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Background: Despite demonstration of its clear benefits relative to open approaches, a video-assisted thoracic surgery technique for pulmonary lobectomy has not been universally adopted. This study aims to overcome potential barriers by establishing the essential components of the operation and determining which steps are most useful for simulation training., Methods: After randomly selecting experienced thoracic surgeons to participate, an initial list of components to a lower lobectomy was distributed. Feedback was provided by the participants, and modifications were made based on anonymous responses in a Delphi process. Components were declared essential once at least 80% of participants came to an agreement. The steps were then rated based on cognitive and technical difficulty followed by listing the components most appropriate for simulation., Results: After 3 rounds of voting 18 components were identified as essential to performance of a video-assisted thoracic surgery for lower lobectomy. The components deemed the most difficult were isolation and division of the basilar and superior segmental branches of the pulmonary artery, isolation and division of the lower lobe bronchus, and dissection of lymphovascular tissue to expose the target bronchus. The steps determined to be most amenable for simulation were isolation and division of the branches of the pulmonary artery, the lower lobe bronchus, and the inferior pulmonary vein., Conclusions: Using a Delphi process a list of essential components for a video-assisted thoracic surgery for lower lobectomy was established. Furthermore 3 components were identified as most appropriate for simulation-based training, providing insights for future simulation development., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Social Determinants of Health (SDOH) can be important contributors in health care outcomes. We hypothesized that certain SDOH independently impact the management and outcomes of stage I Non-Small Cell Lung Cancer (NSCLC)., Study Design: Patients with clinical stage I NSCLC were identified from the National Cancer Database. The impact of SDOH factors on utilization of surgery, perioperative outcomes and overall survival were examined, both in bivariate and multivariable analyses., Results: A total of 236,140 patients were identified. In multivariate analysis, SDOH marginalization were associated with less frequent use of surgery, lower 5-year survival and, in surgical patients, more frequent use of open surgery and lower 90-day postoperative survival., Conclusion: SDOH disparities have a significant impact in the management and outcomes of stage I NSCLC. We identified SDOH patient groups particularly impacted by such disparities, in which higher utilization of surgery and minimally invasive approaches may lead to improved outcomes., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: There are various treatment options for esophageal squamous cell cancer. including surgery, peri-operative chemotherapy, and radiation. More recently, neoadjuvant immunotherapy has also been shown improve outcomes. In this study, we addressed the question, "Can we predict which patients with esophageal squamous cell cancer will benefit from neoadjuvant immunotherapy?"., Methods: All patients with thoracic esophageal squamous-cell carcinoma (T2N+M0-T3-4N0/+M0) (according to the eighth edition of the National Comprehensive Cancer Network guidelines) who underwent immune neoadjuvant immunochemotherapy with programmed cell death protein 1 (PD-1) combined with paclitaxel plus cisplatin or nedaplatin in the Affiliated Cancer Hospital of Zhengzhou University, China, between November 2019 and August 2021 were included in this study. All patients underwent surgical resection. We developed a response [tumor regression grade (TRG)] prediction model using the least absolute shrinkage and selection operator (LASSO) regression incorporating factors associated with response. The accuracy of the prediction model was then validated., Results: We included 79 patients who underwent neoadjuvant immunotherapy combined with chemotherapy, aged 48-78 years (62.05±6.67), including 21 males and 58 females. There were five cases of immune-related pneumonia, of which three cases were diagnosed as immune-related pneumonia during the perioperative period, and one case of immune-related thyroid dysfunction changes. After LASSO regression, the factors that were independently associated with TRG were clinical T stage before neoadjuvant therapy, clinical N stage before neoadjuvant therapy, albumin level difference from before to after neoadjuvant therapy, white blood cell (WBC) count before neoadjuvant therapy, and T stage before surgery. We constructed a prediction model, plotted the nomogram, and verified its accuracy. Its Brier score was 0.13, its calibration slope was 0.98, and its C-index was 0.90 (95% CI: 0.82-0.97)., Conclusions: Our prediction model can predict the likelihood of TRG in patients with esophageal squamous cell cancer after immunotherapy combined with neoadjuvant chemotherapy. Using this prediction model, we plan to conduct a subsequent neoadjuvant radiotherapy in patients with of TRG 2-3 patients with neoadjuvant radiotherapy., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://atm.amegroups.com/article/view/10.21037/atm-22-78/coif). JMP reports leadership or fiduciary role in Florida Chapter American College of Surgeons and Scientific Board ADVOCARE. The other authors have no conflicts of interest to declare., (2022 Annals of Translational Medicine. All rights reserved.)

Background: Concurrent chemoradiation (CRT) followed by surgery is a standard of care for locally advanced esophageal adenocarcinoma. It remains unclear if surgery following CRT offers any meaningful survival benefit compared to CRT alone in patients with clinical N3 disease who are at the highest risk of developing distant disease relapse., Methods: We conducted analysis of the National Cancer Database (NCDB) to compare overall survival (OS) of patients with locally advanced esophageal adenocarcinoma (cTanyN1-3M0 based on AJCC 7th staging system) who underwent CRT with or without surgery and analyzed outcomes based on the cN stage., Results: 7,520 patients were included in the analysis-74.7% had cN1 disease, 21.1% had cN2 disease, and 4.3% had cN3 disease. The median OS advantage offered by CRT followed by surgery was 22, 15.8, and 9.6 months compared to CRT alone in cN1, cN2, and cN3 patients, respectively. The 5-year OS estimates in the surgical group were 36.9%, 31.6% and 15.9% in cN1, cN2 and cN3 groups, respectively., Conclusions: Surgery following CRT in patients with locally advanced esophageal adenocarcinoma leads to improvement in OS, with the largest benefit noted in patients with cN1 and cN2 disease. Surgery following CRT also confers meaningful long-term survival advantage for a subset of cN3 patients., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://dx.doi.org/10.21037/jgo-21-314). HM reports that she has received payment for participation in advisory board for Zentalis and AstraZeneca, as well as travel reimbursement from AstraZeneca for presentation of investigator-initiated trial in national research meeting. SIJ reports that she has received payment for participation in advisory board for Adaptimmune. She is the principal investigator of investigator-initiated trials with AstraZeneca, Astex, and Tesaro where the funding was provided to the institution. TB has no conflicts of interest to declare., (2021 Journal of Gastrointestinal Oncology. All rights reserved.)

Background: Most patients with resectable locally advanced esophageal and gastroesophageal junction (GEJ) adenocarcinoma (AC) receive concurrent chemoradiation (CRT) followed by esophagectomy. The majority of patients do not achieve pathologic complete response (pCR) with neoadjuvant CRT, and the relapse rate is high among these patients., Methods: We conducted a phase II study (ClinicalTrials.gov Identifier: NCT02639065) evaluating the efficacy and safety of PD-L1 inhibitor durvalumab in patients with locally advanced esophageal and GEJ AC who have undergone neoadjuvant CRT followed by R0 resection with evidence of persistent residual disease in the surgical specimen. Patients received durvalumab 1500 mg IV every 4 weeks for up to 1 year. The primary endpoint was 1-year relapse free survival (RFS). Secondary endpoint was safety and tolerability of durvalumab following trimodality therapy. Exploratory endpoints included correlation of RFS with PD-L1 expression, HER-2 expression, and tumor immune cell population., Results: Thirty-seven patients were enrolled. The majority (64.9%) had pathologically positive lymph nodes. The most common treatment related adverse events were fatigue (27%), diarrhea (18.9%), arthralgia (16.2%), nausea (16.2%), pruritus (16.2%), cough (10.8%), and increase in AST/ALT/bilirubin (10.8%). Three (8.1%) patients developed grade 3 immune mediated adverse events. One-year RFS was 73% (95% CI, 56-84%) with median RFS of 21 months (95% CI, 14-40.4 months). Patients with GEJ AC had a trend toward superior 1-year RFS compared to those with esophageal AC (83% vs. 63%, p = 0.1534). There was a numerical trend toward superior 1-year RFS among patients with PD-L1 positive disease compared to those with PD-L1 negative disease, using CPS of ≥10 (100% vs . 66.7%, p = 0.1551) and ≥1 (84.2% vs . 61.1%, p = 0.1510) cutoffs. A higher relative proportion of M2 macrophages and CD4 memory activated T cells was associated with improved RFS (HR = 0.16; 95% CI, 0.05-0.59; p = 0.0053; and HR = 0.37; 95% CI, 0.15-0.93, p = 0.0351, respectively)., Conclusions: Adjuvant durvalumab in patients with residual disease in the surgical specimen following trimodality therapy for locally advanced esophageal and GEJ AC led to clinically meaningful improvement in 1-year RFS compared to historical control rate. Higher PD-L1 expression may have a correlation with the efficacy of durvalumab in this setting. Higher proportion of M2 macrophages and CD4 memory activated T cells was associated with superior RFS., Competing Interests: The authors report following relationships with the companies, none of which has resulted in an actual or potential conflict of interest with regard to this manuscript. HM: Consulting/Advisory board – AstraZeneca, Zentalis; Travel Accommodations: AstraZeneca (IITpresentation at Immuno-oncology conference). BS: Clinical trials funding to the institution – Merck. P. Kasi: Consultancy/advisory board: Taiho (to institution), Ipsen (to institution), Foundation Medicine, Bayer, Axiom, Natera, Roche, IPBA, Merck, QED, Tempus Labs, Daiiche Sankyo, Boston Health Care, Delcath, Eli Lily; Research/Grant Funding: BMS (institution), Advanced Accelerator Applications (institution), Array Biopharma (institution), Tesaro (institution), Boston Scientific (institution), Celgene (institution); Travel Accommodations: AstraZeneca (IITpresentation at Immuno-oncology conference). SJ: Consulting/Advisory board – Adaptimmune; Clinical trials funding to the institution- AstraZeneca, Tesaro, Astex. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Mamdani, Schneider, Perkins, Burney, Kasi, Abushahin, Birdas, Kesler, Watkins, Badve, Radovich and Jalal.)

Background: Outcomes after open esophagogastrectomy (OE) have been shown to depend on institution case volume. We aim to determine whether a similar relationship exists for minimally invasive esophagogastrectomy (MIE)., Methods: Patients who had OE or MIE (excluding robotic procedures) between 2010 and 2013 in the National Cancer Database were included. Outcomes included 30-day and 90-day mortality, length of stay, hospital readmission, margin positivity, and number of lymph nodes harvested. Logistic and linear regression were used to adjust for possible confounders including age, sex, tumor size, Charlson score, induction therapy, and type of institution (academic versus community based)., Results: We identified 2371 patients in the MIE group and 6285 patients in the OE group. In multivariate analysis, high case volume was an independent predictor for lower 30-day mortality and 90-day mortality, shorter length of stay, and higher rate of negative-margin resection in OE (P < .001) but not in MIE. After quartile ranking of institutions based on volume, MIE outcomes were found to be better in institutions in the highest volume quartile compared with those in the lowest (P < .001)., Conclusions: In this dataset, MIE postoperative outcomes, unlike OE postoperative outcomes, did not correlate with hospital case volume. Volume-outcome relationships may be affected by surgical approach. The effect of case volume on long-term outcomes after MIE warrants further study., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Deep vein thrombosis (DVT) represents a major cause of morbidity in surgical patients. Controversial reports exist on the incidence of DVT in burn patients. We report our experience over a 10-year period., Methods: Patients admitted to our Burn Unit over the period 1991-2001 and diagnosed with DVT were identified. Their records were retrospectively reviewed for demographic factors, extent and severity of burn injury and outcome., Results: A total of 4102 patients were admitted to the WPH Burn unit during the study period. All patients received routine subcutaneous heparin prophylaxis. Ten patients were diagnosed with DVT (0.25%). Compared to our total burn population, these patients were older (mean age 47 +/- 22.7 years versus 35 +/- 22 years P = 0.14) and had more extensive burns (mean total body surface area (TBSA) 34.7 +/- 25.3% versus 12 +/- 15.7% P = 0.02). Two patients developed non-fatal pulmonary embolism (PE). There were three deaths, none due to thromboembolic disease. There were no complications from the routine administration of subcutaneous heparin., Conclusion: The incidence of DVT in our study is much less than the incidence reported in other critically ill patients and less than that of most reports on burn patients. In our experience, routine heparin prophylaxis is effective for the prevention of DVT in burn patients.

A 29 year old woman was found to have a chest mass as part of routine screening with a chest x-ray for an unrelated neurosurgical procedure. Further investigation with a chest CT raised the suspicion of a paravertebral neurogenic tumor. The patient underwent bronchoscopy and resection of the lesion by Video Assisted Thoracic Surgery (VATS). The diagnosis of Bronchogenic Cyst was established after histopathologic examination of the resected tumor. Bronchogenic Cysts are relatively rare primary mediastinal tumors. The paravertebral site is an unusual presentation for these tumors.