Lung
Cancer
It is well established
that for early stage lung cancer, surgical resection currently provides
the best chance of cure. In addition to treatment of these lesions,
the Thoracic and Cardiovascular Surgery Division at M. D. Anderson
has long been at the forefront of treatment of more advanced forms
of this neoplasm. Many patients with locally advanced disease may
actually be considered quite treatable utilizing aggressive surgical
approaches and/or preoperative induction therapies. Lesions falling
into this category would include non-small cell carcinomas involving
superior sulcus structures, the chest wall, intrathoracic vascular
structures and the tracheobronchial tree. In addition, mediastinal
adenopathy should not always be considered a contraindication to surgery,
as many of these patients are candidates for induction therapy followed
by surgical resection.
A number of active clinical trials are evaluating novel treatment approaches to this neoplasm in our department. These trials are being conducted in collaboration with other departments at M. D. Anderson as well as colleagues at other institutions around the country to evaluate new uses of combinations of conventional therapies (chemotherapy, radiation, surgery) as well as other newer agents. A weekly multispecialty conference is held to discuss patients that present with particularly complicated disease processes and those felt to be potential candidates for entry into clinical trials. This conference is attended by not only M. D. Anderson thoracic surgeons, but also by thoracic medical oncologists, radiation therapists, pathologists and pulmonologists.
In addition to novel combinations of conventional therapies, surgeons at M. D. Anderson lead one of the few groups in the world investigating clinical gene therapy approaches to lung cancer treatment in appropriate patients. Thus far, this work has concentrated on the replacement or addition of genes that help to control programmed cellular death in tumors.
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Esophageal Cancer
Patients treated with this neoplasm by the surgeons in the Thoracic and Cardiovascular department include those with tumors of the esophagus as well as the gastroesophageal margin. At the outset, all patients referred to M. D. Anderson with this diagnosis are scheduled for appointments with a thoracic surgeon, a gastrointestinal oncologist and a radiation therapist. A specifically tailored treatment plan is designed for each individual patient. An aggressive approach to therapy is taken, with preoperative chemoradiation administered to patients with locally advanced disease as well as those in lower stages in clinical trials. For less advanced local disease, surgery may be considered primary therapy.
Although esophagectomy
is a significant surgical procedure with inherent risk, the perioperative
mortality for esophagectomy for this department has been 1% or less
the past 3 years. A number of active clinical trials are evaluating
novel treatment approaches to this neoplasm in our institution. These
trials are being conducted in collaboration with other departments at
M. D. Anderson to evaluate new uses and combinations of conventional
therapies (chemotherapy, radiation, surgery, photodynamic therapy and
others).
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Mediastinal Tumors
Primary tumors of the mediastinum are rare, and require thoughtful management. Proper staging and histopathologic evaluation are of paramount concern. The surgeons in this division utilize surgical staging techniques for mediastinal tumors such as mediastinoscopy, transbronchial biopsy and thoracoscopy.
Recent reports on the results of surgically based multimodality therapy including both thymoma as well as mediastinal germ cell tumors at this institution illustrate the potential efficacy of these approaches even when tumors are somewhat locally advanced. These efforts are promising to change the way in which many of patients with mediastinal tumors are routinely managed.
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Metastatic Disease to the Lung
The medical literature strongly supports the use of surgical metastasectomy for many types of tumors that have spread to the lung. Many of the reports supporting this aggressive approach have originated here at M. D. Anderson. Very close collaborations with physicians in the Sarcoma and Melanoma Division of Medical Oncology is important and routine.
Patients considered possible surgical candidates are discussed at a weekly combined conference so that treatment recommendations can be made in a tailored fashion. Patients not considered candidates for conventional chemotherapy and/or surgery for metastatic disease of the lung may be entered into novel treatment trials such as one which is evaluating isolated lung perfusion with novel and conventional antitumor agents. Additional novel treatment, including gene therapy approaches and cryotherapy, are being investigated in the department’s laboratories.
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Mesothelioma
Mesothelioma is
a malignancy that arises from the pleura (lining of the chest space
and the surface of the lung). In the past, outcomes for treatment
of this disease have been quite poor. Many centers do not offer curative-intent
treatment for this diagnosis as a result of this experience. However,
recent information suggests that well-selected patients may derive
great benefit from aggressive treatment, including surgical resection,
radiation therapy, and in some cases chemotherapy.. It is important,
however, that patients be chosen carefully, with adequate and expert
medical evaluation, pathologic examination of tissue, and staging
(evaluation of extent of disease) in order to maximize the chances
of success. A multidisciplinary approach is taken with evaluation
at M. D. Anderson for this disease. Diagnostic samples are reviewed
by pathologists internationally known for expertise in this area.
Initial consultation consists of careful radiographic imaging as well
as evaluation by both a surgeon and a radiation oncologist with experience
an interest in this particular disease. Although the surgical procedures
required for removal of this tumor should be considered extremely
aggressive, recent perioperative complication and mortality rates
have been very low. An active area of clinical investigation is the
use of novel computer-modeled conformal radiation techniques which
are being employed with a goal of decreasing local recurrence of tumor
following surgery. Finally, experimental treatment of mesothelioma
is an active area of investigation in the department, where novel
conventional and gene therapy techniques are being evaluated for potential
clinical use.
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Tracheal
and Endobronchial Tumors
Surgical management
of tumors involving the proximal airways is an area that demands facility
in a number of complex endoscopic and surgical techniques. Faculty in
the Thoracic and Cardiovascular Division treat a large number of patients
each year with both primary tumors of the trachea and proximal airways,
as well as tumors which involve the airways by local extension (such
as thyroid carcinoma) and metastatic tumors as well. Diagnosis and treatment
planning are aided by the availability of outpatient bronchoscopy facilities,
and use of flourescence bronchoscopy where indicated. In the operating
room, the most advanced endoscopic techniques, including rigid and flexible
bronchoscopy, stent placement and laser ablation are utilized where
appropriate. In cases amenable to surgery, broncho- and tracheoplastic
techniques of airway reconstruction are utilized in an effort to complete
curative intent removal of tumor. For selected patients, endoluminal
photodynamic therapy may be an option.
Many patients require
multidisciplinary care for tumors that involve the airway. Thoracic
surgical faculty often perform combined operative cases with colleagues
in Head and Neck Surgery and Plastic and Reconstructive Surgery for
complex airway and upper esophageal tumors. Other patients may be referred
to colleagues in Thoracic and Head and Neck radiation oncology for consideration
of use of newer techniques in interluminal (brachytherapy) and external
beam (conformal, IMRT) radiation rather than, or in addition to surgical
management.
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Tumors
Invading Vascular And/Or Cardiac Structures
The
Thoracic and Cardiovascular surgical faculty serve as vascular surgical
consultants for other surgical and medical departments at M. D. Anderson.
In addition to more routine vascular surgical procedures, a large number
of more complex procedures are performed which require expertise in
vascular reconstruction. Multidisciplinary operative procedures are
common in combination with surgical colleagues in Orthopeadics, Urology
and General Surgery. Large tumors of the extremities and abdominal cavity
involving both central and peripheral vascular structures thought to
be unresectable may be rendered surgically removeable via these collaborative
efforts .
Surgeons
at M. D. Anderson have helped to pioneer the aggressive treatment of
intrathoracic tumors involving the heart and great vessels, and involvement
of these structures alone should not be considered an absolute contraindication
to surgical resection. Primary tumors of the heart and great vessels,
tumor of other intrathoracic organs secondarily invading these structures,
and selected metastatic lesions may be removed utilizing techniques
including cardiopulmonary bypass and circulatory arrest. Selected patients
may benefit from adjuvant or neoadjuvant treatment of these malignancies,
and patients are referred to Thoracic and Head and Neck Medical and
Radiation Therapy colleagues when appropriate.
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