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Lung cancer surgery has evolved from its recent past when it was performed through a large thoracotomy primarily by cardiac surgeons at the end of the day when the other cardiac cases had finished. The modern practice of lung cancer surgery involves a comprehensive pre-operative work-up utilizing both PET and CT scans, often in conjunction with pre-operative endobronchial ultrasound and biopsy for accurate pre-operative clinical staging. Surgery for early lung cancer should involves a minimally invasive approach using eithe thoracoscopic or robotic technique and should include a full lymph node dissection. Surgery for late lung cancer should be contemplated after discussion at a multi-disciplinary lung tumor board often in conjunction with neoadjuvant chemo and radiation therapy to the lesion and mediastinum.

Lung nodules or "spots on the lung" are common but abnormal findings on a chest x-ray or more commonly a CAT scan of the chest.  The overwhelming majority of the time, these findings reflect inflammation or infection that is currently present or resolving  Remember, that the lungs are exposed are exposed to millions of bacteria, virus particles, and fungal spores with each breath we take! However, in a minority of patients, especially those with risk factors, they can represent a pre-cancerous process or cancer itself.  It is generally believed by the medical community that the majority but not all lung cancers do start as small nodules that grow and progress sequentially until the cancer becomes advanced.  Therefore, lung nodules should be studied, characterized, and managed by a medical professional who is thoroughly familiar with them, up to date on their management, and
very comfortable with them.

A medical professional who is well versed in the management of lung nodules aims to simultaneously accomplish two goals for patients. One, he or she can spot lesions likely to represent a malignancy quickly and initiate management that is likely to diagnose cancer in an early stage that is highly treatable -and curable -with hopefully, minimal morbidity to the patient.    Two, he can also often spot lesions that are very unlikely to represent malignancy and hence protect patients from the morbidity of unnecessary biopsies and the financial and mental burden of repeat CAT scans that ultimately prove unnecessary.  However, it must be said that for some benign lesions, it is not always possible to avoid a biopsy -that ultimately shows a
non-malignant process.   That’s OK too.   The strong focus on never missing a malignant lesion really does take priority over the desire to avoid biopsies that ultimately are negative -but the two goals mentioned here are often simultaneously attainable.

When lung nodules are discovered, Dr Sternberg is often called on to assist with the management and decision making.   Sometimes a repeat CAT scan is necessary.  This is often done with lesions that are typically quite small and unlikely to represent cancer.  If no growth is seen after a period of time, additional follow-up is often completely unnecessary.    Sometimes a PET scan is ordered.  This test further studies the lesion to see if its metabolism is higher than the normal lung tissue surrounding it.  A higher metabolism  than surrounding lung tissue can often reveal a malignant process, even when one is not strongly suspected based on the CT scan.

When a biopsy of a nodule becomes necessary, Dr Sternberg often performs Superdimension magnetic navigational bronchoscopy to biopsy the lung nodule -without any incision or hospital stay.  This specialized technique makes use of magnetic fields and high resolution 3-D CT scans to guide biopsy needles directly to the nodule. This procedure has many advantages over the traditional core needle biopsy, the most important of which include a lower risk of lung collapse, more tissue acquisition, and a good internal look at the lung anatomy which can also often be of significant benefit.  The patient goes home the same day, and after the biopsy or pathology report becomes available a few days later, Dr Sternberg meets with the family and counsels them about what type of future therapy if any, is needed.

Data from the national Lung Cancer Screening Trial in 2010 showed that yearly screening with low dose CT scans of heavy smokers and ex-smokers could reduce lung cancer specific mortality by over 20% in a 3 year period. This study was terminated prematurely because of the huge improvement in survival that was seen in patients who were screened. Had the study been allowed to continue it is likely that an even larger benefit would have been seen. The Michigan Thoracic Institute will offer a comprehensive annual physical and radiological evaluation on a yearly basis to screen for early lung cancer and to encourage cessation of cigarette use and to optimize pulmonary status in patients with known emphysema.

Benign and malignant pleural effusions represent major morbidities that significantly deteriorates patients quality of life and often their lifespan as well. Centers without dedicated thoracic surgeons often treat these conditions in a haphazard fashion with large bore chest tubes that mandate hospitalization and pigtails catheters which are not designed or safe for intermediate or long term usage.

Dr Sternberg treats more pleural effusions than any other thoracic surgeon in Michigan and was currently invited to join the national Carefusion design team to create the next generation of Pleur-X catheters. His expertise in treating these disorders without the use of large bore catheters, general anesthesia, or prolonged hospitalization allows patients to live symptom free with minimal morbidity and to return to chemotherapy far more quickly than otherwise achievable.

Patients with large refractory pulmonary abscess cavities or pleural infection (empyema) represent specialized thoracic conditions that require the expertise of a thoracic surgeon. Lobectomies for abscesses represent challenging cases in thoracic surgery because of the extensive enlargement and adhesiveness of intrapulmonary lymph nodes. Empyema and decortication while traditionally treated via thoracotomy are now routinely treated thoracoscopically by Dr Sternberg. This represents a huge morbidity benefit to the patient who is already coping with serious infection and who is now spared a large rib spreading incision as well. These cases should only be approached by an experienced thoracic surgeon who is well versed in minimally invasive techniques and thoroughly familiar with intra-pulmonary vascular anatomy.

Anatomy

The lungs are an elastic organ that expand in size with each breath we take.   We do not force air into our lungs (positive pressure breathing); our lungs work on a negative pressure system.  When we breathe, our muscles expand our chest wall volume. As our chest wall increases in size, it pulls the lungs outward with them.  As the lungs expand, the pressure within them drops below atmospheric levels.  Air then rushes in from a higher pressure zone (the atmosphere) into our lower pressure lungs.   We repeat this process 8 to 15 times per minutes to keep our blood saturated with oxygen and properly balanced with just the right amount of carbon dioxide.

The rigid chest wall not only surrounds and protects the lungs, but it also guides and pulls them apart.   A thin layer of fluid sliding between the lungs and inner chest wall serves as a “water seal,” creating a suction effect not unlike a wet dish clinging to a counter top surface.  However, when air is introduced underneath the dish, the suction is broken and the dish immediately released. Similarly, when air is introduced into the chest, the suction effect between the lungs and chest wall is broken, and the lungs are released from the chest wall.  Since the lungs are elastic, they collapse and either partially or completely stop working since the pressure is no longer changing inside of them every time we breathe.

As we will see, spontaneous lung collapse (pneumothorax) tends to happen to two very different segments of our population.

Primary Pneumothorax

For reasons that are poorly understood, the healthiest members of our families sometimes develop air pockets called (Emphysema Like Changes or ELCs).  These tiny air blisters are found in perfectly healthy, tall, thin, athletically-built young men and women.  ELCs sit atop the lungs and sometimes rupture, leaking air into the chest cavity.  When this happens, the water seal is broken and the lung collapses. Interestingly, these young athletes rarely complain of shortness of breath.  Their other lung functions so well and provides so much reserve capacity that they typically notice fatigue only when they exert themselves.  More commonly they present with chest pain, which they experience because the lining of the lung and chest wall are sensitive to separation.   Please be aware that for these patients, the lung collapse is only very rarely dangerous or life threatening. However, if the lung is not properly reflated, it can lead to a permanent loss of lung function and exercise capacity.  Think of the lungs in these healthy young patients as an expensive high performance sports car…with flat tires.  After treatment, the lungs and athletic performance returns completely to normal.  Would you trade in a Porsche because of its flat tires?  Patients with primary pneumothorax have been followed for more than 10 years after treatment have lung function that is 100% of what is expected of their age and demographic group.

Secondary Pneumothorax

At the other end of the population is a second group of individuals who also experience spontaneous lung collapse.  However this group tends to be much older, has an extensive history of smoking, and usually has a history of emphysema as well.  In these patients, smoking has destroyed the upper portion of the upper lobes and has caused large air bubbles to form and coalesce.  These large bubbles are fragile and can also sometimes rupture and leak air - thus leading to lung collapse.  However, unlike the first population of primary pneuomothorax patients, the remaining lung is not normal and healthy.  It is emphysematous and usually incapable of supplying all metabolic needs by itself.  Therefore, these patients are typically quite short of breath when they are brought into the emergency room.  Lung collapse for them is a medical emergency and the expeditious re-inflating of their lung is of paramount importance.  Even one presentation of spontaneous lung collapse can be a dramatic life changing event for these patients with diseased and badly injured lungs.  Essentially, you could say that spontaneous lung collapse is a manifestation of emphysema and a long term consequence of heavy cigarette use.

Treatment

For primary pneumothorax patients, treatment for the intial episode can be observation if the lung collapse is quite small.  Sometimes the lung is re-inflated with a soft flexible suction tube (chest tube) that is left in place for a day or two.  If pneumothorax recurs in the same lung, then statistically the problem is highly likely to continue to recur. After 1 episode, the likelihood of recurrence is between 30-50%.  After a second however, the chance of a 3rdepisode climbs to 85% if the problem is not dealt with definitively.  The Standard of Care is therefore to cause the lungs to adhere to the chest wall and a procedure that accomplishes this is typically offered after the 2nd event.  The most successful procedure is a minimally invasive removal of the leaking air blister and a mechanical irritation of the inner chest wall (VATS Wedge resection and mechanical pleurodesis). This procedure is highly efficacious (95% long term success rate), takes 30 minutes, is accomplished with 2 or 3 small incisions, and usually only requires a 2 day hospital stay afterwards.  While typically offered for a second episode, sometimes it is offered for an initial presentation in patients with high risk features such as those with dangerous occupations or hobbies such as airline personnel, scuba divers, distant hikers, the medically co-morbid, or those who live far from medical care.

For patients with secondary pneumothorax, the treatment for an initial episode is typically minimally invasive removal of the leaking air bubble (bleb) and a mechanical irritation of the inner chest wall.  This is because these patients often present to the emergency Room in extremis, and the excellent safety profile of the procedure far exceeds the risk of another episode of lung collapse in these pulmonary compromised patients.  Other alternatives exist for these patients who are sometimes too frail to go to the operating room.  For example, talc or doxycycline instillation through a chest tube at bedside can avoid the operating room but typically has a much lower success rate.

Outcomes

The success rate of a VATS wedge resection and mechanical pleurodesis is approximately 95% or better.  Therefore we take a patient that may have an expected pneumothorax recurrence rate of 85% or higher…and convert them to a patient with an expected rate of 5% or less.  Primary pneumothorax patients can expect to be in the hospital for 2-3 days after the procedure and stay off work for 1 to 2 weeks, depending on their occupation.  The chance of a significant complication for primary pneumothorax patient is about 1%.  Secondary pneumothorax patients are often in the hospital for 3 to 5 days after the procedure -due to their older age, emphysema, and other medical problems.  Their complication rate is approximately 20% due to these issues. The most common problems we see in this population after the procedure are pneumonia and prolonged air leaks but these are usually easily managed with antibiotics and judicious management of the chest tube.

Severe reflux, achalsia, and para-esophageal hernia represent benign forms of esophageal and foregut disease that when treated minimally invasively can provide long term relief from debilitating eating difficulties as well severe reflux symptoms. Correction of severe reflux also protects patients from increased likelihood of esophageal cancer as well and saves many lives. Dr Sternberg performs these procedures using minimally invasive techniques through the abdominal cavity.

Esophageal cancer, like lung cancer, has evolved into a disease that is now treated through an integrated multi-disciplinary team of surgeons, medical oncologists, radiation oncologists, as well as gastroenterologists. These patients are typically treated with multi-modal therapy utilizing radiation therapy and neoadjuvant chemotherapy prior to surgical resection. The post-surgical care and surveillance of these patients is especially difficult since patients often don't resume eating for a prolonged period of time and because they lose significant amounts of weight and strength. Due to the cancer imposed eating difficulties prior to treatment, many patients head into this process already weakened from weeks or months of near starvation. Treatment of this disease should only be undertaken by an experienced thoracic surgeon.

Thymomas and myasthenia gravis represent tumors that, although traditionally resected by median sternotomy, can now be approached using robotic technology. Dr Sternberg performs these resections robotically, and has also developed skill in the specialized peri-operative management of myasthenic patients as well.

Chest wall injuries including rib and sternal fractures painful conditions that are increasing in frequency as the population in Southeast Michigan ages. Due to the large accumulation of assisted living facilities in the West Bloomfield area, Dr Sternberg has developed considerable experience in managing patients with multiple complicated fractures and has developed a minimally invasive method for plating and reducing fractures thereby decreasing patient pain and hospital stay. Reduction of painful fractures also improves the patients requirement for supplemental oxygen and pulmonary toilet. Dr Sternberg also treats sternal fractures, infections, and tumors of the chest wall as well.