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Background: The aim of this study was to assess the difference (Δ) in neutrophil to lymphocyte ratio (NLR), before and after chemoradiotherapy, as a predictor of treatment response and a prognostic factor for recurrence and disease-free survival in patients with esophageal squamous cell cancer treated with chemoradiotherapy with or without surgery., Methods: Patients with locally advanced esophageal squamous cell cancer treated with chemoradiation with and without surgery who had a complete blood count before and after chemoradiotherapy were included. Pretreatment and posttreatment NLR were calculated by dividing the absolute neutrophil count by the absolute lymphocyte count. The ΔNLR was defined as posttreatment minus pretreatment NLR. Characteristics were evaluated for association with ΔNLR using the Wilcoxon signed rank test or the Kruskal-Wallis test. Risk of recurrence and disease-free survival were evaluated using Gray's and the log rank tests, respectively., Results: We included 217 patients. Of them, 133 patients (61.3%) received only chemoradiotherapy and 84 (38.7%) underwent surgery after chemoradiotherapy. Among the surgical patients, 43% with pathologic complete response showed significantly lower median ΔNLR than patients with residual disease (-0.03 versus 1.04, p = 0.004). High ΔNLR was a negative predictor of treatment response (odds ratio 0.77, 95% confidence interval: 0.62 to 0.9, p = 0.004). A significant association between high ΔNLR and increased risk of recurrence was also identified., Conclusions: The ΔNLR was inversely related to pathologic complete response and associated with risk of recurrence. This simple test, in concert with other clinical tools, can help identify patients with pathologic complete response., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Surgeons are increasingly asked to operate on patients with residual disease after immunotherapy. The safety and utility of lung resection in this setting are unknown., Methods: We retrospectively reviewed patients who underwent lung resection within 6 months of treatment with checkpoint blockade agents for metastatic or unresectable cancer. Survival was estimated from the first resection using the Kaplan-Meier approach., Results: Database query identified 19 patients who underwent 22 resections for suspected residual disease with therapeutic intent after immunotherapy between 2012 and 2016. Lung cancer was the most common diagnosis (47%), followed by metastatic melanoma (37%). The most frequently used agents were nivolumab (32%), pembrolizumab (32%), and ipilimumab (16%). Patients received a mean of 21 doses (range, 1 to 70 doses). The final dose was administered at an average of 75 days (range, 7 to 183 days) before the operation. Anatomic resection (lobectomy or greater) was performed in 11 patients (50%). Four lobectomies were attempted minimally invasively, and one required conversion to thoracotomy. Of the resected patients, 68% had viable tumor remaining. R0 resection was achieved in 95%. Mean operative time for lobectomy was 227 minutes (range, 150 to 394 minutes). Complications occurred in 32% of patients; all but 1 were minor (grade 1/2). The 2-year overall and disease-free survival were 77% and 42%, respectively., Conclusions: In patients with previously metastatic or unresectable cancer, lung resection for suspected residual disease after immunotherapy is feasible, with high rates of R0 resection. Operations can be technically challenging, but significant morbidity appears to be rare. Outcomes are encouraging, with reasonable survivals during short-interval follow-up., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: Postoperative atrial fibrillation (POAF) complicating general thoracic surgery is a marker of increased morbidity and stroke risk. Our goal was to determine whether increased preoperative brain natriuretic peptide (BNP) levels are able to stratify patients by the risk of POAF., Methods: Using a prospective database of 415 patients aged 60 years or older, who had undergone lung or esophageal surgery during a 1-year period, the preoperative clinical data, including BNP levels, were compared between patients who developed POAF lasting longer than 5 minutes during hospitalization and those who did not., Results: POAF occurred in 65 (16%) of the 415 patients and was more frequent among patients who had undergone esophagectomy or anatomic lung resection (22% or 58 of 269) compared with those who did not (5% or 7 of 146; P < .0001). After esophagectomy or anatomic lung resection, 46 (34%) of the 135 patients with BNP levels greater than the median (≥ 30 pg/mL) developed POAF compared with only 12 (9%) of 134 patients with BNP levels less than 30 pg/mL (P < .0001). The rates of POAF in patients undergoing other thoracic procedures were low and not associated with the BNP levels. Multivariate logistic regression analysis showed that in patients undergoing esophagectomy or anatomic lung resection, older age (5-year increments, odds ratio [OR], 1.28; 95% confidence interval [CI], 1.01-1.61; P = .04), male gender (OR, 2.61; 95% CI, 1.12-4.17; P = .02), and BNP level 30 pg/mL or greater (OR, 4.52; 95% CI, 2.19-9.32; P < .0001) were independent risk factors for POAF. The length of hospital stay was significantly increased in patients who developed POAF compared with those who did not (P < .0001)., Conclusions: Among patients undergoing anatomic lung resection or esophagectomy, increased age, male gender, and preoperative BNP level of 30 pg/mL or greater were significant risk factors for the development of POAF. The identification of patients who are more likely to develop POAF will allow the development of trials assessing prevention strategies aimed at reducing this complication., (Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Reports have questioned the oncologic efficacy of video-assisted thoracoscopic surgery when compared with thoracotomy despite similar survival results. In response, we investigated the pattern of recurrent disease and the incidence of second primary tumors after lobectomy by means of video-assisted thoracoscopic surgery and thoracotomy., Methods: All patients who underwent lobectomy for clinical stage IA lung cancer determined by means of computed tomographic and positron emission tomographic analysis were identified from a prospective database at a single institution. All patients were selected for video-assisted thoracoscopic surgery or thoracotomy by an individual surgeon. Patients' characteristics, perioperative results, recurrences, and second primary tumors were recorded. Variables were compared by using Student's t test, the Pearson χ(2) test, and Fisher's exact test. A logistic regression model was constructed to identify variables influencing the development of recurrent disease or metachronous tumors., Results: From 2002 to 2009, 520 patients underwent lobectomy by means of video-assisted thoracoscopic surgery, and 652 underwent lobectomy by means of thoracotomy. Final pathological stage was similar in the video-assisted thoracoscopic surgery and thoracotomy groups. Logistic regression demonstrated a lower risk (odds ratio, 0.65; P = .01) of recurrent disease in patients undergoing video-assisted thoracoscopic surgery after adjusting for age, stage, sex, histology, tumor location, and synchronous primary tumors., Conclusions: Recurrence rates for video-assisted thoracoscopic surgery appear to be at least equivalent to those for thoracotomy. This study supports lobectomy by means of video-assisted thoracoscopic surgery as an oncologically sound technique., (Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Purpose: In patients with adenocarcinoma of the esophagus who receive preoperative chemoradiotherapy (CRT), American Joint Committee on Cancer (AJCC) stage, pathologic complete response (pCR), and estimated treatment response are various means used to stratify patients prognostically after surgery. However, none of these methods has been formally evaluated. The purpose of this study was to establish prognostic pathologic variables after CRT., Patients and Methods: A retrospective review was performed of patients with esophageal adenocarcinoma who received CRT before esophagectomy. Data collected included demographics, CRT details, pathologic findings, and survival. Statistical methods included recursive partitioning and Kaplan-Meier analyses., Results: Two hundred seventy-six patients were appropriate for this analysis. Kaplan-Meier analysis indicates that the current AJCC system poorly distinguishes between stages 0 to IIA (P = .52), IIB to III (P = .87), and IVA to IVB (P = .30). The presence of a pCR conferred improved survival over residual disease (P = .01). Recursive partitioning analysis indicates that involved lymph nodes and metastatic disease are the best predictors of survival and that depth of invasion and degree of treatment response are less predictive., Conclusion: The current AJCC staging system is not a good predictor of survival after CRT. Although patients with a pCR do have improved long-term survival relative to patients with residual disease, this method places too much emphasis on residual depth of invasion and fails to identify patients with residual disease who have good long-term survival. Recursive partitioning analysis more accurately identifies nodal disease and metastatic disease as the most important prognostic variables. Degree of treatment response is less prognostic than nodal involvement.

Unlabelled: Primary solitary plasmacytoma and Ewing's sarcoma of the chest wall are relatively uncommon tumors, and data concerning treatment and results are sparse. To assess the results of therapy we reviewed our 40-year experience., Methods: Records of 24 patients with solitary plasmacytoma and 62 with Ewing's sarcoma arising in the chest wall who were admitted to our institution from 1949 to 1989 were reviewed., Results: In the group with plasmacytoma (n = 24), ages ranged from 35 to 75 years (median 59 years); male/female ratio was 2.4:1. The presenting complaint was pain or mass or both in 92% (22/24). Primary therapy was local only in 5 (resection in 3, radiotherapy in 2), chemotherapy in 16 (resection in 5, radiotherapy in 10, and chemotherapy alone in 1); 3 patients did not receive therapy. Multiple myeloma developed subsequently in 75% (18/24). Overall 5-year survival was 38% (median 56 months). Age, sex, site of primary tumor, and local therapy did not significantly impact on survival. Ages in the patients who had Ewing's sarcoma (n = 62) ranged from 2 to 39 years (median 16 years); male/female ratio was 1.6:1. Presenting complaint was pain or mass or both in 98% (61/62). Primary therapy was local in 17 (resection in 7, radiotherapy in 7, resection plus radiotherapy in 3) and chemotherapy in 45 (plus resection in 29, resection and radiotherapy in 10, and radiation therapy alone in 3). Overall 5-year survival was 48% (median 57 months). Age, sex, and site of primary tumor did not significantly impact on survival. Patients in whom distant metastases developed (n = 48) had a significantly decreased survival (5 year, 28%) compared with those who did not have metastases (n = 14; 5 year, 100%)., Conclusion: Plasmacytoma of the chest wall, even if solitary at presentation, should be considered a systemic disease, and therapy should be directed as such. For Ewing's sarcoma, although resection or radiotherapy may offer local control, because of the prevalence of distant metastases (77%), systemic therapy should be considered an integral part of treatment.