Get It Off Your Chest: Answers to Your Questions About Surgery for Lung Throat&Other Thoracic Conditions (Dr Mason 11 04 13)
David Mason, MD
Staff Surgeon, Cleveland Clinic Department of Thoracic and Cardiovascular Surgery.
Monday, November 4, 2013 - Noon
As one of the largest, most experienced thoracic surgery groups in the world; our surgeons specialize in treating complex cases using groundbreaking procedures, such as minimally invasive thoracic surgery to help treat such diseases as lung and esophageal cancers, emphysema, and swallowing disorders like achalasia. Thoracic surgeon, Dr. Mason, answers your questions.
Esophagus, Neck, Swallowing Problems
jklingenspeil: Head and neck radiation 15 years ago for squamous cell carcinoma. Swallowing difficulty continues. I take 20mg omeprazole 2x daily, (2) caps 300mg gabapentin 2x daily and (1) 50 mg tramadol. Growth of scar tissue required stent in left carotid two years ago. I continually alternate between a very sore throat and tickle in the same area (right side) which prompts severe coughing fits- sometimes including a strong sensation to vomit- but I don't. Any way to numb the throat and at least get rid of the tickle? Brandy helps a lot- sprays and lozenges do not. Thank you.
David_Mason,_MD: This is very complicated. We would need to review your records. It's probably best to follow up with your head and neck doctor.
jklingenspeil: Thank you. I was told that the main reason I needed the stent was that scar tissue from radiation was growing. Is this an ongoing thing posing the possibility for more complication?
David_Mason,_MD: Yes - the effects of radiation can be progressive over time. Certainly you need close follow up in order to treat potential complications.
jklingenspeil: Doctor- Again regarding scar tissue due to head/neck radiation- if it grows to a point that it inhibits breathing, what are the procedures for dealing with that? Thank you.
David_Mason,_MD: I would not expect that the radiation would inhibit your breathing. There are methods to dilate (stretch) or stent the head and neck structures should your disease progress.
jklingenspeil: Doctor- Again regarding radiation- my voice ranges day to day from almost normal to almost non- existent. Can you suggest anything to improve this? How does alcohol affect vocal folds?
David_Mason,_MD: I am not sure why your voice changes from day to day - I am not sure that this would be caused by alcohol. I would suggest an appointment with an otolaryngologist to directly visualize your vocal cords.
rhodge9732: I have had surgery for adenocarcinoma of the esophagus. Lost about 50% of the esophagus and 50% functionally of the stomach. I get extremely tired and sometimes feeling winded after meals no matter what I seem to eat. I eat small amounts. I assume this is from the surgery, but I don't know what to do about it. It does interfere with daily functioning, because I am so tired and some seem to be increasing with age. I am a 66 year old male and 5 years since surgery.
David_Mason,_MD: I am not certain that your fatigue and shortness of breath is directly related to your esophagectomy. This warrants further evaluation. I recommend returning to your original surgeon or seeing your primary care physician.
rhondashayes: I had my thyroid and 3/4 of my parathyroid glands removed in 2010, since then my voice has been getting hoarse and I can't sing simple songs like happy birthday to you. I don't think this happened during surgery, it’s seemed to get worse in the last year. Can you help me understand?
David_Mason,_MD: There are many reasons for hoarseness - I recommend a visit to an otolaryngologist. That doctor can look at your vocal cords to determine the reasons for your hoarseness.
Questioner: Last year a mass the size of a baseball was found in my child's chest connected to the esophagus believed to be a misplaced growth from birth. Recent testing determined it to be 'deflated.' Another MRI will be conducted in one year to see if it grows. Is this normal procedure?
A spot was found on my left lung. It was suggested I wait and see if it grows since false positive and negative results are usual. Other spots were found to be pneumonia related. I realize early lung cancer detection is important. I was exposed to second hand smoke my entire life. If my six month follow up test reveals growth, what do you recommend?
Third question is I have allergic asthma and took myself off Advair. Is this a bad idea if I have mitral valve prolapse and timing issues?
David_Mason,_MD: It sounds as if your child has a cyst. These are not uncommon in childhood. The cyst sounds as though it has gotten smaller on imaging which is a good sign. Conservative management with imaging sounds appropriate. Lung nodules are very common, particularly in this part of the country. Serial imaging over time is appropriate for most of them. If on repeat imaging, there is significant change, a biopsy or surgical consultation would be reasonable. If your physician prescribes you advair - I would continue on the advair as prescribed.
needtoknow: My wife is coming to CC in a week for a bowel resection after some pelvic abscesses post illeostomy reversal post rectal cancer. She has five nondeterminate bilateral lung nodules (we know one has been there since 2007) that are 5mm or less in size that showed up this past February. They have not changed in size since being discovered. Are we doing the "right" thing by just watching them for the past eight months since they have not lit up on a PET and do not seem to be growing or should we see a pulmonologist or thoracic surgeon while my wife is inpatient to CC hospital for the next couple of weeks. Her thoracic surgeon she has visited in KY says to just wait till another scan in January which will almost be a year from discovery.
David_Mason,_MD: Sounds as if these lung nodules have been stable since 2007, it is most likely that these are benign (non-cancerous). Continued surveillance with CT scans sounds appropriate.
Calico: I saw the doctor recently with a serious bout of the flu. He ordered an x-ray which indicated I have "new faint pulmonary nodules bilaterally with metastatic disease not excluded. Previous granulomatous disease" meaning one non malignant nodule which has been present for years. I would be interested in your opinion of what these could possibly be. Also, could it be a fungus i.e. Candida? or a Herpes cold sore virus which I had about six weeks that appeared not only as cold sores but the waist and ankle areas? Could these appear internally and how would we rule this out? Thanks.
David_Mason,_MD: Lung nodules are very common. Possibilities include non-cancerous causes as well as cancerous ones. I would certainly not assume that you have cancer although further investigations are warranted. I doubt this is related to your herpes - I would recommend a consultation with a pulmonologist or thoracic surgeon.
joannh: Is a lobulated nodule in the right middle lobe of the lung, just below the minor fissure, and approximately a centimeter from the pleural surface of the right middle lobe, which is noncalcified, and measures 10 x 8 x 8 mm in size cancer? Can it be removed, and how?
David_Mason,_MD: The size of nodule does not determine whether or not it is cancer. There are other characteristics such as rate of growth; shape and configuration that are important in determining whether a nodule is cancer or not. Certainly it can be removed and usually this is possible via a video assisted thoracic surgery (VATS), which is minimally invasive techniques which uses small incisions and telescopes to perform surgery which has been traditionally performed with large incisions.
needtoknow: Are most non calcified pulmonary nodules malignant?
David_Mason,_MD: Pulmonary nodules, particularly in the Midwest, where environmental exposures are common, are usually not cancerous. Usually these are incidental findings that deserve careful observation but not typically interventions. The physician who performed the CT scan should be able to guide you in your follow up.
joannh: Is a lung nodule cancer?
David_Mason,_MD: A lung nodule is simply a growth that is seen on imaging, such as chest X-ray or CT scan. This does not mean it is cancer and in fact most lung nodules are not cancer.
joannh: A cat scan revealed that I have a lobulated nodule in the right middle lobe, just below the minor fissure and approximately a centimeter from the pleural surface of the right middle lobe, which is non calcified and measures 10 x 8 x 8 mm in size. Is this cancerous. I ask a doctor who stated he did not know, just follow up with another cat scan in six months. Is this something that should be treated now?
David_Mason,_MD: Observation with a CT scan at six months which was recommended is certainly a reasonable plan. Other possible options include biopsy or surgical removal. I would need to review the imaging and your medical history in order to make further recommendations.
needtoknow: Do you think that it is odd that an oncologist would ask about plucking lung nodules out when one of them is stable for six years and the other three are stable for almost nine months. I understand my wife is a former rectal cancer patient at T2N0M0 pathologically staged. Does that seem like diagnostic overkill at this time? We are very apprehensive since PET in May was negative as well. Hopeful that chemo could have caused tiny granulomas. Thank you for your response.
David_Mason,_MD: Your case is complex and I am not certain of the rationale for removing one of the nodules. I would guess that your oncologist believes that that nodule has a higher likelihood of being active cancer. I would need to evaluate your records to provide you with further advice.
Lung Cancer and Surgery
Rogy: Would like your thoughts regarding surgery on lung cancer with tumor over three centimeters in lower right lobe on a patient with advanced idiopathic pulmonary fibrosis. Also, any thoughts on radiation treatment with or without surgery. Thank you.
David_Mason,_MD: I would expect that surgery for lung cancer in the setting of advanced idiopathic pulmonary fibrosis would be contraindicated. Sterotactic body radiation therapy would be the best therapy without surgery. In general, radiation therapy to treat localized lung cancer is reserved for patients with significant medical issues that prohibit surgery.
jeannemt: When is surgery an option for typical lung carcinoid with metastases to the liver? Would this be with or without consideration for transplantation?
David_Mason,_MD: The patient you described has an uncommon form of carcinoid. Most carcinoids of the lung do not spread and are treated by surgery alone. When carcinoids have spread to the liver - treatment is more complex and depends upon the number of areas that are involved in the liver, their location, and consideration of whether those locations can be removed in their entirety. More information would be necessary to make a treatment plan.
Charla1954: My husband needs an upper lobectomy of his left lung due to metastases from a sarcoma. What does that involve? Can it be done with a small incision?
David_Mason,_MD: Lobectomy is removal of a portion of your lung The lung is divided into two lobes on the left side: the upper lobe and the lower lobe. Each lobe contributes around 20 percent of the overall lung function. Minimally invasive approaches are possible in most lobectomies. Although, this depends on the size of the tumor as well as the location.
GloriaPA: My husband has been a smoker for about 40 years. I would like to know the symptoms of lung cancer. He has always woke up coughing up gunk and he definitely gets more tired or short of breath when he is walking or doing heavy work around the house. He won't go to the doctor - but wondering what I should look out for.
David_Mason,_MD: Unfortunately, lung cancer has very few symptoms until it has advanced, at which time treatment is difficult. Early detection appears to be possible depending on his age, smoking history and some other parameters. Cough, shortness of breath are non-specific and certainly not tell tale signs of lung cancer. I recommend he visit his primary care physician to see if he is a candidate for a lung cancer screening CT scan.
Calico: I am having a low dose CT scan next week to rule out lung cancer. I have read that these are frequently false positive readings. How can I protect myself from this?
David_Mason,_MD: There is no way to "protect yourself" from false positive readings. The most important component of follow-up is the interpretation by your provider. Experienced pulomonologists and thoracic surgeons should be able to further guide you to the next course of treatment.
Calico: Dr. Mason, if I brought or sent a CT scan performed locally to you, would you review it and offer a second opinion?
David_Mason,_MD: You can make an appointment by going to the Thoracic Surgery website or use the MyConsult online second opinion.
Calico: Can lung cancer be detected in blood work to confirm?
David_Mason,_MD: At this time, there is no blood test that is accurate in screening for lung cancer.
rhondas: My father has emphysema but heart and other organs are in perfect health, he is so full of life, but can't do the things he enjoys. He mainly sits and gets depressed. Therapy didn't help. He is now on oxygen. He just turned 70 is there a chance for a lung transplant for him?
David_Mason,_MD: Seventy years old is at the higher range for lung transplantation although patients older than your father has been transplanted. He can certainly be evaluated for transplantation although there is no guarantee that he would be a candidate. There are other treatments such as medications which can be optimized for emphysema and there are other types of surgery in select patients.
JuliaS: I live in Connecticut and need a lung transplant. I would like to explore options at Cleveland Clinic - is there a problem being out of state and getting treated at Cleveland Clinic?
David_Mason,_MD: Cleveland Clinic evaluates many patients from out of state for transplant. You would need to first check with your insurance as to whether or not it would cover Cleveland Clinic. Once this is determined, you can utilize our MyConsult online second opinion.
Lana: My friend had surgery hoping that they could go in and remove the mass. When they got in they discovered that it was a fibrous tissue mass, and it had wrapped around the artery and blood vessels. The Dr. took a bigger piece for another biopsy. They weren't able to remove it because it was hard like scar tissue. He went back on Monday, and they told him that they can't do surgery, but it was very slow growing. He was diagnosed with Fibrosing Mediastinitis. They said it was a rare disease. Just wanted to know if your team of doctors are familiar with this disease? I’m just trying to help a friend find his best option. Thank you, Lana.
David_Mason,_MD: Fibrosing Mediastinitis is a rare disease in which the central portions of the chest become very scarred. While the disease is progressive, some patients are minimally impacted. Other patients develop serious complications as the scar tightens around the central connections to the lungs. While this is a rare disease, we have a significant amount of experience with this condition at Cleveland Clinic - we treat with a "multidisciplinary team of doctors" approach.
lrgenskow12: I have a mediastinal cyst between and pushing on both my trachea and esophagus. It is roughly 2x1x2. It has been drained twice. I'm now waiting to see if it fills again (CT scan). Have you or anyone on your staff removed such a cyst? How is it done?
David_Mason,_MD: Mediastinal cysts are relatively common. They usually present no problems to a patient. The one you describe sounds quite small and I would think that observation with CT scans is appropriate. Certainly this can be removed using minimally invasive techniques, although I would doubt this would be necessary.
lrgenskow12: The mediastinal cyst is causing eating and coughing problems. I have lost 24 lbs. (162 to 138). Sometimes I have swallowing problems. Eating seems to irritate my esophagus. My thoracic surgeon here has not used minimally invasive surgery, at least not in this type of situation.
David_Mason,_MD: I would need to review the imaging to tell you if a minimally invasive approach would be an option in your situation.
Annette: I was recently hospitalized for pain under the left rib cage. They performed chest x rays, an echo of the heart and also a CT scan of the chest. I was released today with prescriptions for pain, steroids and an antibiotic. The pain is as bad this evening as it was when I went to the emergency room. Hard to rise from a sitting position, step up a step or even to get out of bed. The hospital focused on my heart, but not on the area of the pain. Any suggestions for questions to ask my physician at my next visit?
David_Mason,_MD: It sounds as though your physicians felt that your pain was caused by pleurisy - an inflammatory condition involving the surface of the lungs and sometimes the ribs. Typically the pain resolves with the anti-inflammatory medications which you have been prescribed. If the pain does not improve, other etiologies may be explored, although it sounds as though your workup was thorough.
KimV: I have Wegener’s Granulamotsis Disease. Is that why I have pain in my chest, and shortness of breath? Are there treatments that can help me breathe better?
David_Mason,_MD: It seems likely that Wegener’s is the cause of your symptoms. Certainly there are treatments both medical as well as bronchoscopic (telescope of the windpipe). I recommend evaluation by a pulmonologist experienced in treating Wegener’s Granulomatosis.
ssuzowsky: I have been diagnosed with a thoracic aneurism currently measuring 4.5 cm. It has been growing at the rate of 0.2 cm per year over the last two years. At what point would you recommend repair. I do not want to have my chest opened: what are my options and risks? I am 84, exercise regularly and have been told by my cardiologist that I have "a forty year old heart"!
David_Mason,_MD: I would recommend an evaluation by a specialist in thoracic aneurysms, which are typically treated by cardiac surgeons. [Note: See web chat transcripts from aortic aneurysm web chats]
futuresurgeon: Hi I'm a high school student and I have a project about interviewing. These are the questions for you:
- What influenced you into choosing this career?
- What are some common struggles that you face everyday?
- In an operation, do you ever get nervous and stressed out? Why?
- How many years of experience do you have?
- What are some everyday things that you do as a cardiothoracic surgeon?
- Are you on-call or set work hours and if so is it stressful or annoying being on-call?
- What are some of the basic procedures or operations that you do?
- I chose to become a surgeon because of direct impact that I have helping patients every day. Surgeons are fortunate enough to see the results of their work immediately.
- Common struggles include long days and patients with difficult diseases to treat and cure.
- Certainly some operations can become anxiety provoking but an important part of becoming a surgeon is learning how to handle the stress. This comes with time and experience.
- Surgical training takes seven or eight years after the completion of medical school. I finished all this training ten years ago.
- My day to day activities are quite varied - these range from seeing patients in the clinic to performing lung transplants to removing portions of the lung in patients with lung cancer or the esophagus in patients with esophageal cancer. I am on call about one week out of every month. Call can be fatiguing.
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