PubMed Health⌕ Search

Biomedical subjects

Robert J Downey

Publications and source records attributed to Robert J Downey.

At least 19 recordsLinked to original sources
PubMed2006

The impact of video-assisted thoracic surgery (VATS) in patients with suspected advanced ovarian malignancies and pleural effusions.

OBJECTIVES: We previously reported our initial experience of patients with suspected advanced ovarian cancer and moderate to large pleural effusions who underwent video-assessed thoracic surgery (VATS) before planned abdominal exploration. The objective of this study was to report the surgical findings and management of patients who underwent VATS in an update of our experience. METHODS: We performed a retrospective review of all patients with suspected advanced ovarian cancer and moderate to large pleural effusions who underwent VATS for assessment of extent of intrathoracic disease at our institution between 6/01 and 8/05. RESULTS: Twenty-three patients with a median age of 61 years (range, 36-79) were identified. VATS was performed for right-sided effusions in 17 patients (74%), and a median of 1350 ml (400-3700 ml) of pleural fluid was drained. VATS demonstrated macroscopic disease in 15 (65%) patients, with nodules >1 cm in 11/15 (73%), and nodules <1 cm in 4/15 (27%). Macroscopic intrathoracic disease was found in 4/10 (40%) patients with negative cytology. Intrathoracic cytoreduction was performed in 3/11 patients (27%) with intrathoracic disease >1 cm. After VATS, 12/23 patients (52%) underwent primary surgical management, with cytoreduction to < or =1 cm achieved in 11/12 patients (92%). The other eleven patients received primary chemotherapy after undergoing diagnostic laparoscopy alone (4/11) or no further abdominal exploration (7/11). Nine of these patients proceeded to interval cytoreduction, while 2 had pathology demonstrating upper gastrointestinal and lymphoma primaries at the time of VATS. Final diagnosis of primary site of disease included: ovary, 14 (61%); endometrial, 2 (9%); dual ovarian/endometrial primaries, 1 (4%); fallopian tube, 1 (4%); primary peritoneal, 1 (4%); other, 4 (17%). Overall, findings at VATS altered primary surgical management in 11/23 (48%) patients. CONCLUSIONS: Sixty-five percent of patients with suspected advanced ovarian cancer and moderate to large pleural effusions had gross intrathoracic disease identified at VATS, with the majority (11/15, 73%) having disease >1 cm in diameter. Use of VATS allows for assessment of intrathoracic disease and may help identify candidates for primary cytoreductive surgery and possible intrathoracic cytoreduction versus neoadjuvant chemotherapy.

Adult↗
PubMed2006

Acupuncture is a feasible treatment for post-thoracotomy pain: results of a prospective pilot trial.

BACKGROUND: Thoracotomy is associated with severe pain that may persist for years. Acupuncture is a complementary therapy with a proven role in pain control. A randomized trial showed that acupuncture was effective in controlling pain after abdominal surgery, but the efficacy of this technique for the treatment of thoracotomy pain has not been established. We developed a novel technique for convenient application of acupuncture to patients undergoing thoracotomy, and in a Phase II trial evaluated the safety of this intervention and the feasibility of doing a randomized trial. METHODS: Adult patients scheduled for unilateral thoracotomy with preoperative epidural catheter placement received acupuncture immediately prior to surgery. Eighteen semi-permanent intradermal needles were inserted on either side of the spine, and four were inserted in the legs and auricles. Needles were removed after four weeks. Using a numerical rating scale, pain was measured on the first five postoperative days. After discharge, pain was assessed using the Brief Pain Inventory at 7, 30, 60 and 90 days. RESULTS: Thirty-six patients were treated with acupuncture. Of these, 25, 23, and 22 patients provided data at 30, 60, and 90 days, respectively. The intervention was well tolerated by patients with only one minor and transient adverse event of skin ulceration. CONCLUSION: The rate of data completion met our predefined criterion for determining a randomized trial to be feasible (at least 75% of patients tolerated the intervention and provided evaluable data). This novel intervention is acceptable to patients undergoing thoracotomy and does not interfere with standard preoperative care. There was no evidence of important adverse events. We are now testing the hypothesis that acupuncture significantly adds to standard perioperative pain management in a randomized trial.

Journal Article↗
PubMed2006

Results of chest wall resection and reconstruction with and without rigid prosthesis.

BACKGROUND: Chest wall resections are associated with significant morbidity, with respiratory failure in as many as 27% of patients. We hypothesized that our selective use of a rigid prosthesis for reconstruction reduces respiratory complications. METHODS: The records of all patients undergoing chest wall resection and reconstruction were reviewed. Patient demographics, use of preoperative therapy, the location and size of the chest wall defect, performance of lung resection if any, the type of prosthesis, and postoperative complications were recorded. Predictor of complications were identified by chi2 and logistic regression analyses. RESULTS: From January 1, 1995, to July 1, 2003, 262 patients (median age, 60 years) underwent chest wall resection for tumor in 251 (96%), radiation necrosis in 7 (2.7%); and infection in 4 patients (1.3%). The median defect size was 80 cm2 (range, 2.7 to 1,200 cm2) and the median number of ribs resected was 3 (range, 1 to 8). Major lung resection was performed in 85 patients (34%). Prosthetic reconstruction was rigid (polypropylene mesh/methylmethacrylate composite) in 112 (42.7%), nonrigid (polytetrafluoroethylene or polypropylene mesh) in 97 (37%), and none in 53 patients. Postoperatively, 10 patients died (3.8%), 4 of whom had pneumonectomy plus chest wall resection. Respiratory failure occurred in 8 patients (3.1%). By multivariate analysis, the size of the chest wall defect was the most significant predictor of complications. CONCLUSIONS: Our incidence of respiratory failure is lower than previously reported and may relate to our use of rigid repair for defects likely to cause a flail segment. Pneumonectomy plus chest wall resection should be performed only in highly selected patients.

Adult↗
PubMed2006

Preoperative 18[F]-fluorodeoxyglucose positron emission tomography standardized uptake values predict survival after esophageal adenocarcinoma resection.

BACKGROUND: Clinical staging modalities for esophageal cancer are inaccurate at determining prognosis, especially in early-stage patients. We performed a retrospective review of patients with esophageal adenocarcinoma imaged by positron emission tomography before surgical resection to determine whether 18[F]-fluorodeoxyglucose uptake predicted overall survival independently of clinical and pathologic stage. METHODS: The study is a retrospective review of patients with adenocarcinoma of the esophagus treated by surgery. All patients were imaged with computed tomography and positron emission tomography imaging, and most patients had an endoscopic ultrasound. We compared positron emission tomography standardized uptake values (SUVmax) with clinical and pathologic stage and survival. Prognostic variables were assessed by log-rank test, and survival by the method of Kaplan and Meier. RESULTS: From January 1996 through June 2004, 50 patients meeting study eligibility criteria were analyzed. Median follow-up for surviving patients was 27 months. The median SUVmax was 4.5. Stratification of patients by the median SUVmax predicted survival. The 3-year survival was 57% for patients with an SUVmax greater than 4.5 and 95% for patients with an SUVmax of 4.5 or less (p = 0.02). The survival advantage of the SUVmax 4.5 or less group was also seen in clinically early-stage patients (defined as no adenopathy on computed tomography and positron emission tomography, and by endoscopic ultrasound T1-2 N0), as well as in patients with pathologically early-stage disease (T-2 N0). CONCLUSIONS: In surgically managed esophageal adenocarcinoma patients, SUVmax predicts overall survival. Moreover, SUVmax identifies patients who have a poor prognosis from a subset of patients that would otherwise be considered to have early-stage disease.

Adenocarcinoma↗
PubMed2006

Surgery for colorectal and sarcomatous pulmonary metastases: history, current management, and future directions.

This article provides a historical review of metastasectomy, reviews current surgical management approaches, and proposes what direction future research must take to determine whether there is a survival advantage associated with pulmonary metastasectomy and how best to integrate metastasectomy with medical therapies, primarily induction, and adjuvant chemotherapy.

Colorectal Neoplasms↗
PubMed2005

Primary epithelial lung malignancies in the pediatric population.

BACKGROUND: Primary epithelial lung malignancies are rare in childhood and adolescence. We reviewed the Memorial Sloan-Kettering Cancer Center experience with these tumors to better understand their histology, time to diagnosis, treatment, and outcome. PROCEDURE: A retrospective review was performed on all patients 21 years of age or younger at diagnosis, treated for primary epithelial lung malignancies at Memorial Sloan-Kettering Cancer Center between 1980 and 2001. RESULTS: We identified 11 patients with primary epithelial lung malignancy. The median age at diagnosis was 19 (range: 12-21) years. The most common radiographic abnormality was a mass (55%) on chest imaging. Seven patients (64%) were initially diagnosed as having pneumonia which contributed to a delay in diagnosis. Final pathologic diagnoses included adenocarcinoma (four), carcinoid tumor (three typical, one atypical), basaloid carcinoma (two), and mucoepidermoid carcinoma (one). A majority of patients presented with advanced disease (two stage III, four stage IV). Patients with localized disease were treated with surgical resection and all but one remains disease free with a median follow-up of 60 months (range: 13-286). Patients with either advanced locoregional or distant metastatic disease were treated with multimodal therapy and a majority had rapid progression of disease. CONCLUSIONS: When children and adolescents present with primary epithelial lung malignancy a majority will have advanced disease and experience a delay in diagnosis. The histologic types of tumors encountered are similar to lung tumors occurring in adults, although the frequency of the various types differs. Carcinoid tumors are more frequent, and less common subtypes of bronchogenic carcinoma are also more prevalent in the pediatric age group. Similar to the adult population, the prognosis of these tumors is dependent on histology and stage. Patients with carcinoid tumors seem to have the best prognosis, followed by adenocarcinoma. The highly aggressive basaloid carcinoma has the worst.

Adenocarcinoma↗
PubMed2005

Invited commentary.

Explore the source record for details and available documents.

Airway Obstruction↗
PubMed2004

Preoperative F-18 fluorodeoxyglucose-positron emission tomography maximal standardized uptake value predicts survival after lung cancer resection.

PURPOSE: A retrospective review of surgically treated lung cancer patients imaged preoperatively by F-18 fluorodeoxyglucose-positron emission tomography ([(18)F]FDG-PET) to determine if the primary tumor standardized uptake value (SUV) predicts survival. PATIENTS AND METHODS: Non-small-cell lung cancer or carcinoid pT1-4, N0-2, M0 patients treated by R0 surgical resection alone were imaged with computed tomography scan and PET within 90 days before surgery. Prognostic variables were assessed by log-rank test; survival was assessed by the method of Kaplan and Meier. RESULTS: One hundred consecutive patients (48 men, 52 women) were retrospectively reviewed. Median follow-up for surviving patients was 28 months (range, 16 to 81 months). Median maximal SUV (SUV(MAX)) was 9. The 2-year survival for patients with SUV(MAX) more than 9 was 68% and for those with SUV(MAX) less than 9, it was 96% (P <.01, log-rank test). In a multivariate analysis including pathologic tumor size, involved nodes, histology, and SUV(MAX), only tumor size (T) more than 3 cm and SUV(MAX) more than 9 and their interaction were significant predictors of survival (P =.01, 0.02, and < 0.01, respectively). The 3-year survivals for patients with both T less than 3 cm and SUV(MAX) less than 9 was 97%; for those with T less than 3 cm and SUV(MAX) more than 9, it was 94%; for those with T more than 3 cm and SUV(MAX) less than 9, it was 93%; and for those with T more than 3 cm and SUV(MAX) more than 9, it was 47% (P <.01). CONCLUSION: In surgically managed lung cancer patients, SUV is a predictor of overall survival after resection. The addition of SUV(MAX) to pathologic tumor size identifies a subgroup of patients at highest risk for death as a result of recurrent disease after resection.

Adult↗
PubMed2004

Surgical management of thoracic malignancies invading the heart or great vessels.

BACKGROUND: Surgical resection of thoracic malignancies involving either the heart or great vessels is uncommonly performed because of the potential morbidity and mortality for an unknown probability of significant palliation or cure. We reviewed our experience of 10 patients treated surgically, either primarily or as a component of multimodality therapy, to assess feasibility and results. METHODS: A retrospective review of the results in 10 patients who underwent resection of thoracic malignancies that included either great vessel or the heart was conducted. RESULTS: Histologic diagnoses included soft tissue sarcoma (n = 7), squamous cell carcinoma (n = 1), malignant thymoma (n = 1), and mediastinal teratoma (n = 1). Three patients underwent induction chemotherapy. Cardiopulmonary bypass was used in 7 patients. Structures resected included superior vena cava (n = 5), left atrium (n = 4), right atrium (n = 2), descending aorta (n = 1), and main pulmonary artery (n = 1). Concomitant anatomic pulmonary resections were performed in 3 patients. Seven patients had an R0 or R1 resection. There were no perioperative deaths. All symptomatic patients had immediate and sustained palliation of their presenting symptoms. The median length of stay was 6 days (range, 4 to 43 days). Six patients underwent postoperative systemic therapy. The overall median survival was 21.7 months (range, 3.2 to 69 months) and was 33.3 months (range, 3.7 to 69 months) for patients who had an R0 or R1 resection. CONCLUSIONS: Resection of the heart and great vessels involved by thoracic malignancies can be performed with acceptable morbidity and mortality and results in significant palliation and, in some cases, prolonged survival.

Adult↗
PubMed2004

Non-small cell lung cancer with a solitary hematogenous metastasis.

The standard treatment for patients with stage IV non-small cell lung cancer (NSCLC) is chemotherapy. Retrospective series suggest, however, that some patients with stage IV lung cancer with a solitary synchronous site of extrathoracic metastatic (M1) disease are effectively treated by resection of both the primary tumor and the meststasis. Although these patients represent a small minority of those with stage IV lung cancer, it appears reasonable to consider highly selected patients with a solitary resectable metastasis from NSCLC for surgical resection of all evident disease or for chemotherapy without surgery. Because of the results of the current author's trial, however, it is difficult to recommend the regimen of combined medical and surgical therapies used in the current protocol in the management of solitary M1 disease. Future trials could be designed to include newer, less toxic chemotherapeutic regimens.

Adrenal Gland Neoplasms↗
PubMed2004

Advanced imaging including PET/CT for cardiothoracic surgery.

Medical imaging has always been essential for the diagnosis and management of many problems encountered in cardiothoracic surgical practice, from the assessment of cardiac function (e.g., by providing the location and extent of an infarct), to defining the extent of a malignancy via noninvasive imaging modalities to guide the choice of more invasive steps (e.g., biopsies or resections). Although most imaging still relies on standard radiological modalities such as computed tomography (CT), positron emission tomography (PET) has become more widely used in the US since its most recent clinical breakthrough. With the increasing availability of combined PET/CT units that deliver both anatomical and metabolic information in a single examination, PET imaging can potentially be used to a greater extent than what has been previously attainable. This review will provide an overview of recent advances in imaging that are likely to influence the direction of cardiothoracic surgery in the near future.

Heart Diseases↗
PubMed2003

Whole body 18FDG-PET and the response of esophageal cancer to induction therapy: results of a prospective trial.

PURPOSE: Whole-body 18F-fluorodeoxyglucose ([18F]FDG) positron emission tomography (PET) imaging before and after induction therapy was prospectively evaluated in patients with esophageal cancer to determine whether changes in PET images could measure response to therapy. PATIENTS AND METHODS: Between April 1997 and April 1999, 39 patients (34 men and five women; median age, 59 years; range, 36 to 76 years) with esophageal cancer were prospectively enrolled in a single-institution clinical trial of staging, including PET, induction therapy, restaging including PET, and esophagectomy. All patients undergoing esophagectomy after induction therapy (n = 17) were followed either to recurrence, to death, or through a disease-free interval of at least 24 months. RESULTS: PET after standard staging studies and before therapy imaged undetected sites of metastatic disease in six patients (15%). Restaging (including PET) after induction therapy did not identify any patients with disease progression or any patients with loco-regionally unresectable disease at exploration. The median decrease in the standardized uptake value (SUV) during induction therapy was 59%. After R0 esophagectomy, the 2-year disease-free and overall survival was 38% and 63%, respectively, among patients who had a less than 60% decrease in SUV, and 67% and 89%, respectively, among patients who had a greater than 60% decrease in SUV (P =.055 and P =.088, respectively). CONCLUSION: Compared with conventional imaging, PET detects additional sites of metastatic disease at initial evaluation. After induction therapy, PET did not add to the estimation of loco-regional resectability and did not detect new distant metastases. However, changes in [18F]FDG PET may predict disease-free and overall survival after induction therapy and resection in patients with esophageal cancer. Further evaluation in larger trials is warranted.

Adult↗
PubMed2003

Results of the American College of Surgeons Oncology Group Z0050 trial: the utility of positron emission tomography in staging potentially operable non-small cell lung cancer.

OBJECTIVES: The American College of Surgeons Oncology Group undertook a trial to ascertain whether positron emission tomography with 18F-fluorodeoxyglucose could detect lesions that would preclude pulmonary resection in a group of patients with documented or suspected non-small cell lung cancer found to be surgical candidates by routine staging procedures. METHODS: A total of 303 eligible patients registered from 22 institutions underwent positron emission tomography after routine staging (computed tomography of chest and upper abdomen, bone scintigraphy, and brain imaging) had deemed their tumors resectable. Positive findings required confirmatory procedures. RESULTS: Positron emission tomography was significantly better than computed tomography for the detection of N1 and N2/N3 disease (42% vs 13%, P =.0177, and 58% vs 32%, P =.0041, respectively). The negative predictive value of positron emission tomography for mediastinal node disease was 87%. Unsuspected metastatic disease or second primary malignancy was identified in 18 of 287 patients (6.3%). Distant metastatic disease indicated in 19 of 287 patients (6.6%) was subsequently shown to be benign. By correctly identifying advanced disease (stages IIIA, IIIB, and IV) or benign lesions, positron emission tomography potentially avoided unnecessary thoracotomy in 1 of 5 patients. CONCLUSIONS: In patients with suspected or proven non-small cell lung cancer considered resectable by standard staging procedures, positron emission tomography can prevent nontherapeutic thoracotomy in a significant number of cases. Use of positron emission tomography for mediastinal staging should not be relied on as a sole staging modality, and positive findings should be confirmed by mediastinoscopy. Metastatic disease, especially a single site, identified by positron emission tomography requires further confirmatory evaluation.

Adult↗
PubMed2003

Management of major hemorrhage during mediastinoscopy.

OBJECTIVE: The management of major hemorrhage complicating mediastinoscopy is not well described. We reviewed our experience to determine the frequency, optimal management strategy, and outcome of these injuries. METHODS: A retrospective review of all mediastinoscopies performed at a single institution during a 12-year period (January 1990-January 2002) was performed. Major hemorrhage was defined as that requiring exploration for definitive control. RESULTS: During the study period, 3391 mediastinoscopies were performed. Fourteen patients (0.4%) experienced major hemorrhage. Most patients (12/14) had non-small cell lung cancer, and only 1 patient each underwent preoperative radiation, repeat mediastinoscopy, or extended mediastinoscopy. The most common biopsy site (4/14 cases) resulting in major hemorrhage was the lower right paratracheal region (level 4R), and the most frequently injured vessels were the azygos vein and the innominate and pulmonary arteries. Initial control of hemorrhage was achieved through packing in 93% (13/14), and the most common initial approach for exploration was sternotomy (8/14). Four patients underwent a planned pulmonary resection after definitive control of bleeding. The median amount of blood transfused was 2 units (range 0-18 units). Postoperative complications occurred in 2 of 14 patients (14%). There were no intraoperative deaths, but 1 patient died postoperatively (1/14, 7% mortality). The median postoperative length of stay was 6 days (range 1-19 days). CONCLUSIONS: Major hemorrhage during mediastinoscopy is an uncommon but potentially morbid event. Initial control can usually be achieved through packing. Subsequent management presents a technical challenge but can result in minimal morbidity and mortality.

Aged↗
PubMed2002

Long-term results of combined-modality therapy in resectable non-small-cell lung cancer.

PURPOSE: Assessment of long-term results of combined-modality therapy for resectable non-small-cell lung cancer is hampered by insufficient follow-up and small patient numbers. To evaluate this, we reviewed our collective experience. PATIENTS AND METHODS: This study was a retrospective chart review recording demographics, tumor stage, treatment, and outcome of consecutive patients undergoing surgery. Survival was analyzed by Kaplan-Meier, and prognostic factors were analyzed by log-rank and Cox regression. RESULTS: From January 1993 to December 1999, 470 patients were treated, with follow-up in 446: 27 stage I, 55 stage II, 316 stage III, 43 stage IV (solitary M1), and five uncertain. Chemotherapy was mitomycin/vinblastine/cisplatin (174 patients [39.0%]), carboplatin/paclitaxel (148 [33.2%]), and other combination (124 [27.8%]); 75 patients (16.8%) received induction radiation. Resection was complete in 77.4%, incomplete in 8.3%, attempted but with gross residual disease afterward in 1.8%, and not performed in 12.6%. Pathologic complete response occurred in 20 patients (4.5%). With median follow-up of 31.0 months for patients still alive, median and 3-year survival for pathologic stages 0, I, II, III, and IV were more than 90 months, 73%; 42 months, 52%; 23 months, 35%; 16 months, 28%; and 16 months, 23% (P <.001). In a multivariate analysis, age, complete resection, pathologic stage, and pneumonectomy, but not induction regimen, significantly influenced survival. CONCLUSION: Although pathologic complete response outside the protocol setting is low, survival of this large patient cohort is comparable to that of patients in published combined-modality trials. Survival is significantly influenced by patient age, complete resection, pathologic stage, and pneumonectomy. These results can help guide standard clinical practice and emphasize the need for novel induction regimens.

Adult↗
PubMed2002

An initial experience with FDG-PET in the imaging of residual disease after induction therapy for lung cancer.

BACKGROUND: The 2-fluoro-2-deoxy-d-glucose positron emission tomography (FDG-PET) imaging is an advance over computed tomography alone in the staging of untreated nonsmall cell lung cancer (NSCLC). Aside from one 9-patient study, there are no data comparing FDG-PET imaging with surgical staging of NSCLC after induction therapy. METHODS: We reviewed our institutional experience with FDG-PET imaging followed by surgical staging of nonsmall cell lung cancer after induction therapy. A nuclear physician blinded to surgical findings reviewed the FDG-PET scans and assigned a clinical TNM stage. A thoracic surgeon assigned a pathologic TNM stage. Then the clinical TNM stage and the pathologic TNM stage were compared. RESULTS: Fifty-six patients (30 males and 26 females; median, age 60) with nonsmall cell lung cancer underwent chemotherapy (40 patients), chemoradiation (11 patients), or radiation alone (5 patients) followed by PET and operations. PET had a positive predictive value of 98% for detecting residual viable disease in the primary tumor. PET over-staged nodal status in 33% of patients, under staged nodal status in 15%, and was correct in 52%. PET correctly classified all patients with M1 disease. CONCLUSIONS: Positron emission tomography after induction therapy accurately detects residual viable primary tumor, but not the involvement of mediastinal lymph nodes.

Carcinoma, Non-Small-Cell Lung↗