Inside the OR: Lung Cancer Robotic Surgery
Northwestern Medicine Thoracic Surgeon Samuel S. Kim, MD, explains a breakthrough in lung cancer surgery.
Inside the OR: Lung Cancer Robotic Surgery
Northwestern Medicine Thoracic Surgeon Samuel S. Kim, MD, explains a breakthrough in lung cancer surgery.
Cancer is a huge problem, since it is actually a collection of a lot of different diseases in different places, resulting from mutation of the genes and invasiveness as the common characteristic. All cancers are different.
Carcinoid tumor is a good illustration. These are so called neutoendocrine tumors. They are slow growing, and are usually not detected until they are quite advanced. They can be located in different organs such as the gastrointestinal tract and the lung.
In their vicinity they produce symptoms characteristic of the area; trouble swallowing, nausea, vomiting, constipation and abdominal pain for gastrointestinal carcinoid, and cough, wheezing, shortness of breath and chest pain for those located in the lung.
Many advanced cancers can produce weight loss, muscle pain and fatigue In addition to symptoms characteristic of their location. The special characteristic of carcinoid tumors is that they may secrete substances that produce diverse symptoms such as flushing of the skin, sudden diarrhea and vomiting and, strangest of all, heart valve leakages.
Diagnosis of carcinoid tumors is often made by checking for serotonin or chromogranin-A in the blood, and 5-Hydroxy indolacetic acid ( 5-HIAA) in the urine, and locating the tumor with Imaging such as CT and MRI.
It is usually treated best for surgery, but cell surface somatostatin can be targeted for hormone therapy, and targeted radiotherapy with PRRT. It is very much to the advantage of the patient if she has a tumor with specific hormone or other marker that can be targeted for treatment, such as a breast cancer with estrogen receptors that can be targeted by tamoxifen.
Please check the accompanying mayo clinic article for more information.
Cryptococcus neoformans and gattii are fungi that most commonly infect people with immunodeficiency, especially AIDS, which is highly prevalent in Africa. Cryptococcus is the final cause of death in perhaps 25% of AIDS patients and preventative treatment is sometimes used if the lymphocyte count is too low.
It is an opportunistic fungus, with similarities to pneumocystis carina, which is discussed in a previous entry.
The areas in the body most commonly affected are the lungs, the skin, and the brain. The lung and skin, being exposed to the environment, are the most common entry points for the fungus, and the brain is a frequently involved area. Chronic meningitis, where the symptoms include headache, blurred vision, and confusion, is frequently caused by cryptococcus.
Sometimes, in healthy people, the skin can be infected with “pigeon breeders disease”. Pigeon droppings are a very common source of cryptococcus organisms.
Infection In the lung is usually restricted to immunocompromised individuals, who develop cough, shortness of breath, and fever. Pulmonary cryptococcosis is a slowly developing disease, can be mistaken for tuberculosis, and frequently gets into the bloodstream and then into the brain.
Treatment is usually with amphotericin B and flucytosine.
Pneumocystis is found in the respiratory tract of most mammals and Man. Pneumonia from this organism was extremely rare or unknown before the advent of AIDS.
When the lymphocyte count of a person with AIDS drops below 500, or especially 200, pneumocystis pneumonia is a frequent complication. Symptoms include cough, fever, rapid breathing, and shortness of breath.. The chest x-ray typically shows a “ground glass” appearance, caused by fluid inside the air sacs and throughout the lung. Treatment is usually with trimethoprim sulfa.
Immunosuppressive therapy is often given for organ transplants and auto immune diseases these days. Patients and doctors should be on the lookout for pneumocystis symptoms in this situation. Even long-term corticosteroids can produce enough immunosuppression to allow pneumocystis to invade the body.
Pneumocystis Jeroveci is the causative organism, and used to be called pneumocystis Carini. Doctors suspect this disease when an immuno-suppressed patient, especially AIDS , has a dry cough, with pneumonia and a very low oxygen concentration, more severe than expected. Fluid taken from the lung shows several organisms in little sacks or cysts.
Treatment is with sulfonamids, if they are tolerated. Cortisone must be given not the same time to prevent a severe reaction from absorption of the dead organisms. Pneumocystis is a yeast-like fungus and is also discussed under opportunistic fungal infections.
The following article will give you more information.
COVID-19 is admittedly a pandemic and has caused much economic and social disruption in the world. Now we learn that it may not be over after a few of weeks of illness. LONG COVID is now an accepted syndrome.
You can tell because of the many clinics for handling it being set up by the NHS in England, and millions in research money being directed towards a solution.
The most disturbing thing to me is that infected but asymptomatic or mildly ill people may get this condition, and have one or more symptoms for a long time .Certainly, those more seriously ill develop long Covid symptoms more commonly.
Long Covid is taking its place with chronic fatigue syndrome, posttraumatic stress disorder and post ICU syndrome as poorly understood conditions. They may in fact be taking place simultaneously, even if they are not identical.
The cause can be due to continuing viral infection in older or immune compromised individuals. Vascular damage is another reason that could account for the widespread involvement of practically any organ system that doesn’t go away after a few weeks.
Structural damage to the alveoli of the lungs and other organs can also play a role, which would account for shortness of breath as a prominent persistent symptom. Although it has not been highlighted in the articles that I have read, auto immunity can also be playing a role in long Covid.
This would go along with The myocarditis rarely caused by the mRNA vaccines; perhaps some of the protein sequences of the spike proteins have similar shapes to some human tissues. Name a symptom, and you’ll probably find it listed among the 50 odd symptoms mentioned in the Wikipedia article on long Covid, which is appended to the end of this article.
The most prominent symptoms include extreme fatigue, mental fog, and shortness of breath. Treatment is mainly supportive and general. After ruminating on this condition, it’s going to be quite a while before Yours truly wants to breathe in other peoples air spaces; I plan to continue masking in public, distancing and avoiding large groups.
That being said, I am planning to go out to eat dinner tonight, and can hopefully be placed at the edge of the room. I will inquire as to the vaccination status of our waiter. The people at my table will all be doubly vaccinated, which is not complete assurance of safety, but will help make me feel relatively comfortable.
I also plan on getting a booster shot as soon as it is available. Hopefully, the vaccine incorporating the special mutations of the delta virus will be soon available. You don’t want to be infected by this nasty, promethian shape-shifter. Take care.
COPD is the brother of asthma. Both can cause shortness of breath and wheezing. Asthma is the more Treatable of the two, and is due to muscle spasm around the airways which narrow those airways making it more difficult to breathe in and especially out.
COPD comes in 2 general forms, Chronic bronchitis and emphysema.
Chronic bronchitis is an inflammation of the airways, which differs from the usual allergic asthmatic TH2 type of inflammation. The inflammation of chronic bronchitis is the more common TH1 inflammation that comes from the likes of bacteria and viruses.
The second type of COPD is usually caused by cigarette smoke or other fumes which lead to the destruction of the air sacs and associated elastic tissue, allowing a check valve type of obstruction to occur on breathing out.
COPD is rarely a pure type of chronic bronchitis or emphysema, and is usually an admixture of the two. In fact there can be an “asthmatic element” mixed into COPD, which allows for a better response to the myriads of medication that we now have for asthma.
The symptoms of COPD include shortness of breath, wheezing, chest tightness and chronic cough with production of sputum. Coughing up a significant volume of phlegm from your chest suggests chronic bronchitis rather than emphysema.
The symptoms of COPD come on rather slowly and are usually not noticed until the problem is severe. After all, the cigarette smoker is EXPECTED to cough isn’t he?
As COPD becomes very advanced, fatigue, lack of energy, and unintended weight loss may occur. Swelling of the legs may be a problem and could indicate involvement of a heart; with COPD the right side of the heart has a hard time moving blood through the diseased lungs.
We’ve all seen people pushing around a cart with an oxygen tank. These people most often are smokers who developed COPD. One particularly disgusting advertisement against cigarette smoking showed a person with a hole in the windpipe (tracheostomy) through which he was smoking his cigarette.
Pulmonary function testing it’s often helpful in diagnosing asthma and COPD. In pulmonary function testing, the amount of air in the lungs and the rapidity with which it can be expelled from the Lungs is measured and graphed. it is the rate of flow on exhalation that is diminished in COPD and asthma, the slower the rate the worse the blockage.
In the case of asthma the test is repeated after a bronchodilating adrenaline type medication has been given. The REVERSIBILITY of the airway obstruction is shown by comparing the airway function before and after treatment With no improvement, usually COPD is usually the culprit.
In both asthma and COPD, respiratory infection is a big problem. The compromised lung is usually very vulnerable to these inflammatory reactions. There are a score of medications that are commonly used in asthma which also benefit COPD to a certain degree. Doctors have a large armamentarium for respiratory disease these days.
As mentioned, asthma is more treatable. However if it is poorly treated or neglected, a condition known as REMODELING can occur which will render treatment less effectual.
Please check with the Mayo clinic article on COPD for more information.
Asthma is a lung condition with narrowing of the airways, especially on exhalation, or breathing out. This narrowing leads to the musical sound on breathing the air out of the lungs that I heard so often with my stethoscope and over the phone, when I was in active allergy practice. With an asthma attack, the blockage to airflow can become severe enough to dangerously raise the carbon dioxide concentration in the blood stream, and lower the oxygen content.
Many attacks occurred at night .Over the phone, I had older kids and adults take a deep breath, and count from 1 to 30 as rapidly as they could. If they could count out loud to 30 with one breath, at least the obstruction and attendant blood gas changes were not usually serious at that moment in time. That helped me decide whether or not I had to see them in the emergency room.
Asthma is an inflammatory condition of the lining of the airway that stimulates the smooth muscle surrounding the airway to constrict and obstruct flow of air, particularly on exhalation. Early on in my medical practice the main pathology was thought to be overactive airway muscles, and the main effort was to relax those muscles so that breathing could be easier. This was typically done with adrenaline injections, or the inhalation of adrenaline-like agents such as albuterol.
More sustained opening the airway was accomplished by oral theophylline. As time went on, it became known that its effectiveness required a certain blood level. We had an HPLC machine in the office to measure this. 5 to 10 µg per milliliter was required for relief, and anything over 20 µg per milliliter was dangerous. Many cases of convulsions have been recorded in people with excessive blood levels.
We were always aware of the fact that cortisone medications would relieve asthma, but regular use of these drugs caused worrisome side effects such as interference with growth in children, osteoporosis, weight gain and loss of sleep or other problems. Most worrisome was the possibility of adrenal insufficiency and sudden death. We used Cortisone only as a last resort.
There was a group of young children especially 1 to 6 years of age that developed extreme asthma a few days after they developed a common cold. I found that giving prednisolone for two or three days at the start of a runny nose would block the advent of this asthma, without suppressing the adrenal gland. Three days of prednisone was also used to blunt severe attacks.
The excellence of Cortisone in the treatment of asthma should’ve told us that inflammation was a particularly important factor. It is now known that Asthma is not a disease of airway smooth muscle sensitivity per se, but rather a chronic inflammation of the airways that causes the muscles to be irritable.
Asthma is more common in allergic individuals, particularly when they are young. For this reason, the allergies are treated by avoidance of exposure to such things as cats, dogs, house dust and pollen. Allergy injections to the skin test positive items is also useful.
Currently, asthma is treated by inhaling special cortisone preparations and long acting bronchodilators.
The chain of chemical reactions that cause asthmatic airway inflammation has become apparent over the years. Drugs to block these are available, and include special antibodies can be exceptionally expensive; but very effective.
The youngest of my former partners is still practicing Allergy, and almost never has to deal with acute severe asthma.
The beast has been tamed, if not conquered.
The genius aspergillus is a Fungus extremely common throughout the world. It is in the air almost everywhere, and it’s estimated that most people breathe hundreds of Aspergillus spores into their lungs daily. It affects almost exclusively people with compromised immune systems or with underlying respiratory illness.
COMPROMISED IMMUNITY is often present in people with diabetes, obesity and malnutrition, The very young and very old, Viral infections, particularly AIDS and Covid, cancer, autoimmune diseases, organ transplants, and the list goes on. With the advances in medicine in the past few decades, people are being kept alive longer, often by suppressing their own immunity.
UNDERLYING REPIRATORY ILLNESS is disease such as asthma, cystic fibrosis, sarcoidosis, tuberculosis and COPD.
When I was in an allergy practice, we were always on the alert for allergic bronchopulmonary aspergillosis in asthmatics who were difficult to control. ABPA at that time was reported mainly in England, which is unsurprising due to the wet British climate: fungi grow especially well where is wet.
Another unusual phenomenon is the Aspergillus fungus ball in the lungs, which is sometimes discovered only by chest x-ray. That such a dense mass of fungi could be tolerated in the lungs without invading the body is a tribute to the immune system‘s efficacy.
Galactomannan is in the cell wall of aspergillus, and can be used as a diagnostic test. PCR can also be used, shades of COVID-19. Of course x-ray, or microscopic study of tissues are also often used.
It is estimated that aspergillosis accounts for around 600,000 deaths annually. Africa, with its large number of AIDS patients, contributes heavily to this. It’s difficult to know how common it is in the United States, because aspergillus is not a reportable illness. Please check with the following mayo clinic article for more information.