Robotic chest wall resection for primary benign chest wall tumors and locally advanced lung cancer: an institutional case series and national report

Background

Limited data exists for robotic chest wall resection; we report institutional and national experience of robotic chest wall resection.

Methods

In this comparative retrospective case series we describe patients who underwent robotic chest wall resection at our institution and enrich this case series with data from the National Cancer Database (NCDB). We describe our preoperative workup, operative technique, and postoperative care. Outcomes included conversion to open, length of stay, readmissions, and 30- and 90-day mortality. The results are descriptively reported and compared.

Results

We describe 6 patients institutionally and 96 NCDB patients. At our institution 66.7% were males, median age was 70.0 (range, 39-91) years, and 50% were primary chest wall tumors. Median tumor size was 5.25 (range, 2.3-8.3) cm. Outcomes were as follows: no open conversions, median length of stay 3 (range, 1-6) days, no unplanned 30-day readmissions or 90-day mortality. In the NCDB, 55.2% were males with median age of 68.5 (range, 30-89) years. Median tumor size was 3.90 (range, 2.4-6.0) cm. NCDB outcomes were as follows: 18.8% open conversion, median length of stay 7 (range, 5-10) days, 3.1% unplanned 30-day readmission, and 8.3% 90-day mortality. Our institutional case series had 18.0 months median follow-up (range, 6-54 months) with no functional deficits. Median survival in NCDB was 49.6 months.

Conclusions

Robotic chest wall resection is feasible and is performed nationally with acceptable short- and long-term outcomes. Our institutional experience reports our technique, resultant short hospital stay, and excellent functional outcomes.

Neoadjuvant Chemotherapy vs Chemoradiation Therapy Followed by Sleeve Resection for Resectable Lung Cancer

BACKGROUND

Traditionally, neoadjuvant chemoradiation therapy is followed by resection in patients with locally advanced non-small cell lung cancer (NSCLC). The risks and benefits of this approach are not well defined in patients requiring a sleeve lung resection. In this context, we compare the short- and long-term outcomes of neoadjuvant chemotherapy alone vs chemoradiation therapy followed by sleeve lung resection.

METHODS

We used the National Cancer Database to identify locally advanced NSCLC patients who received chemotherapy-alone or chemoradiation therapy in the neoadjuvant setting, followed by a sleeve lung resection, between 2006 and 2017. Our outcomes of interest were 30-day mortality, 90-day mortality, and overall survival. To minimize confounding by indication, we used propensity score adjustment, logistic regression, Kaplan-Meier survival analysis, and Cox proportional hazards models to identify associations.

RESULTS

Of 176 patients undergoing sleeve lung resection, 92 (52.3%) received neoadjuvant chemotherapy-alone, and 84 (47.7%) received neoadjuvant chemoradiation therapy. Patients in both groups were well balanced in age, sex, race, Charlson-Deyo comorbidity index, insurance status, median income, and education (all P > .05). Similarly, the groups were well balanced in histology, tumor location, and stage (all P > .05). Patients receiving neoadjuvant chemoradiation therapy had higher 90-day mortality (11.96% vs 2.38%, P = .015), and there was no difference in overall survival between the neoadjuvant chemotherapy-alone vs chemoradiation therapy cohorts (P = .621).

CONCLUSIONS

In this national study of patients with locally advanced resectable NSCLC requiring a sleeve lung resection, neoadjuvant chemoradiation therapy was associated with a 5-fold increase in 90-day mortality without an overall survival benefit over neoadjuvant chemotherapy-alone.

Malignant Pleural Mesothelioma: Current Understanding of the Immune Microenvironment and Treatments of a Rare Disease

Simple Summary

Malignant pleural mesothelioma is a rare disease with an annual incidence of around 3000 cases a year in the United States. Most cases are caused by asbestos exposure, with a latency period of up to 40 years but overall survival of approximately only 6–12 months after the time of diagnosis. Often, the treatment is multimodal and consists of surgery, chemotherapy, and radiation. While the survival benefit of treatment is impactful, overall prolongation remains marginal. Nevertheless, the advent of new treatment approaches involving the interactions of targeted immune therapies and the tumor microenvironment appear to offer some promise. Furthering our understanding of these complex interactions in conjunction with the host immune system will likely prove to be pivotal in advancing current treatment options for malignant pleural mesothelioma.

Abstract

Malignant pleural mesothelioma is a rare disease with an annual incidence of around 3000 cases a year in the United States. Most cases are caused by asbestos exposure, with a latency period of up to 40 years. Pleural mesothelioma is an aggressive disease process with overall survival of roughly 6–12 months after the time of diagnosis. It is divided into three subtypes: epithelioid, mixed type, and sarcomatoid type, with the epithelioid subtype having the best overall survival. Often, the treatment is multimodality with surgery, chemotherapy, and radiation. The survival benefit is improved but remains marginal. New treatment options involving targeted immune therapies appear to offer some promise. The tumor microenvironment is the ecosystem within the tumor that interacts and influences the host immune system. Understanding this complex interaction and how the host immune system is involved in the progression of the disease process is important to define and guide potential treatment options for this devastating and rare disease.

Pulmonary Parenchymal Changes in COVID-19 Survivors

BACKGROUND

As the COVID-19 pandemic moves into the survivorship phase, questions regarding long-term lung damage remain unanswered. Previous histopathologic studies are limited to autopsy reports. We studied lung specimens from COVID-19 survivors who underwent elective lung resections to determine whether postacute histopathologic changes are present.

METHODS

This multicenter observational study included 11 adult COVID-19 survivors who had recovered but subsequently underwent unrelated elective lung resection for indeterminate lung nodules or lung cancer. We compared these against an age- and procedure-matched control group who never contracted COVID-19 (n = 5) and an end-stage COVID-19 group (n = 3). A blinded pulmonary pathologist examined the lung parenchyma focusing on 4 compartments: airways, alveoli, interstitium, and vasculature.

RESULTS

Elective lung resection was performed in 11 COVID-19 survivors with asymptomatic (n = 4), moderate (n = 4), and severe (n = 3) COVID-19 infections at a median 68.5 days (range 24-142 days) after the COVID-19 diagnosis. The most common operation was lobectomy (75%). Histopathologic examination identified no differences between the lung parenchyma of COVID-19 survivors and controls across all compartments examined. Conversely, patients in the end-stage COVID-19 group showed fibrotic diffuse alveolar damage with intra-alveolar macrophages, organizing pneumonia, and focal interstitial emphysema.

CONCLUSIONS

In this study to examine the lung parenchyma of COVID-19 survivors, we did not find distinct postacute histopathologic changes to suggest permanent pulmonary damage. These results are reassuring for COVID-19 survivors who recover and become asymptomatic.

Comparative effectiveness of stereotactic body radiation therapy versus surgery for stage I lung cancer in otherwise healthy patients: An instrumental variable analysis

Objectives

Stereotactic body radiation therapy (SBRT) is an established primary treatment modality in patients with lung cancer who have multiple comorbidities and/or advanced-stage disease. However, its role in otherwise healthy patients with stage I lung cancer is unclear. In this context, we compared the effectiveness of SBRT versus surgery on overall survival using a national database.

Methods

We identified all patient with clinical stage I non–small cell lung cancer from the National Cancer Database from 2004 to 2016. We defined otherwise healthy patients as those with a Charlson-Deyo comorbidity index of 0 and whose treatment plan included options for either SBRT or surgery. We further excluded patients who received SBRT due to a contraindication to surgery. We first used propensity score matching and Cox proportional hazard models to identify associations. Next, we fit 2-stage residual inclusion models using an instrumental variables approach to estimate the effects of SBRT versus surgery on long-term survival. We used the hospital SBRT utilization rate as the instrument.

Results

Of 25,963 patients meeting all inclusion/exclusion criteria, 5465 (21%) were treated with SBRT. On both Cox proportional hazards modeling and propensity-score matched Kaplan-Meier analysis, surgical resection was associated with improved survival relative to SBRT. In the instrumental-variable–adjusted model, SBRT remained associated with decreased survival (hazard ratio, 2.64; P < .001). Both lobectomy (hazard ratio, 0.17) and sublobar resections (hazard ratio, 0.28) were associated with improved overall survival compared with SBRT (P < .001).

Conclusions

In otherwise healthy patients with stage I NSCLC, surgical resection is associated with a survival benefit compared with SBRT. This is true for both lobar and sublobar resections.

The impact of marginal lung function on outcomes in the era of minimally invasive thoracic surgery

Background

The effect of marginal lung function on outcomes after lung resection has traditionally been studied in the context of open thoracic surgery. Its impact on postoperative outcomes in the era of minimally invasive lung resection is unclear.

Methods

In this retrospective cohort study, we included adult patients who underwent minimally invasive lung resection at our institution between January 2017 and May 2020 for known malignancy or lung nodule. Marginal lung function was defined as pre-operative forced expiratory volume in 1 second (FEV1) and/or diffusion lung capacity of carbon monoxide <60% of predicted. Our outcomes included a composite outcome of pulmonary morbidity and/or 30- and 90-day mortality, and hospital length of stay. We used multivariable logistic and Poisson regression models to identify associations with outcomes, and Kaplan-Meier and Cox models to estimate survival.

Results

Of 300 patients, 88 (29%) had marginal lung function. Patients in the marginal group were more likely to be female (69% vs. 56%; P=0.028), and more likely to have: hypertension (HTN) (83% vs. 71%; P=0.028), chronic obstructive pulmonary disease (COPD) (38% vs. 12%; P<0.001), interstitial lung disease (ILD) (9% vs. 3%; P<0.019), and ischemic heart disease (28% vs. 18%; P=0.033). Patients were similar in terms of age (68±8 vs. 68±10 years; P=0.932), and other comorbidities. Anatomic lung resection comprised 56.8% of the marginal group vs. 74% in the non-marginal group (P=0.003). The most common complication was prolonged air leak (18.2% vs. 11.8%; P=0.479). Marginal lung function had a trend toward increased composite respiratory complications (22.7% vs. 15.1%; P=0.112) and 90-day mortality (5.7% vs. 4.2%; P=0.591), although they did not reach statistical significance. There was a statistically significant 1-day average increase in length of stay in the marginal lung function cohort (4.6 vs. 3.4 days; P<0.015) with a stronger association with diffusion lung capacity of carbon monoxide than FEV1. Survival was similar (marginal function HR =1.0; P=0.994).

Conclusions

In the era of minimally invasive thoracic surgery, lung resection in patients with marginal lung function may be considered in select patients. These findings aid in the selection consideration and counseling of this patient population.

Assessment of Textbook Outcome After Surgery for Stage I/II Non-small Cell Lung Cancer

``Outcomes after cancer resection are traditionally measured individually. Composite metrics, or textbook outcomes, bundle outcomes into a single value to facilitate assessments of quality. We propose a composite outcome for non-small cell lung cancer resections, examine factors associated with the outcome, and evaluate its effect on overall survival. We queried the National Cancer Database for patients with stage I/II non-small cell lung cancer who underwent sublobar resection, lobectomy, or pneumonectomy from 2010 to 2016. We defined the metric as margin-negative resection, sampling of ≥10 lymph nodes, length of stay <75th percentile, no 30-day mortality, no readmission, and receipt of indicated adjuvant therapy. Multivariable logistic regression, Cox proportional hazards modeling, survival analyses, and propensity score matching were used to identify factors associated with the outcome and overall survival. Of 88,208 patients, 70,149 underwent lobectomy, 14,922 underwent sublobar resection, and 3,137 underwent pneumonectomy. Textbook outcome was achieved in 26.3% of patients. Failure to achieve the outcome was most commonly driven by inadequate nodal assessment. Textbook outcome was more likely after minimally invasive surgical approaches (aOR = 1.47; P< 0.001) relative to open resection and less likely after sublobar resection (aOR = 0.20; P< 0.001) relative to lobectomy. Achievement of textbook outcome was associated with an 9.6% increase in 5-year survival (P< 0.001), was independently associated with improved survival (aHR = 0.72; P < 0.001), and remained strongly associated with survival independent of resection extent after propensity matching. One in 4 patients undergoing non-small cell lung cancer resection achieve textbook outcome. Textbook outcome is associated with improved survival and has value as a quality metric.

Inflammatory cytokines in robot-assisted thoracic surgery versus video-assisted thoracic surgery

Background

Cytokines play a crucial role in the inflammatory response and are essential modulators of injury repair mechanisms. While minimally invasive operations have been shown to induce lower levels of cytokines compared to open thoracotomy, the inflammatory cytokine profile difference between video-assisted (VATS) and robotic-assisted thoracic surgery (RATS) techniques has yet to be elucidated.

Methods

In this prospective observational study of 45 patients undergoing RATS (n=30) or VATS (n=15) lung resection for malignancy, plasma levels of interleukin (IL)-1α, IL-1β, IL-2, IL-4, IL-6, IL-8, IL-10, vascular endothelial growth factor (VEGF), interferon (IFN)-γ, tumor necrosis factor (TNF)-α, monocyte chemo-attractant protein (MCP)-1, and endothelial growth factor (EGF) were measured before and after surgery via immunoassay.

Results

Levels of IL-6 and MCP-1 were significantly higher in patients undergoing VATS than in patients undergoing RATS (P<0.001 and P=0.005, respectively) 2 hours following surgery. MCP-1 levels were also found to be significantly higher in the VATS group (P<0.001) 24 hours following surgery. IL-1α, IL-1β, IL-2, IL-4, IL-8, IL-10, IFN-γ, TNF-α, and EGF levels were not significantly different at any time-point comparing VATS to RATS.

Conclusions

The VATS approach is associated with a more robust pro-inflammatory cytokine response through the upregulation of MCP-1 and IL-6 when compared to the RATS approach in patients undergoing anatomic lung resection. Further studies are necessary to validate the clinical significance of this finding.

A Case of Giant Primary Pleuropulmonary Synovial Sarcoma

Synovial sarcomas represent an extremely rare subtype of an already rare group of malignancies, soft tissue sarcomas. Among these, primary pulmonary synovial sarcomas comprise an even smaller number, though they have become more frequently reported in the literature. This case report details a case of giant primary pulmonary synovial sarcoma in a 44-year-old male patient who presented with left-sided chest pain and shortness of breath and was found to have a large left-sided pleural effusion. No malignant cells were demonstrated on cytology of pleural fluid after thoracentesis; however, CT-guided needle biopsy of pleural nodules seen on imaging demonstrated pathologic features consistent with monophasic type synovial sarcoma. He was treated with neoadjuvant chemotherapy with minimal response; thus, he was referred for surgical management. A left extrapleural pneumonectomy with resection of the left hemi-diaphragm and Gore-Tex prosthetic reconstruction was performed. Imaging at six-month follow-up demonstrated a new nodule in the contralateral lung, suggestive of metastasis at that time and the patient later developed ascites at nine months, consistent with further intra-abdominal metastasis. Perhaps early diagnosis and aggressive multimodality therapy may have a place in the treatment of this aggressive disease.

When is a patient high risk for resection? A changing paradigm with minimally invasive lung surgery

e20059

Background: The predicted post-operative forced expiratory volume after 1 second (FEV1) and the diffusing capacity of the lung for carbon monoxide (DLCO) are predictors of postoperative complications and survival. Despite the benefits of minimally invasive surgery in patients with marginal lung function current practice guidelines advocates non-surgical approach for treatment from evidence derived from patients undergoing thoracotomy. It is necessary to define what should be minimum acceptable lung function for resection in the era of minimally invasive surgery. Methods: Single institution retrospective study of 61 patients with pre-operative predicted FEV1 and DLCO < 60% that underwent lung resection for pulmonary lung nodules suspected to be malignant between January 2017 to June 2018. Patient demographic and clinical data were collected and the 30-day or in-hospital morbidity and mortality were assessed. Results: 28 (46%) patients with pre-operative predicted FEV1 < 60% and 33 (54%) with DLCO < 60% were reviewed. 10 patients had both FEV1 and DLCO < 60%. There were 12 patients (28% in FEV1, 12% in DLCO group) who had < 40% of pre-operative predicted values. 15 (65%) of FEV1 group and 15 (45%) of DLCO group had anatomic lung resections with either a lobectomy or a segmentectomy. 24 (39%) of cases were done robotically and the remaining with VATS. 80% of patients had cancer in their final pathology. Patients were 68± 7 years old, 34 (56%) were male. Significant baseline clinical findings include high incidence of smoking (82% in FEV1, 97% in DLCO group), HTN (71% in FEV1, 81% in DLCO group), COPD (61% in FEV1, 48% in DLCO group), CAD (25% in FEV1, 30% in DLCO group), and a total of 2 patients suffered previous CVD. Most common complications included persistent air leak > 5 days (21% in FEV1 and DLCO group) and arrhythmia (14% in FEV1, 15% in DLCO group). Of those with an air leak, 50% in the FEV1 group and 29% in the DLCO group had predicted values < 40%. Three patients developed pneumothorax post chest tube removal necessitating chest tube replacement, all of whom had predicted values < 40%. One patient developed acute DVT and PE and another patient required mechanical ventilation for > 48 hours. There were no 30-day mortalities. Conclusions: Lung resection using minimally invasive technique had low rates of 30-day morbidity in patients with reduced pulmonary function. Majority of complications observed were minor. Minimally invasive lung resection is possible and may be extended to selected patients with pre-operative predicted DLCO or FEV1 < 40% suspected of malignancy.

TCR sequencing analysis of cancer tissues and tumor draining lymph nodes in colorectal cancer patients

Tumor draining lymph nodes (TDLNs) are located in the routes of lymphatic drainage from a primary tumor and have the highest risk of metastasis in various types of solid tumors. TDLNs are also considered as a tissue to activate the antitumor immunity, where antigen-specific effector T cells are generated. However, T cell receptor (TCR) repertoires in TDLNs have not been well characterized. We collected 23 colorectal cancer tumors with 203 lymph nodes with/without metastatic cancer cells (67 were metastasis-positive and the remaining 136 were metastasis-negative) and performed TCR sequencing. Metastasis-positive TDLNs showed a significantly lower TCR diversity and shared TCR clonotypes more frequently with primary tumor tissues compared to metastasis-negative TDLNs. Principal component analysis indicated that TDLNs with metastasis showed similar TCR repertoires. These findings suggest that cancer-reactive T cell clones could be enriched in the metastasis-positive TDLNs.

Successful primary repair of late diagnosed spontaneous esophageal rupture: A case report

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Diagnosis of spontaneous rupture of the esophagus is often delayed.

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Significant contamination of the mediastinum and pleural space is not uncommon.

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Debridement and drainage of the mediastinum and pleural space are necessary to control sepsis.

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Debridement of necrotic tissue is necessary.

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Primary repair in layers of the esophagus is possible in majority of the cases regardless of the time lapsed from rupture.

Introduction

Spontaneous esophageal rupture is rare, roughly 300 cases reported annually. Diagnosis is often delayed or missed. Overall mortality is about 20%. This feared high mortality rate has led to the misconception that primary esophageal repair should be avoided in late diagnosed patients. We report a successful primary repair of spontaneous esophageal rupture which was delayed for more than two weeks.

Methods

A 53 year-old male presented to our medical service after falsely having been treated for pneumonia at an outside hospital. He was subsequently diagnosed with spontaneous esophageal rupture and treated with over the scope clips followed by stenting. Persistent leak into mediastinum made surgical exploration necessary. At exploration a primary repair could be performed successfully.

Results

Unsuccessful endoscopic management of esophageal perforation that was delayed for two weeks underwent primary surgical repair without complications.

Conclusion

Primary closure of late diagnosed spontaneous esophageal rupture can be successful, even when it is complicated by a prolonged delay in treatment and failed endoscopic procedures. We conclude that primary surgical repair should be attempted in patients with spontaneous esophageal rupture if tissues are viable.

Limitations of PET/CT in the Detection of Occult N1 Metastasis in Clinical Stage I(T1-2aN0) Non-Small Cell Lung Cancer for Staging Prior to Stereotactic Body Radiotherapy

PURPOSE/OBJECTIVES

Patients receiving stereotactic body radiotherapy for stage I non-small cell lung cancer are typically staged clinically with positron emission tomography-computed tomography. Currently, limited data exist for the detection of occult hilar/peribronchial (N1) disease. We hypothesize that positron emission tomography-computed tomography underestimates spread of cancer to N1 lymph nodes and that future stereotactic body radiotherapy patients may benefit from increased pathologic evaluation of N1 nodal stations in addition to N2 nodes.

MATERIALS/METHODS

A retrospective study was performed of all patients with clinical stage I (T1-2aN0) non-small cell lung cancer (American Joint Committee on Cancer, 7th edition) by positron emission tomography-computed tomography at our institution from 2003 to 2011, with subsequent surgical resection and lymph node staging. Findings on positron emission tomography-computed tomography were compared to pathologic nodal involvement to determine the negative predictive value of positron emission tomography-computed tomography for the detection of N1 nodal disease. An analysis was conducted to identify predictors of occult spread.

RESULTS

A total of 105 patients with clinical stage I non-small cell lung cancer were included in this study, of which 8 (7.6%) patients were found to have occult N1 metastasis on pathologic review yielding a negative predictive value for N1 disease of 92.4%. No patients had occult mediastinal nodes. The negative predictive value for positron emission tomography-computed tomography in patients with clinical stage T1 versus T2 tumors was 72 (96%) of 75 versus 25 (83%) of 30, respectively ( P = .03), and for peripheral versus central tumor location was 77 (98%) of 78 versus 20 (74%) of 27, respectively ( P = .0001). The negative predictive values for peripheral T1 and T2 tumors were 98% and 100%, respectively; while for central T1 and T2 tumors, the rates were 85% and 64%, respectively. Occult lymph node involvement was not associated with primary tumor maximum standard uptake value, histology, grade, or interval between positron emission tomography-computed tomography and surgery.

CONCLUSION

Our results support pathologic assessment of N1 lymph nodes in patients with stage Inon-small cell lung cancer considered for stereotactic body radiotherapy, with the greatest benefit in patients with central and T2 tumors. Diagnostic evaluation with endoscopic bronchial ultrasound should be considered in the evaluation of stereotactic body radiotherapy candidates.

Comprehensive genetic testing identifies targetable genomic alterations in most patients with non-small cell lung cancer, specifically adenocarcinoma, single institute investigation

This study reviews extensive genetic analysis in advanced non-small cell lung cancer (NSCLC) patients in order to: describe how targetable mutation genes interrelate with the genes identified as variants of unknown significance; assess the percentage of patients with a potentially targetable genetic alterations; evaluate the percentage of patients who had concurrent alterations, previously considered to be mutually exclusive; and characterize the molecular subset of KRAS.

Thoracic Oncology Research Program Databases at the University of Chicago provided patient demographics, pathology, and results of genetic testing. 364 patients including 289 adenocarcinoma underwent genotype testing by various platforms such as FoundationOne, Caris Molecular Intelligence, and Response Genetics Inc. For the entire adenocarcinoma cohort, 25% of patients were African Americans; 90% of KRAS mutations were detected in smokers, including current and former smokers; 46% of EGFR and 61% of ALK alterations were detected in never smokers. 99.4% of patients, whose samples were analyzed by next-generation sequencing (NGS), had genetic alterations identified with an average of 10.8 alterations/tumor throughout different tumor subtypes. However, mutations were not mutually exclusive.

NGS in this study identified potentially targetable genetic alterations in the majority of patients tested, detected concurrent alterations and provided information on variants of unknown significance at this time but potentially targetable in the future.

Integrated analysis of somatic mutations and immune microenvironment in malignant pleural mesothelioma

To investigate the link between the genomic landscape of cancer cells and immune microenvironment in tumor tissues, we characterized somatic mutations and tumor-infiltrating lymphocytes (TILs) in malignant pleural mesothelioma (MPM), including mutation/neoantigen load, spatial heterogeneity of somatic mutations of cancer cells and TILs (T-cell receptor β (TCRβ) repertoire), and expression profiles of immune-related genes using specimens of three different tumor sites (anterior, posterior, and diaphragm) obtained from six MPM patients. Integrated analysis identified the distinct patterns of somatic mutations and the immune microenvironment signatures both intratumorally and interindividually. MPM cases showed intratumoral heterogeneity in somatic mutations with unique TCRβ clonotypes of TILs that were restricted to each tumor site, suggesting the presence of a neoantigen-related immune response. Correlation analyses showed that higher neoantigen load was significantly correlated with stronger clonal expansion of TILs (p = 0.048) and a higher expression level of an immune-associated cytolytic factor (PRF1 (p = 0.0041) in tumor tissues), suggesting that high neoantigen loads in tumor cells might promote expansion of functional tumor-specific T cells in the tumor bed. Our results collectively indicate that MPM tumors constitute a diverse heterogeneity in both the genomic landscape and immune microenvironment, and that mutation/neoantigen load may affect the immune microenvironment in MPM tissues.

Amount of Epithelioid Differentiation Is a Predictor of Survival in Malignant Pleural Mesothelioma

BACKGROUND

Macroscopic complete surgical resection with adjuvant chemotherapy can provide a survival advantage in patients with malignant pleural mesothelioma (MPM). Patients with nonepithelioid histology are largely excluded from such radical operations even though they might benefit. The degree of epithelioid differentiation varies in biphasic histology. We report the outcomes of pleurectomy and decortication and the effect of epithelioid differentiation on overall survival of patients with MPM.

METHODS

This report is based on the outcomes of 144 patients who underwent pleurectomy and decortication at a single institution between 2008 and 2015. The variables assessed were age, gender, histology, and pathologic T and N stage. No patients with pure sarcomatoid histology were included. Two independent pathologists estimated the percentage of epithelioid histology. A Cox regression model was used to identify significant predictors of survival. The Kaplan-Meier method was used to summarize overall and subgroup survival.

RESULTS

Included were 116 men and 28 women with a median age of 69 years (range, 43 to 88 years). The 2-year survival from pleurectomy and decortication was 20%. Median survival overall was 13.34 months and was 20.1 months for the 100% epithelioid subgroup (n = 77), 11.8 months for the 51% to 99% epithelioid subgroup (n = 39), and 6.62 months for the less than 50% epithelioid subgroup (n = 28). The amount of epithelioid differentiation was a significant predictor of survival (p < 0.001). Differences in survival based on the T, but N stage, were not statistically significant.

CONCLUSIONS

The percentage of epithelioid differentiation is an independent predictor of survival in MPM and should be taken into careful consideration when recommending surgical treatment for patients with biphasic MPM.

Radiologic-pathologic correlation of mesothelioma tumor volume

OBJECTIVES

Tumor volume promises to become a more important factor in patient management. Mesothelioma, with its unique morphology and complex growth pattern, presents a challenging target for tumor volumetrics derived from computed tomography (CT) scans. This study evaluated the validity of image-based mesothelioma tumor volume against the physical volume of the tumor bulk captured by the images.

MATERIALS AND METHODS

Twenty-eight patients underwent CT scanning prior to pleurectomy/decortication with an intent to achieve a macroscopic complete resection. A radiologist manually outlined the tumor border in all CT sections in which tumor appeared in the pre-surgery scan. CT-based tumor volume was computed as the number of image pixels enclosed by all tumor outlines across all sections in the scan multiplied by the physical dimensions of the voxel of tissue captured by each image pixel. The gross tumor specimen volume was measured ex vivo through a water-displacement technique. Correlation between CT volume and pathology volume was calculated.

RESULTS

A correlation coefficient r-squared value of 0.66 was found between CT-based tumor volume and gross tumor specimen volume. Differences between the mean volume (either CT volume or pathology volume) across tumors of different T stages did not achieve statistical significance.

CONCLUSION

Despite a modest correlation between CT-based tumor volume and gross tumor specimen volume, image-based volumetry for mesothelioma is not straightforward-perhaps, in part, due to the challenges of distinguishing tumor borders from adjacent structures and perhaps, in part, due to a complex pathologic reference standard.

Training in minimally invasive lobectomy: thoracoscopic versus robotic approaches

BACKGROUND

Skills required for thoracoscopic and robotic operations likely differ. The needs and abilities of trainees learning these approaches require assessment.

METHODS

Trainees performed initial components of minimally invasive lobectomies using thoracoscopic or robotic approaches. Component difficulty was scored by trainees using the NASA task load index (NASATLX). Performance of each component was graded by trainees and attending surgeons on a 5-point ordinal scale (naïve, beginning learner, advanced learner, competent, master).

RESULTS

Eleven surgical trainees performed 87 replications among three lobectomy components (divide pulmonary ligament; dissect level 7/8/9 nodes; dissect level 4/5 nodes). Before performance NASATLX scores did not differ among components or between surgical approaches. Trainees' after performance NASATLX scores appropriately calibrated task load for the components. After performance NASATLX scores were significantly lower for thoracoscopy than before performance estimates; robotic scores were similar before surgery and after performance. Task load was higher for robotic than for thoracoscopic approaches. Trainees rated their performance higher than did attending surgeons in domains of knowledge and thinking, but ratings for other domains were similarly low. Ratings for performance improved significantly as component performance repetitions increased.

CONCLUSIONS

Trainees did not differentiate task load among components or surgical approaches before attempting them. Task load scores differentiated difficulty among initial components of lobectomy, and were greater for robotic than for thoracoscopic approaches. Trainees overestimated their level of cognitive performance compared with attending physician evaluation of trainee performance. The study provides insights into how to customize training for thoracoscopic and robotic lobectomy and identifies tools to assess training effectiveness.

Malignant pleural mesothelioma and the Society of Thoracic Surgeons Database: an analysis of surgical morbidity and mortality

BACKGROUND

To date, reported surgical morbidity and mortality for pleurectomy/decortication and extrapleural pneumonectomy performed for malignant pleural mesothelioma primarily represent the experience of a few specialized centers. For comparison, we examined early outcomes of pleurectomy/decortication and extrapleural pneumonectomy from a broader group of centers/surgeons participating in the Society of Thoracic Surgeons-General Thoracic Database.

METHODS

All patients in the Society of Thoracic Surgeons-General Thoracic Database (version 2.081, representing 2009-2011) who underwent pleurectomy/decortication or extrapleural pneumonectomy for malignant pleural mesothelioma were identified. Patient characteristics, morbidity, mortality, center volume, and procedure were examined using univariable and multivariable analyses.

RESULTS

A total of 225 patients underwent pleurectomy/decortication (n = 130) or extrapleural pneumonectomy (n = 95) for malignant pleural mesothelioma at 48 centers. Higher volumes of procedures (≥5/y) were performed at 3 pleurectomy/decortication and 2 extrapleural pneumonectomy centers. Patient characteristics were statistically equivalent between pleurectomy/decortication and extrapleural pneumonectomy groups, except those undergoing extrapleural pneumonectomy were younger (63.2 ± 7.8 years vs 68.3 ± 9.5 years; P < .001) and more likely to have received preoperative chemotherapy (30.1% vs 17.8%; P = .036). Major morbidity was greater after extrapleural pneumonectomy, including acute respiratory distress syndrome (8.4% vs 0.8%; P = .005), reintubation (14.7% vs 2.3%; P = .001), unexpected reoperation (9.5% vs 1.5%; P = .01), and sepsis (4.2% vs 0%; P = .03), as was mortality (10.5% vs 3.1%; P = .03). Multivariate analyses revealed that extrapleural pneumonectomy was an independent predictor of major morbidity or mortality (odds ratio, 6.51; P = .001). Compared with high-volume centers, increased acute respiratory distress syndrome was seen in low-volume centers performing extrapleural pneumonectomy (0% vs 12.5%; P = .05).

CONCLUSIONS

Extrapleural pneumonectomy is associated with greater morbidity and mortality compared with pleurectomy/decortication when performed by participating surgeons of the Society of Thoracic Surgeons-General Thoracic Database. Effects of center volume require further study.

Association of body mass index and outcomes after major lung resection

OBJECTIVES

Obesity has been thought to predispose patients to excess morbidity after lung resection because of decreased diaphragm excursion, reduced lung volumes and relative immobility. We assessed the relationship of body mass index (BMI) to acute outcomes after major lung resection.

METHODS

Information from our database of lung resections was evaluated for the period 1980-2011. Univariate analysis for adverse events (pulmonary, cardiovascular, other and overall) was used to select variables for inclusion in multivariate logistic regression analyses. Missing values were imputed. BMI was categorized as underweight (<18.5), normal (18.5-24.9), overweight (25-29.9), obese (30-34.9) and very obese (≥ 35).

RESULTS

Among 1369 patients, there were 703 males (51%) and the mean age was 62 ± 11 years. Complications included the following: pulmonary 12%, cardiovascular 15%, other 16%, mortality 5% and any 29%. The incidence of complications decreased during each decade of study (40, 30, 26, 20%; P < 0.0001) and the incidence of obese/very obese increased during the same intervals (11, 22, 30, 25%; P = 0.0007). Adjusting for age, performance status, coronary artery disease, smoking status, diffusing capacity of the lung for carbon monoxide, forced expiratory volume in 1 s and operation year, being overweight/obese/very obese did not increase the risk of postoperative complications in any category. In fact, patients in this group showed a lower rate of cardiovascular complications than those with BMI ≤ 25 (odds ratio (OR): 0.72; 95% confidence interval (CI): 0.51-1.00; P = 0.048). However, being underweight was importantly associated with an increased risk of pulmonary complications (OR: 2.5; 95% CI: 1.3-4.9; P = 0.0087) and of operative mortality (OR: 2.96; 95% CI: 1.28-6.86; P = 0.011).

CONCLUSION

Being overweight or obese does not increase the risk of complications after major lung resection. In contrast, patients who are underweight are at significantly increased risk of pulmonary complications and mortality. Knowledge of the relationship of BMI to perioperative risk for major lung resection is essential in proper risk stratification.

Predicted postoperative lung function is associated with all-cause long-term mortality after major lung resection for cancer

OBJECTIVES

Preoperative lung function is an independent predictor of long-term survival after lung resection for non-small-cell lung cancer (NSCLC). The extent of resection has an impact on operative mortality, determines postoperative lung function and may influence both overall- and cancer-specific survival. We sought to determine the impact of predicted postoperative (ppo) lung function on long-term survival after lung cancer resection.

METHODS

We previously reported long-term survival analyses for patients who underwent major lung resection for NSCLC 1980-2006. For this study, we calculated ppo spirometry (forced expiratory volume in the first second, FEV1) and diffusing capacity of the lung for carbon monoxide (DLCO) in the same cohort using the functional segment technique or quantitative perfusion scans when available, and updated survival data; missing data were imputed. We assessed the relationship of ppoFEV1 and ppoDLCO to long-term survival using Cox regression.

RESULTS

Of 854 patients, 471 (55%) were men, the mean age was 63 years and median survival was 42 months. At the time of analysis, 70% of patients had died. On regression analysis, all-cause mortality was related to age, stage, performance status, renal function and prior myocardial infarction. Preoperative lung function was marginally associated with mortality [DLCO (10-percentage point decrease): HR (hazard ratio) 1.04, 95% confidence interval (95% CI) 1.00-1.08, P = 0.056; FEV1 (10-percentage point decrease): HR 1.04, 95% CI 1.00-1.09, P = 0.067]. In contrast, ppo lung function was strongly associated with mortality (ppoDLCO: HR 1.06, 95% CI 1.01-1.12, P = 0.024; ppoFEV1: HR 1.06, 95% CI 1.01-1.12, P = 0.031).

CONCLUSIONS

Ppo lung function is strongly associated with long-term survival after major lung resection and is more strongly related to survival than preoperative lung function. Surgeons struggle with challenging decisions about the appropriate extent of resection for early-stage cancer, balancing factors such as operative morbidity/mortality, local recurrence and postoperative quality of life. Ppo lung function and its relation to survival also should be taken into consideration during such deliberations.

Interobserver variability in grading transbronchial lung biopsy specimens after lung transplantation

BACKGROUND

Acute rejection remains a major source of morbidity after lung transplantation. Given the importance of this diagnosis, an international grading system was developed to standardize the diagnosis of acute lung-allograft rejection. The reliability of this grading system has not been adequately assessed by previous studies.

METHODS

We examined the level of agreement in grading transbronchial biopsy specimens obtained from a large multicenter study (AIRSAC [Comparison of a Tacrolimus/Sirolimus/Prednisone Regimen vs Tacrolimus/Azathioprine/Prednisone Immunosuppressive Regimen in Lung Transplantation] trial). Biopsy specimens were initially graded for acute rejection and lymphocytic bronchiolitis by the site pathologist and subsequently graded by a central pathologist. Reliability of interobserver grading was evaluated using Cohen κ coefficients.

RESULTS

A total of 481 transbronchial biopsy specimens were graded by both the site and central pathologists. The overall concordance rates were 74% and 89% for grade A and grade B biopsy specimens, respectively. When samples from biopsies performed at different time points after transplantation were assessed, there was a higher level of agreement early (≤ 6 weeks) after transplant compared with later time points for acute rejection. However, there was still only moderate agreement for both grade A (κ score 0.479; 95% CI, 0.29-0.67) and grade B (κ score 0.465; 95% CI, 0.08-0.85) rejection.

CONCLUSIONS

These results expand upon previous reports of interobserver variability in grading transbronchial biopsy specimens after lung transplantation. Given the variability in grading these specimens, we advocate further education of the histopathologic findings in lung transplant biopsy specimens, as well as revisiting the current criteria for grading transbronchial biopsy specimens to improve concordance among lung transplant pathologists.

TRIAL REGISTRY

ClinicalTrials.gov; No. NCT00321906; URL: www.clinicaltrials.gov.

Decreased incidence of cytomegalovirus infection with sirolimus in a post hoc randomized, multicenter study in lung transplantation

BACKGROUND

Cytomegalovirus (CMV) is the most common opportunistic infection in lung transplantation. A recent multicenter, randomized trial (the AIRSAC study) comparing sirolimus to azathioprine in lung transplant recipients showed a decreased incidence of CMV events in the sirolimus cohort. To better characterize this relationship of decreased incidence of CMV events with sirolimus, we examined known risk factors and characteristics of CMV events from the AIRSAC database.

METHODS

The AIRSAC database included 181 lung transplant patients from 8 U.S.-based lung transplant centers that were randomized to sirolimus or azathioprine at 3 months post-transplantation. CMV incidence, prophylaxis, diagnosis and treatment data were all prospectively collected. Prophylaxis and treatment of CMV were at the discretion of each institution.

RESULTS

The overall incidence of any CMV event was decreased in the sirolimus arm when compared with the azathioprine arm at 1 year after lung transplantation (relative risk [RR] = 0.67, confidence interval [CI] 0.55 to 0.82, p < 0.01). This decreased incidence of CMV events with sirolimus remained significant after adjusting for confounding factors of CMV serostatus and CMV prophylaxis.

CONCLUSIONS

These data support results from other solid-organ transplantation studies and suggest further investigation of this agent in the treatment of lung transplant recipients at high risk for CMV events.

SaLUTaRy: survey of lung transplant rejection

BACKGROUND

The International Society for Heart and Lung Transplantation (ISHLT) guidelines on the interpretation of lung rejection in pulmonary allograft biopsy specimens were revised most recently in 2007. The goal of our study was to determine how these revisions, along with nuances in the interpretation and application of the guidelines, affect patient care.

METHODS

A Web-based survey was e-mailed to pathologists and pulmonologists identified as being part of the lung transplant team at institutions in the United States with active lung transplant programs as determined from the Organ Procurement and Transplantation Network Web site (http://optn.transplant.hrsa.gov/members/directory.asp).

RESULTS

Grades B1 and B2 in asymptomatic patients would fall into the same treatment group under the 2007 classification, which combines B1 and B2 into B1R. Also, some pulmonologists would not interpret a pathologic diagnosis of lymphocytic bronchiolitis as grade B rejection, resulting in under-treatment of these patients. Regarding bronchiolitis obliterans, most pulmonologists would treat the patient differently if there were an active mononuclear inflammatory infiltrate, and most pathologists would comment on the presence of such an infiltrate, contrary to the 2007 guidelines, which discourage reporting this infiltrate. We also found discrepancies among pathologists in their interpretation of airway lymphocytic infiltrates, whether eosinophils can be present in bronchial-associated lymphoid tissue, and whether airway inflammation represents rejection or bacterial infection.

CONCLUSIONS

The issue of grading and treating airway inflammation in pulmonary allograft biopsy specimens continues to be problematic, despite revised ISHLT guidelines. Clarification of guidelines for pathologists and pulmonologists using evidence-based criteria could lead to improved communication and patient care.

Surgical treatment of pulmonary hypertension: Lung transplantation

Pulmonary hypertension (PH) is a serious and progressive disorder that results in right ventricular dysfunction that lead to subsequent right heart failure and death. When untreated the median survival for these patients is 2.8 years. Over the past decade advances in disease specific medical therapy considerably changed the natural history. This is reflected in a threefold decrease in the number of patients undergoing lung transplantation for PH which used to be main stay of treatment. Despite the successful development of medical therapy lung transplant still remains the gold standard for patients who fail medical therapy. Referral for lung transplant is recommended when patients have a less than 2-3 years of predicted survival or in NYHA class III or IV. Both single and bilateral lung transplants have been successfully performed for PH but outcome analyses and survival comparisons generally favor a bilateral lung transplant.

Diffusing capacity predicts long-term survival after lung resection for cancer

OBJECTIVES

Predictors of long-term survival for patients with lung cancer assist in individualizing treatment recommendations. Diffusing capacity (DLCO) is a predictor of complications after resection for lung cancer. We sought to determine whether DLCO is also prognostic for long-term survival after lung resection for cancer.

METHODS

We assessed survival among patients in our prospective database who underwent lung resection for cancer between 1980-2006. Potential prognostic factors for all-cause mortality were evaluated by computing average annual hazard rates, and variables significantly associated with survival were included in multivariable Cox modelling. Multiple imputation was used to address missing values.

RESULTS

Among 854 unique patients, there were 587 deaths. The median follow-up time from surgery was 9.6 years. Predictors of survival included age, stage, performance status, body mass index, history of myocardial infarction, renal function and DLCO. On univariate analysis, the hazard ratio increased incrementally compared with those with a DLCO of ≥ 80% (70-79%, 1.12; 60-69%, 1.29; <60%, 1.35). On multivariable analysis, DLCO was an independent predictor of long-term survival for all patients (corrected for all other important covariates; HR 1.04 per 10-point decrement; 95% CI 1.00-1.08; P = 0.05). Its prognostic ability for long-term survival was above and beyond its influence on operative mortality.

CONCLUSIONS

DLCO is an independent and clinically important determinant of long-term survival after major lung resection for cancer, a finding that is not generally known. Knowledge of this may help improve selection of patients for lung resection and may help tailor the extent of resection, when possible, in order to appropriately balance operative risk with long-term outcomes.

Validation of a modified scoring system for cardiovascular risk associated with major lung resection

OBJECTIVES

The well-known revised cardiac risk index (RCRI) has recently been modified based on factors and outcomes specific to thoracic surgery patients (ThRCRI). We explored the accuracy of this modified scoring system in predicting cardiovascular morbidity after major lung resection.

METHODS

We analyzed outcomes from a prospective database of patients undergoing major lung resection 1980-2009. ThRCRI score was based on weighted factors for serum creatinine, coronary artery disease, cerebrovascular disease and extent of lung resection. Target adverse outcomes included pulmonary embolism, myocardial infarction, cardiac arrest, pulmonary edema and cardiac death.

RESULTS

A total of 1255 patients (mean age 61.8 years; 649 men) underwent lobectomy or bilobectomy (1070; 85%) or pneumonectomy (185; 15%) for cancer (1037; 83%) or other problems. Severe cardiovascular complications occurred in 30 patients (2.4%), an incidence similar to that in the published derivation group (3.3%). ThRCRI median scores in patients without and with severe CV complications were 0 and 1.5 (P < 0.001). Score categories yielded incremental risks of cardiovascular complications (0: 0.9%; 1-1.5: 4.5%; ≥ 2: 12.8%; P < 0.001). The Hosmer-Lemeshow test demonstrated no significant difference between expected and observed outcomes (P = 0.11).

CONCLUSIONS

The incidences of severe postoperative cardiovascular complications were similar in the published derivation group and the current validation group. The ThRCRI score successfully stratified risk for postoperative cardiovascular events after major lung resection in the validation group. The expected risk in the validation group was similar to the observed risk, indicating that ThRCRI accurately predicted specific risk rather than just relative risk. Further evaluation of the utility of this scoring system is warranted.

A sphingosine 1-phosphate 1 receptor agonist modulates brain death-induced neurogenic pulmonary injury

Lung transplantation remains the only viable therapy for patients with end-stage lung disease. However, the full utilization of this strategy is severely compromised by a lack of donor lung availability. The vast majority of donor lungs available for transplantation are from individuals after brain death (BD). Unfortunately, the early autonomic storm that accompanies BD often results in neurogenic pulmonary edema (NPE), producing varying degrees of lung injury or leading to primary graft dysfunction after transplantation. We demonstrated that sphingosine 1-phosphate (S1P)/analogues, which are major barrier-enhancing agents, reduce vascular permeability via the S1P1 receptor, S1PR1. Because primary lung graft dysfunction is induced by lung vascular endothelial cell barrier dysfunction, we hypothesized that the S1PR1 agonist, SEW-2871, may attenuate NPE when administered to the donor shortly after BD. Significant lung injury was observed after BD, with increases of approximately 60% in bronchoalveolar lavage (BAL) total protein, cell counts, and lung tissue wet/dry (W/D) weight ratios. In contrast, rats receiving SEW-2871 (0.1 mg/kg) 15 minutes after BD and assessed after 4 hours exhibited significant lung protection (∼ 50% reduction, P = 0.01), as reflected by reduced BAL protein/albumin, cytokines, cellularity, and lung tissue wet/dry weight ratio. Microarray analysis at 4 hours revealed a global impact of both BD and SEW on lung gene expression, with a differential gene expression of enriched immune-response/inflammation pathways across all groups. Overall, SEW served to attenuate the BD-mediated up-regulation of gene expression. Two potential biomarkers, TNF and chemokine CC motif receptor-like 2, exhibited gene array dysregulation. We conclude that SEW-2871 significantly attenuates BD-induced lung injury, and may serve as a potential candidate to improve human donor availability.

Early readmission is a predictor of overall survival following isolated lung transplantation

Causes of early readmissions following lung transplantation are not well understood, and the impact is poorly reported. We reviewed 221 consecutive lung transplantations and identified patients readmitted within 90 days. A case control analysis was performed to determine the characteristics that predict readmission and the impact of readmission on survival. Ninety (44%) of the 205 operative survivors required a total of 125 readmissions during the 90 days after transplantation. Twenty-eight patients (13.7%) required multiple readmissions. Causes for readmissions were pulmonary complication (59%), gastrointestinal (18%), cardiac (5%), metabolic (2.5%), neurological (2.5%), hematological (2%), and miscellaneous (11%). The sex, native disease, or type of transplant did not predict readmission. Requirement of cardiopulmonary bypass for transplantation showed a trend toward significance (P = 0.08). The 90-day conditional survival at 1, 3, and 5 years for those patients readmitted within 90 days were 76%, 59%, and 52%, respectively, compared to 93%, 80%, and 76% for patients not readmitted (P = 0.01). Requirement for readmission within 90 days following transplantation is associated with increased mortality. Sex, native disease, and type of transplant are not predictors of readmission or survival.

Cylex ImmuKnow assay levels are lower in lung transplant recipients with infection

BACKGROUND

Current monitoring systems of immunosuppression in solid-organ transplant recipients are typically focused on prevention of clinical toxicities of immunosuppressive drugs. Unfortunately, these strategies are often not tailored to the individual and do not determine the optimal level of immunosuppression for these patients. Recently, the Cylex Immune Cell Function Assay (ImmuKnow; Cylex, Inc., Columbia, MD) was approved by the U.S. Food and Drug Administration (FDA) to measure global immune response in solid-organ transplant patients receiving immunosuppressive therapy. We sought to identify the level of functional immunity as measured by the ImmuKnow assay in lung transplant recipients and to correlate these values with the dose and trough levels of immunosuppression as well as other clinical parameters in lung transplant recipients.

METHODS

We assessed the functional immune response by the ImmuKnow assay in 143 sequential blood samples from 57 lung transplant recipients from Loyola University Medical Center.

RESULTS

The average ImmuKnow assay in stable lung transplant recipients was 244 +/- 138 adenosine triphosphate (ATP) ng/ml and the median level was 236 ATP ng/ml (range 5 to 669 ATP ng/ml), approximately 703 +/- 695 days after lung transplantation. There was no correlation between ImmuKnow levels and tacrolimus trough levels. Stepwise multiple regression analysis identified African American race as an independent predictor of ImmuKnow assay levels when age, gender and underlying diagnosis were taken into account (p < 0.04). Fifteen infected lung transplant recipients had a lower ImmuKnow level at the time of their infections as compared with stable lung transplant recipients (111 +/- 83 vs 283 +/- 143 ATP ng/ml, respectively, p = 0.0001). Sixteen of the remaining 42 patients had low ImmuKnow assay values (<225 ATP ng/ml), but did not have active infection. There were only 2 patients with acute rejection of Grade A1 in this cohort. There were no identifiable associations of the ImmuKnow level with either acute rejection episode.

CONCLUSIONS

The Cylex ImmuKnow assay levels were lower in infected lung transplant recipients compared with non-infected recipients and increased with treatment of these infections. It remains unclear whether the ImmuKnow assay reflects over-immunosuppressed individuals at risk of infection or bone marrow suppression by infectious agents. Further investigation will determine the role of the ImmuKnow assay in tailoring immunosuppression in lung transplant recipients.

A scoring system predicting the risk for intensive care unit admission for complications after major lung resection: a multicenter analysis

BACKGROUND

We aimed to develop and validate a scoring system to predict intensive care unit (ICU) admission for complications after major lung resection for purposes of optimizing planning of resources for patient care.

METHODS

Patients undergoing major lung resections performed between 2000 and 2006 at three thoracic surgery units were analyzed for unplanned admission to the ICU for complications. Variables were initially screened by univariate analysis. Selected variables were used in a stepwise logistic regression analysis that was validated by bootstrap analysis. The scoring system was developed by proportional weighting of the significant and reliable predictors estimates and validated on patients operated on in a different center.

RESULTS

In the derivation set of 1297 patients, 82 (6.3%) had ICU admission for complications, and 30 died (associated mortality rate, 36.5%). Predictive variables and their scores were pneumonectomy, 2 points; and 1 point each for age older than 65, predicted postoperative forced expiratory volume in 1 second below 65%, predicted postoperative carbon monoxide lung diffusion capacity below 50%, and cardiac comorbidity. Patients were grouped into three risk classes by their scores, which were significantly associated with incremental risk of ICU admission in the validation set of 349 patients.

CONCLUSIONS

This scoring system predicts incremental risk of ICU admission for complications after major lung resection. This system may help in assessing the need for additional postoperative resources and in modifying indicators used to determine the appropriateness of initial transfer of postoperative patients from ICU or stepdown status and in developing criteria for future cost-effectiveness trials.

Elevation of interleukin-15 protein expression in bronchoalveolar fluid in acute lung allograft rejection

BACKGROUND

Acute rejection remains a major source of morbidity in lung transplantation. Although interleukin (IL)-2 has been the principal T-cell growth factor implicated in acute rejection, IL-2 blockade does not prevent acute rejection completely. Recently, IL-15, a stromal cell-derived cytokine, has been found to share a similar biological function with IL-2. We hypothesized that IL-15 levels may be elevated in acute lung rejection in the presence of IL-2 blockade.

METHODS

Acute allograft rejection developed in 21 of 42 lung transplant recipients. BAL fluid (BALF) was analyzed for IL-2 and IL-15 protein expression by standard enzyme-linked immunosorbent assay.

RESULTS

The average (+/- SD) BALF IL-15 level was higher in lung transplant recipients with acute rejection compared to those without rejection (25 +/- 25 pg/mL vs 4.5 +/- 1.5 pg/mL, respectively; p < 0.0001). In addition, there appeared to be a bimodal distribution of BALF IL-15 levels in lung transplant recipients with acute rejection. BALF IL-2 levels were not associated with acute rejection. BALF IL-15 levels were not associated with bacterial, fungal, or cytomegalovirus infection.

CONCLUSION

These data show that BALF IL-15 levels are elevated in acute lung allograft rejection in the presence of IL-2 receptor blockade and may be an important mediator for acute rejection in lung transplantation.

Clinical pathway after lung transplantation shortens hospital length of stay without affecting outcome

Transplant programs are under pressure to resolve multiple challenges related to quality, cost, and access in a resource-driven customer-focused health care environment. We reviewed outcomes of patients undergoing isolated lung transplantation using a single postoperative clinical pathway, developed between the specialties of Thoracic Surgery, Pulmonary and Critical Care Medicine, and Nursing. The data were retrospectively reviewed for mortality, length to extubation (LE), hospital length of stay (LOS), and readmissions of 183 consecutive patients. One hundred ten women and 73 men with a mean age of 48 +/- 12 years underwent 90 bilateral, 88 single, and 6 repeat lung transplantations. Median LE was 17 hours, and the LOS was 7 days. The operative mortality was 6.5%. One- and 3-year survivals were 82% and 73%, respectively. We conclude that a single multidisciplinary clinical pathway can facilitate early discharge from the hospital. Early hospital discharge after lung transplantation does not compromise early or late outcome.

Sequential gene expression profiling in lung transplant recipients with chronic rejection

STUDY OBJECTIVES

Chronic allograft rejection is the leading cause of morbidity and mortality for long-term survivors of lung transplantation. Previous studies have implicated only isolated genes in the development of chronic rejection and have not examined multiple pathways in an individual concurrently. Using microarray technology, we identified and compared gene expression profiling in lung transplant recipients with and without chronic rejection, and follow sequential expression of genes differentially expressed between the two groups.

DESIGN

Prospective, cohort study.

SETTING

Single lung transplant center.

PATIENTS OR PARTICIPANTS

Eleven transplant recipients with chronic rejection were matched with 9 control transplant recipients.

INTERVENTIONS

All recipients underwent surveillance bronchoscopies at predetermined times to rule out infection and/or acute rejection. Gene expression profiling was obtained from hybridizing BAL fluid cell RNA to a 96-gene microarray.

MEASUREMENTS AND RESULTS

Fifteen genes were found to be significantly differentially expressed between the two patient groups, and they are involved in inflammatory, fibrotic, and apoptotic pathways. Temporal expression of the significant genes demonstrated a change in their levels at the onset of chronic rejection, with normalization to prerejection levels as rejection continued.

CONCLUSIONS

We conclude that microarray technology is valuable in studying the mechanism of chronic lung rejection, and the expression of genes in multiple pathways is elevated in patients with chronic lung rejection.

Intraabdominal complications after lung transplantation

BACKGROUND

Because more lung transplant recipients survive the perioperative period, nonpulmonary complications become a major source of morbidity and mortality. Of these, intraabdominal complications are of particular concern because of the potential need for surgical intervention. So appropriate management of these complications becomes paramount.

STUDY DESIGN

We retrospectively reviewed 229 lung transplant recipients in a university medical center, between January 1997 and December 2004 developed in forty-seven patients. Abdominal complications. Detailed reviews of these patients' hospital charts were performed. Complications were categorized as early or late depending on if they occurred within 30 days of transplantation or later. The primary outcomes variable studied was mortality.

RESULTS

Fifty-three surgical consultations for abdominal symptoms were requested in these 47 patients. Twenty-two of the 47 patients (47%) with intraabdominal complications required 24 operative interventions. Overall 5-year survival was substantially worse in patients with intraabdominal complications (34%) than in those without (62%, p=0.01). There was no marked difference in the 30-day mortality for patients experiencing early (27%, 4 of 15) versus late (24%, 9 of 38) complications. Mortality in patients with intraabdominal complications was lower among those treated operatively (n=2, 9%) compared with those treated nonoperatively (n=11, 44%, p=0.02).

CONCLUSIONS

Mortality for patients with intraabdominal complications is high after lung transplantation. Operative intervention is well tolerated and associated with lower mortality. A high index of suspicion and timely operative intervention are necessary for the treatment of intraabdominal complications in lung transplant recipients.

Inflammatory Sarcomatoid Carcinoma: A Case Report and Discussion of a Malignant Tumor With Benign Appearance

Inflammatory sarcomatoid carcinoma is an aggressive tumor with an unusually benign appearance. We report the case of a 65-year-old man with a history of inoperable poorly differentiated carcinoma of the right lung, for which he had received chemoradiotherapy. A new solitary mass was discovered 4 years later in the left lung on surveillance computed tomography. The patient underwent thoracotomy with a wedge biopsy on which frozen section was performed. The nodule was vaguely granulomatous and associated with a mixed inflammatory infiltrate and a deceptively bland spindle cell proliferation. Results of immunoperoxidase studies, however, showed that the nodule contained neoplastic cells with an epithelial phenotype that were invading the pulmonary vessels. These are features of the rare inflammatory sarcomatoid carcinoma. In contrast to sarcomatoid carcinomas, this case highlights the deceptively benign appearance of inflammatory sarcomatoid carcinoma. This leads us to concur with the recommendation to exercise caution when attempting the diagnosis of apparently benign lesions on intraoperative frozen section in patients with high clinical suspicion of malignancy.