Quality of Life and Real-time Patient Experience During Neoadjuvant Therapy: A Prospective Cohort Study.

OBJECTIVE: To use a customized smartphone application to prospectively measure QOL and the real-time patient experience during neoadjuvant therapy (NT). BACKGROUND: NT is increasingly used for patients with localized gastrointestinal (GI) cancers. There is little data assessing patient experience and quality of life (QOL) during NT for GI cancers. METHODS: Patients with GI cancers receiving NT were instructed on using a customized smartphone application through which the Functional Assessment of Cancer Therapy-General (FACT-G) questionnaire, a validated measure of health-related QOL, was administered at baseline, every 30 days, and at the completion of NT. Participants also tracked their moods and symptoms and used free-text journaling functionalities in the application. Mean overall and subsection health-related QOL scores were calculated during NT. RESULTS: Among 104 enrolled patients, the mean age was 60.5 ± 11.5 years and 55% were males. Common cancer diagnoses were colorectal (40%), pancreatic (37%), and esophageal (15%). Mean overall FACT-G scores did not change during NT ( P = 0.987). While functional well-being scores were consistently the lowest and social well-being scores the highest, FACT subscores similarly did not change during NT (all P > 0.01). The most common symptoms reported during NT were fatigue, insomnia, and anxiety (39.3%, 34.5%, and 28.3% of patient entries, respectively). Qualitative analysis of free-text journaling entries identified anxiety, fear, and frustration as the most common themes, but also the importance of social support systems and confidence in health care providers. CONCLUSIONS: While patient symptom burden remains high, results of this prospective cohort study suggest QOL is maintained during NT for localized GI cancers.

Surgeon Perspectives on the Management of Aborted Cancer Surgery: Results of a Society of Surgical Oncology Member Survey.

BACKGROUND: While surgery is generally necessary for most solid-organ cancers, curative-intent resection is occasionally aborted due to unanticipated unresectability or occult metastases. Following aborted cancer surgery (ACS), patients have unique and complex care needs and yet little is known about the optimal approach to their management. OBJECTIVE: The aim of this study was to define the practice patterns and perspectives of an international cohort of cancer surgeons on the management of ACS. METHODS: A validated survey assessing surgeon perspectives on patient care needs and management following ACS was developed. The survey was distributed electronically to members of the Society of Surgical Oncology (SSO). RESULTS: Among 190 participating surgeons, mean age was 49 ± 11 years, 69% were male, 61% worked at an academic institution, and most had a clinical practice focused on liver/pancreas (30%), breast (23%), or melanoma/sarcoma cancers (20%). Participants estimated that ACS occurred in 7 ± 6% of their cancer operations, most often due to occult metastases (67%) or local unresectability (30%). Most surgeons felt (very) comfortable addressing their patients' surgical needs (92%) and cancer treatment-related questions (90%), but fewer expressed comfort addressing psychosocial needs (83%) or symptom-control needs (69%). While they perceived discussing next available therapies as the patients' most important priority after ACS, surgeons reported avoiding postoperative complications as their most important priority (p < 0.001). While 61% and 27% reported utilizing palliative care and psychosocial oncology, respectively, in these situations, 46% noted care coordination as a barrier to addressing patient care needs. CONCLUSIONS: Results from this SSO member survey suggest that ACS is relatively common and associated with unique patient care needs. Surgeons may feel less comfortable assessing psychosocial and symptom-control needs, highlighting the need for novel patient-centered approaches.

Comparative effectiveness of perioperative physical activity in older adults with lung cancer and their family caregivers: design of a multicenter pragmatic randomized trial.

BACKGROUND: With a median age at diagnosis of 70, lung cancer remains a significant public health challenge for older Americans. Surgery is a key component in treating most patients with non-metastatic lung cancer. These patients experience postoperative pain, fatigue, loss of respiratory capacity, and decreased physical function. Data on quality of life (QOL) in older adults undergoing lung cancer surgery is limited, and few interventions are designed to target the needs of older adults and their family caregivers (FCGs). The primary aim of this comparative effectiveness trial is to determine whether telephone-based physical activity coaching before and after surgery will be more beneficial than physical activity self-monitoring alone for older adults and their FCGs. METHODS: In this multicenter comparative effectiveness trial, 382 older adults (≥ 65 years) with lung cancer and their FCGs will be recruited before surgery and randomized to either telephone-based physical activity coaching or physical activity self-monitoring alone. Participants allocated to the telephone-based coaching comparator will receive five telephone sessions with coaches (1 pre and 4 post surgery), an intervention resource manual, and a wristband pedometer. Participants in the self-monitoring only arm will receive American Society of Clinical Oncology (ASCO) physical activity information and wristband pedometers. All participants will be assessed at before surgery (baseline), at discharge, and at days 30, 60, and 180 post-discharge. The primary endpoint is the 6-minute walk test (6MWT) at 30 days post-discharge. Geriatric assessment, lower extremity function, self-reported physical function, self-efficacy, and QOL will also be assessed. DISCUSSION: The trial will determine whether this telephone-based physical activity coaching approach can enhance postoperative functional capacity and QOL outcomes for older adults with lung cancer and their FCGs. Trial results will provide critical findings to inform models of postoperative care for older adults with cancer and their FCGs. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT06196008.

Advances in the clinical use of patient-reported outcomes in thoracic surgery.

PURPOSE OF REVIEW: Patient-reported outcomes (PROs) are increasingly recognized as a clinical tool for measuring and improving patient-centric care. This review provides a summary on recent advances in the use of PROs in the field of thoracic surgery. RECENT FINDINGS: PROs have been used as primary endpoints in clinical trials and observational studies evaluating clinical care pathways and quantifying the benefits of minimally invasive surgical techniques for patients undergoing lung surgery. Qualitative and quantitative research has yielded fundamental insights into which PRO domains are meaningful and valued by patients after lung surgery. Patient experience and recovery after esophagectomy have been further characterized by using PROs. New disease-specific survey tools for patients have been developed to track long-term symptoms after esophageal reconstruction. Patient satisfaction has emerged as the key metric used to gauge the patient centeredness of hospital systems. SUMMARY: Advances have been made in the application of PROs in multiple areas of thoracic surgery, which include lung and esophageal surgery. The growing focus on the use of PROs in clinical pathways has led to a better understanding on how to optimize patient experience.

Segmentectomy for clinical stage I non-small cell lung cancer: National benchmarks for nodal staging and outcomes by operative approach.

BACKGROUND: Segmentectomy is increasingly used for parenchyma sparing anatomical resection for small stage I non-small cell lung cancer (NSCLC). This study characterizes the national outcomes for lymph node assessment and perioperative outcomes of segmentectomy for clinical stage I NSCLC by robotic-assisted surgery (RATS), video-assisted thoracoscopic surgery (VATS), and open thoracotomy approach. METHODS: A retrospective cohort study was conducted of patients who underwent segmentectomy for clinical stage I NSCLC captured in the national Society of Thoracic Surgeons General Thoracic Surgery Database between years 2012 and 2018. Inverse probability of treatment weighting (IPTW) was used to balance baseline characteristics. Lymph node (LN) staging and 30-day outcomes were compared by approach. RESULTS: A total of 3680 patients (VATS 61.9%, RATS 20%, open 18%) underwent segmentectomy. The IPTW adjusted rate of pathologic LN upstaging (pN1/pN2) was 6.2% (RATS 6.3%, VATS 5.6%, open 8.6%; P = .05). On multivariate analysis, there was no differences in pN1/N2 upstaging between RATS (odds ratio [OR], 0.81; 95% confidence interval [CI], 0.44-1.49) or VATS (OR, 0.96; 95% CI, 0.57-1.63) with open segmentectomy. The RATS and VATS approach was associated with fewer postoperative events (RATS 31.3%, VATS 28.8%, open 38.3%; P < .001) and shorter length of stay (RATS 4.3 days, VATS 4.4 days, open 5.2 days; P < .001) as compared with thoracotomy. RATS segmentectomy-specific complications included a higher rate of pneumothorax after chest tube removal and discharge with chest tube. Major complications were lower after RATS and VATS as compared with open segmentectomy (RATS 5.9%, VATS 4.5%, open 7.2%; P = .028). CONCLUSIONS: Segmentectomy by VATS and robotic approach resulted in similar high rates of lymph node upstaging as a global marker of the quality of lymph node dissection and were associated with lower overall morbidity and shorter length of stay as compared with open thoracotomy. These national outcomes may serve as benchmarks for future comparative studies.

Racial disparities in provider recommendation for esophagectomy for esophageal carcinoma.

BACKGROUND: Racial disparities currently exist for the utilization rate of esophagectomy for Black patients with operable esophageal carcinoma. METHODS: A total of 37 271 cases with the American Joint Committee on Cancer clinical stage I, II, and III esophageal carcinoma that were reported to the National Cancer Database were analyzed between 2004 and 2016. A multivariable-adjusted logistic regression model was used to evaluate differences in the odds ratio of esophagectomy not being recommended based on race. Kaplan-Meier curves and log-rank tests were used to evaluate differences in overall survival. Propensity score methodology with inverse probability of treatment weighting (IPTW) was used to balance baseline differences in patient demographics. RESULTS: After IPTW adjustment, we identified 30 552 White patients and 3529 Black patients with clinical stage I-III esophageal carcinoma. Black patients had three times greater odds of not being recommended for esophagectomy (odds ratio: 3.03, 95% confidence interval: 2.67-3.43, p < 0.0001) compared to White patients. Black patients demonstrated significantly worse 3- and 5-year overall survival rates compared to White patients (log-rank p < 0.0001). CONCLUSION: Black patients with clinical stage I-III esophageal cancer were significantly less likely to be recommended for esophagectomy even after adjusting for baseline demographic covariates compared to White patients.

Nomograms for predicting overall and recurrence-free survival after trimodality therapy for esophageal adenocarcinoma.

BACKGROUND: Locally advanced esophageal carcinoma is treated with neoadjuvant chemoradiation and esophagectomy. Patients may still experience recurrence and death despite undergoing potentially curative trimodality therapy. This study describes predictive nomograms for recurrence-free (RFS) and overall survival (OS) after the completion of trimodality therapy. METHODS: A total of 215 patients with esophageal adenocarcinoma underwent trimodality therapy from September 2010 to April 2018. Multivariate Cox proportional hazards regression models were used to create nomograms for OS and RFS. Kaplan-Meier survival curves were calculated for OS and RFS comparing high-risk and low-risk cohorts. RESULTS: On multivariate analysis, clinical N-stage, tumor differentiation, tumor regression grade, anastomotic leak, body mass index, age, and number of lymph nodes removed were predictive variables for overall survival. Clinical N-stage, tumor differentiation, tumor regression grade, anastomotic leak, age, and positive lymph nodes were significant predictors of RFS in a multivariate model. The nomogram for OS had good predictive ability (Harrell's Concordance index [C-index]: 0.71 [95% confidence interval {CI}: 0.66-0.76]). The nomogram for RFS also performed well (C-index: 0.70 [95% CI: 0.65-0.74]). CONCLUSION: Our nomograms can accurately predict OS and RFS after trimodality therapy and may provide guidance regarding adjuvant therapy and surveillance.

A successful clinical pathway protocol for minimally invasive esophagectomy.

BACKGROUND: Minimally invasive esophagectomy is associated with significant morbidity, which can substantially influence the hospital length of stay for patients. Anastomotic leak is the most devastating complication. Minimizing major postoperative complications can facilitate adherence to a clinical pathway protocol and can decrease hospital length of stay. METHODS: This is a retrospective study of 130 patients who underwent an elective laparoscopic and thoracoscopic Ivor Lewis esophagectomy for esophageal carcinoma between August 2014 and June 2018. A total of 112 patients (86%) underwent neoadjuvant chemoradiation. All of the 130 patients underwent a laparoscopic gastric devascularization procedure a median of 15 days prior to the esophagectomy. The target discharge date was postoperative day number 8. RESULTS: Thirty patients (23.08%) had postoperative complications. Atrial fibrillation (20 patients) [15.38%] was the most frequent complication. Four patients (3.1%) developed an anastomotic leak. There was one postoperative death (0.77%) in the cohort of patients. The median length of stay was 8 days. The mean length of stay for patients without complications was 8 days ± 1.2 days and 12.4 days ± 7.1 days for patients with one or more complications (p = 0.002). CONCLUSION: The development of postoperative complications after minimally invasive Ivor Lewis esophagectomy significantly increases hospital length of stay. Performing the operation with a specialized tandem surgical team and including preoperative ischemic preconditioning of the stomach minimizes overall and anastomotic complications and facilitates on time hospital discharge as defined by a perioperative clinical pathway protocol.

Accessing surgical care for esophageal cancer: patient travel patterns to reach higher volume center.

While better outcomes at high-volume surgical centers have driven the regionalization of complex surgical care, access to high-volume centers often requires travel over longer distances. We sought to evaluate the travel patterns among patients undergoing esophagectomy to assess willingness of patients to travel for surgical care. The California Office of Statewide Health Planning database was used to identify patients who underwent esophagectomy between 2005 and 2016. Total distance traveled, as well as whether a patient bypassed the nearest hospital that performed esophagectomy to get to a higher volume center, was assessed. Overall 3,269 individuals underwent an esophagectomy for cancer in 154 hospitals; only five hospitals were high volume according to Leapfrog standards. Median travel time to a hospital that performed esophagectomy was 26 minutes (IQR: 13.1-50.7). The overwhelming majority of patients (85%) bypassed the nearest providing hospital to seek care at a destination hospital. Among patients who bypassed a closer hospital, only 36% went to a high-volume hospital. Of the 2,248 patients who underwent esophagectomy at a low-volume center, 1,491 patients had bypassed a high-volume hospital. Of the remaining 757 patients who did not bypass a high-volume hospital, half of the individuals would have needed to travel less than an additional hour to reach a high-volume center. Nearly two-thirds of patients undergoing an esophagectomy for cancer received care at a low-volume center; 85% of patients either bypassed a high-volume hospital or would have needed to travel less than an additional hour to reach a high-volume center.

Defining the learning curve of robotic thoracic surgery: what does it take?

BACKGROUND: Controversy exists as to what constitutes a learning curve to achieve competency, and how the initial learning period of robotic thoracic surgery should be approached. METHODS: We conducted a systematic review of the literature published prior to December 2018 using PubMed/MEDLINE for studies of surgeons adopting the robotic approach for anatomic lung resection or thymectomy. Changes in operating room time and outcomes based on number of cases performed, type of procedure, and existing proficiency with video-assisted thoracoscopic surgery (VATS) were examined. RESULTS: Twelve observational studies were analyzed, including nine studies on robotic lung resection and three studies on thymectomy. All studies showed a reduction in operative time with an increasing number of cases performed. A steep learning curve was described for thymectomy, with a decrease in operating room time in the first 15 cases and a plateau after 15-20 cases. For anatomic lung resection, the number of cases to achieve a plateau in operative time ranged between 15-20 cases and 40-60 cases. All but two studies had at least some VATS experience. Six studies reported on experience of over one hundred cases and showed continued gradual improvements in operating room time. CONCLUSION: The learning curve for robotic thoracic surgery appears to be rapid with most studies indicating the steepest improvement in operating time occurring in the initial 15-20 cases for thymectomy and 20-40 cases for anatomic lung resection. Existing data can guide a standardized robotic curriculum for rapid adaptation, and aid credentialing and quality monitoring for robotic thoracic surgery programs.

Long-Term Survival in Patients with Gastroesophageal Junction Cancer Treated with Preoperative Therapy: Do Thoracic and Abdominal Approaches Differ?

BACKGROUND: The optimal surgical approach for gastroesophageal junction (GEJ) cancer treated with preoperative therapy remains controversial. We compared the outcomes of patients who underwent either esophagectomy or gastrectomy and identified variables associated with overall survival (OS). METHODS: We reviewed records of patients with Siewert types II and III GEJ adenocarcinoma who were treated with preoperative therapy followed by resection from 1995 to 2013. OS was assessed using Kaplan-Meier curves and associated variables were analyzed using Cox proportional hazards models. RESULTS: Of 143 patients, 110 (76.9 %) had type II and 33 (23.1 %) had type III tumors. Most (86 %) patients had stage T3 or T4 disease, and more than half had N+ (62 %) disease. The majority (93 %) received neoadjuvant chemoradiation; 7 % received chemotherapy alone. Patients with type II tumors underwent either esophagectomy (75 %) or gastrectomy (25 %). Patients with type III tumors primarily underwent gastrectomy (88 %). Eighty-six (60 %) patients underwent extended (D1+/D2) abdominal lymphadenectomy. We saw no differences between esophagectomy and gastrectomy patients in R0 resection rate (94 vs. 95 %; p = 0.9), number of nodes removed (mean, 18.3 vs. 19.3; p = 0.6), or 60-day mortality rate (4 vs. 4 %; p = 1.0). The median follow-up period for survivors was 65 months. Esophagectomy and gastrectomy showed similar 5-year OS rates (49 vs. 53 %; p = 0.8). Surgical approach was not associated with OS [hazard ratio (HR) 1.30; 95 % confidence interval (CI) 0.68-2.45; p = 0.43]. The strongest predictor of OS was extended lymphadenectomy (HR 0.55; 95 % CI, 0.32-0.94; p = 0.03). CONCLUSIONS: R0 resection and OS rates were similar in patients undergoing esophagectomy or gastrectomy after neoadjuvant therapy; however, extended abdominal lymphadenectomy may improve OS rates.

Regional disparities affect treatment and survival of patients with intrahepatic cholangiocarcinoma--a Texas Cancer Registry analysis.

BACKGROUND: Intrahepatic cholangiocarcinoma (ICC) is often diagnosed at advanced stage and few patients qualify for resection. Effects of barriers to access on outcomes are unknown. We hypothesized that income and rural residence account for delays in treatment and decreased survival. METHODS: Texas Cancer Registry was queried for ICC patients from 2000 to 2008. Median household income (MHI) and urban/rural status were analyzed. Regression analyses were performed for (1) time-to- treatment (TTT), and (2) overall survival (OS). RESULTS: Among 1,089 patients, 20.2% patients resided in rural areas and MHI ranged $24,497-$81,113/year. Primary treatment included surgery for 9.5%, radiation 5.4% and chemotherapy 21.0%. Median TTT was 29 (range 0-235) days. Patients from low-income areas were less likely to receive treatment (below median MHI, 29.7% vs. above median MHI, 37.5%%; P = 0.007). MHI was associated with TTT (per $10,000/year: hazard ratio (HR) = 1.05; 95% CI: 1.01-1.09). Adjusting for stage, MHI was associated with OS (per $10,000/year: HR = 0.97; 95%CI: 0.94-0.99). Rural residence was neither associated with TTT nor OS. CONCLUSION: Overall treatment rates for ICC patients are low. Regional income, not urbanization was associated treatment and survival independent of stage. Further research is needed to determine how regional prosperity relates to care access.

Management of Major Complications After Esophagectomy.

Esophagectomy remains a procedure with one of the highest complication rates. Given the advances in medical and surgical management of patients and increased patient survival, the number of complications reported has increased. There are different grading systems for complications which vary based on severity or organ system, with the Esophageal Complications Consensus Group unifying them. Management involves conservative intervention and dietary modification to endoscopic interventions and surgical reintervention. Treatment is etiology specific but rehabilitation and patient optimization play a significant role in managing these complications by preventing them. Management is a step-up approach depending on the severity of symptoms.

Sublobar Resection vs Lobectomy for Stage IA Non-Small Cell Lung Carcinoma-Takeaways From Modern Randomized Trials.

Sublobar resection for early-stage non-small cell lung cancer has been an emerging topic of great interest to thoracic surgeons. However, data regarding the efficacy and safety of sublobar resection vs lobectomy was lacking until now. Recently, 3 published randomized controlled trials (Cancer and Leukemia Group B [CALGB]140503/Alliance, Japan Clinical Oncology Group [JCOG]0802 and Das Deutsche Register Klinischer Studien [DRKS]00004897) confirmed the noninferiority of sublobar resection for early-stage non-small cell lung cancer in carefully selected populations. This review aims to summarize and compare these 3 landmark trials and inform surgeons of new best practices.

Large Mediastinal Mass as a Rare Presentation of Schistosomiasis.

A 39-year-old woman originally from Northeast Africa sought medical attention for positional dyspnea. Computed tomography of the chest revealed an 8.5 cm hypodense anterior mediastinal mass with peripheral calcifications that raised a wide differential diagnosis including infectious and neoplastic lesions. Following surgical resection, a large cavitary necrotizing and calcified granuloma involving the thymus was identified on histopathological examination. The changes were associated with parasitic eggs that based on their morphology suggested infection due to trematode species. The diagnosis was further corroborated by identification of the increased IgG titers for Schistosoma species (ELISA Kit, NovaTec). The patient's symptoms improved following surgery and praziquantel therapy. This unique presentation emphasizes an unusual manifestation of schistosomiasis that can pose a diagnostic challenge, especially in non-endemic regions. It suggests that mediastinal involvement by schistosomiasis is likely due to an ectopic deposition of the parasitic eggs within a definitive host. Suspicion for schistosomiasis should be heightened based on patient demographics and travel to endemic areas.

Perioperative Immunotherapy for Node-Negative Non-Small Cell Lung Cancer-Current Evidence and Future Directions.

Neoadjuvant immunotherapy has gone from an idea to an indication in locally advanced lung cancer. Several phase III trials have demonstrated the superiority of neoadjuvant chemoimmunotherapy compared with chemotherapy in this setting. Although such progress has revolutionized the treatment of locally advanced disease, the unmet needs of stage I and stage II patients without lymph node disease have largely been underrepresented in existing trials. Up-front resection with few patients going on to complete adjuvant therapy remains the norm for most stage I and II patients. Emerging evidence now supports the exploration of supplemental checkpoint blockade in well-selected early-stage, node-negative patients with large tumors and no actionable driver mutations. Although concerns surrounding safety and risk exist, patient selection could be substantially improved using novel biomarker approaches that leverage our understanding of the tumor immune microenvironment of lung cancer. This review provides a comprehensive overview of the opportunities and controversies of perioperative immunotherapy in node-negative lung cancer.

Rotational Latissimus Dorsi Flap for Lateral Repair of Thoracic Cerebrospinal Fluid-Pleural Fistula: Case Report.

BACKGROUND AND IMPORTANCE: Giant calcified thoracic discs are challenging surgical pathologies that tend to be more centrally located and calcified. This complicates the removal process and potentiates the formation of dural defects, resulting in persistent cerebrospinal fluid (CSF) leaks and the formation of pleural fistulas. The typical intervention for this is CSF diversion through external ventricular drain or lumbar drain placement, followed by direct repair. However, if all these measures fail, subsequent salvage techniques have not been described previously. CLINICAL PRESENTATION: A 45-year-old man with past medical history of obesity (body mass index: 58), hypertension, and type 2 diabetes mellitus presented to the emergency department with thoracic myelopathy symptoms. MR demonstrated a giant calcified thoracic discs at T7-T8 with severe spinal cord compression. Intraoperatively, the disc was found fused to the dura and removal caused a large ventrolateral dural dehiscence. CSF diversion and direct repair were attempted unsuccessfully, so a salvage procedure with a rotational pedicled latissimus dorsi flap was performed. The patient's latissimus dorsi was exposed and resected from attachments, maintaining thoracodorsal blood supply, while removing thoracodorsal innervation. The flap was then rotated into the previous corpectomy site. The dural defect was repaired with a sealant patch, overlayed with a parietal pleural flap and the latissimus dorsi flap. By the patient's last follow-up, he had full functional independence at home. CONCLUSION: We present a surgical case highlighting the challenges of managing postoperative CSF-pleural fistula occurring after giant calcified thoracic disc removal and the successful use of a novel rotational latissimus dorsi flap to definitively repair the fistula after unsuccessful primary interventions.

Staged complex reconstruction of infected thoracic aortic endograft and adjacent spinal hardware using latissimus wrapped lateral aortic graft.

Thoracic endovascular aortic repair (TEVAR) enables rapid and effective treatment of life-threatening aortic injuries. The occurrence of long-term complications from TEVAR and their management is ill-defined in young patients. This report describes a complex case of a 38-year-old male patient who underwent staged interventions for different acute pathologies instigated by blunt thoracic spinal trauma. The patient was initially treated with a TEVAR for aortic pseudoaneurysm in the setting of infected spinal hardware, which later resulted in an aortobronchial fistula and eroded spinal hardware. This report illustrates a successful multidisciplinary approach for definitive treatment with graft explant and aortic reconstruction.