Patient-clinician communication among patients with stage I lung cancer.

PURPOSE: Limited data exist about patient-centered communication (PCC) and patient-centered outcomes among patients who undergo surgery or stereotactic body radiation therapy (SBRT) for stage I non-small cell lung cancer (NSCLC). We aimed to examine the relationship between PCC and decision-making processes among NSCLC patients, using baseline data from a prospective, multicenter study. METHODS: Patients with stage 1 NSCLC completed a survey prior to treatment initiation. The survey assessed sociodemographic characteristics, treatment decision variables, and patient psychosocial outcomes: health-related quality of life (HRQOL), treatment self-efficacy, decisional conflict, and PCC. RESULTS: Fifty-two percent (n = 85) of 165 individuals planned to receive SBRT. There were no baseline differences detected on patient psychosocial outcomes between those who planned to receive SBRT or surgery. All participants reported high HRQOL (M = 72.5, SD = 21.3) out of 100, where higher scores indicate better functioning; high self-efficacy (M = 1.5, SD = 0.5) out of 6, where lower numbers indicate higher self-efficacy; minimal decisional conflict (M = 15.2, SD = 12.7) out of 100, where higher scores indicate higher decisional conflict; and high levels of patient-centered communication (M = 2.4, SD = 0.8) out of 7 where higher scores indicate worse communication. Linear regression analyses adjusting for sociodemographic and clinical variables showed that higher quality PCC was associated with higher self-efficacy (ß = 0.17, p = 0.03) and lower decisional conflict (ß = 0.42, p < 0.001). CONCLUSIONS: Higher quality PCC was associated with higher self-efficacy and lower decisional conflict. Self-efficacy and decisional conflict may influence subsequent health outcomes. Therefore, our findings may inform future research and clinical programs that focus on communication strategies to improve these outcomes.

Pulmonary Vascular Complication Associated With Coronavirus Infection and Role of Lung Resection.

Pulmonary artery pseudoaneurysms are an uncommon diagnosis and have been minimally described in the coronavirus (COVID-19) literature. In our case, a 31-year-old man presented with severe acute hypoxic respiratory failure, stress cardiomyopathy, and combined septic and cardiogenic shock secondary to COVID-19 pneumonia and Streptococcus anginosus bacteremia. The patient had perfusing granulomas eroding into the pulmonary vasculature, causing impending hemothorax. Thoracic surgical procedures for infectious pulmonary artery pseudoaneurysms or perfusing granulomas in patients who have had COVID-19 should be performed selectively and with thoughtful perioperative planning to prevent the life-threatening complications of rupture and bleeding.

Extended transcervical video-assisted thymectomy.

This article describes surgery using a transcervical approach with thoracoscopic visualization. The video-assisted extended approach is well suited for patients undergoing thymectomy for myasthenia gravis, thymic cysts, small thymoma, or mediastinal parathyroid adenoma. It incorporates the minimally invasive nature of the transcervical method with the extensive anterior mediastinal dissection, while allowing for complete removal of the thymus and anterior mediastinal fat and avoiding the morbidity of a sternotomy.

Longitudinal Health-related Quality of Life among Individuals Considering Treatment for Stage I Non-Small-Cell Lung Cancer.

Rationale: Because of improvements in screening, there is an increasing number of patients with early-stage non-small-cell lung cancer (NSCLC) who are making treatment decisions.Objectives: Among patients with suspected stage I NSCLC, we evaluated longitudinal patient-centered outcomes (PCOs) and the association of changes in PCOs with treatment modality, stereotactic body radiotherapy (SBRT) compared with surgical resection.Methods: We conducted a multisite, prospective, observational cohort study at seven medical institutions. We evaluated minimum clinically important differences of PCOs at four time points (during treatment, 4-6 wk after treatment, 6 mo after treatment, and 12 mo after treatment) compared with pretreatment values using validated instruments. We used adjusted linear mixed models to examine whether the association between treatment and European Organization for Research and Treatment of Cancer global and physical quality-of-life (QOL) scales differed over time.Results: We included 127 individuals with stage I NSCLC (53 surgery, 74 SBRT). At 12 months, approximately 30% of patients remaining in each group demonstrated a clinical deterioration on global QOL from baseline. There was a significant difference in slopes between treatment groups on global QOL (-12.86; 95% confidence interval [CI], -13.34 to -12.37) and physical QOL (-28.71; 95% CI, -29.13 to -28.29) between baseline and during treatment, with the steeper decline observed among those who underwent surgery. Differences in slopes between treatment groups were not significant at all other time points.Conclusions: Approximately 30% of patients with stage I NSCLC have a clinically significant decrease in QOL 1 year after SBRT or surgical resection. Surgical resection was associated with steeper declines in QOL immediately after treatment compared with SBRT; however, these declines were not lasting and resolved within a year for most patients. Our results may facilitate treatment option discussions for patients receiving treatment for early-stage NSCLC.

Management algorithms for stage IIIA non-small cell lung cancer with N2 node involvement.

Stage IIIA non-small cell lung cancer (NSCLC) with N2 node involvement (IIIA[N2]) is a complex area characterized by much confusion and controversy, because data derived from a particular subgroup of IIIA(N2) often are inappropriately applied to another subgroup. The problem is not so much that stage IIIA(N2) encompasses a spectrum of disease, which is true in each stage of NSCLC. Rather, our ability to describe a patient cohort has been limited, and it is therefore often difficult to determine how and when to apply data from published studies. A simple, pragmatic approach is taken in this article to define algorithms for the management of these patients.

"It wasn't as bad as I thought it would be": a qualitative study of early stage non-small cell lung cancer patients after treatment.

OBJECTIVE: While surgical resection is recommended for most patients with early stage lung cancer, stereotactic body radiotherapy (SBRT) is being increasingly utilized. Provider-patient communication regarding risks/benefits of each approach may be a modifiable factor leading to improved patient-centered outcomes. Our objective was to determine a framework and recommended strategies on how to best communicate with patients with early stage non-small cell lung cancer (NSCLC) in the post-treatment setting. We qualitatively evaluated the experiences of 11 patients with early clinical stage NSCLC after treatment, with a focus on treatment experience, knowledge obtained, communication, and recommendations. We used conventional content analysis and a patient-centered communication theoretical model to guide our understanding. RESULTS: Five patients received surgery and six received SBRT. Both treatments were generally well-tolerated. Few participants reported communication deficits around receiving follow-up information, although several had remaining questions about their treatment outcome (mainly those who underwent SBRT). They described feeling anxious regarding their first surveillance CT scan and clinician visit. Overall, participants remained satisfied with care because of implicit trust in their clinicians rather than explicit communication. Communication gaps remain but may be addressed by a trusting relationship with the clinician. Patients recommend clinicians give thorough explanations and personalize when possible.

Minimally invasive management of the mediastinal parathyroid adenoma.

INTRODUCTION/METHODS: Traditional surgical management of mediastinal parathyroid adenomas has required mediastinal exploration via sternotomy or thoracotomy. By contrast minimal access approaches to the mediastinum via videoscopic transthoracic or transcervical approaches can offer equivalent visualization, patient safety and decreased patient morbidity. The availability of sternal retractor systems, the rapid parathyroid hormone (PTH) assay for intraoperative confirmation of cure, recurrent laryngeal nerve monitoring technique and video-assisted thoracic surgery (VATS) instrumentation have made this possible. The purpose of this article is to discuss these approaches and the results with their application in five consecutive patients. RESULTS: Five consecutive patients underwent mediastinal exploration of which three were performed transcervically and three transthoracically (one patient underwent both procedures). One patient had a negative thoracic exploration; one patient's course was complicated by transient recurrent laryngeal nerve injury which resolved spontaneously. CONCLUSION: Transcervical approaches for resection of anterior mediastinal parathyroid adenomas are possible with the use of the Rultract Skyhook Retractor without the need for sternotomy. VATS provides excellent visualization of the middle and posterior mediastinum avoiding the morbidity of thoracotomy.

Presumed Second Focus of Lung Immunoglobulin G4-Related Disease Found to be Adenocarcinoma.

We describe a patient presenting with bilateral radiologically similar lung lesions initially diagnosed as immunoglobulin (Ig) G4-related disease from biopsy of one lesion, but radiographic changes 6 months later prompted biopsy of the second lesion and showed adenocarcinoma. No case of lung IgG4-related disease and a distant lung malignancy has been previously reported. This is notable because lung IgG4-related disease often manifests in multiple thoracic locations but is diagnosed from a representative biopsy specimen.

"Even if I Don't Remember, I Feel Better". A Qualitative Study of Patients with Early-Stage Non-Small Cell Lung Cancer Undergoing Stereotactic Body Radiotherapy or Surgery.

RATIONALE: While surgical resection is recommended for most patients with early stage lung cancer according to the National Comprehensive Cancer Network guidelines, stereotactic body radiotherapy is increasingly being used. Provider-patient communication regarding the risks and benefits of each approach may be a modifiable factor leading to improved patient-centered outcomes. OBJECTIVES: To qualitatively describe the experiences of patients undergoing either surgery or stereotactic body radiotherapy for early stage non-small cell lung cancer. METHODS: We qualitatively evaluated and used content analysis to describe the experiences of 13 patients with early clinical stage non-small cell lung cancer before undergoing treatment in three health care systems in the Pacific Northwest, with a focus on knowledge obtained, communication, and feelings of distress. MEASUREMENTS AND MAIN RESULTS: Although most participants reported rarely having been told about other options for treatment and could not readily recall many details about specific risks of recommended treatment, they were satisfied with their care. The patients paradoxically described clinicians as displaying caring and empathy despite not explicitly addressing their concerns and worries. We found that the communication domains that underlie shared decision making occurred infrequently, but that participants were still pleased with their role in the decision-making process. We did not find substantially different themes based on where the participant received care or the treatment selected. CONCLUSIONS: Patients were satisfied with all aspects of their care, despite reporting little knowledge about risks or other treatment options, no direct elicitation of worries from providers, and a lack of shared decision making. While the development of effective communication strategies to address these gaps is warranted, their effect on patient-centered outcomes, such as distress and decisional conflict, is unclear.

Cervical thoracic duct cyst.

Thoracic duct cysts are rare lesions presenting as mediastinal or supraclavicular masses. We report a case of a 77-year-old female who presented with a left supraclavicular mass. A cervical thoracic duct cyst was suspected after contrast-enhanced computed tomography (CT) of the neck and chest. Diagnosis was confirmed by ultrasound-guided cyst aspiration and lymphangiography. Therapeutic embolization of the thoracic duct was unsuccessful. Definitive treatment was achieved with thoracic duct ligation using video-assisted thoracoscopic surgery (VATS) followed by surgical excision of the cyst. This is believed to be the first report of using minimally invasive surgery for thoracic duct ligation in the treatment of a thoracic duct cyst.

Comparison of perioperative outcomes after combined thoracoscopic-laparoscopic esophagectomy and open Ivor-Lewis esophagectomy.

BACKGROUND: Thoracoscopic-laparoscopic esophagectomy (TLE) has gained popularity in specialized centers. This study compares the perioperative outcomes of TLE and Ivor-Lewis esophagectomy (ILE). METHODS: Forty-four consecutive TLEs were compared with 46 historical ILEs. Outcomes included surgical time and blood loss, hospital length of stay, 30-day mortality rate, and complications. RESULTS: TLE took longer to perform (543 vs 437 min; P < .01) than ILE, but produced less blood loss (407 vs 780 mL; P < .01). The median length of stay and 30-day mortality did not differ between groups. Cardiovascular (41% for TLE vs 30% for ILE; P = .19) and pulmonary complications (31% TLE vs 30% ILE; P = 1.0) occurred frequently in both groups, but TLE patients had fewer wound complications (4% TLE vs 17% ILE; P = .05). CONCLUSIONS: Despite longer surgical times, TLE produced decreased intraoperative blood loss and wound complications. These findings suggest that with further technical refinement TLE may ameliorate the morbidity seen with ILE.

Computer assisted surgical stapling.

Computer assisted surgical stapling is the application of new technology to conventional staplers. The components of the system, their use in open thoracic surgery and a review of the literature to date are presented.

Video-assisted extended transcervical thymectomy.

OBJECTIVE: : The objective of this study was to demonstrate extended thymectomy via the transcervical route. METHODS: : With the use of the Rultract retractor (Rultract, Cleveland, OH), videothoracoscopy and single-lung ventilation allowed complete thymectomy. RESULTS: : This article demonstrates complete resection of all the thymus from the anterior and superior mediastinum. CONCLUSIONS: : In selected patients, the transcervical route can used to completely resect the thymus, avoiding the morbidity of sternotomy.