Common Thoracic Procedures

1
Common Thoracic Procedures

• Cardiothoracic Centre, Liverpool
• Fri 23rd January 2004
• Edwin Woo

2
Overview

• Lung Cancer
• VATS
• Disease of the thorax
• Oesophageal surgery
• Emergency thoracic procedures

3
Omission

• Transplantation
• Anterior mediastinal mass
• Thymoma
• Retro-sternal goitre
• Lung volume reduction surgery

4
Diagnosis

• Sputum cytology
• Bronchoscopic biopsy
• Needle aspiration biopsy
• VATS
• Thoracotomy

5
Diagnosis

• Sputum Cytology
• Yield proportional to number of samples
• Oswald NC, Thorax 26623,1971
• Position of tumor
• Cell type
• Best in squamous, least with SCLC
• Agrees with final histology in 85

6
Diagnosis

• Bronchoscopy
• Flexible vs Rigid

7
Diagnosis

• Bronchoscopy

8
Diagnosis

• Bronchoscopy
• Visual inspection of tumor
• Biopsy of tumor
• Targeted washing brushing for cytology
• Transbronchial biopsy

9
Diagnosis

• Needle aspiration cytology / cutting

• CT / fluoroscopically
• guided
• Trans-bronchial
• aspiration cytology

10
Diagnosis

• VATS

• Excision of peripheral
• lesion
• Biopsy of nodal station

11
Diagnosis

• Thoracotomy
• Frozen section
• Important in pneumonectomy

12
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)

13
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

14
Staging

• 1966 TNM system adopted by UICC (International
  Union Against Cancer)
• Denoix PF Bull Inst Nat Hyg (Paris) 170. 1964
• 1986 International staging system adopted by AJCC
  (American Joint Committee on Cancer) for NSCLC
• Mountain CF Chest 89225S-35S. 1986
• 1997 Updated
• Mountain CF Chest 1111711-7. 1997

15
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

16
Staging
N0 N1 N2 N3 M1
T1 1 A II A III A III B IV
T2 I B 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
17
Prognosis
18
Staging

• Small Cell Carcinoma
• Localised
• Disease limited to ipsilateral hemithorax
• TNM system in very localised disease
• Extensive
• Disease spread beyond ipsilateral hemithorax

19
Prognosis
N0 N1 N2 N3 M1
T1 1 A II A III A III B IV
T2 I B 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
20
Prognosis
N0 N1 N2 N3 M1
T1 1 A II A III A III B IV
T2 I B 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
21
Prognosis
Survival curve of patients with stage III NSCLC
Hara N, J Surg Oncol25153. 1984
22
Operability

• Stage I
• T1N0 and T2N0
• Stage II
• T1N1, T2N1 and T3N0
• Excellent and Reasonable chance of cure by
  surgery alone

23
Operability

• Stage IIIa
• T3N1 and T1N2-T3N2
• NOT Surgery alone
• Consider Adjuvant therapy

24
Operability

• Stage IIIb and Stage IV
• Inoperable
• Stage IIIb (T4N0 and T4N1)
• ? Role of surgery

25
Assessment Staging
26
Assessment Staging

• Mediastinal Lymphadenopathy

27
Assessment Staging
N0 N1 N2 N3 M1
T1 1 A II A III A III B IV
T2 I B 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
28
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

29
Assessment Staging

• PET (Positron Emission Tomography)

30
Assessment Staging

• Integrated PET / CT scanner

31
Assessment Staging

• Mediastinoscopy

32
Assessment Staging

• Anterior Mediastinotomy

33
Lung Resection

• Wedge Excision
• Segmentectomy
• Lobectomy
• Bilobectomy
• Pneumonectomy

34
Lung Resection
35
Lung Resection
36
Lung Resection
37
Lung Resection
38
Video Assisted Thoracoscopic Surgery
39
Video Assisted Thoracoscopic Surgery
40
Video Assisted Thoracoscopic Surgery
41
Video Assisted Thoracoscopic Surgery
42
Sympathectomy

• Palmar hyperhidrosis better response
• T2 to T3 but T2 to T5 for axillary
• 20 compensatory hyerhidrosis
• Horners syndrome if T1 resected

43
Sympathectomy
44
Sympathectomy
45
Sympathectomy
46
Empyema
47
Empyema
48
Empyema

• Complete drainage of purulent collection
• Obliteration of empyema space
• Investigation and treatment of the cause

49
Diaphragmatic Rupture
50
Diaphragmatic Rupture
51
Diaphragmatic Rupture
52
Hiatus Hernia
53
Hiatus Hernia
54
Oesophagectomy
55
Oesophagectomy
56
Oesophagectomy
57
Oesophagectomy
58
Oesophagectomy
59
Emergency Procedures
60
Emergency Procedures
61
Emergency Procedures
62
Emergency Procedures

• Emergency thoracotomy
• Penetrating chest trauma
• Recently dead
• Anterior lateral

63
Emergency Procedures
64
Emergency Procedures
65
Emergency Procedures
66
Emergency Procedures
67
(No Transcript)
68
Pneumothorax
69
(No Transcript)