-eoassisted thoracic surgery in the treatment of pulmonary metastases: results of a prospective trial. Ann Thorac Surg. 1996;62(1):213-216; discussion 216-217. 33. Rivera MP, Mehta AC; American College of Chest Physi-cians. Initial | Surgery_Schwartz. DP. Helical computed tomography of the thorax: clinical applications. Radiol Clin North Am. 1994;32(4): 759-774. 28. Stroobants S, Verschakelen J, Vansteenkiste J. Value of FDG-PET in the management of non-small cell lung cancer. Eur J Radiol. 2003;45(1):49-59. 29. Cahan WG, Shah JP, Castro EB. Benign solitary lung lesions in patients with cancer. Ann Surg. 1978;187(3):241-244. 30. Davidson RS, Nwogu CE, Brentjens MJ, Anderson TM. The surgical management of pulmonary metastasis: current con-cepts. Surg Oncol. 2001;10(1-2):35-42. 31. Pastorino U, Buyse M, Friedel G, et al. Long-term results of lung metastasectomy: prognostic analyses based on 5206 cases. J Thorac Cardiovasc Surg. 1997;113(1):37-49. 32. McCormack PM, Bains MS, Begg CB, et al. Role of vid-eoassisted thoracic surgery in the treatment of pulmonary metastases: results of a prospective trial. Ann Thorac Surg. 1996;62(1):213-216; discussion 216-217. 33. Rivera MP, Mehta AC; American College of Chest Physi-cians. Initial |
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Surgery_Schwartz_4999 | Surgery_Schwartz | PET/CT in non small cell lung cancer staging: clinical and pathological agreement. Rev Port Pneu-mol. 2012;18(3):109-114. 38. Iskender I, Kapicibasi HO. Comparison of integrated positron emission tomography/computed tomography and mediastinos-copy in mediastinal staging of non-small cell lung cancer:analysis of 212 patients. Acta Chir Belg. 2012;112:219-225. 39. Li X, Zhang H, Xing L, et al. Mediastinal lymph nodes staging by 18F-FDG PET/CT for early stage non-small cell lung cancer: a multicenter study. Radiother Oncol. 2012;102:246-250. 40. Lv YL, Yuan DM. Diagnostic performance of integrated posi-tron emission tomography/computed tomography for medi-astinal lymph node staging in non-small cell lung cancer: a bivariate systematic review and meta-analysis. J Thorac Oncol. 2011;6(8):1350-1358. 41. Mountain CF, Dresler CM. Regional lymph node classification for lung cancer staging. Chest. 1997;111:1718-1723. 42. Barrera R, Shi W, Amar D, et al. Smoking and timing of ces-sation: impact | Surgery_Schwartz. PET/CT in non small cell lung cancer staging: clinical and pathological agreement. Rev Port Pneu-mol. 2012;18(3):109-114. 38. Iskender I, Kapicibasi HO. Comparison of integrated positron emission tomography/computed tomography and mediastinos-copy in mediastinal staging of non-small cell lung cancer:analysis of 212 patients. Acta Chir Belg. 2012;112:219-225. 39. Li X, Zhang H, Xing L, et al. Mediastinal lymph nodes staging by 18F-FDG PET/CT for early stage non-small cell lung cancer: a multicenter study. Radiother Oncol. 2012;102:246-250. 40. Lv YL, Yuan DM. Diagnostic performance of integrated posi-tron emission tomography/computed tomography for medi-astinal lymph node staging in non-small cell lung cancer: a bivariate systematic review and meta-analysis. J Thorac Oncol. 2011;6(8):1350-1358. 41. Mountain CF, Dresler CM. Regional lymph node classification for lung cancer staging. Chest. 1997;111:1718-1723. 42. Barrera R, Shi W, Amar D, et al. Smoking and timing of ces-sation: impact |
Surgery_Schwartz_5000 | Surgery_Schwartz | CF, Dresler CM. Regional lymph node classification for lung cancer staging. Chest. 1997;111:1718-1723. 42. Barrera R, Shi W, Amar D, et al. Smoking and timing of ces-sation: impact on pulmonary complications after thoracotomy. Chest. 2005;127:1977-1983. 43. Nakagawa M, Tanaka H, Tsukuma H, Kishi Y. Relationship between the duration of the preoperative smoke-free period and the incidence of postoperative pulmonary complications after pulmonary surgery. Chest. 2001;120:705-710. 44. Colice GL, Shafazand S, Griffin JP, Keenan R, Bolliger CT; American College of Chest Physicians. Physiologic evaluation of the patient with lung cancer being con-sidered for resectional surgery: ACCP evidenced-based clinical practice guidelines (2nd ed). Chest. 2007;132(3 suppl):161S-177S. 45. Richards TB, Henley SJ, Puckett MC, et al. Lung cancer sur-vival in the United States by race and stage (2001-2009): Find-ings from the CONCORD-2 study. Cancer. 2017;123(suppl 24): 5079-5099. 46. Raz DJ, Zell JA, Ou | Surgery_Schwartz. CF, Dresler CM. Regional lymph node classification for lung cancer staging. Chest. 1997;111:1718-1723. 42. Barrera R, Shi W, Amar D, et al. Smoking and timing of ces-sation: impact on pulmonary complications after thoracotomy. Chest. 2005;127:1977-1983. 43. Nakagawa M, Tanaka H, Tsukuma H, Kishi Y. Relationship between the duration of the preoperative smoke-free period and the incidence of postoperative pulmonary complications after pulmonary surgery. Chest. 2001;120:705-710. 44. Colice GL, Shafazand S, Griffin JP, Keenan R, Bolliger CT; American College of Chest Physicians. Physiologic evaluation of the patient with lung cancer being con-sidered for resectional surgery: ACCP evidenced-based clinical practice guidelines (2nd ed). Chest. 2007;132(3 suppl):161S-177S. 45. Richards TB, Henley SJ, Puckett MC, et al. Lung cancer sur-vival in the United States by race and stage (2001-2009): Find-ings from the CONCORD-2 study. Cancer. 2017;123(suppl 24): 5079-5099. 46. Raz DJ, Zell JA, Ou |
Surgery_Schwartz_5001 | Surgery_Schwartz | SJ, Puckett MC, et al. Lung cancer sur-vival in the United States by race and stage (2001-2009): Find-ings from the CONCORD-2 study. Cancer. 2017;123(suppl 24): 5079-5099. 46. Raz DJ, Zell JA, Ou SH, Gandara DR, Anton-Culver H, Jablons DM. Natural history of stage I non–small cell lung cancer: implica-tions for early detection. Chest. 2007;132(1):193-199. 47. Ginsberg RJ, Rubinstein LV. Randomized trial of lobec-tomy versus limited resection for T1 N0 non–small cell lung cancer. Lung Cancer Study Group. Ann Thorac Surg. 1995;60(3):615-622. 48. Warren WH, Faber LP. Segmentectomy versus lobectomy in patients with stage I pulmonary carcinoma. Five-year survival Brunicardi_Ch19_p0661-p0750.indd 74501/03/19 7:02 PM 746SPECIFIC CONSIDERATIONSPART IIand patterns of intrathoracic recurrence. J Thorac Cardiovasc Surg. 1994;107(4):1087-1093; discussion 1093-1094. 49. Bedetti B, Bertolaccini L, Rocco R, Schmidt J, Solli P, Scarci M. Segmentectomy versus lobectomy for stage I non-small cell | Surgery_Schwartz. SJ, Puckett MC, et al. Lung cancer sur-vival in the United States by race and stage (2001-2009): Find-ings from the CONCORD-2 study. Cancer. 2017;123(suppl 24): 5079-5099. 46. Raz DJ, Zell JA, Ou SH, Gandara DR, Anton-Culver H, Jablons DM. Natural history of stage I non–small cell lung cancer: implica-tions for early detection. Chest. 2007;132(1):193-199. 47. Ginsberg RJ, Rubinstein LV. Randomized trial of lobec-tomy versus limited resection for T1 N0 non–small cell lung cancer. Lung Cancer Study Group. Ann Thorac Surg. 1995;60(3):615-622. 48. Warren WH, Faber LP. Segmentectomy versus lobectomy in patients with stage I pulmonary carcinoma. Five-year survival Brunicardi_Ch19_p0661-p0750.indd 74501/03/19 7:02 PM 746SPECIFIC CONSIDERATIONSPART IIand patterns of intrathoracic recurrence. J Thorac Cardiovasc Surg. 1994;107(4):1087-1093; discussion 1093-1094. 49. Bedetti B, Bertolaccini L, Rocco R, Schmidt J, Solli P, Scarci M. Segmentectomy versus lobectomy for stage I non-small cell |
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