Management of Major Complications After Esophagectomy

Esophagectomy remains a procedure with one of the highest complication rates. Given the advances in medical and surgical management of patients and increased patient survival, the number of complications reported has increased. There are different grading systems for complications which vary based on severity or organ system, with the Esophageal Complications Consensus Group unifying them. Management involves conservative intervention and dietary modification to endoscopic interventions and surgical reintervention. Treatment is etiology specific but rehabilitation and patient optimization play a significant role in managing these complications by preventing them. Management is a step-up approach depending on the severity of symptoms.

Quality of Life and Real-time Patient Experience During Neoadjuvant Therapy: A Prospective Cohort Study

OBJECTIVE

To use a customized smartphone application to prospectively measure QOL and the real-time patient experience during neoadjuvant therapy (NT).

BACKGROUND

NT is increasingly used for patients with localized gastrointestinal (GI) cancers. There is little data assessing patient experience and quality of life (QOL) during NT for GI cancers.

METHODS

Patients with GI cancers receiving NT were instructed on using a customized smartphone application through which the Functional Assessment of Cancer Therapy-General (FACT-G) questionnaire, a validated measure of health-related QOL, was administered at baseline, every 30 days, and at the completion of NT. Participants also tracked their moods and symptoms and used free-text journaling functionalities in the application. Mean overall and subsection health-related QOL scores were calculated during NT.

RESULTS

Among 104 enrolled patients, the mean age was 60.5 ± 11.5 years and 55% were males. Common cancer diagnoses were colorectal (40%), pancreatic (37%), and esophageal (15%). Mean overall FACT-G scores did not change during NT ( P = 0.987). While functional well-being scores were consistently the lowest and social well-being scores the highest, FACT subscores similarly did not change during NT (all P > 0.01). The most common symptoms reported during NT were fatigue, insomnia, and anxiety (39.3%, 34.5%, and 28.3% of patient entries, respectively). Qualitative analysis of free-text journaling entries identified anxiety, fear, and frustration as the most common themes, but also the importance of social support systems and confidence in health care providers.

CONCLUSIONS

While patient symptom burden remains high, results of this prospective cohort study suggest QOL is maintained during NT for localized GI cancers.

Sublobar Resection vs Lobectomy for Stage IA Non-Small Cell Lung Carcinoma-Takeaways From Modern Randomized Trials

Sublobar resection for early-stage non-small cell lung cancer has been an emerging topic of great interest to thoracic surgeons. However, data regarding the efficacy and safety of sublobar resection vs lobectomy was lacking until now. Recently, 3 published randomized controlled trials (Cancer and Leukemia Group B [CALGB]140503/Alliance, Japan Clinical Oncology Group [JCOG]0802 and Das Deutsche Register Klinischer Studien [DRKS]00004897) confirmed the noninferiority of sublobar resection for early-stage non-small cell lung cancer in carefully selected populations. This review aims to summarize and compare these 3 landmark trials and inform surgeons of new best practices.

Perioperative Immunotherapy for Node-Negative Non-Small Cell Lung Cancer-Current Evidence and Future Directions

Neoadjuvant immunotherapy has gone from an idea to an indication in locally advanced lung cancer. Several phase III trials have demonstrated the superiority of neoadjuvant chemoimmunotherapy compared with chemotherapy in this setting. Although such progress has revolutionized the treatment of locally advanced disease, the unmet needs of stage I and stage II patients without lymph node disease have largely been underrepresented in existing trials. Up-front resection with few patients going on to complete adjuvant therapy remains the norm for most stage I and II patients. Emerging evidence now supports the exploration of supplemental checkpoint blockade in well-selected early-stage, node-negative patients with large tumors and no actionable driver mutations. Although concerns surrounding safety and risk exist, patient selection could be substantially improved using novel biomarker approaches that leverage our understanding of the tumor immune microenvironment of lung cancer. This review provides a comprehensive overview of the opportunities and controversies of perioperative immunotherapy in node-negative lung cancer.

Surgeon Perspectives on the Management of Aborted Cancer Surgery: Results of a Society of Surgical Oncology Member Survey

BACKGROUND

While surgery is generally necessary for most solid-organ cancers, curative-intent resection is occasionally aborted due to unanticipated unresectability or occult metastases. Following aborted cancer surgery (ACS), patients have unique and complex care needs and yet little is known about the optimal approach to their management.

OBJECTIVE

The aim of this study was to define the practice patterns and perspectives of an international cohort of cancer surgeons on the management of ACS.

METHODS

A validated survey assessing surgeon perspectives on patient care needs and management following ACS was developed. The survey was distributed electronically to members of the Society of Surgical Oncology (SSO).

RESULTS

Among 190 participating surgeons, mean age was 49 ± 11 years, 69% were male, 61% worked at an academic institution, and most had a clinical practice focused on liver/pancreas (30%), breast (23%), or melanoma/sarcoma cancers (20%). Participants estimated that ACS occurred in 7 ± 6% of their cancer operations, most often due to occult metastases (67%) or local unresectability (30%). Most surgeons felt (very) comfortable addressing their patients' surgical needs (92%) and cancer treatment-related questions (90%), but fewer expressed comfort addressing psychosocial needs (83%) or symptom-control needs (69%). While they perceived discussing next available therapies as the patients' most important priority after ACS, surgeons reported avoiding postoperative complications as their most important priority (p < 0.001). While 61% and 27% reported utilizing palliative care and psychosocial oncology, respectively, in these situations, 46% noted care coordination as a barrier to addressing patient care needs.

CONCLUSIONS

Results from this SSO member survey suggest that ACS is relatively common and associated with unique patient care needs. Surgeons may feel less comfortable assessing psychosocial and symptom-control needs, highlighting the need for novel patient-centered approaches.

National learning curves among robotic thoracic surgeons in the United States: Quantifying the impact of procedural experience on efficiency and productivity gains

OBJECTIVE

This study aims to characterize the aggregate learning curves of US surgeons for robotic thoracic procedures and to quantify the impact on productivity.

METHODS

National average console times relative to cumulative case number were extracted from the My Intuitive application (Version 1.7.0). Intuitive da Vinci robotic system data for 56,668 lung resections performed by 870 individual surgeons between 2021 and 2022 were reviewed. Console time and hourly productivity (work relative value units/hour) were analyzed using linear regression models.

RESULTS

Average console times improved for all robotic procedures with cumulative case experience (P = .003). Segmentectomy and thymectomy had the steepest initial learning curves with a 33% and 34% reduction of the average console time for proficient (51-100 cases) relative to novice surgeons (1-10 cases), respectively. The hourly productivity increase for proficient surgeons ranged from 11.4 work relative value units/hour (+26%) for lobectomy to 17.0 work relative value units/hour (+50%) for segmentectomy. At the expert level (101+ cases), average console times continued to decrease significantly for esophagectomy (-18%) and lobectomy (-23%), but only minimally for wedge resections (-1%) (P = .003). The work relative value units/hour increase at the expert level reached 50% for lobectomy and 40% for esophagectomy. Surgeon experience level, dual console use, system model, and robotic stapler use were factors independently associated with console time for robotic lobectomy.

CONCLUSIONS

The aggregate learning curve for robotic thoracic surgeons in the United States varies significantly by procedure type and demonstrate continued improvements in efficiency beyond 100 cases for lobectomy and esophagectomy. Improvements in efficiency with growing experiences translate to substantial productivity gains.

Pedicled osteomyocutaneous pectoralis major flap with osseous rib harvest for salvage mandibular reconstruction: Case and technique

In the era of free flap reconstruction, mandibular defects are routinely reconstructed with osseous free flaps, and non-free flap bony reconstruction options are limited. A patient with T4N0 mandibular squamous cell carcinoma underwent resection with fibula free flap reconstruction of a parasymphyseal to angle defect. After free flap failure due to venous congestion, the flap was explanted. He declined additional free flap reconstruction and elected to proceed with pedicled osteomyocutaneous pectoralis major with rib. In this case presentation, we discuss the technical details of harvest of this flap using the 6th rib. The pedicled osteomyocutaneous pectoralis major flap with osseous rib harvest, which is infrequently described in the literature, remains a viable option for bony reconstruction, particularly in the salvage setting.

Advances in the clinical use of patient-reported outcomes in thoracic surgery

PURPOSE OF REVIEW

Patient-reported outcomes (PROs) are increasingly recognized as a clinical tool for measuring and improving patient-centric care. This review provides a summary on recent advances in the use of PROs in the field of thoracic surgery.

RECENT FINDINGS

PROs have been used as primary endpoints in clinical trials and observational studies evaluating clinical care pathways and quantifying the benefits of minimally invasive surgical techniques for patients undergoing lung surgery. Qualitative and quantitative research has yielded fundamental insights into which PRO domains are meaningful and valued by patients after lung surgery. Patient experience and recovery after esophagectomy have been further characterized by using PROs. New disease-specific survey tools for patients have been developed to track long-term symptoms after esophageal reconstruction. Patient satisfaction has emerged as the key metric used to gauge the patient centeredness of hospital systems.

SUMMARY

Advances have been made in the application of PROs in multiple areas of thoracic surgery, which include lung and esophageal surgery. The growing focus on the use of PROs in clinical pathways has led to a better understanding on how to optimize patient experience.

Single Anesthesia Strategy for Definitive Management of Bilateral Ground Glass Opacities Using Robotic Bronchoscopic Localization and Resection

This case series describes 2 patients who underwent a single anesthesia strategy for definitive management of bilateral ground-glass opacities harboring adenocarcinoma-spectrum lesions using robotic navigational localization paired with robotic thoracoscopic resection.

Prevalence and Predictability of Occult Satellite Nodules in Clinical Stage Ia Non-small Cell Lung Cancer following Lobectomy

INTRODUCTION

We sought to assess the prevalence and clinical predictors of satellite nodules in patients undergoing lobectomy for clinical stage Ia disease.

PATIENTS AND METHODS

The National Cancer Database was queried for patients who underwent lobectomy for clinical stage cT1N0 NSCLC. Collaborative staging information was used to identify patients who were pathologically upstaged based on having separate tumor nodules in the same lobe as the primary tumor. Multivariable logistic regression was used to assess the association of clinical factors with the detection of separate nodules.

RESULTS

A separate tumor nodule was recorded in 2.8% (n = 1284) of 45,842 clinical stage Ia patients treated with lobectomy or bilobectomy. Female gender (3.1% vs. male 2.5%; P = .002) and non-squamous histology (adenocarcinoma 3.2% and large cell neuroendocrine 3.0% vs. squamous cell 1.9% tumors; P < .001) were associated with the presence of separate nodules. The frequency increased for tumors larger than 3 cm (≤ 3cm, 2.7% vs. > 3cm, 3.8%; P < .001). Other factors associated with separate nodules were upper lobe location, pleural and/or lymphovascular invasion and occult lymph node disease. The best predictive model for separate nodules based on the available clinical variables resulted in an area under the curve of 0.645 (95% CI 0.629-0.660).

CONCLUSION

Separate tumor nodules may be detected with a low but relatively consistent frequency across the spectrum of patients with clinical stage Ia NSCLC. The predictive ability using basic clinical factors in the database is limited.

Case report: Pulmonary synovial sarcoma in a long-term survivor of childhood Hodgkin lymphoma

Solid organ malignancies have been reported in survivors of Hodgkin lymphoma treated with chemoradiation; however, to the best of our knowledge no cases of pulmonary synovial sarcoma have been documented in the literature in this cohort. We herein provide a detailed description of synovial sarcoma occurring in the lung of a long-term survivor of childhood Hodgkin lymphoma. A 29-year-old female never smoker with past medical history of Hodgkin lymphoma diagnosed at the age of 7 years and treated with chemotherapy and radiation therapy was admitted for management of pneumothorax. Wedge lung resection of an ulcerated subpleural nodule revealed a malignant spindle cell tumor that based on light microscopic and immunohistochemical features was classified as monophasic synovial sarcoma. The diagnosis was further confirmed by identification of SS18 (SYT) rearrangement by fluorescence in situ hybridization and SS18-SSX1 gene fusion by RNA sequencing. The case documents a rare occurrence of synovial sarcoma in a long-term survivor of childhood Hodgkin lymphoma. While comprising a typical genetic profile for synovial sarcoma, the tumor had unusual histological features such as cystic and low-grade morphology. The case suggests that synovial sarcoma falls within an expanding spectrum of secondary malignancies following prior treatment of Hodgkin lymphoma.

Lymph Node Upstaging for Robotic, Thoracoscopic, and Open Lobectomy for Stage T2-3N0 Lung Cancer

BACKGROUND

There may be equivalent efficacy of the lymph node evaluation for minimally invasive lobectomy compared with open lobectomy for stage I non-small cell lung cancer. We sought to compare the lymph node evaluation for lobectomy by approach for patients with larger tumors who are clinically node negative.

METHODS

This retrospective study analyzed 24 257 patients with clinical stage T2-3N0M0 non-small cell lung cancer from the National Cancer Database. Inverse probability of treatment weighting (IPTW) was applied to balance baseline characteristics. The rates of pathologic lymph node upstaging were compared. A Cox multivariable regression model was performed to test the association with overall survival.

RESULTS

After IPTW adjustment 20 834 patients were included in the analysis. Of these, 1996 patients underwent robotic lobectomy, 5122 patients underwent thoracoscopic lobectomy, and 13 725 patients underwent open lobectomy from 2010 to 2017. The IPTW-adjusted N1 upstaging rate was similar for robotic (11.79%), thoracoscopic (11.49%), and open (11.85%) lobectomy (P = .274). The adjusted N2 upstaging rates were 5.03%, 5.66%, and 6.15% for robotic, thoracoscopic, and open lobectomy, respectively (P = .274). On IPTW-adjusted multivariable analysis, robotic and thoracoscopic lobectomy were associated with improved survival compared with open lobectomy (P < .001).

CONCLUSIONS

There was no significant difference in N1 and N2 lymph node upstaging rates between surgical approaches for patients with clinical stage T2-3N0 non-small cell lung cancer, indicating similarly effective lymph node evaluation. Overall survival after robotic and thoracoscopic lobectomy was significantly better compared with open lobectomy in this patient population with a high propensity for occult nodal disease.

Preventable operating room delays in robotic-assisted thoracic surgery: Identifying opportunities for cost reduction

BACKGROUND

This study aimed to characterize the types of intraoperative delays during robotic-assisted thoracic surgery, operating room staff awareness/perceptions of delays, and cost impact of delays on overall operative costs.

METHODS

Robotic-assisted thoracic surgery cases from May to August 2019 were attended by 3 third-party observers to record intraoperative delays. The postoperative surveys were given to operating room staff to elicit perceived delays. Observed versus perceived delays were compared using the McNemar test. Direct costs and charges per delay were calculated.

RESULTS

Forty-four cases were observed, of which a majority were lobectomies (n = 38 [86%]). A total of 71 delays were recorded by observers, encompassing 75% of cases (n = 33), with an average delay length of 3.6 minutes (±5.3 minutes). The following delays were observed: equipment failure (n = 40, average delay length 5.0 minutes (±6.5 minutes), equipment missing (n = 15, 2.2 minutes [±1.4 minutes]), staff unfamiliarity with equipment (n = 4, 3.4 minutes [± 1.5 minutes]), and other (n = 12, 4.5 minutes [±5.3 minutes]). The detection rates for any intraoperative delay were consistently lower for all of the operating room team members compared with observers, including surgeons (34.3% vs 77.1%; P = .0003), first assistants (41.9% vs 74.2%; P = .0075), surgical technologists (39.4% vs 72.7%; P = .0045), and circulating nurses (41.18% vs 76.47% minutes; P = .0013). The average operating room variable direct cost of delays based on the average total delay length per case was $225.52 (±$350.18) and was 1.6% (range 0-10.6%) of the total case charges.

CONCLUSION

The lack of perception of intraoperative delays hinders operating teams from effectively closing the variable cost gaps. Future studies are needed to explore methods of increasing perception of delays and opportunities to improve operating room efficiency.

Wedge Resection Versus Lobectomy for Clinical Stage IA NSCLC with Occult Lymph Node Disease

BACKGROUND

Sublobar resection is increasingly performed for stage Ia non-small cell lung cancer (NSCLC), but pathologic lymph node upstaging remains a common clinical scenario. This study compares the long-term prognosis of patients with clinical stage Ia disease and occult lymph node disease undergoing wedge resection versus lobectomy.

METHODS

The National Cancer Database was queried for patients treated with wedge resection or lobectomy for clinical stage Ia (cT1N0) NSCLC and who were pathologically upstaged with either pN1/pN2 disease. Overall survival (OS) was compared by extent of resection using inverse probability of treatment weight (IPTW) adjusted Cox regression analyses.

RESULTS

A total of 5,437 clinical stage Ia patients with were included, who were found to have occult pN1 (n= 3,408, 62.7%) or pN2 (n= 2,029, 37.3%). The majority of patients were treated with lobectomy (n=5,082, 93.5%) and 6.5% of patients underwent wedge resection (n=355). Lobectomy was associated with improved OS compared to wedge resection for patients with occult pN1 disease (median OS, 70.0 (95% CI:66.6-77.4) months vs. 36.4 (95% CI:24.2-45.6) months, p<0.001), but not for pN2 disease (median OS, 48.2.1 (95% CI:43.8-52.9) months vs. 43.7 (95%CI:31.2-62.4) months, p=00.24). On IPTW adjusted multivariable analysis, adjusting for demographics, comorbidities, margin status and pathologic T and N-stage, lobectomy remained associated with improved survival (adjusted hazard ratio 0.73 (95% CI:0.60-0.89; p=0.0016).

CONCLUSIONS

Lobectomy is associated with improved survival in clinical stage Ia NSCLC patients with occult lymph node disease. These data may aid the decision for completion lobectomy for patients with unanticipated N1 lymph node upstaging.

Analysis of trends in perioperative outcomes in over 1000 robotic-assisted anatomic lung resections

Robotic-assisted surgery is gaining popularity as a minimally invasive approach for anatomic lung resection. We investigated the temporal changes in case volume, costs, and postoperative outcomes for robotic-assisted anatomic lung resection in over 1000 cases. We reviewed our institutional STS database for patients who had undergone robotic-assisted lobectomy, bi-lobectomy, or segmentectomy as the primary procedure between years 2009-2021. The patients were divided into two groups: first 500 cases (n = 501) and second 500 cases (n = 500). Temporal trends of case volume, surgical indications, hospital length of stay, costs, and perioperative outcomes were analyzed. A total of 1001 patients were analyzed, of which 968 (96.7%) patients underwent robotic-assisted lobectomy, 21 (2.1%) patients underwent bi-lobectomy, 10 (1.0%) patients underwent segmentectomy, and 3 (0.3%) patients underwent sleeve lobectomy. Primary lung cancer was the most common indication (87.7%), followed by metastatic lung tumors (7.1%), and benign diagnosis (5.2%). The overall postoperative complication rate decreased from 46.1% for the first 500 cases compared to 29.6% for the second 500 cases (p < 0.0001). The median hospital length of stay was down trending, which was 4 days [IQR: 3-7] for the first 500 cases and 3 days [IQR: 3-5] (p = 0.0001) for the second. The inflation-adjusted direct and indirect hospital costs were significantly lower in the second 500 cases (p < 0.0001). The complications rates, hospital costs, and hospital length of stay for robotic-assisted anatomic pulmonary resection decreased significantly over time at a single institution. Continuous improvement in perioperative outcomes may be observed with increasing institutional experience.

National Trends and Outcomes of Segmentectomy in the Society of Thoracic Surgeons Database

BACKGROUND

Segmentectomy is gaining popularity as a parenchyma-sparing alternative for anatomic lung resection. This study sought to investigate temporal changes in patient selection, case volume, and outcomes for segmentectomy using the Society of Thoracic Surgeons (STS) National Database.

METHODS

The STS General Thoracic Database was queried for patients who had undergone segmentectomy as the primary procedure between 2002 and 2018. The American College of Surgeons Oncology Group definition of high-risk patients on the basis of pulmonary function and major cardiovascular comorbidities was applied. Annual trends of case volume, patient risk profile, surgical indication, approach, and outcomes were analyzed.

RESULTS

A total of 10 629 patients were analyzed from 310 contributing centers. The annual segmentectomy volume more than doubled from <4 per center in 2009 to 8.6 per center by 2017. Lung cancer was the most common indication (70.1%), followed by benign disease (15.6%) and metastatic tumors (14.3%). Although the operative indication remained constant, the subset of high-risk patients (24.5%) decreased gradually over time (slope, -0.6% per year; P = .001). After 2012, segmentectomies were most commonly performed minimally invasively (video-assisted thoracoscopic surgery, 58.3%; robotic surgery, 19.4%), with a steadily declining use of thoracotomy (overall, 22.3%; slope, -2.4%/y; P = .001). Overall complication rates decreased over the study period from 41.7% to 26.1% (slope, -0.57%/y; P = .001). The overall major complication rate was 4.6% (range, 2.0%-7.1%), 30-day mortality was 1.0% (range, 0.7%-5.0%), and both have been trending downward since 2009 (P = .01).

CONCLUSIONS

Segmentectomies are increasingly performed nationally, with a steady decline in the subset of high-risk patients over time. Complication rates have decreased significantly, parallel to the increasing use of minimally invasive techniques by video-assisted thoracoscopic surgery and robotic surgery.

Segmentectomy for clinical stage I non-small cell lung cancer: National benchmarks for nodal staging and outcomes by operative approach

BACKGROUND

Segmentectomy is increasingly used for parenchyma sparing anatomical resection for small stage I non-small cell lung cancer (NSCLC). This study characterizes the national outcomes for lymph node assessment and perioperative outcomes of segmentectomy for clinical stage I NSCLC by robotic-assisted surgery (RATS), video-assisted thoracoscopic surgery (VATS), and open thoracotomy approach.

METHODS

A retrospective cohort study was conducted of patients who underwent segmentectomy for clinical stage I NSCLC captured in the national Society of Thoracic Surgeons General Thoracic Surgery Database between years 2012 and 2018. Inverse probability of treatment weighting (IPTW) was used to balance baseline characteristics. Lymph node (LN) staging and 30-day outcomes were compared by approach.

RESULTS

A total of 3680 patients (VATS 61.9%, RATS 20%, open 18%) underwent segmentectomy. The IPTW adjusted rate of pathologic LN upstaging (pN1/pN2) was 6.2% (RATS 6.3%, VATS 5.6%, open 8.6%; P = .05). On multivariate analysis, there was no differences in pN1/N2 upstaging between RATS (odds ratio [OR], 0.81; 95% confidence interval [CI], 0.44-1.49) or VATS (OR, 0.96; 95% CI, 0.57-1.63) with open segmentectomy. The RATS and VATS approach was associated with fewer postoperative events (RATS 31.3%, VATS 28.8%, open 38.3%; P < .001) and shorter length of stay (RATS 4.3 days, VATS 4.4 days, open 5.2 days; P < .001) as compared with thoracotomy. RATS segmentectomy-specific complications included a higher rate of pneumothorax after chest tube removal and discharge with chest tube. Major complications were lower after RATS and VATS as compared with open segmentectomy (RATS 5.9%, VATS 4.5%, open 7.2%; P = .028).

CONCLUSIONS

Segmentectomy by VATS and robotic approach resulted in similar high rates of lymph node upstaging as a global marker of the quality of lymph node dissection and were associated with lower overall morbidity and shorter length of stay as compared with open thoracotomy. These national outcomes may serve as benchmarks for future comparative studies.

Comparative analysis of long-term oncologic outcomes for minimally invasive and open Ivor Lewis esophagectomy after neoadjuvant chemoradiation: a propensity score matched observational study

BACKGROUND

Locally advanced esophageal carcinoma is typically treated with neoadjuvant chemoradiation and esophagectomy (trimodality therapy). We compared the long-term oncologic outcomes of minimally invasive Ivor Lewis esophagectomy (M-ILE) cohort with a propensity score weighted cohort of open Ivor Lewis esophagectomy (O-ILE) cases after trimodality therapy.

METHODS

This is a retrospective review of 223 patients diagnosed with esophageal carcinoma who underwent neoadjuvant chemoradiation followed by M-ILE or O-ILE from April 2009 to February 2019. Inverse probability of treatment weighting (IPTW) adjustment was used to balance the baseline characteristics between study groups. Kaplan-Meier survival curves were calculated for overall survival and recurrence-free survival comparing the two groups. Multivariate Cox proportional hazards regression models were used to determine predictive variables for overall and recurrence-free survival.

RESULTS

The IPTW cohort included patients with esophageal carcinoma who underwent M-ILE (n = 142) or O-ILE (n = 68). The overall rate of postoperative adverse events was not significantly different after IPTW adjustment between the O-ILE and M-ILE trimodality groups (53.4% vs. 39.2%, p = 0.089). The 3-year overall survival (OS) for the M-ILE group was 59.4% (95% CI: 49.8-67.8) compared to 55.7% (95% CI: 39.2-69.4) for the O-ILE group (p = 0.670). The 3-year recurrence-free survival for the M-ILE group was 59.9% (95% CI: 50.2-68.2) compared to 61.6% (95% CI: 41.9-76.3) for the O-ILE group (p = 0.357). A complete response to neoadjuvant chemoradiation was significantly predictive of improved OS and RFS.

CONCLUSION

The overall and recurrence-free survival rates for M-ILE were not significantly different from O-ILE for esophageal carcinoma after trimodality therapy. Complete response to neoadjuvant chemoradiation was predictive of improved overall and recurrence- free survival.

Linear Endobronchial Ultrasound in the Era of Personalized Lung Cancer Diagnostics-A Technical Review

Major advances in molecular profiling for available targeted treatments and immunotherapy for lung cancer have significantly increased the complexity of tissue-based diagnostics. Endobronchial ultrasound-guided transbronchial needle aspirations (EBUS-TBNA) are commonly performed for diagnostic biopsies and lymph node staging. EBUS-TBNA has increasingly become one of the main sources of tumor cells for molecular analyses. As a result, there is a growing need for high quality EBUS-TBNA samples with adequate cellularity. This has increased the technical demands of the procedure and has created additional challenges, many of which are not addressed in the current EBUS guidelines. This review provides an overview of current evidence on the technical aspects of EBUS-TBNA in light of comprehensive sample processing for personalized lung cancer management. These include sonographic lymph node characterization, optimal needle choice, suction biopsy technique, and the role of rapid on-site evaluation. Attention to these technical details will be important to maximize the throughput of EBUS-TBNA biopsies for molecular testing.

A simplified model for determining the cutting plane during thoracoscopic anatomical partial lobectomy of the right lower lobe

Background

Few studies have examined the use of two-dimensional computed tomography (2D CT) and three-dimensional (3D) reconstruction images to determine the intersegmental plane (ISP) for pulmonary segmentectomy, but a systematic approach and nomenclature are currently lacking. This current study used 3D reconstruction of CT imaging to analyze variations in the right lower lobe’s pulmonary ISP and created a simplified model to determine the optimum cutting plane (CP) for clinical application for operative planning and use during thoracoscopic anatomical partial lobectomy (APL).

Methods

Between January 2018 and October 2019, 325 patients with pulmonary lesions were identified who underwent thin-slice CT scans of the chest. The ISPs were identified by analyzing the 2D CT scans and 3D reconstruction images and the anatomical characteristics segmental boundary. The CP for the thoracoscopic procedure was then determined within the safe surgical margins, and a simplified CP model was created.

Results

The boundary between adjacent lung segment A and segment B was be expressed as “ISP: Sa-Sb”. The ISP was divided into venous ISP (VISP), arterial ISP (AISP), and bronchial ISP (BISP). The proposed model of the CP can be expressed as follows: CP (f) = (V/A/B) ISP (x) + (V/A/B) sub ISP (y) + (V/A/B) sub-sub ISP (z).

Conclusions

This report is a first attempt to provide a nomenclature for identifying the ISP, and create a simplified model for determining the CP for thoracoscopic partial lobectomy.

The Academic Facility Is Associated with Higher Utilization of Esophagectomy and Improved Overall Survival for Esophageal Carcinoma

BACKGROUND

Operable esophageal carcinoma is potentially curable with surgical resection. The short-term outcomes and overall survival rate for operable esophageal carcinoma may be impacted by the healthcare facility type where patients receive care.

METHODS

A total of 37, 271 cases with the American Joint Committee on Cancer clinical stage I, II, and III esophageal carcinoma that were reported to the National Cancer Data Base at over 12,721 facilities were analyzed. Healthcare facilities were dichotomized into the community and academic facility types. Marginal multivariable Cox proportional hazard models were used to evaluate differences in overall survival between facility types, which accounted for facility esophageal cancer volume. Propensity score methodology with inverse probability of treatment weighting was used to adjust for patient related baseline differences between facility types.

RESULTS

Patients with clinical stage I-III esophageal carcinoma who underwent esophagectomy at academic healthcare facilities had a significantly better overall survival compared with patients who underwent esophagectomy at community healthcare facilities [HR = 0.89: CI [0.84-0.95] (p = 0.0005)]. The rate of esophagectomy was significantly higher at the academic facilities (49.0% versus 26.5%; p < 0.0001). The 30-day and 90-day mortality rates for esophagectomy were significantly better for patients who underwent esophagectomy for esophageal cancer at the academic facility types.

CONCLUSION

Patients with clinical stage I-III esophageal carcinoma who received care at academic facility types had significantly better overall survival compared with community facility types. The utilization of esophagectomy was significantly higher and the short-term surgical outcomes were better for patients treated at academic facility types.

Racial disparities in provider recommendation for esophagectomy for esophageal carcinoma

BACKGROUND

Racial disparities currently exist for the utilization rate of esophagectomy for Black patients with operable esophageal carcinoma.

METHODS

A total of 37 271 cases with the American Joint Committee on Cancer clinical stage I, II, and III esophageal carcinoma that were reported to the National Cancer Database were analyzed between 2004 and 2016. A multivariable-adjusted logistic regression model was used to evaluate differences in the odds ratio of esophagectomy not being recommended based on race. Kaplan-Meier curves and log-rank tests were used to evaluate differences in overall survival. Propensity score methodology with inverse probability of treatment weighting (IPTW) was used to balance baseline differences in patient demographics.

RESULTS

After IPTW adjustment, we identified 30 552 White patients and 3529 Black patients with clinical stage I-III esophageal carcinoma. Black patients had three times greater odds of not being recommended for esophagectomy (odds ratio: 3.03, 95% confidence interval: 2.67-3.43, p < 0.0001) compared to White patients. Black patients demonstrated significantly worse 3- and 5-year overall survival rates compared to White patients (log-rank p < 0.0001).

CONCLUSION

Black patients with clinical stage I-III esophageal cancer were significantly less likely to be recommended for esophagectomy even after adjusting for baseline demographic covariates compared to White patients.

Pulmonary artery size on computed tomography is associated with major morbidity after pulmonary lobectomy

OBJECTIVE

To investigate the relationship of pulmonary artery diameter (PAD) measured by computed tomography (CT) with outcomes following lobectomy.

METHODS

Records of patients undergoing pulmonary lobectomy for lung cancer between 2011 and 2018 were reviewed. Baseline characteristics and postoperative outcome data were derived from the institutional Society of Thoracic Surgeons database. Luminal diameter of the central pulmonary arteries and ascending aorta were measured on preoperative CTs. Logistic regression analyses were performed to test the association of PAD with complications.

RESULTS

A total of 736 lobectomy patients were included, who had a preoperative CT scan (25% with contrast, 75% noncontrast) available for review. A total of 141 (19.2%) patients had an enlarged main PAD ≥30 mm, and 58 (7.9%) patients had a main PAD that was larger than the ascending aorta (PA/ascending aorta ratio > 1). The right or left PAD on the surgical side was associated with major complication (odds ratio per mm, 1.12; 95% confidence interval, 1.05-1.18; P < .001), unexpected intensive care unit admission (odds ratio per millimeter, 1.11; 95% confidence interval, 1.04-1.19; P = .002), and 30-day mortality (odds ratio per millimeter, 1.25; 95% confidence interval, 1.06-1.46; P = .007). On multivariable analysis, adjusted for cardiovascular comorbidities, pulmonary function, and the operative approach, surgical side PAD remained an independent factor associated with major complication.

CONCLUSIONS

CT-based measurements of the PAD on the operative side may inform of the about the risk of major complications after lobectomy. Review of PA size on preoperative CT scans may help identify patients who would benefit from formal evaluation of PA pressures to improve the operative risk assessment.

Estimating the risk of conversion from video-assisted thoracoscopic lung surgery to thoracotomy-a systematic review and meta-analysis

Background

Understanding the risk of conversion from video-assisted thoracic surgery (VATS) to thoracotomy is important when considering patient selection and preoperative surgical risk assessment. This review aims to estimate the rate of intraoperative conversions to thoracotomy, predictive factors, and associated outcomes for VATS anatomic lung resections.

Methods

PubMed/MEDLINE and EMBASE were searched systematically in May of 2020. Observational studies examining conversions of VATS anatomic resections to thoracotomy were included. Conversion rates, causes, risk factors, and post-operative outcomes were reviewed and analyzed in aggregate.

Results

Twenty retrospective studies were reviewed, with a total of 72,932 patients undergoing VATS anatomic lung resection. The median conversion rate was 9.6% (95% CI: 6.6–13.9%). Nine studies reported a total of 114 emergency conversions, with a median incidence rate of 1.3% (95% CI: 0.6–2.8%). The most common reasons for thoracotomy were vascular injury/bleeding, difficulty lymph node dissection, and adhesions, accounting for 27.9%, 26.2% and 19% of conversions, respectively. Risk factors for conversion varied, but frequently included nodal disease, large tumors, and induction therapy. The risk of complications (OR 2.06; 95% CI: 1.77–2.40) and mortality (OR 4.11; 95% CI: 1.59–10.61) were significantly increased following conversions. There was also a significant increase in chest tube duration and length of stay following conversion.

Conclusions

The risk of conversion to thoracotomy may be as high as one in ten patients undergoing VATS anatomic lung resections, but may vary significantly based on patient selection. Although emergent conversions are rare, the need for thoracotomy may significantly increase postoperative morbidity and mortality.

Racial Disparities in Overall Survival and Surgical Treatment for Early Stage Lung Cancer by Facility Type

BACKGROUND

Early stage Non-small cell lung cancer (NSCLC) is potentially curable with surgical resection. There are persistent racial disparities for the receipt of surgery and overall survival rate for early stage NSCLC. The facility type where patients receive NSCLC treatment may directly impact racial disparities.

METHODS

A total of 111,009 patients with the American Joint Committee on Cancer TNM clinical stage I and II NSCLC that were reported to the National Cancer Data Base were analyzed. Healthcare facilities were dichotomized into the community and academic facility types. A multivariate adjusted multinomial logistic regression was used to evaluate differences in the probability of undergoing surgery based on race and facility type. Kaplan Meier 3 and 5-year overall survival estimates were calculated for black and white patients based on treatment and the facility type where patients received care.

RESULTS

We identified 99,767 white (89.87%) and 11,242 (10.12%) black patients with early stage NSCLC. Black patients were more likely to undergo surgery at academic facilities (OR: 1.12; 95% CI: 1.01-1.24; P-value = .04) compared to community facilities. Black patients treated at academic facility types demonstrated significantly better 3 and 5-year overall survival compared to black patients treated at community facilities (Log Rank P-value < .0001).

CONCLUSION

Black patients with early stage NSCLC who were treated at academic facility types had a significantly higher overall survival compared black patients treated at community facility types. The odds of black patients undergoing surgery were higher at academic facilities compared to community facilities.

Nomograms for predicting overall and recurrence-free survival after trimodality therapy for esophageal adenocarcinoma

BACKGROUND

Locally advanced esophageal carcinoma is treated with neoadjuvant chemoradiation and esophagectomy. Patients may still experience recurrence and death despite undergoing potentially curative trimodality therapy. This study describes predictive nomograms for recurrence-free (RFS) and overall survival (OS) after the completion of trimodality therapy.

METHODS

A total of 215 patients with esophageal adenocarcinoma underwent trimodality therapy from September 2010 to April 2018. Multivariate Cox proportional hazards regression models were used to create nomograms for OS and RFS. Kaplan-Meier survival curves were calculated for OS and RFS comparing high-risk and low-risk cohorts.

RESULTS

On multivariate analysis, clinical N-stage, tumor differentiation, tumor regression grade, anastomotic leak, body mass index, age, and number of lymph nodes removed were predictive variables for overall survival. Clinical N-stage, tumor differentiation, tumor regression grade, anastomotic leak, age, and positive lymph nodes were significant predictors of RFS in a multivariate model. The nomogram for OS had good predictive ability (Harrell's Concordance index [C-index]: 0.71 [95% confidence interval {CI}: 0.66-0.76]). The nomogram for RFS also performed well (C-index: 0.70 [95% CI: 0.65-0.74]).

CONCLUSION

Our nomograms can accurately predict OS and RFS after trimodality therapy and may provide guidance regarding adjuvant therapy and surveillance.

Effect of operative approach on quality of life following anatomic lung cancer resection

Patient-reported outcomes (PRO) after lung cancer surgery are of increasing interest to patients and clinicians. A variety of studies have investigated the impact of the surgical approach on quality of life (QOL) after surgery for early non-small-cell lung cancer (NSCLC). Our aim is to review the current evidence on how minimally-invasive approaches, including video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracoscopic surgery (RATS), versus open thoracotomy for lung cancer affect QOL. We conducted a systematic review of the literature of studies comparing QOL after VATS/RATS versus thoracotomy approach using studies published before 2019 on PubMed and Google Scholar. Studies were assessed for differences in QOL by domains. Fifteen studies met our inclusion criteria including 14 observational studies and one randomized trial. Survey instruments and timing of QOL assessments differed between all studies. A thoracoscopic (VATS or RATS) approach was associated with better general health (3/10 studies), physical functioning (9/14 studies), social functioning (1/12 studies), mental health (3/13 studies), emotional role functioning (4/12 studies), physical role functioning (7/12 studies), and bodily pain (7/12 studies) as compared to open surgery. The open thoracotomy approach was associated with better general health and mental health in one study each. Although QOL assessment in current studies is highly variable, the existing evidence suggests that a thoracoscopic approach is associated with improved QOL, particularly in the areas of physical functioning and pain as compared to open lung cancer surgery.

Improving patient engagement, adherence, and satisfaction in lung cancer surgery with implementation of a mobile device platform for patient reported outcomes

Background

Active patient engagement may improve their perioperative experience and outcomes. We sought to evaluate the use of a mobile device application (App) for patient engagement and patient reported outcomes (PROs) assessment following robotic lung cancer surgery.

Methods

Patients with suspected lung cancer undergoing robotic resection between January–May 2019, were offered the SeamlessMD App, which was customized to meet requirements of the thoracic enhanced recovery pathway. The App guided patients through preoperative preparation, in-hospital recovery, and post-op discharge care with personalized reminders, task lists, education, progress tracking, and surveys.

Results

Fifty patients participated in the study (22.1%). Of the 50 patients, 20 (40%) patients completed the preoperative compliance survey, and 31 (62%) completed the hospital satisfaction survey. A total of 62 inpatient recovery checks were completed, identifying non-compliance with incentive spirometer use in 2 (3.2%) and patient worries about self-care after discharge in 18 (29%) instances. Postoperative health-checks were completed by 27 (54%) patients with a median of 3 [0–17] completed surveys per patient. Patient reported symptom scores up to 30 days after surgery, demonstrating a significant decrease maximum pain level (P=0.002) and anxiety scores (P<0.001). The App enabled health-checks improved confidence and decreased worries in over 80% of patients. Nine patients (40.9%) reported the health-checks helped avoid 1+ calls and 4 (18.2%) reported the App helped avoid 1+ visits to the hospital. Over 74% of patients reported the App was very or extremely useful in each of the preoperative, inpatient, and post-discharge settings.

Conclusions

A mobile device platform may serve as an effective mechanism to record perioperative PROs and satisfaction while facilitating patient-provider engagement in perioperative care.

Nomograms for Predicting Overall and Recurrence-free Survival From Pathologic Stage IA and IB Lung Cancer After Lobectomy

BACKGROUND

Stage I non-small-cell lung cancer (NSCLC) is potentially curable with surgical resection. Significant proportions of patients may still experience recurrence and death despite undergoing curative surgery. This study describes predictive nomograms for recurrence-free (RFS) and overall survival (OS) after lobectomy.

PATIENTS AND METHODS

A total of 301 patients with the American Joint Committee on Cancer pathologic stage IA and IB NSCLC who underwent open, thoracoscopic, or robotic lobectomy from January 2011 to April 2017 were analyzed. Multivariate Cox proportional hazards regression models were used to create nomograms for OS and RFS. Kaplan-Meier survival curves were calculated for OS and RFS comparing high-risk and low-risk cohorts based on nomogram scores.

RESULTS

Histology (hazard ratio [HR], 0.24; 95% confidence interval [CI], 0.10-0.56; P = .002), lymphovascular invasion (HR, 0.46; 95% CI, 0.29-0.74; P = .001), smoking status (HR, 3.46; 95% CI, 1.25-9.55: P = .02), and total lymph nodes removed (HR, 1.05; 95% CI, 1.01-1.10; P = .021) were significant predictors for OS in a multivariate model. Lymphovascular invasion (HR, 0.55; 95% CI, 0.36-0.83; P = .0040), smoking status (HR, 2.56; 95% CI, 1.16-5.62; P = .02), total lymph nodes removed (HR, 1.04; 95% CI, 1.00-1.08; P = .029), and tumor size (HR, 1.30; 95% CI, 1.30-1.68; P = .047) were significant predictors of RFS in a multivariate model.

CONCLUSION

Nomograms can predict OS and RFS for pathologic stage IA and IB NSCLC after lobectomy regardless of operative approach. The risk for death and recurrence after stratification by the nomogram scores may provide guidance regarding adjuvant therapy and surveillance.

Diagnosis and management of small pulmonary atypical carcinoid tumor associated with Cushing syndrome

Ectopic adrenocorticotropic hormone (ACTH) syndrome is rare and identification of its source is often challenging. We report the case of an ectopic Cushing syndrome in a young adult male secondary to an occult ACTH producing atypical carcinoid tumor. Extensive biochemical and imaging workup was unrevealing. The diagnosis was aided by Ga-DOTA PET scan demonstrating a suspicious left upper lobe lung nodule. The patient underwent video-assisted thoracoscopic exploration with wedge resection and mediastinal lymphadenectomy of a T2aN2M0 atypical carcinoid, resulting in the normalization of ACTH levels and complete resolution of symptoms. The role of a Ga-DOTA PET scan in diagnosing pulmonary carcinoid tumors and their management are discussed.

Considerations for the Surgical Management of Early Stage Lung Cancer During the COVID-19 Pandemic

The highly transmissible novel coronavirus (COVID-19) has infected over 8.8 million people globally and has upended the delivery of health care in the United States, creating unprecedented challenges to providing care to patients with early stage non–small cell lung cancer (NSCLC). The initial surge of patients with COVID-19 that have flooded hospitals has put a strain on physical space, workforce, and supplies. In addition, social distancing and the risk of COVID-19 transmission has created significant barriers for thoracic surgeons to diagnose and treat patients. Many hospitals across the country have temporarily suspended elective operations to preserve hospital beds, ventilators, and personal protective equipment. Currently, the pandemic has greatly disrupted the current standard of resection after adequate staging with imaging and/or surgical staging for early stage NSCLC well beyond the initial acute phase; therefore, a new paradigm for effective management will need to be devised until the COVID-19 pandemic is eradicated with systematic vaccination and herd immunity. Thoracic surgeons will need to recalibrate their approach to ensure that patients receive timely and effective treatment for early stage NSCLC. The management of early stage NSCLC during the COVID-19 pandemic should be balanced with available hospital resources, risk of progression of disease, risk of transmission of COVID-19 to patient and surgeon, and the availability of alternative therapies. This article will address the current challenges with treating early stage NSCLC during the COVID-19 pandemic and provide a clinical framework for providing effective surgical therapy while mitigating the risk of transmission of the SARS-CoV-2 virus to patients and surgeons.

The Academic Facility Type Is Associated With Improved Overall Survival for Early-Stage Lung Cancer

BACKGROUND

Early-stage non-small cell lung cancer (NSCLC) is potentially curable with surgical resection. The overall survival rate for early-stage NSCLC may be determined by the healthcare facility type where patients receive their lung cancer treatment.

METHODS

A total of 103,748 cases with the American Joint Committee on Cancer clinical stage I and II NSCLC that were reported to the National Cancer Database at over 1150 facilities were analyzed in this study. Healthcare facilities were dichotomized into the community and academic facility types. Marginal multivariable Cox proportional hazards models were used to evaluate differences in overall survival. Propensity score methodology with inverse probability of treatment weighting was used to adjust for facility volume and patient-related baseline differences between facility types.

RESULTS

Patients with early-stage NSCLC who were treated at academic facility types had a significantly better median overall survival (63.2 months) compared with patients who received care at community healthcare facilities (54.2 months) (hazard ratio, 0.86; 95% confidence interval, 0.82-0.91; P < .0001). The surgical quality outcomes for NSCLC surgery, including 30-day mortality, 90-day mortality, and the median number of lymph nodes removed were significantly better for patients treated at the academic facility types.

CONCLUSIONS

Patients with early-stage NSCLC who were treated at academic facility types had a significantly higher overall median survival compared with patients treated at community facility types. The short-term surgical quality outcomes were significantly better for patients who underwent surgery for early-stage NSCLC at academic facility types.

Recurrence After Stereotactic Body Radiation Therapy Versus Lobectomy for Non-Small Cell Lung Cancer

BACKGROUND

Although lobectomy remains the standard of care for early-stage non-small cell lung cancer, several studies suggest equipoise between lobectomy and stereotactic body radiation therapy (SBRT). However randomized evidence is lacking. We compared outcomes of early-stage non-small cell lung cancer patients treated with lobectomy or SBRT.

METHODS

We included clinical T1-2N0 non-small cell lung cancer treated with lobectomy or SBRT to a biologically effective dose of ≥100 Gy₁₀. We used Cox proportional hazards and nearest-neighbor propensity score (2:1) matching to adjust for confounders. Kaplan-Meier curves were used to assess survival and recurrence.

RESULTS

We identified 554 patients treated with lobectomy (n = 389) or SBRT (n = 165) at our institution between 2008 and 2018. After propensity score matching, there were 132 SBRT patients and 85 lobectomy patients. SBRT was associated with increased local recurrence (hazard ratio [HR], 6.80; 95% confidence interval [CI], 1.92-24.10; P = .003) and regional nodal recurrence (HR, 2.58; 95% CI, 1.17-5.68; P = .018), and with worse overall survival (HR, 2.00; 95% CI, 1.21-3.32; P = .007) and progression-free survival (HR, 2.34; 95% CI, 1.50-3.67; P < .001). There was no difference in distant recurrence (HR, 1.19; 95% CI, 0.57-2.52; P = .64).

CONCLUSIONS

We found superior outcomes in patients with early-stage non-small cell lung cancer treated with lobectomy compared with SBRT, including locoregional control. These findings should be interpreted with caution because of selection bias but underscore the importance of robust randomized prospective data to clarify the relative efficacy of these modalities.