Transcript Common Thoracic Procedures - Mike Poullis

Common Thoracic Procedures
Cardiothoracic Centre, Liverpool
Fri 23rd January 2004
Edwin Woo
Overview
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Lung Cancer
VATS
Disease of the thorax
Oesophageal surgery
Emergency thoracic procedures
Omission
• Transplantation
• Anterior mediastinal mass
– Thymoma
– Retro-sternal goitre
• Lung volume reduction surgery
Diagnosis
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Sputum cytology
Bronchoscopic biopsy
Needle aspiration biopsy
VATS
Thoracotomy
Diagnosis
Sputum Cytology
• Yield proportional to number of samples
Oswald NC, Thorax 26:623,1971
• Position of tumor
• Cell type
– Best in squamous, least with SCLC
• Agrees with final histology in 85%
Diagnosis
Bronchoscopy
• Flexible vs Rigid
Diagnosis
Bronchoscopy
Diagnosis
Bronchoscopy
• Visual inspection of tumor
• Biopsy of tumor
• Targeted washing & brushing for cytology
• Transbronchial biopsy
Diagnosis
Needle aspiration cytology / cutting
• CT / fluoroscopically
guided
• Trans-bronchial
aspiration cytology
Diagnosis
VATS
• Excision of peripheral
lesion
• Biopsy of nodal station
Diagnosis
Thoracotomy
• Frozen section
– Important in pneumonectomy
Diagnosis
Tissue diagnosis from metastasis
• Cervical lymph node biopsy
• Mediastinal lymph nodes
– Trans bronchial biopsy
– Cervical mediastinoscopy
– Anterior mediastinotomy
• Cytology of pleural effusion
• Pleural biopsy (needle, open & VATS)
Diagnosis
Non Small Cell Carcinoma
– Squamous Cell Carcinoma
– Ademocarcinoma
– Large Cell Undifferentiated Carcinoma
Small Cell Carcinoma
– Oat Cell Carcinoma
– Intermediate Cell Type
– Mixed Cell Type
Staging
• 1966 TNM system adopted by UICC
(International Union Against Cancer)
Denoix PF: Bull Inst Nat Hyg (Paris) 1:70. 1964
• 1986 International staging system adopted
by AJCC (American Joint Committee on Cancer) for NSCLC
Mountain CF: Chest 89:225S-35S. 1986
• 1997 Updated
Mountain CF: Chest 111:1711-7. 1997
Staging
TNM classification
• T
Tumor
TX, T0, TIS, T1 – T4
– Site, size & local extent
• N
Node
N0 – N3
– Presence & location of regional node involvement
• M
Metastases
M0 or M1
– Presence or absence of distal metastasis
Staging
N0
N1
N2
N3
M1
T1
1A
II A
III A
III B
IV
T2
IB
II B
III A
III B
IV
T3
II B
III A
III A
III B
IV
T4
III B
III B
III B
III B
IV
M1
IV
IV
IV
IV
Prognosis
Staging
Small Cell Carcinoma
• Localised
– Disease limited to ipsilateral hemithorax
– TNM system in very localised disease
• Extensive
– Disease spread beyond ipsilateral hemithorax
Prognosis
N0
N1
N2
N3
M1
T1
1A
II A
III A
III B
IV
T2
IB
II B
III A
III B
IV
T3
II B
III A
III A
III B
IV
T4
III B
III B
III B
III B
IV
M1
IV
IV
IV
IV
Prognosis
N0
N1
N2
N3
M1
T1
1A
II A
III A
III B
IV
T2
IB
II B
III A
III B
IV
T3
II B
III A
III A
III B
IV
T4
III B
III B
III B
III B
IV
M1
IV
IV
IV
IV
Prognosis
Palliative resection
Thoracotomy
No surgical intervention
Survival curve of patients with stage III NSCLC
Hara N, J Surg Oncol:25;153. 1984
Operability
• Stage I
– T1N0 and T2N0
• Stage II
– T1N1, T2N1 and T3N0
• Excellent and Reasonable chance of cure by
surgery alone
Operability
• Stage IIIa
– T3N1 and T1N2-T3N2
• NOT Surgery alone
• Consider Adjuvant therapy
Operability
• Stage IIIb and Stage IV
• Inoperable
• Stage IIIb (T4N0 and T4N1)
– ? Role of surgery
Assessment & Staging
Assessment & Staging
Mediastinal Lymphadenopathy
Assessment & Staging
N0
N1
N2
N3
M1
T1
1A
II A
III A
III B
IV
T2
IB
II B
III A
III B
IV
T3
II B
III A
III A
III B
IV
T4
III B
III B
III B
III B
IV
M1
IV
IV
IV
IV
Assessment & Staging
PET (Positron Emission Tomography)
• 18F-fluorodeoxyglucose is used as the tracer molecule.
• Preferential metabolism of glucose in tumor cells.
• When Phosphorylated, it is trapped within the cell.
• Positron releases reacts with an electron, releasing
gamma rays.
• However, uptake by inflammatory processes,
myocardium, and brain
Assessment & Staging
PET (Positron Emission Tomography)
Assessment & Staging
Integrated PET / CT scanner
Assessment & Staging
Mediastinoscopy
Assessment & Staging
Anterior Mediastinotomy
Lung Resection
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Wedge Excision
Segmentectomy
Lobectomy
Bilobectomy
Pneumonectomy
Lung Resection
Lung Resection
Lung Resection
Lung Resection
Video Assisted Thoracoscopic
Surgery
Video Assisted Thoracoscopic
Surgery
Video Assisted Thoracoscopic
Surgery
Video Assisted Thoracoscopic
Surgery
Sympathectomy
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Palmar hyperhidrosis better response
T2 to T3 but T2 to T5 for axillary
20 % compensatory hyerhidrosis
Horner’s syndrome if T1 resected
Sympathectomy
Sympathectomy
Sympathectomy
Empyema
Empyema
Empyema
• Complete drainage of purulent collection
• Obliteration of empyema space
• Investigation and treatment of the cause
Diaphragmatic Rupture
Diaphragmatic Rupture
Diaphragmatic Rupture
Hiatus Hernia
Hiatus Hernia
Oesophagectomy
Oesophagectomy
Oesophagectomy
Oesophagectomy
Oesophagectomy
Emergency Procedures
Emergency Procedures
Emergency Procedures
Emergency Procedures
Emergency thoracotomy
• Penetrating chest trauma
• Recently dead
• Anterior lateral
Emergency Procedures
Emergency Procedures
Emergency Procedures
Emergency Procedures