A machine learning approach to high-risk cardiac surgery risk scoring.

INTRODUCTION: In patients undergoing high-risk cardiac surgery, the uncertainty of outcome may complicate the decision process to intervene. To augment decision-making, a machine learning approach was used to determine weighted personalized factors contributing to mortality. METHODS: American College of Surgeons National Surgical Quality Improvement Program was queried for cardiac surgery patients with predicted mortality ≥10% between 2012 and 2019. Multiple machine learning models were investigated, with significant predictors ultimately used in gradient boosting machine (GBM) modeling. GBM-trained data were then used for local interpretable model-agnostic explanations (LIME) modeling to provide individual patient-specific mortality prediction. RESULTS: A total of 194 patient deaths among 1291 high-risk cardiac surgeries were included. GBM performance was superior to other model approaches. The top five factors contributing to mortality in LIME modeling were preoperative dialysis, emergent cases, Hispanic ethnicity, steroid use, and ventilator dependence. LIME results individualized patient factors with model probability and explanation of fit. CONCLUSIONS: The application of machine learning techniques provides individualized predicted mortality and identifies contributing factors in high-risk cardiac surgery. Employment of this modeling to the Society of Thoracic Surgeons database may provide individualized risk factors contributing to mortality.

Electromagnetic navigation bronchoscopy to access lung lesions in 1,000 subjects: first results of the prospective, multicenter NAVIGATE study.

BACKGROUND: Electromagnetic navigation bronchoscopy (ENB) is an image-guided, minimally invasive approach that uses a flexible catheter to access pulmonary lesions. METHODS: NAVIGATE is a prospective, multicenter study of the superDimension™ navigation system. A prespecified 1-month interim analysis of the first 1,000 primary cohort subjects enrolled at 29 sites in the United States and Europe is described. Enrollment and 24-month follow-up are ongoing. RESULTS: ENB index procedures were conducted for lung lesion biopsy (n = 964), fiducial marker placement (n = 210), pleural dye marking (n = 17), and/or lymph node biopsy (n = 334; primarily endobronchial ultrasound-guided). Lesions were in the peripheral/middle lung thirds in 92.7%, 49.7% were <20 mm, and 48.4% had a bronchus sign. Radial EBUS was used in 54.3% (543/1,000 subjects) and general anesthesia in 79.7% (797/1,000). Among the 964 subjects (1,129 lesions) undergoing lung lesion biopsy, navigation was completed and tissue was obtained in 94.4% (910/964). Based on final pathology results, ENB-aided samples were read as malignant in 417/910 (45.8%) subjects and non-malignant in 372/910 (40.9%) subjects. An additional 121/910 (13.3%) were read as inconclusive. One-month follow-up in this interim analysis is not sufficient to calculate the true negative rate or diagnostic yield. Tissue adequacy for genetic testing was 80.0% (56 of 70 lesions sent for testing). The ENB-related pneumothorax rate was 4.9% (49/1,000) overall and 3.2% (32/1,000) CTCAE Grade ≥2 (primary endpoint). The ENB-related Grade ≥2 bronchopulmonary hemorrhage and Grade ≥4 respiratory failure rates were 1.0 and 0.6%, respectively. CONCLUSIONS: One-month results of the first 1,000 subjects enrolled demonstrate low adverse event rates in a generalizable population across diverse practice settings. Continued enrollment and follow-up are required to calculate the true negative rate and delineate the patient, lesion, and procedural factors contributing to diagnostic yield. TRIAL REGISTRATION: ClinicalTrials.gov NCT02410837 . Registered 31 March 2015.

Effect of Obesity on Perioperative Outcomes After Robotic-Assisted Pulmonary Lobectomy.

OBJECTIVE: We investigated whether higher body mass index (BMI) affects perioperative and postoperative outcomes after robotic-assisted video-thoracoscopic pulmonary lobectomy. METHODS: We retrospectively studied all patients who underwent robotic-assisted pulmonary lobectomy by one surgeon between September 2010 and January 2015. Patients were grouped according to the World Health Organization's definition of obesity, with "obese" being defined as BMI >30.0 kg/m2. Perioperative outcomes, including intraoperative estimated blood loss (EBL) and postoperative complication rates, were compared. RESULTS: Over 53 months, 287 patients underwent robotic-assisted pulmonary lobectomy, with 7 patients categorized as "underweight," 94 patients categorized as "normal weight," 106 patients categorized as "overweight," and 80 patients categorized as "obese." Because of the relatively low sample size, "underweight" patients were excluded from this study, leaving a total cohort of 280 patients. There was no significant difference in intraoperative complication rates, conversion rates, perioperative outcomes, or postoperative complication rates among the 3 groups, except for lower risk of prolonged air leaks ≥7 days and higher risk of pneumonia in patients with obesity. CONCLUSIONS: Patients with obesity do not have increased risk of intraoperative or postoperative complications, except for pneumonia, compared with "normal weight" and "overweight" patients. Robotic-assisted pulmonary lobectomy is safe and effective for patients with high BMI.

Design of a prospective, multicenter, global, cohort study of electromagnetic navigation bronchoscopy.

BACKGROUND: Electromagnetic navigation bronchoscopy (ENB) procedures allow physicians to access peripheral lung lesions beyond the reach of conventional bronchoscopy. However, published research is primarily limited to small, single-center studies using previous-generation ENB software. The impact of user experience, patient factors, and lesion/procedural characteristics remains largely unexplored in a large, multicenter study. METHODS/DESIGN: NAVIGATE (Clinical Evaluation of superDimension™ Navigation System for Electromagnetic Navigation Bronchoscopy) is a prospective, multicenter, global, cohort study. The study aims to enroll up to 2,500 consecutive subjects presenting for evaluation of lung lesions utilizing the ENB procedure at up to 75 clinical sites in the United States, Europe, and Asia. Subjects will be assessed at baseline, at the time of procedure, and at 1, 12, and 24 months post-procedure. The pre-test probability of malignancy will be determined for peripheral lung nodules. Endpoints include procedure-related adverse events, including pneumothorax, bronchopulmonary hemorrhage, and respiratory failure, as well as quality of life, and subject satisfaction. Diagnostic yield and accuracy, repeat biopsy rate, tissue adequacy for genetic testing, and stage at diagnosis will be reported for biopsy procedures. Complementary technologies, such as fluoroscopy and endobronchial ultrasound, will be explored. Success rates of fiducial marker placement, dye marking, and lymph node biopsies will be captured when applicable. Subgroup analyses based on geography, demographics, investigator experience, and lesion and procedure characteristics are planned. DISCUSSION: Study enrollment began in April 2015. As of February 19, 2016, 500 subjects had been enrolled at 23 clinical sites with enrollment ongoing. NAVIGATE will be the largest prospective, multicenter clinical study on ENB procedures to date and will provide real-world experience data on the utility of the ENB procedure in a broad range of clinical scenarios. TRIAL REGISTRATION: ClinicalTrials.gov NCT02410837 . Registered 31 March 2015.

Robotic-Assisted Videothoracoscopic Mediastinal Surgery.

BACKGROUND: Tumors of the mediastinum as well as normal thymus glands in patients with myasthenia gravis have traditionally been resected using large and morbid incisions. However, robotic-assisted mediastinal resections are gaining popularity because of the many advantages that the robot provides. However, few comprehensive reviews of the literature on robotic-assisted mediastinal resections exist. METHODS: A systemic review of the current medical literature was performed, excluding cases related to esophageal pathology. These studies were evaluated and their findings are reported in this comprehensive review. Approximately 48 papers met the inclusion criteria for review. RESULTS: Robotic-assisted surgical systems are increasingly being used in mediastinal resections. Based on the available literature, robotic-assisted thoracoscopic surgery in the mediastinum is feasible and safe. Robotic-assisted mediastinal surgery appears to be superior to open approaches of the mediastinum and is comparable with videothoracoscopic surgery when patient outcomes are considered. CONCLUSIONS: Increased robotic experience and more studies, including randomized controlled trials, are needed to validate the findings of the current literature.

Robotic-Assisted Videothoracoscopic Surgery of the Lung.

BACKGROUND: Despite initial concerns about the general safety of videothoracoscopic surgery, minimally invasive videothoracoscopic surgical procedures have advantages over traditional open thoracic surgery via thoracotomy. Robotic-assisted minimally invasive surgery has expanded to almost every surgical specialty, including thoracic surgery. Adding a robotic-assisted surgical system to a videothoracoscopic surgical procedure corrects several shortcomings of videothoracoscopic surgical cameras and instruments. METHODS: We performed a literature search on robotic-assisted pulmonary resections and compared the published robotic series data with our experience at the H. Lee Moffitt Cancer Center & Research Institute. All perioperative outcomes, such as intraoperative data, postoperative complications, chest tube duration, hospital length of stay (LOS), and in-hospital mortality rates were noted. RESULTS: Our literature search found 23 series from multiple surgical centers. We divided the literature into 2 groups based on the year published (2005-2010 and 2011-2014). Operative times from earlier studies ranged from 150 to 240 minutes compared with 90 to 242 minutes for later studies. Conversion rates (to open lung resection) from the earlier studies ranged from 0% to 19% compared with 0% to 11% in the later studies. Mortality rates for the earlier studies ranged from 0% to 5% compared with 0% to 2% for the later studies. Since 2010, our group has performed more than 600 robotic-assisted thoracic surgical procedures, including more than 200 robotic-assisted pulmonary lobectomies, which we also divided into 2 groups. Our median skin-to-skin operative time improved from 179 minutes for our early group (n = 104) to 172 minutes for our later group (n = 104). The overall conversion rate was 9.6% and the emergent conversion rate (for bleeding) was 5% for our robotic-assisted lobectomies. The most common postoperative complications in our cohort were prolonged air leak (> 7 days; 16.8%) and atrial fibrillation (12%). Hospital LOS for the early series ranged from 3 to 11 days compared with 2 to 6 days for the later series. Median hospital LOS decreased from 6 to 4 days. Our mortality rate was 1.4%; 3 in-hospital deaths occurred in the early 40 cases. Mediastinal lymph node (LN) dissection and detection of occult mediastinal LN metastases were improved during robotic-assisted lobectomy for non-small-cell lung cancer, as demonstrated by an overall 30% upstaging rate, including a 19% nodal upstaging rate, in our cohort. CONCLUSIONS: Robotic-assisted videothoracoscopic pulmonary lobectomy appears to be as safe as conventional videothoracoscopic surgical lobectomy, which has decreased perioperative complications and a shorter hospital LOS than open lobectomy. Both mediastinal LN dissection and the early detection of occult mediastinal LN metastatic disease were improved by robotic-assisted videothoracoscopic surgical compared with conventional videothoracoscopic surgical or open thoracotomy.

Robotic-Assisted Esophageal Surgery.

BACKGROUND: The adoption of minimally invasive approaches to the management of esophageal disease has been slow, except for the laparoscopic management of gastroesophageal reflux disease. However, the advent of new surgical technologies - in particular, robotic-assisted surgical systems - has revolutionized esophageal surgery. METHODS: The literature was systematically reviewed using the keywords "robotic," "esophageal surgery," "esophagectomy," "fundoplication," and "esophageal myotomy." The reference lists from these articles were then also analyzed. RESULTS: Forty-nine studies were included in our comprehensive review of robotic-assisted esophageal surgery, and they consisted of literature reviews, case reports, retrospective and prospective case series, and randomized controlled trials. CONCLUSIONS: Robotic-assisted esophageal surgery is a safe and effective way of treating esophageal disorders, including gastroesophageal reflux disease, achalasia, leiomyomas, and cancer. The use of robotic surgical systems has many benefits for managing disorders of the esophagus, but more studies, including randomized controlled trials, are necessary.

Outcomes and clinical predictors of improved survival in a patients undergoing pulmonary metastasectomy for sarcoma.

BACKGROUND: Pulmonary metastasectomy (PM) for metastatic sarcoma can result in long-term survival. The purpose of this study was to describe factors associated with survival in a series of patients undergoing PM for metastatic sarcoma. METHODS: We reviewed all patients undergoing PM for metastatic sarcoma over a 12-year period (2000-2012). Multivariate analyses were used to identify factors associated with outcomes. Survival was calculated with Kaplan-Meier and Cox proportional hazard models. RESULTS: A total of 120 patients underwent PM with a median follow-up was 48 months. Among 81 (85%) patients who presented with local disease, the median disease free interval (DFI) was 13 months and median overall survival (OS) was 48 months. Fourteen patients (15%) had synchronous metastasis with a median OS of 21 months. On multivariate analysis, synchronous metastasis (P = 0.005), older age (P = 0.02), and number of lung lesions (P = 0.003) were associated with poor survival. The median OS of patients with a DFI ≥12 versus <12 months following primary resection was 93 and 43 months (P = 0.004). CONCLUSION: While patients with a DFI >12 months have the best OS following PM, patients with a DFI <12 months also have excellent outcomes as compared to systemic therapy and should be considered for PM.

Minimally invasive mediastinal staging of non-small-cell lung cancer: emphasis on ultrasonography-guided fine-needle aspiration.

BACKGROUND: Mediastinal staging in patients with non-small-cell lung cancer (NSCLC) is crucial in dictating surgical vs nonsurgical treatment. Cervical mediastinoscopy is the "gold standard" in mediastinal staging but is invasive and limited in assessing the posterior subcarinal, lower mediastinal, and hilar lymph nodes. Less invasive approaches to NSCLC staging have become more widely available. METHODS: This article reviews several of these techniques, including noninvasive mediastinal staging of NSCLC, endobronchial ultrasound (EBUS) and fine-needle aspiration (FNA), endoscopic ultrasound (EUS) and FNA, and the combination of EBUS/EUS. RESULTS: Noninvasive mediastinal staging with computed tomography and positron-emission tomography scans has significant false-negative and false-positive rates and requires lymph node tissue confirmation. FNA techniques, with guidance by EBUS and EUS, have become more widely available. The combination of EBUS-FNA and EUS-FNA of mediastinal lymph nodes can be a viable alternative to surgical mediastinal staging. Current barriers to the dissemination of these techniques include initial cost of equipment, lack of access to rapid on-site cytology, and the time required to obtain sufficient skills to duplicate published results. CONCLUSIONS: Within the last decade, these approaches to NSCLC staging have become more widely available. Continued study into these noninvasive techniques is warranted.

Associations between marital quality and the prognosis of breast cancer in young Chinese women: 10.3-year median follow-up.

BACKGROUND: Some evidence has revealed that marital status is an important predictor of breast cancer (BC) prognosis. However, what role marital quality plays in the effect of marital status on BC prognosis remains unclear. METHODS: We conducted a prospective cohort study of women aged 20-50 years with stage I-III BC treated in accordance with a standard treatment protocol. The following three categories of marital quality were assessed: marital satisfaction, sexual relationship, and couple communication. The log-rank test was used to compare survival. Cox proportional hazards models were used to estimate hazard ratio (HR) and 95% confidence interval (CI) for recurrence and metastasis, BC-specific mortality, and overall mortality, adjusting for clinical variables. RESULTS: A total of 1,043 married women were initially recruited in the study. Forty-five (4.3%) patients refused to participate in this study and 141 (13.5%) were excluded from the analysis. Among 857 participants, there were 59 deaths, including 57 from BC. Multivariate Cox regression analysis showed that patients with poor marital satisfaction had significantly higher risks of recurrence and metastasis (HR 3.942, 95% CI: 1.903-8.167), BC-specific mortality (HR 3.931, 95% CI: 1.896-8.150), and overall mortality (HR 3.916, 95% CI: 1.936-7.924). Those with poor sexual relationship had significantly higher risks of recurrence and metastasis (HR 5.763, 95% CI: 3.012-11.027), BC-specific mortality (HR 5.724, 95% CI: 2.992-10.949), and overall mortality (HR 5.653, 95% CI: 2.993-10.680). CONCLUSIONS: Our results identified a subset of BC patients who have a poor prognosis, namely, those with poor marital quality. Early screening for marital quality and applying necessary social support interventions are helpful in improving the prognosis of patients with poor marital quality.

Effect of Surgical Day of Week on Postoperative Outcomes After Robotic-Assisted Pulmonary Lobectomy.

Introduction Patients who have surgery late in the week could potentially receive different postoperative care due to a reduced weekend staff compared to patients who have surgery early in the week, who will be cared for by a full staff during the work week. Our aim was to determine if patients who underwent robotic-assisted video-thoracoscopic (RAVT) pulmonary lobectomy during the first half of the week had different outcomes than patients who also underwent RAVT pulmonary lobectomy during the second half of the week. Methods We analyzed 344 consecutive patients who underwent RAVT pulmonary lobectomy by one surgeon from 2010 to 2016. Depending on the day of the surgical procedure, these patients were either put into a Monday through Wednesday (M-W) group or a Thursday through Friday (Th-F) group. Patient demographics, tumor histopathology, intraoperative and postoperative complications, and perioperative outcomes were compared between groups using the Student's t-test, Kruskal-Wallis test, or chi-square (or Fisher's exact) test, with p≤0.05 as significant. Results There were more non-small cell lung cancers (NSCLCs) resected in the M-W group than in the Th-F group (p=0.005). Skin-to-skin and total operative times were greater for the Th-F group than for the M-W group (p=0.027 and p=0.017, respectively). There were no significant differences in any other variables assessed. Conclusions Our study showed that, despite reduced weekend staffing and potential differences in postoperative care, there were no significant differences seen in postoperative complications or perioperative outcomes based on surgical day of the week.

Outcomes of robotic lobectomy for non-small cell lung cancer in a National Cancer Institute-Comprehensive Cancer Center vs. National Cancer Database.

Background: There continues to be a rise in the proportion of resectable non-small cell lung cancer (NSCLC) with the recent expansion of criteria for low-dose lung cancer screening. These are increasingly being treated with minimally invasive techniques. Our study aims to compare outcomes of robotic lobectomy (RL) for NSCLC at a National Cancer Institute-designated Comprehensive Cancer Center (NCI-CCC) to those of open lobectomy (OL), video-assisted thoracoscopic lobectomy (VL), or RL as reported in the National Cancer Database (NCDB). Methods: The first 1,021 patients with NSCLC who underwent RL between 2010 and 2020 were matched with peers from the NCDB who had OL, VL, or RL. Matching was performed based on a propensity score calculated by logistic regression using multiple variables. Surgical outcomes included numbers of examined lymph nodes, performance of mediastinal lymphadenectomy, length of stay (LOS), and 30-day mortality. Kaplan-Meier curves and overall survival (OS) were analyzed using log-rank tests. Results: Most common postoperative complications were persistent air leak, atrial fibrillation, and pneumonia. Median LOS was 4 days, and the 30-day mortality rate was 1% (n=10/1,021). Compared to NCDB patients who underwent OL, NCI-CCC patients had a higher mean number of retrieved lymph nodes (P=0.001), higher rate of mediastinal lymphadenectomy (P<0.001), and shorter median LOS (4 vs. 6 days; P<0.001). There was no difference in 30-day mortality (P=0.176). Kaplan-Meier analyses showed no differences in median OS (log-rank P=0.953) or 5-year OS (P=0.774). Compared to NCDB VL, NCI-CCC patients had a higher nodal yield (P<0.001), higher rates of mediastinal lymphadenectomy (P<0.001), and lower conversion rates (4.1% vs. 13.8%, P<0.001). There were no differences in 30-day mortality (P=0.379) or in median LOS (P=0.351). Kaplan-Meier analyses showed no differences in median OS (P=0.720) or 5-year OS (P=0.735). NCI-CCC patients were also matched with NCDB RL patients and had a higher nodal yield (P<0.001), higher rates of mediastinal lymphadenectomy (P<0.001), and lower conversion rates (4.1% vs. 9.5%; P <0.001). There were no differences in 30-day mortality (P=0.899) or in median LOS (P=0.252). Kaplan-Meier analyses showed no differences in median OS (P=0.484) or 5-year OS (P=0.524). Conclusions: RL for NSCLC performed in an NCI-CCC appears to have improved perioperative outcomes with comparable long-term OS compared to national benchmarks in OL and VL.

Association between the Preoperative Standard Uptake Value (SUV) and Survival Outcomes after Robotic-Assisted Segmentectomy for Resectable Non-Small Cell Lung Cancer (NSCLC).

BACKGROUND: Lung-sparing procedures, specifically segmentectomies and wedge resections, have increased over the years to treat early-stage non-small cell lung cancer (NSCLC). We investigate here the perioperative and long-term outcomes of patients who underwent robotic-assisted segmentectomy (RAS) at an NCI-designated cancer center and aim to show associations between the preoperative standard update value (SUV) to tumor stage, recurrence patterns, and overall survival. METHODS: A retrospective analysis was performed on 166 consecutive patients who underwent RAS at a single institution from 2010 to 2021. Of this number, 121 robotic-assisted segmentectomies were performed for primary NSCLC, and a total of 101 patients were evaluated with a PET-CT scan. The SUV from the primary tumor was determined from the PET-CT. The clinical, surgical, and pathologic profiles and perioperative outcomes were summarized via descriptive statistics. Numerical variables were described as the median and interquartile range because all numerical variables were not normally distributed as assessed by the Shapiro-Wilk test of normality. Categorical variables were described as the count and proportion. Chi-square or Fisher's exact test was used for association. The main outcomes were overall survival (OS) and recurrence-free survival (RFS). Kaplan-Meier (KM) curves were constructed to visualize the OS and RFS, which were also stratified according to tumor histology, the pathologic stage, and standard uptake value. A log-rank test for the equality of survival curves was performed to determine significant differences between groups. RESULTS: The most common postoperative complications were atrial fibrillation (8.8%, 9/102), persistent air leak (7.84%, 8/102), and pneumonia (4.9%, 5/102). The median operative duration was 168.5 min (IQR 59), while the median estimated blood loss was 50 mL (IQR 125). The conversion rate to thoracotomy in this cohort was 3.9% (4/102). Intraoperative complications occurred in 2.9% (3/102). The median hospital length of stay was 3 days (IQR 3). The median chest tube duration was 3 days (IQR 2), but 4.9% (5/102) of patients were sent home with a chest tube. The recurrence for this cohort was 28.4% (29/102). The time to recurrence was 353 days (IQR 504), while the time to mortality was 505 days (IQR 761). The NSCLC patients were divided into the following two groups: low SUV (<5, n = 55) and high SUV (≥5, n = 47). Statistically significant associations were noted between SUV and the tumor histology (p = 0.019), tumor grade (p = 0.002), lymph-vascular invasion (p = 0.029), viscera-pleural invasion (p = 0.008), recurrence (p < 0.001) and the site of recurrence (p = 0.047). KM survival analysis showed significant differences in the curves for OS (log-rank p-value 0.0204) and RFS (log-rank p-value 0.0034) between the SUV groups. CONCLUSION: Robotic-assisted segmentectomy for NSCLC has reasonable perioperative and oncologic outcomes. Furthermore, we demonstrate here the prognostic implication of preoperative SUV to pathologic outcomes, recurrence-free survival, and overall survival.

Changes in Perioperative Outcomes after Robotic-Assisted Pulmonary Lobectomy during the COVID-19 Era.

Background: The COVID-19 pandemic presented patients with barriers to receiving healthcare. We sought to determine whether changes in healthcare access and practice during the pandemic affected perioperative outcomes after robotic-assisted pulmonary lobectomy (RAPL). Methods: We retrospectively analyzed 721 consecutive patients who underwent RAPL. With March 1st, 2020, defining the start of the COVID-19 pandemic, we grouped 638 patients as "PreCOVID-19" and 83 patients as "COVID-19-Era" based on surgical date. Demographics, comorbidities, tumor characteristics, intraoperative complications, morbidity, and mortality were analyzed. Variables were compared utilizing Student's t-test, Wilcoxon rank-sum test, and Chi-square (or Fisher's exact) test, with significance at p ≤ 0.05 . Multivariable generalized linear regression was used to investigate predictors of postoperative complication. Results: COVID-19-Era patients had significantly higher preoperative FEV1%, lower cumulative smoking history and higher incidences of preoperative atrial fibrillation, peripheral vascular disease (PVD), and bleeding disorders compared to PreCOVID-19 patients. COVID-19-Era patients had lower intraoperative estimated blood loss (EBL), reduced incidence of new-onset postoperative atrial fibrillation (POAF), but higher incidence of effusion or empyema postoperatively. Overall postoperative complication rates between the groups were similar. Older age, increased EBL, lower preoperative FEV1%, and preoperative COPD are all predictive of an increased risk for postoperative complication. Conclusions: COVID-19-Era patients having lower EBL and less new-onset POAF, despite greater incidences of multiple preoperative comorbidities, demonstrates that RAPL is safe during the COVID-19 era. Risk factors for development of postoperative effusion should be determined to minimize risk of empyema in COVID-19-Era patients. Age, preoperative FEV1%, COPD, and EBL should all be considered when planning for complication risk.

Effects of preoperative pulmonary function on perioperative outcomes after robotic-assisted pulmonary lobectomy.

INTRODUCTION: Effects of pulmonary function test (PFT) results on perioperative outcomes were investigated after robotic-assisted video-thoracoscopic (RAVT) pulmonary lobectomy. METHODS: We retrospectively analyzed 706 consecutive patients who underwent RAVT lobectomy by one surgeon over 10.8 years. Preoperative (preop) forced expiratory volume in 1 s as a percent of predicted (FEV1%) was used to group patients as having normal FEV1% (≥80%) versus reduced FEV1% (<80%). Demographics, preop comorbidities, intraoperative (intraop) and postoperative (postop) complications, perioperative outcomes, and median survival time (MST) were compared across patients with normal vs. reduced FEV1% using Chi-Square (X2), Fisher's Exact test, Student's t-test, Kruskal-Wallis test, or Kaplan-Meier analysis respectively, with significance at p ≤ 0.05. Multivariable analysis was performed for perioperative outcomes to investigate the differences across patients in the FEV1% groups. RESULTS: There were 470 patients with normal FEV1% and 236 patients with reduced FEV1%. The two FEV1% groups did not differ in intraop or postop complication rates, except for higher postop other arrhythmia requiring intervention (p = 0.004), prolonged air leak >5 days (p = 0.002), mucous plug formation (p = 0.009), hypoxia (p < 0.001), and pneumonia (p = 0.002), and total postop complications (p < 0.001) in reduced-FEV1% patients. Reduced FEV1% correlated with increased intraop estimated blood loss (p < 0.0001) and skin-to-skin operative time (p < 0.0001). Median overall survival in patients with normal FEV1% was 93.20 months (95% CI: 76.5-126.0) versus 58.9 months (95% CI: 50.4-68.4) in patients with reduced FEV1% (p = 0.0004). CONCLUSION: Patients should have PFTs conducted before surgery to determine at-risk patients. However, RAVT pulmonary lobectomy is feasible and safe even in patients with reduced FEV1%.

Surgical results of the Lung Cancer Mutation Consortium 3 trial: A phase II multicenter single-arm study to investigate the efficacy and safety of atezolizumab as neoadjuvant therapy in patients with stages IB-select IIIB resectable non-small cell lung cancer.

OBJECTIVE: Multimodality treatment for resectable non-small cell lung cancer has long remained at a therapeutic plateau. Immune checkpoint inhibitors are highly effective in advanced non-small cell lung cancer and promising preoperatively in small clinical trials for resectable non-small cell lung cancer. This large multicenter trial tested the safety and efficacy of neoadjuvant atezolizumab and surgery. METHODS: Patients with stage IB to select IIIB resectable non-small cell lung cancer and Eastern Cooperative Oncology Group performance status 0/1 were eligible. Patients received atezolizumab 1200 mg intravenously every 3 weeks for 2 cycles or less followed by resection. The primary end point was major pathological response in patients without EGFR/ALK+ alterations. Pre- and post-treatment computed tomography, positron emission tomography, pulmonary function tests, and biospecimens were obtained. Adverse events were recorded by Common Terminology Criteria for Adverse Events v.4.0. RESULTS: From April 2017 to February 2020, 181 patients were entered in the study. Baseline characteristics were mean age, 65.1 years; female, 93 of 181 (51%); nonsquamous histology, 112 of 181 (62%); and clinical stages IIB to IIIB, 147 of 181 (81%). In patients without EGFR/ALK alterations who underwent surgery, the major pathological response rate was 20% (29/143; 95% confidence interval, 14-28) and the pathological complete response rate was 6% (8/143; 95% confidence interval, 2-11). There were no grade 4/5 treatment-related adverse events preoperatively. Of 159 patients (87.8%) undergoing surgery, 145 (91%) had pathologic complete resection. There were 5 (3%) intraoperative complications, no intraoperative deaths, and 2 postoperative deaths within 90 days, 1 treatment related. Median disease-free and overall survival have not been reached. CONCLUSIONS: Neoadjuvant atezolizumab in resectable stage IB to IIIB non-small cell lung cancer was well tolerated, yielded a 20% major pathological response rate, and allowed safe, complete surgical resection. These results strongly support the further development of immune checkpoint inhibitors as preoperative therapy in locally advanced non-small cell lung cancer.

Optimal management of malignant pleural effusions (results of CALGB 30102).

The optimal strategy to achieve palliation of malignant pleural effusions (MPEs) is unknown. This multi-institutional, prospective, randomized trial compares 2 established methods for controlling symptomatic unilateral MPEs. Patients with unilateral MPEs were randomized to either daily tunneled catheter drainage (TCD) or bedside talc pleurodesis (TP). This trial is patterned after a previous randomized trial that showed that bedside TP was equivalent to thoracoscopic TP (CALGB 9334). The primary end point of the current study was combined success: consistent/reliable drainage/pleurodesis, lung expansion, and 30-day survival. A secondary end point, survival with effusion control, was added retrospectively. This trial randomized 57 patients who were similar in terms of age (62 years), active chemotherapy (28%), and histologic diagnosis (lung, 63%; breast, 12%; other/unknown cancers, 25%) to either bedside TP or TCD. Combined success was higher with TCD (62%) than with TP (46%; odds ratio, 5.0; P = .064). Multivariate regression analysis revealed that patients treated with TCD had better 30-day activity without dyspnea scores (8.7 vs. 5.9; P = .036), especially in the subgroup with impaired expansion (9.1 vs. 4.6; P = .042). Patients who underwent TCD had better survival with effusion control at 30 days compared with those who underwent TP (82% vs. 52%, respectively; P = .024). In this prospective randomized trial, TCD achieved superior palliation of unilateral MPEs than TP, particularly in patients with trapped lungs.

Adopting robotic thoracic surgery impacts hospital overall lung resection case volume.

PURPOSE: We sought to evaluate the role of robotic-assisted lung surgery on hospital volume using difference in difference (DID). We propose hospital adoption of robotic thoracic technology increases total volume of specific procedures as compared to non-robotic hospitals. METHODS: The 2010-2015 Florida Agency for Health Care Administration dataset was queried for open, video-assisted thoracoscopic, and robotic-assisted thoracic surgeries. Incident Rate Ratios (IRR) from DID analysis determined the significance of robotic technology. For each technique, length of stay and elements of charges were compared to determine statistical significance. RESULTS: A total of 28,484 lung resection procedures performed at 162 hospitals, 65 of which had robotic capabilities were included. Robotic hospitals experienced an 85% increase in total lung surgical volume (IRR 1.85, p-value <0.001). This increase in volume was consistent for each lung resection procedure separately. CONCLUSION: Hospital adoption of robotic technology significantly increases the overall lung surgical volume for select lung resection procedures.

Surgical Considerations for Tumor Tissue Procurement to Obtain Tumor-Infiltrating Lymphocytes for Adoptive Cell Therapy.

ABSTRACT: Adoptive cell therapy with tumor-infiltrating lymphocytes (TILs), an investigational cellular therapy, has demonstrated antitumor efficacy in patients with advanced solid tumors, including melanoma. Tumor-infiltrating lymphocyte cell therapy involves surgical resection of a patient's tumor, ex vivo TIL expansion under conditions that overcome immunosuppressive responses elicited by the tumor and the tumor microenvironment, administration of a lymphodepleting regimen, and infusion of the final TIL cell therapy product back into the patient followed by interleukin 2 administration to support T-cell activity. The surgeon plays a central role in patient identification and tumor selection-steps that are critical for successful outcomes of TIL cell therapy. Commercialization of TIL cell therapy and its broader access to patients will require education and collaboration among surgeons, oncologists, and cellular therapists. This review highlights the unique role that surgeons will play in the implementation of TIL cell therapy and serves as a contemporary report of best practices for patient selection and tumor resection methods.

Distance of Residence From the Cancer Center Influences Perioperative Outcomes After Robotic-Assisted Pulmonary Lobectomy?

Introduction Increased distance of residence from the hospital has been previously associated with worse postoperative outcomes, especially increased hospital length of stay (LOS) after elective surgery in the USA as well as after pulmonary lobectomy in Japan. We sought to determine if the distance from our cancer center affects postoperative outcomes after robotic-assisted pulmonary lobectomy. Methods We retrospectively analyzed 449 patients who underwent robotic-assisted pulmonary lobectomy by one surgeon for known or suspected lung cancer. Two patients were excluded due to incomplete data. Each patient's residential ZIP code was used to determine the distance of their primary residence from our cancer center. Group 1 consisted of patients living less than 120 miles away while Group 2 consisted of patients living more than 120 miles away. Demographic factors, preoperative comorbidities, the incidence of postoperative complications, chest tube duration, and hospital LOS were compared by the Pearson chi-square or Kruskal-Wallis tests, and Kaplan-Meier survival was compared by Cox regression. Statistical significance was established as p≤0.05. Results Group 1 was found to have a higher mean body mass index (BMI) (28.3 kg/m2) than Group 2 (27.0 kg/m2; p=.031). Group 1 also tended to have a higher rate of preoperative hypertension (HTN; 59%) than Group 2 (47%; p=.018). No other preoperative comorbidities were significant. Median hospital LOS was found to differ between Group 1 (4 days) and Group 2 (5 days; p=.048). Postoperative complication rates did not differ between Group 1 (35%) and Group 2 (40%; p=.370). Median chest tube durations for Group 1 (4 days) vs. Group 2 (4 days) did not differ (p=.093). Five-year overall survival (OS) did not differ between the two groups (p=.550). Conclusions Longer distance from patient residence to our cancer center was associated with higher BMI, higher rates of preoperative HTN, and longer LOS. Postoperative complication rates, chest tube duration, and five-year OS were not significantly affected by distance. These results supported similar results in a Japanese study that indicated distance extends the LOS, regardless of the type of transportation used by patients. Further research analyzing the effects of socioeconomic status and insurance coverage on perioperative outcomes should be conducted to identify subpopulations in the USA that suffer disparities in access to and delivery of healthcare.