Surgery for Pleural Diseases
Disorders of the pleura range from some of the
most common and highly treatable problems encountered
in medicine, such as pneumothorax and empyema,
to some of the rarest and most difficult problems,
like malignant pleural mesothelioma. Penn thoracic
surgeons offer not only state-of-the-art treatment
for these pleural problems but also research
protocols that are not available elsewhere.
Penn thoracic surgeons offer both
state-of-the-art treatment for
these pleural problems and protocols
not available elsewhere.
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Pneumothorax
Spontaneous pneumothorax is a very common problem, and
when surgery is indicated, we can nearly always employ minimally
invasive (VATS) techniques to resect the culprit portions of the
lung and create a pleurodesis. We are one of the few centers who
will often perform a thoracoscopic parietal pleurectomy in this
instance, the gold standard for obliterating the pleural space
and a procedure commonly viewed as requiring a thoracotomy to
accomplish. We have published one of the largest series on the
problem of menses-associated pneumothorax and are
thus particularly aware of the issues involved when a woman
presents with spontaneous pneumothorax.
Pleural Effusion
Pleural effusions are very common problems and can result from
benign or malignant etiologies. Failure to recognize or intervene
early enough for effusions may result in a “solid” disorder that
is more difficult to treat — such as untreated malignant effusion
or early stage empyema resulting in trapped lung. The judgment
as to when surgery is indicated as an initial or subsequent
step, what procedure to perform, and how to perform it in the
least invasive way, requires the subspecialist level of expertise
provided by Penn thoracic surgeons.
Solid Tumors of the Pleura
Malignant disorders of the pleura are among the most lethal
cancers, generally with survival of less than a year. Although the
pleura is a common site for metastatic disease, it is a rare
location for primary tumors. Of the primary tumors, mesothelioma
is the most common. In an effort to move beyond simple
palliation, we have adopted a multimodal
approach to develop effective, novel therapies
for these malignancies.
Combining surgery with intraoperative
photodynamic therapy (PDT) for malignant
pleural disease has become a special focus
for our surgeons based at Penn Presbyterian
Medical Center. PDT, a light
based cancer treatment, allows us to treat the
residual microscopic disease that will likely
remain after even the most “complete”
surgical resection of pleural cancers. We
evaluate patients with pleural malignancies
confined to one hemithorax, and have treated
nearly a dozen different types of cancers.
Now, with over a hundred patients, the groups
with which we have the most experience are
patients with stage IIIB non-small cell lung
cancer (NSCLC with pleural spread) and
mesothelioma. For mesothelioma patients,
our approach offers the advantage
of allowing us to perform lung-sparing
procedures. In addition to decreasing
morbidity and increasing postoperative
quality of life, the ability to spare the lung
can make aggressive adjuvant therapy an
option for older or less robust patients.
We are currently the only cancer center in the
country employing this type of experimental
treatment for Stage IIIB NSCLC. The
published median survival for patients with
this disease is six to nine months. We reported
in the Journal of Clinical
Oncology a median
survival of 22 months in our initial group of
patients. We are now hoping to recruit other
thoracic surgery groups with PDT experience
for a multi-center clinical trial.
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