Cost of a 5-year lung cancer survivor: symptomatic tumour identification vs proactive computed tomography screening.

BACKGROUND: Our objective was to analyse the cost effectiveness of computed tomography (CT) screening for lung cancer in terms of the cost per long-term survivor, which has not been evaluated to date. METHODS: Estimations were computed based on data from the Surveillance, Epidemiology, and End Results registries covering years 1999-2003. The design framework of our model allowed for the incorporation of multiple values taken from the epidemiological and clinical literature to be utilised for cost inputs, scope of patients screened, diagnostic staging, and survival percentages applied separately to two cohorts: age 40-79 and 60-79 years. This enabled the analysis of over 1400 scenarios, each containing a unique set of input values, for which the estimated cost per 5-year survivor (CP5YS) was compared between the symptom-detected and proactive screening approaches. RESULTS: Estimated CP5YS were higher for the symptom-detected approach in all 729 scenarios analysed for the cohort ages 60-79 years, ranging from approximately $5800 to $116,700 increased cost per 5-year survivor (CP5YS). For the cohort ages 40-79 years, 75% of the 729 scenarios analysed showed increased CP5YS for the symptom-detected approach ranging from $5700 to $110,000 increased CP5YS. Total costs and total 5-year survivors were higher for the proactive screening method for all scenarios analysed across both cohorts with increases ranging from 50-256% and 98-309%, respectively. CONCLUSION: The predicted increase in long-term survival with CT screening and the potential for better utilisation of health-care dollars in terms of CP5YS, particularly when screening patients over the age of 60 years, are critically important considerations in directing effective future lung cancer management strategy.

Combined bronchoscopy and esophagoscopy using a flexible fiberoptic bronchoscope.

A method is described for the performance of combined bronchoscopy and esophagoscopy using a simple modification of the standard flexible fiberoptic bronchoscope. This technique allows safe, simple, and effective examination of the esophagus after the completion of bronchoscopy in patients in whom this examination is indicated.

Aortic valve replacement in the presence of sternal metastases from prostatic carcinoma: a case report.

A 65-year-old man was admitted with New York Heart Association Class IV heart failure, refractory to maximal medical therapy. High-grade aortic insufficiency and severe left ventricular dysfunction were demonstrated by cardiac catheterization. The patient had known prostatic carcinoma with extensive metastatic involvement of the sternum. Aortic valve replacement was performed successfully through a median sternotomy incision and the patient returned to full activities.

Massive air embolism in an adult following positive pressure ventilation.

A 95-year-old woman presented in cardiac arrest. She had been intubated and positive pressure ventilation had been administered by paramedics. Air was aspirated during cannulation of the subclavian vein and the femoral artery. Chest roentgenogram revealed the heart and great vessels filled with air. Massive air embolism caused by positive pressure ventilation is a well described complication in premature infants, but has not, to our knowledge, been previously reported in an adult.

Surgical treatment of complications 45 years after extraperiosteal pneumonolysis and plombage using acrylic resin balls for cavitary pulmonary tuberculosis.

An infected axillary sinus tract discharged balls made of an acrylic resin consisting essentially of polymerized methyl methacrylate (Lucite) 45 years following performance of an extraperiosteal pneumonolysis and Lucite ball plombage for collapse therapy of right upper lobe cavitary tuberculosis. Surgical extraction of the balls was performed, followed by a partial decortication of the lung and intrathoracic transposition of a pectoralis major muscle flap to fill the residual pleural space. Primary healing was attained, and the patient is well 1 1/2 years after surgery.

Continuous extrapleural intercostal nerve block with continuous infusion of lidocaine after thoracotomy. A descriptive pilot study.

Continuous extrapleural intercostal block (EPIB) with bupivacaine has been reported to be an effective analgesic technique in patients after thoracotomy. We report a retrospective study of EPIB using a continuous infusion of 1% lidocaine hydrochloride at a dose of 1 mg/kg/h. A posterior parietal pleural pocket was created and cannulated with a 16-g polyethylene catheter. Lidocaine was perfused over a 3-day period following surgery. Patients also had access to morphine sulfate via patient-controlled analgesia. Eighteen consecutive posterolateral thoracotomies (in 17 patients) performed during a 6-month period were reviewed. Serum lidocaine exceeded the toxic level of 5 microgram/mL in only one patient, a 104.5-kg man who had a level of 5.9 micrograms/mL on postoperative day 2 but experienced no clinical toxicity. Pain was evaluated by verbal analog scores (0 = no pain and 10 = worst pain), which averaged 3.02, 3.14, and 2.8 in the 3 days following surgery. Mean total daily MS doses were 24.3, 37.75, and 34.32 mg (range, 0 to 94 mg). Sedation was scored on a 1 to 5 scale. Mean scores were 2.78, 2.56, and 2.6. No patient died or had a major respiratory complication. Continuous EPIB with lidocaine appears to be a promising adjuvant technique in the management of postthoracotomy pain. Effectiveness needs to be confirmed in a prospective randomized study.

Primary lymphoepithelioma-like carcinoma of the lung in a child. Report of an Epstein-Barr virus-related neoplasm.

Lymphoepithelioma-like carcinoma (LEC), an undifferentiated carcinoma with pronounced lymphocytic infiltration, often is seen in the nasopharynx as well as in other areas. But such primary pulmonary lung neoplasms in children are rare, and we present the first reported case of primary pulmonary LEC in a child.

Subcutaneous nodules as a manifestation of onchocerciasis. A rare condition in the United States.

Although infection with tissue nematodes is a significant health problem in many parts of the world, such cases are unusual in the continental United States. This report describes a case of Onchocerca volvulus infection, acquired by a 38-year-old female missionary in northern Brazil, that manifested as subcutaneous nodules in the groin and flank two years after the patient's return to the United States. A year previously, a wrong diagnosis of Wuchereria bancrofti was made at biopsy. At that time, treatment with diethylcarbamazine citrate had to be discontinued because of intense pruritus. Examination of a wet saline impression smear of a new biopsy specimen showed the adult worms to have regularly arranged outer annular ridges, which, together with the pruritus after treatment with diethylcarbamazine (a positive Mazzotti test), led to the diagnosis of onchocerciasis. Retreatment with diethylcarbamazine again caused pruritus, but this was tolerated as were subsequent treatments.

Thoracic surgeons and tobacco: past failures and present opportunity.

Thoracic surgeons play a major role in the treatment of tobacco-caused disease. Historically, thoracic surgeons have been committed investigators of tobacco-caused disease and activists for tobacco control reform. This editorial reviews and comments on the current activity of American thoracic surgeons, thoracic surgical societies, and journals in these areas. Thoracic surgeons have been remiss in their individual and collective public health responsibility to inform the public and advocate tobacco control reforms. We must commit to a more energetic effort.

Repair of a complex body wall defect using polytetrafluorethylene patches.

Techniques for repair of chest wall, abdominal wall, and diaphragm have been well described, but simultaneous repair of defects involving each of these three areas after tumor ablation provides the surgeon with a difficult technical problem. Repair of a large defect with two polytetrafluorethylene patches after resection of an osteosarcoma invading the lower chest wall, abdominal wall, and diaphragm is described.

Recurrence of pulmonary mucinous cystic tumor of borderline malignancy.

Cystic mucinous tumors of the lung are recently described neoplasms whose histology is different from most lung adenocarcinomas, and represent a spectrum of malignant potential. Little is known of the behavior of the more malignant subtype. We present a cystic mucinous tumor of borderline malignancy that recurred locally following initial limited resection, and was treated with lobectomy.

Mediastinal germ cell tumor in a child with precocious puberty and Klinefelter syndrome.

An 8-year-old boy presented with precocious puberty and a mediastinal mass. A computer search showed that this rare presentation is most common with germ cell tumor of the mediastinum in children with Klinefelter syndrome. The tumor was completely resected after preoperative chemotherapy, and the patient is well 2 years after the operation. In patients with Klinefelter syndrome, germ cell tumors are 50 times more common than in patients without Klinefelter syndrome, usually contain nonseminomatous elements, present at an earlier age, and are seldom testicular in location.

Lung cancer found unresectable at thoracotomy: reappraisal of an old problem.

We review our experience with unresectable non-small cell lung cancer, after adoption of a more aggressive surgical approach, including mediastinal lymph node dissection. Cases with enlarged mediastinal lymph nodes (MLNs, cN2) that were predicted to be resectable were included. Our objective was to identify preoperative findings to prevent unnecessary thoracotomy. In 1988-1997, 192 patients had thoracotomy for non-small cell lung cancer. Fifteen cases (7.7%) were found unresectable at thoracotomy. CT scans demonstrated enlarged MLNs in 7 of 15 and enlarged hilar lymph nodes in 6 of 15 cases. The tumor abutted the hilum in 5 of 15, chest wall in 2 of 15, and mediastinal structures in 7 of 15 cases. Atelectasis was seen in 3 of 15 cases. During the same period, 63 patients with stage III disease, including 39 patients with enlarged MLNs, were resected. The unresectability rate for cN2 patients was 15.2 per cent. Five (33%) patients were physiologically unable to tolerate the required pneumonectomy [forced expiratory volume in 1 second, 1.65 liters (range, 1.15-2.07)]. There were three (20%) esophageal invasions, two (13.3%) mediastinal invasions, two (13.3%) aortic invasions, two (13.3%) metastases to the diaphragm, and one (6.6%) invasion of proximal pulmonary artery. Median survival was 4 months. Two-year actuarial survival was 8 per cent. We conclude that careful palpation and dissection were required to establish unresectability. Preliminary thoracoscopy would have prevented thoracotomy in two cases (13.3%) of diaphragmatic metastases but would not reliably establish unresectable invasion of mediastinal structures.

The Lung Cancer and Cigarette Smoking Web page: a pilot study in telehealth promotion on the World Wide Web.

BACKGROUND: Diseases caused by tobacco products are the number one preventable health problem. STUDY OBJECTIVES: A pilot study was performed to determine the characteristics of persons searching the World Wide Web (WWW) for information on tobacco-caused diseases, the type of information sought and the feasibility of meeting informational needs. METHODS: The Lung Cancer and Cigarette Smoking Web Page at the unique reference location, created in January 1996, consists of hypertext metafile language files in a 'frequently asked questions' format on tobacco-caused diseases, nicotine dependence and smoking cessation. Links to other Web pages, a counter, e-mail access and Web forms were included. SETTING: Personal computer. PARTICIPANTS: People browsing the WWW. RESULTS: Between April 1996 and March 1999, there were more than 150,000 hits and 1510 individual e-mail or form responses; 597 (51.3%) of the respondents were female and 566 (48.7%) were male. They ranged between nine and 79 years of age, with a median of 29 years and a mean of 34 years. The percentage of respondents 20 years old or younger was 34.3%. Five hundred thirteen people resided in 45 American states, and 195 individuals resided in 39 other nations. Students, people with tobacco-caused diseases, and relatives or friends of persons with tobacco-caused diseases made up the large majority of correspondents. Smokers represented 40.2% of the respondents, ex-smokers 34.3% and never-smokers 25.5%. There were three main types of questions: questions for information on the diagnosis and treatment of lung cancer, for help with smoking cessation and for information on tobacco-caused diseases from students working on a school-related project. Images of tobacco-caused diseases were requested frequently. CONCLUSIONS: An educational WWW page is a potentially important resource in the control of tobacco-caused diseases because it fosters primary prevention of smoking in young people, facilitating smoking cessation and providing information on the diagnosis and treatment of tobacco-caused diseases.