Seminars in thoracic and cardiovascular surgery
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Improving existing means of sentinel lymph node identification in non-small cell lung cancer will allow for molecular detection of occult micrometastases that may cause recurrence in early stage non-small cell lung cancer. Furthermore, targeted application of chemical and biological cytotoxic agents can potentially improve outcomes in patients with lymph node (LN) metastases. "Therapeutic Sentinel Lymph Node Imaging" incorporates these modalities into a single agent thereby identifying which LNs harbor tumor cells and simultaneously eradicating metastatic disease. In this review, we summarize the novel preclinical agents for identification and treatment of tumor bearing LNs and discuss their potential for clinical translation.
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Semin. Thorac. Cardiovasc. Surg. · Jan 2009
ReviewMultimodality strategies in malignant pleural mesothelioma.
Over the last decade, several improvements have been made in the diagnosis and treatment of malignant pleural mesothelioma, including better understanding of tumor biology, availability of more potent chemotherapeutic drugs, improved surgical management, and optimized multidisciplinary therapy. Radical tumor resection by means of extrapleural pneumonectomy (EPP) is now feasible with acceptable morbidity and mortality, even after neoadjuvant chemotherapy, if performed in specialized centers. To date, the best survival data have been reported after multimodality treatment strategies that include surgical resection. In this article, we discuss several strategies that involve EPP or pleurectomy/decortication in combination with various adjuvant and neoadjuvant therapies.
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Semin. Thorac. Cardiovasc. Surg. · Jan 2009
ReviewCurrent status of screening for malignant pleural mesothelioma.
Malignant mesothelioma is characterized by its association with asbestos, its long latency period, and the propensity for the diagnosis to be obtained in the later stages of the disease. Because the high-risk cohorts for mesothelioma are fairly well defined by the association with asbestos, and the exposure is usually in the workplace, it is hypothesized that early detection of the disease could (1) find patients at an earlier, more treatable stage and (2) result in prolonged survival over the present median 12 months from the start of therapy. ⋯ Most recently, serum biomarkers with the potential to discriminate asbestos-exposed, non-cancer-bearing individuals from those with mesothelioma have been investigated both at single institutions and with multi-institutional-blinded trials. These markers, including soluble mesothelin-related protein, osteopontin, and megakaryocyte potentiating factor, may, in the future, be incorporated into a screening algorithm for high-risk asbestos-exposed individuals to help monitor these cohorts in a noninvasive fashion and guide the use of computerized tomography.
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Semin. Thorac. Cardiovasc. Surg. · Jan 2009
ReviewTeaching off-pump coronary artery bypass surgery.
Off-pump coronary artery revascularization requires a unique skill set and a different conduct of operation compared with on-pump coronary artery bypass. Not only must the surgeon perform anastomoses on the beating heart, but he/she must understand the hemodynamic consequences of cardiac positioning and stabilization, the effects of regional ischemia on hemodynamic function, contractility, and arrhythmias, and the importance of anesthesia and grafting sequence given variants of anatomy and clinical conditions. Given these differences, the ability to teach off-pump coronary artery bypass to residents and surgeons places unique demands on the teaching surgeon. In this article, we review the available literature about the safety and efficacy of teaching off-pump coronary artery bypass to residents, discuss the fundamentals for training residents, and review the future of simulation and new training paradigms and the impact this will have on current training methods.
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Semin. Thorac. Cardiovasc. Surg. · Jan 2009
ReviewHybrid thoracoabdominal aortic aneurysm repair: concomitant visceral revascularization and endovascular aneurysm exclusion.
Thoracoabdominal aortic aneurysms (TAAA) remain a formidable surgical challenge, with conventional open repair associated with significant rates of mortality and morbidity. Furthermore, many of these patients are elderly with significant comorbidities and may not be candidates for repair. Consequently, the availability of a "hybrid" option, including open visceral debranching with concomitant endovascular aneurysm exclusion, may have advantages in these high-risk patients, including the potential to offer therapy to those ineligible for conventional repair. ⋯ In all cases, endovascular exclusion of the aneurysm has been performed at the same operation. The procedure is applicable to all types of TAAA (Extent I-V), although a bifurcated abdominal aortic endograft may be required if inadequate distal landing zone for a tube endograft exists above the aortic bifurcation. Results to date suggest this technique of "hybrid" TAAA repair to be a safe alternative to conventional repair for TAAA in older patients with significant comorbidity, with results in our institution similar to those previously published for younger patients undergoing conventional repair in high-volume centers.