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Barrett's esophagus represents replacement of normal distal esophageal squamous epithelium with specialized columnar epithelium containing goblet cells. Typically arising in the setting of chronic gastroesophageal reflux disease, the presence of Barrett's esophagus carries a 50- to 100-fold increased risk of developing esophageal cancer. Risk factors include male sex, smoking history, obesity, Caucasian ethnicity, age > 50 and > 5-year history of reflux symptoms. Aggressive medical or surgical antireflux therapy may ameliorate symptoms, but have not yet been proven to affect the risk of developing esophageal adenocarcinoma in randomized trials. Although dysplasia is an imperfect biomarker for the development of subsequent malignancy, random sampling of esophageal tissue for dysplasia remains the clinical standard. There have been no studies to establish that endoscopic screening/surveillance programs decrease the rates of death from cancer. Fit patients with Barrett's esophagus and high-grade dysplasia should undergo esophagectomy to prevent the risk of developing esophageal adenocarcinoma. For non-operative candidates, endoscopic ablative approaches may represent a reasonable therapeutic alternative. [ABSTRACT FROM AUTHOR]

Extracorporeal membrane oxygenation (ECMO) has been primarily used for respiratory and circulatory failure, but its airway-related use has not been investigated well. Tracheal procedures are a situation when ECMO could be used to support patients during anticipated difficult airway management. The Extracorporeal Life Support Organization registry was queried for adult patients treated with ECMO in 2010-2022 during the same admission with types of tracheal procedures. Tracheal procedures were divided into surgical procedure and bronchoscopic procedure groups, and the survival rate was analyzed for each procedural type. Two-hundred sixty-nine patients met the inclusion criteria (64 surgical procedures and 205 bronchoscopic procedures), and 173 (64.3%) patients survived to discharge. Among the surgical procedures, tracheal resection was most performed (30 patients; 46.9%) and was associated with a high survival rate to discharge (86.7%; p = 0.003) compared with airway reconstruction (57.1%) and airway injury repair (46.2%). In bronchoscopic procedure, tracheal stent had favorable survival (76.1%; p = 0.004), whereas tumor debulking was associated with poor prognosis (48.3%; p = 0.006). Hemorrhagic complications were seen in 70 (26.0%) patients and were associated with a worse survival rate (58.6%; p < 0.001). Among them, surgical site bleeding was seen in 35 (13.0%) patients and was also associated with worse survival (42.9%; p = 0.007)., Competing Interests: Disclosure: The authors have no conflicts of interest to report., (Copyright © ASAIO 2025.)

The Clinical Practice Standards Committee of the American Association for Thoracic Surgery assembled an expert panel and conducted a systematic review of the literature detailing studies directly comparing treatment options for high-risk patients with stage I non-small cell lung cancer (NSCLC). A systematic search was performed to identify publications comparing outcomes following image-guided thermal ablation (IGTA), stereotactic ablative radiotherapy (SABR; also called stereotactic body radiation therapy [SBRT] and stereotactic radiosurgery [SRS]), and sublobar resection-the main treatment options applicable to high-risk patients with stage I NSCLC. There were no publications detailing completed randomized controlled trials comparing these treatment options. Several retrospective studies with comparisons were identified, some of which used large, population-based registries. The findings of several of these studies are summarized in this Expert Review article. Registry studies comparing IGTA with SABR in propensity-score matched patients with stage I NSCLC found no difference in overall survival. The use of thermal ablation was less frequent and had wider variation depending on geographic region as compared with SABR, however. Studies yielding high-quality data comparing SABR with sublobar resection have been limited. When comparing sublobar resection with IGTA, sublobar resection was associated with superior primary tumor control and overall survival in the retrospective cohort studies. Retrospective comparative studies are difficult to assess due to the inherent biases or treatment selection and the definitions of loco-regional control. Prospective randomized trials are needed to fully evaluate the outcomes of treatment options applicable to high-risk patients with early-stage lung cancer., (Copyright © 2025. Published by Elsevier Inc.)

Stereotactic ablative radiotherapy (SABR) has emerged as an alternative, non-surgical treatment for high-risk patients with stage I non-small cell lung cancer (NSCLC) with increased use over time. The American Association for Thoracic Surgery (AATS) Clinical Practice Standards Committee (CPSC) assembled an expert panel and conducted a systematic review of the literature evaluating the results of SABR, which is also referred to as stereotactic body radiation therapy (SBRT) or stereotactic radiosurgery (SRS), prior to developing treatment recommendations for high-risk patients with stage I NSCLC based on expert consensus. Publications detailing the findings of 16 prospective studies of SABR and 14 retrospective studies of SABR for the management of early-stage lung cancer in 54,697 patients were identified by systematic review of the literature with further review by members of our expert panel. Medical inoperability (93-95%) was the primary reason for utilizing SABR. The median rate of histologically confirmed cancer in treated patients was 67% (range 57-86%). In retrospective studies and prospective studies, the most common dosing regimens were 48-54Gy in 3-5 fractions and 44-66Gy in 3-5 fractions respectively. The median follow-up after SABR was 30 months (range 15-50). The complications, oncological results and quality of life after SABR in high-risk patients with early-stage NSCLC are summarized in this Expert Review article. Further prospective randomized trials are needed and are currently underway to compare outcomes after SABR with outcomes after sublobar resection to fully evaluate treatment options applicable this high-risk group of patients., (Copyright © 2025. Published by Elsevier Inc.)

Sublobar resection offers a parenchymal-sparing surgical alternative to lobectomy and includes wedge resection and segmentectomy. Sublobar resection has been historically utilized in high-risk patients with compromised lung function; however, the technique is becoming more prevalent for normal-risk patients with peripheral stage IA non-small cell lung cancer (NSCLC) <2 cm. In this article, we summarize the technique of sublobar resection, the importance of surgical margins and lymph node sampling, patient selection, perioperative complications, outcomes, and the impact of sublobar resection on the quality of life. There is limited data on short-term and long-term outcomes after sublobar resection for stage I NSCLC in high-risk patients. Results from randomized clinical trials (RCTs) of sublobar resection have been variable. We have summarized the results of the ACOSOG Z4032 RCT, which compared outcomes in high-risk patients who underwent sublobar resection alone versus sublobar resection with brachytherapy for stage I NSCLC. In addition, we have summarized recent findings of the CALGB/Alliance 140503 RCT comparing sublobar resection and lobectomy, which suggested that disease-free survival after sublobar resection in patients with small (<2 cm) peripheral stage IA NSCLC was non-inferior to lobectomy, and another RCT (JCOG 0802) of segmentectomy vs. lobectomy for small peripheral clinical stage IA NSCLC, where segmentectomy was associated with better overall survival despite a higher local recurrence rate. Sublobar resection is primarily performed with minimally invasive approaches, including robotic-assisted and video-assisted thoracoscopic techniques. From an oncologic perspective, obtaining adequate surgical margins and performing an adequate lymph node evaluation are critical for good outcomes after sublobar resection., (Copyright © 2025. Published by Elsevier Inc.)

Image-guided thermal ablation (IGTA) applied to pulmonary pathology is an alternative to surgery in high-risk patients with stage I non-small cell lung cancer (NSCLC). Its application to lung neoplasm was first introduced in 2001 and has been implemented to treat metastatic disease to the lung or in select medically inoperable patients with peripheral stage I NSCLC. IGTA may also be an alternative to treat stage I NSCLC in non-operable patients with interstitial lung disease in whom a radiation modality is deemed too high risk. There are 3 methods of delivery: radiofrequency ablation (RFA), microwave ablation and cryoablation. Observational series and some prospective trials have shown safety and efficacy across all three modalities. Despite accumulating experience, there are no large randomized clinical trials comparing the outcomes of lung IGTA to alternative locoregional therapies (eg, stereotactic body radiotherapy or sublobar pulmonary resection) for the treatment of stage I NSCLC. Because IGTA is a local therapy, a higher risk of locoregional recurrence is inherently understood as compared with anatomic resection. In the literature, primary tumor control after RFA ranges from 47 to 90% and is dependent on tumor size and proximity to bronchovascular structures. Local failure ranges from 10 to 47%, and tumors ≥3 cm have the highest rate of local recurrence. The most prevalent side effects are pneumothorax and reactive pleural effusion; hemorrhage is uncommon. Of note, observational series show no significant loss of lung function after IGTA. This expert review contextualizes limitations, complications and outcomes of IGTA in patients with stage I NSCLC., (Copyright © 2025. Published by Elsevier Inc.)

Background: With the increasing use of computed tomography scans for lung cancer screening and surveillance of other cancers, thoracic surgeons are being referred patients with lung lesions for biopsies. Electromagnetic navigational bronchoscopy-guided lung biopsy is a relatively new technique for bronchoscopic biopsy. Our objective was to evaluate the diagnostic yields and safety of electromagnetic navigational bronchoscopy-guided lung biopsy., Methods: We conducted a retrospective review of patients who underwent an electromagnetic navigational bronchoscopy biopsy, performed by a thoracic surgical service, and evaluated its safety and diagnostic accuracy., Results: In total, 110 patients (men 46, women 64) underwent electromagnetic navigational bronchoscopy sampling of pulmonary lesions (n = 121; median size 27 mm; interquartile range 17-37 mm). There was no procedure-related mortality. Pneumothorax requiring pigtail drainage occurred in 4 patients (3.5%). Ninety-three (76.9%) of the lesions were malignant. Eighty-seven (71.9%) of the 121 lesions had an accurate diagnosis. Accuracy increased with increased lesion size (P = .0578) with a yield of 50% for lesions <2 cm, increasing to 81% for lesions ≥2 cm. The lesions that demonstrated a positive "bronchus sign" had a yield of 87% (45/52) compared with 61% (42/69) in lesions with a negative "bronchus sign" (P = .0359)., Conclusion: Thoracic surgeons can perform electromagnetic navigational bronchoscopy safely, with minimal morbidity and with good diagnostic yields. Accuracy increases with the presence of a bronchus sign and increasing lesion size. Patients with larger tumors and the bronchus sign may be candidates for this approach to biopsy. Further work is required to define the role of electromagnetic navigational bronchoscopy in the diagnosis of pulmonary lesions., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objectives: Pulmonary sarcomatoid carcinoma (PSC) is a rarely occurring variant of non-small cell lung cancer with sarcoma-like features. Compared with traditional non-small cell lung cancer, PSC patients typically present later and have poorer prognoses, irrespective of stage. The standard of care is resection, but guidelines for the use of adjuvant chemotherapy have not been established. To advance the development of evidence-based management algorithms for PSC after resection, a statistical analysis on a nationwide representative sample of patients was performed., Methods: A retrospective cohort study was performed by querying the National Cancer Database for patients with a diagnosis of PSC between 2004 and 2015. Patients who received complete anatomical resection with or without adjuvant chemotherapy were included. Multivariable regression was used to detect factors associated with the receipt of adjuvant chemotherapy. Multivariable Cox regression of overall survival and Kaplan-Meier survival analysis on propensity-matched groups was conducted to study the association between adjuvant chemotherapy and prognosis., Results: We included 1497 patients with PSC in the final analysis. Factors associated with receiving adjuvant chemotherapy were age, histology, and receipt of adjuvant radiation. The results of multivariable Cox analysis and Kaplan-Meier analysis on propensity matched groups yielded similar trends: adjuvant chemotherapy was associated with improved 5-year overall survival for stage II and III disease, but not for stage I disease., Conclusions: Multiple factors are associated with receipt of adjuvant chemotherapy for PSC, and this treatment appears to be associated with improved survival in stage II and stage III, but not stage I patients., (Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Academic productivity during cardiothoracic surgery residency training is an important program metric, but is highly variable due to multiple factors. This study evaluated the influence of implementing a protocol to increase resident physicians' academic productivity in cardiac surgery., Methods: A comprehensive protocol for cardiac surgery was implemented at our institution that included active pairing of residents with academically productive faculty, regular research meetings, centralized data storage and analysis with a core team of biostatisticians, a formal peer-review protocol for analytic requests, and project prioritization and feedback. We compared cardiothoracic surgery residents' academic productivity before implementation (July 2015-June 2017) versus after implementation (July 2017-June 2019). Academic productivity was measured by peer-reviewed articles, abstract presentations (oral or poster) at national cardiothoracic surgery meetings, and textbook chapters., Results: Thirty-four resident physicians (from traditional and integrated programs) trained at our institution during the study. A total of 122 peer-reviewed articles were produced over the course of the study: 74 (60.7%) cardiac- and 48 (39.3%) thoracic-focused. The number of cardiac-focused resident-produced articles increased from 10 preimplementation to 64 postimplementation (0.61 vs 2.03 articles per resident; P < .01). Abstract oral or poster presentations also increased, from 11 to 40 (0.61 vs 1.33 abstracts per resident; P = .01). Textbook chapters increased from 4 to 15 following the intervention (0.22 vs 0.5 chapters per resident; P = .01)., Conclusions: Implementation of a dedicated protocol to facilitate faculty mentoring of resident research and streamline the data access, analysis, and publication process substantially improved cardiothoracic surgery residents' academic productivity., (Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: While robotic-assisted lung resection has seen a significant rise in adoption, concerns remain regarding initial programmatic outcomes and potential increased costs. We present our initial outcomes and cost analysis since initiation of a robotic lung resection program., Methods: Patients undergoing either video-assisted thoracoscopic lobectomy or segmentectomy (VATS) or robotic-assisted lobectomy or segmentectomy (RALS) between August of 2014 and January of 2017 underwent retrospective review. Patients underwent 1:1 propensity matching based on preoperative characteristics. Perioperative and 30-day outcomes were compared between groups. Detailed activity-based costing analysis was performed on individual patient encounters taking into effect direct and indirect controllable costs, including robotic operative supplies., Results: There were no differences in 30-day mortality between RALS (n = 74) and VATS (n = 74) groups (0% vs 1.4%; P = 1). RALS patients had a decreased median length of stay (4 days vs 7 days; P < .001) and decreased median chest tube duration (3 days vs 5 days, P < .001). Total direct costs, including direct supply costs, were not significantly different between RALS and VATS ($6621 vs $6483; P = .784). Median total operating costs and total unit support costs, which are closely correlated to length of stay, were lower in the RALS group. Overall median controllable costs were significantly different between RALS and VATS ($16,352 vs $21,154; P = .025)., Conclusions: A potentially cost-advantageous robotic-assisted pulmonary resection program can be initiated within the context of an existing minimally invasive thoracic surgery program while maintaining good clinical outcomes when compared with traditional VATS. Process-of-care changes associated with RALS may account for decreased costs in this setting., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Pleural metastasis in lung cancer found at diagnosis has a poor prognosis, with 5-11 months' survival. We hypothesized that prognosis might be different for patients who have had curative-intent surgery and subsequent pleural recurrence and that survival might differ based on the location of the first metastasis (distant versus pleural). This may clarify if pleural recurrence is a local event or due to systemic disease., Methods: A database of 5089 patients who underwent curative-intent surgery for lung cancer was queried, and 85 patients were found who had biopsy-proven pleural metastasis during surveillance. We examined survival based on pattern of metastasis (pleural first versus distant first/simultaneously)., Results: Median survival was 34 months (range: 1-171) from the time of surgery and 13 months (range: 0-153) from the time of recurrence. The shortest median survival after recurrence was in patients with adenocarcinoma and pleural metastasis as the first site (6 months). For patients with pleural metastasis as the first site, those with adenocarcinoma had a significantly shorter post-recurrence survival when compared with squamous cell carcinoma (6 vs. 12 months; HR = 0.34) and a significantly shorter survival from the time of surgery when compared with distant metastases first/simultaneously (25 vs. 52 months; HR = 0.49)., Conclusions: Patients who undergo curative-intent surgery for lung adenocarcinoma that have pleural recurrence as the first site have poor survival. This may indicate that pleural recurrence after lung surgery is not likely due to a localized event but rather indicates systemic disease; however, this would require further study.

Objective: We hypothesize that segmentectomy is associated with similar recurrence-free and overall survival when compared with lobectomy in the setting of patients with clinical T1cN0M0 non-small cell lung cancer (NSCLC; >2-3 cm), as defined by the American Joint Committee on Cancer 8th edition staging system., Methods: We performed a single-institution retrospective study identifying patients undergoing segmentectomy (90) versus lobectomy (279) for T1c NSCLC from January 1, 2003, to December 31, 2016. Univariate, multivariable, and propensity score-weighted analyses were performed to analyze the following endpoints: freedom from recurrence, overall survival, and time to recurrence., Results: Patients undergoing segmentectomy were older than patients undergoing lobectomy (71.5 vs 68.8, respectively, P = .02). There were no differences in incidence of major complications (12.4% vs 11.7%, P = .85), hospital length of stay (6.2 vs 7 days, P = .19), and mortality at 30 (1.1% vs 1.7%, P = 1) and 90 days (2.2% vs 2.3%, P = 1). In addition, there were no statistical differences in locoregional (12.2% vs 8.6%, P = .408), distant (11.1% vs 13.9%, P = .716), or overall recurrence (23.3% vs 22.5%, P = 1), as well as 5-year freedom from recurrence (68.6% vs 75.8%, P = .5) or 5-year survival (57.8% vs 61.0%, P = .9). Propensity score-matched analysis found no differences in overall survival (hazard ratio [HR], 1.034; P = .764), recurrence-free survival (HR, 1.168; P = .1391), or time to recurrence (HR, 1.053; P = .7462)., Conclusions: In the setting of clinical T1cN0M0 NSCLC, anatomic segmentectomy was not associated with significant differences in recurrence-free or overall survival at 5 years. Further prospective randomized trials are needed to corroborate the expansion of the role of anatomic segmentectomy to all American Joint Committee on Cancer 8th Edition Stage 1A NSCLC., (Copyright © 2020. Published by Elsevier Inc.)

Objective: The aim of the study was to determine whether prolonged air leak (PAL) is associated with postoperative morbidity and mortality following pulmonary resection after adjusting for differences in baseline characteristics using propensity score analysis., Summary Background Data: Patients with PAL after lung resection have worse outcomes than those without PAL. However, adverse postoperative outcomes may also be secondary to baseline risk factors, such as poor lung function., Methods: Patients who underwent pulmonary resection for lung cancer/nodules (1/2009-6/2014) were stratified by the presence of PAL [n = 183 with/1950 without; defined as >5 d postoperative air leak; n = 189 (8.3%)]; probability estimates for propensity for PAL from 31 pretreatment/intraoperative variables were generated. Inverse probability-of-treatment weights were applied and outcomes assessed with logistic regression., Results: Standardized bias between groups was significantly reduced after propensity weighting (mean = 0.18 before vs 0.08 after, P < 0.01). After propensity weighting, PAL was associated with increased odds of empyema (OR = 8.5; P < 0.001), requirement for additional chest tubes for pneumothorax (OR = 7.5; P < 0.001), blood transfusion (OR = 2; P = 0.03), pulmonary complications (OR = 4; P < 0.001), unexpected return to operating room (OR = 4; P < 0.001), and 30-day readmission (OR = 2; P = 0.009). Among other complications, odds of cardiac complications (P = 0.493), unexpected ICU admission (P = 0.156), and 30-day mortality (P = 0.270) did not differ. Length of hospital stay was prolonged (5.04 d relative effect, 95% confidence interval, 3.77-6.30; P < 0.001)., Conclusions: Pulmonary complications, readmission, and delayed hospital discharge are directly attributable to having a PAL, whereas cardiac complications, unexpected admission to the ICU, and 30-day mortality are not after propensity score adjustment., Competing Interests: The authors report no conflicts of interest., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: Recruiting medical students to cardiothoracic surgery is critical given new training paradigms and projected cardiothoracic surgeon shortages. This study characterizes current perceptions and exposure to cardiothoracic surgery among all levels of medical students., Methods: Currently active medical students at all levels at a US allopathic medical school were sent an invitation to complete an online survey. Baseline demographics, medical specialty interest, interest and exposure to cardiac surgery specifically, and awareness of procedures performed by cardiothoracic surgeons were evaluated. Five-point Likert scales were used to evaluate attitudes toward facets of the field of cardiothoracic surgery. Only complete surveys over the 4-week enrollment period were used for analysis., Results: There were 126 surveys (22%) completed during the study period. Interest in cardiothoracic surgery at any point was indicated by 37% of students, but only 13% indicated an interest at the time of the survey. Interest among first-year students was greater than all other classes (30% vs <15%, P = .02). Lifestyle factors and personal attributes of cardiothoracic surgeons were noted as negative factors influencing cardiothoracic surgery perception, whereas intellectual challenge and clinical impact were cited as positive factors. Increasing interaction with faculty/residents and simulation experiences were factors noted to increase interest in the field., Conclusions: Although medical students report early interest in cardiothoracic surgery because of intellectual stimulation and patient care attributes, lack of early exposure and perceived poor lifestyle negatively affect interest in the field. Early interaction between students and cardiothoracic faculty/trainees along with early exposure opportunities may increase recruitment., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Integrated cardiothoracic (CT) surgery training programs are an increasingly popular pathway to train CT surgeons. Identifying and engaging medical students early is important to generate interest and ensure highly qualified applicants are aware of opportunities provided by a career in CT surgery., Methods: An optional CT surgery "mini-elective" was developed for preclinical medical students consisting of five 2-hour sessions covering major procedures in cardiac surgery. Each session had an inital 1 hour lecture immediatly followed by a hands on simulation component. Sessions were taught by CT surgery faculty and residents. A precourse and postcourse survey was administered to identify interest in and awareness of the field of CT surgery., Results: There were 22 students enrolled in the course who provided precourse surveys, while 21 provided postcourse surveys. CT surgery was a career consideration for 95.4% of students who took the mini-elective. nine percent of the students who had either scrubbed or observed a CT case precourse, increased to 33.3% postcourse (P = .11). With regards to mentorship, 23.8% felt they could easily find a mentor in CT surgery precourse, increasing to 66.7% postcourse (P = .01). Eighty-one percent of students reported that the mini-elective significantly increased their CT knowledge over the standard cardiovascular curriculum, and 100% of those completing the course were "extremely satisfied" with the experience., Conclusions: A CT surgery mini-elective increased awareness and interest in the field among preclinical medical students. Longitudinal exposure and mentorship provided in programs such as this will be key to the continued recruitment of high-quality medical students to the field., (© 2019 Wiley Periodicals, Inc.)

Objectives: Sublobar resection (SLR) for early non-small-cell lung carcinoma (NSCLC) has been shown to have a survival rate similar to that of lobectomy. Large-cell neuroendocrine carcinoma (LCNEC) of the lung, although treated like an NSCLC, has a poor prognosis compared to NSCLC. We sought to determine if outcomes are poor in patients with early stage LCNEC treated with SLR versus lobectomy., Methods: We searched for patients with pathological stage I LCNEC ≤3 cm within the National Cancer Database between 2004 and 2014. Propensity score matching was used to compare the 5-year overall survival rate of patients having SLR (wedge or segmentectomy) to that of patients having a lobectomy. Patients were matched for age, node sampling, comorbidity score, tumour size, insurance status and other factors. Patients who received neoadjuvant therapy were excluded. Kaplan-Meier methods were used for analysis., Results: A total of 1011 patients met the inclusion criteria: 263 were treated with SLR (223 wedges and 40 segmentectomies) and 748 patients, with lobectomy. Patients who received SLR were older, had more comorbidities and smaller tumours. On unadjusted Kaplan-Meier analysis, patients who had SLR had decreased 5-year overall survival compared to those who had a lobectomy (37.9% vs 56.6%, P < 0.001). Propensity score matching (1:1) across 12 demographic and tumour variables yielded 185 patients per group with 34 segmentectomies and 151 wedge resections in the SLR cohort. On Kaplan-Meier analysis of the matched cohort, patients who had SLR had a worse 5-year overall survival rate compared to those who had a lobectomy (41.5% vs 60.3%; P = 0.001)., Conclusions: SLR for early stage LCNEC is associated with a lower 5-year overall survival rate compared to lobectomy on unadjusted and propensity matched analyses., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Segmentectomy for well-selected early stage non-small-cell lung carcinoma (NSCLC) has been shown to have similar oncologic outcomes and survival to lobectomy. However, these data are based on the presumption that the disease is node negative. Few data exist regarding the risk factors for and the outcomes of patients with disease treated with segmentectomy that is found to be node positive. We sought to determine the risk factors for and outcomes of clinical stage I NSCLC patients who are treated with segmentectomy but are determined to be node positive., Patients and Methods: We queried patients with clinical stage I NSCLC ≤ 3 cm within the National Cancer Data Base between 2004 and 2014 who were treated with segmentectomy or lobectomy and found to have positive nodes. Kaplan-Meier curves with log-rank tests were used to compare overall survival (OS) between segmentectomy and lobectomy. For comparison only, segmentectomy patients with pathologically node-negative disease were identified to determine predictors of node positivity after segmentectomy via multivariable logistic regression., Results: A total of 4556 patients with node-positive disease were identified, comprising 115 segmentectomy patients and 4441 lobectomy patients. Multivariable analysis identified increasing tumor size, squamous-cell histology, and increasing number lymph nodes sampled as significant predictors of node positivity after segmentectomy. There was no difference in OS between segmentectomy and lobectomy, with 3-year OS rates of 66.3% and 68.1%, respectively (P = .723)., Conclusion: There are discrete risk factors for discovering positive nodes after segmentectomy. Segmentectomy is associated with similar OS compared to lobectomy for clinical stage I NSCLC found to be node positive., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: Computed tomography-guided fine needle aspiration (CT-FNA) biopsy is a well-established diagnostic technique in the evaluation of lung nodules that is performed by radiologists in most centers. In this series, we analyzed the diagnostic and perioperative outcomes following CT-FNA performed by a dedicated group of thoracic surgeons., Methods: We conducted a retrospective analysis of 955 patients undergoing CT-FNA by the thoracic surgery service. Primary outcome variables included diagnostic yield and accuracy, number of needle passes, complication rates, and adequacy of specimen for molecular testing., Results: A satisfactory diagnostic specimen was obtained in 94.1% of cases. The average number of needle passes was 3.2 ± 1.5 (range, 1-10 passes). Diagnostic yield was significantly improved by increasing the number of passes from 1 to 2 to 3 passes (P = .0003). CT-FNA diagnostic accuracy was 88.8%. Diagnostic accuracy did not significantly improve with ≥4 passes (P = .20). Molecular testing was successful in 43.1%, and did not improve with ≥4 passes (P = .5). Molecular testing success did improve with the addition of core needle biopsy (P = .005). The pneumothorax rate for CT-FNA alone was 26.4%, and increased with ≥4 passes (P = .009). The median length of stay for CT-FNA alone was 0 days (range, 0-74 days), with same-day discharge in 67.5% of patients., Conclusions: Thoracic surgeons can perform CT-FNA with excellent diagnostic yield and accuracy. Diagnostic yield, accuracy, and success in molecular testing do not improve with ≥4 CT-FNA passes. Pneumothorax rates do increase with ≥4 passes. The addition of core needle biopsy enhances success with molecular testing., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: Anatomic lung resection provides the best opportunity for long-term survival in the setting of early-stage non-small cell lung cancer (NSCLC). However, 20-30% of patients develop recurrent disease following complete (R0) resection for Stage I disease. In the current study, we analyze the impact of patient, surgical and pathologic variables upon recurrence patterns following anatomic lung resection for clinical stage I NSCLC., Patients and Methods: A total of 1132 patients (384 segmentectomies, 748 lobectomies) with clinical stage I NSCLC were evaluated. Predictors of recurrence were identified by proportional hazards regression. Differences in recurrence patterns between groups are illustrated by log rank tests applied to Kaplan-Maier estimates., Results: A total of 227 recurrences (20.0%) were recorded at a median follow-up of 36.8 months (65 locoregional, 155 distant). There was no significant difference in recurrence patterns when comparing segmentectomy and lobectomy. Multivariate analysis demonstrated that angiolymphatic invasion, tumor size, tumor grade and the presence of only mild-moderate tumor inflammation were independent predictors of recurrence risk., Conclusions: Recurrence following anatomic lung resection is influenced predominantly by pathological variables (tumor size, tumor grade, angiolymphatic invasion, tumor inflammation). Optimization of surgical margin in relation to tumor size may improve outcomes. Extent of resection (segmentectomy vs. lobectomy) does not appear to have an impact on recurrence-free survival when adequate margins are obtained., (Copyright © 2018 Elsevier B.V. All rights reserved.)

The role of anatomic segmentectomy as an acceptable, lung parenchymal sparing alternative to pulmonary lobectomy for the small peripheral stage I lung cancer is under great scrutiny today. This is not a new consideration, particularly for the patient with impaired cardiopulmonary reserve where preservation of lung function may be a critical issue in deciding on surgical resection for local/regional control of their cancer. In this review, we discuss the oncologic issues along with past and present evidence supporting "anatomic" lung preservational surgery in the management of lung cancer., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Background: Studies in the past have identified selected immune cells that associate with different clinical outcomes in non-small cell lung cancer (NSCLC). Considering the fact that immune responses are heterogenous and that the clinical outcome could be influenced by the interplay of various immune cell types, it is imperative to evaluate multiple intra-tumoral immune cell types in the same set of patients. Objective: To evaluate the individual and combined effects of diverse intra-tumoral immune cell types on recurrence after complete surgical resection in early stage lung adenocarcinoma. Methods: We obtained NCBI GEO datasets for lung adenocarcinoma, the most prevalent histological subtype of NSCLC and re-analyzed the gene expression data of 292 patients with early stage cancer (IA/IB). CIBERSORT was used to resolve 22 immune cell types from the tumor transcriptomes. Survival analysis was carried out to assess the effect of immune cell types and genes associated with recurrence. Results: Out of the 22 cell types, a high proportion of Tregs and monocyte-macrophages in the tumors were associated with significantly increased probability of recurrence. Conversely, increased proportion of non-Treg CD4+ T cells and plasma cells were associated with a lower probability of recurrence. The higher expression of CCL20 (which can direct the migration of cells of B cell lineage), XCL1 (associated with prototypical Th1 responses) and the immunoglobulin chains IGHV4.34 and IGLV6.57 were associated with a significantly lower probability of recurrence. Importantly, the intra-tumoral immune phenotype comprising these four cell types varied among patients and differentially associated with recurrence depending on net levels of positive and negative prognostic factors. Despite a high level of intra-tumoral plasma cells, a concomitant high level of monocyte-macrophages reduced the freedom from recurrence from ~80 to ~50% at 80 months ( p < 0.05). Furthermore, stratification of the patients on the basis of a score estimated from the levels of four cell types enabled the identification of patients with significantly increased probability of recurrence (~50%) after surgery. Significance: Our analysis suggests that concomitant levels of macrophages and plasma cells, in addition to the T regs and non-TregCD4+ T cells in tumors can identify patients with early stage lung cancer at greater risk of recurrence.

Background: Surgical resection with curative-intent remains the gold standard for clinically operable early-stage non-small cell lung cancer (NSCLC). This goal can be accomplished using a minimally invasive option, e.g., video assisted thoracic surgery (VATS) or standard thoracotomy. Surgical techniques continue to evolve and few studies have compared the QOL of patients managed with these procedures using current approaches. The primary goal of this study was to investigate differences between patients managed surgically via VATS compared to thoracotomy with respect to ratings of chronic pain, anxiety/depression and quality of life (QOL). The secondary goal was to investigate differences between patients converted from VATS to thoracotomy versus those managed with the originally with thoracotomy., Methods: We conducted a prospective cross sectional design study comparing the QOL after surgical resection of NSCLC. Data were obtained between 3-12 months postoperatively, from patients with potentially resectable stage I-IIIa NSCLC, who underwent a thoracotomy or VATS resection. All patients were consented. Pain was evaluated with a 0 to 10 numeric pain assessment scale (NAS), mood with the Hospital Anxiety and Depression Scale (HADS) (mood disorders) and QOL with FACT-L (Functional Assessment of Cancer Therapy-Lung)., Results: A total of 97 patients with stage I-IIIa lung cancer were enrolled; of these 66 (68%) underwent a standard thoracotomy and 31 (32%) underwent VATS resection. The preferred surgical approach was a thoracotomy for patients with stage IIIa lung cancer, or patients requiring a pneumonectomy or a bi-lobectomy. There were no significant differences between VATS and thoracotomy patients in ratings of chronic pain, mood disorders, or QOL. Conversion from VATS to thoracotomy occurred in 22 (23%) of patients. There were no significant differences between VATS conversion to thoracotomy and those with initial thoracotomy procedures in ratings of chronic pain, mood disorders, or QOL. Conversion from VATS to standard thoracotomy occurred more commonly early in the series., Conclusions: While previous studies have shown that VATS offers an early advantage with regards to perioperative outcomes, our study demonstrated that VATS and thoracotomy patients had similar late QOL outcomes., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Checkpoint inhibitors (eg, programmed cell death protein 1 [PD-1], programmed cell death ligand 1 [PD-L1], cytotoxic T-lymphocyte associated protein 4 [CTLA-4] antibodies) are changing how we understand cancer and provide a means to develop modern immunotherapies. An emergent notion relates success with checkpoint inhibitors with high mutational load tumors. There are few studies that examine checkpoint protein expression and relate these to clinical outcomes after the conventional treatment of patients with esophageal cancer, which has a high mutational load. The objective of this review is to summarize the literature that examines checkpoint expression and clinical outcomes, as well as propose an accelerated approach to introducing these therapies into the clinic to treat patients with esophageal cancer., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Prolonged air leak increases costs and worsens outcomes after pulmonary resection. We aimed to develop a clinical prediction tool for prolonged air leak using pretreatment and intraoperative variables., Methods: Patients who underwent pulmonary resection for lung cancer/nodules (from January 2009 to June 2014) were stratified by prolonged parenchymal air leak (>5 days). Using backward stepwise logistic regression with bootstrap resampling for internal validation, candidate variables were identified and a nomogram risk calculator was developed., Results: A total of 2317 patients underwent pulmonary resection for lung cancer/nodules. Prolonged air leak (8.6%, n = 200) was associated with significantly longer hospital stay (median 10 vs 4 days; P < .001). Final model variables associated with increased risk included low percent forced expiratory volume in 1 second, smoking history, bilobectomy, higher annual surgeon caseload, previous chest surgery, Zubrod score >2, and interaction terms for right-sided thoracotomy and wedge resection by thoracotomy. Wedge resection, higher body mass index, and unmeasured percent forced expiratory volume in 1 second were protective. Derived nomogram discriminatory accuracy was 76% (95% confidence interval [CI], 0.72-0.79) and facilitated patient stratification into low-, intermediate- and high-risk groups with monotonic increase in observed prolonged air leaks (2.0%, 8.9%, and 19.2%, respectively; P < .001). Patients at intermediate and high risk were 4.80 times (95% CI, 2.86-8.07) and 11.86 times (95% CI, 7.21-19.52) more likely to have prolonged air leak compared with patients at low risk., Conclusions: Using readily available candidate variables, our nomogram predicts increasing risk of prolonged air leak with good discriminatory ability. Risk stratification can support surgical decision making, and help initiate proactive, patient-specific surgical management., (Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Computed tomography scans are increasingly used not only for lung cancer screening but also for staging and evaluation of other cancers. As a result, more patients with pulmonary nodules, many with subcentimeter lesions, are being referred to thoracic surgeons, some with concern for primary lung neoplasm and others with possible metastatic lung lesions. Obtaining a definitive diagnosis of these lesions is difficult. Electromagnetic navigational bronchoscopy (ENB)-guided pleural dye marking followed by thoracoscopic resection is a novel alternative technique for definitive diagnosis. The main objective of this study was to evaluate the feasibility and our initial experience with ENB-guided dye localization and minimally invasive resection for diagnosis of lung lesions., Methods: Selected patients with lung lesions underwent ENB-guided dye marking and minimally invasive resection. The primary end points were the rate of nodule localization and definitive diagnosis of the nodule., Results: We performed ENB-guided localization and minimally invasive resection in 29 patients. The median lesion size was 10 mm, with a median distance from pleural surface of 13 mm. The operative mortality was 0%. The median hospital stay was 3 days. The nodule was localized and resected, and a definitive diagnosis was obtained in all patients (29 of 29; 100%). The nodule was neoplastic in 19 patients. All malignant lesions were completely resected with negative microscopic margins., Conclusions: Our initial experience with ENB-guided dye localization and minimally invasive resection found that the technique was feasible, safe, and successful in the diagnosis of small lung lesions. Thoracic surgeons should further investigate this method and incorporate it into their armamentarium., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Although the role for endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for metastatic lung cancer is well described, the usefulness of EBUS-TBNA for diagnosing lymphoma is less well defined. We aimed to determine the diagnostic accuracy for lymphoma of EBUS-TBNA with rapid, on-site evaluation in the evaluation of mediastinal lymphadenopathy in patients with a low-suspicion for lung cancer., Methods: Medical records for all EBUS-TBNA (381 total procedures) from 2007 to 2013 were reviewed, and procedure indication, prior workup, cytologic diagnosis, histologic follow-up, and available ancillary studies were abstracted. Intraoperative rapid on-site evaluation was performed for 170 of 173 patients (98%), and evaluations for 133 (78%) were adequate for diagnosis., Results: Of 381 patients, 173 (45.4%) underwent mediastinal tissue sampling to evaluate indeterminate mediastinal lymphadenopathy; 208 patients with known or suspected lung cancer were excluded. EBUS-TBNA provided a definitive diagnosis (predominantly carcinoma and granulomatous inflammation) in 71%. EBUS-TBNA was diagnostic in 8 of 16 patients (50%) where the final diagnosis of lymphoma in 16 was confirmed (9 non-Hodgkin, 6 Hodgkin, and 1 posttransplant lymphoproliferative disorder). EBUS-TBNA was indeterminate in 3 (19%), inadequate in 4 (25%), and falsely negative in 1 (6%). Histologic follow-up was available in 10 patients (63%). When the specimen was adequate for diagnosis, sensitivity for lymphoma was 89%., Conclusions: EBUS-TBNA has high sensitivity and a low false-negative rate for lymphoproliferative disorders when specimens are adequate for analysis and provides alternative diagnoses in most cases, thus reducing the need for mediastinoscopy. Rapid, on-site evaluation was nondiagnostic in approximately 25% of patients; performing EBUS-TBNA in the operating room facilitated conversion to mediastinoscopy and definitive diagnosis in this setting., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: A significant number of patients have recurrent or persistent lung cancer despite complete resection or treatment with definitive chemoradiation. Stereotactic radiosurgery (SRS)/stereotactic body radiation therapy is emerging as an important modality for the treatment of early-stage lung neoplasm; SRS may also offer an alternative treatment option for patients with recurrent lung disease. We evaluated outcomes after treatment with SRS for recurrent lung neoplasm in a large series of patients., Methods: Selected patients with limited recurrent, persistent, or progressive disease after one or more prior treatments for lung cancer were offered SRS. Thoracic surgeons evaluated all patients, placed fiducials when needed, and planned treatment in close collaboration with radiation oncologists and medical physicists. In our early experience, a single fraction of 20 Gy radiation was prescribed and was subsequently increased to 45 to 60 Gy in three to five fractions. The primary endpoint evaluated was overall survival., Results: We treated 100 patients with recurrent lung cancer (median age 72 years) with SRS. The postprocedure 30-day mortality rate was 0%; median follow-up was 51 months (range, 5 to 123). The median overall survival for the entire group was 23 months (95% confidence interval: 19 to 41). The probability of 2-year and 5-year overall survival was 49% (95% confidence interval: 40% to 60%) and 31% (95% confidence interval: 23% to 43%), respectively., Conclusions: Our experience indicates that SRS is safe, and offers an alternative modality for selected patients with recurrent oligometastatic or persistent lung cancer. Thoracic surgeons should actively participate in SRS and continue to evaluate the efficacy of this treatment strategy., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Thoracic esophageal diverticula are uncommon, and controversies exist regarding their management. The objective of this study was to evaluate the outcomes of a relatively large cohort of patients with thoracic esophageal diverticula treated with minimally invasive surgical techniques., Methods: We conducted a retrospective review of patients who underwent minimally invasive surgical treatment for symptomatic esophageal diverticula during a 15-year period. The primary end point was 30-day mortality. In addition, we evaluated the morbidity, improvement in dysphagia (score: 1, best to 5, worst), and quality of life (Gastroesophageal Reflux Disease-Health-Related Quality of Life score: 0, best to 50, most symptoms)., Results: Fifty-seven patients underwent minimally invasive surgical treatment of symptomatic thoracic esophageal diverticula. The most common symptom was dysphagia (45 of 57; 79%). A motility disorder or distal mechanical obstruction was identified in 49 patients (86%). Approaches used included video-assisted thoracoscopic surgery (n = 33), laparoscopy (n = 18), and combined video-assisted thoracoscopic surgery and laparoscopy (n = 6). The most common procedure performed was diverticulectomy and myotomy (47 of 57 patients; 82.5%). The 30-day mortality was 0%. There were 4 patients (7%) with postoperative leaks requiring reoperation. During follow-up, the median dysphagia score improved from 3 to 1 (p < 0.001). The median Gastroesophageal Reflux Disease-Health-Related Quality of Life score after surgery was 5 (excellent)., Conclusions: A minimally invasive surgical approach for the management of thoracic esophageal diverticula is safe and effective during intermediate-term follow-up when performed by surgeons experienced in esophageal surgery and minimally invasive techniques. Further follow-up is required to assess the durability of these results. The optimal approach and procedures performed should be determined on an individualized basis after a thorough investigation., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: Accurate cancer localization and negative resection margins are necessary for successful segmentectomy. In this study, we evaluate a newly developed software package that permits automated segmentation of the pulmonary parenchyma, allowing 3-dimensional assessment of tumor size, location, and estimates of surgical margins., Methods: A pilot study using a newly developed 3-dimensional computed tomography analytic software package was performed to retrospectively evaluate preoperative computed tomography images of patients who underwent segmentectomy (n = 36) or lobectomy (n = 15) for stage 1 non-small cell lung cancer. The software accomplishes an automated reconstruction of anatomic pulmonary segments of the lung based on bronchial arborization. Estimates of anticipated surgical margins and pulmonary segmental volume were made on the basis of 3-dimensional reconstruction., Results: Autosegmentation was achieved in 72.7% (32/44) of preoperative computed tomography images with slice thicknesses of 3 mm or less. Reasons for segmentation failure included local severe emphysema or pneumonitis, and lower computed tomography resolution. Tumor segmental localization was achieved in all autosegmented studies. The 3-dimensional computed tomography analysis provided a positive predictive value of 87% in predicting a marginal clearance greater than 1 cm and a 75% positive predictive value in predicting a margin to tumor diameter ratio greater than 1 in relation to the surgical pathology assessment., Conclusions: This preoperative 3-dimensional computed tomography analysis of segmental anatomy can confirm the tumor location within an anatomic segment and aid in predicting surgical margins. This 3-dimensional computed tomography information may assist in the preoperative assessment regarding the suitability of segmentectomy for peripheral lung cancers., (Published by Elsevier Inc.)

Purpose: Locally recurrent non-small cell lung cancer (LR-NSCLC) remains challenging to treat, particularly in patients having received prior radiotherapy. Heterogeneous populations and varied treatment intent in existing literature result in significant limitations in evaluating efficacy of lung re-irradiation. In order to better establish the impact of re-irradiation in patients with LR-NSCLC following high-dose radiotherapy, we report outcomes for patients treated with prior sublobar resection and brachytherapy that subsequently underwent stereotactic body radiotherapy (SBRT)., Methods: A retrospective review of patients initially treated with sublobar resection and I(125) vicryl mesh brachytherapy, who later developed LR-NSCLC along the suture line, was performed. Patients received salvage SBRT with curative intent. Dose and fractionation were based on tumor location and size, with a median prescription dose of 48 Gy in 4 fractions (range 20-60 Gy in 1-4 fractions)., Results: Thirteen consecutive patients were identified with median follow-up of 2.1 years (range 0.7-5.6 years). Two in-field local failures occurred at 7.5 and 11.1 months, resulting in 2-year local control of 83.9% (95% CI, 63.5-100.0%). Two-year disease-free survival and overall survival estimates were 38.5% (95% CI, 0.0-65.0%) and 65.8% (95% CI, 38.2-93.4%). Four patients (31%) remained disease-free at last follow-up. All but one patient who experienced disease recurrence developed isolated or synchronous distant metastases. Only one patient (7.7%) developed grade ≥3 toxicity, consisting of grade 3 esophageal stricture following a centrally located recurrence previously treated with radiofrequency ablation., Conclusion: Despite high-local radiation doses delivered to lung parenchyma previously with I(125) brachytherapy, re-irradiation with SBRT for LR-NSCLC results in excellent local control with limited morbidity, allowing for potential disease cure in a subset of patients.

Background: A suggested benefit of sublobar resection for stage I non-small cell lung cancer (NSCLC) compared to lobectomy is a relative preservation of pulmonary function. Very little objective data exist, however, supporting this supposition. We sought to evaluate the relative impact of both anatomic segmental and lobar resection on pulmonary function in patients with resected clinical stage I NSCLC., Methods: The records of 159 disease-free patients who underwent anatomic segmentectomy (n = 89) and lobectomy (n = 70) for the treatment of stage I NSCLC with pre- and postoperative pulmonary function tests performed between 6 to 36 months after resection were retrospectively reviewed. Changes in forced expiratory volume in one second (FEV1) and diffusion capacity of carbon monoxide (DLCO) were analyzed based upon the number of anatomic pulmonary segments removed: 1-2 segments (n = 77) or 3-5 segments (n = 82)., Results: Preoperative pulmonary function was worse in the lesser resection cohort (1-2 segments) compared to the greater resection group (3-5 segments) (FEV1(%predicted): 79% vs. 85%, p = 0.038; DLCO(%predicted): 63% vs. 73%, p = 0.010). A greater decline in FEV1 was noted in patients undergoing resection of 3-5 segments (FEV1 (observed): 0.1 L vs. 0.3 L, p = 0.003; and FEV1 (% predicted): 4.3% vs. 8.2%, p = 0.055). Changes in DLCO followed this same trend (DLCO(observed): 1.3 vs. 2.4 mL/min/mmHg, p = 0.015; and DLCO(% predicted): 3.6% vs. 5.9%, p = 0.280)., Conclusions: Parenchymal-sparing resections resulted in better preservation of pulmonary function at a median of one year, suggesting a long-term functional benefit with small anatomic segmental resections (1-2 segments). Prospective studies to evaluate measurable functional changes, as well as quality of life, between segmentectomy and lobectomy with a larger patient cohort appear justified.

Background: Intractable gastroesophageal reflux disease (GERD) after antireflux operations presents a challenge-particularly in obese patients and patients with esophageal dysmotility-and increases the complexity of the redo operation. This study evaluated the results of Roux-en-Y near esophagojejunostomy (RNYNEJ) in the management of recurrent GERD after antireflux operations., Methods: We conducted a retrospective review of overweight patients with intractable GERD who underwent RNYNEJ for failed antireflux operations. We evaluated perioperative outcomes, dysphagia (ranging from 1 = no dysphagia to 5 = unable to swallow saliva), and quality of life (QOL) (assessed using the GERD health-related quality-of-life instrument (HRQOL)., Results: Over a 12-year period, 105 patients with body mass index (BMI) greater than 25 underwent RNYNEJ for failed antireflux operations. Most were obese (BMI > 30; 82 patients [78%]); esophageal dysmotility was demonstrated in more than one-third of patients. Forty-eight (46%) patients had multiple antireflux operations before RNYNEJ, and 27 patients had undergone a previous Collis gastroplasty. There was no perioperative mortality. Major complications, including anastomotic leak requiring surgical intervention (n = 3 [2.9%]), were noted in 25 patients (24%).The median length of stay was 6 days. During follow-up (mean, 23.39 months), median BMI decreased from 35 to 27.6 (p < 0.0001), and the mean dysphagia score decreased from 2.9 to 1.5 (p < 0.0001). The median GERD HRQOL score, assessed in a subset of patients, was 9 (classified as excellent)., Conclusions: RNYNEJ for persistent GERD after antireflux operations in appropriately selected patients can be performed safely with good results in experienced centers. RNYNEJ should be considered an important option for the treatment of intractable recurrent symptoms after antireflux operations, particularly in obese patients., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose: Although anatomic segmentectomy has been considered a compromised procedure by many surgeons, recent retrospective, single-institution series have demonstrated tumor recurrence and patient survival rates that approximate those achieved by lobectomy. The primary objective of this study was to use propensity score matching to compare outcomes after these anatomic resection approaches for stage I non-small-cell lung cancer., Patients and Methods: A retrospective data set including 392 segmentectomy patients and 800 lobectomy patients was used to identify matched segmentectomy and lobectomy cohorts (n = 312 patients per group) using a propensity score matching algorithm that accounted for confounding effects of preoperative patient variables. Primary outcome variables included freedom from recurrence and overall survival. Factors affecting survival were assessed by Cox regression analysis and Kaplan-Meier estimates., Results: Perioperative mortality was 1.2% in the segmentectomy group and 2.5% in the lobectomy group (P = .38). At a mean follow-up of 5.4 years, comparing segmentectomy with lobectomy, no differences were noted in locoregional (5.5% v 5.1%, respectively; P = 1.00), distant (14.8% v 11.6%, respectively; P = .29), or overall recurrence rates (20.2% v 16.7%, respectively; P = .30). Furthermore, when comparing segmentectomy with lobectomy, no significant differences were noted in 5-year freedom from recurrence (70% v 71%, respectively; P = .467) or 5-year survival (54% v 60%, respectively; P = .258). Segmentectomy was not found to be an independent predictor of recurrence (hazard ratio, 1.11; 95% CI, 0.87 to 1.40) or overall survival (hazard ratio, 1.17; 95% CI, 0.89 to 1.52)., Conclusion: In this large propensity-matched comparison, lobectomy was associated with modestly increased freedom from recurrence and overall survival, but the differences were not statistically significant. These results will need further validation by prospective, randomized trials (eg, Cancer and Leukemia Group B 140503 trial)., (© 2014 by American Society of Clinical Oncology.)

This investigation was aimed to see whether PJ34(TM), a PARP inhibitor, could exert cytotoxicity in six nonsmall cell lung cancer cell lines developed from surgically resected tissues. Using various biochemical assays, we have seen that PJ34(TM) effects are consistent between untreated and treated samples but still somewhat variable between each cell line. Changes in protein expression and mitochondrial membrane potential between treated and untreated cells were indicating the possibility of apoptosis induction through an intrinsic pathway which causes cytotoxicity. Present results open the possibility of elucidating a decisive mechanism and effectiveness of chemotherapeutics specific to a patient.

Background: Thoracic surgeons are commonly consulted to provide anterior thoracic exposure for infection and malignant neoplasms involving the thoracolumbar spine. These cases can present significant technical and management challenges secondary to the underlying pathology, associated anatomic inflammation, and impaired functional status. In this study, we review the perioperative outcomes in patients undergoing anterior spinal exposure for infection and neoplasm., Methods: 130 consecutive patients (61 women, 69 men) undergoing corpectomy, debridement, or debulking for osteomyelitis (n=50) or neoplasms (n=80) with decompression/stabilization at a single institution were analyzed. Primary endpoints included morbidity, mortality, and perioperative neurologic outcomes., Results: The mean age was 61.1 years. A cervical/sternotomy (n=8) approach was used for levels C7 to T2, thoracotomy (n=79) for levels T3 to T10, and thoracoabdominal (n=43) for T11 to L2 involvement. Primary spinal neoplasms (n=22, 16.9 %) and metastases (n=58, 44.6%) were treated with corpectomy and prosthetic stabilization and were associated with increased operative time (310 vs 243 minutes, p=0.02) and blood loss (825 vs 500 mL, p=0.002). Osteomyelitis was associated with longer hospital stays (12 vs 7 days, p<0.001). The 30-day and 90-day mortality was 9.2% and 20.8%, respectively. The major complication rate was 27.7%. The median length of stay was 9 days. Surgical intervention resulted in significant improvement in pain, numbness, weakness, and bowel and bladder dysfunction., Conclusions: Anterior spinal exposure represents an important modality in facilitating the treatment of patients with osteomyelitis, pathologic fractures, and spinal cord compression syndromes. These procedures are associated with a significant risk of morbidity and mortality, but they are effective in achieving spinal stabilization and alleviating neurologic symptoms., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Sublobar wedge resection is associated with an increased risk of locoregional recurrence (15-20%) compared with lobectomy for early non-small cell lung cancer (NSCLC). We have previously shown that the addition of brachytherapy mesh at the time of sublobar resection might decrease the risk of local recurrence in this setting, equivalent to that of lobectomy [Santos et al. Surgery 2003;134:691-7]. In the current study, we evaluated the impact of brachytherapy mesh implantation after formal anatomic segmentectomy on local recurrence rates in the management of clinical stage I NSCLC., Methods: We undertook a retrospective review of 369 patients undergoing anatomic segmentectomy for clinical stage I NSCLC from 2002 to 2010 with (n = 155) or without (n = 214) the use of I(131) brachytherapy mesh applied over the staple line. The primary end point was local recurrence. Secondary end points included morbidity, mortality, and recurrence-free survival., Results: Patients undergoing brachytherapy mesh implantation were older (71.0 vs 69.0 years, P = .03) and had larger tumors (2.3 cm vs 2.0 cm, P = .001) compared with those treated without mesh. There were no differences noted in sex, histology, or tumor stage. Overall mortality was 1.1% (mesh, 0.6%; no mesh 1.4%). Perioperative morbidity was similar in patients receiving mesh (45.8% vs 37.4%, P = .11). At a mean follow-up of 32.9 months, the overall local recurrence rate was 5.4% (mesh: 6.4% vs no mesh: 4.6%, P = .49). Five-year actuarial freedom from local recurrence was 92% in the mesh group, and 90% in patients undergoing segmentectomy without mesh (P = .24)., Conclusion: It appears that the local recurrence noted with non-anatomic wedge resection is not an equivalent concern when anatomic segmentectomy with adequate margins are obtained. This implies that adjuvant brachytherapy after anatomic segmentectomy is not required for local control, thus avoiding the costs of radiation therapy and its associated potential toxicity. These data also suggest that proper anatomic segmentectomy alone may be associated with local recurrence rates similar to those of anatomic lobectomy in the setting of clinical stage I NSCLC., (Copyright © 2014 Mosby, Inc. All rights reserved.)

Background: This retrospective study aims to assess the usefulness of SUV(max) from FDG-PET imaging as a prognosticator for primary biopsy-proven stage I NSCLC treated with SBRT., Methods: This study includes 95 patients of median age 77 years, with primary, biopsy-confirmed peripheral stage IA/IB NSCLC. All patients were treated with 60 Gy in 3 fractions with a median treatment time of six days. Local, regional, and distant failures were evaluated independently according to the terms of RTOG1021. Local, regional, and distant control, overall- and progression-free survival were estimated by the Kaplan-Meier method. Cox proportional hazards regression was performed to determine whether SUV(max), age, KPS, gender, tumor size/T stage, or smoking history influenced outcomes. SUV(max) was evaluated as both a continuous and as a dichotomous variable using a cutoff of <5 and ≥ 5., Results: Median follow-up for the cohort was 16 months. Median OS and PFS were 25.3 and 40.3 months, respectively. SUV with a cutoff value of 5 predicted for OS and PFS (p = .024 for each) but did not achieve significance for LC (p = .256). On Cox univariate regression analysis, SUV as a dichotomous variable predicted for both OS and PFS (p = .027 and p = .030, respectively). Defined as a continuous variable, SUV(max) continued to predict for OS and PFS (p = .032 and p = .003), but also predicted LC (p = .045) and trended toward significance for DC (p = .059). SUV(max) did not predict for OS as a dichotomous or continuous variable. It did, however, predict for PFS as a continuous variable (p = .008), neared significance for local control (p = .057) and trended towards, significance for distant control (p = .092)., Conclusions: SUV(max) appears to be a statistically and clinically significant independent prognostic marker for progression-free survival in patients with stage I NSCLC treated with SBRT. Prospective studies to more accurately define the role of tumor FDG uptake in the prognosis of NSCLC are warranted.