Search

Background Optimal time to surgery for lung cancer is not well established. We aimed to assess whether time to surgery correlates with outcomes. Methods We assessed patients 18–84 years old who were diagnosed with stage I/II lung cancer at our integrated healthcare system from 2009 to 2019. Time to surgery was defined to start with disease confirmation (imaging or biopsy) prior to the surgery scheduling date. Outcomes of unplanned return to care within 30 days of lung cancer surgery, all-cause mortality, and disease recurrence were compared based on time to surgery before and after 2, 4, and 12 weeks. Results Of 2861 included patients, 70% were over 65 years old and 61% were female. Time to surgery occurred in 1–2 weeks for 6%, 3–4 weeks for 31%, 5–12 weeks for 58%, and 13–26 weeks for 5% of patients. Patients with time to surgery > 4 (vs. ≤ 4) weeks had greater risk of both death (hazard ratio (HR) 1.18, 95% confidence interval (CI) 1.00–1.39) and recurrence (HR 1.33, 95% CI 1.10–1.62). Associations were not statistically significant when dichotomizing time to surgery at 2 or 12 weeks for death (2 week HR 1.23, 95% CI 0.93–1.64; 12 week HR 1.35, 95% CI 0.97–1.88) and recurrence (2 week HR 1.54, 95% CI 0.85–2.80; 12 week HR 2.28, 95% CI 0.80–6.46). Conclusions Early stage lung cancer patients with time to surgery within 4 weeks experienced lower rates of recurrence. Optimal time to surgical resection may be shorter than previously reported.

OBJECTIVE The aim of this study was to investigate whether our previously reported improvements in short-term cancer esophagectomy outcomes after large-scale regionalization in the U.S. translated to longer-term survival benefit. BACKGROUND Regionalization is associated with better early postoperative outcomes following cancer esophagectomy; however, data regarding its effect on long-term survival is mixed. METHODS We retrospectively reviewed 461 patients undergoing cancer esophagectomy before (2009-2013, N = 272) and after (2014-2016, N = 189) regionalization. Kaplan-Meier curves and χ2 tests were used to describe 1- and 3-year survival in each era. Hierarchical logistic regression models examined the adjusted effect of regionalization on mortality. RESULTS Compared to pre-regionalization patients, post-regionalization patients had significantly higher 1-year survival (83.1% versus 73.9%, p = 0.02) but not 3-year survival (52.9% versus 58.2%, p = 0.26).Subgroup analysis by cancer stage revealed that 1-year survival benefit was only significant among mid-stage (IIB-IIIB) patients, whereas differences in 3-year survival only approached significance among early-stage (IA-IIA) patients.In multivariable analysis, only regionalization was a predictor of lower mortality at 1 year (OR 0.54, 95%CI:0.29,1.00), and only thoracic specialty at 3 years (OR 0.62, 95%CI:0.38,0.99). Older age, more advanced stage, and complications were associated with higher 1- and 3-year mortality. Comorbidity, minimally invasive approach, surgeon volume, facility volume, and neoadjuvant treatment were not significant in this model. CONCLUSIONS Regionalization was associated with improved 1-year survival after cancer esophagectomy, independent of factors such as morbidity or volume in our adjusted models. This survival benefit did not persist at 3 years, likely due to the aggressive nature of the disease.

Regional analgesia, such as intercostal nerve blockade (INB), is a viable modality for postoperative pain control in thoracic surgery patients. Asian patients have historically been underrepresented in studies of pain responses and pain medication requirements based on race. In this study, we examined the postoperative opioid medications used by Asian and Caucasian patients undergoing video-assisted thoracoscopic surgery (VATS) lobectomy who received different bupivacaine-based INB.We retrospectively reviewed patients undergoing VATS lobectomy who received standard bupivacaine (SB), liposomal bupivacaine (LB), or liposomal bupivacaine mixed with standard bupivacaine (MIX). Length of stay (LOS), postoperative pain scores, postoperative opioid use (in intravenous morphine equivalents) were evaluated. The Chi-square test was used to compare categorical variables; Student's t-test for normally distributed variables; and the Wilcoxon rank-sum test for non-normally distributed variables. Multivariable linear regression was used to assess opioid use in Asians compared to Caucasians.Of the 239 patients in the cohort, 212 received LB or MIX and 27 received SB. In the LB/MIX group, 48 (22.6%) were Asian and 164 (77.4%) were Caucasian. In the SB group, 7 (25.9%) were Asian and 20 (74.1%) were Caucasian. There were no differences in height, weight, and body mass index (BMI) between the SB and LB/MIX groups, but there was a significant difference in weight and BMI between Asian and Caucasian patients. The median LOS was comparable between the SB and LB/MIX groups. The average 24-hour postoperative pain score in the LB/MIX group was 2.5, and 2.0 and 2.7 in the Asian and Caucasian subgroups, respectively (P0.01). The median opioid use in the LB/MIX group was 27.2 mg, and 16.9 and 31.1 mg in the Asian and Caucasian subgroups, respectively (P0.01). On multivariable linear regression analysis adjusting for sex, age, BMI, and bupivacaine type, we found Asians used 25.5 mg less opioids compared to Caucasians (P0.01).INB with LB or liposomal-standard bupivacaine mix resulted in statistically significant decreased postoperative pain scores and opioid use in Asians compared to Caucasians. There was no difference in LOS between the LB/MIX and SB groups.

BACKGROUND: Intercostal nerve blockade (INB) for thoracic surgery analgesia has gained popularity in practice, but evidence demonstrating its efficacy remains sparse and inconsistent. We investigated the effect of INB with standard bupivacaine (SB) with epinephrine versus liposomal bupivacaine (LB) versus a mixed solution of the two on postoperative pain control and outcomes in video assisted thoracoscopic lobectomy patients. METHODS: Since 2014, our practice has shifted from using INBs with SB with epinephrine, to LB, to a mix of the two as the central component of multimodal analgesia after video assisted thoracoscopic surgery. The blocks are performed in a standardized fashion under thoracoscopic visualization consecutively from two rib spaces above to two below the outermost incisions. We retrospectively compared all minimally invasive lobectomies performed at our institution between January 2014 and July 2018 by type of local anesthetic used for INB. We examined median length of stay (LOS), opioid utilization, and subjective pain scores [0–10]. RESULTS: Out of 302 minimally invasive lobectomy patients, 34 received SB with epinephrine, 222 received LB alone, and 46 received the mixed solution. LOS was almost a full day shorter in the LB group than in the SB group (34.8 vs. 56.5 hours, P=0.01). There was nearly 25% lower median total morphine equivalent utilization in the mixed solution cohort compared to the LB cohort (−7.1 mg, P=0.02). Additionally, IV morphine equivalent utilization was over 50% lower in the mixed solution group than in the SB with epinephrine group (−10.0 mg, P=0.03). CONCLUSIONS: Our study is by far the largest (N=302) to compare types of local anesthetic used for INB within a uniform case population. The reductions in LOS and opiate utilization observed in our study among patients receiving LB-based formulations were both statistically and clinically significant.

Bronchopleural fistula (BPF) is a sinus tract between a mainstem, lobar or segmental bronchus and the pleural space. We present a 68-year-old male with a 13 mm spiculated left lower lobe nodule who underwent video-assisted thoracoscopic surgery left lower lobe wedge resection followed by persistent BPF requiring open window thoracostomy. We present a step-up approach to management of persistent BPF with discussion of conservative, operative and reconstructive techniques for closure.

BACKGROUND: To improve nutritional status and dysphagia, esophageal cancer patients starting neoadjuvant therapy in advance of curative-intent surgery may receive a jejunostomy tube (J-tube) or esophageal stent, or they may be managed without a feeding modality. We examined percent total weight loss (%TWL), reinterventions, and progression to surgery in relation to these options. METHODS: The retrospective cohort study included stage II–III esophageal cancer patients diagnosed during 2010–2017 who received J-tube, stent, or nutritional counseling only, without a procedure, when starting chemotherapy or combined modality chemoradiation. Data were obtained from the electronic medical record and chart review. We compared median %TWL between intervention groups and reinterventions using Chi-square and Kruskal-Wallis tests. RESULTS: Among the 366 patients, median %TWL reached a nadir at 120 days, when it was 7% for patients with no procedure (N=307), 4% for J-tube (N=39), and 16% for stent (N=20) (P=0.01). Individual case analysis revealed 72–80% of the patients in the three groups started chemotherapy or chemoradiation as neoadjuvant curative-intent therapy (P difference =0.79). In J-tube patients, the reasons for intervention was anticipation of weight loss in 49% and mitigation of actual weight loss in 15%, whereas 95% of stent patients received the stent for dysphagia (P

After being diagnosed with myasthenia gravis, a 55-year-old male was referred for treatment of an invasive thymoma. Preoperative imaging revealed a thymoma adjacent to the superior vena cava (SVC) with possible invasion of the left innominate vein. After multidisciplinary discussion, he underwent upfront en bloc resection of the tumor with SVC resection and reconstruction. He was discharged after an uncomplicated postoperative course with improvement of his symptoms.

BACKGROUND: Anastomosis management is the main challenge of airway resection and reconstruction, and postoperative anastomotic complications, including ischemia, stenosis, dehiscence, and separation may lead to severe outcomes and a poor prognosis. The anastomotic buttress is vital in airway reconstruction, but the selection of surgical buttress and reinforcement remains controversial. We aimed to demonstrate and evaluate the buttress options of anastomosis, including their preoperative characteristics, the intraoperative process, and the incidence of postoperative complications to help address the controversy regarding anastomosis management. METHODS: This retrospective study was conducted at a single institution. Patients who underwent airway reconstruction with anastomotic wrapping from Jan. 2019 to Sep. 2021 were enrolled in this study and preoperative characteristics and operational features were collected. All patients were carefully followed up by telephone and outpatient. Their postoperative complications and postoperative status after 6 months were recorded. The surgical procedures and clinical characteristics of the buttress options of anastomosis were assessed. RESULTS: A total of 62 patients undergoing either cervical tracheal, thoracic tracheal, carinal, or secondary carinal and main bronchus resection and reconstruction were evaluated. The anastomotic buttress used included mediastinal pleural flap (24/62, 38.7%), anterior cervical muscle (14/62, 22.6%), sternocleidomastoid (2/62, 3.2%), thymus flap (12/62, 19.4%), intercostal muscle flap (2/62, 3.2%), biological patch (2/62, 3.2%), prepericardial fat (1/62, 1.6%), thyroid gland (1/62, 1.6%), pectoralis major flap (2/62, 3.2%), and omental flap (2/62, 3.2%). All procedures produced satisfactory results without short-term anastomotic complications. A follow-up for 6 months was conducted and all patients were alive postoperatively. Tracheomalacia stenosis postoperatively occurred in 3 patients and they were subsequently treated with an endotracheal stent. One patient had tumor recurrence 3 months after surgery and received adjuvant chemotherapy. CONCLUSIONS: Various anastomotic wrapping materials are used in airway reconstruction. Different utilizations of buttress are selected according to the anatomic characteristics and the reconstruction method used. This study indicated that appropriate surgical buttresses for wrapping anastomoses are legitimate alternatives to reduce the risk of anastomotic complications.

Evidence is limited characterizing sociodemographically diverse patient populations with lung cancer in relation to smoking status.In a cross-sectional analysis of adults diagnosed with lung cancer at ages ≥30 years from 2007-2018 within an integrated healthcare system, overall and sex-specific prevalence of never smoking were estimated according to sociodemographic and clinical characteristics. Adjusted prevalence ratio (aPR) and 95% confidence interval (CI) were also estimated using modified Poisson regression to identify patient characteristics associated with never smoking, overall and by sex. Similar analyses were conducted to explore whether prevalence and association patterns differed between non-Hispanic White and Asian/Pacific Islander patients.Among 17,939 patients with lung cancer, 2,780 (15.5%) never smoked and 8,698 (48.5%) had adenocarcinoma. Overall prevalence of never smoking was higher among females than males (21.2%Our findings suggest that patterns of never-smoking status associated with sociodemographic and clinical characteristics are different across sex and race/ethnicity among patients with lung cancer. Such data are critical to increasing awareness and expediting diagnosis of this disease.

Optimal therapy for malignant pleural mesothelioma (MPM) remains unclear. We compared overall survival in patients with MPM after various multimodal treatment regimens including combinations of immunotherapy, chemotherapy, and surgery.We examined MPM patients treated within our integrated health system from January 1, 2009 to December 31, 2020. Patients were grouped based on treatment regimen: chemotherapy alone (CT), immunotherapy with or without chemotherapy (iCT), surgery with chemotherapy (sCT), and surgery with immunotherapy and chemotherapy (siCT). We analyzed baseline characteristics and overall patient survival among these groups and several subgroups.One hundred seventy-nine patients were included. Among the study groups, there was no difference in age, sex, race/ethnicity, Charlson Comorbidity Index, or Eastern Cooperative Oncology Group performance status. Patients treated with CT (N = 109), iCT (N = 35), sCT (N = 26), and siCT (N = 9) had median (95% confidence interval) survivals of 11.7 (9.9-16.3), 18.2 (14.5-29.8), 20.7 (11.6-37.2), and 22.6 (19.7-37.8) months, respectively (P.001). Median survival among patients with and without immunotherapy was 19.7 (17.4-29.8) and 12.3 (10.6-17.3) months, respectively (P = .023). Median survival among patients with and without surgery was 21.7 (17.6-34.8) and 13.6 (11.5-17.3) months, respectively (P = .007). Patients with biphasic/sarcomatoid subtypes who received immunotherapy experienced 76.2% (55.8%-100.0%) 12 month survival vs. 13.6% (4.8%-39.0%) among those who did not (P.001).MPM patients receiving surgery and immunotherapy as part of multimodal treatment regimens experienced the longest survival. Surgery and immunotherapy are each associated with survival. Further investigations are warranted to assess the benefit of immunotherapy within multimodal treatment regimens for MPM.

Malignant pleural mesothelioma (MPM) is a rare and aggressive tumor that should be managed by an experienced surgical and multidisciplinary group. Our objective was to determine the impact of proficient surgeons and MPM bi-disciplinary review on outcomes of patients with MPM.Through this cohort study, electronic medical records of 368 adult patients with MPM from 1/1/2009 to 12/31/2020 were reviewed and compared before and after MPM surgeries were regionalized to specialized surgeons and bi-disciplinary review of MPM patient treatment options. We used the Kaplan-Meier method and log-rank tests to compare survival rates by period, by treatment type, and by stage. Patients were followed from cancer diagnosis date until they died or end of study follow-up, whichever occurred first. We also conducted Cox proportional hazards regression model to examine the overall survival (OS) with adjustments for age, histology, stage, and Charlson comorbidity index (CCI).Despite similar staging, more patients received any MPM directed treatment from 2015-2020 compared with those patients from 2009-2014. Specifically, there was an increase in patients who received pleurectomy/decortication (PD) from 2015-2020 compared to those who received PD in 2009-2014. Patients with similar age, CCI, stage, and histology had an increase in OS of 12 months with multimodality therapy (surgery, systemic therapy, +/- radiation) compared to those patients who received no treatment.Consolidating mesothelioma surgery to a specialized surgical team and regular bi-disciplinary review of MPM cases to determine appropriate multimodality therapy, increases the incorporation of surgical treatments in the management of patients with MPM.

A 50-year-old male with history of HIV, syphilis, paraneoplastic Morvan syndrome secondary to thymoma resected in 2013 presented recently with tachycardia, tremors, diarrhea, hyperhidrosis and bilateral lower extremity pain leading to the discovery of thymoma recurrence. He initially developed Morvan Syndrome after thymectomy in 2013 and gradually improved with negative anti-contactin-associated protein-like 2 antibody testing in 2017 and symptom resolution in 2018. Upon return of dysautonomia symptoms, subsequent imaging revealed widespread disease recurrence diffusely in the right lung parenchyma and pleura for which he underwent right extrapleural pneumonectomy. He was managed with low-dose prednisone perioperatively, but when his symptoms worsened, he was started on rituximab and methylprednisolone. Nearly 3 months from surgery, he died from urinary sepsis. This represents a unique case of recurrent paraneoplastic Morvan syndrome leading to the diagnosis of metastatic thymoma as well as the challenges of symptom control during the surgical management of the underlying disease.

Background A few observational studies have found that outcomes after esophagectomies by thoracic surgeons are better than those by general surgeons. Methods Non-emergent esophagectomy cases were identified in the 2016-2017 American College of Surgeons NSQIP database. Associations between patient characteristics and outcomes by thoracic versus general surgeons were evaluated with univariate and multivariate logistic regression. Results Of 1,606 cases, 886 (55.2%) were performed by thoracic surgeons. Those patients differed from patients treated by general surgeons in race (other/unknown 19.3% vs 7.8%; PDiscussion In our large, national database study, we found that outcomes of esophagectomies by general surgeons were comparable with those by thoracic surgeons. General surgeons managed postoperative leaks differently than thoracic surgeons.

BACKGROUND: In recent years, a series of clinical trials have explored the application of neoadjuvant immunotherapy or chemoimmunotherapy in non-small cell lung cancer (NSCLC). However, no randomized control trials comparing neoadjuvant immunotherapy with chemoimmunotherapy have yet been reported. This study aimed to summarize and compare the efficacy and safety of neoadjuvant immunotherapy and chemoimmunotherapy in NSCLC. METHODS: Literature focusing on the efficacy and safety of neoadjuvant immunotherapy or chemoimmunotherapy in NSCLC published before June 2021 was retrieved from PubMed, Embase, and the Cochrane Library. Study endpoints included major pathological response (MPR), complete pathological response (pCR), treatment-related adverse events (TRAEs), severe adverse events (SAEs), resection rate, surgical delay rate, and conversion to thoracotomy. The risk of bias was assessed using the Cochrane bias risk assessment tool. Subgroup and sensitivity analyses were further performed. RESULTS: A total of 988 patients from 16 studies were included in this meta-analysis. For patients who received neoadjuvant immunotherapy with single/combined ICIs or chemoimmunotherapy, the pooled MPR rate was 43.5% and the pooled pCR rate was 21.9%. The pooled incidence of TRAEs and SAEs were 54.8% and 15.3%, respectively. The pooled resection rate was 85.8%, the surgical delay rate was 7.4%, and the conversion rate was 17.4%. Patients who received neoadjuvant chemoimmunotherapy had remarkably improved pathological response (MPR rate: 53.3% vs. 28.6%; pCR rate: 28.6% vs. 9.9%) compared with those receiving neoadjuvant single-agent immunotherapy, while the incidence of SAEs (18.0% vs. 12.3%) and surgical delay rate (3.8% vs. 7.4%) did not significantly increase. Neoadjuvant nivolumab combined with ipilimumab also achieved a high pCR rate (28.6%) with tolerable toxicity. Nivolumab- and pembrolizumab-based neoadjuvant therapy showed a higher MPR rate (nivolumab 51.5%, pembrolizumab 46.8%) and pCR rate (nivolumab 29.1%, pembrolizumab 31.5%). Besides, patients with positive programmed death-ligand 1 (PD-L1) expression [tumor proportion score (TPS) ≥1%] exhibited favorable pathological responses than PD-L1 negative patients. DISCUSSION: Overall, neoadjuvant immunotherapy or chemoimmunotherapy is effective and safe in NSCLC. Compared with single-agent immunotherapy, neoadjuvant chemoimmunotherapy provides a significant improvement in pathological response without increasing the incidence of SAEs or surgical delay. These results need further confirmation by more large-scale randomized controlled trials.

The traditional approach to mediastinal cyst and mass resection has been open via median sternotomy or thoracotomy. With the advent of minimally invasive techniques, there have been successful cases completed via video-assisted thoracoscopic (VATS) and robot-assisted thoracoscopic surgery (RATS). Although mediastinal cysts are uncommon, they are a significant and relevant topic in the practice of thoracic surgery. Thus, this clinical practice review aims to summarize and highlight some of the key case series and retrospective studies in order to provide insight on each of the approaches. In addition, there is a brief review of other approaches, such as subxiphoid, and the utility of endobronchial ultrasound in the management of mediastinal cysts. In this review, the identified benefits of VATS and RATS lie largely in quality improvement of the patient experience-decreased length of stay (LOS) and pain-without compromising patient outcomes. However, the open approach remains a viable option, particularly for the management of large cysts or as a bail-out option. When surgeons approach with VATS or RATS and encounter bleeding or difficult dissection planes, it is consistent in the literature that conversion to thoracotomy is the safe next step. Our clinical practice is to attempt VATS or RATS approach for mediastinal cysts when possible. The data used for this review relies heavily on case reports and case series, and thus is the main limitation of this clinical practice review.

Background Limited evidence exists assessing whether anastomotic evaluation using indocyanine green fluorescence (IGF) during minimally invasive esophagectomy (MIE) predicts or improves outcomes. We hypothesized that IGF helps surgeons predict anastomotic complications and reduces anastomotic leaks after MIE. Methods In September 2019, our institution began routinely using IGF for intraoperative evaluation of anastomoses during MIE. Data were collected from patients undergoing MIE in the two years before and after this technology began being routinely used. Baseline characteristics and outcomes, including anastomotic leak, in patients who underwent indocyanine green fluorescence evaluation (ICG) and those who did not (nICG) were compared. Outcomes were also compared between ICG patients with normal versus abnormal fluorescence. Results Overall, 181 patients were included. Baseline demographic and clinical characteristics did not differ between the ICG and nICG groups. ICG patients experienced higher rates of anastomotic leak (10.2% vs. 1.6%, P = .015) and 90-day mortality (8.5% vs. 1.6%, P = .04) compared to nICG patients. Due to lack of equipment availability, 19 nICG patients underwent MIE after the use of IGF became routine, and none developed leaks. ICG patients with abnormal fluorescence had higher rates of anastomotic leak (71.4% vs 1.9%, P < .001) and 30-day mortality (28.6% vs 0%, P = .012) compared to those with normal fluorescence. Discussion Abnormal intraoperative IGF was associated with increased rate of anastomotic leak, suggesting predictive potential of IGF. However, its use was associated with an increased leak rate and higher mortality. Further studies are warranted to assess possible physiologic effects of indocyanine green on the esophageal anastomosis.

57 Background: Delivering cancer care by high-functioning multidisciplinary teams promises to address care fragmentation and complexity, which threaten care quality, impact patient outcomes, and strain the oncology workforce. We assessed whether the 4R Oncology model (Trosman et al 2021) for team-based interdependent care delivery and patient self-management impacted team functioning at Kaiser Permanente Northern California (KPNC), a large community-based health system. Methods: We deployed the 4R intervention in breast and lung cancers at 4 KPNC centers. The intervention encompassed team development and care delivery optimizations enabling teamwork. 4R Care Sequences – novel patient-facing care plans outlining timing and sequence of care – informed team formation, activities and functioning. We assessed intervention along 4 characteristics of high-functioning teams (Vogel JOP 2016). Results: 4R facilitated development of a high-functioning team along all 4 characteristics. (1) We formed an internally and externally recognized multidisciplinary team of 24 specialties who assumed team responsibilities for relevant care. (2) All participants committed to a shared goal of delivering interdependent care at the optimal time and sequence based on Care Sequences. (3) The team conducted 40 optimizations to enable effective interdependent care: 22 in breast, 7 in lung, and 11 in both cancers (Table). The optimizations impacted 6 care domains at 4 points in care continuum. Half of optimizations entailed low effort; 70% resulted in improved process efficiency. (4) An ongoing teamwork adaptation process was established. Conclusions: 4R is an effective and feasible approach to fostering high-functioning teams, which may contribute to improvement of multidisciplinary care delivery and support viability of the oncology workforce. Our intervention and taxonomy of results inform other institutions motivated to strengthen teamwork and improve delivery of complex interdependent care.[Table: see text]

A 29-year-old male developed acute onset severe shortness of breath and fevers and was found to have a 17 cm anterior mediastinal mass with immature teratoma and possible mixed germ cell tumor on biopsy. He remained hospitalized during neoadjuvant cisplatin-based chemotherapy due to compressive symptoms from his mass and neutropenic fevers. Despite 3 cycles of therapy, his tumor mildly increased in size. After multidisciplinary discussion, he underwent urgent en bloc resection with a right hemi-clamshell incision. His postoperative course was uncomplicated and he was discharged to home within a week. His final pathology demonstrated mixed germ cell tumor.

We report a rare case of thymoma associated with pancytopenia and Good's syndrome. The patient was a previously healthy 60-year-old female who presented to the emergency department with a severe headache. Her initial work up was significant for a parenchymal hemorrhage and severe pancytopenia. A CAT scan of her chest, abdomen, and pelvis demonstrated a large mediastinal mass and core biopsy confirmed thymoma. Bone marrow aspirate was hypocellular. Initial multidisciplinary discussion recommended immunosuppressive therapy to treat her aplastic anemia prior to resection. However, she remained transfusion-dependent from her pancytopenia and required prolonged admission. Ultimately, the patient was unable to undergo immunosuppressive therapy due to persistent infection. Hematology/oncology believed that the initial response to immunosuppressive therapy would further compromise her immune function and would be detrimental for the patient. After undergoing thymectomy, she suffered from persistent severe pancytopenia, diarrhea, and pneumonia. She remained transfusion-dependent and despite remaining on broad spectrum antimicrobials, she continued to have fevers. She was diagnosed with Good's syndrome postoperatively after she was found to be hypogammaglobulinemic. She received intravenous immunoglobulin (IVIG) immediately, but ultimately expired from multi-system organ failure. This case report highlights the importance of early diagnosis and multidisciplinary treatment for patients who have hypogammaglobulinemia, severe pancytopenia, and thymoma. We recommend early treatment of IVIG.

Adequate reconstruction of sternal defects is critical for function and quality of life. Reconstructive techniques have historically included a rigid component, most often a synthetic prosthesis, but these are associated with complications related to presence of a foreign body and the loss of native bone's flexibility and growth capability. Recently, biologic mesh has been used as an alternative for reconstructions of the chest wall, but not the sternum. We present the case of a large sternal defect after chondrosarcoma resection reconstructed with porcine acellular dermal matrix and soft tissue flaps, without rigid component, and with excellent patient outcome through 2 years of follow-up.

BACKGROUND: Some studies have found that outcomes from cancer esophagectomy are better at higher-volume centers than at lower-volume centers. Reports on outcomes following systematic centralization have largely demonstrated subsequent improvements, but these originate in nationalized healthcare systems that are not very comparable to the heterogeneous private-payer systems that predominate in the United States. We examined how regionalization of thoracic surgery to Centers of Excellence (CoE) within our American integrated healthcare system changed overall care for our patients, and whether it changed outcomes. METHODS: We conducted a retrospective chart review of 461 consecutive patients undergoing cancer esophagectomy between 2009–2016, spanning the 2014 shift to regionalization. High-volume was defined as ≥5 esophagectomies per year. We compared characteristics of the surgeon, hospital, and operation pre- and post-regionalization using Chi-square or Fisher’s exact test for categorical variables and Kruskal-Wallis test for age. We evaluated their associations with patient outcomes with hierarchical linear and logistic mixed models, which adjusted for clustering within surgeon and facility levels and relevant covariates. RESULTS: While there was no difference in their baseline demographics, patients undergoing esophagectomy post-regionalization were much more likely to have their surgery performed at a designated Center of Excellence (78.8% of cases versus 34.2%, P

Transforming potentially resectable advanced esophageal squamous cell carcinoma (ESCC) into resectable ESCC through preoperative induction therapy is an important component of ESCC comprehensive treatment. Immune checkpoint inhibitor (ICI) therapy has been shown to have significant effects in the treatment of advanced ESCC, but its role in the neoadjuvant treatment of potentially resectable ESCC is unclear. This study aims to investigate the safety and effectiveness of camrelizumab combined with chemotherapy in the neoadjuvant treatment of ESCC.We recruited consecutive patients with potentially resectable ESCC who received preoperative camrelizumab in combination with chemotherapy. Data including demographic data, clinicopathological characteristics, neoadjuvant treatment regimens, lesion changes observed by imaging, and surgical details were retrospectively collected through specially designed forms. Toxic effects of neoadjuvant therapy on hematology, gastrointestinal tract, liver, kidney, skin, and thyroid were also collected. Imaging assessments were performed every 1-2 treatment cycles. Follow-up is based on the patient's regular admission to the hospital for examination and treatment, at least 3 months after surgery.A total of 66 patients with locally advanced ESCC were included in this study, including 8 patients with stage II, 29 patients with stage III, and 29 patients with stage IVA. The objective response rate (ORR) of the neoadjuvant immunotherapy combined with chemotherapy was 75.76% (50/66), and no one developed disease progression. A total of 60 patients underwent surgery, and the R0 resection rate was 98.3% (59/60). The pathological complete remission (pCR) rate and the major pathological response (MPR) rate was 6.7% (4/60) and 20% (12/60), respectively. There were 14 cases of treatment-related adverse reactions3, but no perioperative deaths occurred.Neoadjuvant immunotherapy combined with chemotherapy followed by surgical resection may be an available treatment for patients with locally advanced ESCC.

With the evolution of minimally invasive esophagectomy (MIE) and robot-assisted minimally invasive esophagectomy (RAMIE), questions remain regarding the benefits and indications of these methods. Given that set indications do not exist, this article aims first to review the reported outcomes of MIE, RAMIE, and open esophagectomy. Then, considerations based on the reported outcomes are discussed to guide surgeons in selecting the best approach. MIE and RAMIE offer the potential to improve outcomes for esophagectomy patients; however, surgeon experience as well as individual patient factors play important roles when deciding upon the surgical approach.

Objective: Newer minimally invasive approaches to esophagectomy have brought substantial benefits to esophageal-cancer patients and continue to improve. We report here our experience with a streamlined procedure as part of a comprehensive perioperative-care program that provides additional advances in the continued evolution of this procedure.Methods: All patients with primary esophageal cancer referred for resection to the Oakland Medical Center of the Kaiser-Permanente Northern California health plan who underwent this approach between January 2013 and August 2018 were included. Operative and clinical outcome variables were extracted from the electronic medical record, operating-room files, and manual chart review.Results: 142 patients underwent the new procedure and care program; 121 (85.2%) were men with mean age of 64.5 years. 127 (89.4%) were adenocarcinoma; 117 (82.4%) were clinical stage III or IVA. 115 (81.0%) required no jejunostomy. Median hospital length-of-stay was 3 days and 8 (5.6%) patients required admission to the intensive care unit. Postoperative complications occurred in 22 (15.5%) patients within 30 days of the procedure. There were no inpatient deaths; one patient (0.7%) died within 30 days following discharge and three additional deaths (2.1%) occurred through 90 days of follow-up.Conclusions: This approach resulted in excellent clinical outcomes, including short hospital stays with limited need for the intensive care unit, few perioperative complications, and relatively few patients requiring feeding tubes on discharge. This comprehensive approach to esophagectomy is feasible and provides another clinically meaningful advance in the progress of minimally invasive esophagectomy. Further development and dissemination of this method is warranted.

e16105 Background: This study evaluates survival outcomes of esophageal cancer patients treated at a large, tertiary care integrated healthcare system and whether there are differences based on race. Methods: We conducted a retrospective study from January 2010 to December 2019 among patients at Kaiser Permanente Northern California (KPNC). Self-reported racial ethnic groups included Caucasian, African American, Hispanic, Asian, and Other. Kaplan Meier and Cox regression analyses were used to evaluate differences in race, age, stage, and treatment utilization in relation to overall survival. Results: A total of 1,692 patients were diagnosed with esophageal cancer. Of these, 11% were Asian, 8.1% were Hispanic, and 6% were African American. Caucasians had the oldest mean age at diagnosis, 70.2 years, and the Hispanics had the youngest mean age at diagnosis, 64.6 years (p < 0.001). There were no statistically significant differences in stage at time of diagnosis between race groups (p = 0.41). Adenocarcinoma was more common in Caucasians and Hispanics, while squamous cell was more common in African Americans and Asians (p < 0.001). Treatments received by the patients included, surgery, chemotherapy, radiation, and a combination thereof (multimodal). There was no statistical significance among the races in treatment modalities received, including multimodal therapy (p = 0.12-0.66). The difference in mean overall survival (OS) between the race groups was not statistically significant. Kaplan-Meier survival analyses were performed and demonstrated statistically significant differences in mean OS between the two histologies, with adenocarcinoma having the highest survival of 33.9 months (p < 0.001). Conclusions: We identified racial parity in survival outcomes and treatment utilization for esophageal cancer patients who were treated at a large integrated healthcare system where patients have equal access to care.[Table: see text]

We appreciate the insightful editorials by Martin and Mehran (1) and Caso and Marshall (2) regarding our recent manuscript (3), which described a decreased length of stay (LOS) in patients receiving intercostal nerve blocks with liposomal bupivacaine (LB) (Exparel ® ) compared to standard bupivacaine after video-assisted thoracoscopic surgery (VATS) or minimally-invasive esophagectomy (MIE). Both articles raise a number of interesting points, and we would like to clarify some details of our study and expand on their discussion.