Surgical Treatment Of Emphysema

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Presented by: Joseph Shrager, MD
Chief, Division of Thoracic Surgery
Stanford University Medical Center
May 21, 2009

Lecture Overview:

  • Emphysema is a type of chronic obstructive pulmonary disease, the fourth leading cause of death in the U.S.
  • In emphysema, the tissues that support the shape and function of the lung are destroyed
  • Smoking is the leading cause of emphysema
  • A large national study showed that lung volume reduction surgery (LVRS) can help certain patients with advanced, heterogeneous disease
  • Only a limited number of patients qualify for LVRS
  • Stanford is one of only a few centers expert in LVRS for emphysema

Normally, the lungs are very spongy and elastic. During inhalation, the chest wall inflates, expanding the tissue like a sponge soaking in water. A type of chronic obstructive pulmonary disease (COPD), emphysema is characterized by the  gradual destruction of the air sacs at the ends of the airways called alveoli.

As it progresses, emphysema turns the alveoli into large, irregular pockets with holes in their inner walls. The deterioration makes the alveoli less effective and keeps oxygen from reaching the bloodstream. In addition, the elastic fibers that hold open the lung’s airways are slowly destroyed in emphysema, so they collapse during exhalation, making it difficult to breathe.

Smoking is the leading cause of emphysema, and COPD ranks as the fourth leading cause of death in the United States.

“Medical treatments may slow, but they do not reverse, the process,” said Joseph Shrager, MD, chief of the Division of Thoracic Surgery, who discussed ways to treat the disease at a presentation sponsored by the Stanford Health Library. “There’s really no therapy available to halt the downward course.”

Among non-surgical therapies, only oxygen therapy in patients with low blood oxygen levels appears to improve survival, he said.

Unlike other types of COPD, like chronic bronchitis and asthma, which are mainly inflammatory conditions, emphysema is a structural problem that is sometimes amenable to surgery, he said.

Surgery for emphysema evolved from a procedure used to treat giant bullae: When these large dilated airspaces were removed, nearby lung tissue could expand. The same logic held for emphysema—removing a portion of the damaged lung created more space for the working areas. The theory underlying lung volume reduction surgery (LVRS) is to reduce the lung size by taking out the parts that are taking up space but not contributing much to the exchange of oxygen and CO2. The airways will be held open better and the breathing muscles will return to a more normal position, making breathing easier.

“You are generally better off taking out more rather than less of the lung tissue,” said Dr. Shrager, who has performed 67 LVRS surgeries to date using both traditional sternotomy to open the chest and less-invasive thorascopic techniques.

LVRS was first used to treat emphysema in the 1950s but  didn’t gain popularity until the 1990s. In 1997, the National Emphysema Treatment Trial was established to clarify the risks and benefits of the surgery. The study showed that certain patients had impressive, improvement in function and in quality of life, and it helped identify the criteria for the people who would most benefit from this approach. One group of patients even showed an improved longevity after the operation.

The ideal patient for LVRS has heterogeneous disease, with some sections of the lung more affected than others; has severe disease, with lungs more than double the normal size; and has emphysema, not chronic bronchitis. Age is not necessarily a factor—only physiology.

“Only a limited number of patients qualify for LVRS, and it’s important to be careful in patient selection,” said Dr. Shrager. “We screen at least twice as many patients as we do surgeries on because we want to provide a successful result. Stanford is one of only about 30 centers in the country experienced in treating emphysema by surgery, and the results have been outstanding.”

Though advanced cases can be treated with lung transplantation, Dr. Shrager said there is usually a wait of one year or more for a transplant, and four-year survival rates are about 60 percent. Also, with the need for lifelong immunosuppressant drugs, he added, “you are replacing one disease with another.”  Lung transplant is therefore reserved for emphysema patients who are not candidates for LVRS.

About the Speaker
Joseph Shrager, MD, is a professor of cardiothoracic surgery and chief of the Division of Thoracic Surgery at Stanford. His clinical expertise is in surgery for lung cancer, emphysema, and mediastinal masses, and his research focus is in the molecular physiology of the diaphragm and other respiratory muscles. He received his MD from Harvard Medical School, trained in surgery at the University of Pennsylvania, and completed his thoracic surgery training at Massachusetts General Hospital. He served as chief of thoracic surgery at Pennsylvania Hospital and the Hospital of the University of Pennsylvania before joining Stanford in 2008. Dr. Shrager is listed as one of “America’s Top Doctors” and appeared for several years as a “Top Doc” in Philadelphia Magazine.

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Living Better with COPD

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Presented by: Daya Upadhyay, MD
Assistant Professor, Pulmonary and Critical Care Medicine
Stanford University Medical Center
November 3, 2011

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Chronic obstructive pulmonary disease (COPD) is a progressive lung disease which blocks the airflow and makes it increasingly difficult to breathe. COPD can cause shortness of breath, coughing, wheezing, excess mucus, chest tightness, and other symptoms.

More than 12 million people are currently diagnosed with COPD, and many more may have the disease and not even know it. In 2000 there were 2.74 million deaths from COPD worldwide, and the numbers continue to grow.

COPD is the fourth leading cause of death in the United States, said Daya Upadhyay, MD, an assistant professor of pulmonary and critical care medicine, who spoke at a presentation sponsored by the Stanford Health Library. “Everyone knows about the first three causes —heart disease, cancer, and stroke—but we need to be aware about the impact of COPD and be more aggressive in treating it. Over the past 40 years, cases of COPD have increased 163 percent while numbers of these other diseases are dropping.”

Slow Development
Most cases of COPD occur from long-term exposure to lung irritants that damage the lungs and airways. Smoking is the most common cause, although many cases stem from secondhand smoke, occupational exposure to chemical fumes or dust, or environmental pollution, such as fireplace smoke. In rare cases, a genetic deficiency can affect the lungs and cause COPD. Recurring respiratory infections also damage the lungs, making some people more susceptible to the disease.

COPD develops slowly, and patients usually have no symptoms at first. Symptoms often worsen over time and can limit the ability to do even routine activities. Because it usually develops slowly, many COPD sufferers do not even realize they have the disease. Some people attribute their shortness of breath to simply getting older and slowing down. But age should not make you short of breath and affect your ability to do basic activities like walking, cooking, or taking a shower, said Dr. Upadhyay.

Symptoms include coughing, spitting, wheezing or noisy breathing, and shortness of breath. Many people suffer from morning headaches and fatigue because of lack of oxygen, and they experience shortness of breath, even at rest. “COPD makes you work very hard just to breathe,” said Dr. Upadhyay.

Emphysema and chronic bronchitis are the two main types of COPD. In emphysema, the walls between air sacs of the lungs are damaged and destroyed, causing the air sacs to become larger, which reduces the amount of gas exchange in the lungs. Dr. Upadhyay refers to these patients as “pink puffers” because they have pink lips. Hyperinflation of the chest causes them to purse their lips as they breathe, which also makes them appear ruddy. These individuals are underweight because they lose muscle mass.

In chronic bronchitis, the lining of the airways is constantly irritated and inflamed, which causes the lining to thicken. Mucus forms in the airways, making it hard to breathe. They are known as “blue bloaters” because of the blue-ish cast of their skin caused by the high levels of carbon dioxide in their blood. They tend to be overweight, with swelling in their arms and legs. Their poor blood oxygenation often points to a poor prognosis.

Diagnosis and Treatment
To diagnose the condition, your doctor will try to determine the source of the problem—whether it’s from smoking, pollution, genetics, or another cause. After chest X-rays, you may need to take a series of lung function tests, such as spirometry to measure how much air you can exhale. You may also receive lung volume measurements to check your lung capacity; an oxygen diffusion measurement, and a six-minute walk to assess your resilience in maintaining sufficient oxygenation.

Based on lung function, COPD is ranked on a FEV1 (forced expiratory volume) scale from mild to severe, and tests are administered annually to track disease progression and to monitor how well treatment is working.

Managing COPD involves a relationship between the patient and caregivers, Dr. Upadhyay said. “Since there is no cure yet for COPD, our goal is to assess the extent of the disease, improve breathing and lung function, and prevent further damage,” she added. “It’s important that you stay aware of your condition and know the triggers in your environment that worsen your breathing. Let us know your needs so we can continue to improve care.”

Depending on the FEV1 level, you may be prescribed a short-acting bronchodilator to open the airways (Proventil, Alupent, Ventolin, Atrovent, Combivent) as well as a long-acting medication (Spiriva, Advair, Severent, Foradil) so you can continue your daily activities. Moderate to severe cases may benefit from inhaled glucocorticosteroids. Flu and pneumonia vaccination shots are highly recommended for everyone.

In some rare and severe cases, lung volume reduction surgery or lung transplantation are important treatment options.

All COPD patients should ask their physician to prescribe a spacer chamber, which improves inhaled medication drug delivery by 80 percent. It is also important to do exercises that can improve your breathing reserve.You may receive pulmonary rehabilitation or breathing exercises to train your muscles and improve overall function. Pulmonary rehabilitation is an essential part of the COPD therapy.

Patients with heavy smoking history may need CT monitoring since they are at very high risk for lung cancer. These patients should be scanned annually to identify early signs of lung cancer.

The most important step in preventing and managing the disease, Dr. Upadhyay said, is education. “Understand how COPD occurs, learn how to take the inhalers properly, and take vaccinations to prevent lung infections. Most importantly, “if you don’t smoke, don’t start. If you smoke, stop. The damage from smoking is progressive, so it’s never too late to quit.”

About the Speaker
Daya Upadhyay, MD, is an assistant professor of pulmonary and critical care medicine, specializing in the diagnosis and management of obstructive airway diseases, such as asthma and COPD, and the early diagnosis of lung cancer. She received a medical doctorate in chest medicine from the University of Bombay; an MD in internal medicine from New York University School of Medicine, where she completed her residency; and from Northwestern University, where she did her fellowship in pulmonary medicine and critical care medicine. She joined Stanford in 2002.

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GOLD: Global Initiative for Obstructive Lung Disease

Latest Advances in Lung Cancer Screening and Treatment

Posted By SHL Librarian

Presented by:

Daya Upadhyay, MD
Assistant Professor, Pulmonary and Critical Care Medicine

Joseph Shrager, MD
Professor of Cardiothoracic Surgery; Chief, Division of Thoracic Surgery

Billy W. Loo, Jr., MD, PhD
Assistant Professor, Radiation Oncology

Heather Wakelee, MD, Associate Professor of Medicine, Oncology Division
Stanford University Medical Center
November 15, 2012

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Lung cancer gets less press than many other terrible cancers that affect wide swaths of the population, but, sadly, it is still the number one cause of cancer deaths in both men and women. At a presentation hosted by the Stanford Health Library, four Stanford doctors specializing in various aspects of lung cancer testing, diagnosis and treatment outlined advances that are making screening more accurate, surgery less invasive, radiation therapy more precise and genetics-based medical therapies far more targeted.

The doctors included: Daya Upadhyay, MD, an assistant professor of pulmonary and critical care medicine; Joseph Shrager, MD, professor of cardiothoracic surgery and the chief of Stanford’s division of thoracic surgery; Billy W. Loo, Jr., MD, PhD, assistant professor, radiation oncology; and Heather Wakelee, MD, an associate professor of medicine in the division of oncology.

There is no mystery concerning the most prevalent cause of lung cancer. Nearly 90% of all cancers of this type are related to smoking, although a substantial number of patients, especially in Northern California, develop the disease without a history of smoking. About 226,000 new lung cancer cases are diagnosed every year in the United States; 160,000 lung cancer patients die annually. The rate of lung cancer survival over five years is less than 15%, Dr. Upadhyay said.

“This is why we are so aggressive about diagnosis,” she added. “If we can stop or prevent smoking, certainly lung cancer is preventable for many,” Dr. Upadhyay said. “But early diagnosis is the only factor that can improve survival.”

It is a proven fact, she added. The National Lung Screening Trial, the results of which were published in the New England Journal of Medicine in August 2011, found that with former smokers between the ages of 55 and 74, low-dose computed tomography, or LDCT, screening reduced lung cancer mortality in screened patients by 20%.

To confirm potential lung cancers that turn up in screening, surgery “is the only sure answer,” said Dr. Shrager, who heads Stanford Medical Center’s thoracic surgery division. Yet surgery “hurts, and it’s costly and it does have some small risk,” he added.

If a tumor is detected, the standard method a decade ago — even for removal of the smallest nodules — was a thoracotomy: major surgery involving the cutting of major muscles and the spreading of a patient’s ribs.

Less invasive surgical methods are often not able to detect small tumors. This is true with bronchoscopy, and with trying to get a biopsy by passing a needle through the chest wall.

Advances in surgical technology, however, have led to video-assisted thoracic surgery, or VATS, which involves three small incisions, a video camera inserted into the patient’s lung, and specialized instruments that can remove a suspicious nodule identified on a screening CT scan. .

“If we can do that and prove it’s a cancer, we can then go on at the same sitting and complete whatever full operation is required,” Dr. Shrager said.

Once a tumor is identified, the basic operation in the past has generally been the removal of the whole lung lobe containing the cancer, he said. But that school of thought has evolved too, with smaller portions of the lung being removed, especially for smaller tumors, and usually with VATS technology, Dr. Shrager said.

“We are getting smaller and smaller with the things we do,” he said.

Stanford has been on the forefront of this trend; the center conducts about 50% of its lobectomies using VATS, while the national average is about 20%.

Assuming the cancer has not spread to lymph nodes, using the VATS method “we can do exactly the same operation as we used to do with a thoracotomy, but with much less pain medication, and people can get back to their normal lives more quickly,” Dr. Shrager said. The ease and speed of recovery from this less-invasive surgical procedure also enables adding chemotherapy into the treatment mix when necessary, he added.

Drug treatments for lung cancer have come a long way too, said Dr. Wakelee, a clinical investigator who focuses on researching drugs that target particular mutations in lung cancer.

“We have a much better understanding of the biology behind lung cancer,” Dr. Wakelee said.

As a result, the list of drug treatments that have shown promise in treating cancerous tumors has been growing. Many of them were developed for patients whose lung cancer had advanced to the metastatic stage; now these successful drugs are being used in earlier stage cancer treatment, she said.

For example, so called VEGF (vascular endothelial growth factor) inhibitors, which block the growth of blood vessels that help small cancer cells grow into tumors, have improved survivability in patients who received this drug in conjunction with chemotherapy, Dr. Wakelee said. An effort is underway to use the VEGF inhibitor bevacizumab as part of a clinical trial in early stage lung cancer patients who have had surgery, she added.

Yet with the successes come more challenges. Patients with particular genetic mutations in their tumors have responded dramatically well to some targeted drugs, such as gefitinib and erlotinib. Yet, on average, these patients’ tumors “figure out how to become resistant, the cancer starts to grow again and we have to come up with a new plan,” Dr. Wakelee said. Research is underway to come up with new drug combinations to overcome this resistance, she added.

Despite the advances in drug therapies and surgery techniques, “chemo is still a very important part of therapy,” Dr. Wakelee said. Dr. Loo, whose clinical specialty is radiation treatment of lung and head and neck cancer, added that while surgery remains the standard of care for early stage lung cancer, with a cure rate of about 70%, roughly 20% of early stage lung cancer patients cannot tolerate surgery because of risks due to old age or poor health.

The major alternative to surgery has been conventional radiation therapy, Dr. Loo said, but the unsatisfactory results from this mode of treatment has driven the development of new, more targeted radiotherapy techniques.

One such technique is stereotactic ablative radiotherapy, or SABR. It incorporates many highly focused beams of radiation that enable the accurate delivery of high doses of radiation.

“SABR allows us to concentrate the radiation on the tumor with less damage to the surrounding organs,” Dr. Loo said.

The technology is impressive. Using scanning equipment, SABR can either follow a tumor with its beams as it moves with a patient’s breathing, or switch on the beam when the breath of a patient returns the tumor to the target area.

The technique has been proven effective. A recent U.S. study focusing on cancer patients too ill to have surgery found a 98% tumor control rate over three years when they were treated with SABR. The overall survival rate was 56%, an impressive statistic for patients too stricken with other illnesses to undergo surgery, Dr. Loo said. Most of the mortality in this this group of patients was due to causes other than cancer, he added. More clinical trials on the efficacy of SABR treatments are underway at Stanford and across the globe, Dr. Loo said. The medical center’s tradition of innovation, with its invention of the medical linear accelerator and the CyberKnife (a robotic radiosurgery system), continues with its latest advances in radiation therapy.

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