Safety and Efficacy Outcomes From a Single-Center Study of Image-Guided Percutaneous Microwave Ablation for Primary and Metastatic Lung Malignancy.

Introduction: Image-guided percutaneous microwave ablation (MWA) is becoming a more common treatment option for patients with primary and metastatic lung malignancies. Nevertheless, there is limited literature on the safety and efficacy of MWA compared with standard-of-care therapy, including surgical resection and radiation. This study will report the long-term outcomes after MWA for pulmonary malignancies and investigate the factors related to efficacy, including lesion size, location, and ablation power. Methods: Retrospective single-center study analyzing 93 patients who underwent percutaneous MWA for primary or metastatic lung malignancies. Outcomes included immediate technical success, local tumor recurrence, overall survival, disease-specific survival, and complications. Results: At a single institution, 190 lesions (81 primary and 109 metastatic) were treated in 93 patients. Immediate technical success was achieved in all cases. Freedom from local recurrence was 87.6%, 75.3%, and 69.2% and overall survival was 87.7%, 76.2%, and 74.3% at 1 year, 2 years, and 3 years, respectively. Disease-specific survival was 92.6%, 81.8%, and 81.8%. The most common complication was pneumothorax, which occurred in 54.7% (104 of 190) of procedures, with 35.2% (67 of 190) requiring a chest tube. No life-threatening complications occurred. Conclusions: Percutaneous MWA seems safe and effective for treatment of primary and metastatic lung malignancies and should be considered for patients with limited metastatic burden and lesions less than 3 cm in size.

Value of a Multidisciplinary Team Approach to Treatment of Emphysema.

Lung volume reduction surgery can significantly improve quality of life for properly selected patients who are symptomatic despite maximal medical management for emphysema. This requires a well-constructed multidisciplinary team (including transplant) to evaluate and treat these patients.

The role of thoracoscopic pneumonectomy in the management of non-small cell lung cancer: A multicenter study.

OBJECTIVE: The objective of this study was to evaluate the impact of the video-assisted thoracoscopic (VATS) approach on the outcomes of patients who underwent pneumonectomy. METHODS: The effect of the surgical approach on perioperative complications and survival in patients who underwent pneumonectomy for nonmetastatic non-small cell lung cancer across 3 institutions (2000-2016) was assessed using multivariable logistic regression, Cox proportional hazards analysis, and propensity-score matching. Completion pneumonectomies were excluded from this study, and an "intent-to-treat" analysis was performed. RESULTS: During the study period, 359 patients met inclusion criteria and underwent pneumonectomy for nonmetastatic non-small cell lung cancer; 124 (35%) underwent pneumonectomy via VATS and 235 (65%) via thoracotomy. Perioperative mortality (VATS, 7% [n = 9] vs open, 8% [n = 19]; P = .75) and morbidity (VATS, 28% [n = 35] vs open, 28% [n = 65]; P = .91) were similar between the groups, even after multivariable adjustment. VATS showed similar 5-year survival when compared with thoracotomy in unadjusted analysis (47% [95% confidence interval (CI), 36-56] vs 33% [95% CI, 27-40]; P = .19), even after multivariable adjustment (hazard ratio, 0.76 [95% CI, 0.50-1.18]; P = .23). In a propensity score-matched analysis that balanced patient characteristics, there were no significant differences found in overall survival between the 2 groups (P = .69). CONCLUSIONS: Although the role of VATS pneumonectomy will likely become clearer as more surgeons report results, this multicenter study suggests that the VATS approach for pneumonectomy can be performed safely, with at least equivalent oncologic outcomes when compared with thoracotomy.

Video-Assisted Thoracic Surgery in Patients With Previous Sternotomy and Cardiac Surgery.

OBJECTIVE: Although video-assisted thoracic surgery (VATS) lobectomy has become a standard approach for early-stage 1 lung cancer, concerns exist regarding potential damage to the heart or bypass grafts when VATS is performed after cardiac surgery via median sternotomy. We could find only case reports regarding VATS lobectomy after sternotomy for cardiac surgery. Therefore, we reviewed our series of patients who underwent VATS anatomic resections after sternotomy for cardiac surgery. METHODS: Between 1996 and 2010, there were 87 patients who underwent 88 pulmonary resections after sternotomy for coronary artery bypass grafting (64), valve replacement or repair (12), coronary artery bypass graft and valve replacement (6), and transplant (5). There were 10 women (11.5%) and 77 men (88.5%) with a mean age of 76.2 years. Diagnoses included lung cancer (83), pulmonary metastases (4), and benign disease (1). RESULTS: Dense adhesions between the lung and the mediastinum sometimes occur after cardiac surgery. Compared with the total series of 2684 VATS lobectomies, operations after sternotomy are associated with greater mortality (12, 0.4% vs 5, 5.7%), myocardial infarction (13, 0.5% vs 2, 2.3%), transfusion (45, 1.7% vs 12, 13.6), conversion to thoracotomy (188, 7% vs 14, 15.9%). Injury occurred to the left main pulmonary artery (1, 1%) and internal mammary artery graft (1, 1%). There were no intraoperative deaths. CONCLUSIONS: Previous sternotomy for cardiac surgery does increase the risk for VATS lobectomy. Conversion to thoracotomy should be considered if dense adhesions are found. Techniques to reduce the risk for the heart are discussed.

Video-Assisted Intercostal Muscle Flaps for Bronchial Stump Coverage.

This article describes the surgical technique for performing an intercostal muscle flap for bronchial stump coverage using a video-assisted thoracic surgery approach.

Video-Assisted Thoracic Surgery After Median Sternotomy for Cardiac Surgery.

Video-assisted thoracic surgery (VATS) lobectomy has become a standard approach for early stage 1 lung cancer. However, concerns still remain regarding certain clinical situations, such as potential damage to the heart or bypass grafts when VATS is performed after median sternotomy for cardiac surgery. In this article, techniques are described to minimize risk to an internal mammary artery graft during a VATS anatomic pulmonary resection in this group of patients. The article reviews data on VATS after median sternotomy for cardiac surgery and describes techniques to prevent, treat, and mitigate problems in this group of patients. Management of intraoperative crises is also discussed.

A video-assisted thoracoscopic approach to transaxillary first rib resection.

OBJECTIVE: Thoracic outlet syndrome (TOS) can be associated with neurologic, arterial, or venous deficiencies. When nonsurgical treatment has failed to adequately palliate TOS, surgical intervention is indicated. The supraclavicular and transaxillary approaches are currently the most commonly used approaches for first rib resection, yet little has been reported to date on outcomes of minimally invasive procedures, such as video-assisted thoracoscopic surgery (VATS). The purpose of this article was to describe a minimally invasive approach to TOS and the associated outcomes. METHODS: This study is a retrospective analysis of a prospectively maintained database. Patients who failed nonsurgical therapy for TOS were referred to our practice for evaluation of surgery with a VATS minimally invasive first rib resection. Between 2001 and 2010, 66 VATS procedures were performed on 58 patients (41 women, 17 men). Patients were followed postoperatively for a mean time of 13.5 months. RESULTS: Forty-one patients were women (70.7%), and the mean age was 40.5 years, with a patient age range of 17 to 59 years. The mean length of hospital stay was 2.47 days; median length of stay was 2 days. There were a total of eight complications (12.1%). There were no mortalities. CONCLUSIONS: Video-assisted thoracoscopic surgery first rib resection for TOS is another feasible option for TOS, which can be added to the armamentarium of the thoracic surgeon. The outcomes associated with our technique are comparable with the outcomes related to other current standards of care.

Patterns of survival and recurrence after surgical treatment of early stage non-small cell lung carcinoma in the ACOSOG Z0030 (ALLIANCE) trial.

OBJECTIVE: Surgical resection has been the mainstay of curative treatment of early stage lung cancer in selected patients. We evaluated survival and patterns of recurrence after surgical resection for early stage lung cancer from the American College of Surgeons Oncology Group Z0030/Alliance trial. METHODS: One thousand eighteen patients enrolled in the Z0030 trial were analyzed according to clinical T stage. Differences between groups were compared using the 2-sample rank test or χ(2) test. Log rank test and Cox proportional hazards regression were used to compare survival and recurrence. To compare patients who underwent open versus video-assisted thoracoscopic surgery (VATS) resections, propensity-score matched analysis was performed. Seven hundred fifty-two patients (66 undergoing VATS and 686 undergoing open surgery) were classified into 5 equal-sized propensity-score groups. Proportional hazards regression was used to compare these outcomes. RESULTS: There were 578 patients with cT1 tumors and 440 patients with cT2 tumors. Median follow-up was 6.7 years. Median overall survival was 9.1 years (stage T1) and 6.5 years (stage T2). Overall survival at 5 years was 72% (stage T1) and 55% (stage T2). Local recurrence-free survival at 5 years was 95% (stage T1) and 91% (stage T2) (P = .015). Among patients with stage T1 cancer, 4.2% (23 out of 542) had local recurrences, whereas 7.3% (30 out of 409) of those with stage T2 tumors had local failure. There was no difference in the development of new primary tumors between stage T1 and stage T2 groups. In the propensity-score matched analysis of VATS versus open lobectomy patients, there was no difference in overall survival, disease-free survival, and freedom from development of a new primary tumor. CONCLUSIONS: Results of patients with resected early stage non-small cell carcinoma from a large-scale, multicenter trial serve as benchmarks against which to compare nonsurgical therapies for early stage lung cancer. Propensity-score matched analysis shows no difference in survival between patients undergoing VATS and open lobectomy.

Prospective phase II trial of preresection thoracoscopic mediastinal restaging after neoadjuvant therapy for IIIA (N2) non-small cell lung cancer: results of CALGB Protocol 39803.

OBJECTIVE: Accurate pathologic restaging of N2 stations after neoadjuvant therapy in stage IIIA (N2) non-small cell lung cancer is needed. METHODS: A prospective multi-institutional trial was designed to judge the feasibility of videothoracoscopy to restage the ipsilateral nodes in mediastinoscopy-proven stage IIIA (N2) non-small cell lung cancer after 2 cycles of platinum-based chemotherapy and/or 40 Gy or more of radiotherapy. The goals included biopsy of 3 negative N2 node stations or to identify 1 positive N2 node or pleural carcinomatosis. RESULTS: Ten institutions accrued 68 subjects. Of the 68 subjects, 46 (68%) underwent radiotherapy and 66 (97%) underwent chemotherapy. Videothoracoscopy successfully met the prestudy feasibility in 27 patients (40%): 3 negative stations confirmed at thoracotomy in 7, persistent stage N2 disease in 16, and pleural carcinomatosis in 4. In 20 procedures (29%), no N2 disease was found, 3 stations were not biopsied because of unanticipated nodal obliteration. Thus, 47 videothoracoscopy procedures (69%, 95% confidence interval, 57%-80%) restaged the mediastinum. Videothoracoscopy was unsuccessful in 21 patients (31%) because the procedure had to be aborted (n = 11) or because of false-negative stations (n = 10). Of the 21 failures, 15 were right-sided, and 10 had a positive 4R node. The sensitivity of videothoracoscopy was 67% (95% confidence interval, 47%-83%), and the negative predictive value was 73% (95% confidence interval, 56%-86%) if patients with obliterated nodal tissue were included. The sensitivity was 83% (95% confidence interval, 63%-95%) and the negative predictive value was 64% (95% confidence interval, 31%-89%) if those patients were excluded. The specificity was 100%. One death occurred after thoracotomy. CONCLUSIONS: Videothoracoscopy restaging was "feasible" in this prospective multi-institutional trial and provided pathologic specimens of the ipsilateral nodes. Videothoracoscopy restaging was limited by radiation and the 4R nodal station.

Validation of the lung cancer staging system revisions using a large prospective clinical trial database (ACOSOG Z0030).

OBJECTIVES: A new revision of the international lung cancer staging system has been recently introduced. The revisions are largely focussed on the T descriptor. We sought to test the validity of this new system on a separate prospectively collected cohort of patients from a recent multicentre trial of early-stage lung cancer. METHODS: We reviewed the prospectively collected data from 1012 patients undergoing pulmonary resection for early-stage lung cancer in the ACOSOG Z0030 trial. TNM descriptors and overall staging were assessed using both the sixth and seventh editions of the American Joint Committee on Cancer and the Union Internationale Contre le Cancer (AJCC/UICC) lung cancer staging system. Survival results were analysed according to both staging allocations. RESULTS: Using the proposed criteria, the number of patients by stage in the sixth and seventh edition allocations, respectively, were as follows: IA (432, 431); IB (402, 303); IIA (39, 167); IIB (94, 70); IIIA (26, 40); IIIB (19,0); there were no stage IV patients by either version. Overall, 180 (18%) patients had a change in the stage group from the sixth to seventh edition versions with 76 (8%) being downstaged and 104 (10%) being upstaged. In the sixth edition staging system based on pathological stages, median survivals in years were as follows: IA, NA; IB, 7.7; IIA, 4.0; IIB, 3.6; IIIA, 2.6 and IIIB, 2.4. Five-year survivals were: IA, 76.4%; IB, 62.0%; IIA, 47.8%; IIB, 40.4%; IIIA, 31.3% and IIIB, 44.4%. In the new system, median survivals in years were as follows: IA, NA; IB, 8.2; IIA, 4.4; IIB, 3.6 and IIIA, 1.8. Five-year survivals were: IA, 76.9%; IB, 65.0%; IIA, 48.5%; IIB, 42.9% and IIIA, 30.6%. Survival analysis and Kaplan-Meier survival curves showed more monotonic progression, distinction and homogeneity within groups in the seventh edition. CONCLUSIONS: This study provides an external validation of the recently revised lung cancer staging system using a large multicentre database. The seventh edition of the AJCC/UICC lung cancer staging system appears to be an improvement over the preceding system.

Video-assisted thoracoscopic trisegmentectomy and left upper lobectomy provide equivalent survivals for stage IA and IB lung cancer.

OBJECTIVES: Despite a trend toward sublobar resections for lung cancers, some question the adequacy of limited resections in the treatment of lung cancer and questions remain about performing these procedures by video-assisted thoracoscopic surgery (VATS). We compared the survival for lung cancers treated with VATS segmentectomy versus VATS lobectomy. METHODS: VATS segmentectomy and lobectomy for both malignant and benign lung pathology are reviewed from a single institution. RESULTS: Between 1998 and 2010, 73 VATS trisegmentectomies were performed in 49 women and 24 men (mean age, 72 years). Diagnoses included primary lung cancer (91%), benign disease (4%), and metastatic disease (5%). Primary lung cancers were 68% for stage IA, 17% for stage IB, and 15% for stage II-IV. Seventy-three left upper lobe (LUL) trisegmentectomies were performed. Mean hospital stay after VATS trisegmentectomy was 3.8 days, versus 5.5 days after VATS LUL lobectomy (P = .0736). Complication rates for trisegmentectomy group (37%) and lobectomy (17%; P > .05) were not statistically different. Survival after VATS trisegmentectomy and LUL lobectomy for either stage IA lung cancer or stage IB lung cancer was not statistically significant. CONCLUSIONS: Segmentectomy can be performed by VATS with no greater morbidity and mortality than with VATS lobectomy. LUL trisegmentectomy provides the same survival as lobectomy for stage IA and IB tumors. Our experience supports the use of lingular-sparing trisegmentectomy in the treatment of stage IA and IB lung cancer.

In-hospital clinical and economic consequences of pulmonary wedge resections for cancer using video-assisted thoracoscopic techniques vs traditional open resections: a retrospective database analysis.

OBJECTIVE: The objective of this study was to compare the safety, use, and cost profiles of open thoracotomy vs video-assisted thoracoscopic surgery (VATS) for wedge resection in lung cancer performed by thoracic surgeons in the United States. METHODS: The Premier database, which contains complete patient billing, hospital cost, and coding histories from > 25 million inpatient discharges and > 175 million hospital outpatient visits, was used for this analysis. Eligible patients were those who underwent wedge resection by a thoracic surgeon for cancer diagnosis or treatment through open thoracotomy or VATS in 2007 or 2008. Multivariable logistic regression analyses were run for binary outcomes, and ordinary least squares regressions were used for continuous outcomes. All models were adjusted for patient demographics, comorbid conditions, and hospital characteristics. RESULTS: Of 8,228 eligible procedures, 2,051 patients underwent wedge resections by a thoracic surgeon using the open technique (n = 999) or VATS (n = 1,052). Hospital costs remained significantly higher for open wedge resections than for VATS ($17,377 vs $14,795, P = .000). Surgery time was significantly longer for open resections vs VATS (3.16 vs 2.82 h). Length of stay was 6.34 days for open vs 4.44 days for VATS. Adverse events were significant in the multivariable analysis, with an OR of 1.57 (95% CI, 1.29-1.91) in favor of VATS. CONCLUSIONS: Although this retrospective database analysis could not address the issue of oncologic outcome equivalence, a clear advantage of VATS over open wedge lung cancer resection was found for both acute clinical outcomes and hospital costs.

Video-assisted thoracoscopic lobectomy is less costly and morbid than open lobectomy: a retrospective multiinstitutional database analysis.

BACKGROUND: The Premier Perspective Database (Premier Inc, Charlotte, NC) was used to compare hospital costs and perioperative outcomes for video-assisted thoracoscopic surgery (VATS) and open lobectomy procedures in the United States. METHODS: Eligible patients underwent a lobectomy for cancer by a thoracic surgeon, by VATS or open thoracotomy and were captured in the database between third quarter of 2007 and through 2008. Multivariable logistic regression analyses were performed for binary outcomes. Ordinary least-squares regressions were used to estimate continuous outcomes. All models were adjusted for patient and hospital characteristics. RESULTS: A total of 3,961 patients underwent a lobectomy by a thoracic surgeon by open (n = 2,907) or VATS (n = 1,054) approach. Hospital costs were higher for open versus VATS; $21,016 versus $20,316 (p = 0.027). Adjustment for surgeon experience with VATS over the 6 months prior to each operation showed a significant association between surgeon experience and cost. Average costs ranged from $22,050 for low volume surgeons to $18,133 for high volume surgeons. For open lobectomies, cost differences by surgeon experience were not significant and both levels were estimated at $21,000. Length of stay was 7.83 versus 6.15 days, for open versus VATS (p = 0.000). Surgery duration was shorter for open procedures at 3.75 versus 4.09 for VATS (p = 0.000). The risk of adverse events was significantly lower in the VATS group, odds ratio of 1.22 (p = 0.019). CONCLUSIONS: Lobectomy performed by the VATS approach as compared with an open technique results in shorter length of stay, fewer adverse events, and less cost to the hospital. Economic impact is magnified as the surgeon's experience increases.

The Society of Thoracic Surgeons expert consensus for the surgical treatment of hyperhidrosis.

Significant controversies surround the optimal treatment of primary hyperhidrosis of the hands, axillae, feet, and face. The world's literature on hyperhidrosis from 1991 to 2009 was obtained through PubMed. There were 1,097 published articles, of which 102 were clinical trials. Twelve were randomized clinical trials and 90 were nonrandomized comparative studies. After review and discussion by task force members of The Society of Thoracic Surgeons' General Thoracic Workforce, expert consensus was reached from which specific treatment strategies are suggested. These studies suggest that primary hyperhidrosis of the extremities, axillae or face is best treated by endoscopic thoracic sympathectomy (ETS). Interruption of the sympathetic chain can be achieved either by electrocautery or clipping. An international nomenclature should be adopted that refers to the rib levels (R) instead of the vertebral level at which the nerve is interrupted, and how the chain is interrupted, along with systematic pre and postoperative assessments of sweating pattern, intensity and quality-of-life. The recent body of literature suggests that the highest success rates occur when interruption is performed at the top of R3 or the top of R4 for palmar-only hyperhidrosis. R4 may offer a lower incidence of compensatory hyperhidrosis but moister hands. For palmar and axillary, palmar, axillary and pedal and for axillary-only hyperhidrosis interruptions at R4 and R5 are recommended. The top of R3 is best for craniofacial hyperhidrosis.

Randomized trial of mediastinal lymph node sampling versus complete lymphadenectomy during pulmonary resection in the patient with N0 or N1 (less than hilar) non-small cell carcinoma: results of the American College of Surgery Oncology Group Z0030 Trial.

OBJECTIVE: To determine whether mediastinal lymph node dissection improves survival compared with mediastinal lymph node sampling in patients undergoing resection for N0 or nonhilar N1, T1, or T2 non-small cell lung cancer. METHODS: Patients with non-small cell lung cancer underwent sampling of 2R, 4R, 7, and 10R for right-sided tumors and 5, 6, 7, and 10L for left-sided tumors. If all tumors were negative for malignancy, patients were randomized to no further lymph node sampling (mediastinal lymph node sampling) or complete mediastinal lymph node dissection. RESULTS: Of 1111 patients randomized, 1023 (mediastinal lymph node sampling in 498, mediastinal lymph node dissection in 525) were eligible and evaluable. There were no significant differences between the 2 groups in terms of demographics, Eastern Cooperative Oncology Group status, histology, cancer location, type or extent of resection, and pathologic stage. Occult N2 disease was found in 21 patients in the mediastinal lymph node dissection group. At a median follow-up of 6.5 years, 435 patients (43%) have died: mediastinal lymph node sampling in 217 (44%) and mediastinal lymph node dissection in 218 (42%). The median survival is 8.1 years for mediastinal lymph node sampling and 8.5 years for mediastinal lymph node dissection (P = .25). The 5-year disease-free survival was 69% (95% confidence interval, 64-74) in the mediastinal lymph node sampling group and 68% (95% confidence interval, 64-73) years in the mediastinal lymph node dissection group (P = .92). There was no difference in local (P = .52), regional (P = .10), or distant (P = .76) recurrence between the 2 groups. CONCLUSIONS: If systematic and thorough presection sampling of the mediastinal and hilar lymph nodes is negative, mediastinal lymph node dissection does not improve survival in patients with early stage non-small cell lung cancer, but these results are not generalizable to patients staged radiographically or those with higher stage tumors.

Number of lymph nodes harvested from a mediastinal lymphadenectomy: results of the randomized, prospective American College of Surgeons Oncology Group Z0030 trial.

BACKGROUND: Lymph node status is a major determinant of stage and survival in patients with lung cancer; however, little information is available about the expected yield of a mediastinal lymphadenectomy. METHODS: The American College of Surgeons Oncology Group Z0030 prospective, randomized trial of mediastinal lymph node sampling vs complete mediastinal lymphadenectomy during pulmonary resection enrolled 1,111 patients from July 1999 to February 2004. Data from 524 patients who underwent complete mediastinal lymph node dissection were analyzed to determine the number of lymph nodes obtained. RESULTS: The median number of additional lymph nodes harvested from a mediastinal lymphadenectomy following systematic sampling was 18 with a range of one to 72 for right-sided tumors, and 18 with a range of four to 69 for left-sided tumors. The median number of N2 nodes harvested was 11 on the right and 12 on the left. A median of at least six nodes was harvested from at least three stations in 99% of patients, and 90% of patients had at least 10 nodes harvested from three stations. Overall, 21 patients (4%) were found to have occult N2 disease. CONCLUSIONS: Although high variability exists in the actual number of lymph nodes obtained from various nodal stations, complete mediastinal lymphadenectomy removes one or more lymph nodes from all mediastinal stations. Adequate mediastinal lymphadenectomy should include stations 2R, 4R, 7, 8, and 9 for right-sided cancers and stations 4L, 5, 6, 7, 8, and 9 for left-sided cancers. Six or more nodes were resected in 99% of patients in this study. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT00003831; URL: clinicaltrials.gov.

The presence of isolated tumor cells and micrometastases in the intrathoracic lymph nodes of patients with lung cancer is not associated with decreased survival.

The prognostic role of small intrathoracic nodal metastases in primary patients with lung cancer has been controversial, and it is unclear how their presence should be used for pathologic staging and treatment planning. The intrathoracic lymph nodes from 266 clinical stage I non-small cell carcinoma patients treated at Cedars Sinai Medical Center from 1992 to 2006 were evaluated with immunohistochemistry for keratin AE1/AE3 for the presence of isolated tumor cells and micrometastases, as defined by American Joint Commission on Cancer criteria, correlated with survival using the Kaplan-Meier method and analyzed with power analysis. The English literature from 1995 to 2008 was reviewed to identify best available evidence regarding the prognostic value of isolated tumor cells and micrometastases detected with various immunohistochemistry and molecular methods in non-small cell carcinoma patients. Results were combined with our own data and evaluated with meta-analysis using Comprehensive Meta-analysis 2.0 software (Biostat Inc, Englewood, NJ). Isolated tumor cells and micrometastases were detected in 8 and 67 of 4148 lymph nodes, respectively, and their presence was not significantly associated with survival. Power analysis showed that 3060 cases followed up for 60 months would be needed to achieve 80% power in a study designed to detect survival differences between patients with negative nodes and micrometastases. Meta-analysis of 835 non-small cell carcinoma patients reported in 13 studies showed scanty data to evaluate patients with isolated tumor cells, no significant association between micrometastases and survival and significant data heterogeneity. Current best evidence suggests that non-small cell carcinoma patients should probably not be "upstaged" in the presence of isolated tumor cells and micrometastases. There is no data demonstrating survival benefits for patients treated with adjuvant chemotherapy and/or radiation therapy because of the presence of small nodal metastases.

Treatment of persistent pulmonary air leaks using endobronchial valves.

BACKGROUND: Prolonged pulmonary air leaks are a significant source of frustration for patients and physicians. When conventional therapy fails, an alternative to prolonged chest tube drainage or surgery is needed. Bronchoscopic blockage of a bronchus can be performed with the hope of accelerating closure of the air leak by reducing the flow of air through the leak. To our knowledge, this article presents the largest series of patients with prolonged air leaks treated with an endobronchial valve. METHODS: With Internal Review Board approval, endobronchial valves were compassionately placed using flexible bronchoscopy in patients with prolonged air leaks at 17 international sites. RESULTS: Between December 2002 and January 2007, 40 patients (15 women; mean age +/- SD, 60 +/- 14 years) were treated with one to nine endobronchial valves per patient. The air leaks had recurrent spontaneous pneumothorax (n = 21), postoperative (n = 7), iatrogenic (n = 6), first-time spontaneous pneumothorax (n = 4), bronchoscopic lung volume reduction (n = 1), and trauma (n = 1) etiologies. Nineteen patients (47.5%) had a complete resolution of the air leak, 18 (45%) had a reduction, 2 had no change, and 1 had no reported outcome. The mean time from valve insertion to chest tube removal was 21 days (median, 7.5 days; interquartile range [IQR], 3 to 29 days) and from valve procedure to hospital discharge was 19 +/- 28 days (median, 11 days; IQR, 4 to 27 days). CONCLUSIONS: Use of endobronchial valves is an effective, nonsurgical, minimally invasive intervention for patients with prolonged pulmonary air leaks.