BACKGROUND: Endoscopic ultrasound (EUS)-guided fine needle aspiration is a safe, cost-effective procedure that can confirm the presence of mediastinal lymph node metastases and mediastinal tumor invasion. We studied the accuracy of EUS in a large population of lung cancer patients with and without enlarged mediastinal lymph nodes on computed tomographic (CT) scan. METHODS: From 1996 to 2000 all patients referred to our institution with lung tumors and no proven distant metastases were considered for EUS and surgical staging. Patients had endoscopic ultrasound with fine needle aspiration of abnormal appearing mediastinal lymph nodes and evaluation for mediastinal invasion of tumor (stage III or IV disease). Patients without confirmed stage III or IV disease had surgical staging. RESULTS: Two hundred seventy-seven patients met the inclusion criteria, including 121 who had EUS. Endoscopic ultrasound and fine needle aspiration detected stage III or IV disease in 85 of 121 (70%). Among patients with enlarged lymph nodes on CT, 75 of 97 (77%) had stage III or IV disease detected by EUS. Among a small cohort of patients without enlarged mediastinal lymph nodes on CT, 10 of 24 (42%) had stage III or IV disease detected by EUS. For mediastinal lymph nodes only, the sensitivity of endoscopic ultrasound and CT was 87%. The specificity of EUS (100%) was superior to that of CT (32%) (p < 0.001). CONCLUSIONS: Endoscopic ultrasound with fine needle aspiration identified and histologically confirmed mediastinal disease in more than two thirds of patients with carcinoma of the lung who have abnormal mediastinal CT scans. Although mediastinal disease was more likely in patients with an abnormal mediastinal CT, EUS also detected mediastinal disease in more than one third of patients with a normal mediastinal CT and deserves further study. Endoscopic ultrasound should be considered a first line method of presurgical evaluation of patients with tumors of the lung.

Adult↗

PubMed2001

Predicted impact of attaining smoking reduction goals on mortality.

The impact of reducing smoking initiation, increasing smoking cessation, and combination approaches on life expectancy, deaths averted, and life-years gained in a birth cohort of 50,000 persons and in the state population (3.6 million) were analyzed. A 60% reduction in initiation of smoking in adolescents would increase life expectancy by 0.42 years. Over the next 100 years, there would be an additional 18,000 years of life for a birth cohort and an additional 675,000 years of life for the state's population. The reduction in mortality, however, would not begin before 35 years, and only 25% of the benefit would occur in the next 70 years. An increase in smoking cessation would have a smaller impact that would occur sooner. Maximum reduction in mortality could be achieved by reducing initiation and increasing cessation at all ages, but a reduction in mortality would not occur for several decades.

Adolescent↗

PubMed2000

Case studies in the diagnosis and staging of non-small cell lung cancer.

Lung cancer is the most common cause of cancer death in men and women. While overall survival rates remain dismal, survival for early stage disease approaches 70%. Expedient, accurate staging is vital to ensure timely resection of all potentially curable disease. Conversely, accurate staging is important in preventing unnecessary surgery. While a negative clinical evaluation has a high negative predictive value, many clinicians routinely order conventional imaging to exclude distant metastases. In this article, five case vignettes are presented to demonstrate the international system for staging lung cancer, including the most recent modifications. Various tumor characteristics and patterns of lymph node involvement are explored to demonstrate the subtleties of staging. The accuracy of various diagnostic modalities in the evaluation for mediastinal and distant metastasis is discussed.

Journal Article↗

PubMed2000

Palliation for the dying patient with lung cancer.

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Analgesics, Opioid↗

PubMed1999

Cost-efficacy of endoscopic ultrasonography with fine-needle aspiration vs. mediastinotomy in patients with lung cancer and suspected mediastinal adenopathy.

BACKGROUND AND STUDY AIMS: The use of endoscopic ultrasonography (EUS) guidance for fine-needle aspiration (FNA) of mediastinal lymph nodes has become an important aid in the staging of bronchogenic carcinoma. In many cases, it may be an alternative to mediastinoscopy/mediastinotomy (MED), but the cost-effectiveness of the two techniques has not been compared. The aim of this study was to apply a decision-analysis model to compare the cost-effectiveness of EUS and MED in the preoperative staging of patients with non-small-cell lung cancer. PATIENTS AND METHODS: A decision-analysis model was designed, taking as entry criteria lung cancer and abnormal mediastinal lymph nodes verified by computerized tomography (CT). Performance characteristics of MED and EUS were retrieved from the published literature, as were life expectancy data. Direct actual costs of the relevant procedures were retrieved from the billing system of our hospital. RESULTS: The cost per year of expected survival is US$ 1.729 with the EUS strategy, and US$ 2.411 with the MED strategy. The advantage conferred by EUS remains even when the negative predictive value of EUS is as low as 0.22. CONCLUSION: Because of its low cost and high yield, EUS-guided FNA is a cost-effective aid assessing mediastinal lymphadenopathy.

Biopsy, Needle↗

PubMed1998

Specialists achieve better outcomes than generalists for lung cancer surgery.

OBJECTIVE: A push toward care provided by generalists as opposed to specialists has occurred in the health-care marketplace despite a lack of provider specific outcome data. The objective of this study was to determine whether the outcome of patients undergoing lung cancer surgery is different between general surgeons (GSs) and thoracic surgeons (TSs). DESIGN: Examination of data from a state-wide severity-adjusted administrative hospital discharge database. SETTING/PARTICIPANTS: Patients undergoing lung cancer resection in all nonfederal acute care hospitals within South Carolina. MAIN OUTCOME MEASURES: Mortality by specialty adjusted for case mix. RESULTS: From 1991 to 1995, 1,720 resections for lung cancer were performed in South Carolina. One hundred thirty-seven cases were excluded because surgeons did not meet the predefined criteria for board certification, leaving 1,583 resections for analysis. One-half of lobectomies and nearly 60% of pneumonectomies were performed by GSs. Patients were similar in age, sex, gender, race, and the proportion in each severity of illness subclass. Mortality was significantly higher in patients who underwent lobectomy by GSs vs TSs (5.3% vs 3.0%; p<0.05) and in patients with extreme comorbidities (43.6% vs 25.4%; p=0.03) or age >65 years (7.4% vs 3.5%; p<0.05). Seventy percent of TSs performed > 10 cases in the series, whereas 75% of GSs performed <10 (p=0.05). Logistic regression analysis failed to identify any significant variable that might explain the mortality differences between TSs and GSs. CONCLUSION: Mortality is lower for lung cancer resection when the surgery is performed by a TS.

Female↗

PubMed1996

Endoscopic ultrasound with fine-needle aspiration in the diagnosis and staging of lung cancer.

BACKGROUND: Esophageal endoscopic ultrasonographic (EUS) guidance for fine-needle aspiration (FNA) of mediastinal lymph nodes has been introduced only recently. The utility of EUS/FNA in diagnosing and staging bronchogenic carcinoma is unknown. METHODS: After a thoracic computed tomographic scan, 27 patients with known or suspected lung cancer underwent EUS. Accessible abnormal mediastinal lymph nodes were aspirated under EUS guidance. Patients with positive cytologic studies did not undergo further testing, whereas the remaining patients underwent mediastinal exploration. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were calculated for both chest computed tomography and EUS/FNA: RESULTS: Twenty-two of 27 patients had mediastinal adenopathy by computed tomography scan. Sixteen patients had positive findings on EUS, 15 with positive FNA (10 non-small cell lung cancer; 5 small cell lung cancer) and 1 with T4 status. Fourteen patients with positive FNA had lymph nodes sampled at level 5, level 7, or both. Of 11 patients with negative EUS/FNA, 2 had positive findings at operation (sensitivity 89%). The diagnosis of lung cancer was established in 7 patients. CONCLUSIONS: The results showed that EUS/FNA improves the accuracy of computed tomographic scan in the staging of lung cancer. By accessing lymph nodes at levels 5 and 7, EUS/FNA complements mediastinoscopy and is considered the staging modality of choice in these regions. Positive EUS/FNA can obviate the need for further invasive staging.

Biopsy, Needle↗

PubMed1996

Pulmonary blastoma: a rare lung malignancy.

We describe a case of pulmonary blastoma, a rare lung malignancy which affects a younger population. Despite its usually indolent presentation, it is an aggressive malignancy with a prognosis similar to that for bronchogenic carcinoma.

Adult↗

PubMed1995

The clinical evaluation for detecting metastatic lung cancer. A meta-analysis.

The objective of this study was to assess the performance of the clinical evaluation in detecting extrathoracic metastases compared with brain and abdomen CT and radionuclide bone scans in patients with newly diagnosed bronchogenic carcinoma. The included studies were selected using the MEDLARS database from 1977 through August 1992 as well as reference lists from published articles or abstracts. Studies eligible for consideration met six criteria. The most important criterion was that results of a clinical evaluation and a CT scan of the head or abdomen or a radionuclide bone scan, obtained during the initial evaluation of a patient with primary lung cancer, must be included. Data were categorized by the type of clinical evaluation performed and whether patients had a clinical evaluation suggesting metastases (positive) or not (negative). The negative predictive value (NPV) of the clinical evaluation was calculated in all studies. The sensitivity, specificity, and the positive predictive value (PPV) were calculated in studies including positive and negative clinical evaluation patients. Twenty-five studies are included in this analysis. A total of 3,089 imaging scans were obtained in the study patients after a clinical evaluation was performed. The mean NPV of the clinical evaluation for CT of the brain, abdomen, and radionuclide bone scan is 95, 94, and 89%, respectively. When an expanded clinical evaluation was performed, the NPV was even higher. The NPV was influenced by the prevalence of metastases, but still performed well in series with high prevalence rates.(ABSTRACT TRUNCATED AT 250 WORDS)

Abdominal Neoplasms↗

PubMed1994

Does entrained breathing improve the economy of rowing?

A previous study has shown that subjects who entrain breathing during cycling exhibit a lower oxygen consumption (VO2) compared with random breathing. We sought to investigate the hypothesis that entrainment of breathing during rowing improved biomechanical economy (reduced VO2) compared with spontaneous breathing. A secondary hypothesis was that perceptual ratings of breathing difficulty would be lower with entrained breathing. Sixteen physically active male subjects (mean +/- SD age: 21 +/- 5 yr) with no previous rowing experience received instruction in rowing and then performed progressive incremental exercise on the variable-resistance rowing ergometer (Concept II, Morrisville, VT). Peak VO2 was 53.1 +/- 5.4 ml.kg-1.min-1. At three subsequent visits subjects rowed at power productions of 50% and 75% of peak VO2 for 6 min each. At each visit they were randomized to a specific pattern of breathing: inspire during drive, expire during recovery; expire during drive, inspire during recovery; or spontaneous breathing. At the end of each session subjects rated "breathing difficulty" using the 0-10 category-ratio scale. Analysis of variance revealed no significant differences in VO2, VO2/power production, or perceptual ratings at either intensity of exercise for the three different breathing patterns. Although our results do not support either the primary or secondary hypothesis, it is possible that any physiologic and/or perceptual benefits of locomotor-respiratory coupling might be specific for exercise mode or might require months to years of training.

Adult↗

PubMed1993

Deciding timing and technique for tracheostomy.

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Contraindications↗

PubMed1993

Evaluation of dyspnea in the elderly patient.

The symptom of dyspnea in the elderly person should not be considered part of the "normal aging process." Instead, the history, examination, and testing should focus on cardiac disease, respiratory disease, and deconditioning as the most likely causes. Because respiratory sensation is diminished with aging, breathlessness may not develop until a more advanced stage of disease or dysfunction. Clinical measurement of dyspnea is important to assess its severity and to evaluate response to treatment. Specific treatment should be directed toward the pathophysiology of the underlying disease. General strategies for relieving dyspnea include breathing techniques, exercise training and reconditioning, oxygen therapy, improved nutrition, and, in selective cases, psychotropic medication.

Aged↗

PubMed1992

Prognostic significance of tumor proliferative fraction and DNA content in stage I non-small cell lung cancer.

Analyses of tumor DNA content and proliferative fraction by flow cytometry have been useful as prognostic determinants in a variety of solid tumors. The significance of this analysis in Stage I (T1N0M0 and T2N0M0) non-small cell lung carcinoma (NSCC) is unestablished. We determined DNA content (ploidy) and proliferative fraction (percentage S phase) on 44 surgically resected Stage I NSCC specimens obtained between 1977 and 1982. All cases had a minimum follow-up of 5 yr. Of the 44 cases, 27 were adenocarcinomas, 15 squamous cell carcinomas, and 2 large cell carcinomas. Of these, 32 (73%) had T1N0M0 lesions and 12 (27%) had T2N0M0 lesions. Overall 5-yr survival was 70%. All patients surviving 5 yr were free of detectable tumor. Patients with T1N0M0 lesions had an 81% 5-yr survival, but those with T2N0M0 lesions had a 42% 5-yr survival (p = 0.009). Analysis of tumor DNA content revealed 35 diploid tumors (79%) and 9 aneuploid tumors (21%). The 5-yr survival for diploid tumors was 77% compared with a 44% 5-yr survival in aneuploid lesions (p = 0.048). The median proliferative fraction was 6%. All patients with a percentage S phase less than 6% survived 5 yr, and 41% (9 of 22) of those greater than 6% survived 5 yr (p less than 0.001). When 8% S phase was used as a cutoff, 93% (28 of 30) below the cutoff survived 5 yr but only 21% (3 of 14) above the cutoff survived 5 yr (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Adenocarcinoma↗

PubMed1992

The relationship of clinical findings to CT scan evidence of adrenal gland metastases in the staging of bronchogenic carcinoma.

OBJECTIVE: To determine whether, during the staging of newly diagnosed bronchogenic carcinoma, clinical indicators predict the presence or absence of adrenal metastases detected by computerized tomographic (CT) scans. DESIGN: Retrospective review of charts and roentgenograms. SETTING: Academic medical center. PATIENTS: Two hundred five consecutive patients diagnosed with bronchogenic carcinoma, of whom 173 had sufficient data available for analysis. MEASUREMENTS: Charts were reviewed for abnormalities in three clinical categories (signs, symptoms, and routine laboratory tests) and the presence of extrapulmonary tumor spread. The CT scans were reviewed for evidence of adrenal involvement by radiologists blinded to clinical findings. MAIN RESULTS: Thirty patients had abnormal adrenal glands on CT scan. In 26 the abnormality was believed to represent adrenal metastasis, whereas in four the CT findings were consistent with adrenal adenomas. The frequency of adrenal metastases varied with the number of positive, clinical findings (chi 2 = 105.4; p < 0.001). All 26 patients with adrenal metastases had at least one clinical abnormality, and 21 (81 percent had abnormalities in either two or all three clinical categories. In 40 patients without any clinical indicators of widespread disease, none had CT evidence of adrenal metastases. The presence of adrenal metastases also varied with the extent of coexistent disease (chi 2 = 111.82; p < 0.001). Eighty-one percent (21) of the patients with and 18 percent of those without adrenal metastases had both intrathoracic and extrathoracic involvement. CONCLUSIONS: Our findings indicate that adrenal metastases are found in patients with a large tumor burden who have clinical indicators of widespread disease. We found no evidence of adrenal metastases by CT in any patient with a normal clinical evaluation. We conclude that CT scans through the adrenal glands are unnecessary when staging newly diagnosed bronchogenic carcinoma if the findings from the initial clinical evaluation are normal.

Adrenal Gland Neoplasms↗