Spinal cord ischemia following thoracotomy without epidural anesthesia

Paraplegia is an uncommon yet devastating complication following thoracotomy, usually caused by compression or ischemia of the spinal cord. Ischemia without compression may be a result of global ischemia, vascular injury and other causes. Epidural anesthesia has been implicated as a major cause. This report highlights the fact that perioperative cord ischemia and paraplegia may be unrelated to epidural intervention. A 71-yr-old woman was admitted for a left upper lobectomy for resection of a non-small cell carcinoma of the lung. The patient refused epidural catheter placement and underwent a left T5-6 thoracotomy under general anesthesia. During surgery, she was hemodynamically stable and good oxygen saturation was maintained. Several hours following surgery the patient complained of loss of sensation in her legs. Neurological examination disclosed a complete motor and sensory block at the T5-6 level. Magnetic resonance imaging (MRI) revealed spinal cord ischemia. The patient received iv steroid treatment, but remained paraplegic. Five months following the surgery there was only partial improvement in her motor symptoms. A follow-up MRI study was consistent with a diagnosis of spinal cord ischemia. In this case of paraplegia following thoracic surgery for lung resection, epidural anesthesia/analgesia was not used. The MRI demonstrated evidence of spinal cord ischemia, and no evidence of cord compression. This case highlights that etiologies other than epidural intervention, such as injury to the spinal segmental arteries during thoracotomy, should be considered as potential causes of cord ischemia and resultant paraplegia in this surgical population

Stereotactic body radiotherapy for central lung tumors, yes we can!

Abstract Background SBRT is standard therapy for early stage lung cancer. Toxicity in central tumors has been a concern. RTOG 0813 showed that central SBRT is safe and effective. We report our experience with central SBRT. Methods We reviewed the records of patients treated with SBRT for central lung tumors (< 2 cm of the carina). Patients included primary lung cancer and recurrence following surgery and\ or conventional radiotherapy. All patients underwent 4DCT simulation and treatment planning was done with IMRT or VMAT techniques. Dose to the PTV was prescribed to the 95% isodose line. Results Seventy patients, between 5/09 and 4/13, were treated. Patients had early non-small cell lung cancer (n = 13) or locally recurrent lung cancer (n = 29) and pulmonary oligometastases (n = 28). Fifty-seven percent of the patients received BED of 132 with a schedule of 60Gy in 12 Gy fractions. Median follow up time was 18.3 months, 4/70 patients experienced local failure (6%). Median OS for the whole cohort was 4.6 years (CI 3-7 years). Ten patients had grade 1-2 radiation pneumonitis. One patient developed fatal bronchial bleeding. Conclusions SBRT for central tumors is safe and effective in patients with central disease, reiradiation, recurrence following surgery and in oligometastes

Referral rates and barriers to lung transplantation based on pulmonary function criteria in interstitial lung diseases: a retrospective cohort study

Background: Interstitial lung diseases (ILD) unresponsive to medical therapy often require lung transplantation (LTx), which prolongs quality of life and survival. Ideal timing for referral for LTx remains challenging, with late referral associated with significant morbidity and mortality. Among other criteria, patients with ILD should be considered for LTx if forced vital capacity (FVC) is less than 80% or diffusion capacity for carbon monoxide (DLCO) is less than 40%. However, data on referral rates are lacking. Objectives: To evaluate referral rates for LTx based on pulmonary function tests (PFTs) and identify barriers associated with non-referral. Design: A single-center retrospective cohort study. Methods: The study consisted of ILD patients who performed PFT between 2014 and 2020. Patients with FVC < 80% or a DLCO < 40% were included in the study. Patients with absolute contraindications to LTx were excluded. Referral rates were computed, and a comparison was made between referred and non-referred subjects. Results: Out of 114 ILD patients meeting criteria for referral to LTx, 35 were referred (30.7%), and 7 proceeded to undergo LTx. Median time from PFT to referral for assessment was 255 days [interquartile range (IQR) 35–1077]. Median time from referral to LTx was 89 days (IQR 59–143). Referred patients were younger ( p  = 0.003), had lower FVC ( p  < 0.001), DLCO ( p  < 0.001), and a higher rate of pulmonary hypertension ( p  = 0.04). Relatively better PFT, and older age, were significantly associated with non-referral of patients. Conclusion: There is under-referral of ILD patients who are eligible for LTx, which is associated with severe disease and missed opportunities for LTx. Further research is required to validate these findings