Impact of facility type and volume in locally advanced esophageal cancer

BACKGROUND

We hypothesized that academic facilities and high-volume facilities would be independently associated with improved survival and a greater propensity for performing surgery in locally advanced esophageal cancer.

METHODS

We identified patients diagnosed with stage IB-III esophageal cancer during 2004-2016 from the National Cancer Database. Facility type was categorized as academic or community, and facility volume was based on the number of times a facility's unique identification code appeared in the dataset. Each facility type was dichotomized into high- and low-volume subgroups using the cutoff of 20 esophageal cancers treated/year. We fitted multivariable regression models in order to assess differences in surgery selection and survival between facilities according to type and volume.

RESULTS

Compared to patients treated at high-volume community hospitals, those at high-volume academic facilities were more likely to undergo surgery (odds ratio: 1.865, p < 0.001) and were associated with lower odds of death (odds ratio: 0.784, p = 0.004). For both academic and community hospitals, patients at high-volume facilities were more likely to undergo surgery compared to those at low-volume facilities, p < 0.05. For patients treated at academic facilities, high-volume facilities were associated with lower odds of death (odds ratio: 0.858, p = 0.02) compared to low-volume facilities, while there was no significant difference in the odds of death between high- and low-volume community hospitals (odds ratio: 1.018, p = 0.87).

CONCLUSIONS

Both facility type and case volume impact surgery selection and survival in locally advanced esophageal cancer. Compared to community hospitals, academic facilities were more likely to perform surgery and were associated with improved survival.

Increasing Time-to-Treatment for Lung Cancer: Are We Going Backward?

BACKGROUND

Treatment delays in lung cancer care in the United States may be attributable to a diverse range of patient, provider, and institutional factors, the precise contributions of which remain unclear. The objective of our study was to use the National Cancer Database to investigate specific predictors of increased time-to-treatment initiation.

METHODS

We identified 567 783 patients undergoing treatment for stage I to stage IV non-small cell lung cancer during 2010 to 2018. Time-to-treatment initiation was defined as the number of days from radiologic diagnosis to initiation of first treatment. We used mixed effect negative binomial regression to determine predictors of time-to-treatment initiation.

RESULTS

We noted a steady rise in the overall mean time-to-treatment initiation interval from 33 days (2010) to 39 days (2018; P < .01). Black race, a later year at diagnosis, nonprivate insurance, and diagnosis and treatment at different facilities were independent predictors of increased time-to-treatment initiation, irrespective of disease stage. Compared with White race, Black race corresponded to a 15% to 20% increase in time-to-treatment initiation, depending on disease stage (P < .01). For stages I and II, radiation as first course of therapy corresponded with a 69% and 33% increase in time-to-treatment initiation, respectively, compared with surgery (P < .01).

CONCLUSIONS

Lung cancer treatment initiation times have seen an upward trajectory in recent years. Black patients encountered significantly longer treatment initiation times, regardless of treatment modality or disease stage. Prolonged initiation times appear to contribute to existing health care disparities by disproportionately affecting medically underserved communities.

Lobectomy Demonstrates Superior Survival Than Segmentectomy for High-Grade Non-Small Cell Lung Cancer: The National Cancer Database Analysis

BACKGROUND

Current recommendations for segmentectomy for non-small cell lung cancer (NSCLC) include size ≤2 cm, margins ≥ 2 cm, and no nodal involvement. This study further stratifies the selection criteria for segmentectomy using the National Cancer Database (NCDB).

METHODS

The NCDB was queried for patients with high-grade (poorly/undifferentiated) T1a/b peripheral NSCLC (tumor size ≤2 cm), who underwent either lobectomy or segmentectomy. Patients with pathologic node-positive disease or who received neoadjuvant/adjuvant treatments were excluded. Propensity score analysis was used to adjust for differences in pretreatment characteristics.

RESULTS

11 091 patients were included with 10 413 patients (93.9%) treated with lobectomy and 678 patients (6.1%) underwent segmentectomy. In a propensity matched pair analysis of 1282 patients, lobectomy showed significantly improved median survival of 88.48 months vs 68.30 months for segmentectomy, P = .004. On multivariate Cox regression, lobectomy was associated with significantly improved survival (hazard ratio (HR): .81, 95% CI .72-.92, P = .001). Subgroup analysis of propensity score matched patients with a Charlson-Deyo comorbidity score (CDCC) of 0 also demonstrated a trend of improved survival with lobectomy.

DISCUSSION

Lobectomy may confer significant survival advantage over segmentectomy for high-grade NSCLC (≤2 cm). More work is needed to further stratify various NSCLC histologies with their respective grades allowing more comprehensive selection criteria for segmentectomy.

Treatment quality and outcomes vary with hospital burden of uninsured and Medicaid patients with cancer in early non–small cell lung cancer

Objectives

Safety-net hospitals deliver a significant level of care to uninsured patients, Medicaid-enrolled patients, and other vulnerable patients. Little is known about the impact of safety-net hospital status on outcomes in non–small cell lung cancer. We aimed to compare treatment characteristics and outcomes between hospitals categorized according to their relative burden of uninsured or Medicaid-enrolled patients with non–small cell lung cancer.

Methods

We queried the National Cancer Database for patients with clinical stage I and II non–small cell lung cancer presenting from 2004 to 2018. We categorized hospitals on the basis of their relative burden of uninsured or Medicaid-enrolled patients with non–small cell lung cancer into low-burden (<8.2%), medium-burden (8.2%-12.0%), high-burden (12.1%-16.8%), and highest burden (>16.8%) quartiles. We investigated the impact of care at these hospitals on outcomes while controlling for sociodemographic, clinical, and facility characteristics.

Results

We identified 204,189 patients treated at 1286 facilities. There were 592 low-burden, 297 medium-burden, 219 high-burden, and 178 highest burden hospitals. Patients at highest burden hospitals were more likely to be younger, male, Black, and Hispanic (P < .01), and to reside in rural, low-income, and low-educated regions (P < .01). Patients at these facilities had a greater likelihood of not receiving surgery, undergoing an open procedure, undergoing a regional lymph node examination involving less than 10 lymph nodes, having a length of stay more than 4 days, and not receiving treatment (P < .05).

Conclusions

Our results indicate reduced treatment quality and higher mortality in patients undergoing surgery for early non–small cell lung cancer at hospitals with an increased burden of uninsured or Medicaid-enrolled patients with non–small cell lung cancer. There is a need to raise the standard of care to improve outcomes in vulnerable populations.

Conversion to Thoracotomy in Non-Small Cell Lung Cancer: Risk Factors and Perioperative Outcomes

Objective: We aimed to identify predictors of conversion to thoracotomy and test the hypothesis that conversion is associated with inferior perioperative outcomes in non-small cell lung cancer (NSCLC). Methods: We queried the National Cancer Database for patients with stage I to III NSCLC undergoing minimally invasive surgery (MIS) during 2010 to 2016. We compared clinicopathologic factors between patients undergoing MIS with and without conversion. We fitted multivariable regression models to identify independent predictors of conversion and compare perioperative outcomes between the 2 groups. Results: A rising trend in the use of MIS was accompanied by a declining trend in the rate of conversion to thoracotomy. A total of 11.3% of the 83,219 cases were converted. Conversion was associated with a higher Charlson-Deyo score, squamous histology, nodal involvement, high tumor grade, tumor size ≥5 cm, and a higher T stage ( P < 0.05). Successful MIS without conversion was predicted by advanced age, sublobar resection, robotic approach, and treatment at an academic high-volume facility ( P < 0.05). Conversion was linked to longer hospital stays, higher 30-day and 90-day mortality, and unplanned readmission ( P < 0.05), irrespective of the type of MIS approach. Conclusions: Conversion rates for video-assisted and robot-assisted thoracoscopic surgery have seen a decline in recent years. Irrespective of the type of MIS approach, conversion was associated with inferior perioperative outcomes. The robotic approach and treatment at an academic high-volume facility were associated with a lower likelihood of conversion. Early recognition of the individual risk factors for conversion may help to counsel patients about the likelihood of, and detriments associated with, conversion and ultimately reduce conversion rates.

Social determinants and facility type impact adherence to best practices in operable IIIAN2 lung cancer

OBJECTIVES

We aimed to identify patient- and facility-specific predictors of collective adherence to 4 recommended best treatment practices in operable IIIAN2 non-small-cell lung cancer (NSCLC) and test the hypothesis that collective adherence is associated with superior survival.

METHODS

We queried the National Cancer Database for clinical stage IIIAN2 NSCLC patients undergoing surgery during 2010-2015. The following best practices were examined: performance of an anatomic resection, performance of an R0 resection, examination of regional lymph nodes and administration of induction therapy. Multivariable regression models were fitted to identify independent predictors of guideline-concordance.

RESULTS

We identified 7371 patients undergoing surgical resection for IIIAN2 lung cancer, of whom 90.8% underwent an anatomic resection, 88.2% received an R0 resection, 92.5% underwent a regional lymph node examination, 41.6% received induction therapy and 33.7% received all 4 best practices. Higher income, private insurance and treatment at an academic facility were independently associated with adherence to all 4 best practices (P < 0.01). A lower level of education and residence in a rural county were associated with a lack of adherence (P < 0.05). Adherence to all 4 practices correlated with improved survival (P < 0.01).

CONCLUSIONS

National adherence to best treatment practices in operable IIIAN2 lung cancer was variable as evidenced by the majority of patients not receiving recommended induction therapy. Socioeconomic factors and facility type are important determinants of guideline-concordance. Future efforts to improve outcomes should take this into account since guideline concordance, in the form of collective adherence to all 4 best practices, was associated with improved survival.

Anatomic resection has superior long-term survival compared with wedge resection for second primary lung cancer after prior lobectomy

OBJECTIVES

The extent of surgical resection for early-stage second primary lung cancer (SPLC) in patients with a previous lobectomy is unclear. We sought to compare anatomic lung resections (lobectomy and segmentectomy) and wedge resections for small peripheral SPLC using a population-based database.

METHODS

The Surveillance, Epidemiology and End Results database was queried for all patients with ≤2 cm peripheral SPLC diagnosed between 2004 and 2015 who underwent prior lobectomy for the first primary and surgical resection only for the SPLC. American College of Chest Physicians guidelines were used to classify SPLC. Kaplan-Meier analysis and multivariable Cox regression were used to compare overall survival.

RESULTS

A total of 356 patients met the inclusion criteria with 203 (57%) treated with wedge resection and 153 (43%) treated with anatomic resection. Significantly better median survival was observed with anatomic resection than with wedge resection using a Kaplan-Meier analysis (124 vs 63 months; P < 0.001). With multivariable Cox regression, improved long-term survival was observed for anatomic resection (hazard ratio: 0.44, confidence interval: 0.27-0.70; P = 0.001). Improvement in survival was demonstrated with wedge resection when lymph node sampling was done. Lastly, we calculated the average treatment effect on the treated with inverse probability weighting for a subgroup of patients and found that those with wedge resection and lymph node sampling had shorter long-term survival times.

CONCLUSIONS

Anatomic resections may provide better long-term survival than wedge resections for patients with early-stage peripheral SPLC after prior lobectomy. Significant improvement in survival was observed with wedge resection for SPLC when adequate lymph node dissection was performed.

Invasive thymoma - Which patients benefit from post-operative radiotherapy?

BACKGROUND

The aim of this study is to identify patients with thymoma who should receive post-operative radiotherapy.

METHODS

The Surveillance, Epidemiology, and End Results database was queried for stage IIB-IV thymoma patients diagnosed during 1988-2015. We analyzed the prognostic implications of various clinical-pathological factors by comparing the outcomes of those who received surgery with and without post-operative radiotherapy.

RESULTS

A total of 1120 patients were identified; 62% received post-operative radiotherapy and 38% underwent surgery alone. In a propensity-matched cohort of 812 patients, no survival difference was seen in World Health Organization A, AB, B1, B2, or B3 tumors with the addition of post-operative radiotherapy to surgery (p>0.05). Post-operative radiotherapy also did not improve survival over surgery alone for tumors ≥ or < less than the 4 cm, 7 cm, 10 cm, and 13 cm cutoffs, all p>0.05. Post-operative radiotherapy was an independent, positive prognostic indicator only in the subgroup with stage III disease and in those receiving chemotherapy in addition to post-operative radiotherapy, both p<0.05.

CONCLUSIONS

Patients with stage III thymoma are most likely to benefit from the addition of post-operative radiotherapy to surgical treatments. Tumor size or World Health Organization histology alone should not be criteria for determining the need for post-operative radiotherapy in locally advanced thymoma. Masaoka-Koga stage, which has traditionally been used to help make such decisions, appears to be the most reliable determinant of the use of post-operative radiotherapy.

Travelling to a High-Volume Center Confers Improved Survival in Stage I Non-small Cell Lung Cancer

BACKGROUND

The association of hospital volume with outcomes has been assessed previously for patients with non-small cell lung cancer (NSCLC), but there are limited data on the cumulative effect of travel burden and hospital volume on treatment decisions and survival outcomes. We used the National Cancer Database to evaluate this relationship in early-stage NSCLC.

METHODS

Outcomes of interest were compared between 2 propensity-matched groups with stage I NSCLC: patients in the bottom quartile of distance travelled who underwent surgery at low-volume centers (Local) and those in the top quartile of distance travelled who received surgery at high-volume centers (Distant). Outcomes included type of resection (anatomic or nonanatomic), time to resection (< or ≥8 weeks), number of lymph nodes examined (< or ≥10 nodes) and R0 resection.

RESULTS

We identified 3325 Local patients who travelled 2.3 miles (interquartile range [IQR]: 1.4-3.3 miles) to centers that treated 10.5 (IQR: 6.5-16.5) stage I NSCLCs/year and 3361 Distant patients who travelled 40.0 miles (IQR: 29.1-63.4 miles) to centers treating 56.9 (IQR: 40.1-84.7) stage I NSCLCs/year. Local patients were less likely to receive surgery <8 weeks post-diagnosis, have ≥10 lymph nodes examined during surgery, and undergo an R0 resection (all P < .01). Distant patients had shorter hospital stays and superior median survival, both P < .01.

CONCLUSIONS

Patients travelling longer distances to high-volume centers receive better and more timely surgical care, leading to shorter hospital stays and improved survival outcomes. Regionalization of lung cancer care by improving travel support to larger treatment facilities may help improve early-stage NSCLC outcomes.

Lobectomy is superior to segmentectomy for peripheral high grade non-small cell lung cancer ≤2 cm

Background

Current practice guidelines recommend the following criteria for segmentectomy for non-small cell lung cancer (NSCLC): size ≤2 cm, margins ≥2 cm and no lymph node involvement. We sought to further stratify the selection criteria for segmentectomy for small peripheral high-grade tumors.

Methods

This retrospective database study was conducted using the Surveillance, Epidemiology and End Results (SEER) database. We queried for patients with high-grade (poorly differentiated/undifferentiated) pathological (p)T1a/b peripheral NSCLC (tumor size ≤2 cm), who underwent either lobectomy or segmentectomy between 2004 and 2015. Patients with node-positive disease or those who received any form of induction or adjuvant treatments were excluded.

Results

A total of 4,332 patients met the inclusion criteria, with 3,977 patients (91.8%) treated with lobectomy and 355 patients (8.2%) who underwent segmentectomy. In a propensity matched pair analysis of 640 patients, lobectomy (n=320) showed significantly improved 5-year survival of 45.9% vs. 33.8% for segmentectomy (n=320), P<0.01. In a multivariate Cox regression analysis, lobectomy was associated with significantly improved survival (HR: 0.84, 95% CI: 0.714–0.989, P=0.036). Interestingly, married status, adenocarcinoma histology, number of lymph nodes sampled were associated with better survival (P<0.05), while advanced age and male gender had worse survival outcomes (P<0.05).

Conclusions

For small peripheral NSCLC ≤2 cm and high grades of tumor differentiation, lobectomy is associated with better long-term survival outcomes as compared to segmentectomy. Additional data is needed to further stratify various NSCLC histologies with their respective grades to allow for better selection for segmentectomy.

Nutritional intervention in high-risk patients receiving radiation for a broad spectrum of tumor types

203

Background: Malnutrition is very common in patients receiving radiation therapy. This can result in significant weight loss, decreased functioning, depression, increased mortality, and dramatic declines in quality of life during and after treatment. Targeting patients at risk with nutritional counseling and progressive intervention can have important clinical implications. Methods: A total of 106 patients at a hospital-based cancer center getting radiation for a wide spectrum of cancers (breast, lung, gastrointestinal, genitourinary, and other types) were evaluated for individualized nutritional counseling and education. Patients with identified risk factors were deemed to be at high risk by nursing staff if meeting pre-specified criteria for weight loss ( > 2.5%), body mass index < 18.5%, and/or gastrointestinal symptoms (poor appetite, diarrhea, or constipation affecting quality of life). After high risk patients were identified by a nursing staff triage questionnaire, an automatic computer generated referral was made to the nutritionist. Results: Prior to the institution of this protocol, 13.7% of patients getting radiation therapy were noted to be at high risk and not receiving any nutritional intervention during their course of radiotherapy. However, after the initiation of adequate screening by nursing staff triggering a nutrition referral, the percentage of high risk patients without an associated nutrition consult declined to 1.1%. Conclusions: This study conveys important information for having a systemic screening process in place to identify those at risk for progressive malnutrition while getting radiotherapy for a broad spectrum of tumor types.

Can racial and financial disparities be overcome in the surgical treatment of NSCLC?

208

Background: Considerable data exists examining disparities in the treatment of non-small cell lung cancer (NSCLC) patients. Black patients, in particular those of lower socioeconomic status (SES), are less likely to receive appropriate care, including induction therapy and resection of surgically treatable lesions. We analyzed the outcomes of resection of NSCLC among a racially and financially diverse patient population at a large urban hospital network with a comprehensive thoracic oncology program. In this system, a patient navigation support team helped overcome barriers to preoperative preparation and multidisciplinary referral. Methods: A retrospective review of 345 patients who underwent lobectomy at our institution from 2002 - 2011 was performed. Data was retrieved from the Society of Thoracic Surgeons (STS) database and patient charts. Patient demographics, payor information and preoperative characteristics were noted. Postoperative complications, 30-day survival and 3-year survival were compared. Statistical analysis was performed using SPSS 17.0 (SPSS Inc, Chicago, IL). Chi-square test was used to compare categorical variables and Student's t-test was used to compare continuous variables. Results: Demographics of black and non-black patients were similar. There were more black patients within the Medicaid group than non-Medicaid (48.9% and 25.3%, p=0.001). Physiologic characteristics, risk factors and use of pre-operative RT and chemotherapy were similar. Post-operative complications were comparable in Medicaid vs. non-Medicaid (11.1% and 14.7%, p=0.524), however black patients had a lower rate of complications vs. non-black (6.1% and 17.4%, p=0.007). 3-year survival was similar in the black vs. non-black (82.3% and 78.6%, p=0.879) and Medicaid vs. non-Medicaid (66.7% and 78.8%, p=0.342) groups. Conclusions: We demonstrated equivalent surgical outcomes for NSCLC in addition to the similar use of induction therapy. Surprisingly, complications were lower in the black cohort. Our results reveal that appropriate treatment is being provided regardless of race or SES, and postulate that our system of preoperative patient support eliminates potential barriers to care.

Internal mammary silicone lymphadenopathy diagnosed by robotic thoracoscopic lymphadenectomy

Internal mammary lymphadenopathy can be caused by a variety of disease processes and is a difficult diagnostic dilemma. We report a case of internal mammary lymphadenopathy, in a patient with a significant history of malignancy, requiring a tissue diagnosis. Robotic thoracoscopic lymphadenectomy was used to facilitate excisional biopsy. Pathology was significant for silicone granulomatous lymphadenitis secondary to silicone breast implants inserted after mastectomy for breast cancer.

HIV-associated lung cancer in New York City

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Background: Recent evidence suggests that HIV may be a risk factor of lung cancer, independent of smoking . Due to the expanding population of HIV patients with lung cancer, there is a need to define the clinical course and tumor biology of these patients. Our analysis seeks to characterize the clinical and molecular features of HIV associated non small cell lung cancer (HIV-NSCLC) and evaluate outcomes in a New York City Cancer center that serves a racially and economically diverse population. Methods: We searched the Continuum Cancer Center Registry for cases of HIV-NSCLC diagnosed from 2002 to 2012. Charts were reviewed to determine patient and tumor characteristics, treatment and outcomes. Kaplan-Meier curves were constructed for survival and compared by means of the log rank test. Patient characteristics were compared to national data from the SEER database. Mutational analysis of archival tissue was performed by OnkoMatch Tumor genotyping. Results: HIV-NSCLC was idenfied in 74 patients. Median age (MA) was 55 compared to MA of 70 for non HIV-NSCLC. Patients were predominantly male (72%). Histology distribution was reflective of the non-HIV population (SEER): adenocarcinoma [31 (42%)], squamous [18 (24%)], NSCLC NOS [8 (11%)], poorly differentiated [6 (8%)], and other [9 (15%)]. Distribution of stage was similar to SEER with 39 (53%) patients presenting with stage IV. Lowest recorded CD4 count was <200 in 34 patients (68%) with available CD4 counts. Chemotherapy and radiation were administered to 28 (49%) and 19 patients (31%), respectively. Median survival was 5.2 months. Kaplan-Meier curves were not statistically different by CD4 count (> or < 200), or by receipt of chemo or radiation. Mutational analysis on 7 patients demonstrated 3 with cMet overexpression, 2 KRAS mutations and 1 BRAF mutation. Conclusions: Among our HIV-NSCLC cohort, patients were diagnosed at younger age, but had similar stage and histology distributions as SEER database averages. HIV associated lung cancer appears to have a poor prognosis similar to that of the general population. Rates of treatment were low in our cohort and the potential for undertreatment warrants further study. Observed increased rate of cMET overexpression should prompt further molecular profiling in this population.

KRAS mutations and outcomes for patients with stage IV NSCLC treated with frontline platinum/pemetrexed based chemotherapy

e18139

Background: KRAS mutations are the most common driver mutation indentified in NSCLC, occurring in 20 - 30% of adenocarcinomas. While several studies suggest KRAS predicts for lack of response to TKI therapy, few data exist regarding its association with outcomes for patients treated with cytotoxic chemotherapy. This study explores the association between KRAS mutations and outcomes (RR, PFS) in a cohort of patients treated with frontline platinum/pemetrexed (PPm) based therapy. Methods: In this retrospective chart review, we evaluated RR and PFS for 16 KRAS + EGFR – pts treated with carboplatin (AUC 5-6) or Cisplatin 75mg/m2 and (Pm)pemetrexed (500 mg/m2) +/- (B)bevacizumab 15mg/kg. For comparators, we identified 19 KRAS - EGFR - patients treated with the same regimen. Maintenance therapy with Pm or Pm+B was given at the discretion of the treating physician. KRAS and EGFR mutational status were assessed by RT-PCR on tumor tissue collected at first diagnosis. RR was assessed using RECIST criteria. Kaplan-Meier estimates for PFS were evaluating using log rank test. Fisher exact test was used to assess the association between KRAS mutation status and response rate. Results: The groups were similar in age (KRAS + mean 61 vs. 60; p=0.87), gender (62% vs. 57% F; p= 0.9), ECOG 2 (0 vs. 10%,p=0.47), smoking hx (93% vs. 94% current/former smokers, p=0.7), brain mets (0% vs. 18% p=0.22), mean number induction cycles (4 in each, p=0.6), cisplatin and bevacizumab use (12% vs 10%, p > 0.1;10% vs. 40%, p=0.10). Pm maintenance was used in 31% KRAS+ (5/16) and 26% KRAS-(5/19) (p=0.79). P+B maintenance was used in 12% (2/16) and 5% (1/19) (p=0.70). RR was 56% in the KRAS + (9/16) vs. 36% KRAS- (7/19) respectively (p=0.3). There was a statistically significant improvement in PFS in the KRAS + group (10.3 mos vs. 5.7 mos, p =0.03). Conclusions: In this small retrospective review, KRAS mutations appeared to be associated with a non-significant improvement in RR and significant improvement in PFS for patients treated with frontline PPm based therapy. Future prospective studies should investigate and validate the predictive value of KRAS for this cytotoxic regimen. [Table: see text]

The Society of Thoracic Surgeons expert consensus for the surgical treatment of hyperhidrosis

Significant controversies surround the optimal treatment of primary hyperhidrosis of the hands, axillae, feet, and face. The world's literature on hyperhidrosis from 1991 to 2009 was obtained through PubMed. There were 1,097 published articles, of which 102 were clinical trials. Twelve were randomized clinical trials and 90 were nonrandomized comparative studies. After review and discussion by task force members of The Society of Thoracic Surgeons' General Thoracic Workforce, expert consensus was reached from which specific treatment strategies are suggested. These studies suggest that primary hyperhidrosis of the extremities, axillae or face is best treated by endoscopic thoracic sympathectomy (ETS). Interruption of the sympathetic chain can be achieved either by electrocautery or clipping. An international nomenclature should be adopted that refers to the rib levels (R) instead of the vertebral level at which the nerve is interrupted, and how the chain is interrupted, along with systematic pre and postoperative assessments of sweating pattern, intensity and quality-of-life. The recent body of literature suggests that the highest success rates occur when interruption is performed at the top of R3 or the top of R4 for palmar-only hyperhidrosis. R4 may offer a lower incidence of compensatory hyperhidrosis but moister hands. For palmar and axillary, palmar, axillary and pedal and for axillary-only hyperhidrosis interruptions at R4 and R5 are recommended. The top of R3 is best for craniofacial hyperhidrosis.

Dietary flaxseed protects against lung ischemia reperfusion injury via inhibition of apoptosis and inflammation in a murine model

BACKGROUND

The hallmark of lung ischemia-reperfusion injury (IRI) is the production of reactive oxygen species (ROS), and the resultant oxidant stress has been implicated in apoptotic cell death as well as subsequent development of inflammation. Dietary flaxseed (FS) is a rich source of naturally occurring antioxidants and has been shown to reduce lung IRI in mice. However, the mechanisms underlying the protective effects of FS in IRI remain to be determined.

METHODS

We used a mouse model of IRI with 60 min of ischemia followed by 180 min of reperfusion and evaluated the anti-apoptotic and anti-inflammatory effects of 10% FS dietary supplementation.

RESULTS

Mice fed 10% FS undergoing lung IRI had significantly lower levels of caspases and decreased apoptotic activity compared with mice fed 0% FS. Lung homogenates and bronchoalveolar lavage fluid analysis demonstrated significantly reduced inflammatory infiltrate in mice fed with 10% FS diet. Additionally, 10% FS treated mice showed significantly increased expression of antioxidant enzymes and decreased markers of lung injury.

CONCLUSIONS

We conclude that dietary FS is protective against lung IRI in a clinically relevant murine model, and this protective effect may in part be mediated by the inhibition of apoptosis and inflammation.

IMPACT OF COMPENSATORY HYPERHIDROSIS ON PATIENT SATISFACTION AFTER ENDOSCOPIC THORACIC SYMPATHECTOMY

OBJECTIVE

Endoscopic thoracic sympathectomy (ETS) remains the definitive treatment for primary focal hyperhidrosis. Compensatory hyperhidrosis (CH) is a significant drawback of ETS. We sought to identify the predictors for the development of severe CH after ETS, its anatomic locations, and its frequency of occurrence, and we analyzed the impact of CH on patient satisfaction with ETS.

METHODS

Bilateral ETS for primary focal hyperhidrosis was performed in 220 patients, and a retrospective chart review was conducted. Follow-up evaluation was conducted using a telephone questionnaire, and 73% of all patients were contacted. Patients' responses regarding CH and their level of satisfaction after ETS were analyzed. Statistical analysis was performed using SPSS software (Version 14.0; SPSS, Inc., Chicago, IL). A P value of &lt;0.05 was considered statistically significant.

RESULTS

Some degree of CH developed in 94% of patients. The number of levels treated was not related to the occurrence of severe CH. Isolated T3 ganglionectomy led to a significantly lower incidence of severe CH, when compared with all other levels (P &lt; 0.03). Ninety percent of patients were satisfied with the procedure. The development of severe CH, as opposed to mild or moderate CH, significantly correlated with a lower satisfaction rate (P = 0.003).

CONCLUSION

CH is common after ETS procedures, and the occurrence of severe, but not mild or moderate, CH is a major source of dissatisfaction after ETS. The overall occurrence of severe CH is reduced after T3 ganglionectomy as opposed to ganglionectomies performed at all other levels. The level of satisfaction with ETS is high.

Independent predictors for early and midterm mortality after thoracic surgery

BACKGROUND

The purpose of the present study was to determine independent predictors for early and midterm mortality for the whole context of thoracic surgery.

METHODS

We studied 1453 consecutive patients who underwent thoracic surgery between 2002 and 2005. Operations included lung resections (n = 504), mediastinal (n = 468), pleural and pericardial (n = 226), esophageal (n = 83), chest wall (n = 85), tracheal (n = 50) and other procedures (n = 37). Midterm survival data (mean follow-up 2.0 +/- 1.1 years) were obtained from the National Death Index. Multivariate logistic regression was used to assess in-hospital mortality. Independent predictors for midterm mortality were determined by multivariate Cox regression analysis.

RESULTS

There were 47 (3.2 %) in-hospital and 312 (21.5 %) late deaths. Independent predictors for in-hospital mortality included Zubrod score (OR 2.72, P < 0.001), ASA score (OR 3.42, P < 0.001), pneumonectomy (OR 20.71, P = 0.001) and no history of cerebrovascular events (OR 0.27, P = 0.011). Independent predictors for midterm mortality included age (HR 1.03, P < 0.001), weight loss (HR 1.57, P = 0.005), Zubrod score (HR 1.47, P < 0.001), primary lung cancer (HR 1.98 P < 0.001), intrathoracic extrapulmonary metastases (HR 2.78, P < 0.001), primary chest wall tumor (HR 0.14, P = 0.008), diabetes requiring insulin (HR 1.71, P = 0.017), no preoperative renal failure (HR 0.57, P = 0.004), no comorbidities (HR 0.54, P = 0.009), ASA score (HR 1.69, P < 0.001), postoperative radiation treatment (HR 1.90, P = 0.016), pneumonectomy (HR 2.18, P = 0.040), reoperation for bleeding and/or postoperative transfusion (HR 3.10, P = 0.027) and postoperative pulmonary complications (HR 1.89, P = 0.013).

CONCLUSIONS

We determined independent predictors for in-hospital and midterm mortality for the whole context of thoracic surgery. Zubrod and ASA scores affect both early and midterm mortality.

Thoracoscore predicts midterm mortality in patients undergoing thoracic surgery

OBJECTIVE

Thoracoscore is the first multivariate model for the prediction of in-hospital mortality after general thoracic surgery. We aimed to evaluate the performance of Thoracoscore in predicting in-hospital and midterm all-cause mortality.

METHODS

We retrospectively evaluated 1675 patients who underwent thoracic surgery (lung resections [n = 626], mediastinum [n = 535], pleura and pericardium [n = 268], esophagus [n = 88], chest wall [n = 90], trachea [n = 45], and other procedures [n = 23]) from October 2002 to March 2006 at a single institution. Midterm survival data (mean follow-up 25 +/- 16 months) were obtained from the National Death Index. Kaplan-Meier survival plots of the quartiles of Thoracoscore were constructed and compared with the log-rank test with adjustment for trend.

RESULTS

Starting from the lower-risk to the higher-risk quartile, the in-hospital mortality rates were 0% (0/418), 1% (4/415), 2.5% (11/435), and 9.6% (54/407). Thoracoscore was a strong independent predictor for in-hospital mortality (odds ratio 1.20, 95% confidence intervals 1.15-.25; P < .001). The 2-year survivals of the Thoracoscore quartiles were 98.7% +/- 0.6%, 87.0% +/- 1.8%, 73.8% +/- 2.3%, and 54.8% +/- 2.7%, respectively (P < .0001). Thoracoscore was a strong independent predictor for midterm mortality (hazard ratio 1.12, 95% confidence intervals 1.11-1.14; P < .001).

CONCLUSION

Thoracoscore is a good and useful clinical tool for preoperative prediction of in-hospital and midterm mortality among patients undergoing general thoracic surgery.

Endoscopic resection of thoracic paravertebral and dumbbell tumors

OBJECTIVE

Neurogenic paravertebral tumors are uncommon neoplasms arising from neurogenic elements within the thorax. These tumors may be dumbbell shaped, extending into the spinal canal or exclusively paraspinal. Generally encapsulated, they are located in the posterior mediastinum. In this report, we present our experience in the thoracoscopic resection of these tumors, including surgical technique and potential pitfalls.

METHODS

A retrospective review of patients undergoing endoscopic surgery for paravertebral tumors was undertaken. Patient demographics, charts, operative reports, and pre- and postoperative images were reviewed.

RESULTS

Between 1997 and 2004, 13 patients were treated thoracoscopically for paravertebral tumors in our departments. Our population consisted of four men and nine women. The median age was 44.9 years (range, 29-66 yr). Eight patients presented with pain, dyspnea, cough, and weakness. Five patients had tumors found incidentally. Sizes of the tumors varied from 3 to 9 cm. Final pathology included four neurofibromas, eight schwannomas, and one unclassified granular cell tumor. Gross total resection was achieved endoscopically in all cases. Three patients required a hemilaminectomy for resection of the intraspinal dumbbell component of the tumor during the same operation. The mean operative time was 229.5 minutes. The mean estimated blood loss was 371.1 ml. Postoperative morbidities included one each of tongue swelling, ulnar neuropathy, and intercostal hyperesthesia. The mean hospital stay was 2.8 days.

CONCLUSION

Paravertebral tumors in the posterior mediastinum are amenable to endoscopic removal, even in hard to reach locations. Tumors with intraspinal extension can be removed concurrently by performing a hemilaminectomy, followed by thoracoscopy, without the need for a thoracotomy.

Does leukofiltration reduce pulmonary infections in CABG patients? A prospective, randomized study with early results and mid-term survival

BACKGROUND

We present the first prospective randomized study of primary coronary artery bypass grafting (CABG) patients who were analyzed for postoperative infections after undergoing blood and/or blood product transfusion (BBPT) with a Pall Purecell leukoreducing filter.

METHODS AND RESULTS

One hundred and four patients were enrolled between March 1998 and March 1999. Seventy-two of the patients received BBPT (average 5.6 units BBPT/filter patient and 5.6 units/control patient). Three patients who had CABG without extracorporeal circulation or mixed transfusions of filtered and unfiltered BBPT were excluded. The remaining 69 transfused patients (38 filtered, 31 control) were analyzed and the incidence of culture proven infections was recorded. Mid-term survival data were obtained from the National Death Index and Kaplan-Meier survival plots were constructed. All patients were stratified and matched according to the EuroSCORE.Thirty-day mortality was 2.6% and 3.2% for the filtered and control patients, respectively. There were 5 cases of culture proven infections in 38 filtered patients (13.2%) and 8 in 31 controls (25.8%), P = 0.224. No pulmonary tract infections were recorded in the filter group vs. 4 (12.9%) in controls, P = 0.048. Reduced length for mechanical ventilation (16.3 hours vs. 57.8, P = 0.103), length of stay (9.1 vs. 10.8 days, P = 0.685), as well as increased 50-month actuarial survival, (45.5 vs. 42.3 months, P=0.695) in filtered vs. control, respectively, were recorded.

CONCLUSIONS

The use of leukoreduced BBPT reduced the incidence of pulmonary tract infections in patients undergoing CABG.