Thymus-derived B cell clones persist in the circulation after thymectomy in myasthenia gravis.

Myasthenia gravis (MG) is a neuromuscular, autoimmune disease caused by autoantibodies that target postsynaptic proteins, primarily the acetylcholine receptor (AChR) and inhibit signaling at the neuromuscular junction. The majority of patients under 50 y with AChR autoantibody MG have thymic lymphofollicular hyperplasia. The MG thymus is a reservoir of plasma cells that secrete disease-causing AChR autoantibodies and although thymectomy improves clinical scores, many patients fail to achieve complete stable remission without additional immunosuppressive treatments. We speculate that thymus-associated B cells and plasma cells persist in the circulation after thymectomy and that their persistence could explain incomplete responses to resection. We studied patients enrolled in a randomized clinical trial and used complementary modalities of B cell repertoire sequencing to characterize the thymus B cell repertoire and identify B cell clones that resided in the thymus and circulation before and 12 mo after thymectomy. Thymus-associated B cell clones were detected in the circulation by both mRNA-based and genomic DNA-based sequencing. These antigen-experienced B cells persisted in the circulation after thymectomy. Many circulating thymus-associated B cell clones were inferred to have originated and initially matured in the thymus before emigration from the thymus to the circulation. The persistence of thymus-associated B cells correlated with less favorable changes in clinical symptom measures, steroid dose required to manage symptoms, and marginal changes in AChR autoantibody titer. This investigation indicates that the diminished clinical response to thymectomy is related to persistent circulating thymus-associated B cell clones.

Quality Versus Quantity: The Potential Impact of Public Reporting of Hospital Safety for Complex Cancer Surgery.

OBJECTIVE: To estimate the potential mortality reduction if patients chose the safest hospitals for complex cancer surgery. BACKGROUND: Mortality after complex oncologic surgery is highly variable across hospitals, and directing patients away from unsafe hospitals could potentially improve survivorship. Hospital quality measures are becoming increasingly accessible at a time when patients are more engaged in choosing providers. It is currently unclear what information to share with patients to maximally capitalize on patient-centered realignment. METHODS: The National Cancer Database was queried for adults undergoing 5 complex cancer surgeries (pulmonary lobectomy, pneumonectomy, esophagectomy, gastrectomy, and colectomy) for a primary cancer between 2008 and 2012. Risk-standardized mortality rate (RSMR) methodology, currently used by Medicare-based hospital rating systems, was used to classify hospitals as "safest" and "least safe" by procedure. Patients were modeled moving from "least safe" to "safest" hospitals and the potential number of lives saved through patient realignment determined. As surgical volume has historically been used to distinguish safe hospitals, comparisons were made to models moving patients from low-volume to high-volume hospitals. RESULTS: A total of 292,040 patients were analyzed. In an optimally modeled scenario, realignment using RSMR would result in a greater number of lives saved (3592 vs 2161, P < 0.01) and require only 15 patients to change hospitals to save a life, compared to 78 patients using volume models (P < 0.01). CONCLUSIONS: Public reporting of hospital safety, specifically based on RSMR instead of volume, has the potential to lead to meaningful reductions in surgical mortality after complex cancer surgery, even in the setting of a modest patient realignment.

Incorporating Coexisting Chronic Illness into Decisions about Patient Selection for Lung Cancer Screening. An Official American Thoracic Society Research Statement.

BACKGROUND: Lung cancer screening (LCS) has the potential to reduce the risk of lung cancer death in healthy individuals, but the impact of coexisting chronic illnesses on LCS outcomes has not been well defined. Consideration of the complex relationship between baseline risk of lung cancer, treatment-related harms, and risk of death from competing causes is crucial in determining the balance of benefits and harms of LCS. OBJECTIVES: To summarize evidence, identify knowledge and research gaps, prioritize topics, and propose methods for future research on how best to incorporate comorbidities in making decisions regarding LCS. METHODS: A multidisciplinary group of international clinicians and researchers reviewed available data on the effects of comorbidities on LCS outcomes, focusing on the juxtaposition of lung cancer risk and competing risks of death, consideration of benefits and risks in patients with chronic obstructive pulmonary disease, communication of risk, and treatment of screen-detected lung cancer. RESULTS: This statement identifies gaps in knowledge regarding how comorbidities and competing causes of death impact outcomes in LCS, and we have developed questions to help guide future research efforts to better inform patient selection, education, and implementation of LCS. CONCLUSIONS: There is an urgent need for further research that can help guide clinical decision-making with patients who may not benefit from LCS owing to coexisting chronic illness. This statement establishes a research framework to address essential questions regarding how to incorporate and communicate risks of comorbidities into patient selection and decisions regarding LCS.

Recommendations for the Appropriate Structure, Communication, and Investigation of Tobacco Harm Reduction Claims. An Official American Thoracic Society Policy Statement.

RATIONALE: The tobacco harm reduction literature is replete with vague language, far-reaching claims, and unwarranted certainty. The American Thoracic Society has increasingly recognized the need for a framework for reliably making such claims. Evidence-based standards improving the scientific value and transparency of harm reduction claims are expected to improve their trustworthiness, clarity, and consistency. METHODS: Experts from relevant American Thoracic Society committees identified key topic areas for discussion. Literature search strategy included English language articles across Medline, Google Scholar, and the Cochrane Collaborative databases, with expanded search terms including tobacco, addiction, smoking, cigarettes, nicotine, and harm reduction. Workgroup members synthesized their evidentiary summaries into a list of candidate topics suitable for inclusion in the final report. Breakout groups developed detailed content maps of each topic area, including points to be considered for suggested recommendations. Successive draft recommendations were modified using an iterative consensus process until unanimous approval was achieved. Patient representatives ensured the document's relevance to the lay public. RESULTS: Fifteen recommendations were identified, organized into four framework elements dealing with: estimating harm reduction among individuals, making claims on the basis of population impact, appropriately careful use of language, and ethical considerations in harm reduction. DISCUSSION: This statement clarifies important principles guiding valid direct and inferential harm reduction claims. Ideals for effective communication with the lay public and attention to unique ethical concerns are also delineated. The authors call for formal systems of grading harm reduction evidence and regulatory assurances of longitudinal surveillance systems to document the impact of harm reduction policies.

The Significance of Upfront Knowledge of N2 Disease in Non-small Cell Lung Cancer.

BACKGROUND: Previous literature suggests that patients with non-small cell lung cancer (NSCLC) and unsuspected N2 disease (cN0, pN2) represent a distinct subgroup associated with improved overall survival compared to patients with N2 disease identified prior to resection (cN2, pN2). METHODS: Retrospective analysis of the National Cancer Database of patients from 2004 to 2011 with cN0 and cN2 status found to be pathologic stage III-N2 NSCLC after surgical resection. Comparison of 5-year survival of patients with unsuspected N2 disease versus those with known N2 disease after surgical resection using Kaplan-Meier analysis was made. The independent effect of unsuspected N2 disease on mortality was analyzed using multivariate analysis. RESULTS: A total of 3271 patients with pathologic stage III-N2 NSCLC underwent curative intent surgical resection with or without adjuvant chemotherapy or chemotherapy and radiation. Unsuspected N2 disease was identified in 48% of patients. Patients with unsuspected N2 disease were more likely to have T1 tumors (37 vs. 32%, p < 0.001). Unsuspected N2 disease did not impact 5-year overall survival compared with known N2 when adjuvant therapy was utilized (40 vs. 37%, p = 0.167). Multivariate analysis identified older age, higher comorbidity score, and treatment with surgery alone as independent risk factors for mortality. The presence of unsuspected N2 disease was not significant in this model. CONCLUSIONS: The findings of this study suggest that unsuspected N2 disease is associated with equivalent 5-year survival compared to cN2 disease when adjuvant therapy is employed. These results support the use of adjuvant chemotherapy and radiation therapy when confronted with unsuspected N2 disease after surgical resection for stage IIIA-NSCLC.

Stakeholder Research Priorities for Smoking Cessation Interventions within Lung Cancer Screening Programs. An Official American Thoracic Society Research Statement.

RATIONALE: Smoking cessation counseling in conjunction with low-dose computed tomography (LDCT) lung cancer screening is recommended in multiple clinical practice guidelines. The best approach for integrating effective smoking cessation interventions within this setting is unknown. OBJECTIVES: To summarize evidence, identify research gaps, prioritize topics for future research, and propose standardized tools for use in conducting research on smoking cessation interventions within the LDCT lung cancer screening setting. METHODS: The American Thoracic Society convened a multistakeholder committee with expertise in tobacco dependence treatment and/or LDCT screening. During an in-person meeting, evidence was reviewed, research gaps were identified, and key questions were generated for each of three research domains: (1) target population to study; (2) adaptation, development, and testing of interventions; and (3) implementation of interventions with demonstrated efficacy. We also identified standardized measures for use in conducting this research. A larger stakeholder panel then ranked research questions by perceived importance in an online survey. Final prioritization was generated hierarchically on the basis of average rank assigned. RESULTS: There was little consensus on which questions within the population domain were of highest priority. Within the intervention domain, research to evaluate the effectiveness in the lung cancer screening setting of evidence-based smoking cessation interventions shown to be effective in other contexts was ranked highest. In the implementation domain, stakeholders prioritized understanding strategies to identify and overcome barriers to integrating smoking cessation in lung cancer screening settings. CONCLUSIONS: This statement offers an agenda to stimulate research surrounding the integration and implementation of smoking cessation interventions with LDCT lung cancer screening.

Length of Stay From the Hospital Perspective: Practice of Early Discharge Is Not Associated With Increased Readmission Risk After Lung Cancer Surgery.

OBJECTIVE: To determine if hospitals that routinely discharge patients early after lobectomy have increased readmissions. BACKGROUND: Hospitals are increasingly motivated to reduce length of stay (LOS) after lung cancer surgery, yet it is unclear if a routine of early discharge is associated with increased readmissions. The relationship between hospital discharge practices and readmission rates is therefore of tremendous clinical and financial importance. METHODS: The National Cancer Database was queried for patients undergoing lobectomy for lung cancer from 2004 to 2013 at Commission on Cancer-accredited hospitals, which performed at least 25 lobectomies in a 2-year period. Facility discharge practices were characterized by a facility's median LOS relative to the median LOS for all patients in that same time period. RESULTS: In all, 59,734 patients met inclusion criteria; 2687 (4.5%) experienced an unplanned readmission. In a hierarchical logistic regression model, a routine of early discharge (defined as a facility's tendency to discharge patients faster than the population median in the same time period) was not associated with increased risk of readmission (odds ratio 1.12, 95% confidence interval 0.97-1.28, P = 0.12). In a risk-adjusted hospital readmission rate analysis, hospitals that discharged patients early did not experience more readmissions (P = 0.39). The lack of effect of early discharge practices on readmission rates was observed for both minimally invasive and thoracotomy approaches. CONCLUSIONS: It is possible for hospitals to develop early discharge practices without increasing readmissions. Further study is needed to identify the critical practice elements that have enabled hospitals to aggressively discharge patients without increasing readmission risk.

Gender, Age, and Comorbidity Status Predict Improved Survival with Adjuvant Chemotherapy Following Lobectomy for Non-small Cell Lung Cancers Larger than 4 cm.

PURPOSE: To identify pretreatment prognostic factors associated with improved outcomes in patients with non-small cell lung cancer (NSCLC) tumors larger than 4 cm receiving adjuvant chemotherapy following surgery versus surgery alone. METHODS: Information was collected from the National Cancer Data Base on adults diagnosed with NSCLC who underwent lobectomy with or without adjuvant chemotherapy for pathologic T2 tumors measuring at least 4 cm, with no lymph node involvement or distant metastasis. The data were analyzed using model-based recursive partitioning for survival. RESULTS: Patients who underwent chemotherapy following surgery experienced a survival benefit compared with patients who were treated with surgery alone (5-year survival of 66 vs. 49 %, p<0.0001). Overall, women had improved 5-year survival relative to men (60 vs. 47 %, p<0.0001). Despite this observation, three groups of women experienced no benefit from adjuvant chemotherapy:women 65-72 years with a Charlson-Deyo (CD) score ≥1 (5-year survival: 51 vs. 58 %, p = 0.29), women >72 with a CD score = 0 (5-year survival: 53 vs. 56 %, p = 0.57), and women >72 with a CD score ≥1 (5-year survival: 40 vs. 56 %, p = 0.04). By contrast, all groups of men identified by recursive partitioning analysis demonstrated improved survivals with adjuvant chemotherapy. CONCLUSIONS: Adjuvant chemotherapy appears to increase survival for patients with resected NSCLC tumors larger than 4 cm. Women with NSCLC experience improved survival relative to men regardless of treatment. However,there are certain groups of women over 65 years old who do not benefit from adjuvant chemotherapy.

Resection of oligometastatic lung cancer to the pancreas may yield a survival benefit in select patients--a systematic review.

OBJECTIVES: To conduct a systematic review of the existing literature regarding surgical therapy for oligometastatic lung cancer to the pancreas. METHODS: Data was collected on patients with singular pancreatic metastases from lung cancer from papers published between January 1970 and June 2014. This was performed following the Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) guidelines. Kaplan-Meier and Cox Regression analyses were then used to determine and compare survival. RESULTS: There were 27 papers that fulfilled the search criteria, from which data on 32 patients was collected. Non-small cell lung cancer (NSCLC) was the most prevalent type of primary lung malignancy, and metachronous presentations of metastases were most common. Lesions were most frequently located in the pancreatic head and consequently the most common curative intent metastasectomy was pancreaticoduodenectomy. There was a statistically significant survival benefit for patients whose metastasis were discovered incidentally by surveillance CT as opposed to those whose metastasis were discovered during a work up for new somatic complaints (p = 0.024). The overall median survival for patients undergoing curative intent resection was 29 months, with 2-year and 5-year survivals of 65% and 21% respectively. Palliative surgery or medical only management was associated with a median survival of 8 months and 2-year and 5-year survivals of 25% and 8% respectively. CONCLUSIONS: Curative intent resection of isolated pancreatic metastasis from lung cancer may be beneficial in a select group of patients.

Pediatric thymomas: report of two cases and comprehensive review of the literature.

PURPOSE: Thymomas are rare pediatric malignancies with indolent behavior. There are fewer than 50 reported cases and no comprehensive review. We sought to evaluate our recent experience with pediatric thymomas, and comprehensively review the extant literature. METHODS: A systematic search of the PubMed database was performed using keywords: "thymoma", "pediatric", "juvenile", "childhood", and "child". Additional studies were identified by a manual search of the reference list. RESULTS: We report two patients with thymomas. We identified 22 case reports or series that described 48 patients; 62 % were male, 15 % presented with myasthenia gravis. Fifty percent were Masaoka Stage I, 15 % were Stage II, 13 % were Stage III, and 23 % were Stage IV. Four patients with early stage (I or II) disease were treated with adjuvant therapies in addition to surgical excision, while five patients with late stage (III or IV) disease treated with surgical excision alone. Of studies reporting at least 2-year follow-up, survival was 71 %. CONCLUSION: Pediatric thymomas are rare tumors with a slight male predominance. Wide variations were observed in the treatment of thymomas across all stages. Our review indicates a need for large database and multi-institutional studies to clearly elucidate clinical course, prognostic factors and outcome.

The Proposed 9th Edition TNM Classification of Lung Cancer.

A universal nomenclature of the anatomic extent of lung cancer has been critical for individual patient care as well as research advances. As progress occurs, new details emerge that need to be included in a refined system that aligns with contemporary clinical management issues. The 9th edition TNM classification of lung cancer, which is scheduled to take effect in January 2025, addresses this need. It is based on a large international database, multidisciplinary input, and extensive statistical analyses. Key features of the 9th edition include validation of the significant changes in the T component introduced in the 8th edition, subdivision of N2 after exploration of fundamentally different ways of categorizing the N component, and further subdivision of the M component. This has led to reordering of the TNM combinations included in stage groups, primarily involving stage groups IIA, IIB, IIIA, and IIIB. This article summarizes the analyses and revisions for the TNM classification of lung cancer to familiarize the broader medical community and facilitate implementation of the 9th edition system.

Completeness of Resection and Long-Term Survival of Patients Undergoing Resection for Pathologic T3 NSCLC: An International Association for the Study of Lung Cancer Analysis.

INTRODUCTION: Currently, tumors with different histopathologic characteristics and oncologic outcomes comprise the T3 category of the eight edition TNM classification for lung cancers. To better understand the T3 category, we evaluated completeness of resection and long-term survival in patients undergoing resection for T3 NSCLC. METHODS: The International Association for the Study of Lung Cancer 1999 to 2010 database was queried for patients with pathologic T3N0M0 NSCLC who underwent lobectomy or pneumonectomy. The primary outcome evaluated was overall survival (OS) stratified by T3 descriptors and completeness of resection. RESULTS: Of 1448 patients with T3N0M0 tumors, 1187 (82.0%) had a single descriptor defining them as T3. T3 tumors with chest wall infiltration (CWI) or parietal pleura infiltration (PL3) had the highest rates of incomplete resection (9.8% and 8.4%, respectively), and those classified as T3 by size only had the lowest rate of incomplete resection (2.9%). Individual T3 descriptors were associated with significant differences in OS (p = 0.005). When tumors with similar survival and complete resection rates were grouped, patients with T3 tumors characterized by size or the presence of a separate nodule (SN) in the same lobe had better 5-year OS than patients with tumors characterized by PL3 or CWI (size/SN 60% versus CWI/PL3 53%, p = 0.017) independent of completeness of resection. CONCLUSIONS: Significant differences in 5-year OS were associated with size, SN, PL3, or CWI T3 descriptors. Subdividing pathologic T3N0M0 tumors according to the presence or absence of CWI or PL3 may increase the prognostic accuracy of tumor staging.

The International Association for the Study of Lung Cancer Lung Cancer Staging Project: Proposals for Revision of the Classification of Residual Tumor After Resection for the Forthcoming (Ninth) Edition of the TNM Classification of Lung Cancer.

INTRODUCTION: The goal of surgical resection is to completely remove a cancer; it is useful to have a system to describe how well this was accomplished. This is captured by the residual tumor (R) classification, which is separate from the TNM classification that describes the anatomic extent of a cancer independent of treatment. The traditional R-classification designates as R0 a complete resection, as R1 a macroscopically complete resection but with microscopic tumor at the surgical margin, and as R2 a resection that leaves gross tumor behind. For lung cancer, an additional category encompasses situations in which the presence of residual tumor is uncertain. METHODS: This paper represents a comprehensive review of evidence regarding these R categories and the descriptors thereof, focusing on studies published after the year 2000 and with adjustment for potential confounders. RESULTS: Consistent discrimination between complete, uncertain, and incomplete resection is revealed with respect to overall survival. Evidence regarding specific descriptors is generally somewhat limited and only partially consistent; nevertheless, the data suggest retaining all descriptors but with clarifications to address ambiguities. CONCLUSION: On the basis of this review, the R-classification for the ninth edition of stage classification of lung cancer is proposed to retain the same overall framework and descriptors, with more precise definitions of descriptors. These refinements should facilitate application and further research.

The International Association for the Study of Lung Cancer (IASLC) Staging Project for Lung Cancer: Recommendation to Introduce Spread Through Air Spaces as a Histologic Descriptor in the Ninth Edition of the TNM Classification of Lung Cancer. Analysis of 4061 Pathologic Stage I NSCLC.

INTRODUCTION: Spread through air spaces (STAS) consists of lung cancer tumor cells that are identified beyond the edge of the main tumor in the surrounding alveolar parenchyma. It has been reported by meta-analyses to be an independent prognostic factor in the major histologic types of lung cancer, but its role in lung cancer staging is not established. METHODS: To assess the clinical importance of STAS in lung cancer staging, we evaluated 4061 surgically resected pathologic stage I R0 NSCLC collected from around the world in the International Association for the Study of Lung Cancer database. We focused on whether STAS could be a useful additional histologic descriptor to supplement the existing ones of visceral pleural invasion (VPI) and lymphovascular invasion (LVI). RESULTS: STAS was found in 930 of 4061 of the pathologic stage I NSCLC (22.9%). Patients with tumors exhibiting STAS had a significantly worse recurrence-free and overall survival in both univariate and multivariable analyses involving cohorts consisting of all NSCLC, specific histologic types (adenocarcinoma and other NSCLC), and extent of resection (lobar and sublobar). Interestingly, STAS was independent of VPI in all of these analyses. CONCLUSIONS: These data support our recommendation to include STAS as a histologic descriptor for the Ninth Edition of the TNM Classification of Lung Cancer. Hopefully, gathering these data in the coming years will facilitate a thorough analysis to better understand the relative impact of STAS, LVI, and VPI on lung cancer staging for the Tenth Edition TNM Stage Classification.

The international thymic malignancy interest group.

Thymic tumors are considered an orphan disease, and therefore treatment recommendations have been largely empiric, based on small, retrospective, often poorly characterized series of patients. The International Thymic Malignancy Interest Group (ITMIG) has organized individual efforts, making collation of individual experiences and global collaboration possible. This article summarizes the development of ITMIG and accomplishments achieved since its inception in 2010. A great deal of infrastructure has been built, paving the way for scientifically robust progress in the future. Guidelines such as the NCCN Clinical Practice Guidelines in Oncology are of significant clinical value despite being, of necessity, largely consensus-based. The ITMIG provides the foundation for development of more evidence-based guidelines in the future.

Impact of preoperative radiation on survival of patients with T3N0 >7-cm non-small cell lung cancers treated with anatomic resection using the Surveillance, Epidemiology, and End Results database.

BACKGROUND: Very large non-small cell lung cancers (NSCLC) remain a therapeutic challenge. The objective of this study was to evaluate the effect of surgery in the presence and absence of neoadjuvant radiation (NRT) on survival of patients with T3N0 >7-cm NSCLCs. MATERIALS AND METHODS: The Surveillance, Epidemiology, and End Results database was used to identify patients undergoing lobectomy or pneumonectomy for T3N0 NSCLC tumors >7 cm from 1999-2008. Patients were categorized into groups based on type of surgery performed and whether NRT was used. Five-year overall (OS) and lung cancer-specific survival (LCSS) were estimated by the Kaplan-Meier method and comparisons made using log-rank tests and Cox regression models. RESULTS: There were 1301 patients evaluated, including 1232 undergoing primary surgical therapy (PST) and 69 receiving NRT. NRT was not associated with improvements in 5-y OS (48% versus 41%, P = 0.062) or LCSS (59% versus 52%, P = 0.116) compared with PST. Lobectomies were associated with better 5-y OS (43% versus 33%; P = 0.006) and LCSS (54% versus 43%, P = 0.005) compared with pneumonectomies. On multivariate analysis, NRT did not produce any significant advantage in OS (P = 0.242) and LCSS (P = 0.208). Pneumonectomies were associated with significantly worse OS (hazard ratio, 1.32; P = 0.007) and LCSS (hazard ratio, 1.38; P = 0.005) when compared with lobectomies. CONCLUSIONS: NRT, which most likely was a combination of chemotherapy and radiation, was not associated with improvements in OS or LCSS in patients with T3N0 >7-cm NSCLC compared with PST. When feasible, lobectomy appears more beneficial than pneumonectomy in terms of long-term survival for very large tumors.

Advances in surgical techniques in non-small cell lung cancer.

Thoracic surgery is a dynamic field, and many scientific, technological, technical, and organizational changes are occurring. A prominent example is the use of less invasive approaches to major resection of non-small cell lung cancer (NSCLC), both thoracoscopic and robotic. Sophisticated technology corroborated by clinical data has led to these approaches becoming accepted additions to the armamentarium. Additionally, improvements in perioperative pain management have also contributed to dramatically changing the experience of patients who undergo modern thoracic surgery. Lung cancer is being detected more often at an early stage. At the same time, advances in techniques, patient care, clinical science, and multidisciplinary treatment support an increased role for aggressive resection in the face of larger locally advanced tumors or for those with limited metastatic disease. These advances, conducted in the setting of multidisciplinary decision making, have resulted in real and palpable advancements for patients with lung cancer.

Innovations in thoracic surgery.

PURPOSE OF REVIEW: To discuss the innovations in general thoracic surgery and how they affect anesthetic management perioperatively. However, rather than listing various thoracic procedures and their inherent issues that complicate providing anesthesia, the approach of this article is to raise the anesthetic issues associated with innovations in thoracic surgery perceived to be important by the thoracic surgeon. RECENT FINDINGS: Recently, there have been advances in thoracic surgery that have necessitated a joint approach to the preoperative, intraoperative, and postoperative management of patients undergoing thoracic procedures. Substantial forethought and collaboration have resulted in the successful adoption of many new and innovative advances in thoracic surgery. SUMMARY: Innovations in thoracic surgery continually emerge and challenge thoracic surgeons and anesthesiologists to evaluate their utility and benefits. The increased adoption of minimally invasive operations is a testament to this collaboration. This process requires an ongoing dialog between the clinicians within these two disciplines to advance the science of surgery.