Seminars in thoracic and cardiovascular surgery
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Semin. Thorac. Cardiovasc. Surg. · Jan 2013
ReviewThe state of the art in the technical performance of lung-sparing operations for malignant pleural mesothelioma.
Malignant pleural mesothelioma remains an incurable disease for which the role of surgery remains controversial. Though not yet clearly defined there does appear to be a subset of patients who benefit from a surgery-based multimodal treatment plan, beyond what would be expected with current nonoperative therapies. As with other pleural cancers it is probably not possible to achieve a microscopic complete resection with any operation. ⋯ Many of these cases involved bulky cancers, some exceeding two liters in volume, and often with extensive invasion of the pulmonary fissures. With the described technique there has not yet been an instance where conversion to extrapleural pneumonectomy would have contributed to the ability to achieve a macroscopic complete resection. Whether or not radical pleurectomy is the optimal approach for any or all patients undergoing surgery-based multimodal treatment for malignant pleural mesothelioma is not known, but the described technique does offer an operation that can serve as a consistent foundation for any surgery-based treatment strategy where achieving a macroscopic complete resection, while sparing the lung, is desired.
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Semin. Thorac. Cardiovasc. Surg. · Jan 2013
ReviewCurrent readings: sublobar resection for non-small-cell lung cancer.
The Lung Cancer Study Group consensus recommending lobectomy for stage I non-small-cell lung cancer (NSCLC) to reduce local recurrence associated with sublobar resections has directed NSCLC care since its 1995 publication. However, enhancements in imaging technology and in our understanding of the molecular biology of NSCLC over the past 2 decades have produced large cohorts of patients with smaller, better staged, and more indolent tumors than evaluated by the Lung Cancer Study Group. Numerous single-institution trials have demonstrated that in well-selected patients, sublobar resection can afford comparable survival and recurrence rates with lobectomy with a more favorable risk profile. This review of recent literature will focus on 2 separate issues with regard to the use of sublobar resections for stage I NSCLC: (1) a comparison to nonoperative ablative therapies in medically unfit patients, and (2) identifying in which subset of the noncompromised standard-risk population, sublobar resections provide equivalent outcome to lobectomy.
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Semin. Thorac. Cardiovasc. Surg. · Jan 2013
ReviewCurrent readings: improvements in intensity-modulated radiation therapy for malignant pleural mesothelioma.
The treatment of malignant pleural mesothelioma with radiation therapy has always been a technical challenge. Early experience with intensity-modulated radiation therapy demonstrated troubling toxicity. Recent reports from institutions have demonstrated that with greater experience, intensity-modulated radiation therapy can be delivered safely, both in the setting of pneumonectomy or pleurectomy. ⋯ In the setting of 2 intact lungs, the mean lung dose can be as high as 20 Gy. Expected rates of grade 3 or worse radiation pneumonitis are 12%-20%. The rates of fatal pneumonitis are approximately 3%-8% in these studies, which demonstrate the considerable toxicity of treatment, even with improved technique.
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Modern cardiac practice in the United States is conservative when it comes to using bilateral internal mammary or radial artery grafts in coronary artery bypass surgery. Here, we examine the evidence regarding using other arterial grafts instead of veins as a complement to left internal mammary artery in surgical revascularization. In addition, we put our report in perspective relative to prevailing practice, professional societal guidelines, and future directions in coronary artery bypass grafting.
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Semin. Thorac. Cardiovasc. Surg. · Jan 2013
Lobar lung transplantation: emerging evidence for a viable option.
The field of lung transplantation has seen an exciting evolution recently, with novel approaches to increasing the number of organs available for patients with end-stage lung disease. We review 2 recent reports describing the approach of lobar lung transplant as a successful and viable option for those recipients who are challenged by size mismatch and clinical course decline while on the transplant waiting list.