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Ask the Thoracic Surgeon (Drs. Mason and Murthy 12/16/11)

David Mason, MD
Staff Surgeon, Cleveland Clinic Department of Thoracic and Cardiovascular Surgery.

Sudish Murthy, MD
Staff Thoracic Surgeon, Department of Cardiothoracic Surgery Miller Family Heart & Vascular Institute

Friday, December 16, 2011 - Noon

Description

As one of the largest, most experienced cardiac and thoracic surgery groups in the world; our surgeons offer virtually every type of thoracic surgery. We specialize in very complex cases as well as groundbreaking surgeries procedures, such as minimally invasive thoracic surgery. Thoracic Surgeons treat a variety of patients that require surgery on the heart, lungs, esophagus, and other organs in the chest. Areas of focus for thoracic surgeons are lung cancer, severe emphysema, cancer of the esophagus, gastro esophageal reflux disease, hiatal hernias, swallowing disorders such as achalasia and excess sweating, usually of the upper extremity called hyperhydrosis.

Dr. Sudish Murthy and Dr. David Mason, thoracic surgeons from Cleveland Clinic answer your questions.

More Information

Cleveland_Clinic_Host: Welcome to our "Ask the Thoracic Surgeon" online health chat with thoracic surgeons Drs. Murthy and Mason. They will be answering a variety of questions on the topic of thoracic surgery. We are very excited to have them here today! Let's begin with the questions.


Lung Tumors

JeanMarie: I was just diagnosed with a multi focal cartinoid tumor of the lung. Does Cleveland Clinic have any specialists in this rather rare tumor?

Dr__Mason: While cartinoid is a real tumor, it is seen relatively commonly here at the Clinic given its large referral base. We definitely have specialists here at the clinic.

JeanMarie: And doest this tumor usually originate in the lung or could it be coming from some other site. I am due to have an Atria scan next week.

Dr__Mason: The tumor can be primarily located in the lung or also be a metastatic site. Careful review of your imaging would be necessary to determine this.

JeanMarie: Is multi-focal cartinoid tumor curable?

Dr__Mason: Curability is dependent upon location and extent of the tumor. Certainly cure is the goal.

ffernandez: My mother is in the early stages of diagnosis of what is likely a tumor to the right, upper lung. What is the latest technique used to remove malignant tumors in the lung and before starting treatment/surgical intervention is it beneficial to get a second opinion or does this delay treatment unnecessarily?

Dr__Murthy: Transbronchial biopsy is the standard of care and after a diagnosis is obtained, a PET scan is usually performed to help determine the stage of the cancer. Once this is known, the treatment can be decided upon. For early stage cancers in reasonable fit patients, surgery (often with video cameras) can be performed. For more advanced stage cancers, chemotherapy and radiation are often indicated. The most important issue is getting the stage correct BEFORE commencing with a treatment plan

jamm1: Can you please talk about robotic surgery? I know its smaller incisions and probably quicker recovery, but when do you recommend a robotic surgery? do you look for a specific patient? how many lung-cancer related robotic surgeries do you perform?

Dr__Mason: Robotic surgery is a new technique using small incisions and robotic arms that may facilitate recovery and decrease pain. It is slowly being adopted for appropriate procedures. The specifics of the tumor dictate a patient's candidacy.

sahra31: my lung nodule was centimeter in upper left lobe which was removed. would you recommend surgery for removal of the rest of the lobe they found sclc.

Dr__Mason: We would need to review the specific pathology of the tumor as well as your overall medical condition and pulmonary function before recommending further surgery.


Lung Cancer

Oleta: Have been diagnosed with a mass in my right lung, upper left quadrant. If it turns out to be malignant, can the quadrant be removed and eliminate the problem?

Dr__Murthy: The most important aspect in the management of lung cancer is determining the precise STAGE of the cancer prior to making any decisions on therapy. For small lung cancers in any segment of lung, and WITHOUT local lymph node or body involvement, removal of the tumor with adjacent lung is often indicated.

The lung doesn't really have quadrants like the breast so removal of a "Quadrant" is difficult. The most common operation is lobectomy (in your case, removal of about a 1/3 of the lung), though smaller "wedges" of lung can be removed (though, often with a much higher chance of local recurrence compared to lobectomy).

charlaA: My aunt had a lobe removed from her lung due to lung cancer? What is the chance that will cure lung cancer?

Dr__Murthy: Cure of lung cancer is stage related. If her final stage after her operation was stage I (NO lymph node involvement and the tumor completely removed) survival across the country is about 70%. For cancers that are stage I in this institute, the survival is about 80%; largely do to more lymph nodes being removed at the time of the operation.

steven: I had a lobectomy due to cancer in 2008. They said they got all the cancer - but I still have pain in the surgery site. Is that normal to have pain all this time?

Dr__Murthy: Pain following a thoracotomy for lung cancer is not that uncommon. About 5% of people will have pain lasting more than 1 year (as is your case). It's called post-thoracotomy pain syndrome and perhaps you should be referred to a chronic pain team. This pain likely has nothing to do with whether you're cured. You're coming up on 3 years thus far, and if you've had no evidence of recurrence by now, you've gotten through the peak of when lung cancer returns. Stay well

cherly: My mother was recently diagnosed with Lung cancer. It was found on her lower left lung and in her lymph nodes. The Doctors are doing radiation and planning on Chemo. They basically told us that this is "not curable" and that this is basically just prolonging the time till she dies. 1-2 years at best, a few weeks if she does not respond to treatment. I was wondering it would be possible to do a surgery to remove the cancerous lung? Would that help her? The doctors said it’s not possible, but when do you decide when you can treat with surgery?

Dr__Mason: Sometimes, surgery is performed in patients who do have cancer in their lymph nodes. chemotherapy and radiation therapy is almost always a part of the treatment plan in addition to surgery. The specifics of your mother's case would need to be reviewed before making further recommendations.

carolee3: How often can surgery truly cure cancer??

Dr__Mason: The "curability" of lung cancer is dependent upon its stage. Stage refers to whether the cancer is localized to the lung or spread elsewhere in the body as well as size of the tumor. Lung cancer survival rates are dependent upon these stages and pathologies.


Pulmonary Nodule

jillk: My husband had an x-ray and it showed nodules in his lungs. Does that mean he has cancer?

Dr__Mason: Lung nodules are very common. Most lung nodules are NOT cancer. None-the-less, he should receive a CT scan of the chest and medical follow-up.

cinci87: I am scheduled for surgery in two weeks to remove a pulmonary nodule. what are the chances of the nodule removal being all that is needed for this?

Dr__Murthy: Is your nodule cancer? If so, as in the above responses, survival is stage dependent. If you have a true stage I, your chance of remaining cancer free for >5 yrs is ~70%. Factors that suggest a higher "cure rate" for stage I tumors include smaller cancers, and better vigor of the patient.


Emphysema

jellyb: My husband has extreme emphysema. He has 18% airflow. I have read that surgery is a very patient-specific and not good for everyone? is this true?? When do you decide when someone needs or is eligible for it?

Dr__Mason: I would assume the 18% refers to FEV1 - if that is true, he is not a good candidate for surgical treatments of emphysema. He may be a candidate for lung transplant evaluation, depending on his age and his medical problems.

khans4: can you talk about surgical treatments for emphysema?

Dr__Mason: Emphysema is a disease characterized by chronic destruction of normal lung tissue. Over time, lungs become over-inflated and inefficient. In very carefully chosen patients, surgery to reduce the size of the diseased lung can help alleviate symptoms of shortness of breath and decrease oxygen requirements. Additionally, lung volume reduction surgery, as it is called, can increase survival. Cleveland Clinic offers this form of surgery as well as multiple novel non-surgical strategies to treat emphysema. A team of thoracic surgeons and pulmonary physicians with expertise in emphysema will evaluate and treat you.


Lung Transplant

carrie77: Have you seen the recent news about a patient from univ. of maryland receiving a lung transplant through a new treatment called "lung perfusion"? are you aware of this? does Cleveland Clinic offer it? what do you think about it?

Dr__Mason: Ex-vivo lung perfusion is a technique that is largely experimental and is being investigated here at Cleveland Clinic. It is too early to truly know the value of this technique.

soccer03: My father is in severe stages of emphysema and I know he would benefit from a lung transplant. He is on oxygen 100% of the time. Other than the constant oxygen, he is very health and goes on daily walks. I feel he is very young (73 years old). We have the same blood type so I would like to know if it’s possible for me to give one of my lungs to my father? I know people can live with only one lung. Also, would the surgeons have to remove both his lungs for this?

Dr__Mason: Lung transplantation might be an option for your father although he is in the older range for consideration. However, living-related lung transplantation which you are describing is rarely, if ever, performed now in the United States. We would be happy to evaluate your father in our Lung Transplant Center. Nurses are available in the Heart Resource Center at 866.289.6911 to assist you.


Mediastinal Cyst

george: do you treat mediastinal cysts. My son had a chest infection, xray and the doctor said he has one. What is the treatment for that?

Dr__Mason: Treatment of mediastinal cysts is dependent upon location, size and symptoms. It would be necessary to review the imaging and hear your son's medical history prior to determining the best therapy.


Pectus

stephanie1987: What is the best type of treatment for a 27 year old with pectus?

Dr__Murthy: A pectus deformity should only be repaired for severe heart or lung compression. There are a few cosmetic options that are available, but I only repair adults with SEVERE deformities whose symptoms usually include shortness-of-breath and rapid heart rate.


Achalasia

mickey00: I am a 35 yr old woman with achalasia and I have had the heller myotomy and I still have chest pain and I would like some help with the pain????? any ideas????

Dr__Murthy: I would suggest that you have a manometry study to assess your esophagus again and see if spasm is the cause of your problem.

sarahr: Hi there, I was diagnosed with achalasia 2 years ago. I have had two myotomy. prior to the surgery I would have really bad pain in my chest and drinking water would help, but now the pain doesn’t go away. I just had an appt. with my thoracic surgeon and he is suggesting having gastric bypass because of excessive acid and bile. Apparently the second surgery was so successful I am now battling with ulcers which are causing excruciating pain. I am also having a very difficult time swallowing and food is getting stuck frequently which leads to me vomiting. Not sure I want to go that route but I definitely don't think I can live with this pain. what is your opinion? would you recommend a gastric bypass after myotomy?? thank you!!

Dr__Mason: It sounds like you have reflux after your myotomy. This certainly is a known side effect. Non-surgical treatment would certainly be advisable if symptoms are mild, but surgery could be considered if all therapies have otherwise failed. A thorough evaluation by a surgeon experienced with achalasia should be performed before embarking on another operation.


Barrett’s Esophagus

glt5527: My husband was diagnosed with Barrett's esophagus last year. the doctor prescribed a medication for him to take daily. I read this can turn into cancer. How often does that happen? When do they do surgery to remove what they saw during his endoscopy? If they remove it - what is the chance of returning? How extensive is the surgery? He has a follow up endoscopy next month

Dr__Mason: Barretts Esophagus warrants close follow-up. Careful review of the biopsies is necessary to determine follow-up and treatment as well as potential for cancer.


Hiatal Hernia

d3452: I had surgery to repair a hiatal hernia a few months ago. Since then I am experiencing frequent nausea and don’t know why! it just hits me. sometimes putting me in my bed... I also have found I can't vomit. There are certain foods my body no longer tolerates. Can you explain this? is this because of the surgery? does or will it get better?

Dr__Mason: Side effects such as nausea are relatively common after hiatal hernia repair. Dietary modifications and anti-nausea medicines usually provide relief. Typically, with time, these symptoms resolve.


Esophageal Cancer

sm12: My dad has just been diagnosed with esophageal cancer. he has had indigestion and trouble swallowing for sometime now and that is why he went to the doctors. looking online, I found that if you already experiencing symptoms, the cancer may be more advanced - is this true? we are all worried and just want some hope. He is 72 was a smoker (stopped after diagnosis)

Dr__Mason: Patients who present with symptoms and esophageal cancer are typically in more advanced stages of their disease. None the less, treatment for cure is still possible and requires multi-disciplinary (oncology and surgery) treatment.


Esophagus Surgery

renataOR: I have a nephew that had severe burns on his esophagus. The doctors are still trying to figure out what caused it. But his doctor told him he may need to have part of his esophagus replaced with part of his intestine. Is that what they do? Can the intestine work like the esophagus? Does the esophagus do anything special other than get the food to the stomach that this works fine?

Dr__Murthy: Sounds like it was an accidental ingestion of lye or some other caustic agent. These agents lead to intractable scarring of the esophagus and it will eventually need to be replaced. NOTHING will ever replace a normal esophagus and whether the stomach or Colon is used to replace the esophagus, swallowing and digestion will forever be changed, but I suspect, will probably be much better than what your nephew has now.


Thoracic Surgery – Latest Advances

Cleveland_Clinic_Host: Dr. Mason, can you please touch on some of the latest advancements in thoracic surgery?

Dr__Mason: Technical advances have allowed the performance of thoracic procedures that previously required thoracotomy (large incisions and rib spreading) that can now be performed with VATS. VATS stands for video assisted thoracic surgery. This avoids rib spreading, decreases pain, speeds recovery and is improved cosmetically. Use of VATS has allowed more liberal criteria for surgery since the recovery is much easier.

Additionally, the multi-disciplinary approach to treatment of lung cancer has improved survival. A multi-disciplinary approach means that multiple doctors from different disciplines such as thoracic surgery, medical oncology, radiation oncology and pulmonary medicine collaboratively choose a patient's best treatment options. These doctors work together to individualize care. At the Cleveland Clinic, all patients with thoracic malignancies are evaluated in this fashion. We believe that where you get treated FIRST for thoracic malignancies is critical to obtaining optimal survival.

Thoracic surgery outcomes are available on our website - www.my.clevelandclinic.org/heart/about-heart-vascular-institute/treatment-outcomes.aspx


Second Opinion Consultation

JeanMarie: Does it take long to get an appointment at Cleveland Clinic for a 2nd opinion?

Dr__Mason: An appointment with the thoracic surgeons can typically take place within a week - we would be happy to see you. This can be done in person - the number is 216.445.6860 or we offer an internet-based second opinion available through www.eclevelandclinic.com.

Cleveland_Clinic_Host: I'm sorry to say that our time is now over. Thank you again Drs. Murthy and Mason for taking the time to answer our questions about thoracic surgery.

Dr__Mason: Thank you for having us, this was great.

Reviewed: 12/11


This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician's independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians.

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