Intraoperative Cytology for Video-Assisted Thoracic Surgery: A Quality Improvement Analysis.

BACKGROUND: Frozen section is a standard of care procedure during thoracic surgery when an immediate diagnosis is needed. An alternative procedure is intraoperative cytology. Video-assisted thoracic surgery is currently widely used for thoracic surgical procedures. The aim of this study was to assess intraoperative cytology together with frozen section for accuracy, turnaround time, and total response time during video-assisted thoracic surgery. METHODS: We included patients having video-assisted thoracic surgery between August 2018 and February 2019 at our institution. A cytopathologist and a surgical pathologist independently performed intraoperative cytology and frozen sections, respectively. Final histologic diagnosis was the reference standard. Intraoperative cytology, frozen section turnaround, and total response times were analyzed. RESULTS: A total of 52 specimens from 27 patients were included. The intraoperative cytology correlated with final histology in 98% of cases. Frozen section correlated with final histology in 100% of cases. Intraoperative cytology turnaround and total response times were equal (mean, 4.35 minutes; range, 2-15 minutes). Mean frozen section turnaround and response times were 26.2 minutes (range, 9-61 minutes) and 36.7 minutes (range, 16-90 minutes), respectively. We found a statistically significant difference between intraoperative cytology and frozen section turnaround time and total response times (P < .001). CONCLUSIONS: This study highlights that intraoperative cytology could be as accurate as frozen section and considerably faster during video-assisted thoracic surgery (P < .001). Total response time could potentially be used as a quality metric for video-assisted thoracic surgery.

Optimising rapid on-site evaluation-assisted endobronchial ultrasound-guided transbronchial needle aspiration of mediastinal lymph nodes: The real-time cytopathology intervention process.

INTRODUCTION: Lymph node sampling by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the state of art procedure for staging the mediastinum and hilar regions in lung cancer patients. Our experience of implementing the real-time cytopathology intervention (RTCI) process for intraoperative EBUS-TBNAs is presented. This study is aimed to describe in detail the RTCI process for EBUS-TBNAs, and assess its utility and diagnostic yield before and after its implementation in parallel to conventional rapid on-site evaluation (c-ROSE). METHODS: A retrospective review of all EBUS-TBNAs between July 2016 and July 2017 at the University of Rochester Medical Center was performed. Final diagnoses, patient clinical data, and number of non-diagnostic samples (NDS) were reviewed. The numbers of NDS obtained from EBUS-TBNAs with no cytology assistance (NCA), with RTCI and with c-ROSE were analysed. RESULTS: Non-diagnostic lymph node samples were found in 20 out of 116 (17%), three out of 114 (2.6%) and 33 out of 286 (11.5%) cases with NCA, RTCI and c-ROSE, respectively. Application of statistical analysis revealed significant difference in the NDS between the groups of cases in the operating room with NCA and RTCI (P = .005). The different settings and variables between the cases performed using RTCI in the operating room and those assisted with c-ROSE in the bronchoscopy suite preclude legitimate comparison. CONCLUSION: Our results indicate that the use of RTCI could yield a significantly low proportion of NDS when assisting EBUS-TBNA of mediastinal and hilar lymph node for lung cancer patients enhancing the diagnostic efficiency of the procedure.

Recurrence and survival outcomes after anatomic segmentectomy versus lobectomy for clinical stage I non-small-cell lung cancer: a propensity-matched analysis.

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).

Anatomic segmentectomy and brachytherapy mesh implantation for clinical stage I non-small cell lung cancer (NSCLC).

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.

Sequence makes a difference: paradoxical effects of stress in vivo.

In vitro studies have shown that induction of heat shock before an inflammatory stimulus is cytoprotective, whereas induction of heat shock after an inflammatory stimulus can lead to apoptosis (the "heat shock paradox"). We sought to determine whether induction of the heat shock response in vivo caused similar, order-dependent effects on survival, and if so, by what mechanism. ND4 and C57BL/6 mice were used to calibrate the response to hyperthermia at 41.5 degrees C via induction of inducible heat shock protein 70. Sequences of heat shock and septic stresses were studied in murine models of hyperthermia (41.5 degrees C for 20 min) and cecal ligation and puncture (CLP), respectively. Previous heat shock to 41.5 degrees C did not protect CLP mice when compared with control CLP animals heated to 37 degrees C, but heat shock increased mortality when activated after CLP compared with controls. This effect of heat shock on CLP mortality was strain independent, and did not involve alterations in CLP-induced thymus, spleen, or intestinal apoptosis. We conclude that the heat shock paradox can occur in vitro and in vivo, and that the negative effects of heat shock on survival after CLP appeared to be strain independent. Furthermore, the stress of general anesthesia and warming also altered CLP mortality unexpectedly. The cellular mechanisms responsible for these "stressor" paradoxes in vivo are not known, but do not involve altered sepsis-induced apoptosis.

Iron overload before cecal ligation and puncture increases mortality.

Iron metabolism is dysregulated in critically ill patients. A mouse model of dysregulated iron metabolism was used to examine the consequence of iron loading upon sepsis. Mice deleted in the hfe gene (hfe-/-) abnormally accumulate iron in tissue; defects in the human hfe gene are clinically expressed as hemochromatosis. Hfe-/- mice and wild-type counterparts were randomized to receive either high- or low-iron diets for 2 weeks. After iron loading, mice were subjected to cecal ligation and puncture (CLP), a clinically relevant animal model of intra-abdominal sepsis. A preliminary (but underpowered) study suggested that iron-loaded hfe-/- mice had increased mortality as compared with hfe-/- mice fed a low-iron diet. There was no difference between wild-type and hfe-/- mice fed a low-iron diet or between wild-type mice fed hihg- and low-iron diets. A subsequent, appropriately powered study showed that iron-loaded hfe-/- mice had significantly higher mortality from intra-abdominal sepsis than hfe-/- mice fed a low-iron diet. Iron loading was confirmed through chemical assay of iron concentration in hepatic tissue. Animals with dysregulated iron handling, loaded with iron and subjected to CLP, had double the mortality of animals with normal iron levels. Critical care patients often have altered iron metabolism. In clinical practice, critically ill patients may receive iron through direct administration and the transfusion of blood products. Iron therapy may adversely affect the clinical outcome from sepsis.