Diagnostic Methods in Solitary Pulmonary Nodules: Diagnostic Surgical Approach
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Türk Toraks Derneği 12.Yıllık Kongresi, 8-11 Nisan 2009, Antalya
Diagnostic Methods in Solitary Pulmonary Nodules: Diagnostic
Surgical Approach
Cengiz GEBİTEKİN, FETCSUludağ Üniversitesi Tıp Fakültesi
Göğüs Cerrahisi ABD, BURSA
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SPN 5-year survival in stage I Lung
carcinoma diagnosed as SPN – med.%70*
Stage I symptomatic patients %10**
Stage I according to Chest X-ray %30***, CT -%85*****Flehinger BJ. Chest 1992;101:1013-1018, **Melamed MR.Chest 1984;86:44-53 ***Fontana RS. J Occuo Med 1986;28:746-750, ****Swensen SJ Am J Respir Crit Care Med 2002;165:508-
11111513
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Surgery: When, to Whom?Primary Lung Carcinoma
SPNs with spiculary margin SPNs with irregular margin, %83
malignant, with spiculated margins %90 malignant
PET/CT positive SPNs ≥1.5cm in size- high malignancy Increased 5-year survival with
early surgery Low Morbidity and mortality
Türk Toraks Derneği 12.Yıllık Kongresi, 8-11 Nisan 2009, Antalya
Stage of the disease Neoadjuvant treatment Chemotherapy VATS or open surgery for
diagnosis and treatment
Surgery: When and to Whom?Primary Malignancy with
metachronous/syncronous SPN
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SPN – History of Malignancy
What is the risk of follow-up?
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Primary Squamous Cell Ca. and Primary Lung Adenocarcinoma
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Videothoracoscopic Surgery
Finger Palpation
Easy to palpate lesions 2cm away from pleura
Intrathoracic US Radiologic procedures- ”needle
wire”, stains, radiolabelled guiding
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SPN- Reassurence of Patient Surgical approach? Follow-up? Complications? Mortality?
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Hamartoma with spiculated margins
Follow-up? Direct surgery?
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History of malignancy: Breast, Colon and malignant melanomas
SPNs less than 1.5 cm At least 2cm away from the
pleura med.2.6±0.5cm Intrathoracic US (ITUS)+finger
palpation (FP) Radio-guided tracing (RGT)
+finger palpaption
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ITUS %96 FP %76 RGT %80 Finger Palpation %80 p=NS Finding with US med.8min., finger
palpation med.6min. and radio-guided 21 min.
%40 pneumothorax with RGT The most reliable method - ITUS
Türk Toraks Derneği 12.Yıllık Kongresi, 8-11 Nisan 2009, Antalya
40 patients SPN 5-10 mm Without finger palpation Thoracic surgical decision
according to characterstics and growt rate of the SPN
RTG VATS resection Lobectomy if malignant
Türk Toraks Derneği 12.Yıllık Kongresi, 8-11 Nisan 2009, Antalya
Türk Toraks Derneği 12.Yıllık Kongresi, 8-11 Nisan 2009, Antalya
Total 54 patients Peripheric lesions not visible in
fluroscopy med. 2.2±0.7 cm Intrabronchial EBUS and biopsy Lesion was found in 48 (%89)
patients Diagnosis in 38 (%70) patients Avoidance of 9 (%17) thoracotomy Surgery for 16 patients
Türk Toraks Derneği 12.Yıllık Kongresi, 8-11 Nisan 2009, Antalya
%11 patients lesion was not found Med. procedure time 12 dak. Median 4.5 biopsies taken 16 (%30) patients was sent for surgical biopsy
Türk Toraks Derneği 12.Yıllık Kongresi, 8-11 Nisan 2009, Antalya
Türk Toraks Derneği 12.Yıllık Kongresi, 8-11 Nisan 2009, Antalya
Yatış Süresi
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VATS resections in 429 patients Med. size 1.8cm %54 smoker Resection with VATS - %77 Minithoracotomy %23 Med. Size for malignant lesions
2.3cm Median hospital stay 4.6days %14 malignant lesions
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129 patients with SPN %76 minithoracotomy, %24 VATS
resections, at least 2cm. Healty resection margin
Malignant lesions %63 (%47 primary, %16 secondary malignancy)
Med. Hospital stay 6 days Mortality %2.3 5-year survival %66 for primary lung
cancer
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Toplam 276 hasta
%28 %50 %22
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Türk Toraks Derneği 12.Yıllık Kongresi, 8-11 Nisan 2009, Antalya
Reasons for Lobectomy Primer lung cancer Deep SPN Technical difficulties
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Uludağ University Medical Faculty Thoracic Surgery Department
1997-2008 Total 62 patients- 24/62 (%39) Malignant- 38/62 (%61) Benign
Metastases 9/24 (%37.5) History of malignancy in all patients Carcinoid 2/24 (%8) Primary Lung Ca. 13/24 (%54.5) Thoracotmy 21/24 (%87.5) Lobectomy 7/13 (%54) Segmentectomy 6/13 (%46)
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Benign Lezyonlar 38/62 - %61
Hamartoma 18 (%47) Tuberculoma 12 (%31) Benign 4 (%10) Organizing Pneumonia 1 (%3) Leimyoma 1 (%3) Pseudo inflmatory Tm. 1 (%3) Alveolar Fibrozis 1 (%3) Thoracoscopy % 53 Thoracotomy % 47
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Minithoracotomy-Wedge ResectionCarcinoid Tm-Wedge
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Toracoscopic wedgeHamartoma
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Toracoscopic SegmentectomyBronchioloalveolar carcinoma
PET-SUV1.5
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Open excisionInf. pseudotümör
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VATS WedgeAdeno Ca Lobectomy
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Resection with full muscle sparing minithoracotomy
Approx. 8-10 cm. incision
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Left Pneumonectomy
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Conclusion
Surgery in patients with malignancy history
VATS in all patients Main problem is palpation Finger palpation is reliable
procedure Minithoracotomy/VATS no difference Short hospital stay (med.2.3 days) Diagnostic value 100% Early return to daily activities
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Thank You