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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.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.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).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.

BACKGROUND Contemporary data on lung volume reduction surgery (LVRS) is sparse, particularly in regard to utilization and surgical outcomes. In this context, we analyzed the practice patterns and outcomes of LVRS nationally. METHODS We identified all patients (n = 1617) undergoing LVRS at 165 hospitals between 2001 and 2017 from The Society of Thoracic Surgeons (STS) General Thoracic Database. Practice patterns were assessed at the hospital and STS regional levels. In addition, we obtained regional chronic obstructive pulmonary disease prevalence data from the Centers for Disease Control. We used hierarchical logistic regression to estimate associations with each outcome of interest and calculate risk- and reliability-adjusted outcome rates. RESULTS Since 2011, national LVRS utilization has been increasing with decreasing mortality rates (3.1% risk-adjusted mortality in 2016). There is wide regional variation in LVRS average caseload that is not congruent with national chronic obstructive pulmonary disease prevalence (Pearson correlation coefficient -0.11). On multivariable analysis, only older age (adjusted odds ratio 1.05, P < .001), male sex (adjusted odds ratio 1.5, P = .007), underweight body mass index (adjusted odds ratio 1.94, P = .027), and ECOG score of 4 (adjusted odds ratio 5.17, Z-score 3.91, P = .001) were associated with the occurrence of the composite outcome of major morbidity or mortality. At the hospital level, six hospitals performed 40% of all LVRS nationally with adjusted national 30-day mortality rate of 4.3% and composite outcome rate of 15.8%. Despite this, there was minimal variation in adjusted outcome rates. CONCLUSIONS National utilization of LVRS is increasing and it has become safer overall, even at lower volume hospitals. There is regional variation in LVRS use that does not mirror national chronic obstructive pulmonary disease prevalence, suggesting access disparities. The findings have potential policy implications.

In December 2013, the United States Preventative Services Task Force (USPSTF) recommended annual lung cancer screening for high-risk patients. The Centers for Medicare and Medicaid Services (CMS) later announced coverage in 2015. The impact of these federal decisions at the population-level is unknown.Using the Surveillance, Epidemiology, and End Results (SEER) database, we studied changes in lung cancer incidence by stage and linked to US census data to obtain age-adjusted estimates standardized to the US population. Based on age at diagnosis, we stratified patients as age-eligible or age-ineligible for screening. We used difference-in-differences regression to determine the effect of screening on lung cancer incidence by stage.For all age groups, the incidence of early-stage lung cancer both before- and after- the USPSTF guidelines remained relatively stable at 12.8±0.52 and 13.5±0.92 per 100,000 patients, respectively (p=0.068). However, the difference-in-differences analysis estimated an absolute increase in the age-adjusted incidence by 3.4 per 100,000 persons in the age-eligible group after the announcement of the guidelines (p=0.007). The effect was even larger after the CMS decision (4.3 per 100,000 persons; p0.001). Similarly, there was a 14.2 per 100,000 persons absolute reduction in the incidence of advanced-stage lung cancer (p0.001).The 2013 USPSTF lung cancer screening guidelines and CMS coverage decisions were associated with an increased incidence of early-stage lung cancer and decreased incidence of advance-staged lung cancer at the population-level.

A preoperative type and screen (TS) is traditionally routinely obtained before noncardiac thoracic surgery; however an intraoperative blood transfusion is rare. This practice is overly cautious and expensive.We included adult patients undergoing major thoracic surgery at the Mayo Clinic from 2007 to 2016. Patients receiving a TS blood test ≤72 hours of surgery was the main exposure. We randomly split the cohort into derivation and validation datasets. We used multiple logistic regression to create a parsimonious nomogram predicting the need for a TS in relation to the likelihood of intraoperative blood transfusion. We validated the nomogram in terms of discrimination, calibration, and negative predictive value.Of 6280 patients 46.1% had a preoperative TS, but only 7.1% received intraoperative transfusions. The derivation dataset had 4196 patients. Patients who had a TS were more likely to have baseline hemoglobin level10 g/dL (7.9% vs 3.6%, P.001) and less likely to have minimally invasive operations (36.1% vs 43.5%, P.001) but were otherwise similar in baseline age and comorbidities. A transfusion threshold of 5% was selected a priori. The nomogram included age, planned operation, approach, body mass index, and preoperative hemoglobin. The nomogram was validated with a c-statistic of 86% and a negative predictive value of 97.9%. Patients who needed a blood transfusion but who did not have a preoperative TS did not have a higher rate of mortality (P = .121).An intraoperative blood transfusion during major thoracic surgery is a rare event. Patient who required transfusion but did not have a TS did not have worse outcomes. A simple nomogram can aid in the selective use of TS orders preoperatively.

The National Lung Screening Trial (NLST) established a role for lung cancer screening. Mortality benefits with screening are predicated on successful treatment with low surgical mortality. Given variations observed in perioperative outcomes after lung cancer resection, it remains unknown whether benefits observed in the NLST are generalizable to a broader population. We sought to determine whether NLST perioperative outcomes are reflective of contemporary practice in a national cohort.We identified patients diagnosed with non-small cell lung cancer who underwent lung resection in the 2014 to 2015 National Cancer Database (NCDB) and the NLST. We compared demographic and cancer characteristics in both datasets. We used hierarchical logistic regression to compare 30-day and 90-day postoperative mortality across facilities in both datasets.In all, 65054 patients in NCDB and 1003 patients in the NLST treated across 1119 NCDB hospitals and 33 NLST hospitals were included. After risk and reliability adjustment, mean 30-day and 90-day mortality were significantly higher among NCDB hospitals (mean 30-day, 2.2 [95% confidence interval (CI), 2.2 to 2.2] vs 1.8 [95% CI, 1.8 to 1.8], P .001; mean 90-day, 4.2 [95% CI, 4.2 to 4.3] vs 2.9 [95% CI, 2.9 to 2.9], P.001). Variation in risk- and reliability-adjusted 30-day mortality (95% CI, 1.1% to 4.9%) and 90-day mortality (95% CI, 2.6% to 9.7%) was observed among NCDB hospitals. Adjusted mortality was similar among NLST facilities (30 days, 1.8% to 1.8%; 90 days, 2.9% to 2.9%).Risk- and reliability-adjusted postoperative mortality varies widely in a national cohort compared with outcomes observed in the NLST. Efforts to minimize this variation are needed to ensure that benefits of lung cancer screening are fully realized in the United States.

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.

The ideal surgical reconstruction of the aortic root in patients with complex endocarditis is controversial. We compared the short- and long-term outcomes between mechanical valves, bioprostheses, and homografts.We identified all patients undergoing an operation for active complex aortic endocarditis at our institution between 2003 and 2017. We grouped patients according to those who received a mechanical valve, bioprosthesis, or homograft. We used multiple logistic regression and proportional hazards models. To minimize confounding by indication, we used marginal risk adjustment to simulate that every patient would undergo (contrary to fact) all 3 operations.Of 159 patients with complex active endocarditis, 48 (30.2%) had a valve plus patch reconstruction, and 85 (53.4%) had a root replacement. Of all, 50 (31.5%) had a mechanical valve, 56 (35.2%) had a bioprosthesis, and 53 (33.3%) had a homograft. The groups were similar in age, sex, body mass index, comorbid conditions, organism, abscess location, and mitral involvement (all P.05). However, patients receiving mechanical reconstructions were more likely to have native valve endocarditis (46% vs 37.5% vs 17%; P = .005) and less likely to undergo root replacement (32% vs 28.6% vs 100%; P.001). Marginal risk-adjusted operative mortality was lowest for mechanical valves (4.8%) and highest for homografts (16.9%; P = .041). Long-term survival after root replacement was worse with homografts than with mechanical valve conduits (adjusted hazard ratio, 2.9; P = .045).In patients with complex endocarditis, mechanical valves are associated with similar, if not better, short- and long-term outcomes compared with homografts, even after adjusting for important baseline characteristics and limiting the analysis to root replacements only.

Data on failure to rescue (FTR) after esophagectomy are sparse. We sought to better understand the patient factors associated with FTR and to assess whether FTR is associated with hospital volume.We identified all patients undergoing esophagectomy between 2010 and 2014 from the Agency for Healthcare Research and Quality Nationwide Readmission Database. We defined FTR as mortality after a major complication. Multiple logistic regression was used to identify patient factors and hospital-volume associations with FTR.Of 26,820 patients undergoing an esophagectomy, 7130 (26.6%) experienced a major complication. Of those, 1321 did not survive the index hospitalization (FTR rate, 18.5%). Risk factors for FTR included increasing age (adjusted odds ratio [aOR], 1.06; P.001), congestive heart failure (aOR, 2.07; P.001), bleeding disorders (aOR, 2.9; P.001), liver disease (aOR, 2.37; P = .001), and renal failure (aOR, 2.37; P = .002). At the hospital level there was wide variation in FTR rates across hospital volume quintiles, with 21.2% of patients suffering a complication not surviving to discharge at low-volume hospitals compared with 13.4% at high-volume hospitals (P.001). At low-volume hospitals the highest FTR rates were acute renal failure (35.3%), postoperative hemorrhage (31.9%), and pulmonary failure (28.1%).One in 5 esophagectomy patients suffering a complication at low-volume hospitals do not survive to discharge. Several patient factors are associated with death after a major complication. Strategies to improve the recognition and management of complications in at-risk patients may be essential to improve outcomes at low-volume hospitals.

When identified, rib fractures in children are associated with high-energy trauma, nonaccidental trauma, or both. Traditionally, the optimal management of rib fractures in children is supportive care. In this case report, we present a 6-year-old boy who underwent surgical rib fixation for multiple displaced and comminuted rib fractures after being stepped on by a horse.

Malignant pleural mesothelioma (MPM) remains an aggressive malignancy that is difficult to cure. However, the treatment paradigm of MPM has evolved, and the national practice patterns are unknown. This study examined the national trends in the epidemiology, national treatment patterns, and survival of patients with this disease.We identified all patients (n = 19,134) with MPM from the National Cancer Data Base from 2004 to 2013. We analyzed patient, tumor characteristics, and treatment patterns using descriptive statistics and used Kaplan-Meier and Cox proportional hazards models to estimate survival stratified by the type of therapy administered.Four histologic subtypes were represented in the National Cancer Data Base, these included sarcomatoid (n = 2,355 [12.3%]), epithelioid (n = 6,858 [35.8%]), biphasic (n = 13,617 [11%]), and not otherwise specified (n = 8,560 [44.7%]). Across all subtypes, the prevalence of mesothelioma was highest among white men. Sarcomatoid had the worst survival (adjusted hazard ratio, 2.2; p0.001). Most patients did not receive any specific modality of treatment (40.2%). Chemotherapy alone was the most common treatment used (31.8%). Trimodality treatment with chemotherapy, surgical resection, and radiation therapy was associated with the best survival (adjusted hazard ratio, 0.43; p0.001), followed by combination chemotherapy and resection (adjusted hazard ratio, 0.49; p 0.001).This is the first publication to date to analyze the mesothelioma National Cancer Data Base. Although survival remains poor, multimodality therapy with surgical resection is associated with the best survival for MPM. Further research is needed to improve survival and overall patient outcomes.

Background This study examined the variation in the adoption of video-assisted thoracoscopic surgery (VATS) for lobectomy across United States hospitals from a population-based national database. Methods We used the National Cancer Data Base to identify patients undergoing lobectomy between 2010 and 2012 and used hierarchical regression to estimate case-mix–adjusted VATS lobectomy rates using patient and tumor characteristics. We stratified hospitals into quintiles by adjusted VATS lobectomy rates. To account for lack of equipment to perform minimally invasive thoracoscopic operations, we also obtained data on VATS wedge resections. Results Of 55,972 cancer lobectomies performed at 905 hospitals, 17,072 (30.5%) were VATS. Crude hospital VATS use varied widely (mean was 25.5% of all lobectomies per hospital; interquartile range, 4.4% to 42.3%). Variation persisted after case-mix adjustment. For example, VATS rates at the highest and lowest quintiles were 76% vs 0.6%, respectively. Differences in patient and tumor characteristics across quintiles were negligible, and there was no indication that those hospitals lacked VATS equipment. The risk-adjusted same-hospital readmission (6.7% vs 7%; p > 0.2), 30-day mortality (1.5% vs 1.5%; p > 0.2), and 90-day mortality (2.9% vs 2.7%; p = 0.038) rates were similar between the highest and lowest quintiles. Length of stay was shorter at hospitals in the highest VATS quintile (6.6 vs 7.4 days; p Conclusions Adoption of VATS lobectomy varies widely across United States hospitals. This variation cannot be explained by patient or tumor characteristics or by a shortage of VATS equipment. Efforts to reduce this variation will require the dissemination and implementation of novel training techniques and learning opportunities for surgeons.