Induction chemoimmunotherapy with surgery versus concurrent chemoradiation followed by immunotherapy for stage III-N2 non-small cell lung cancer

OBJECTIVE

Despite the growing relevance of immunotherapy for non-small cell lung cancer (NSCLC), there is limited consensus on the optimal treatment strategy for locally advanced NSCLC. This study evaluated the overall survival of patients with stage III-N2 NSCLC undergoing induction chemoimmunotherapy with surgery (CT/IO+Surgery) and definitive concurrent chemoradiation followed by immunotherapy (cCRT+IO).

METHODS

Patients with cT1-3, N2, M0 NSCLC in the National Cancer Database (2013 to 2019) were included and stratified by treatment regimen: CT/IO+Surgery or cCRT+IO. Overall survival was evaluated using Kaplan-Meier analysis, Cox proportional hazards modeling, and propensity score matching on 10 prognostic variables.

RESULTS

Of the 3382 patients who met the study eligibility criteria, 3289 (97.3%) received cCRT+IO and 93 (2.8%) received CT/IO+Surgery. The 3-year overall survival of the entire cohort was 58.2% (95% CI, 56.2% to 60.1%). Multivariable-adjusted Cox proportional hazards modeling demonstrated better survival after CT/IO+Surgery than after cCRT+IO (hazard ratio [HR], 0.52; 95% confidence interval [CI], 0.32 to 0.84; P = .007). In a 3:1 variable ratio propensity score-matched analysis of 223 patients who received cCRT+IO and 76 patients who received CT/IO+Surgery, 3-year overall survival was 63.2% (95% CI, 55.9% to 70.2%) after cCRT+IO and 77.2% (95% CI, 64.6% to 85.7%) after CT/IO+Surgery (P = .029).

CONCLUSIONS

In this national analysis, multimodal treatment including immunotherapy was associated with a 3-year overall survival rate of 58.2% for all patients with stage III-N2 NSCLC and 77.2% for patients who underwent chemoimmunotherapy followed by surgery. These results should be considered hypothesis-generating and demonstrate the importance of developing a randomized trial to evaluate the role of surgery versus chemoradiation for locally advanced NSCLC in the modern immunotherapy era.

Shortage of thoracic surgeons in the United States: Implications for treatment and survival for stage I lung cancer patients

OBJECTIVES

To evaluate whether there is a shortage of thoracic surgeons in the United States and whether any potential shortage is impacting lung cancer treatment and outcomes.

DESIGN

Using the US Area Health Resources File and Surveillance Epidemiology End Results database, we assessed the number of cardiothoracic surgeons per 100,000 people and the number of stage I non-small cell lung cancer (NSCLC) diagnoses in the US in 2010 versus 2018. Changes in the percentage of patients diagnosed with stage I NSCLC who underwent surgery and stereotactic body radiotherapy and changes in overall survival of patients with stage I NSCLC from 2010 to 2018 in the National Cancer Database were evaluated using multivariable logistic regression and Cox proportional hazards modeling.

RESULTS

From 2010 to 2018, the number of cardiothoracic surgeons per 100,000 people in the US decreased by 12% (P < .001), while the number of patients diagnosed with stage I NSCLC increased by 40% (P < .001). Over the same period, the percentage of patients who underwent surgery for stage I NSCLC decreased from 81.0% to 72.3% (adjusted odds ratio, 0.59; 95% confidence interval, 0.55-0.63); this decrease was similarly seen in a subgroup of young and otherwise healthy patients. Greater decreases in the percentage of patients who underwent surgery in nonmetropolitan and underserved regions corresponded with worse improvements in survival among patients in these regions from 2010 to 2018.

CONCLUSIONS

Recent declines in the US cardiothoracic surgery workforce may have led to significantly fewer patients undergoing surgery for stage I NSCLC and worsening disparities in survival between different patient populations.

Long-term Survival After Lung Cancer Resection in the National Lung Screening Trial

BACKGROUND

This study sought to evaluate the long-term survival and causes of death after surgery among patients with pathologic stage IA non-small cell lung cancer (NSCLC) in the National Lung Screening Trial (NLST).

METHODS

Patients who underwent surgery and who had a diagnosis of pathologic stage IA NSCLC in the NLST were identified for analysis. The 5- and 10-year overall survival and lung cancer-specific survival, stratified by operation type, were evaluated. Among patients who underwent lobectomy, the causes of death and the cumulative incidence of lung cancer death were assessed.

RESULTS

A total of 380 patients (n = 329, 86.6% lobectomy; n = 20, 5.3% segmentectomy; n = 31, 8.1% wedge resection) met inclusion criteria. Median follow-up time from the date of surgery was 7.8 years (interquartile range, 4.8-10.7 years). The 10-year overall survival rate was 58.3% (95% CI, 52.4%-63.8%) for lobectomy, 59.9% (95% CI, 33.2%-78.8%) for segmentectomy, and 45.2% (95% CI, 20.8%-66.9%) for wedge resection. The 10-year lung cancer-specific survival rate was 74.3% (95% CI, 68.6%-79.1%) for lobectomy, 81.3% (95% CI, 51.3%-93.8%) for segmentectomy, and 84.8% (95% CI, 64.0%-94.1%) for wedge resection. Lung cancer was the leading cause of death, accounting for 55.8% of deaths after lobectomy. The 10-year cumulative incidence of lung cancer death after lobectomy was 22.5% (95% CI, 18.3%-27.1%).

CONCLUSIONS

The 10-year overall survival rate after lobectomy among patients with pathologic stage IA NSCLC in the NLST was 58%. Lung cancer was the leading cause of death, accounting for more than 55% of deaths.

Five-Year Sustained Impact of a Thoracic Enhanced Recovery After Surgery Program

BACKGROUND

Our thoracic enhanced recovery program (ERP) decreased the use of postoperative morphine equivalents and hospital costs 1 year after implementation at our tertiary center. The sustainability and potential increasing benefit of this program were evaluated.

METHODS

From 2015 to 2021, we prospectively analyzed the outcomes of patients who underwent elective pleural, pulmonary, or mediastinal operations at our institution. Patients were separated on the basis of the incision (video-assisted thoracoscopic surgery [VATS] or thoracotomy). The ERP protocol was initiated on May 1, 2016, and includes preoperative education, carbohydrate loading, opioid-sparing analgesia, conservative fluid management, protective ventilation, and early ambulation. Outcomes of patients before (2015, pre-VATS and pre-thoracotomy) and after (May 1, 2016, to December 31, 2021, ERP-VATS and ERP-thoracotomy) ERP implementation were compared.

RESULTS

The cohort included 1079 patients (pre-ERP era, n = 224 [21%]; ERP era, n = 855 [79%]). There was a median reduction of 1.5 hospital days per patient for ERP-thoracotomy and 1 hospital day per patient for ERP-VATS. Median postoperative morphine equivalents decreased in both groups (125 vs 45 mg, in ERP-thoracotomy; 84 vs 23 mg, ERP-VATS; P < .001), as did total admission cost ($32,118 vs $23,775, ERP-thoracotomy; $17,367 vs $11,560, ERP-VATS; P < .001). Median total fluid balance during the hospital stay decreased significantly. Rates of postoperative atrial fibrillation and urinary retention decreased across both subgroups.

CONCLUSIONS

ERP for thoracic surgery is sustainable and has been demonstrated to improve patient outcomes, to decrease opioid use, and to lower hospital costs. Therefore, it has the potential to become the standard of care.

Impact of Opioid Use on Duration of Therapy and Overall Survival for Patients with Advanced Non-Small Cell Lung Cancer Treated with Immune Checkpoint Inhibitors

Immune checkpoint inhibitors (ICI) have significantly improved outcomes in advanced non-small cell lung cancer (NSCLC). We evaluated the effect of opioid use on outcomes in patients receiving ICI either alone or with chemotherapy. We conducted a retrospective review of 209 patients with advanced NSCLC who received an ICI at the University of Virginia between 1 February 2015 and 1 January 2020. We performed univariate and multivariate analyses to evaluate the impact of opioid use on duration of therapy (DOT) and overall survival (OS). Patients with no or low opioid use (n = 172) had a median DOT of 12.2 months (95% CI: 6.9-17.4) compared to 1.9 months (95% CI: 1.8-2.0) for those with high opioid use (n = 37, HR 0.26 95% CI: 0.17-0.40, p < 0.001). Patients with no or low opioid use had a median OS of 22.6 months (95% CI: 14.8-30.4) compared to 3.8 months (95% CI: 2.7-4.9) for those with high opioid use (HR 0.26 95% CI: 0.17-0.40 p < 0.001). High opioid use was associated with a shorter DOT and worse OS. This difference remained significant when accounting for possible confounding variables. These data warrant investigation of possible mechanistic interactions between opioids, tumor progression, and ICIs, as well as prospective evaluation of opioid-sparing pain management strategies, where possible.

Segmentectomy versus lobectomy in the United States: Outcomes after resection for first primary lung cancer and treatment patterns for second primary lung cancers

OBJECTIVE

The study objective was to identify whether the results of JCOG0802 could be generalized to US clinical settings.

METHODS

Patients diagnosed with clinical stage IA (≤2 cm) non-small cell lung cancer who underwent segmentectomy versus lobectomy (2004-2017) in the National Cancer Database were identified. Overall survival of patients in the National Cancer Database was assessed using propensity score-matched analysis. A separate analysis of the Surveillance Epidemiology End Results database was conducted to evaluate treatment patterns of second primary lung cancers among patients who underwent segmentectomy versus lobectomy for a first primary lung cancer.

RESULTS

Of the 23,286 patients in the National Cancer Database meeting inclusion criteria, 1397 (6.0%) underwent segmentectomy and 21,889 (94.0%) underwent lobectomy. In a propensity score-matched analysis of all patients in the study cohort, there were no significant differences in overall survival between patients undergoing segmentectomy versus lobectomy (5-year overall survival: 79.9% [95% CI, 76.7%-82.0%] vs 81.8% [95% CI, 78.7%-84.4%], log-rank: P = .72). In subgroup analyses by tumor grade and histologic subtype, segmentectomy was associated with similar overall survival compared with lobectomy in all subgroups evaluated. In a propensity score-matched analysis of patients in the Surveillance Epidemiology End Results database, there were no significant differences in treatment patterns of second primary lung cancers between patients who underwent segmentectomy and patients who underwent lobectomy for their first primary lung cancer.

CONCLUSIONS

In this national analysis of US patients diagnosed with stage IA (≤2 cm) non-small cell lung cancer, there were no significant differences in overall survival between segmentectomy and lobectomy in the overall cohort or in subgroup analyses by tumor grade or histologic subtype.

Pafolacianine for intraoperative molecular imaging of cancer in the lung: The ELUCIDATE trial

OBJECTIVE

The study objective was to determine the clinical utility of pafolacianine, a folate receptor-targeted fluorescent agent, in revealing by intraoperative molecular imaging folate receptor α positive cancers in the lung and narrow surgical margins that may otherwise be undetected with conventional visualization.

METHODS

In this Phase 3, 12-center trial, 112 patients with suspected or biopsy-confirmed cancer in the lung scheduled for sublobar pulmonary resection were administered intravenous pafolacianine within 24 hours before surgery. Participants were randomly assigned to surgery with or without intraoperative molecular imaging (10:1 ratio). The primary end point was the proportion of participants with a clinically significant event, reflecting a meaningful change in the surgical operation.

RESULTS

No drug-related serious adverse events occurred. One or more clinically significant event occurred in 53% of evaluated participants compared with a prespecified limit of 10% (P < .0001). In 38 participants, at least 1 event was a margin 10 mm or less from the resected primary nodule (38%, 95% confidence interval, 28.5-48.3), 32 being confirmed by histopathology. In 19 subjects (19%, 95% confidence interval, 11.8-28.1), intraoperative molecular imaging located the primary nodule that the surgeon could not locate with white light and palpation. Intraoperative molecular imaging revealed 10 occult synchronous malignant lesions in 8 subjects (8%, 95% confidence interval, 3.5-15.2) undetected using white light. Most (73%) intraoperative molecular imaging-discovered synchronous malignant lesions were outside the planned resection field. A change in the overall scope of surgical procedure occurred for 29 of the subjects (22 increase, 7 decrease).

CONCLUSIONS

Intraoperative molecular imaging with pafolacianine improves surgical outcomes by identifying occult tumors and close surgical margins.

Recurrence After Complete Resection for Non-Small Cell Lung Cancer in the National Lung Screening Trial

BACKGROUND

The objective of this study was to evaluate patterns, predictors, and long-term outcomes of recurrent disease after complete resection for early-stage non-small cell lung cancer (NSCLC) using the National Lung Screening Trial (NLST).

METHODS

The frequency of recurrence in patients with pathologic stage I-II NSCLC who underwent complete resection (lobectomy or bilobectomy) in the NLST was evaluated. Predictors of increased risk of recurrence were assessed by Fine-Gray competing risks regression.

RESULTS

Of the 497 patients meeting study inclusion criteria, 94 experienced a recurrence-a rate of 4.9 (95% CI, 4.0-6.0) per 100 person-years. The 5-year cumulative incidence of recurrence was 20.1% (95% CI, 16.5%-23.9%). Most patients experienced recurrences at distant sites alone (n = 47 [50.0%]) or at both locoregional and distant sites (n = 30 [31.9%]). The median time from resection to recurrence was 18.8 (10.6-30.7) months. The incidence rate of recurrence was significantly lower among patients with lung cancer detected by low-dose computed tomography screening during one of the three screening rounds of the NLST when compared with patients with lung cancer detected by chest radiography screening and patients with lung cancer not detected by any form of screening (ie, those diagnosed after a negative or missed screening exam and those diagnosed during follow-up after the three screening rounds of the NLST were completed) (P < .001). Median survival (from the date of recurrence) of patients with pathologic stage I and stage II disease who had recurrences at locoregional, distant, or both sites was 63.0, 23.1, and 9.8 months and 28.9, 8.7, and 10.2 months, respectively.

CONCLUSIONS

In this analysis of NLST participants with completely resected stage I-II NSCLC, the 5-year cumulative incidence of recurrence was 20%. Nearly 82% of recurrences were at distant sites and associated with poor survival.

Delayed esophageal anastomotic complication and ramucirumab therapy: A case report

Current NCCN guidelines for second-line therapy in recurrent or metastatic esophago-gastric cancers recommend the use of VEGF inhibitors such as ramucirumab. VEGF inhibitors have been shown to be associated with gastrointestinal perforation in clinical trials and late colorectal anastomotic leaks in a few case reports. Here, we present a case of late esophageal anastomotic leak in a patient receiving ramucirumab. Case information was obtained from our institution's electronic medical records. The patient was found to have T4N1M0, poorly differentiated invasive adenocarcinoma and subsequently received neoadjuvant chemoradiation followed by hybrid Ivor-Lewis esophagectomy 6 weeks later. He recovered well with no leak or perioperative complications. The patient had disease progression 9 months postoperatively on CT and PET imaging. Sixteen months after surgery he began paclitaxel and ramucirumab and 16 weeks after ramucirumab initiation, he was found to have an esophago-pulmonary fistula in the region of the anastomosis. Biopsies were negative for recurrence at the anastomosis. He died one week later from progressive pneumonia despite stenting. In conclusion, this is the only known report of delayed esophageal anastomotic complication associated with ramucirumab. VEGF inhibitor therapies such as bevacizumab have been associated with late (greater than 3 months postoperative) colorectal anastomotic complications including fistulas and leaks. Risk factors that have been associated are perioperative radiotherapy and history of early postoperative leak. These findings raise concern whether VEGF inhibitor therapy should be used in post-esophagectomy patients with recurrence if these rare but catastrophic events are likely to be terminal.

A National Survey of Surgeons Evaluating the Accuracy of Mediastinal Lymph Node Identification

BACKGROUND

The Commission on Cancer implemented Standard 5.8 in 2021, which requires removal of 3 mediastinal nodes and 1 hilar node with lung cancer resection. We conducted a national survey to assess whether surgeons who treat lung cancer in different clinical settings correctly identify mediastinal lymph node stations.

METHODS

Cardiac or thoracic surgeons expressing interest in lung cancer surgery on the Cardiothoracic Surgery Network were asked to complete a 7-question survey assessing their knowledge of lymph node anatomy. General surgeons whose practice includes thoracic surgery were invited through American College of Surgeon's Cancer Research Program. Results were analyzed using Pearson's chi-square test. Multivariable linear regression was used to identify predictors of a higher score on the survey.

RESULTS

Of the 280 surgeons that responded, 86.8% were male and 13.2% were female; the median age was 50 years. Of these surgeons, 211 (75.4%) were thoracic, 59 (21.1%) were cardiac, and 10 (3.6%) were general surgeons. Surgeons were most likely to correctly identify lymph node stations 8R and 9R and least likely to correctly identify the midline pretracheal node just superior to the carina (4R). Surgeons whose practice involved a greater percentage of thoracic surgery patients and surgeons who performed a greater number of lobectomies scored higher on the lymph node assessment.

CONCLUSION

Knowledge of mediastinal node anatomy among surgeons who perform thoracic surgery is generally high, but varies by clinical setting. Efforts are under way to better educate lung cancer surgeons on nodal anatomy, and to increase adoption of Standard 5.8.

Carcinoembryonic Antigen-Related Cell Adhesion Molecule Type 5 Receptor-Targeted Fluorescent Intraoperative Molecular Imaging Tracer for Lung Cancer: A Nonrandomized Controlled Trial

Importance

Localization of subcentimeter ground glass opacities during minimally invasive thoracoscopic lung cancer resections is a significant challenge in thoracic oncology. Intraoperative molecular imaging has emerged as a potential solution, but the availability of suitable fluorescence agents is a limiting factor.

Objective

To evaluate the suitability of SGM-101, a carcinoembryonic antigen-related cell adhesion molecule type 5 (CEACAM5) receptor-targeted near-infrared fluorochrome, for molecular imaging-guided lung cancer resections, because glycoprotein is expressed in more than 80% of adenocarcinomas.

Design, Setting, and Participants

For this nonrandomized, proof-of-principal, phase 1 controlled trial, patients were divided into 2 groups between August 1, 2020, and January 31, 2022. Patients with known CEACAM5-positive gastrointestinal tumors suggestive of lung metastasis were selected as proof-of-principle positive controls. The investigative group included patients with lung nodules suggestive of primary lung malignant neoplasms. Patients 18 years or older without significant comorbidities that precluded surgical exploration with suspicious pulmonary nodules requiring surgical biopsy were included in the study.

Interventions

SGM-101 (10 mg) was infused up to 5 days before index operation, and pulmonary nodules were imaged using a near-infrared camera system with a dedicated thoracoscope.

Main Outcomes and Measures

SGM-101 localization to pulmonary nodules and its correlation with CEACAM5 glycoprotein expression by the tumor as quantified by tumor and normal pulmonary parenchymal fluorescence.

Results

Ten patients (5 per group; 5 male and 5 female; median [IQR] age, 66 [58-69] years) with 14 total lesions (median [range] lesion size, 0.91 [0.90-2.00] cm) were enrolled in the study. In the control group of 4 patients (1 patient did not undergo surgical resection because of abnormal preoperative cardiac clearance findings that were not deemed related to SGM-101 infusion), the mean (SD) lesion size was 1.33 (0.48) cm, 2 patients had elevated serum CEA markers, and 2 patients had normal serum CEA levels. Of the 4 patients who underwent surgical intervention, those with 2+ and 3+ tissue CEACAM5 expression had excellent tumor fluorescence, with a mean (SD) tumor to background ratio of 3.11 (0.45). In the patient cohort, the mean (SD) lesion size was 0.68 (0.22) cm, and no elevations in serum CEA levels were found. Lack of SGM-101 fluorescence was associated with benign lesions and with lack of CEACAM5 staining.

Conclusions and Relevance

This in-human proof-of-principle nonrandomized controlled trial demonstrated SGM-101 localization to CEACAM5-positive tumors with the detection of real-time near-infrared fluorescence in situ, ex vivo, and by immunofluorescence microscopy. These findings suggest that SGM-101 is a safe, receptor-specific, and feasible intraoperative molecular imaging fluorochrome that should be further evaluated in randomized clinical trials.

Trial Registration

ClinicalTrials.gov identifier: NCT04315467.

Enhanced Recovery Protocol Associated With Decreased 3-Month Opioid Use After Thoracic Surgery

BACKGROUND

Enhanced recovery protocols (ERPs) have been shown to decrease inhospital opioid use after thoracic surgery. However, the impact on opioid use after discharge has not been reported. We hypothesized that prolonged opioid use would decrease after implementation of a comprehensive ERP.

METHODS

Records from all patients undergoing elective pulmonary, pleural, and mediastinal operations at a single institution (2015-2018) were abstracted from a prospective ERP database and The Society of Thoracic Surgeons institutional database. Records were reviewed for documentation of opioid use at 3-month and 6-month postoperative visits. Patients with preoperative chronic opioid use were excluded. Univariate analysis compared patients with and patients without 3-month opioid use, and a multivariable logistic regression evaluated independent predictors of prolonged opioid use.

RESULTS

A total of 499 patients was included: 160 pre-ERP, and 339 post-ERP. Three-month opioid use rates were decreased after implementation of an ERP (44% vs 30%, P = .01); 6-month opioid use rates were not significantly different (25% vs 18%, P = .10). Univariate analysis demonstrated increased 3-month opioid use rates among patients with preoperative tobacco use (38% vs 27%, P = .05) and chronic pain disorder (88% vs 32%, P < .01), with no impact from surgical incision (video-assisted thoracoscopic surgery 33%; open 37%, P = .49). On multivariable analysis, participation in an ERP was independently associated with decreased opioid use at 3 months (odds ratio 0.53; 95% CI, 0.31-0.89; P = .02).

CONCLUSIONS

There is a high burden of prolonged opioid use after elective thoracic surgery. Participation in a comprehensive ERP is associated with decreased opioid use 3 months postoperatively.

Malignant undifferentiated and rhabdoid tumors of the gastroesophageal junction and esophagus with SMARCA4 loss: a case series

Undifferentiated SMARCA4-deficient carcinoma of the esophagus and gastroesophageal junction is a rare, highly aggressive, and diagnostically challenging malignancy. Here we present a case series of high-grade undifferentiated malignant neoplasms of the esophagus and gastroesophageal junction that share SMARCA4 loss by immunohistochemistry and demonstrate a rhabdoid phenotype. Five cases are presented, including 4 men and 1 woman with an age range of 48-79 years. Interestingly, only one case showed intestinal metaplasia (Barrett's esophagus) and no cases demonstrated glandular dysplasia or glandular differentiation. In all, the lesional cells were immunoreactive with antibodies to keratins (3/5), CD34 (2/4), and CD138 (4/5). SMARCA4 expression was diffusely lost in all cases, whereas SMARCB1 expression was intact. OncoScan™ assay demonstrated loss of SMARCA4 in all cases analyzed. Additional OncoScan™ findings included abnormalities of CDKN2A in 2 of 3 cases, abnormalities of TP53 in 2 of 3 cases, and abnormalities of PTPRD in 2 of 3 cases, among other abnormalities.

Consensus for Thoracoscopic Lower Lobectomy: Essential Components and Targets for Simulation

BACKGROUND

Despite demonstration of its clear benefits relative to open approaches, a video-assisted thoracic surgery technique for pulmonary lobectomy has not been universally adopted. This study aims to overcome potential barriers by establishing the essential components of the operation and determining which steps are most useful for simulation training.

METHODS

After randomly selecting experienced thoracic surgeons to participate, an initial list of components to a lower lobectomy was distributed. Feedback was provided by the participants, and modifications were made based on anonymous responses in a Delphi process. Components were declared essential once at least 80% of participants came to an agreement. The steps were then rated based on cognitive and technical difficulty followed by listing the components most appropriate for simulation.

RESULTS

After 3 rounds of voting 18 components were identified as essential to performance of a video-assisted thoracic surgery for lower lobectomy. The components deemed the most difficult were isolation and division of the basilar and superior segmental branches of the pulmonary artery, isolation and division of the lower lobe bronchus, and dissection of lymphovascular tissue to expose the target bronchus. The steps determined to be most amenable for simulation were isolation and division of the branches of the pulmonary artery, the lower lobe bronchus, and the inferior pulmonary vein.

CONCLUSIONS

Using a Delphi process a list of essential components for a video-assisted thoracic surgery for lower lobectomy was established. Furthermore 3 components were identified as most appropriate for simulation-based training, providing insights for future simulation development.

Racial and Treatment Center Differences on Time to Treatment Initiation for Nonsmall Cell Lung Cancer Patients Receiving Radiation Therapy As an Initial Treatment

Objective:

Because time to treatment has been shown to be associated with increase in the risk of death for Non Small Cell Lung Cancer (NSCLC) patients, we examined the prevalence and magnitude of racial disparities in mean time to radiation therapy (TTRT) for Stage I-III non-small cell lung cancer patients across a variety of treatment facilities.

Methods:

Utilizing the United States National Cancer Database (NCDB), we determined differences in TTRT between different races and different treatment facilities.

Results:

Concordant with past research, we found that non-White patients and patients treated at academic facilities, regardless of race, have longer mean TTRT, and that racial disparities in TTRT extend across all treatment facilities (all p<0.05).

Conclusions:

These findings shed light on the potential presence of and impact of structural racism on patients seeking cancer treatment, and the need for further investigation behind the reasonings behind longer TTI for non-White patients. To elucidate the real-world applicability of these results, further investigation into the societal determinants that perpetuate disparity in time to radiation therapy, and potential interventions in the clinical setting to improve cultural and racial sensitivity among healthcare professionals is recommended.

Enabling ultra-low-voltage switching in BaTiO3

Single crystals of BaTiO₃ exhibit small switching fields and energies, but thin-film performance is considerably worse, thus precluding their use in next-generation devices. Here, we demonstrate high-quality BaTiO₃ thin films with nearly bulk-like properties. Thickness scaling provides access to the coercive voltages (<100 mV) and fields (<10 kV cm^-1) required for future applications and results in a switching energy of <2 J cm^-3 (corresponding to <2 aJ per bit in a 10 × 10 × 10 nm³ device). While reduction in film thickness reduces coercive voltage, it does so at the expense of remanent polarization. Depolarization fields impact polar state stability in thicker films but fortunately suppress the coercive field, thus driving a deviation from Janovec-Kay-Dunn scaling and enabling a constant coercive field for films <150 nm in thickness. Switching studies reveal fast speeds (switching times of ~2 ns for 25-nm-thick films with 5-µm-diameter capacitors) and a pathway to subnanosecond switching. Finally, integration of BaTiO₃ thin films onto silicon substrates is shown. We also discuss what remains to be demonstrated to enable the use of these materials for next-generation devices.

Esophagectomy for End-Stage Achalasia

Esophagectomy for achalasia is reserved for patients with end-stage disease for whom prior treatment has failed. Esophagectomy can be performed safely through a variety of techniques. Conduit options include stomach, colon, and small intestine. There are many potential complications following esophagectomy. Outcomes of esophagectomy for achalasia are good when performed in experienced surgical centers.

A multimodal protocol utilizing liposomal bupivacaine rib blocks leads to opioid reduction in patients undergoing the Nuss procedure

Background

A major challenge associated with the Nuss procedure for pectus excavatum repair is postoperative pain control. Early Recovery Program (ERP) protocols for the Nuss procedure are becoming common, but there is a paucity of experience using liposomal bupivacaine (LB), a long-acting local anesthetic, for rib blocks in this setting. We investigated whether a protocol utilizing LB rib blocks decreased opioid use after the Nuss procedure while achieving equivalent pain control.

Methods

All adolescent patients undergoing the Nuss procedure at our institution between January 2013 and January 2021 were included. Patients were divided into a pre-intervention cohort (n=15), a transition cohort (n=4), and a post-intervention cohort (n=13). Patients in all groups received scheduled acetaminophen and non-steroidals postoperatively. The pre-intervention cohort received an opioid patient-controlled analgesia (PCA) pump postoperatively, with a transition to oral opiates. The transition and post-intervention cohorts received scheduled gabapentin in addition to intraoperative bilateral rib blocks with longer-acting local anesthetic. Rib blocks were performed using 0.25% Bupivacaine in the pre-intervention group. In the transition group, epinephrine (1 mg/kg) was added to 0.25% bupivacaine for the rib block. Following approval in patients aged 13–18 years, 1.3% LB (2.25 mg/kg) was given for a rib block in the post-intervention cohort.

Results

Demographic and clinical variables were equivalent in all groups. Post-intervention patients received 90% fewer opioids [median morphine equivalent (MME) mg/kg] compared to the pre-intervention cohort (0.8 vs. 8.2 MME mg/kg, P<0.0001), with no significant difference in pain scores between groups. Hospital length of stay was decreased among the intervention cohort (3 vs. 4 days, P=0.002).

Conclusions

Significant decreases in opioid use and length of stay after the Nuss procedure were achieved by the implementation of a multimodal ERP for pain management, without increase in patient-reported pain scores.

Multi-Institutional Evaluation of a Debate-Style Journal Club for Cardiothoracic Surgery Trainees

BACKGROUND

Traditional journal clubs address individual articles and are limited in terms of breadth and depth of content covered. The present study describes the outcomes of a novel debate-style journal club in a multi-institutional setting.

METHODS

Participating institutions were recruited through the Thoracic Education Cooperative Group (TECoG). The distributed curriculum included instructions, debate scenarios, suggested article lists, moderator slides, debate scoresheets, exams, and feedback surveys.

RESULTS

Six institutions participated in the study (2015-2019), consisting of a total of 10 years' worth of cumulative debates. Cardiothoracic surgery trainees participated in 10 monthly debates over each academic year. Trainee performance on the written examination in the realm of evidence-based medicine and critical appraisal improved over the course of the academic year (beginning 55.2% vs end 76.3%, p=0.040). Importantly, written examination after debates revealed a significant improvement in scores on questions relating to topics that were debated as compared to those that were not (+27.1% vs +2.5%, p=0.006), emphasizing the importance of the debates as compared to other sources of knowledge gain. Surveys completed by trainees and faculty overall favored the debate-style journal club as compared to the traditional journal club in gaining familiarity with seminal literature in the field, improving upon oral presentation skills, and applying published literature to questions encountered clinically.

CONCLUSIONS

In this multi-institutional prospective study, we demonstrate that the novel debate-style cardiothoracic surgery journal club is an effective educational intervention for cardiothoracic surgical trainees to acquire, retain, and gain practice in applying literature-based evidence to case-based scenarios.

The role of gender in non-small cell lung cancer: a narrative review

The role of gender in the development, treatment and prognosis of thoracic malignancies has been underappreciated and understudied. While most research has been grounded in tobacco-related malignancies, the incidence of non-smoking related lung cancer is on the rise and disproportionately affecting women. Recent research studies have unveiled critical differences between men and women with regard to risk factors, timeliness of diagnosis, incongruent screening practices, molecular and genetic mechanisms, as well as response to treatment and survival. These studies also highlight the increasingly recognized need for targeted therapies that account for variations in the response and complications as a function of gender. Similarly, screening recommendations continue to evolve as the role of gender is starting to be ellucidated. As women have been underrepresented in clinical trials until recently, the data regarding optimal care and outcomes is still lagging behind. Understanding the underlying similarities and differences between men and women is paramount to providing adequate care and prognostication to patients of either gender. This review provides an overview of the critical role that gender plays in the care of patients with non-small cell lung cancer and other thoracic malignancies, with an emphasis on the need for increased awareness and further research to continue elucidating these disparities.

Intraoperative molecular imaging clinical trials: a review of 2020 conference proceedings

SIGNIFICANCE

Surgery is often paramount in the management of many solid organ malignancies because optimal resection is a major factor in disease-specific survival. Cancer surgery has multiple challenges including localizing small lesions, ensuring negative surgical margins around a tumor, adequately staging patients by discriminating positive lymph nodes, and identifying potential synchronous cancers. Intraoperative molecular imaging (IMI) is an emerging potential tool proposed to address these issues. IMI is the process of injecting patients with fluorescent-targeted contrast agents that highlight cancer cells prior to surgery. Over the last 5 to 7 years, enormous progress has been achieved in tracer development, near-infrared camera approvals, and clinical trials. Therefore, a second biennial conference was organized at the University of Pennsylvania to gather surgical oncologists, scientists, and experts to discuss new investigative findings in the field. Our review summarizes the discussions from the conference and highlights findings in various clinical and scientific trials.

AIM

Recent advances in IMI were presented, and the importance of each clinical trial for surgical oncology was critically assessed. A major focus was to elaborate on the clinical endpoints that were being utilized in IMI trials to advance the respective surgical subspecialties.

APPROACH

Principal investigators presenting at the Perelman School of Medicine Abramson Cancer Center's second clinical trials update on IMI were selected to discuss their clinical trials and endpoints.

RESULTS

Multiple phase III, II, and I trials were discussed during the conference. Since the approval of 5-ALA for commercial use in neurosurgical malignancies, multiple tracers and devices have been developed to address common challenges faced by cancer surgeons across numerous specialties. Discussants also presented tracers that are being developed for delineation of normal anatomic structures that can serve as an adjunct during surgical procedures.

CONCLUSIONS

IMI is increasingly being recognized as an improvement to standard oncologic surgical resections and will likely advance the art of cancer surgery in the coming years. The endpoints in each individual surgical subspecialty are varied depending on how IMI helps each specialty solve their clinical challenges.

Local negative permittivity and topological phase transition in polar skyrmions

Topological solitons such as magnetic skyrmions have drawn attention as stable quasi-particle-like objects. The recent discovery of polar vortices and skyrmions in ferroelectric oxide superlattices has opened up new vistas to explore topology, emergent phenomena and approaches for manipulating such features with electric fields. Using macroscopic dielectric measurements, coupled with direct scanning convergent beam electron diffraction imaging on the atomic scale, theoretical phase-field simulations and second-principles calculations, we demonstrate that polar skyrmions in (PbTiO₃)_n/(SrTiO₃)_n superlattices are distinguished by a sheath of negative permittivity at the periphery of each skyrmion. This enhances the effective dielectric permittivity compared with the individual SrTiO₃ and PbTiO₃ layers. Moreover, the response of these topologically protected structures to electric field and temperature shows a reversible phase transition from the skyrmion state to a trivial uniform ferroelectric state, accompanied by large tunability of the dielectric permittivity. Pulsed switching measurements show a time-dependent evolution and recovery of the skyrmion state (and macroscopic dielectric response). The interrelationship between topological and dielectric properties presents an opportunity to simultaneously manipulate both by a single, and easily controlled, stimulus, the applied electric field.

Use of endoscopic ultrasound in pre-treatment staging of esophageal cancer did not alter management plan

Background

Initial staging of esophageal cancer relies on EUS in addition to FDG-PET/CT. It is our hypothesis that with the advancement of FDG-PET/CT staging, endoscopic ultrasound may not be required for initial staging in all cases. The purpose of this study is to analyze whether EUS affects initial treatment stratification in patients diagnosed with esophageal cancer.

Methods

A retrospective database at the University of Virginia was queried for patients diagnosed with esophageal squamous cell carcinoma and adenocarcinoma who underwent EGD with EUS and FDG-PET/CT at their initial evaluation from 10/2013 to 5/2017. Two thoracic surgeons were asked to determine appropriate management for each case. Options included surgical resection, neoadjuvant chemoradiotherapy followed by resection, definitive chemoradiotherapy, or chemotherapy with or without palliative radiation. Both surgeons received the FDG-PET/CT report along with the EGD report. For each case, one or both surgeons were randomly allocated to review EUS results in addition to the clinical information. The treatment decisions of each thoracic surgeon were compared to determine if EUS reports impacted clinical management. Simple and weighted correlation coefficients (kappa) were calculated to compare agreement of treatment choices between the two surgeons using McNemars test. Conditional logistic regression was used to assess the influence of EUS on the treatment recommendations.

Results

A total of 50 patients (44 male and 6 female) were enrolled and data was collected. The thoracic surgeons agreed on treatment decisions in 39 cases and disagreed on 11 cases. Agreement between surgeons was good despite lack of EUS information for one surgeon on each case (weighted Kappa =0.73, 95% CI: 0.57-0.89). Using conditional logistic regression, EUS did not have a statistically independent association with agreement on treatment plan (P for model =0.17).

Conclusions

EUS did not have a statistically independent association with agreement on treatment plan for newly diagnosed esophageal cancer (P for model =0.17). Our findings suggest that EUS may not be necessary in the algorithm for the initial staging of every case of esophageal cancer. Selective, rather than mandatory use of EUS seems warranted.

Striving toward Improved Outcomes for Surgically Resectable Non-Small Cell Lung Cancer: the Promise and Challenges of Neoadjuvant Immunotherapy

PURPOSE OF REVIEW

Immunotherapy has revolutionized the treatment of non-surgical stage III and stage IV non-small cell lung cancer (NSCLC). Here, we review emerging data on the safety, feasibility, and efficacy of neoadjuvant immunotherapy in the setting of earlier stage surgically resectable lung cancer.

RECENT FINDINGS

Several small studies support the safety and feasibility of neoadjuvant immunotherapy, noting similar perioperative rates of morbidity and mortality compared with historical controls. Data from several phase II trials have shown high rates of major pathologic response (MPR), though it is unclear if this will correlate with a survival benefit. Phase III trials of neoadjuvant immunotherapy alone or in combination with chemotherapy are ongoing. Neoadjuvant immunotherapy offers a promising treatment modality in earlier stage NSCLC patients. Results of ongoing phase II and phase III trials will be essential in determining how to best integrate this treatment modality in the future.

Enhanced Recovery after Thoracic Surgery

Enhanced recovery programs (ERPs) aim to reduce psychological and physiological stress related to surgery, and minimize opioid use. This article describes the tenets of enhanced recovery, the guidelines for ERP in lung surgery, and the University of Virginia experience with developing and implementing a program. The impact of these strategies on short-term patient outcomes and potential long-term benefits including influence on lung cancer-specific outcomes are reviewed. The opioid crisis is of utmost importance; this article will explore how ERPs may be a mitigating factor.

Is less really more? Reexamining video-assisted thoracoscopic versus open lobectomy in the setting of an enhanced recovery protocol

OBJECTIVES

Video-assisted thoracoscopic surgery lobectomy has been associated with improved pain, length of stay, and outcomes compared with open lobectomy. However, enhanced recovery protocols improve outcomes after both procedures. We aimed to compare video-assisted thoracoscopic surgery and open lobectomy in the setting of a comprehensive enhanced recovery protocol.

METHODS

All patients undergoing lobectomy for lung cancer at a single institution since the adoption of an enhanced recovery protocol (May 2016 to December 2018) were stratified by video-assisted thoracoscopic surgery versus open status and compared. Demographics and outcomes, including length of stay, daily pain scores, and short-term operative complications, were compared using standard univariate statistics and multivariable models.

RESULTS

A total of 130 patients underwent lobectomy, including 71 (54.6%) undergoing video-assisted thoracoscopic surgery and 59 (45.4%) undergoing open surgery. Video-assisted thoracoscopic surgery versus open cases exhibited similar length of stay (median 4 days for both, P = .07), opioid requirement (33.2 vs 30.8 mg morphine equivalents, P = .86), and pain scores at 0, 1, 2, and 3 days after surgery (4.3 vs 2.8, P = .12; 4.4 vs 3.7, P = .27; 3.9 vs 3.5, P = .83; and 3.4 vs 3.5, P = .98, respectively). Patients undergoing video-assisted thoracoscopic surgery lobectomy exhibited lower rates of readmission (1.4% vs 17.0%, P < .01), postoperative transfusion requirement (0% vs 10.2%, P < .01), and pneumonia (1.4% vs 10.2%, P = .05). After risk adjustment, an open procedure (vs video-assisted thoracoscopic surgery status) did not significantly affect the length of stay (effect 0.18; P = .10) or overall complication rate (odds ratio, 1.9; P = .12).

CONCLUSIONS

In the setting of a comprehensive enhanced recovery protocol, patients undergoing video-assisted thoracoscopic surgery versus open lobectomy exhibited similar short-term outcomes. Surgical incision may have less impact on outcomes in the setting of a comprehensive thoracic enhanced recovery protocol.

How Many Nodes Need to be Removed to Make Esophagectomy an Adequate Cancer Operation, and Does the Number Change When a Patient has Chemoradiotherapy Before Surgery?

INTRODUCTION AND DESIGN

Node dissection during esophagectomy is an important aspect of esophageal cancer staging. Controversy remains as to how many nodes need to be resected in order to properly stage a patient and whether the removal of more nodes carries a stage-independent survival benefit. A review of the literature performed by a group of experts in the subject may help define a minimum accepted number of lymph nodes to be resected in both primary surgery and post-induction therapy scenarios.

RESULTS AND CONCLUSIONS

The existing evidence generally supports the goal of obtaining a minimum of 15 lymph nodes for pathological examination in both primary surgery and post-induction therapy scenarios.

Optical creation of a supercrystal with three-dimensional nanoscale periodicity

Stimulation with ultrafast light pulses can realize and manipulate states of matter with emergent structural, electronic and magnetic phenomena. However, these non-equilibrium phases are often transient and the challenge is to stabilize them as persistent states. Here, we show that atomic-scale PbTiO₃/SrTiO₃ superlattices, counterpoising strain and polarization states in alternate layers, are converted by sub-picosecond optical pulses to a supercrystal phase. This phase persists indefinitely under ambient conditions, has not been created via equilibrium routes, and can be erased by heating. X-ray scattering and microscopy show this unusual phase consists of a coherent three-dimensional structure with polar, strain and charge-ordering periodicities of up to 30 nm. By adjusting only dielectric properties, the phase-field model describes this emergent phase as a photo-induced charge-stabilized supercrystal formed from a two-phase equilibrium state. Our results demonstrate opportunities for light-activated pathways to thermally inaccessible and emergent metastable states.

Kinetic control of tunable multi-state switching in ferroelectric thin films

Deterministic creation of multiple ferroelectric states with intermediate values of polarization remains challenging due to the inherent bi-stability of ferroelectric switching. Here we show the ability to select any desired intermediate polarization value via control of the switching pathway in (111)-oriented PbZr_0.2Ti_0.8O₃ films. Such switching phenomena are driven by kinetic control of the volume fraction of two geometrically different domain structures which are generated by two distinct switching pathways: one direct, bipolar-like switching and another multi-step switching process with the formation of a thermodynamically-stable intermediate twinning structure. Such control of switching pathways is enabled by the competition between elastic and electrostatic energies which favors different types of ferroelastic switching that can occur. Overall, our work demonstrates an alternative approach that transcends the inherent bi-stability of ferroelectrics to create non-volatile, deterministic, and repeatedly obtainable multi-state polarization without compromising other important properties, and holds promise for non-volatile multi-state functional applications.

The use of ferroeletric materials for multi-state device applications is still challenging. Here, the authors present a mechanism to stabilize non-volatile polarization states by populating volume fractions of two domain structures in PbZr_0.2Ti_0.8O₃ via kinetic control of switching pathways.

Ambipolar ferromagnetism by electrostatic doping of a manganite

Complex-oxide materials exhibit physical properties that involve the interplay of charge and spin degrees of freedom. However, an ambipolar oxide that is able to exhibit both electron-doped and hole-doped ferromagnetism in the same material has proved elusive. Here we report ambipolar ferromagnetism in LaMnO₃, with electron-hole asymmetry of the ferromagnetic order. Starting from an undoped atomically thin LaMnO₃ film, we electrostatically dope the material with electrons or holes according to the polarity of a voltage applied across an ionic liquid gate. Magnetotransport characterization reveals that an increase of either electron-doping or hole-doping induced ferromagnetic order in this antiferromagnetic compound, and leads to an insulator-to-metal transition with colossal magnetoresistance showing electron-hole asymmetry. These findings are supported by density functional theory calculations, showing that strengthening of the inter-plane ferromagnetic exchange interaction is the origin of the ambipolar ferromagnetism. The result raises the prospect of exploiting ambipolar magnetic functionality in strongly correlated electron systems.

Quantification of flexoelectricity in PbTiO3/SrTiO3 superlattice polar vortices using machine learning and phase-field modeling

Flexoelectricity refers to electric polarization generated by heterogeneous mechanical strains, namely strain gradients, in materials of arbitrary crystal symmetries. Despite more than 50 years of work on this effect, an accurate identification of its coupling strength remains an experimental challenge for most materials, which impedes its wide recognition. Here, we show the presence of flexoelectricity in the recently discovered polar vortices in PbTiO₃/SrTiO₃ superlattices based on a combination of machine-learning analysis of the atomic-scale electron microscopy imaging data and phenomenological phase-field modeling. By scrutinizing the influence of flexocoupling on the global vortex structure, we match theory and experiment using computer vision methodologies to determine the flexoelectric coefficients for PbTiO₃ and SrTiO₃. Our findings highlight the inherent, nontrivial role of flexoelectricity in the generation of emergent complex polarization morphologies and demonstrate a viable approach to delineating this effect, conducive to the deeper exploration of both topics.

Flexoelectric coupling between strain gradients and polarization influences the physics of ferroelectric devices but it is difficult to directly probe its effects. Here, Li et al. use principal component analysis to compare STEM images with phase-field modeling and extract the flexoelectric contributions.