Baylor Scott & White Center for Thoracic Surgery

Achalasia

The Center for Thoracic Surgery and The Center for Esophageal Diseases work together to diagnose and treat Achalasia.

We have a multidisciplinary group composed of gastroenterologists and surgeons who work hand-in-hand to offer all aspects of care for patients.

We evaluate more than 400 patients with this rare condition every year and perform more than 100 surgical procedures yearly, including Dilations, Heller Myotomy and POEM, which we tailor and individualize to each patient's needs.

Diagnostic studies include:

Barium esophagram

A contrast radiologic swallowing study performed on an outpatient basis. A patient swallows barium while sequential images are taken of the esophagus. Classic radiologic findings in a patient with achalasia include dilatation of the esophagus and narrowing of the gastroesophageal junction, which causes a "bird beak" appearance on an X-ray. Other findings include esophageal aperistalsis and poor emptying of contrast from the esophagus. The esophagram helps establish the diagnosis of achalasia and determine the stage of achalasia (early or late) judged by the dilatation and deformity (tortuosity) of the esophagus. Both these findings have implications on treatment and prognosis.

Upper endoscopy

A small camera (endoscope) is inserted through the mouth and used to examine the esophagus and stomach. Upper endoscopies are performed on an outpatient basis and under sedation. In evaluating patients with possible achalasia, an upper endoscopy rules out tumors or scarring (strictures) as causes of dysphagia, which may mimic achalasia symptoms (pseudoachalasia).

Esophageal manometry

A small tube (catheter) with pressure transducers along its length is briefly inserted through the nose or mouth, through the esophagus, and into the stomach. Esophageal manometry is performed on an outpatient basis. The patient is asked to swallow while pressure readings are performed, and then the catheter is removed. These readings determine the esophagus's peristalsis and relaxation of the lower esophageal sphincter. Manometric findings of aperistalsis and incomplete lower esophageal sphincter relaxation solidify achalasia's diagnosis.

EndoFLIP®

EndoFLIP® (endolumenal functional lumen imaging probe) is a newer, minimally invasive device created to complement traditional diagnostic tests. EndoFLIP uses a balloon mounted on a thin catheter placed transorally at the time of a sedated endoscopy. In comparison to traditional diagnostic tests, EndoFLIP offers the additional capability of measuring the cross-sectional area and intraluminal pressure of the esophagus while under distension (as if a solid bolus was present). The technology uses impedance planimetry to estimate cross-sectional area.

Benign fibrous tumors of the pleura

The pleura is the smooth, pale yellow transparent membrane that lines the thorax and envelopes the lungs. Its function is to protect and cushion the lungs.

The most common tumors that occur in the pleura are malignant (cancerous) forms of mesothelioma caused by exposure to asbestos. But sometimes fibrous tumors unrelated to asbestos exposure can develop in the pleura. These can be either malignant or benign (non-cancerous).

Benign fibrous tumors of the pleura are sometimes called solitary fibrous tumors. They make up approximately 78% to 88% of non-mesothelioma tumors of the pleura. Fibrous tumors of the pleura are much less common than mesothelioma tumors of the pleura.

Benign fibrous tumors of the pleura are confined to the surface of the lung, where they start.

Who gets benign fibrous tumors of the pleura?

These tumors are slightly more prevalent in females than males. Most patients diagnosed with benign fibrous tumors of the pleura are in their 50s and 60s.

What causes benign fibrous tumors of the pleura?

The causes of benign fibrous tumors of the pleura are not known. It is known, however, that exposure to asbestos – the primary cause of mesothelioma tumors – does not cause this condition. Smoking, though discouraged, is also not considered a cause of benign tumors of the pleura.

What are the symptoms of benign fibrous tumors of the pleura?

Many patients with benign fibrous tumors of the pleura do not have any symptoms at all, even though these tumors are often very large (up to 40 cm in diameter). Some patients may have these symptoms:

• Chest pain
• A persistent cough
• Shortness of breath

If you notice any of these symptoms in yourself, you should consult your healthcare provider as soon as possible.

How are benign fibrous tumors of the pleura diagnosed?

If your doctor thinks you may have a pleural tumor, he or she will obtain a chest X-ray or chest CT scan to check for masses. A needle or surgical biopsy will be done to find out if the tumor is benign or malignant.

How are benign fibrous tumors of the pleura treated?

Even though fibrous tumors of the pleura are not cancer, surgery is still the recommended treatment. Without surgical removal, the tumors have the potential to become malignant. Your healthcare provider can best suggest a plan of treatment to suit your diagnosis.

What is the prognosis for someone with benign fibrous tumors of the pleura?

The outlook for a patient with benign fibrous tumors of the pleura is excellent with surgical treatment. Only about eight percent recur after surgery, and these are usually successfully treated with follow-up surgery.

Conditions of the diaphragm

• Diaphragmatic plication for diaphragmatic paralysis
• Diaphragmatic pacing

The Department of Thoracic Surgery and Lung Transplantation at Baylor University Medical Center, part of Baylor Scott & White Health is dedicated to excellence in the field of thoracic surgery. Surgeons on the medical staff have world renowned reputations in thoracic oncology, minimally invasive surgery, esophageal disorders and lung transplantation. Our advanced treatments provide you with quality outcomes and are coupled with compassionate care.

Conditions of the trachea

The trachea is the windpipe which transports air from the mouth to the lungs. It is connected above in the neck to the larynx (“Adam’s apple”) and below in the chest it divides into the left and right bronchi which connect to each lung. The surgeons in the Department of Thoracic Surgery at Baylor University Medical Center diagnose and treat a variety of diseases affecting the trachea.

Benign conditions include:

• Tracheal stenosis: narrowing of the trachea, most commonly following intubation (breathing tube placement) or previous surgery
• Tracheal inflammation: associated with systemic diseases such as Wegener’s granulomatosis

Malignant conditions include:

• Tumors of the airway
• Cancer of adjacent organs causing compression or invasion of the trachea

Tracheal Stenosis

Tracheal stenosis is narrowing of the trachea. Babies can be born with this condition, but most adult cases develop due to the growth of scar tissue during a period of prolonged intubation (breathing tube placement) or following tracheostomy, a surgically-created opening in the neck for breathing. The trachea can also be externally compressed by other structures, most commonly tumors of the thyroid gland and esophagus.

Tracheal Inflammation

Several autoimmune disorders and infections can cause inflammation of the trachea which functionally blocks air flow similar to tracheal stenosis. These include Wegener’s granulomatosis, sarcoidosis, and amyloidosis. It can also occur as a side effect of radiation therapy to the head, neck, or chest for other conditions.

Tumors Of The Airway

Tumors that arise in the trachea and bronchi are much more uncommon that tumors of adjacent structures that involve the trachea.

Benign tracheal and bronchial tumors include:

• Carcinoid tumors: these tumors grow much more commonly in the bronchi than the trachea. They occur most often between the ages of 40-60 years, are not associated with smoking, and can produce hormones that cause other systemic symptoms in the heart and gastrointestinal tract.
• Papillomas: these tumors are benign growths associated with human papillomavirus (HPV). They often grow in groups, referred to as papillomatosis, and can carry the risk of transforming into squamous cell carcinoma.
• Chondroma: these tumors grow from the cartilage portion of the airway and are very rare.
• Hemangioma: these are tumors of the blood vessels of the airway and can cause significant bleeding if rupture or during surgical manipulation.

Malignant tracheal and bronchial tumors include:

• Squamous cell carcinoma: this most common type of tracheal tumor usually grows in the lower part of the trachea. Smoking is the main risk factor, and these tumors tend to grow quickly and cause bleeding and shortness of breath.
• Adenoid cystic carcinoma: much less common, these tumors grow slowly and are not associated with smoking.

Cancer Of Adjacent Organs

Cancer of the structures around the airway can affect the passage of air through the trachea. These include:

• Thyroid gland: benign goiter as well as cancer of the thyroid gland can compress the trachea in the neck or chest region and cause shortness of breath.
• Esophagus: the food pipe sits directly next to the trachea. Cancers of this organ can (1) grow into the airway; (2) develop abnormal communication with the airway (fistula) and (3) treatment of this condition with radiation therapy or stents can damage the airway.
• Lung: the lung is directly communicating with the airway at the level of the bronchi, but tumors of the upper part of the lung as well as abnormal lymph nodes in the chest can compress the trachea and cause symptoms.

Diagnosing Diseases Of The Trachea

Diseases of the trachea are evaluated using a combination of non-invasive and invasive tests.

Non-Invasive Testing Includes:

• Pulmonary function testing determines how much air can be breathed in and out and helps classify types of airway and lung diseases. It can also be used to assess the muscles of the chest wall and mechanics of breathing.
• Ultrasound uses sonography to see inside the body. It is particularly useful for assessing the thyroid gland when it is abnormally large and impinging on the trachea.
• CT (computed tomography) scan uses X-ray images to create virtual images of the inside of the body. It is essential in the diagnosis of airway and lung diseases. Advanced 3D reconstructions are particularly useful in planning treatment for airway conditions.
• PET (positron emission tomography) scan uses an injected dye to assess metabolic activity and detect the likelihood of cancer.

Invasive testing includes:

• Endoscopy: fiberoptic tubes that are inserted through the mouth or nose and relay a high-definition image to the operator allowing direct visualization inside the body. Bronchoscopy includes endoscopic evaluation of the larynx, trachea, and bronchi. This can be augmented with endobronchial ultrasound (EBUS), which allows sonographic visualization of the tissue around the airway, most specifically the lymph nodes. EBUS is essential in diagnosing and staging tumors of the trachea, lungs, and esophagus.
• Biopsy: tumors of the airway or surrounding structures can be biopsied at the time of endoscopy, or rarely at a separate appointment through the skin. Biopsy samples are evaluated under the microscope by our pathologists, and rare cases are further reviewed at an interdisciplinary tumor board.

Treating Diseases Of The Trachea

Diseases of the trachea are complex and require a multidisciplinary approach. The Department of Thoracic Surgery at Baylor University Medical Center coordinates care between our thoracic surgeons, interventional pulmonologists, head and neck surgeons, radiologists, anesthesiologists, and pathologists to determine the optimal strategy for each individual patient.

Treatments range from the administration of medication (such as chemotherapy) or radiation, to endoscopic interventions, to open surgery. Our physicians are constantly trialing new products and techniques to stay on the cutting edge of tracheal medicine, and often will provide therapy to patients deemed untreatable at other centers.

Endoscopic interventions can be performed for definitive treatment of many conditions or for palliation of symptoms. They can typically be performed through a tiny fiberoptic camera (flexible bronchoscope), but occasionally require a larger metal scope (rigid bronchoscope); either way, no incisions are made and side effects are minimal. These interventions include:

• Tumor resection: some tumors can be partially or completely removed through a scope with no open surgery necessary. This can be done mechanically, or with the aid of argon beam or laser therapy.
• Dilation: tracheal stenosis or compression by an external structure can be relieved by pneumatically dilating the blocked area with a balloon, which can result in temporary or permanent resolution.
• Stents: placement of metal or silicone stents within the area can keep the constricted area open. This can be performed as a temporary or permanent measure, and allows for symptom relief while other treatments are administered, such as chemotherapy or radiation.

Surgery

Open tracheal surgery is complex, and requires a specialized center and a highly trained team. The surgeons in the Department of Thoracic at Baylor University Medical Center all underwent advanced training in airway surgery, which is only performed a select centers in the country.

Surgery on the trachea involves removal (resection) of the diseased segment followed by reattachment of the ends of the airway (reconstruction). This is the preferred method of treating cancerous diseases, as well as benign diseases that have not responded to less-invasive techniques. Sometimes there is a need for a temporary or permanent tracheostomy, a surgically created opening in the neck for breathing.

Surgical resection and reconstruction is most often done through an incision in the neck, but occasionally requires extension of the incision into the chest through a sternotomy, or dividing the upper part of the breast bone. Diseases of the lower airway, or bronchi, can be approached through the side of the chest, dividing the muscle between the ribs (thoracotomy), and sometimes can be performed in a minimally invasive fashion (video-assisted thoracic surgery, VATS).

The Bonnie J. Addaio Lung Cancer Foundation - Lung Cancer Living Room. Read And Listen To Monthly Presentations By Lung Cancer Specialists, Physicians And Researchers. Read Here

Esophageal cancer

The esophagus is the muscular tube of swallowing that connects the throat to the stomach. It passes through the neck and chest until it meets the stomach in the abdomen. Like all cancers, esophageal cancer develops as a result of uncontrolled cell division leading to uninterrupted growth. Cancerous cells begin their growth microscopically, but as they continue to multiply, turn into masses called tumors. These tumors may remain local in the tissue in which they originated or in more advanced cases, invade into surrounding structures or spread throughout the body, known as metastasizing. A cell with the ability to invade or spread is considered malignant or “cancerous”.

Esophageal cancer starts in the inner layer of the esophagus (mucosa) and then grows outward. As the tumor grows, patients develop difficulty swallowing (dysphagia) and eventually chest pain. Men are three times more likely to develop esophageal cancer than women and chronic acid exposure (gastroesophageal reflux disease) is believed to increase risk for its development. While gastroesophageal reflux disease (GERD) is common, most patients with GERD do not develop esophageal cancer. Heavy alcohol and tobacco use is believed to increase the risk for developing esophageal cancer.

There were 18,170 new esophageal cancers diagnosed in the United States in 2014 with 15,450 deaths reported. Esophageal cancer makes up 1% of the cancers diagnosed in the United States. Treatment and survival continue to improve and while overall survival for esophageal cancer is poor, prognosis for early stage cancer is considerably higher.

For more information on esophageal cancer, see

• Esophagus Cancer
• Chest Cancer Center

What Are The Symptoms Of Esophageal Cancer?

Esophageal cancer in its early stages has no symptoms and is usually picked up accidentally when evaluating for other problems. As the tumor grows, the most common symptom is difficulty swallowing (dysphagia) with food sticking in the throat or chest. This symptom worsens as the tumor grows and esophagus narrows. If not diagnosed and treated, swallowing becomes more difficult and progresses to the point where a patient is only able to swallow liquids. With decreased caloric intake, a patient loses weight.

How Is Esophageal Cancer Diagnosed?

Swallowing symptoms typically lead to further testing. The first test obtained is typically a barium swallow. Barium is a chalky liquid and when swallowed, outlines the esophagus on X-rays. If an X-ray shows narrowing or irregularity, the concern is raised for esophageal cancer.

Endoscopy

Endoscopy is performed on an outpatient basis. A patient is sedated and a flexible telescope (endoscope) is inserted into the mouth, through the esophagus and directed into the stomach. Esophageal cancer is visible as a growth (tumor) from the wall of the esophagus during endoscopy and samples (biopsies) of the tumor are taken using specially designed instruments inserted through the endoscope. These biopsies are looked at under the microscope by a pathologist who is physician specially trained in diagnosing cancers.

How Is Esophageal Cancer Staged?

Staging allows physicians to understand the extent of a patient’s cancer, helps guide treatment decisions and predict outcomes. Staging used by physicians for esophageal cancer is specific, but a straightforward way to describe staging is shown below:

• Localized – The lung cancer is confined to the esophagus and has not spread
• Regional – The esophageal cancer has moved from the esophagus into local drainage basins known as lymph nodes (glands) attached to the esophagus
• Distant – The cancer has spread (metastasized) to other parts of the body
• M Stage – (whether or not the tumor has metastasized) and Grade (pattern of the tumor cells aggressiveness under the microscope).

Computed Tomography (CAT) Scan

A CAT scan obtains high resolution images using cross-sectional X-rays of the entire body from chest to abdomen. It is noninvasive and takes only a few minutes perform. These images help determine the size of the tumor and whether it has spread into lymph nodes or other organs. It is useful in staging esophageal cancer.

Positron Emission Tomography Scan

A PET scan is a noninvasive study that involves the injection of a radioactive sugar into the blood. The tracer is safe and rapidly passes out of the body. Cancer cells are more active than normal cells and pick up more of the tracer. During a PET scan, the patient lies in a special scanner with a camera that records the radioactive activity and creates a picture of areas involved by tumor. This test adds information on the stage of the cancer and will be ordered by your physician.

More specifically, esophageal cancer is staged by T stage (depth of the tumor into the wall of the esophagus, N stage (involvement of lymph nodes with cancer cells).

Your physician will inform you of the stage of your esophageal cancer and the best treatment options.

Who Treats Esophageal Cancer?

Esophageal cancer is diagnosed and treated by gastroenterologists (specialists of the gastrointestinal tract), thoracic surgeons (surgeons who specialize in esophageal surgery) as well as medical and radiation oncologists (doctors who treat cancers using chemotherapy or radiation therapy). These doctors work together to choose the best treatment for each patient dependent on the stage of the cancer (how advanced it is) and a patient’s overall medical condition. At the Baylor University Medical Center in Dallas, our team of experts works together to choose the best treatment for you.

Hiatal hernia repair

Any time an internal body part protrudes into an area where it doesn’t typically belong, it is called a hernia. The hiatus is an opening in the diaphragm — the muscular wall that separates the chest cavity from the abdomen. Normally, the esophagus (tube of swallowing) passes from the neck, through the chest and then down through the hiatal passageway to the abdomen where the esophagus joins the stomach. A hiatal hernia is a protrusion of the stomach or other abdominal contents through the hiatus into the chest.

There are two main types of hiatal hernias:

• Sliding hernia
• Paraesophageal hernia (next to the esophagus)

In a sliding hiatal hernia, the stomach and the portion of the esophagus that joins the stomach (gastroesophageal junction) slide up through the hiatus and into the chest. This is the most common type of hiatal hernia. Not all hiatal hernias cause symptoms. A paraesophageal hernia is less common, but can be more problematic. The esophagus and majority of the stomach stay in their normal locations, but a portion of the stomach squeezes through the hiatus and next to the esophagus. With a paraesophageal hernia, there is the possibility of the stomach twisting and possibly strangulating (twisting off its blood supply).

What is gastroesophageal reflux disease (GERD)?

Many people with hiatal hernia have no symptoms, but others may have heartburn like symptoms that are related to gastroesophageal reflux disease, or GERD. GERD is caused by the backwash of gastric contents into the esophagus. This backwash causes symptoms of burning. Hiatal hernias are thought to predispose to GERD due to the abnormal location of a portion of the stomach in the chest. Although there appears to be a link between hiatal hernias and GERD, one condition does not necessarily mandate the other. Many people have a hiatal hernia without having GERD, and others have GERD without having a hiatal hernia. The symptoms of GERD can easily be mistaken for other disease processes. For example, people with heartburn may experience chest pain that can easily be confused with the pain of a heart attack. On the other hand, patients with a hiatal hernia may have symptoms attributed to it that are in fact related to another process. Therefore, it is critical to undergo thorough evaluation and testing before undergoing any surgery for a hiatal hernia or GERD. Your surgeon will help guide you in making this determination.

What causes a hiatal hernia?

The cause of a hiatal hernia is not entirely known. A person may be born with a larger hiatal opening. Increased pressure in the abdomen such as from pregnancy, obesity, coughing, or straining during bowel movements may leading to stretching of the hiatus. Obesity may predispose to hiatal hernia and certainly worsens the symptoms of GERD.

Who is at risk for hiatal hernia?

Hiatal hernias occur more often in women, people who are overweight, and people older than 50.

How is a hiatal hernia diagnosed?

A hiatal hernia can be diagnosed by chest X-ray, CAT scan or esophagram (a specialized form of X-ray study where a patient swallows barium contrast while X-rays are taken. Additionally, an endoscopy (telescope placed into the esophagus and stomach) may be used to diagnose a hiatal hernia.

How are hiatal hernias treated?

Most people do not experience any symptoms from their hiatal hernia so no treatment is necessary. Patients with significant symptoms of heartburn should first be treated with antacid medications and modification of their eating habits to avoid foods that predispose to heartburn. If symptoms persist despite antacid therapy or if a patient has difficulty swallowing with food sticking (dysphagia), they should have their hiatal hernia repaired.

Hyperhidrosis

Hyperhidrosis is a condition of excessive sweating in the hands (palmar hyperhidrosis), armpits (axillary hyperhidrosis) or feet (plantar hyperhidrosis). This sweating is independent of exercise or heat. It is a benign condition but can have a serious impact on a patient’s quality of life. It occurs in up to 3% of the population. The exact cause of hyperhidrosis is unknown but there may be a genetic component with some families having many members with this condition. It is known that sweating is controlled by the sympathetic nervous system. This set of nerves helps regulate our body temperature by controlling the sweat glands. These nerves are not under a patient’s voluntary control. Hyperhidrosis is an inappropriate control of these glands that leads to excessive sweating.

Types of hyperhidrosis

• Generalized hyperhidrosis affects large areas of the body with excessive sweating, typically in adults whose sweating occurs during both waking and sleeping hours.
• Localized hyperhidrosis or excessive sweating that occurs in specific parts of the body that markedly impacts quality of life and self-image.
• Palmar hyperhidrosis is excessive sweating that occurs in the palms of the hands. It can occur spontaneously but can be worsened by stress, anxiety or exercise. The hands become soaking wet which makes it difficult to grasp objects, drive or shake hands. The hands are typically clammy and cool. Over time, patients avoid hand-shaking and become extremely anxious about social environments.
• Axillary (armpit) hyperhidrosis is when individuals sweat profusely from their underarms causing them to soak their clothes shortly after they dress. This serves as a social embarrassment. Many patients resort to wearing baggy shirts and sweatshirts and change their clothes multiple times a day.
• Plantar hyperhidrosis is the excessive sweating of the soles of the feet leading to soaked socks and significant foot odor.

Treatment options for hyperhidrosis

Antiperspirants: Antiperspirants and topical drying agents are the first line treatment for hyperhidrosis. These are available over the counter or as a prescription (typically aluminum chloride) from your primary care physician or a dermatologist. Other treatment options include iontophoresis. This consists of a daily home treatment of electrical stimulation to the affected area with a portable device.

Botulinum toxin (Botox): Botox treatment involves injecting small doses of the toxin in and around the sweat glands to decrease sweat production. It remains effective for up to 6 months. Repeated injections are required to maintain the effect.

Surgery for hyperhidrosis: Surgery is an option to treat severe hyperhidrosis in patients who have failed topical therapies. The surgical treatment involves dividing the sympathetic chain which is the nerve that conducts the abnormal stimulation to the sweat glands.

Lung cancer

Lung cancer develops as a result of uncontrolled cell division leading to uninterrupted growth. Cancerous cells begin their growth microscopically, but as they continue to multiply, turn into masses called tumors. These tumors may remain local in the tissue in which they originated or in more advanced cases, invade into surrounding structures or spread throughout the body, known as metastasizing. A cell with the ability to invade or spread is considered malignant or “cancerous”.

There is the mistaken impression that lung cancer is a disease that only strikes smokers. This is not the case. While cigarette smoking is the greatest risk factor for the development of lung cancer, an increasing number of patients are developing lung cancer with no history of smoking or smoke exposure.

There were over 224,000 new lung cancers diagnosed in the United States in 2014 with 159,000 deaths reported. It is the leading cause of cancer death. However, new programs aimed at the early detection of lung cancer coupled with innovative treatments hold promise for improved survival in the future. To learn more about lung cancer statistics, see LungCancer.org.

How is lung cancer diagnosed?

Lung cancer in its early stages has no symptoms. Often, it is picked up on an X-ray or CAT scan as an incidental finding. As the diseases progresses, symptoms such as chest pain, shortness of breath, cough and weight loss can develop. Diagnosis typically requires some form of biopsy; a sample of the tissue of concern for cancer. These biopsies can be performed with a needle guided by a CAT scan or by a bronchoscopy (a small camera inserted into the patient’s windpipe through the mouth or nose). Occasionally, a surgical biopsy is required. A biopsy is important to determine whether or not the growth is cancerous and to determine the type of cancer.

Lung cancer screening

Recent studies have demonstrated that screening patients with risk factors for lung cancer using CAT scans of the chest can pick up lung cancer in its early stages when cure is likely. These studies have demonstrated a significant reduction in death from lung cancer using CAT scan screening. Widespread utilization of this screening technique holds great promise in improving survival from lung cancer.

Who treats lung cancer?

Lung cancer is diagnosed and treated by pulmonologists (lung specialists), thoracic surgeons (surgeons who specialize in lung surgery) as well as medical and radiation oncologists (doctors who treat cancers using chemotherapy or radiation therapy). These doctors work together to choose the best treatment for each patient dependent on the stage of the cancer (how advanced it is) and a patient’s overall medical condition. At the Baylor University Medical Center in Dallas, our team of experts works together to choose the best treatment for you. Use our Physician Finder to search for a specialist.

The most important determinants of how a patient will be treated are the stage of the cancer (whether the tumor is localized in the lung or if it has moved) and a patient’s overall health condition. The treatment most likely to achieve a cure is chosen while being mindful of maintaining the patient’s quality of life.

How is lung cancer staged?

Staging allows physicians to understand the extent of a patient’s cancer, helps guide treatment decisions and predict outcomes. Staging used by physicians is specific, but a straightforward way to describe staging is shown below:

• Localized: The lung cancer is confined to the lung and has not spread
• Regional: The lung cancer has moved from the lung into local drainage basins known as lymph nodes (glands) attached to the lung
• Distant: The cancer has spread (metastasized) to other parts of the body

How is lung cancer treated?

In most cases, the treatment of lung cancer is determined by its stage. Localized cancers are treated by surgery. Regional cancers are treated by a combination of therapies including chemotherapy, radiation and surgery. Distant disease is treated by chemotherapy.

Mediastinal surgery

The mediastinum is an anatomic description of the central portion of the chest. Mediastinal surgery represents any procedure performed within this area. The mediastinum is surrounded by the breastbone in front, the spine in back, and the lungs on each side (Figure). The types of surgery range from small procedures performed to diagnose disease processes as well as more significant operations necessary to remove larger tumors that grow in this region.

Why is mediastinal surgery needed?

Many types of growths (tumors) occur in the mediastinum. These can range from non-cancerous (benign) to cancerous (malignant). It can sometimes be difficult to distinguish between benign and malignant conditions. Obtaining a piece of the tumor (biopsy) can differentiate between benign and malignant growths and allow appropriate treatment. Some benign and many malignant tumors are best treated by surgical removal (resection) although this varies by the type of tumor. Some tumors are best treated by chemotherapy or radiation therapy and do not require removal. Your surgeon will help guide you in this decision. Some diseases such as Myasthenia Gravis, a disease affecting a patient’s strength and vision, can be treated by removal of the thymus gland which resides in the mediastinum.

Who is a candidate for mediastinal surgery?

Most tumors that grow in the mediastinum should be biopsied or removed. Most biopsies can be performed with minimally invasive techniques and rapid recovery. Almost all patients are candidates for biopsy while candidacy for resection depends on the size of the tumor, its location, relationship with other structures in the chest and a patient’s overall medical condition.

What tests are performed before mediastinal surgery?

Your surgeon will perform a thorough history and physical exam. Breathing tests are generally performed (pulmonary function tests). Blood tests are drawn that can give clues to the cause of some tumors. Additionally, imaging is performed including but not limited to:

• Chest X-ray
• Computed tomography (CT) scan of the chest
• Magnetic resonance imaging (MRI) of the chest

Your surgeon will determine if additional preoperative tests are necessary based on the findings of these studies and your medical history.

Biopsy

A biopsy is the removal of a sample of tissue for examination under the microscope by a pathologist, a physician trained in examining this tissue. The following are biopsy techniques:

• Percutaneous biopsy – Performed by a radiologist, this procedure is completed using a computed tomography (CT)-guided needle biopsy while a patient is awake but sedated. During the procedure, a needle is placed between the ribs to sample the mass.
• Mediastinoscopy with biopsy – Performed under general anesthesia, mediastinoscopy is a minimally invasive method to examine the mediastinum and sample tissue. A mediastinoscope (small lighted instrument approximately an inch in diameter) is inserted through a small incision at the base of the neck or between the ribs in the front of the chest. Mediastinoscopy accurately and safely diagnoses almost all tumors and is typically performed on an outpatient basis.
• Thoracoscopic biopsy (Video-Assisted Thoracic Surgery) – A procedure performed in the operating room under general anesthesia, this procedure uses video-assisted technology that maximizes visualization while minimizing trauma. A thoracoscope (small video-scope) and specially designed instruments are inserted through small incisions between the ribs to biopsy masses and sometimes remove them completely.

Surgical resection

Some tumors of the mediastinum require complete removal. Techniques to remove them include:

• Sternotomy – Division of the breastbone, identical to what is performed in open-heart surgery . A sternotomy allows access to the entire chest cavity including the heart, great vessels and lungs, and may be necessary to remove larger tumors and masses.
• Thoracotomy – An incision between the ribs. Similar to a sternotomy, this procedure allows wide access to the right or left chest and removal of large tumors that are localized to one side or the other.

Minimally invasive surgery

Some tumors of the mediastinum are amenable to less invasive approaches. This depends on the type, size and location of the tumor. Minimally invasive approaches include:

Video-assisted thoracic surgery (VATS) is a procedure that uses video-assisted technology to minimize trauma and speed recovery. A small camera is inserted between the ribs and two other instrument “ports” utilized to manipulate and remove the tumor.

Robotic Surgery Robotic surgery utilizes robotic technology to minimize surgical trauma. The surgeon works at a console next to the patient in the operating room that provides visualization of the inside of the chest and control of highly responsive robotic arms. Advantages include 3D technology to visualize and fine robotic dexterity to manipulate and remove tumors. Your surgeon will discuss with you and choose the best approach for your tumor.

Myasthenia gravis

Myasthenia gravis (MG) is a neuromuscular disease caused by a disorder in the immune system. It occurs in approximately 14-20 patients out of 100,000. In people with MG, the immune system produces abnormal antibodies that prevent the muscles from appropriately receiving signals from the nerves that tell them when to relax or contract. This causes muscle weakness and symptoms that can include double vision or blurred vision (eye muscle weakness), drooping eyelids (eyelid muscle weakness), difficulty with speaking and swallowing (throat muscle weakness) and weakness of the limbs.

When the immune system acts against healthy tissue in an inappropriate manner, it is called an autoimmune disorder, with “auto” meaning “self. MG is considered to be a neuromuscular autoimmune disease.

Myasthenia gravis is most common in young women and older men, but people of any age or either sex can get it.

What causes myasthenia gravis?

Scientists do not completely understand what triggers the autoimmune reaction in MG, but they do know that the thymus gland plays an important role in the disease.

The thymus is a small gland that lies in the front (anterior) portion of the central chest, beneath the breastbone, and extends into the lower part of the neck. It is most important early in life during immune system development. A baby’s thymus gland weighs between .7 and 1.1 oz. The gland continues to grow and by puberty weighs 1.1 to 1.8 oz. The thymus gland’s importance in immune development is felt to dissipate by puberty and diminish in size. Over time, fat replaces the majority of the gland.

Tumors of the thymus gland are called thymomas. Around 10-15 percent of people with MG have a thymoma. Another 60%, however, will have other abnormalities of the gland including thymic hyperplasia (an enlarged gland). The original association between the thymus gland and MG was made back in the early 1900’s when surgeons observed that removal of a thymoma resulted in improvement in the patient’s myasthenic symptoms. Based on this observation, surgeons began removing the thymus gland in myasthenic patients without thymic tumors and noted a similar response.

How is myasthenia gravis diagnosed?

The diagnosis of MG is usually made by a neurologist (a physician expert in diagnosing and treating neurologic disorders. Infusion of a specific medication (edrophonium chloride) under close observation should cause improvement of a patient’s symptoms if the patient has MG and therefore confirm the diagnosis. Additionally, blood tests can be performed that may demonstrate the presence of an antibody against acetylcholine receptor (AChR) and muscle-specific receptor tyrosine kinase (MuSK). This can help confirm the clinical diagnosis.

How is myasthenia gravis treated?

Once the diagnosis of MG has been confirmed, a treatment plan by your neurologist is developed with the goal of reducing the number of antibodies causing the disease and/or improving the communication between the nerves and muscles.

This results in improvement in muscle strength and symptoms. Medical treatment options include:

• Medicines that suppress antibody production or improve nerve signal transmission. Cholinesterase inhibitors such as pyridostigmine bromide (Mestinon) and neostigmine bromide (Prostigmin) are the most commonly used inhibitors. Corticosteroids and other immunosuppressive therapies are also effective.
• Plasmapheresis, a procedure that removes antibodies from the blood
• High-dose intravenous immune globulin (IVIG); the infusion of normal antibodies from donated blood to temporarily modify the immune system

Pleural mesothelioma

Mesothelioma is a rare form of cancer in which tumors form in the lining of the chest (pleural mesothelioma) or the abdomen (peritoneal mesothelioma). Rarely, it can affect the outside covering of the heart (pericardial mesothelioma).

What is pleural mesothelioma?

Pleural mesothelioma is cancer that affects the lining of the lungs and chest wall. It is rare, with about 3000 new cases diagnosed in the United States per year.

Symptoms of pleural mesothelioma

• Shortness of breath
• Chest wall pain
• Cough
• Fever
• Sweating
• Fatigue
• Weight loss
• Trouble swallowing
• Hoarseness
• Generalized weakness

What causes this type of cancer?

Exposure to asbestos is strongly linked to mesothelioma and is felt to be the primary cause in most cases of the cancer. This exposure can usually be linked to a patient’s work-place or home. Asbestos is a naturally occurring mineral that was once widely used as a component of insulation due to its remarkable fire and heat resistance. It was used in factories, shipyards, building construction, automobile brakes and clutches until it became clear that exposure to microscopic asbestos fibers could cause cancer.

Most asbestos use was discontinued in the United States in the 1970s and 1980s although some homes and buildings constructed before this time do still contain asbestos. Almost all cases of pleural mesothelioma can be linked to asbestos exposure. Family members of those who worked with asbestos are at risk due to secondhand exposure to asbestos fibers carried home on clothing. It can take decades between the initial exposure to asbestos and the development of mesothelioma

How is mesothelioma diagnosed?

The diagnosis of mesothelioma begins with a thorough history and physical exam. During the physical exam, your doctor will look for signs of fluid accumulation within the chest which is common with pleural mesothelioma. If the history or physical suggests mesothelioma, imaging, blood tests as well as other procedures may be ordered.

Imaging

• Chest X-ray– A chest X-ray may show thickening or calcium deposits in the lung lining, fluid accumulation within the chest or changes to the lungs themselves secondary to asbestos or tumor growth
• Computed tomography (CT) scan– This cross sectional X-ray of the chest gives a more detailed map of the location of the tumor and any potential regions of spread.
• Positron emission tomography (PET) scan– This non-invasive test involves the injection of radioactive sugar into the blood. Because cancer cells take up more sugar when compared to normal cells, a special camera that picks up the radiation creates a picture of the area where cancer is located.
• Magnetic resonance imaging (MRI) scan– MRI scans are non-invasive tests in which radio waves created by powerful magnets produce a detailed picture of the body. MRIs can clarify the extent and location of tumor.

Tests of fluids and other tissues

• Cytology– Mesothelioma often causes irritation of the lining of the chest leading to fluid accumulation known as a pleural effusion. Your doctor may draw fluid out of your chest with a needle and look for cancer cells within this fluid. Examination of this fluid for cancer cells under the microscope is known as cytology.
• Needle biopsy– Larger samples of tissue that line the chest can be drawn out using a needle that is guided using CT scan imaging. This tissue, known as a needle biopsy, is then examined under the microscope for cancer cells.
• Surgical biopsy– In some cases, more tumor tissue must be obtained to make a diagnosis. This can typically be done minimally invasively using VATS (video-assisted thoracic surgery) and a single incision about 1 inch in length. Patients are typically discharged on the same day as surgery. Results of this biopsy are close to 100% accurate

What treatments are available for mesothelioma?

Although there is not yet a known cure for mesothelioma, there are several treatment options available that are aimed at extending and improving a patient’s quality of life. These options vary dependent on the stage of the cancer (how advanced it is), a patient’s age and overall medical condition as well as the tumor’s histology (how aggressive the tumor appears under the microscope). Mesothelioma can be difficult to treat given the fact that it is often discovered after it has spread throughout the body. However, for patients with disease that is still localized within the chest, a combination of surgery, chemotherapy and radiation may be of benefit.

What treats mesothelioma?

Because mesothelioma is a rare disease, it is important that you choose a team of physicians with experience treating mesothelioma. The team at the Chest Cancer Research and Treatment Center has extensive experience in treating mesothelioma. This team is composed of medical oncologists (doctors specialized in diagnosing and treating cancers), radiation oncologists (doctor specialized in giving radiation treatments to kill cancer cells) and thoracic surgeons (doctors who specializes in operating on organs inside the chest), all with the most up to date techniques in treating this disease.

Surgery for mesothelioma

Surgery is most commonly performed when disease is in its earlier stages (localized to the chest). The purpose of surgery is to remove all cancer from the chest. Types of surgery include.

• Pleurectomy – Complete removal of the covering of the lungs and the lining of the chest
• Extrapleural pneumonectomy – Removal of one lung along with the lining of the chest, the diaphragm (muscle of breathing) and pericardium (outside covering of the heart).

Radiation or chemotherapy may be used as follow-up to surgery to kill any invisible cancer cells. This form of treatment is known as adjuvant therapy (given after surgery). Your chest surgery should be performed by a specialized thoracic (chest surgeon) with expertise treating pleural mesothelioma. All thoracic surgeons in the Department of Thoracic Surgery at Baylor University Medical Center have extensive experience in surgery for mesothelioma. Your thoracic surgeon will determine whether you are a candidate for surgery and whether tumor is removable. Some tumors cannot be removed due to their location or if the cancer has spread. If you are not a candidate for surgery, chemotherapy may be recommended or you may be offered a clinical trail through the Chest Cancer Research and Treatment Center.

Resources

• American Cancer Society: Malignant Mesothelioma
• National Cancer Institute. Malignant Mesothelioma.
• Mesothelioma Applied Research Foundation
• The Mesothelioma Center

Thoracic outlet syndrome

Thoracic outlet syndrome is produced by compression of the nerves and vessels in the area behind the collarbone.  Pain and swelling of the neck, shoulder and arm are common symptoms.

Presentation depends on the structure that is mainly affected by the compression.  Patients can present with neurogenic, venous or arterial compression.

This condition can affect patients of any age.  It is common among people who perform over-the-head activities where repetitive motions of the arm and shoulder are carried out.  Also, compression can occur from trauma in the area, the presence of an extra rib, obesity, or anatomical variation of the first rib.

What are the symptoms?

• Neurogenic
  • Tingling of arm and hands
  • Weakness
  • Muscle wasting
  • Numbness
  • Weak grip
• Venous
  • Swelling and heaviness of arm and hand
  • Bluish discoloration
  • Dilation of veins of the arm and chest
• Arterial
  • Cold feeling of arm and hand.
  • Pain and numbness
  • Loss of pulses

How is it diagnosed?

Diagnosis of thoracic outlet syndrome requires a good interview with the patient followed by a detailed physical exam.  During the physical exam, the goal is to replicate the maneuvers that elicit those symptoms.

Additionally, X-rays of the neck and chest can evidence the presence of an anatomical variation or the existence of an extra rib.  In cases of venous or arterial compression, venograms and arteriograms help us identify the area impinged and plan the appropriate treatment.  Treating the clot only with medications to dissolve it and blood thinners most of the time results in recurrence. If there is vein compression, surgery is recommended to relieve the impingement.