Report of a vagal paraganglioma at the cervicothoracic junction

BACKGROUND

Vagus nerve paragangliomas are rare tumors, comprising 0.03% of head and neck neoplasms. These tumors are usually located cephalad to the hyoid bone, and there is only one previously reported case that arose from the lower third of the neck.

METHODS

We describe the second reported case of a lower neck vagus nerve paraganglioma that was managed with a limited sternotomy for access and surgical removal.

RESULTS

A 66-year-old male presented with a long-standing lesion of the cervicothoracic junction. CT, MRI, and Ga-68 DOTATATE PET/CT showed an avidly enhancing 5.2 × 4.2 × 11.5 cm mass extending from C6 to approximately T4 level. FNA confirmed the diagnosis. The patient underwent catheter angiography and embolization via direct puncture technique followed by excision of the mass via a combined transcervical and limited sternotomy approach.

CONCLUSION

We describe an unusual case of vagal paraganglioma at the cervicothoracic junction with retrosternal extension requiring a sternotomy for surgical excision.

Comparative Effectiveness of Robotic-Assisted Surgery for Resectable Lung Cancer in Older Patients

BACKGROUND

Robotic-assisted surgery (RAS) is a novel surgical approach increasingly used for patients with non-small cell lung cancer (NSCLC). However, data comparing the effectiveness and costs of RAS vs open thoracotomy and video-assisted thoracoscopic surgery (VATS) for NSCLC are limited.

METHODS

Patients > 65 years old with stage I to IIIA NSCLC treated with RAS, VATS, or open thoracotomy were identified from the Surveillance, Epidemiology, and End Results-Medicare database and matched according to age, sex, stage, and extent of resection. Propensity score methods were used to compare adjusted rates of postoperative complications, adequate lymph node staging, survival, and treatment-related costs.

RESULTS

In this matched study cohort of 2,766 patients with resected NSCLC, RAS was associated with lower complication rates (OR, 0.57; 95% CI, 0.42-0.79) compared with open thoracotomy, and similar complication rates (OR, 1.02; 95% CI, 0.76-1.37) compared with VATS. Patients undergoing RAS were as likely to have adequate lymph node sampling as those undergoing open thoracotomy (OR, 1.28; 95% CI, 0.94-1.74) or VATS (OR, 0.88; 95% CI, 0.66-1.18). There was no significant difference in overall survival after RAS vs open thoracotomy (hazard ratio, 0.81; 95% CI, 0.63-1.04) or VATS (hazard ratio, 0.91; 95% CI, 0.70-1.18). Costs were similar for RAS ($54,702) vs open thoracotomy ($57,104; P = .08), and higher compared with VATS ($48,729; P = .02).

CONCLUSIONS

RAS led to improved operative outcomes compared with open thoracotomy but may not offer an advantage over VATS. The comparative effectiveness of RAS should be further evaluated prior to widespread adoption.

Oxygen Use After Lung Cancer Surgery

BACKGROUND

There are no published reports on predictors of oxygen (O₂) use after lung cancer surgery. The prospect of O₂ use after lung cancer surgery may affect a patient's therapy choice.

METHODS

The Surveillance, Epidemiology, and End Results (SEER)-Medicare data set was queried to identify patients diagnosed with primary lung cancer (stage I/II) who underwent surgical resection from 1994 to 2010. Patients with a second resection within 6 months of their first and those with preoperative O₂ use were excluded. Multivariable logistic regression was performed to evaluate the odds ratios and 95% confidence intervals of O₂ use (defined as being billed for home O₂) after discharge for lung cancer surgery.

RESULTS

Of 21,245 eligible patients from 1994 to 2010, 3,255 (15.3%) were billed for O₂ use in the first month of discharge. Of these, 13.7% (447 of 3,255) stopped using within 1 month, and 1.47% died. By 6 months, an additional 6.7% died, and 46.27% (1,384 of 2,991) were still alive and using O_2. Discharge on O₂ was associated with higher odds of death within 6 months (odds ratio, 1.35; 95% confidence interval, 1.17 to 1.55). The significant, independent risk factors for O₂ use at discharge were procedure, sex, race, histology, pulmonary comorbidities, obesity, length of stay, pulmonary complications, and discharge mode.

CONCLUSIONS

Home O₂ use after lung cancer surgery comprises a sizable portion of this population and is correlated with death in the first 6 months. Various predictors significantly increased the risk of O₂ use at discharge. However, 49.3% of those originally discharged on O₂ were alive and off O₂ at 6 months.

Personal and hospital factors associated with limited surgical resection for lung cancer, in-hospital mortality and complications in New York State

BACKGROUND AND OBJECTIVES

Early stage lung cancer is generally treated with surgical resection. The objective of the study was to identify patient and hospital characteristics associated with the type of lung cancer surgical approach utilized in New York State (NYS), and to assess in-hospital adverse events.

METHODS

A total of 33 960 lung cancer patients who underwent limited resection (LR) or lobectomy (L) were selected from the NYS Statewide Planning and Research Cooperative System database (1995-2012).

RESULTS

LR patients were more likely to be older (adjusted odds ratio OR_adj and [95% confidence interval]: 1.01 [1.01-1.02]), female (OR_adj : 1.11 [1.06-1.16]), Black (OR_adj : 1.17 [1.08-1.27]), with comorbidities (OR_adj : 1.08 [1.03-1.14]), and treated in more recent years than L patients. Length of stay and complications were significantly less after LR than L (OR_adj : 0.56 [0.53-0.58] and 0.65 [0.62-0.69]); in-hospital mortality was similar (OR_adj : 0.93 [0.81-1.07]), and was positively associated with age and urgent/emergency admission, but inversely associated with female gender, private insurance, recent admission year, and surgery volume.

CONCLUSIONS

There was a growing trend toward LR, which was more likely to be performed in older patients with comorbidities. In-hospital outcomes were better after LR than L, and were affected by patient and hospital characteristics.

Is occult lymph node disease in colorectal cancer patients clinically significant? A review of the relevant literature

The clinical significance of micrometastasis of colorectal cancer (CRC) to regional lymph nodes remains controversial. In this review, we analyze publications that have evaluated the clinical significance of occult lymph node metastasis in CRC. An extensive literature search identified 19 publications that evaluated the clinical significance of micrometastatic CRC by various methods, including immunohistochemistry (IHC; n = 13) and reverse transcription-polymerase chain reaction (RT-PCR, n = 6). These studies were reviewed for methodology and findings. Significant limitations in methodology were identified, including inconsistent histological definitions of micrometastatic disease, poor sampling because of an inadequate number of lymph nodes or number of sections per lymph node analyzed, lack of conformity with respect to IHC antibody or RT-PCR marker, and inadequate power because of small sample size. Micrometastatic lymph node metastasis identified by RT-PCR was consistently found to be prognostically significant, but this was not true of micrometastatic disease identified by IHC. RT-PCR analysis of lymph nodes with specific markers can help identify pN0 (pathological-negative lymph node) CRC patients at increased risk for recurrence. The identification of occult disease by IHC techniques may also ultimately prove to be associated with worse outcome, but a number of inadequately powered studies have concluded conversely.

Evaluation of efficacy of an ultrasonic scalpel for pulmonary vascular ligation in an animal model

OBJECTIVE

Dissection to accommodate bulky stapling devices may cause injury to pulmonary arteries in thoracoscopic lobectomies. The Harmonic Ace (Ethicon Endo-Surgery, Inc; Cincinnati, Ohio), a small ultrasonic scalpel used in systemic vessels, was tested on pulmonary vessels in pigs.

METHODS

Nine pigs were assigned 1- or 6-week survival. Lobectomies were performed using the device to divide and ligate pulmonary vessels. Vessel diameter was measured, and ligation outcome was recorded. Necropsies were then performed.

RESULTS

Permanent ligation occurred in 76% of arteries and 92% of veins. At the highest power setting, the instrument showed no failure in arteries 5 mm or less and veins 7 mm or less. Necropsies revealed no evidence of postoperative bleeding. Histopathologic analysis revealed acute coagulation necrosis at 1 week. By 6 weeks, the vessel stumps displayed features consistent with normal wound healing.

CONCLUSIONS

This device reliably divides pulmonary vessels 4 mm and smaller, typically encountered in pig lobectomies. Higher power settings and operator experience may increase effectiveness. Further testing is necessary to delineate the device's limitations before potential use in human pulmonary vasculature.

Optimal markers for real-time quantitative reverse transcription PCR detection of circulating tumor cells from melanoma, breast, colon, esophageal, head and neck, and lung cancers

BACKGROUND

The detection of circulating tumor cells (CTCs) may prove useful for screening, prognostication, and monitoring of response to therapy. However, given the large background of circulating cells, it is probably necessary to detect 1 cancer cell in >10(6) leukocytes. Although reverse transcription (RT)-PCR is potentially sensitive and specific enough to achieve this goal, success will require the use of appropriate mRNA markers. The goal of this study was to identify optimal marker combinations for detection of CTCs.

METHODS

An extensive literature and internet database survey was conducted to identify potential markers. We then used real-time quantitative RT-PCR to test for expression of selected potential markers in tissue samples from primary tumors of breast, colon, esophagus, head and neck, lung, and melanoma and normal blood samples. Markers with high expression in tumors and a median 1000-fold lower expression in normal blood were considered potentially useful for CTC detection and were tested further in an expanded sample set.

RESULTS

A total of 52 potential markers were screened, and 3-8 potentially useful markers were identified for each tumor type. The mRNAs for all but 2 markers were found in normal blood. Marker combinations were identified for each tumor type that had a minimum 1000-fold higher expression in tumors than in normal blood.

CONCLUSIONS

Several mRNA markers may be useful for RT-PCR-based detection of CTCs from each of 6 cancer types. Quantification of these mRNAs is essential to distinguish normal expression in blood from that due to the presence of CTCs. Few markers provide adequate sensitivity individually, but combinations of markers may produce good sensitivity for detection of the presence of these 6 neoplasms.

Complete surgical resection of a 40-cm leiomyosarcoma of the large bowel mesentery

INTRODUCTION

Leiomyosarcoma of the large bowel mesentery is a rare entity and characteristically behaves in an aggressive fashion. Surgical resection is the mainstay of treatment and offers both symptomatic and therapeutic benefit.

CASE

We describe the case of a 55-year-old woman who presented with weight loss, increasing abdominal girth and a large solid inhomogenous mass within the abdomen and pelvis demonstrated on a computed tomography (CT) scan. The patient underwent an exploratory laparotomy and extensive tumor debulking procedure with complete resection of her tumor. Final pathology revealed leiomyosarcoma of the large bowel mesentery. The patient has chosen not to receive adjuvant therapy.

CONCLUSIONS

Leiomyosarcoma of the large bowel mesentery often presents as an advanced lesion making surgical resection a challenging and potentially morbid procedure. Although surgical resection may be faced with significant morbidity, maximum surgical effort with complete resection offers the best overall outcome for patients with this disease.