1
|
Zeineddine RM, Botros M, Shawwaf KA, Moosavi R, Aly MR, Farina JM, Lackey JJ, Sandstrom BA, Jaroszewski DE. Does a high Haller index influence outcomes in pectus excavatum repair? J Thorac Cardiovasc Surg 2024:S0022-5223(24)00292-7. [PMID: 38608864 DOI: 10.1016/j.jtcvs.2024.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/21/2024] [Accepted: 04/04/2024] [Indexed: 04/14/2024]
Abstract
OBJECTIVE Severity for pectus excavatum includes Haller index (HI) > 3.25. An extremely high HI (≥8) may influence surgical approach and complications. This study reviews outcomes of patients with high HI after repair. METHODS A single institution retrospective analysis was performed on adult patients with HI ≥ 8 undergoing pectus excavatum repairs. For outcomes, a propensity score-matched control group with a HI ≤ 4 was utilized. RESULTS In total, 64 cases (mean age, 33.5 ± 10.9 years; HI, 13.1 ± 5.0; 56% women) were included. A minimally invasive repair was successful in 84%. A hybrid procedure was performed in the remaining either to repair fractures of the ribs (8 patients) and sternum (5 patients) or when osteotomy and/or cartilage resection was required (10 patients). In comparison with the matched cohort (HI ≤ 4), patients with high HI had longer operative times (171 vs 133 minutes; P < .001), more frequently required hybrid procedures (16% vs 2%; P = .005), experienced higher incidences of rib (22% vs 3%; P = .001) and sternal fractures (12% vs 0%; P = .003), and had increased repair with 3 bars (50% vs 19%; P < .001). There were no significant differences between the groups for length of hospital stay or postoperative 30-day complications. CONCLUSIONS Patients with an extremely high HI can be challenging cases with greater risks of fracture and need for osteotomy/cartilage resection. Despite this, minimally invasive repair techniques can be utilized in most cases without increased complications when performed by an experienced surgeon.
Collapse
Affiliation(s)
- Rawan M Zeineddine
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Ariz
| | - Michael Botros
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Ariz
| | - Kenan A Shawwaf
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Ariz
| | - Ryan Moosavi
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Ariz
| | - Mohamed R Aly
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Ariz
| | - Juan M Farina
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Ariz
| | - Jesse J Lackey
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Ariz
| | - Beth A Sandstrom
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Ariz
| | - Dawn E Jaroszewski
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Ariz.
| |
Collapse
|
2
|
Jaroszewski DE, Bostoros P, Farina JM, Botros MM, Aly MR, Peterson M, Lackey J, Pulivarthi KV, Smith B, Craner R, Stearns JD. Evolution of Pain Control for Adult Pectus Excavatum Repair. Ann Thorac Surg 2024; 117:829-837. [PMID: 37279827 DOI: 10.1016/j.athoracsur.2023.04.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 03/31/2023] [Accepted: 04/10/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND Pain control after minimally invasive repair of pectus excavatum (MIRPE) can be challenging, especially in adult patients undergoing surgical repair. This study reviewed different analgesic modalities used over ≥10 years after pectus repair. METHODS A retrospective analysis was performed of adult patients (≥18 years) who underwent uncomplicated primary MIRPE at a single institution from October 2010 to December 2021. Patients were classified by analgesic modality used: epidural, elastomeric continuous infusion subcutaneous catheters (SC-Caths), and intercostal nerve cryoablation. Comparisons among the 3 groups were performed. RESULTS In total, 729 patients were included (mean age, 30.9 ±10.3 years; 67% male; mean Haller index, 4.9 ±3.0). Patients in the cryoablation group required significantly lower doses of morphine equivalents (P < .001) and had overall the shortest hospital stay (mean, 1.9 ±1.5 days; P < .001) with <17% staying >2 days (vs epidural at 94% and SC-Cath at 48%; P < .001). The cryoablation group had a lower incidence of ileus and constipation (P < .001) but a higher incidence of pleural effusion requiring thoracentesis (P = .024). Mean pain scores among groups were minor (<3), and differences were insignificant. CONCLUSIONS The use of cryoablation in conjunction with enhanced recovery pathways provided significant benefit to our patients undergoing MIRPE compared with previous analgesic modalities. These benefits included a decrease in length of hospital stay, a reduction of in-hospital opioid use, and a lower incidence of opioid-related complications associated with constipation and ileus. Further studies to assess additional potential benefits with long-term follow-up after discharge are warranted.
Collapse
Affiliation(s)
- Dawn E Jaroszewski
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Arizona.
| | - Peter Bostoros
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Arizona
| | - Juan M Farina
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Arizona
| | - Michael M Botros
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Arizona
| | - Mohamed R Aly
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Arizona
| | - Michelle Peterson
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Arizona
| | - Jesse Lackey
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Arizona
| | - Krishna V Pulivarthi
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Arizona
| | - Bradford Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, Arizona
| | - Ryan Craner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, Arizona
| | - Joshua D Stearns
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, Arizona
| |
Collapse
|
3
|
Farina JM, Yinadsawaphan T, Jaroszewski DE, Aly MR, Botros M, Cheema KP, Fatunde OA, Sorajja D. The electrocardiographic manifestations of pectus excavatum before and after surgical correction. J Electrocardiol 2024; 82:19-26. [PMID: 38000149 DOI: 10.1016/j.jelectrocard.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 10/31/2023] [Accepted: 11/10/2023] [Indexed: 11/26/2023]
Abstract
BACKGROUND Pectus excavatum (PEx) can cause cardiopulmonary limitations due to cardiac compression and displacement. There is limited data on electrocardiogram (ECG) alterations before and after PEx surgical repair, and ECG findings suggesting cardiopulmonary limitations have not been reported. The aim of this study is to explore ECG manifestations of PEx before and after surgery including associations with exercise capacity. METHODS A retrospective review of PEx patients who underwent primary repair was performed. ECGs before and after surgical correction were evaluated and the associations between preoperative ECG abnormalities and cardiopulmonary function were investigated. RESULTS In total, 310 patients were included (mean age 35.1 ± 11.6 years). Preoperative ECG findings included a predominant negative P wave morphology in V1, and this abnormal pattern significantly decreased from 86.9% to 57.4% (p < 0.001) postoperatively. The presence of abnormal P wave amplitude in lead II (>2.5 mm) significantly decreased from 7.1% to 1.6% postoperatively (p < 0.001). Right bundle branch block (RBBB) (9.4% versus 3.9%, p < 0.001), rsr' patterns (40.6% versus 12.9%, p < 0.001), and T wave inversion in leads V1-V3 (62.3% vs 37.7%, p < 0.001) were observed less frequently after surgery. Preoperative presence of RBBB (OR = 4.8; 95%CI 1.1-21.6) and T wave inversion in leads V1-3 (OR = 2.3; 95%CI 1.3-4.2) were associated with abnormal results in cardiopulmonary exercise testings. CONCLUSION Electrocardiographic abnormalities in PEx are frequent and can revert to normal following surgery. Preoperative RBBB and T wave inversion in leads V1-3 suggested a reduction in exercise capacity, serving as a marker for the need for further cardiovascular evaluation of these patients.
Collapse
Affiliation(s)
- Juan M Farina
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, AZ, USA; Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ, USA
| | | | - Dawn E Jaroszewski
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Mohamed R Aly
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Michael Botros
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Kamal P Cheema
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ, USA
| | | | - Dan Sorajja
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ, USA.
| |
Collapse
|
4
|
Aly MR, Farina JM, Bostoros PM, Botros MM, Pulivarthi VS, Peterson MA, Lackey JJ, Jaroszewski DE. Risk Factors and Techniques for Safe Pectus Bar Removal in Adults After Modified Nuss Repair. Ann Thorac Surg 2023; 116:787-794. [PMID: 36549569 DOI: 10.1016/j.athoracsur.2022.11.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 10/26/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND The Nuss repair involves implants designed for removal after 2 to 3 years. Although rare, significant complications can occur with bar removal, and the incidence of these complications may be higher in adults. This study was performed to review complications and risk factors associated with bar removal and discuss strategies to improve operative safety. METHODS A retrospective study was performed including all patients after pectus excavatum repair who underwent Nuss implant removal at Mayo Clinic Arizona (Phoenix, AZ) from 2013 to 2022. RESULTS In total, 1555 bars were removed (683 patients; 71% men; median age, 34 years[(range, 15-71 years]). Of the removals, 12.45% of patients had bars placed at outside institutions. Major complications were rare, with bleeding most common (2.05%), followed by pneumothorax (0.88%), infection (0.59%), and effusions (0.44%). Most major bleeding (85.71%) occurred from the bar track during removal and was controlled by packing the track. One patient required subsequent hematoma evacuation and transfusion. Bleeding secondary to lung injury was also successfully controlled with packing. Bar removal in 1 patient with significantly displaced bars required sternotomy and cardiopulmonary bypass as a result of aortic injury. Risk factors identified for bleeding included sternal erosion (P < .001), bar migration (P < .001), higher number of bars (P = .037), and revision of a previous pectus repair (P = 0.001). Bar migration was additionally associated with major complications (P < .001). Older age, although a risk factor for overall complications (P = 0.001), was not a risk factor for bleeding. CONCLUSIONS Bar removal can be safely performed in most patients; however, significant complications, including bleeding, may occur. Identifying potential risk factors and being prepared for rescue maneuvers are critical to prevent catastrophic outcomes.
Collapse
Affiliation(s)
- Mohamed R Aly
- Department of Cardiovascular and Thoracic Surgery, Division of Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Juan M Farina
- Department of Cardiovascular and Thoracic Surgery, Division of Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Peter M Bostoros
- Department of Cardiovascular and Thoracic Surgery, Division of Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Michael M Botros
- Department of Cardiovascular and Thoracic Surgery, Division of Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Venkata S Pulivarthi
- Department of Cardiovascular and Thoracic Surgery, Division of Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Michelle A Peterson
- Department of Cardiovascular and Thoracic Surgery, Division of Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Jesse J Lackey
- Department of Cardiovascular and Thoracic Surgery, Division of Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Dawn E Jaroszewski
- Department of Cardiovascular and Thoracic Surgery, Division of Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona.
| |
Collapse
|
5
|
Janssen N, Franssen AJPM, Daemen JHT, van Roozendaal LM, Hulsewé KWE, Vissers YLJ, Jaroszewski DE, de Loos ER. Combining the best of both worlds: sternal elevation for resection of anterior mediastinal tumors through the subxiphoidal uniportal video-assisted thoracoscopic surgery approach. J Thorac Dis 2023; 15:4573-4576. [PMID: 37868878 PMCID: PMC10587001 DOI: 10.21037/jtd-23-1167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 08/21/2023] [Indexed: 10/24/2023]
Affiliation(s)
- Nicky Janssen
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Center, Heerlen, the Netherlands
| | - Aimée J. P. M. Franssen
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Center, Heerlen, the Netherlands
| | - Jean H. T. Daemen
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Center, Heerlen, the Netherlands
| | - Lori M. van Roozendaal
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Center, Heerlen, the Netherlands
| | - Karel W. E. Hulsewé
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Center, Heerlen, the Netherlands
| | - Yvonne L. J. Vissers
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Center, Heerlen, the Netherlands
| | - Dawn E. Jaroszewski
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Erik R. de Loos
- Division of General Thoracic Surgery, Department of Surgery, Zuyderland Medical Center, Heerlen, the Netherlands
| |
Collapse
|
6
|
Aly MR, Farina JM, Botros MM, Jaroszewski DE. Minimally invasive repair of pectus excavatum in adults: a review article of presentation, workup, and surgical treatment. J Thorac Dis 2023; 15:5150-5173. [PMID: 37868874 PMCID: PMC10587002 DOI: 10.21037/jtd-23-87] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 05/29/2023] [Indexed: 10/24/2023]
Abstract
Pectus excavatum (Pex) is one of the most common congenital deformities of the chest wall, with pectus constituting 90% of all chest wall deformities and excavatum being reported in almost 1:400 to 1:1,000 live births with predominant occurrence in males up to five times more than in females. Depending on the severity, presentation varies from mild cosmetic complaints to life limiting cardiopulmonary symptoms. Patients may develop symptoms as they age, and these symptoms may worsen over the years. A technique for minimally invasive repair for pectus excavatum (MIRPE) was introduced with the concept of temporarily implanting metal bars to correct the deformity. This has rapidly become the standard of care for the pediatric and adolescent patients. The use of MIRPE in adults, however, has been slower to adopt and more controversial. This is largely due to the increased calcification and rigidity of the chest wall in adults which can make the repair more complex and lead to a higher risk of complications. We present a literature review of the presentation, workup, and surgical treatment of adult patients with Pex undergoing MIRPE. Adult patients can, with advanced preoperative evaluations and technique modifications, undergo a highly successful repair resulting in symptom resolution and satisfying results.
Collapse
Affiliation(s)
- Mohamed R Aly
- Division of Thoracic Surgery, Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Juan M Farina
- Division of Thoracic Surgery, Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Michael M Botros
- Division of Thoracic Surgery, Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Dawn E Jaroszewski
- Division of Thoracic Surgery, Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| |
Collapse
|
7
|
Malan SH, Jaroszewski DE, Craner RC, Weis RA, Murray AW, Meinhardt JR, Girardo ME, Abdelrazek AS, Borah BJ, Dholakia R, Smith BB. Erector Spinae Plane Block With Liposomal Bupivacaine: Analgesic Adjunct in Adult Pectus Surgery. J Surg Res 2023; 289:171-181. [PMID: 37121043 DOI: 10.1016/j.jss.2023.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 02/16/2023] [Accepted: 03/16/2023] [Indexed: 05/02/2023]
Abstract
INTRODUCTION Pain management may be challenging in patients undergoing pectus excavatum (PE) bar removal surgery. To enhance recovery, opioid sparing strategies with regional anesthesia including ultrasound-guided erector spinae plane block (ESPB) have been implemented. The purpose of this study was to evaluate the safety and efficacy of bilateral ESPB with a liposomal bupivacaine/traditional bupivacaine mixture as part of an enhanced patient recovery pathway. MATERIALS AND METHODS A retrospective review of adult patients who underwent PE bar removal from January 2019 to December 2020 was performed. Perioperative data were reviewed and recorded. Patients who received ESPB were compared to historical controls (non-ESPB patients). RESULTS A total of 202 patients were included (non-ESPB: 124 patients; ESPB: 78 patients). No adverse events were attributed to ESPB. Non-ESPB patients received more intraoperative opioids (milligram morphine equivalents; 41.8 ± 17.0 mg versus 36.7 ± 17.1, P = 0.05) and were more likely to present to the emergency department within 7 d postoperatively (4.8% versus 0%, P = 0.05) when compared to ESPB patients. No significant difference in total perioperative milligram morphine equivalents, severe pain in postanesthesia care unit (PACU), time from PACU arrival to analgesic administration, PACU length of stay, or postprocedure admission rates between groups were observed. CONCLUSIONS In patients undergoing PE bar removal surgery, bilateral ESPB with liposomal bupivacaine was performed without complications. ESPB with liposomal bupivacaine may be considered as an analgesic adjunct to enhance recovery in patients undergoing cardiothoracic procedures but further prospective randomized clinical trials comparing liposomal bupivacaine to traditional local anesthetics with and without indwelling nerve catheters are necessary.
Collapse
Affiliation(s)
- Shawn H Malan
- Adult Cardiothoracic Anesthesiology Fellow, Baylor Scott & White Medical Center, Texas A&M Health Science Center College of Medicine, Temple, Texas
| | - Dawn E Jaroszewski
- Professor of Surgery, Department of Cardiovascular Surgery, Mayo Clinic, Phoenix, Arizona
| | - Ryan C Craner
- Assistant Professor of Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, Arizona
| | - Ricardo A Weis
- Assistant Professor of Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, Arizona
| | - Andrew W Murray
- Assistant Professor of Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, Arizona
| | | | | | - Ahmad S Abdelrazek
- Research Fellow, Cardiovascular Surgery Research, Mayo Clinic, Rochester, Minnesota
| | - Bijan J Borah
- Mayo Clinic College of Medicine & Science Robert D. & Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota
| | - Ruchita Dholakia
- Mayo Clinic College of Medicine & Science Robert D. & Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota
| | - Bradford B Smith
- Assistant Professor of Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, Arizona.
| |
Collapse
|
8
|
Farina JM, Chen Y, Jaroszewski DE, Bostoros P, Wang J. Genetic variants in pectus excavatum. J Pediatr Surg 2023; 58:600-601. [PMID: 36384937 DOI: 10.1016/j.jpedsurg.2022.10.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 10/18/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Juan M Farina
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ 85054, United States
| | - Yanxi Chen
- Department of Quantitative Health Sciences, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Dawn E Jaroszewski
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ 85054, United States.
| | - Peter Bostoros
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ 85054, United States
| | - Junwen Wang
- Department of Quantitative Health Sciences, Mayo Clinic Arizona, Phoenix, AZ, United States
| |
Collapse
|
9
|
Stephens EH, Dearani JA, Jaroszewski DE. Pectus Excavatum in Cardiac Surgery Patients. Ann Thorac Surg 2023; 115:1312-1321. [PMID: 36781097 DOI: 10.1016/j.athoracsur.2023.01.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/23/2022] [Accepted: 01/09/2023] [Indexed: 02/13/2023]
Abstract
BACKGROUND Pectus excavatum frequently accompanies congenital heart disease and connective tissue diseases requiring cardiac surgery. Sometimes the indication is cardiac repair, with the pectus being incidentally noticed; other times, the pectus subsequently develops or becomes more significant after cardiac surgery. This review arms cardiac and congenital surgeons with background about the physiologic impact of pectus, indications for repair and repair strategies, and outcomes for cardiac surgery patients requiring pectus repair. METHODS A comprehensive literature review was performed using keywords related to pectus excavatum, pectus repair, and cardiac/congenital heart surgery within the PubMed database. RESULTS The risks of complications related to pectus repair, including in the setting of cardiac surgery or after cardiac surgery, are low in experienced hands, and patients demonstrate cardiopulmonary benefits and symptom relief. Concomitant pectus and cardiac surgery should be considered if it is performed in conjunction with those experienced in pectus repair, particularly given the increased cardiopulmonary impact of pectus after bypass. In the setting of potential bleeding or hemodynamic instability, delayed sternal closure is recommended. For those with anticipated pectus repair after cardiac surgery, the pericardium should be reconstructed for cardiac protection. For those undergoing pectus repair after cardiac surgery without a membrane placed, a "hybrid" approach is safe and effective. CONCLUSIONS Patients undergoing cardiac surgery noted to have pectus should be considered for possible concomitant or staged pectus repair. For those who will undergo a staged procedure, a barrier membrane should be placed before chest closure.
Collapse
Affiliation(s)
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Dawn E Jaroszewski
- Division of Thoracic Surgery, Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Arizona.
| |
Collapse
|
10
|
Du L, Ernani V, Liu A, Schild SE, Jaroszewski DE, Cassivi SD, Beamer SE, Luo YH, Wampfler JA, Santos PARD, Wigle D, Sun D, Shen KR, Yang P. Prognostic factors in resected pulmonary carcinoid tumors: A retrospective study with 10 years of follow‑up. Oncol Lett 2023; 25:80. [PMID: 36742364 PMCID: PMC9853094 DOI: 10.3892/ol.2023.13666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 12/08/2022] [Indexed: 01/11/2023] Open
Abstract
The objective of the present study was to characterize the difference in 10-year carcinoid-specific survival (CSS) and disease-free survival (DFS) among patients with resected pulmonary typical carcinoid (TC) and atypical carcinoid (AC). Patients diagnosed with pulmonary carcinoid tumors (PCT) between January 1, 1997, and December 31, 2016, were identified. All patients underwent video-assisted thoracoscopic surgery or thoracotomy with thoracic lymphadenectomy. Cumulative CSS was estimated using the Kaplan-Meier model. The analysis of hazard ratios (HRs) and 95% confidence intervals (CIs) was performed using univariate and multivariate Cox proportional hazards models. A total of 404 patients with PCT were included in the present study. The 10-year CSS and DFS rates of patients with AC were significantly worse than those of patients with TC (49.1 vs. 86.8% and 52.2 vs. 92.6%, respectively; P<0.001). In the CSS multivariate analysis, older age and lymph node involvement (HR, 2.45; P=0.022) were associated with worse survival in AC, while age, male sex, M1 stage, cigarette smoking and inadequate N2 lymphadenectomy were associate with worse survival in TC. In the recurrence multivariate analysis, N1-3 stage (HR, 2.62; 95% CI, 1.16-5.95; P=0.018) and inadequate N2 lymphadenectomy (HR, 2.13; 95% CI, 1.04-4.39; P=0.041) were associated with an increase in recurrence in AC, while male sex (HR, 3.72; 95% CI, 1.33-10.42; P=0.010) and M1 stage (HR, 14.93; 95% CI, 4.77-46.77; P<0.001) were associated with an increase in recurrence in TC. In conclusion, patients with AC tumors had significantly worse CSS and DFS rates compared with patients with TC. The degree of nodal involvement in AC was a prognostic marker, in contrast to that in TC. Inadequate lymphadenectomy increased the risk of recurrence in AC and mortality in TC, although surgical approaches did not have a significant impact. The present study therefore emphasizes the importance of mediastinal nodal dissection in patients with PCTs.
Collapse
Affiliation(s)
- Lin Du
- Department of Thoracic Surgery, Tianjin Chest Hospital, Tianjin 300222, P.R. China,Division of Epidemiology, Department of Quantitative Health Sciences, Mayo Clinic, Scottsdale, AZ 85260, USA,Graduate School, Tianjin Medical University, Tianjin 300070, P.R. China
| | - Vinicius Ernani
- Division of Hematology and Medical Oncology, Mayo Clinic, Scottsdale, AZ 85260, USA
| | - Alex Liu
- Division of Hematology and Medical Oncology, Mayo Clinic, Scottsdale, AZ 85260, USA
| | - Steven E. Schild
- Division of Radiation Oncology, Mayo Clinic, Scottsdale, AZ 85260, USA
| | | | - Steven D. Cassivi
- Division of General Thoracic Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Staci. E. Beamer
- Division of Thoracic Surgery, Mayo Clinic, Scottsdale, AZ 85260, USA
| | - Yung-Hung Luo
- Division of Medical Oncology, Mayo Clinic, Rochester, MN 55905, USA,Institute of Clinical Medicine, National Yang-Ming University, Taipei 112, Taiwan, R.O.C.,Department of Chest Medicine, Taipei Veterans General Hospital, Taipei 112, Taiwan, R.O.C.,School of Medicine, National Yang-Ming University, Taipei 112, Taiwan, R.O.C.,Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN 55905, USA
| | - Jason A. Wampfler
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Dennis Wigle
- Division of General Thoracic Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Daqiang Sun
- Department of Thoracic Surgery, Tianjin Chest Hospital, Tianjin 300222, P.R. China,Graduate School, Tianjin Medical University, Tianjin 300070, P.R. China
| | - K. Robert Shen
- Division of General Thoracic Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Ping Yang
- Division of Epidemiology, Department of Quantitative Health Sciences, Mayo Clinic, Scottsdale, AZ 85260, USA,Correspondence to: Professor Ping Yang, Division of Epidemiology, Department of Quantitative Health Sciences, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ 85260, USA, E-mail:
| |
Collapse
|
11
|
Parrado RH, Notrica DM, Jaroszewski DE, McMahon LE. Surgical technique for Nuss bar exchange due to metal allergy. J Pediatr Surg 2023; 58:179-180. [PMID: 35973861 DOI: 10.1016/j.jpedsurg.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 08/01/2022] [Indexed: 01/07/2023]
Affiliation(s)
- Raphael H Parrado
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ 85016, USA; Division of Pediatric Surgery, Department of Surgery, Shawn Jenkin's Children's Hospital, Charleston, SC, USA.
| | - David M Notrica
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ 85016, USA; Department of Surgery, Mayo Clinic School of Medicine and Science, Phoenix, AZ, USA; Department of Child Health, University of Arizona College of Medicine Phoenix, Phoenix, AZ, USA
| | - Dawn E Jaroszewski
- Division of Pediatric Surgery, Department of Surgery, Shawn Jenkin's Children's Hospital, Charleston, SC, USA; Department of Surgery, Mayo Clinic School of Medicine and Science, Phoenix, AZ, USA
| | - Lisa E McMahon
- Division of Pediatric Surgery, Department of Surgery, Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ 85016, USA; Department of Surgery, Mayo Clinic School of Medicine and Science, Phoenix, AZ, USA; Department of Child Health, University of Arizona College of Medicine Phoenix, Phoenix, AZ, USA
| |
Collapse
|
12
|
Farina JM, Jaroszewski DE, Aly M, Botros M, Chaliki HP. Right atrial collapse in the absence of pericardial effusion. Eur Heart J Cardiovasc Imaging 2022; 24:e21. [PMID: 36347763 DOI: 10.1093/ehjci/jeac208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 10/02/2022] [Indexed: 11/10/2022] Open
Affiliation(s)
- Juan M Farina
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, 5777 East Mayo Boulevard, USA
| | - Dawn E Jaroszewski
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, 5777 East Mayo Boulevard, USA
| | - Mohamed Aly
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, 5777 East Mayo Boulevard, USA
| | - Michael Botros
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, 5777 East Mayo Boulevard, USA
| | - Hari P Chaliki
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ, USA
| |
Collapse
|
13
|
Jaroszewski DE. BioBridge Prosthesis Failure After a Ravitch Repair for Pectus Excavatum. Ann Thorac Surg 2022:S0003-4975(22)01499-0. [DOI: 10.1016/j.athoracsur.2022.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 11/19/2022] [Indexed: 12/02/2022]
|
14
|
Jaroszewski DE, Farina JM, Gotway MB, Stearns JD, Peterson MA, Pulivarthi VSKK, Bostoros P, Abdelrazek AS, Gotimukul A, Majdalany DS, Wheatley-Guy CM, Arsanjani R. Cardiopulmonary Outcomes After the Nuss Procedure in Pectus Excavatum. J Am Heart Assoc 2022; 11:e022149. [PMID: 35377159 PMCID: PMC9075480 DOI: 10.1161/jaha.121.022149] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Pectus excavatum is the most common chest wall deformity. There is still controversy about cardiopulmonary limitations of this disease and benefits of surgical repair. This study evaluates the impact of pectus excavatum on the cardiopulmonary function of adult patients before and after a modified minimally invasive repair. Methods and Results In this retrospective cohort study, an electronic database was used to identify consecutive adult (aged ≥18 years) patients who underwent cardiopulmonary exercise testing before and after primary pectus excavatum repair at Mayo Clinic Arizona from 2011 to 2020. In total, 392 patients underwent preoperative cardiopulmonary exercise testing; abnormal oxygen consumption results were present in 68% of patients. Among them, 130 patients (68% men, mean age, 32.4±10.0 years) had post‐repair evaluations. Post‐repair tests were performed immediately before bar removal with a mean time between repair and post‐repair testing of 3.4±0.7 years (range, 2.5–7.0). A significant improvement in cardiopulmonary outcomes (P<0.001 for all the comparisons) was seen in the post‐repair evaluations, including an increase in maximum, and predicted rate of oxygen consumption, oxygen pulse, oxygen consumption at anaerobic threshold, and maximal ventilation. In a subanalysis of 39 patients who also underwent intraoperative transesophageal echocardiography at repair and at bar removal, a significant increase in right ventricle stroke volume was found (P<0.001). Conclusions Consistent improvements in cardiopulmonary function were seen for pectus excavatum adult patients undergoing surgery. These results strongly support the existence of adverse cardiopulmonary consequences from this disease as well as the benefits of surgical repair.
Collapse
Affiliation(s)
- Dawn E Jaroszewski
- Department of Cardiovascular and Thoracic Surgery Mayo Clinic Arizona Phoenix AZ
| | - Juan M Farina
- Department of Cardiovascular and Thoracic Surgery Mayo Clinic Arizona Phoenix AZ
| | | | - Joshua D Stearns
- Department of Anesthesiology and Perioperative Medicine Mayo Clinic Arizona Phoenix AZ
| | - Michelle A Peterson
- Department of Cardiovascular and Thoracic Surgery Mayo Clinic Arizona Phoenix AZ
| | | | - Peter Bostoros
- Department of Cardiovascular and Thoracic Surgery Mayo Clinic Arizona Phoenix AZ
| | - Ahmad S Abdelrazek
- Department of Cardiovascular and Thoracic Surgery Mayo Clinic Arizona Phoenix AZ
| | - Ashwini Gotimukul
- Department of Cardiovascular and Thoracic Surgery Mayo Clinic Arizona Phoenix AZ
| | - David S Majdalany
- Department of Cardiovascular Medicine Mayo Clinic Arizona Phoenix AZ
| | | | - Reza Arsanjani
- Department of Cardiovascular Medicine Mayo Clinic Arizona Phoenix AZ
| |
Collapse
|
15
|
Farina JM, Gotway MB, Larsen CM, Lackey J, Sell-Dottin KA, Morozowich ST, Jaroszewski DE. Chest Pain and Dyspnea After a Minimally Invasive Repair of Pectus Excavatum. JACC Case Rep 2022; 4:476-480. [PMID: 35493796 PMCID: PMC9044284 DOI: 10.1016/j.jaccas.2021.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/09/2021] [Accepted: 11/15/2021] [Indexed: 11/30/2022]
Abstract
Although infrequent, damage to cardiovascular structures can occur during or following a minimally invasive repair of pectus excavatum. We present a case of right ventricular outflow tract compression caused by a displaced intrathoracic bar. Removal of the bar resulted in an improvement in symptoms and hemodynamics. (Level of Difficulty: Advanced.)
Collapse
|
16
|
Ravanbakhsh S, Farina JM, Bostoros P, Abdelrazek A, Mi L, Lim E, Mead-Harvey C, Arsanjani R, Peterson M, Gotimukul A, Lackey JJ, Jaroszewski DE. Gender differences in objective measures of adult patients presenting for pectus excavatum repair. Ann Thorac Surg 2021; 114:1159-1167. [PMID: 34600903 DOI: 10.1016/j.athoracsur.2021.08.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 08/02/2021] [Accepted: 08/30/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Women have a reported incidence of pectus deformities 4-5 times less than men. Gender differences have not been well studied. METHODS A retrospective review was performed of adult patients (≥18 years) who underwent a pectus excavatum repair at Mayo Clinic in Arizona (January 1, 2010-December 31, 2019). RESULTS In total, 776 adults underwent pectus repair with 30% being women. Women presented older (mean age 35 vs 32 years, p=0.007) and more symptomatic. Despite this, women performed better on cardiopulmonary exercise testing (higher VO2 max and O2 pulse). Women had more severe deformities (Haller index 5.9 vs 4.3, p<0.001). However, in 609 patients undergoing attempted primary minimally invasive pectus repair, intraoperative fractures/osteotomies occurred equally between genders with the majority occurring in patients ≥30 years of age (11.5% in ≥30, 1.7% in <30, total 7%). Women were also less likely to require 3 bars for repair (12% vs 42%, p<0.001). Hospital length of stay and postoperative complication rates were not significantly different. Postoperatively women reported a greater daily intensity of pain, but only on the initial postoperative day used significantly more opioids than men. Cardiopulmonary exercise testing in 142 patients undergoing baseline and postoperative evaluation at bar removal showed equal and significant benefits in both genders. CONCLUSIONS Women presented for pectus excavatum repair older and with greater symptoms and severity. Despite this, women required fewer bars, with no significant differences in length of stay or complications. Cardiopulmonary benefits of repair were significant and equal for both genders.
Collapse
Affiliation(s)
| | | | - Peter Bostoros
- Department of Cardiothoracic Surgery, Mayo Clinic Arizona
| | | | - Lanyu Mi
- Department of Cardiothoracic Surgery, Mayo Clinic Arizona
| | - Elisabeth Lim
- Department of Cardiothoracic Surgery, Mayo Clinic Arizona
| | | | - Reza Arsanjani
- Department of Cardiothoracic Surgery, Mayo Clinic Arizona
| | | | | | - Jesse J Lackey
- Department of Cardiothoracic Surgery, Mayo Clinic Arizona
| | | |
Collapse
|
17
|
Abstract
Background The Nuss procedure temporarily places intrathoracic bars for repair of pectus excavatum (PE). The bars may impact excursion and compliance of the anterior chest wall while in place. Effective chest compressions during cardiopulmonary resuscitation (CPR) require depressing the anterior chest wall enough to compress the heart between sternum and spine. We assessed the force required to perform the American Heart Association’s recommended chest compression depth after Nuss repair. Methods A lumped element elastic model was developed to simulate the relationship between chest compression forces and displacement with focus on the amount of force required to achieve a depth of 5 cm in the presence of 1–3 Nuss bars. Literature review was conducted for evidence supporting potential use of active abdominal compressions and decompression (AACD) as an alternative method of CPR. Results The presence of bars notably lowered compression depth by a minimum of 69% compared to a chest without bar(s). The model also demonstrated a dramatic increase (minimum of 226%) in compressive forces required to achieve recommended 5 cm depth. Literature review suggests AACD could be an alternative CPR in patients with Nuss bar(s). Conclusions In our model, Nuss bars limited the ability to perform chest compressions due to increased force required to achieve a 5 cm compression. The greater the number of Nuss bars present the greater the force required. This may prevent effective CPR. Use of active abdominal compressions and decompressions should be studied further as an alternative resuscitation modality for patients after the Nuss procedure.
Collapse
Affiliation(s)
- Joshua D Stearns
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Jaffalie Twaibu
- School of Biological and Health Systems Engineering, Arizona State University, Tempe, Arizona, USA
| | - Dzifa Kwaku
- School of Biological and Health Systems Engineering, Arizona State University, Tempe, Arizona, USA
| | - Vincent Pizziconi
- School of Biological and Health Systems Engineering, Arizona State University, Tempe, Arizona, USA
| | - James Abbas
- School of Biological and Health Systems Engineering, Arizona State University, Tempe, Arizona, USA
| | - Ashwini Gotimukul
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Dawn E Jaroszewski
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| |
Collapse
|
18
|
Notrica DM, Sayrs LW, Krishna N, Rowe D, Jaroszewski DE, McMahon LE. The impact of state laws on motor vehicle fatality rates, 1999-2015. J Trauma Acute Care Surg 2020; 88:760-769. [PMID: 32195995 PMCID: PMC7473820 DOI: 10.1097/ta.0000000000002686] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 02/18/2020] [Accepted: 02/29/2020] [Indexed: 12/03/2022]
Abstract
BACKGROUND Motor vehicle crash (MVC) fatalities have been declining while states passed various legislation targeting driver behaviors. This study assesses the impact of state laws on MVC fatality rates to determine which laws were effective. METHODS Publically available data were collected on driver-related motor vehicle laws, law strengths, enactment years, and numbers of verified-trauma centers. Prospective data on crash characteristics and MVC fatalities 16 years or older from Fatality Analysis Reporting System 1999 to 2015 (n = 850) were obtained. Generalize Linear Autoregressive Modeling was used to assess the relative contribution of state laws to the crude MVC fatality rate while controlling for other factors. RESULTS Lowering the minimum blood alcohol content (BAC) was associated with largest declines for all ages, especially the older cohorts: 16 years to 20 years (B = 0.23; p < 0.001), 21 years to 55 years (B = 1.7; p < 0.001); 56 years to 65 years (B = 3.2; p < 0.001); older than 65 years (B = 4.1; p < 0.001). Other driving under the influence laws were also significant. Per se BAC laws accompanying a reduced BAC further contributed to declines in crude fatality rates: 21 years to 55 years (B = -0.13; p < 0.001); older than 65 years (B = -0.17; p < 0.05). Driving under the influence laws enhancing the penalties, making revocation automatic, or targeting social hosts had mixed effects by age. Increased enforcement, mandatory education, vehicle impoundment, interlock devices, and underage alcohol laws showed no association with declining mortality rates. Red light camera and seatbelt laws were associated with declines in mortality rates for all ages except for older than 65 years cohort, but speed camera laws had no effect. Graduated Driver License laws were associated with declines for 16 years to 21 years (B = -0.06; p < 0.001) only. Laws targeting specific risks (elderly, motorcycles, marijuana) showed no effect on declining MVC mortality rates during the study period. CONCLUSION States have passed a wide variety of laws with varying effectiveness. A few key laws, specifically laws lowering allowable BAC, implementing red light cameras, and mandating seatbelt use significantly reduced MVC mortality rates from 1999 to 2015. Simply adding more laws/penalties may not equate directly to lives saved. Continued research on state laws will better inform policy makers to meet evolving public health needs in the management of MVC fatalities. LEVEL OF EVIDENCE Epidemiological, Level III.
Collapse
Affiliation(s)
- David M Notrica
- From the Level 1 Pediatric Trauma Center (D.M.N., L.W.S., N.K., D.R., D.E.J., L.E.M.), Phoenix Children's Hospital; University of Arizona College of Medicine-Phoenix (D.M.N., L.W.S., D.R., L.E.M.); and Department of Cardiovascular and Thoracic Surgery, Mayo Clinic School of Medicine-Phoenix (D.M.N., D.R., D.E.J., L.E.M.), Phoenix, Arizona
| | | | | | | | | | | |
Collapse
|
19
|
Zhu M, Fuentes HE, Westin GFM, Sonbol MB, Leventakos K, Wigle DA, Jaroszewski DE, Molina JR, Halfdanarson TR. Management of bronchopulmonary carcinoid: NCDB database analysis. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.e21007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e21007 Background: There is a lack of data to guide the management of resectable bronchopulmonary carcinoid tumors (BCTs). Methods: The NCDB database was retrospectively reviewed to analyze the roles of surgery, chemotherapy and radiation. Patients with a diagnosis of clinically staged T1-2/N0-1 typical carcinoid (TC) and atypical carcinoid (AC) between 2004-2012 were included. Kaplan-Meier methods and multivariable analysis were performed. Results: A total of 2148 patients (TC 1874 & AC 274; T1/1648 & T2/500) were identified. The median age was 59 (range 18-89). There was a female (69.7%) and right lung (56.9%) predominance. Fifty-three patients received pneumonectomy, 68 chemotherapy, and 84 radiation therapy. The impact of age, histology (TC vs. AC), medical comorbidities (Charlson/Deyo score 0 vs. ≥1) and type of surgery [sublobar resection (SR) vs. lobectomy vs. lobectomy with mediastinal lymph node dissection (L/MLND)] were subsequently examined. AC, older age, and comorbidities were associated with shorter overall survival (OS) by both univariate and multivariable analysis. Patients who underwent lobectomy had longer OS (119 months) than those with SR (109 months) or L/MLND (115 months). However, this association was not significant by multivariable analysis with age incorporated as either a categorical ( < 60 vs. ≥60) or a continuous variable (Table). In the subgroup analysis of patients with T1, T2, TC and AC respectively, type of surgical resection was not significantly associated with OS by multivariable analysis. Conclusions: Patients with resectable BCTs have excellent OS. Atypical histology, older age, and comorbidities predicted inferior OS. There were insufficient data to support the use of perioperative chemotherapy or radiation therapy. Lobectomy was associated with prolonged OS by univariate analysis but this was not significant in the multivariable model, suggesting that SR is a reasonable approach for patients who cannot tolerate lobectomy. MLND did not seem to provide additional survival benefits. [Table: see text]
Collapse
|
20
|
Giorgakis E, Chong B, Oklu R, Jaroszewski DE, Knuttinen G, Mathur AK. Successful treatment of visceral pseudoaneurysm after pancreatectomy using flow-diverting stent device. Ann Hepatobiliary Pancreat Surg 2020; 24:114-118. [PMID: 32181440 PMCID: PMC7061036 DOI: 10.14701/ahbps.2020.24.1.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 12/27/2019] [Accepted: 01/19/2020] [Indexed: 11/17/2022] Open
Abstract
Aim of the study is the description of the successful management of gastroepiploic artery pseudoaneurysm with preservation of parent vessels using flow-diversion technology. The present report describes the application of a flow-diversion Pipeline™ Flex device for occlusion of a sidewall bleeding pseudoaneurysm on a patient who was status-post sub-total pancreatectomy and remote esophagectomy with a gastric conduit. The pseudoaneurysm was on the solitary vessel supplying the patient's conduit. Use of flow diversion technology excluded the sidewall pseudoaneurysm while maintaining gastric conduit perfusion. In our case, the application of flow diversion technology allowed the preservation of patency of the main arterial supply to the gastric conduit on a post-esophagectomy patient; loss of the right gastroepiploic artery in that case would had been otherwise catastrophic. Flow-diversion technology can be considered for the treatment of pseudoaneurysms post-pancreatic resections, especially when there is no other surgical or endovascular treatment option.
Collapse
Affiliation(s)
- Emmanouil Giorgakis
- Division of Transplantation and Hepatopancreatobiliary Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ, USA.,Department of Solid Organ Transplantation, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Brian Chong
- Division of Neuroradiology, Department of Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Rahmi Oklu
- Department of Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Dawn E Jaroszewski
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Grace Knuttinen
- Department of Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Amit K Mathur
- Division of Transplantation and Hepatopancreatobiliary Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ, USA
| |
Collapse
|
21
|
Holst KA, Thiels CA, Ubl DS, Blackmon SH, Cassivi SD, Nichols FC, Shen KR, Wigle DA, Thomas M, Makey IA, Beamer SE, Jaroszewski DE, Allen MS, Habermann EB. Postoperative Opioid Consumption in Thoracic Surgery Patients: How Much Is Actually Used? Ann Thorac Surg 2019; 109:1033-1039. [PMID: 31689406 DOI: 10.1016/j.athoracsur.2019.08.115] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 07/10/2019] [Accepted: 08/08/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND The objective of this initiative was to perform a prospective, multicenter survey of patients after lung resection to assess the amount of opioid medication consumed and the disposition of unused opioids to inform the development of evidence-based prescribing guidelines. METHODS Adults undergoing lung resection with either minimally invasive surgery (MIS; n = 108) or thoracotomy (n = 45) were identified prospectively from 3 academic centers (from March 2017 to January 2018) to complete a 28-question telephone survey 21 to 35 days after discharge. Discharge opioids were converted into morphine milligram equivalents (MME) and were compared across patient and surgical details. RESULTS Of the 153 patients who completed the survey, 89.5% (137) received opioids at discharge with a median prescription of 320 MME (interquartile range [IQR], 225, 450 MME) after MIS and 450 MME (IQR, 300, 600 MME) after thoracotomy (P = .001). Median opioid consumption varied by surgical approach: 90 MME (IQR, 0, 262.5) after MIS and 300 MME (IQR, 50, 382.5 MME) after thoracotomy (P < .001). The majority of patients (73.7%; 101) had residual opioid medication at the time of the survey, and patients after MIS had a relative increase in amount of remaining opioid medication: 58.3% vs 33.3% (P = .05) of the original prescription. Only 5.9% of patients with opioids remaining had properly disposed of them. CONCLUSIONS Although patients undergoing MIS lung resection used significantly less opioid medication over a shorter duration of time than did patients after thoracotomy, they had relatively more excess opioid prescription. Evidence-based, procedure-specific guidelines with tailored pain regimens should be developed and implemented to reduce the amount of postoperative opioid medication remaining in the community.
Collapse
Affiliation(s)
- Kimberly A Holst
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Daniel S Ubl
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Surgical Outcomes Program, Mayo Clinic, Rochester, Minnesota
| | - Shanda H Blackmon
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Stephen D Cassivi
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Francis C Nichols
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - K Robert Shen
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Dennis A Wigle
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Mathew Thomas
- Division of Cardiothoracic Surgery, Department of Surgery, Mayo Clinic, Jacksonville, Florida
| | - Ian A Makey
- Division of Cardiothoracic Surgery, Department of Surgery, Mayo Clinic, Jacksonville, Florida
| | - Staci E Beamer
- Division of Cardiothoracic Surgery, Department of Surgery, Mayo Clinic, Scottsdale, Arizona
| | - Dawn E Jaroszewski
- Division of Cardiothoracic Surgery, Department of Surgery, Mayo Clinic, Scottsdale, Arizona
| | - Mark S Allen
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Elizabeth B Habermann
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Surgical Outcomes Program, Mayo Clinic, Rochester, Minnesota.
| |
Collapse
|
22
|
Yu NY, DeWees TA, Liu C, Daniels TB, Ashman JB, Beamer SE, Jaroszewski DE, Ross HJ, Paripati HR, Rwigema JCM, Ding JX, Shan J, Liu W, Schild SE, Sio TT. Early Outcomes of Patients With Locally Advanced Non-small Cell Lung Cancer Treated With Intensity-Modulated Proton Therapy Versus Intensity-Modulated Radiation Therapy: The Mayo Clinic Experience. Adv Radiat Oncol 2019; 5:450-458. [PMID: 32529140 PMCID: PMC7276663 DOI: 10.1016/j.adro.2019.08.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 06/20/2019] [Accepted: 08/06/2019] [Indexed: 12/25/2022] Open
Abstract
Purpose There are very little data available comparing outcomes of intensity-modulated proton therapy (IMPT) to intensity-modulated radiation therapy (IMRT) in patients with locally advanced NSCLC (LA-NSCLC). Methods Seventy-nine consecutively treated patients with LA-NSCLC underwent definitive IMPT (n = 33 [42%]) or IMRT (n = 46 [58%]) from 2016 to 2018 at our institution. Survival rates were calculated using the Kaplan-Meier method and compared with the log-rank test. Acute and subacute toxicities were graded based on Common Terminology Criteria for Adverse Events, version 4.03. Results Median follow-up was 10.5 months (range, 1-27) for all surviving patients. Most were stage III (80%), received median radiation therapy (RT) dose of 60 Gy (range, 45-72), and had concurrent chemotherapy (65%). At baseline, the IMPT cohort was older (76 vs 69 years, P < .01), were more likely to be oxygen-dependent (18 vs 2%, P = .02), and more often received reirradiation (27 vs 9%, P = .04) than their IMRT counterparts. At 1 year, the IMPT and IMRT cohorts had similar overall survival (68 vs 65%, P = .87), freedom from distant metastasis (71 vs 68%, P = .58), and freedom from locoregional recurrence (86 vs 69%, P = .11), respectively. On multivariate analyses, poorer pulmonary function and older age were associated with grade +3 toxicities during and 3 months after RT, respectively (both P ≤ .02). Only 5 (15%) IMPT and 4 (9%) IMRT patients experienced grade 3 or 4 toxicities 3 months after RT (P = .47). There was 1 treatment-related death from radiation pneumonitis 6 months after IMRT in a patient with idiopathic pulmonary fibrosis. Conclusions Compared with IMRT, our early experience suggests that IMPT resulted in similar outcomes in a frailer population of LA-NSCLC who were more often being reirradiated. The role of IMPT remains to be defined prospectively.
Collapse
Affiliation(s)
- Nathan Y Yu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Todd A DeWees
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Chenbin Liu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | | | | | - Staci E Beamer
- Department of Cardiothoracic Surgery, Mayo Clinic, Phoenix, Arizona
| | | | - Helen J Ross
- Department of Hematology and Medical Oncology, Mayo Clinic, Phoenix, Arizona
| | - Harshita R Paripati
- Department of Hematology and Medical Oncology, Mayo Clinic, Phoenix, Arizona
| | | | - Julia X Ding
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Jie Shan
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Wei Liu
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Steven E Schild
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| | - Terence T Sio
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona
| |
Collapse
|
23
|
Abstract
e20029 Background: Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) is a pulmonary disorder with neuroendocrine cell proliferation with potential progression to lung neuroendocrine tumor (Lu-NET). Optimal diagnostic and treatment strategies have yet to be well defined. Herein, we aim to describe the Mayo Clinic experience with DIPNECH. Methods: A retrospective analysis was performed of patients diagnosed with DIPNECH within Mayo Clinic between January 2000-Febuary 2019. Cases were identified from clinical databases at Mayo Clinic. Data on demographics, disease characteristics, time of diagnosis, surgery, and last follow up date were extracted. Extent of symptom burden, treatment approaches, disease progression, and disease-free survival (DFS) were evaluated by chart review. Results: A total of 59 patients were identified with a median age of 63(43-81) years. The cohort was predominantly female (93.2%) and non-smoking (76.3%). Most patients (86.4%) had symptomatic disease with chronic cough being the most common (71.2%) followed by exertional dyspnea (44.1%). Imaging typically showed bilateral lung nodules (93.2%) with mosaic attenuation noted 69.5% of the time. Surgical resection was frequently completed to confirm diagnosis (94.9%). Most patients received inhaled glucocorticoids combined with a beta agonist (79.7%). Oral steroid use was seen in 49.2% of patients whereas a somatostatin analog was used in 15.3% following the diagnosis of DIPNECH. These medical interventions led to symptom relief in 23.7% of the patients. The median follow up for all patients was 19.5 months. Progression of tumorlets was seen in 48.7% of patients with only 7(17.9%) patients progressing to a diagnosis of Lu-NET. The 3-year DFS was 90.5%. Conclusions: This is amongst the largest studies completed evaluating DIPNECH patients. DIPNECH remains a rare disease more commonly diagnosed in women in their early 60’s. DIPNECH appears to have an indolent course with obstructive symptoms being the most common finding. A minority of patients experienced symptom relief with therapy. Overall, DIPNECH appears to have a low risk of progressing to Lu-NET based on the observation of this study.
Collapse
|
24
|
Affiliation(s)
| | - Lobna Mahmoud
- Department of Cardiothoracic Surgery, Mayo Clinic Arizona
| |
Collapse
|
25
|
Briggler AM, Graham RP, Westin GF, Folpe AL, Jaroszewski DE, Okuno SH, Halfdanarson TR. Clinicopathologic features and outcomes of gastrointestinal stromal tumors arising from the esophagus and gastroesophageal junction. J Gastrointest Oncol 2018; 9:718-727. [PMID: 30151268 DOI: 10.21037/jgo.2018.04.06] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background Our aim was to characterize the clinicopathological features and outcomes of gastrointestinal stromal tumors (GISTs) arising from the esophagus and gastroesophageal junction (GEJ) and describe the survival of patients treated at our institution as well as from a national hospital-based registry. Methods Twenty-eight cases were identified using the Mayo Clinic Cancer Registry from 1997 to 2016, and 1,010 cases from the National Cancer Database (NCDB) between 2004 and 2014, with analysis of TNM staging, histopathological features, mitotic index, immunohistochemical studies, and KIT mutational analysis. Results At Mayo Clinic, the tumors ranged in size from 0.3-13 cm (mean 5.40 cm). IHC results were: CD117 (KIT) in 100% (23/23 cases) and DOG1 in 100% (6/6), followed by CD34 (85.7%, 12/14), smooth muscle actin (27.8%, 5/18), desmin (18.2%, 2/11), and S-100 protein (13.3%, 2/15). Mutational analysis (performed in 10 cases) showed KIT exon 11 mutations in 8 cases; KIT mutation was not identified in 2 cases (presumed wild-type). Two-thirds of patients underwent surgery, of which 70% had an esophagectomy. Fourteen patients received adjuvant imatinib mesylate. Five patients had liver metastases at the time of diagnosis; none had lymph node metastases. A total of 38.9% of cases had recurrent or metastatic disease. Complete clinical follow-up was available for 10 patients (median follow-up duration 31.5 months; range, 10-145 months): one (male) had a local recurrence at the anastomotic site and one (female) suffered a liver metastasis; the others were either disease-free or had stable disease at the time of last follow-up. There was a significant association seen among metastatic disease and mitotic count >5/50 high-powered field (HPF) (P=0.016), with median mitotic rate 90/50 HPF (range, 7-500) for metastatic tumors versus 6/50 HPF (range, 0-100) for non-metastatic tumors. For metastatic disease, median tumor size was 7.3 cm (range, 1-66 cm) compared to 4.8 cm (range, 0.02-71 cm) for non-metastatic disease, which was also statistically significant (P≤0.0001). Two hundred and fifty-eight NCDB cases were risk stratified using the Joensuu criteria. Among 89 low risk category tumors, only 2 (2.2%) were ultimately metastatic. A total of 10.9% (15/138) of high risk category tumors were metastatic. The median overall survival (OS) from the time of diagnosis for the Mayo Clinic cohort was 129.5 months (95% CI, 55.7-not reached), with 5-year OS 85.7%. Median OS for the NCDB cohort was 135.95 months (95% CI, 104.08-not reached) with 5-year OS 68.2%. Superior OS was seen in females (HR 0.67, 95% CI, 0.49-0.89, P=0.006). Conclusions Among esophageal and GEJ GISTs, metastatic disease was associated with increased mitotic count and increased tumor size. Men were found to have inferior OS. The Joensuu risk criteria were validated for risk stratification of esophageal and GEJ GISTs.
Collapse
Affiliation(s)
| | - Rondell P Graham
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | | | - Andrew L Folpe
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | | | - Scott H Okuno
- Department of Medical Oncology, Mayo Clinic, Rochester, MN, USA
| | | |
Collapse
|
26
|
Jaroszewski DE, Velazco CS, Pulivarthi VSKK, Arsanjani R, Obermeyer RJ. Cardiopulmonary Function in Thoracic Wall Deformities: What Do We Really Know? Eur J Pediatr Surg 2018; 28:327-346. [PMID: 30103240 DOI: 10.1055/s-0038-1668130] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Patients with pectus excavatum (PE) frequently present with complaints of exercise intolerance and cardiopulmonary symptoms. There continues to be controversy regarding the physiologic benefits of repair. The aim of this review is to summarize and discuss recent data regarding the cardiopulmonary effects of PE deformity and the evidence for improvement obtained after surgical repair including (1) a greater efficiency of breathing (chest wall mechanics), (2) improvement in pulmonary restrictive deficits, (3) an increase in cardiac chamber size and output, with improved cardiac strain and strain rate, and (4) improvement in exercise capacity.
Collapse
Affiliation(s)
- Dawn E Jaroszewski
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Arizona, United States
| | - Cristine S Velazco
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Arizona, United States
| | | | - Reza Arsanjani
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, Arizona, United States
| | - Robert J Obermeyer
- Department of Pediatric Surgery, Children's Hospital of the King's Daughters, Norfolk, Virginia, United States
| |
Collapse
|
27
|
Abstract
The adverse physiologic effects of pectus excavatum and subsequent resolution following correction have been a subject of controversy. There are numerous accounts of patients reporting subjective improvement in exercise tolerance after surgery, but studies showing clear and consistent objective data to corroborate this phenomenon physiologically have been elusive. This is partially due to a lack of consistent study methodologies but even more so due to a mere paucity of data. As experts in the repair of pectus excavatum, it is not uncommon for pediatric surgeons to operate on adult patients. For this reason, this review evaluates the contemporary literature to provide an understanding of the physiologic impact of repairing pectus excavatum on pediatric and adult patients separately.
Collapse
Affiliation(s)
- Robert J Obermeyer
- Children's Hospital of The King's Daughters, Norfolk, VA, USA ; Eastern Virginia Medical School, Norfolk, VA, USA.
| | - Nina S Cohen
- Eastern Virginia Medical School, Norfolk, VA, USA
| | | |
Collapse
|
28
|
Abstract
Minimally invasive repair of pectus excavatum has been successfully modified for use in adult patients. Many patients present in adulthood with progression of symptoms as the chest wall becomes less compliant with age. A thorough workup is completed including echocardiogram and chest CT to evaluate for anatomic abnormalities. Cardiopulmonary exercise testing is done to quantify the physiologic impact. Modifications of the original Nuss procedure required to allow for successful adult repair include the use of forced sternal elevation, the use of multiple bars, medial bar fixation, and interspace support to prevent bar rotation and migration. Occasionally, fractures may occur that require an open procedure and osteotomy or cartilage resection and hybrid approach incorporating the principals of intrathoracic support and osteotomy with bar stabilization.
Collapse
Affiliation(s)
- Cristine S Velazco
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Reza Arsanjani
- Department of Cardiovascular Medicine, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Dawn E Jaroszewski
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States.
| |
Collapse
|
29
|
Niska JR, Sio TT, Daniels TB, Beamer SE, Jaroszewski DE, Ross HJ, Paripati HR, Schild SE. Stereotactic body radiotherapy for early-stage non-small cell lung cancer has low post-treatment mortality. J Thorac Dis 2018; 10:S2004-S2006. [PMID: 30023104 PMCID: PMC6036010 DOI: 10.21037/jtd.2018.04.169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 04/26/2018] [Indexed: 11/06/2022]
Affiliation(s)
- Joshua R. Niska
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Terence T. Sio
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Thomas B. Daniels
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| | - Staci E. Beamer
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Dawn E. Jaroszewski
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Helen J. Ross
- Division of Hematology/Medical Oncology, Department of Internal Medicine, Mayo Clinic, Phoenix, Arizona, USA
| | - Harshita R. Paripati
- Division of Hematology/Medical Oncology, Department of Internal Medicine, Mayo Clinic, Phoenix, Arizona, USA
| | - Steven E. Schild
- Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA
| |
Collapse
|
30
|
Liu C, Sio TTW, Bhangoo RS, Rule WG, Ross HJ, Paripati H, Jaroszewski DE, Beamer S, Fleischer D, Ramirez F, Ding X, Bues M, Ashman JB, Liu W. Dosimetric analysis of distal esophageal adenocarcinoma patients treated by intensity-modulated proton therapy with small spot size. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.4_suppl.159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
159 Background: Intensity-modulated proton therapy (IMPT) with small spot size has the potential to reduce dose to normal tissues but also introduces new confounding factors such as setup uncertainty, range uncertainty, and interplay effects due to breathing motion. We investigated plan quality and robustness of IMPT with small spot size for distal esophageal adenocarcinoma (DEA). Methods: 19 patients with DEA treated by IMPT were retrospectively evaluated. Spot sizes ranged from 2 to 6mm, with spot spacing of 5mm. All plans were generated using a commercial treatment planning system. In-house-developed dose-evaluation software modeled time-dependent spot delivery to incorporate interplay effects. Dose-volume-histogram (DVH) indices were used to evaluate plan quality and robustness was evaluated using the DVH band method. Results: For plan quality, median values of clinical target volume D95% and D5%-D95% (normalized to the prescribed doses), total lung mean dose, heart mean dose, and cord Dmax were 1.014, 0.035, 3.82Gy[RBE], 7.73Gy[RBE], 39.16Gy[RBE], respectively. For plan robustness, median band widths of the aforementioned DVH indices were 0.018, 0.048, 0.60Gy[RBE], 4.17Gy[RBE], and 2.36Gy[RBE], respectively. For interplay effects, median values of the aforementioned DVH indices were 0.99, 0.061, 4.07Gy[RBE], 7.87Gy[RBE], and 39.66Gy[RBE], respectively. Seven patients underwent esophagectomy after neoadjuvant chemoradiation, and five, three, and one of them achieved downstaging, near complete response, and pathologic complete response, respectively; R0 resection was achieved in all cases. For all patients, acute side effects were mostly limited to grades 1-2 only. The only grade 3 adverse events were related to feeding tube placement (8 patients); there were no RT-induced pneumonitis or other lung-related toxicities. Conclusions: IMPT plans with small spot size for DEA have good target dose coverage, homogeneity and normal tissue protection. Treatment plans are also robust to uncertainties and interplay effects. Early clinical results demonstrate low acute toxicity and encouraging clinical and pathologic response.
Collapse
|
31
|
Abstract
Pectus excavatum (PEx) is one of the most common congenital chest wall deformities. Depending on the severity, presentation of PEx may range from minor cosmetic issues to disabling cardiopulmonary symptoms. The effect of PEx on adult patients has not been extensively studied. Symptoms may not occur until the patient ages, and they may worsen over the years. More recent publications have implied that PEx may have significant cardiopulmonary implications and repair is of medical benefit. Adults presenting for PEx repair can undergo a successful repair with a minimally invasive "Nuss" approach. Resolution of symptoms, improved quality of life, and satisfying results are reported.
Collapse
Affiliation(s)
- MennatAllah M Ewais
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, Phoenix, AZ, USA
| | - Shivani Chaparala
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, Phoenix, AZ, USA
| | - Rebecca Uhl
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, Phoenix, AZ, USA
| | - Dawn E Jaroszewski
- Department of Cardiothoracic Surgery, Mayo Clinic Hospital, Phoenix, AZ, USA
| |
Collapse
|
32
|
Abstract
Osteopathic medicine places a special emphasis on the musculoskeletal system, and understanding how chest wall structure may influence function is critical. Pectus excavatum is a common congenital chest wall defect in which the sternum is depressed posteriorly. Patients may present with complaints of chest wall discomfort, exercise intolerance, and tachycardia. The medical implications, diagnosis, and treatment options for patients with pectus excavatum are reviewed.
Collapse
|
33
|
Jaroszewski DE, Gustin PJ, Haecker FM, Pilegaard H, Park HJ, Tang ST, Li S, Yang L, Uemura S, De Campos JRM, Obermeyer R, Frantz FW, Torre M, McMahon L, Hebra A, Chu CC, Phillips JD, Notrica DM, Messineo A, Kelly R, Yüksel M. Pectus excavatum repair after sternotomy: the Chest Wall International Group experience with substernal Nuss bars. Eur J Cardiothorac Surg 2017; 52:710-717. [DOI: 10.1093/ejcts/ezx221] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
|
34
|
Welch G, Ross HJ, Patel NP, Jaroszewski DE, Fleischer DE, Rule WG, Paripati HR, Ramirez FC, Ashman JB. Incidence of brain metastasis from esophageal cancer. Dis Esophagus 2017; 30:1-6. [PMID: 28859365 DOI: 10.1093/dote/dox071] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 05/23/2017] [Indexed: 12/11/2022]
Abstract
We investigated whether the incidence of brain metastasis (BM) from primary esophageal and esophagogastric cancer is increasing. A single-institution retrospective review identified 583 patients treated from January 1997 to January 2016 for stages I through IV cancer of the esophagus and esophagogastric junction (follow-up, ≥3 months). Collected data included demographic information, date and staging at primary diagnosis, histologic subtype, treatment regimen for primary lesion, date of BM diagnosis, presence or absence of central nervous system symptoms, presence or absence of extracranial disease, treatment regimen for intracranial lesions, and date of death. The overall cohort included 495 patients (85%) with adenocarcinoma and 82 (14%) with squamous cell carcinoma (492 [84%] were male; median age at diagnosis, 68 years [range: 26-90 years]). BM was identified in 22 patients (3.8%) (median latency after primary diagnosis, 11 months). Among patients with BM, the primary histology was adenocarcinoma in 21 and squamous cell carcinoma in 1 (P = 0.30). BM developed in 12 who were initially treated for locally advanced disease and in 10 stage IV patients who presented with distant metastases. Overall survival (OS) after BM diagnosis was 18% at 1 year (median, 4 months). No difference in OS after BM diagnosis was observed in patients initially treated for localized disease compared to patients who presented with stage IV disease; however, OS was superior for patients who initially had surgical resection compared to patients treated with whole brain radiotherapy or stereotactic radiosurgery alone (1-year OS, 67% vs. 0%; median OS, 13.5 vs. 3 months; P = 0.003). The incidence of BM is low in patients with esophageal cancer. Outcomes were poor overall for patients with BM, but patients who underwent neurosurgical resection had improved survival.
Collapse
Affiliation(s)
- G Welch
- Department of Radiation Oncology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - H J Ross
- Division of Hematology and Medical Oncology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - N P Patel
- Department of Neurologic Surgery, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - D E Jaroszewski
- Division of Cardiovascular and Thoracic Surgery Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - D E Fleischer
- Divisions of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | | | - H R Paripati
- Division of Hematology and Medical Oncology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - F C Ramirez
- Divisions of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | | |
Collapse
|
35
|
Rowse PG, Jaroszewski DE, Thomas M, Harold K, Harmsen WS, Shen KR. Sex Disparities After Induction Chemoradiotherapy and Esophagogastrectomy for Esophageal Cancer. Ann Thorac Surg 2017; 104:1147-1152. [PMID: 28842111 DOI: 10.1016/j.athoracsur.2017.05.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 05/02/2017] [Accepted: 05/11/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND The impact of sex on the outcomes of treatment for locally advanced esophageal carcinoma is unclear. This study analyzed the impact of sex on response to neoadjuvant chemoradiotherapy (nCRT), tumor recurrence, and survival. METHODS From January 1990 through December 2013, female patients who received nCRT followed by esophagogastrectomy at 3 affiliated centers were compared with control male patients based on age, pretreatment clinical stage, histologic type, and surgical era. Only patients staged preoperatively with computed tomographic scans and endoscopic ultrasonography (EUS) were included. RESULTS There were 366 patients (145 women and 221 men). The median female age was 64 years (range, 22-81 years), whereas male patients were 61 years (range, 33-82 years). The histologic type was adenocarcinoma in 105 (72%) women and 192 (87%) men, and it was squamous cell carcinoma in 40 (28%) women and 29 (13%) men (p = 0.005). Women were more likely to attain either a complete pathologic (CP) response or a nearly complete pathologic (NCP) response to induction therapy (84 [58%]) compared with men (103 [47%]; p = 0.034). Men had an 80% increased risk of recurrence (hazard ratio [HR], 1.80; 95% CI, 1.15-2.68; p = 0.008). There was no sex association with risk of death (p = 0.538). Irrespective of sex, a partial responder (relative to a complete or nearly complete responder) was 3 times more likely to have recurrence (HR, 2.96; 95% CI, 1.98-4.43; p < 0.001) and 2.5 times more likely to die (HR, 2.56; 95% CI, 1.88-3.48; p < 0.001). CONCLUSIONS Female sex correlated with improved rates of achieving either a CP response or an NCP response after neoadjuvant chemotherapy and a smaller likelihood of experiencing tumor recurrence. Future efforts should be directed at understanding determinants of this sex disparity.
Collapse
Affiliation(s)
- Phillip G Rowse
- Division of General Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Dawn E Jaroszewski
- Division of Cardiovascular and Thoracic Surgery, Mayo Clinic, Scottsdale, Arizona
| | - Mathew Thomas
- Division of Cardiothoracic Surgery, Mayo Clinic, Jacksonville, Florida
| | - Kristi Harold
- Division of Cardiovascular and Thoracic Surgery, Mayo Clinic, Scottsdale, Arizona
| | - William S Harmsen
- Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - K Robert Shen
- Division of General Thoracic Surgery, Mayo Clinic, Rochester, Minnesota.
| |
Collapse
|
36
|
Beamer S, Gatalica Z, Xiu J, Jaroszewski DE, Stanton M, Pai R, Krishna M, Thomas M, Ross HJ, Ho TH. A study of thymidylate synthase gene expression as a biomarker for the treatment of esophageal adenocarcinoma. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.e15563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e15563 Background: Expression of thymidylate synthase (TS), a target of fluoropyrimidine-based (5-FU) chemotherapy, has prognostic value in colorectal adenocarcinoma. Its value as a biomarker in treatment of esophageal adenocarcinoma (EAC) is unknown. With widespread adoption of CROSS trial protocol for treatment of EAC, 5-FU is frequently omitted from regimens. We retrospectively analyzed the association between TS protein expression and clinical outcomes in EAC. Methods: TS expression levels were measured by immunohistochemistry in formalin-fixed paraffin-embedded specimens from 35 primary EAC patients from 2 institutions (range 5/2006-1/2016); at time of diagnosis and surgical resection (33 neoadjuvant chemoradiation and 2 surgery alone). TS expression higher than 1+, 5% was read as positive. Mean follow up was 1323 days (range 263-3677). TS expression correlated with treatment response and survival in patients treated with and without 5-FU therapy (log-rank test, Kaplan-Meier method). Results: In the cohort of 35 patients, 21 patients (60%) had pretreatment positive TS expression. Overall survival (OS) for TS negative patients was 1216 days versus 974 days for TS positive (p = 0.15). In the 23 patients treated with 5-FU, TS-negative patients had a trend towards longer overall survival compared to TS-positive patients, mean OS (1272 days versus 743 days, p = 0.08). In the group of 12 patients not treated with 5-FU, 2 patients showed negative TS staining. Neoadjuvant chemoradiation was performed in 33/35 patients. Downstaging was observed in 69% (9/13) of patients with negative pre-treatment TS levels versus 55% (11/20) in pre-treatment TS positive patients (p = 0.48). In 23 patients treated with 5FU, 9/12 (75%) were downstaged in the TS-negative cohort versus 6/11 (45%) in the TS-positive cohort (p = 0.21). In the 5FU treatment group, complete response was seen in 2 patients with negative TS staining. Conclusions: Low TS expression in EAC patients trended towards improved survival and tumor downstaging, particularly in patients treated with neoadjuvant 5-FU and platinum based therapy. Prospective data and greater patient numbers may be necessary to demonstrate statistical significance.
Collapse
Affiliation(s)
| | | | | | | | | | - Rish Pai
- Mayo Clinic Arizona, Phoenix, AZ
| | | | | | | | | |
Collapse
|
37
|
Jaroszewski DE, Xiu J, Gatalica Z, Beamer S, Stanton M, Pai R, Krishna M, Thomas M, Ross HJ, Ho TH. PDL-1 and immunohistochemistry markers in esophageal adenocarcinoma. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.e15567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e15567 Background: Esophageal adenocarcinoma (EAC) prognosis is poor and there is a need to identify patients that benefit most from neoadjuvant therapy. To examine the association of various biomarkers with clinical outcomes in neoadjuvant treatment of EAC, we retrospectively evaluated the biomarker expression (TS, ERCC1, TOPO1, PD-L1, PD-1) in patient matched formalin-fixed paraffin-embedded (FFPE) tumor samples. Methods: Immunohistochemistry of TS (TS106/4H4B1) , ERCC1 (Ab. 8F1), TOPO1 (1D6), PD-L1 (both 22c3 and SP142), PD-1 (NAT105), and chromogenic in-situ hybridization (CISH) of Her2 were performed on FFPE samples from 35 patients across 2 institutions at time of EAC diagnosis and after treatment when available. Retrospective clinical data and survival (5/2006-1/2016) was analyzed with a mean follow up of 110 months (range 22-306). Results: Overexpression (pre/post-treatment) of TS (60%/54%), ERCC1 (69%/16%), TOPO1 (74%/50%), PD-1 (54%/63%), PD-L1 (SP142) (2.9%/4%), PD-L1 (22c3) (0%/4%) and amplification of Her2 (18%/23%) were observed. Pretreatment observed PD-L1 levels were lower in our study (3%) when compared to other studies in EAC specimens (35%). Immunohistochemistry and changes observed after chemoradiation are reviewed in Table. No markers had significant correlation with prognosis however TS negative expression showed a non-significant (p=0.15) trend towards improved survival. Conclusions: Analyzing biomarkers in our neoadjuvant EAC cohort demonstrated a lower than expected PD-L1 positivity. In the largest cohort, to our knowledge, of patient matched FFPE tumor samples, we did not observe a statistically significant association between TS, ERCC1, TOPO1, PD-L1, or PD-1 with improved clinical outcomes. [Table: see text]
Collapse
Affiliation(s)
| | | | | | | | | | - Rish Pai
- Mayo Clinic Arizona, Phoenix, AZ
| | | | | | | | | |
Collapse
|
38
|
Ashman JB, Welch G, Patel NP, Jaroszewski DE, Fleischer D, Rule WG, Paripati H, Ramirez F, Ross HJ. Incidence of brain metastasis from esophageal cancer. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.4_suppl.165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
165 Background: Distant metastases are common in primary esophageal cancer, but data conflict regarding the rates of brain metastases (BM) ranging from 0% to 13%. We sought to investigate whether the incidence of BM from esophageal malignancies is increasing in the modern era. Methods: After IRB approval, a single institution retrospective review identified 583 patients (pts) treated between 1/1997 and 1/2016 for stage I-IV cancer of the esophagus/esophagogastric junction with at least 3 months follow-up. Data collected included demographic information, primary diagnosis date and staging, histologic subtype, treatment regimens for primary and BM, date of BM diagnosis, status of neurologic symptoms and extracranial disease at BM diagnosis, and date of death. Data were analyzed by Fischer’s exact test and Kaplan-Meier analysis. Results: The overall cohort was comprised of 495 pts (85%) with adenocarcinoma and 82 pts (14%) with squamous cell carcinoma. 492 pts (84%) were male; the median age was 68 years (range 26-90). BM were identified in 22 pts (3.8%) with a median latency of 11 months from the primary diagnosis. Of the pts with BM, the primary histology was adenocarcinoma in 21 pts and squamous cell carcinoma in 1 pt ( P = 0.3). BM developed in 12 pts who were initially treated for locally advanced disease and in 10 pts who presented with distant metastases. Diagnosis of BM was at the time of initial presentation in 4 of these 10 stage IV pts. A solitary BM was identified in 9 pts. Initial treatments of BM were surgical resection followed by stereotactic radiosurgery (SRS; n = 5); surgical resection followed by whole brain radiotherapy (WBRT; n = 1); WBRT alone (n = 13); SRS alone (n = 3). Overall survival (OS) following diagnosis of BM was 18% at 1 year with a median of 4 months. OS was superior for pts who had surgical resection as initial treatment of BM compared to pts treated with WBRT or SRS alone (1-year OS 67 vs. 0%; median OS 13.5 vs. 3 months; P = 0.003). Conclusions: The incidence of BM is low in esophageal cancer with no statistically significant increased rate of BM developing in patients with adenocarcinoma compared with squamous cell carcinoma. Outcomes were poor overall for pts who developed BM, but pts who were appropriate for neurosurgical resection had improved survival.
Collapse
|
39
|
Briggler AM, Graham RP, Westin GFM, Folpe A, Jaroszewski DE, Okuno SH, Halfdanarson TR. Gastrointestinal stromal tumors (GISTs) of the esophagus and gastroesophageal junction (GEJ). J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.4_suppl.179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
179 Background: GISTs arise from interstitial cells of Cajal anywhere within the gastrointestinal tract, but those of the esophagus and GEJ are exceedingly rare ( < 1% of cases). Our aim was to characterize clinicopathological features and outcomes of esophageal and GEJ GISTs and compare survival with a population-based registry (SEER). Methods: 28 cases were identified using the Mayo Clinic Cancer Registry from 1997 to 2016, and 378 cases from the SEER 18 registry from 2000 to 2013. Mayo cases were re-reviewed by Mayo pathologists. We analyzed patient characteristics, tumor location, TNM staging, mitotic index, molecular diagnostics, IHC staining, and histomorphology. JMP software was used to calculate time to recurrence (TTR) and overall survival (OS) utilizing Kaplan-Meier and log-rank. Results: At Mayo, 60% of tumors arose in the distal esophagus. Mean tumor size was 5.73 cm. 42% of cases were low grade. None had nodal involvement. Five cases were metastatic at diagnosis, all to the liver. 86.7% had spindle cell morphology. IHC staining was positive for KIT in 92%, followed by CD34 (52%), DOG-1 (24%), and actin (16%). Mutational analysis was done on 10 cases and KIT mutation was found in 8 cases; 2 were wild-type. Two-thirds of patients underwent surgery, mostly esophagectomy. 14 patients received adjuvant imatinib. Median time to diagnosis from symptom onset was 2 months; median time to surgery from diagnosis was 1 month. Of 10 patients with complete follow-up, 2 had recurrences: 1at the anastomotic site and 1 in the liver. Median TTR from surgery was 36.5 months. Median follow-up time was 31.5 months. Median OS from diagnosis for the Mayo cohort was 129.5 months (95% CI 55.7-x). SEER cohort median OS was 81 months (95% CI 63-101), and females had superior OS compared to males (HR 0.67; 95% CI 0.48-0.93, p = 0.016). Conclusions: Patients undergoing surgical resection for esophageal and GEJ GISTs had a favorable prognosis, but recurrences occurred. The superior OS seen in the Mayo cohort suggests early resection and adjuvant imatinib may improve outcomes.
Collapse
|
40
|
|
41
|
Rodgers B, Jaroszewski DE, Ashman JB, Rule WG, Sio TT, Keole SR. Advantages of Post-Mastectomy Proton Beam Therapy in a Breast Cancer Patient With Pectus Excavatum. J Med Cases 2017. [DOI: 10.14740/jmc2781w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
|
42
|
Borad MJ, Egan JB, Condjella RM, Liang WS, Fonseca R, Ritacca NR, McCullough AE, Barrett MT, Hunt KS, Champion MD, Patel MD, Young SW, Silva AC, Ho TH, Halfdanarson TR, McWilliams RR, Lazaridis KN, Ramanathan RK, Baker A, Aldrich J, Kurdoglu A, Izatt T, Christoforides A, Cherni I, Nasser S, Reiman R, Cuyugan L, McDonald J, Adkins J, Mastrian SD, Valdez R, Jaroszewski DE, Von Hoff DD, Craig DW, Stewart AK, Carpten JD, Bryce AH. Clinical Implementation of Integrated Genomic Profiling in Patients with Advanced Cancers. Sci Rep 2016; 6:25. [PMID: 28003660 PMCID: PMC5431338 DOI: 10.1038/s41598-016-0021-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 11/02/2016] [Indexed: 12/20/2022] Open
Abstract
DNA focused panel sequencing has been rapidly adopted to assess therapeutic targets in advanced/refractory cancer. Integrated Genomic Profiling (IGP) utilising DNA/RNA with tumour/normal comparisons in a Clinical Laboratory Improvement Amendments (CLIA) compliant setting enables a single assay to provide: therapeutic target prioritisation, novel target discovery/application and comprehensive germline assessment. A prospective study in 35 advanced/refractory cancer patients was conducted using CLIA-compliant IGP. Feasibility was assessed by estimating time to results (TTR), prioritising/assigning putative therapeutic targets, assessing drug access, ascertaining germline alterations, and assessing patient preferences/perspectives on data use/reporting. Therapeutic targets were identified using biointelligence/pathway analyses and interpreted by a Genomic Tumour Board. Seventy-five percent of cases harboured 1–3 therapeutically targetable mutations/case (median 79 mutations of potential functional significance/case). Median time to CLIA-validated results was 116 days with CLIA-validation of targets achieved in 21/22 patients. IGP directed treatment was instituted in 13 patients utilising on/off label FDA approved drugs (n = 9), clinical trials (n = 3) and single patient IND (n = 1). Preliminary clinical efficacy was noted in five patients (two partial response, three stable disease). Although barriers to broader application exist, including the need for wider availability of therapies, IGP in a CLIA-framework is feasible and valuable in selection/prioritisation of anti-cancer therapeutic targets.
Collapse
Affiliation(s)
- Mitesh J Borad
- Division of Hematology/Oncology Mayo Clinic, Scottsdale, AZ, USA. .,Mayo Clinic Cancer Center, Scottsdale, AZ, USA. .,Center for Individualized Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Jan B Egan
- Center for Individualized Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Winnie S Liang
- Translational Genomics Research Institute, Phoenix, AZ, USA
| | - Rafael Fonseca
- Division of Hematology/Oncology Mayo Clinic, Scottsdale, AZ, USA.,Mayo Clinic Cancer Center, Scottsdale, AZ, USA.,Center for Individualized Medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | - Michael T Barrett
- Mayo Clinic Cancer Center, Scottsdale, AZ, USA.,Translational Genomics Research Institute, Phoenix, AZ, USA
| | - Katherine S Hunt
- Division of Hematology/Oncology Mayo Clinic, Scottsdale, AZ, USA
| | - Mia D Champion
- Center for Individualized Medicine, Mayo Clinic, Rochester, MN, USA.,Department of Biomedical Statistics and Informatics, Mayo Clinic, Scottsdale, AZ, USA
| | | | - Scott W Young
- Department of Radiology, Mayo Clinic, Scottsdale, AZ, USA
| | - Alvin C Silva
- Department of Radiology, Mayo Clinic, Scottsdale, AZ, USA
| | - Thai H Ho
- Division of Hematology/Oncology Mayo Clinic, Scottsdale, AZ, USA.,Mayo Clinic Cancer Center, Scottsdale, AZ, USA.,Center for Individualized Medicine, Mayo Clinic, Rochester, MN, USA
| | - Thorvardur R Halfdanarson
- Division of Hematology/Oncology Mayo Clinic, Scottsdale, AZ, USA.,Mayo Clinic Cancer Center, Scottsdale, AZ, USA.,Center for Individualized Medicine, Mayo Clinic, Rochester, MN, USA
| | - Robert R McWilliams
- Center for Individualized Medicine, Mayo Clinic, Rochester, MN, USA.,Mayo Clinic Cancer Center, Rochester, MN, USA
| | | | - Ramesh K Ramanathan
- Division of Hematology/Oncology Mayo Clinic, Scottsdale, AZ, USA.,Mayo Clinic Cancer Center, Scottsdale, AZ, USA
| | - Angela Baker
- Translational Genomics Research Institute, Phoenix, AZ, USA
| | | | - Ahmet Kurdoglu
- Translational Genomics Research Institute, Phoenix, AZ, USA
| | - Tyler Izatt
- Translational Genomics Research Institute, Phoenix, AZ, USA
| | | | - Irene Cherni
- Translational Genomics Research Institute, Phoenix, AZ, USA
| | - Sara Nasser
- Translational Genomics Research Institute, Phoenix, AZ, USA
| | - Rebecca Reiman
- Translational Genomics Research Institute, Phoenix, AZ, USA
| | - Lori Cuyugan
- Translational Genomics Research Institute, Phoenix, AZ, USA
| | | | | | | | | | | | | | - David W Craig
- Translational Genomics Research Institute, Phoenix, AZ, USA
| | - A Keith Stewart
- Division of Hematology/Oncology Mayo Clinic, Scottsdale, AZ, USA.,Mayo Clinic Cancer Center, Scottsdale, AZ, USA.,Center for Individualized Medicine, Mayo Clinic, Rochester, MN, USA
| | - John D Carpten
- Translational Genomics Research Institute, Phoenix, AZ, USA
| | - Alan H Bryce
- Division of Hematology/Oncology Mayo Clinic, Scottsdale, AZ, USA.,Mayo Clinic Cancer Center, Scottsdale, AZ, USA.,Center for Individualized Medicine, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
43
|
Jaroszewski DE, Temkit M, Ewais MM, Luckritz TC, Stearns JD, Craner RC, Gaitan BD, Ramakrishna H, Thunberg CA, Weis RA, Myers KM, Merritt MV, Rosenfeld DM. Randomized trial of epidural vs. subcutaneous catheters for managing pain after modified Nuss in adults. J Thorac Dis 2016; 8:2102-10. [PMID: 27621865 DOI: 10.21037/jtd.2016.06.62] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Minimally invasive repair of pectus excavatum (MIRPE) is now performed in adults. Managing adult patients' pain postoperatively has been challenging due to increased chest wall rigidity and the pressure required for supporting the elevated sternum. The optimal pain management regimen has not been determined. We designed this prospective, randomized trial to compare postoperative pain management and outcomes between thoracic epidural analgesia (TEA) and bilateral subcutaneous infusion pump catheters (On-Q). METHODS Patients undergoing MIRPE (modified Nuss) underwent random assignment to TEA or On-Q group. Both groups received intravenous, patient-controlled opioid analgesia, with concomitant delivery of local anesthetic. Primary outcomes were length of stay (LOS), opioid use, and pain scores. RESULTS Of 85 randomly assigned patients, 68 completed the study [52 men, 76.5%; mean (range) age, 32.2 (20.0-58.0) years; Haller index, 5.9 (range, 3.0-26.7)]. The groups were equally matched for preoperative variables; however, the On-Q arm had more patients (60.3%). No significant differences were found between groups in mean daily pain scores (P=0.52), morphine-equivalent opioid usage (P=0.28), or hospital stay 3.5 vs. 3.3 days (TEA vs. On-Q; P=0.55). Thirteen patients randomized to TEA refused the epidural and withdrew from the study because they perceived greater benefit of the On-Q system. CONCLUSIONS Postoperative pain management in adults after MIRPE can be difficult. Both continuous local anesthetic delivery by TEA and On-Q catheters with concomitant, intravenous, patient-controlled anesthesia maintained acceptable analgesia with a reasonable LOS. In our cohort, there was preference for the On-Q system for pain management.
Collapse
Affiliation(s)
- Dawn E Jaroszewski
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - M'hamed Temkit
- Department of Biostatistics, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - MennatAllah M Ewais
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Todd C Luckritz
- Department of Pharmacy, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Joshua D Stearns
- Department of Anesthesiology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Ryan C Craner
- Department of Anesthesiology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Brantley D Gaitan
- Department of Anesthesiology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Harish Ramakrishna
- Department of Anesthesiology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | | | - Ricardo A Weis
- Department of Anesthesiology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Kelly M Myers
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Marianne V Merritt
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - David M Rosenfeld
- Department of Anesthesiology, Mayo Clinic Hospital, Phoenix, Arizona, USA
| |
Collapse
|
44
|
Kocher GJ, Gstrein N, Jaroszewski DE, Ewais MM, Schmid RA. Nuss procedure for repair of pectus excavatum after failed Ravitch procedure in adults: indications and caveats. J Thorac Dis 2016; 8:1981-5. [PMID: 27621850 DOI: 10.21037/jtd.2016.06.60] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Recurrence of pectus excavatum (PE) is not an uncommon problem after open repair using the Ravitch technique. The optimal approach for redo surgery is still under debate, especially in adults with less chest wall pliability. Aim of this study was to investigate the usefulness and efficacy of the minimally invasive Nuss technique for repair of recurrent PE after conventional open repair. METHODS We performed a retrospective multicentre review of 20 adult patients from University Hospital Bern (n=6) and the US Mayo Clinic (n=14) who underwent minimally invasive repair of recurrent PE after unsuccessful prior Ravitch procedure. RESULTS Mean patient age at primary open correction was 21 years, with recurrence being evident after a mean duration of 10.5 years (range, 0.25-47 years). Mean age at redo surgery using the Nuss technique was 31 years, with a mean Haller index of 4.7 before and 2.5 after final correction. Main reason for redo surgery was recurrent or persistent deformity (100%), followed by chest pain (75%) and exercise intolerance (75%). No major intraoperative or postoperative complications occurred and successful correction was possible in all patients. CONCLUSIONS Although the procedure itself is more challenging, the minimally invasive Nuss technique can be safely and successfully used for repair of recurrent PE after failed open surgery. In our series final results were good to excellent in the majority of patients without major complications or recurrence.
Collapse
Affiliation(s)
- Gregor J Kocher
- Division of General Thoracic Surgery, University Hospital Bern/Inselspital, Bern, Switzerland
| | - Nathalie Gstrein
- Division of General Thoracic Surgery, University Hospital Bern/Inselspital, Bern, Switzerland
| | | | | | - Ralph A Schmid
- Division of General Thoracic Surgery, University Hospital Bern/Inselspital, Bern, Switzerland
| |
Collapse
|
45
|
Jaroszewski DE, Ewais MM, Chao CJ, Gotway MB, Lackey JJ, Myers KM, Merritt MV, Sims SM, McMahon LE, Notrica DM. Success of Minimally Invasive Pectus Excavatum Procedures (Modified Nuss) in Adult Patients (≥30 Years). Ann Thorac Surg 2016; 102:993-1003. [DOI: 10.1016/j.athoracsur.2016.03.105] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 02/17/2016] [Accepted: 03/31/2016] [Indexed: 11/28/2022]
|
46
|
Jaroszewski DE, Ewais MM, Lackey JJ, Myers KM, Merritt MV, Stearns JD, Gaitan BD, Craner RC, Gotway MB, Naqvi TZ. Revision of failed, recurrent or complicated pectus excavatum after Nuss, Ravitch or cardiac surgery. J Vis Surg 2016; 2:74. [PMID: 29078502 DOI: 10.21037/jovs.2016.03.17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 02/17/2016] [Indexed: 11/06/2022]
Abstract
Pectus excavatum (PE) can recur after both open and minimally invasive repair of pectus excavatum (MIRPE) techniques. The cause of recurrence may differ based on the initial repair procedure performed. Recurrence risks for the open repair are due to factors which include incomplete previous repair, repair at too young of age, excessive dissection, early removal or lack of support structures, and incomplete healing of the chest wall. For patients presenting after failed or recurrent primary MIRPE repair, issues with support bars including placement, number, migration, and premature removal can all be associated with failure. Connective tissue disorders can complicate and increase recurrence risk in both types of PE repairs. Identifying the factors that contributed to the previous procedure's failure is critical for prevention of another recurrence. A combination of surgical techniques may be necessary to successfully repair some patients.
Collapse
Affiliation(s)
- Dawn E Jaroszewski
- Department of Surgery, Division of Cardiothoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - MennatAllah M Ewais
- Department of Surgery, Division of Cardiothoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Jesse J Lackey
- Department of Surgery, Division of Cardiothoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Kelly M Myers
- Department of Surgery, Division of Cardiothoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Marianne V Merritt
- Department of Surgery, Division of Cardiothoracic Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Joshua D Stearns
- Department of Anesthesia, Division of Cardiothoracic Anesthesia, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Brantley D Gaitan
- Department of Anesthesia, Division of Cardiothoracic Anesthesia, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Ryan C Craner
- Department of Anesthesia, Division of Cardiothoracic Anesthesia, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Michael B Gotway
- Department of Radiology, Division of Thoracic Imaging, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Tasneem Z Naqvi
- Department of Cardiology, Division of Echocardiogram, Mayo Clinic Arizona, Phoenix, Arizona, USA
| |
Collapse
|
47
|
Ernst B, Ross HJ, Paripati H, Pannala R, Rule WG, Ashman JB, Harold KL, Jaroszewski DE. Endoscopic stenting for esophageal leak after minimally invasive esophagectomy. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.4_suppl.110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
110 Background: Anastomotic leaks can occur after esophagectomy and optimal management after minimally invasive esophagectomy (MIE) is not well defined. We reviewed endoscopic management of leaks after MIE in patients undergoing trimodality therapy at Mayo Clinic Arizona. Methods: Records of patients undergoing MIE from November, 2006 to February, 2015 were reviewed after appropriate IRB approval. Results: 148 patients underwent MIE including 136 (91.8%) thoracic and 12 (8.1%) cervical anastomoses. Clinically significant anastomotic leaks were observed in 13 (8.8%) patients with 2 (16%) cervical and 11 (8%) thoracic anastomosis at a median of 6.1 days (0-14). 11 (11%) patients treated with neoadjuvant chemoradiotherapy experienced esophageal leak and 2 who did not receive chemoradiotherapy (4%). For treatment of anastomotic leaks, 10 patients underwent VATS with pleural space irrigation and chest tube replacement, and 11 patients underwent stent deployment at the anastomosis for repair. Stents were placed such that the fistula/leak was in the fully covered portion with the greater portion of the stent residing in the esophageal remnant. Stents were removed at a mean of 54 days (28-114). In 2 patients, overgrowth into the stent body required stent-in-stent placement (fully covered) with removal of both stents. Stents were successful at sealing all leaks. Conclusions: Leaks after MIE represent a small, but significant, morbidity in MIE. The majority can be managed by endoscopic stent placement. Stenting is an effective management tool for postoperative leaks in locally advanced esophageal malignancies.
Collapse
|
48
|
Chao CJ, Jaroszewski DE, Kumar PN, Ewais MM, Appleton CP, Mookadam F, Gotway MB, Naqvi TZ. Surgical repair of pectus excavatum relieves right heart chamber compression and improves cardiac output in adult patients—an intraoperative transesophageal echocardiographic study. Am J Surg 2015; 210:1118-24; discussion 1124-5. [DOI: 10.1016/j.amjsurg.2015.07.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 06/15/2015] [Accepted: 07/16/2015] [Indexed: 12/24/2022]
|
49
|
Jaroszewski DE, Ewais MM, Gotway MB, McMahon LE, Notrica DM. Successful Singleton and Twin Pregnancies With the Nuss Bars in Place. Ann Thorac Surg 2015; 100:1877-8. [PMID: 26522529 DOI: 10.1016/j.athoracsur.2014.12.094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Revised: 11/12/2014] [Accepted: 12/16/2014] [Indexed: 11/15/2022]
Abstract
Pectus excavatum (PE) occurs less commonly in women, and the implications on a pregnancy after repair during the period when support bars are in place are unknown. We present 2 cases: 1 with a successful twin gestation and another with a successful singleton gestation. These women carried the pregnancies to term and delivered their infants with the Nuss bars in place.
Collapse
Affiliation(s)
| | | | | | - Lisa E McMahon
- Department of Surgery, Mayo Clinic, Arizona, Phoenix, Arizona
| | - David M Notrica
- Department of Surgery, Mayo Clinic, Arizona, Phoenix, Arizona
| |
Collapse
|
50
|
Schleifer JW, Jaroszewski DE, Shah N, Scott LR. Long-term follow-up of minimally invasive video-assisted thoracoscopic surgery with epicardial radiofrequency ablation for complex cases of inappropriate sinus tachycardia. HeartRhythm Case Rep 2015; 1:477-480. [PMID: 28491610 PMCID: PMC5419723 DOI: 10.1016/j.hrcr.2015.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
| | | | - Nilay Shah
- Department of Surgery, Division of General Surgery, Mayo Clinic, Phoenix, Arizona
| | - Luis R. Scott
- Department of Medicine, Division of Cardiovascular Diseases, Phoenix, Arizona
- Address reprint requests and correspondence: Dr Luis R. Scott, Department of Medicine, Division of Cardiovascular Diseases, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054
| |
Collapse
|