Overcoming barriers to lung cancer screening using a systemwide approach with additional focus on the non-screened.

BACKGROUND: The lung cancer screening program at St Elizabeth Healthcare (Kentucky, USA) began in 2013. Over 33,000 low-dose computed tomography lung cancer screens have been performed. From 2015 through 2021, 2595 lung cancers were diagnosed systemwide. A Screening Program with Impactful Results from Early Detection, reviews that experience; 342 (13.2%) were diagnosed by screening and 2253 (86.8%) were non-screened. As a secondary objective, the non-screened cohort was queried to determine how many additional individuals could have been screened, identifying barriers and failures to meet eligibility. METHODS: Our QlikSense database extracted the lung cancer patients from the Cancer Patient Data and Management System, and identified and categorized them separately as screened or non-screened populations. Stage distribution was compared in screened and non-screened groups. Those meeting age criteria, with any smoking history, were further queried for screening eligibility, accessing the electronic medical record smoking history and audit trail, and determining if enough information was available to substantiate screening eligibility. The same methodology was applied to CMS 2015 and USPSTF 2021 criteria. RESULTS: The screened and non-screened patients were accounted for in a stage migration chart demonstrating clear shift to early stage among screened lung cancer patients. Additionally, analysis of non-screened individuals is presented. CONCLUSION: Of the St Elizabeth Healthcare eligible patients attributed to primary care providers, 49.6% were screened in 2021. Despite this level of success, this study highlighted a sizeable pool of additional individuals that could have been screened. We are shifting focus to the non-screened pool of patients that meet eligibility, further enhancing the impact on our community.

A Defined Esophagectomy Perioperative Clinical Care Process Can Improve Outcomes and Costs.

Esophagectomy (EG) is a high-risk therapy for esophageal cancer and end-stage benign disease. This study compares the results of EG before and after implementation of a perioperative clinical care process including a health provider education program (EP) and institutional uncomplicated postoperative clinical pathway (POP) for purpose quality improvement. This is a single institution retrospective cohort study. The EP was provided to critical care and telemetry unit nurses and the POP was imbedded in the electronic health record. Patients undergoing elective EG with reconstruction with the stomach for benign disease or cancer were included from 2005 to 2011. Cohorts were pre- and postimplementation (PreI and PostI) of an EP and 8-day POP (August 2008). Patient, tumor and peri/postoperative-specific variables were compared between cohorts, as well as resource utilization and hospital costs. We identified 33 PreI and 41 PostI patients. Both cohorts had similar patient demographics, preoperative comorbidities, majority cancer diagnosis, and for cancer patients, majority adenocarcinoma and IIB/III pathologic stage. Both groups had one death and similar rate of discharge to home. The PostI cohort demonstrated reduced 30-day readmission rate (2.4% vs 24.2%); P < 0.05. In regard to clinical outcomes, the PostI group exhibited reduced deep venous thrombosis/pulmonary emboli (2.4% vs 18.2%); P < 0.05. The PostI group demonstrated significantly reduced radiographic test utilization and costs, as well as total overall 30-day readmission costs. A defined perioperative clinical process involving educating the patient care team and implementing a widely disseminated POP can reduce complications, 30-day readmission rates, and hospital costs after EG.

Outcomes and efficacy of thoracic surgery biopsy for tumor molecular profiling in patients with advanced lung cancer.

BACKGROUND: Molecular testing of patients with advanced non-small cell lung cancer for personalized therapy often is limited by insufficient specimen from nonsurgical biopsies. We measured the feasibility, patient safety, and clinical impact of thoracic surgical tumor biopsy in patients with stage IV non-small cell lung cancer. METHODS: This is a single institution retrospective analysis. Patients with stage IV non-small cell lung cancer undergoing elective surgical tissue biopsy for molecular analysis were evaluated from March 2011 to November 2012. Perioperative specific variables were measured. RESULTS: Twenty-five patients with known or suspected stage IV non-small cell lung cancer undergoing surgical biopsy were identified. All cases were discussed at a multidisciplinary thoracic oncology conference or a multidisciplinary thoracic oncology clinic. Preoperative histologies included adenocarcinoma in 20 patients (80.0%) and squamous cell carcinoma in 2 patients (8.0%). Surgical procedures consisted of video-assisted thoracic surgery wedge biopsy (16, 64%), video-assisted thoracic surgery pleural biopsy (4, 16.0%), mediastinoscopy (2, 8.0%), supraclavicular/cervical lymph node excisional biopsy (3, 12.0%), and rib/chest wall resection (2, 8.0%). There were no deaths and 5 postoperative complications (20.0%). Surgery identified potentially targetable molecular information in 19 of the total patients undergoing operation (76.0%) and changed the treatment strategy in 14 patients (56.0%); 10 of the total cohort (40.0%) were enrolled into therapeutic targeted clinical trials. CONCLUSIONS: These data suggest that thoracic surgical biopsy can be safely performed in appropriately selected patients with stage IV non-small cell lung cancer and direct personalized therapy and enrollment into relevant clinical trials. Patients with advanced-stage non-small cell lung cancer should be discussed in a multidisciplinary setting to determine the need and strategy for thoracic surgical biopsy for molecular analysis.

Size of Stage IIIA primary lung cancers and survival: a surveillance, epidemiology and end results database analysis.

Size of early-stage lung cancer is important in the prognosis of patients. We examined the large population-based Surveillance, Epidemiology and End Results database to determine if tumor size was an independent risk factor of survival in patients undergoing lobectomy for N2 positive Stage IIIA nonsmall cell lung cancer (NSCLC). This study identified 1971 patients diagnosed with N2 positive Stage IIIA NSCLC, from 1998 to 2007, and who underwent lobectomy. Five tumor groups based on the seventh edition TNM lung cancer staging system (pathologic T1a 2 cm or less; T1b greater than 2 cm and 3 cm or less; T2a greater than 3 cm and 5 cm or less; T2b greater than 5 cm and 7 cm or less; T3 greater than 7 cm) were analyzed. Survival was reduced in patients with T3, T2a, and T2b tumors compared with patients with T1a and T1b (P < 0.001). Survival estimates correlated with tumor size with poorer survival in T3 followed by T2b, T2a, and then T1b and T1a. Cohorts with T1a (hazard ratio [HR], 0.53; P = 0.01) and T1b (HR, 0.54; P = 0.01) were both found to have decreased hazard of death. Negative predictors of survival, in addition to increasing tumor size, included age and male gender, whereas positive predictors included tumor Grade I and upper lobe location. Increasing size of tumor is an independent negative risk factor for survival in patients undergoing lobectomy for N2 positive Stage IIIA NSCLC.

Repair of nonmalignant postlaryngectomy pharyngotracheal fistula.

The repair of nonmalignant postlaryngectomy pharyngotracheal fistulae is not commonly encountered in medical literature. This rare complication can occur years after laryngectomy for cancer and reconstruction of a neopharynx, and is often associated with adjuvant radiation to the area, making the choice of method for surgical repair critical for success. Optimally, a pedicled myofascial flap from the pectoralis major muscle, from outside the field of radiation, is used to reinforce the repair of the fistula. We present 2 rare cases.

Survival comparison of adenosquamous, squamous cell, and adenocarcinoma of the lung after lobectomy.

BACKGROUND: Primary adenosquamous carcinoma (ASC) of the lung is a rare tumor that may carry a poor prognosis. We examined a national database to see if ASC exhibited distinct clinical behavior from squamous cell (SC) and adenocarcinoma (AC) of the lung. METHODS: This is a retrospective study querying the Surveillance, Epidemiology, and End Results database to identify 872 surgical patients diagnosed with ASC, 7888 with SC, and 12,601 with AC of the lung from 1998 to 2002. Analysis characterized clinical variables to determine patterns of presentation and compared survival among the above three histologic groups after lobectomy for stage I and II disease. RESULTS: ASC represented 4.1% of the 21,361 patients examined. ASC tended toward right side (56.9%) laterality and upper lobe (60.0%) location. Compared with AC, patients with ASC and SC were more likely to be male (p < 0.0001), and ASC patients had worse histologic grade (p< 0.0001). Survival after lobectomy for stage I and II disease was significantly reduced in ASC and SC compared with AC (p < 0.0001). ASC had a significantly increased hazard ratio of 1.35 and 1.27 relative to AC and SC, respectively. Other significant negative predictors of survival included tumor grade of III and IV, stage II, age, and black ethnicity. CONCLUSIONS: This large review demonstrates that ASC is an uncommon tumor with distinct clinical behavior and worse prognosis than AC and SC. Further insight into the molecular profile of ASC is needed to determine the cause of its biologic aggressiveness.

Video assisted thoracic surgery sublobar resection of intralobar pulmonary sequestration after preoperative embolization of systemic blood supply.

Intralobar pulmonary sequestration is abnormal lung tissue of embryonic origin that receives arterial blood supply from the systemic arterial circulation from the abdominal aorta. The arterial blood supply traverses the diaphragm and courses through the inferior pulmonary ligament. Intralobar pulmonary sequestrations are usually treated by anatomic lobar or sublobar resections via an open thoracotomy. Recent reports suggest the utility of a video assisted thoracic surgery (VATS) pulmonary resection. However, the presence of the feeding systemic artery often makes VATS resection difficult or impossible, due to the risk of injury to the feeding vessel, and subsequent retraction below the diaphragm. We present procedural video recordings describing a multidisciplinary procedure, where precedent coil embolization of the feeding systemic vessel allows for relative risk-free VATS sublobar resection of the intralobar pulmonary sequestration.

Diagnosis and management of subclavian artery stenosis prior to coronary artery bypass grafting in the current era.

There are several approaches to managing subclavian artery stenosis (SAS) prior to coronary artery bypass grafting (CABG) with an intended internal thoracic artery (ITA) graft to the left anterior descending (LAD) artery. We herein review the incidence of and various diagnostic modalities for detecting SAS. Published relevant clinical studies from the interventional cardiovascular and cardiac surgical literature are summarized. Particular emphasis is placed on the efficacy of various approaches to the patient diagnosed with SAS prior to CABG. Stenting the subclavian artery prior to bypass surgery and using an in situ ITA is compared to using the ITA as a "free" graft. The incidence of restenosis after subclavian artery angioplasty or stenting is not trivial and has been reported to occur at a rate of 6% to 21%; however, the average rate of restenosis with stenting appears to be in the mid-teens. Subacute subclavian stent thrombosis or occlusion is exceptionally rare, suggesting that a percutaneous approach to SAS is reasonable prior to CABG. For patients requiring emergent revascularization, placement of a free ITA graft to the LAD appears to be a safe and durable treatment as patency rates are comparable to that of an in situ LITA to the LAD. In summary, although no randomized clinical trials address the optimal management of SAS prior to CABG, both percutaneous and surgical options appear to be safe and reasonably durable.

A novel operative approach to scimitar syndrome.

Scimitar syndrome is a rare congenital cardiac anomaly defined by an anomalous right pulmonary vein draining the right lung to the inferior vena cava. We describe a unique operative approach performed on 2 patients with infantile scimitar syndrome.