Prognostic Factors in Patients with Clinic Locally Advanced T4 Lung Cancer: Surgical Considerations.

BACKGROUND: Inclusion of surgery in the treatment of T4 lung cancer has been a debate for the last two decades. The aim of this study is to investigate the potential prognostic factors which could affect the outcome. METHODS: Fifty-seven clinical T4 non-small cell lung carcinoma (NSCLC) patients out of 716 lung resections, who were operated at a single institution in 7 years period, were included in this study. Patients are grouped into three groups as patients with neoadjuvant treatment group (group 1 n: 16), salvage surgery group (surgery after 3 months of definitive chemotherapy and radiotherapy) (group 2 n: 14), and straightforward surgery group (group 3 n: 27) with adjuvant treatment. Groups were analyzed and compared in terms of postoperative complications, 30 days of mortality, disease free survival, and overall survival. RESULTS: Mean overall survival (OS) was 48.43 ± 4.4 months and mean disease-free survival (DFS) 40.55 ± 4.46 months for all patients. Thirty days mortality was 5.2% and complication rates were 63.1%. Two years OS was 61.4 ± 6.4%, DFS was 58.1 ± 7.8%. Group 1, Group 2, and Group 3 patients had mean 39.14 ± 5.6, 44.7 ± 7.1, and 62.9 ± 4.8 months for OS (p: 0.09), and 29.6 ± 7.2, 38.4 ± 9.1, and 46.9 ± 6 months for DFS (p: 0.27). Patients who received blood transfusion showed significantly worse outcomes (p: 0.001 for DFS and p: 0.004 for OS). CONCLUSION: According to our outcomes, surgery should be included in the treatment of clinical T4 lung cancer when physiologically and oncologically possible with careful patient selection. This study demonstrates that patients receiving straightforward surgery have longer survival, in spite of higher perioperative mortality rate. Risks and benefits should be considered carefully.

Does Fissureless Videothoracoscopic Lobectomy Help for Postoperative Air Leak?

BACKGROUND: Postoperative air leak is a common problem in patients undergoing pulmonary resections. A conventional fissure dissection technique during videothoracoscopic lobectomy, particularly in patients with fused fissures is very likely to result in parenchymal damage and prolonged air leak (PAL). In contrast, fissureless video-assisted thoracoscopic surgery (VATS) lobectomy may have advantages regarding PAL and hospital stay. METHODS: We conducted a retrospective study consisting of 103 consecutive patients who underwent a VATS lobectomy either with a conventional or fissureless technique and statistically analyzed the results particularly with respect to PAL, chest tube duration (CTD), and length of hospital stay (LOS). RESULTS: We had 21 (20.4%) cases with PAL. Gender (p = 0.009), histological size of tumor (p = 0.003), and surgical technique (p = 0.009) showed statistically significant differences for PAL in contingency tables. Significant predictors for PAL in univariate analysis were male sex (p = 0.017), histological size of tumor more than 24 mm (p = 0.005), and conventional technique (p = 0.017). Similarly, multivariate analysis revealed male sex (p = 0.036), histological size of tumor more than 24 mm (p = 0.043), and conventional technique (p = 0.029) as significant predictors for PAL. In addition, both the medians of CTD (p = 0.015) and LOS (p = 0.005) were comparably lesser as 3 days, in patients who underwent fissureless videothoracoscopic lobectomy. CONCLUSION: The fissureless technique helps for PAL in patients undergoing videothoracoscopic lobectomy.

Early trends in ECMO mortality during the first quarters of 2019 and 2020: Could we have predicted the onset of the pandemic?

OBJECTIVE: To compare mortality trends in patients requiring Extracorporeal Membrane Oxygenation (ECMO) support between the first quarters of 2019 and 2020 and determine whether these trends might have predicted the severe acute respiratory syndrome coronavirus-2 (SARS)-Cov-2 pandemic in the United States. METHODS: We analyzed 5% Medicare claims data at aggregate, state, hospital, and encounter levels using MS-DRG (Medicare Severity-Diagnosis Related Group) codes for ECMO, combining state-level data with national census data. Necessity and sufficiency relations associated with change in mortality between the 2 years were modeled using qualitative comparative analysis (QCA). Multilevel, generalized linear modeling was used to evaluate mortality trends. RESULTS: Based on state-level data, there was a 3.36% increase in mortality between 2019 and 2020. Necessity and sufficiency evaluation of aggregate data at state and institutional levels did not identify any association or combinations of risk factors associated with this increase in mortality. However, multilevel and generalized linear models using disaggregated patient-level data to evaluate institution mortality and patient death, identified statistically significant differences between the first (p = .019) and second (p = .02) months of the 2 years, the first and second quarters (p < .001 and p = .042, respectively), and the first 6 months (p < .001) of 2019 and 2020. CONCLUSION: Mortality in ECMO patients increased significantly during the first quarter of 2020 and may have served as an early warning of the SARS-Cov-2 pandemic. Granular data shared in real-time may be used to better predict public health threats.

Successful Sleeve Resection as a Marker for Proficiency for Robotic Pulmonary Resection.

BACKGROUND: Robot technology is a revolutionary technique to overcome limitations of minimal invasive surgery. The proficiency level varies from study to study. We considered the first sleeve lobectomy as a benchmark procedure to evaluate the proficiency level. METHODS: We retrospectively analyzed 197 patients who underwent robot-assisted thoracoscopic surgery (RATS) for primary lung cancer between December 2011 and May 2018. Patients were divided into two groups based on undergoing surgery earlier period (EP) or later period (LP) than the first sleeve lobectomy by RATS (May 25, 2015). The preoperative, operative, and short- and long-term postoperative outcomes were compared. Seven-year survival was also compared between two periods for T1N0 and T2N0 diseases. RESULTS: Preoperative features were similar. The mean operative time was 166.8 ± 55.1 and 142.4 ± 43.9 minutes in EP and LP, respectively (p = 0.005). The mean number of dissected lymph nodes in LP was also significantly higher than that in EP (24.4 ± 9.4 vs. 20.8 ± 10.4, p = 0.035). The complication rate was significantly lower in LP (29/86 vs. 25/111, p = 0.048). The extended resection (ER) rate was significantly higher in LP (p = 0.023). The 7-year survival was comparable in EP and LP in both patients with T1N0 and T2N0 (p = 0.28 and p = 0.11, respectively). CONCLUSION: Perioperative outcomes, such as duration of surgery, number of dissected lymph nodes, complications, and ERs are favorable in patients who underwent surgeries after the first sleeve resection. The first sleeve lobectomy may be considered as the benchmark procedure for the proficiency level in RATS.

Lung Cancer Surgery in Patients With a History of Coronary Artery Bypass Graft: A Multicentre Study.

BACKGROUND: Lung cancer surgery may be required for patients with a history of coronary artery bypass graft (CABG). In this study, we evaluated the general characteristics of patients, the difficulties experienced during and after lung cancer surgery and complications and mortality rates. METHOD: Patients who were operated on for primary lung cancer between January 2012 and July 2017 in the participating centres were analysed retrospectively (n=7,530). Patients with a history of CABG (n=220) were examined in detail. This special group was analysed and compared with other patients operated on for lung cancer who did not have CABG (n=7,310) in terms of 30-day mortality and revision for haemorrhage. RESULTS: Of the 7,530 patients operated on for primary lung cancer, 2.9% were found to have undergone CABG. Surgical revision was required in the early postoperative period for 6.8% of those who had CABG and 3.5% in those who did not have CABG (p=0.009). Thirty-day (30-day) mortality was 4.5% in those who had CABG and 2.9% in those who did not have CABG (p=0.143). Further analysis of patients who had undergone CABG demonstrated that video-assisted thoracoscopic surgery (VATS) resulted in fewer complications (p=0.015). Patients with a left-sided left internal mammary artery (LIMA) graft had a higher number of postoperative complications (p=0.30). CONCLUSIONS: Patients who had CABG suffered postoperative haemorrhage requiring a revision twice as often, and a tendency towards higher mortality (non-statistically significant). In patients with a history of CABG, VATS was demonstrated to have fewer complications. Patients with a LIMA graft who had a left-sided resection had more postoperative complications.

Oxygen Uptake Efficiency Slope and Prediction of Post-operative Morbidity and Mortality in Patients with Lung Cancer.

OBJECTIVE: Peak oxygen consumption is a very valuable cardiopulmonary functional parameter in pre-operative evaluation of patients with lung cancer. However, it has several critical limitations for operability decision due to failure in achieving maximal level of exercise test for cases. The aim of this study was to reveal the importance of more accurate cardiopulmonary parameters that can be calculated from data of submaximal level test, such as oxygen uptake efficiency slope (OUES) and to determine whether it could be used in the operability decision phase for borderline cases by means of morbidity and mortality. MATERIALS AND METHODS: One hundred and twenty-five patients who were scheduled to undergo lung surgery due to lung cancer were included in the study. Peak oxygen uptake (pVO2), heart rate at the anaerobic threshold, and oxygen consumption volume at anaerobic threshold values were obtained after performing the cardiopulmonary exercise test. The OUES value was calculated from the ratio of the peak VO2 value and logarithmic equivalent of the ventilatory volume (VE). The following equation was used for determining OUES: VO2/log10 VE. RESULTS: The peak VO2 mean value was 21.37 ± 4.20 mL/min/kg in patients. However, OUES mean value was 12.44 ± 2.11. When the metabolic parameters of the patients were compared, a significant correlation was determined between the peak VO2 value and peak VE, OUES, and survival (p < 0.01). CONCLUSION: This study demonstrated that OUES is significantly correlated with peak VO2 and it does not require the performance of maximal exercise and can be used together with peak VO2 in this patient population when there is difficulty in making decision for surgery in patients with lung cancer.

Prompt Response to Prednisone Predicts Benign Course in MuSK-MG.

BACKGROUND: The difficult course of patients with myasthenia gravis (MG) with anti-muscle-specific tyrosine kinase antibodies (MuSK) has been emphasized. However, no clear information is available on patients who have a benign course. METHODS: This study was aimed at comparing patients with favorable (minimal manifestations [MM] or better) and unfavorable outcomes to determine whether excellent response to corticosteroid (CS) treatment within 3 months (good response-3 months) has any predictive effect on the prognosis. RESULTS: Forty-six percent of 46 patients had a favorable outcome at year 3 and 54% at final follow-up. The major finding of this study was its high predictive value with good response-3 months. Those with good response-3 months had significantly more favorable outcome as compared to those without at year 3. The positive predictive value of good response-3 months was high (89% at year 3 and 84% at final follow-up). The negative predictive value diminished from 85% at year 3 to 67% at final follow-up due to increasing number of patients improving in the long run. Overall, 33% of the patients had a benign course with good response-3 months and no major exacerbations until the end of follow-up. CONCLUSIONS: Excellent response to CSs within 3 months appears to predict a favorable outcome in MuSK-MG.

Robotic anatomic lung resections: the initial experience and description of learning in 102 cases.

BACKGROUND: The aim of this study was to analyze our initial pulmonary resection experience with robotic surgery (Da Vinci, Intuitive Surgical, Inc., Mountain View, California, USA) and define the learning curve based on the duration of operations. METHODS: A retrospective review was conducted on patients undergoing robotic pulmonary resections from October 2011 to December 2014. The operating time, including the docking and console times, postoperative hospitalization, and peri- and postoperative complications were studied. RESULTS: Hundred patients underwent 102 robotic anatomic pulmonary resections due to various pathologies. Fifty-three percent of the patients underwent lobectomy procedure, whereas 45% underwent segmentectomy. The mean operating time was 104 ± 34 min. The learning curve was calculated to be 14 patients (R(2) = 0.57). The complication rate in our series was 24% (n = 24) and higher in elderly patients (p = 0.03) and in patients with longer operating times (p = 0.03). Prolonged air leaks were observed in 10, and arrhythmia developed in nine patients. Two patients died, due to a concurrent lymphoblastic leukemia diagnosed at the postoperative period and exacerbation of interstitial fibrosis, respectively. CONCLUSIONS: Robotic pulmonary resections prove to be safe and effective even at the initial learning experience. The duration of operations is considered to be acceptable. The learning curve could be established after 14 cases.

Sleeve resection for bronchial carcinoid tumour in two children under six years old.

BACKGROUND: Paediatric tracheobronchial tumours are very rare, and pneumonectomy and lobectomy procedures are rarely indicated due to their surgical difficulties and high sequelae. Bronchoplastic techniques preserving lung parenchyma allow the resection and reconstruction of the main bronchi and carina. CASE PRESENTATION: Here, we present a 6-year-old boy suffering from a carcinoid tumour of the right main bronchus which was successfully managed with a right upper sleeve lobectomy and a 4-year-old girl with an endobronchial carcinoid tumour narrowing the left main bronchus that received a sleeve resection of that bronchus. CONCLUSION: Bronchoplastic techniques are widely used in adults, can be very successful in paediatric patients where the preservation of the lung parenchyma is more important.

Has there been a paradigm shift in mediastinal surgery from open to minimally invasive, and from magnetic resonance imaging (MRI) to positron emission tomography-computerized tomography (PET-CT) in the last decade?

OBJECTIVE: The purpose of this study was to investigate the effects of diagnostic and surgical developments in the complete resection of the mediastinal masses. METHODS: Of 313 patients, 236 underwent therapeutic or diagnostic complete resections. We analyzed age, gender, diagnostic interventions, neoadjuvant treatment, type of surgical intervention (sternotomy, video-assisted thoracic surgery [VATS], thoracotomy), pathology, duration of hospital stay, complications, mortality, and associated diseases. Patients were divided into two groups according to the period of operation: group A included patients who were operated on between January 2002 and January 2007; group B included patients who were operated on between January 2007 and January 2012. RESULTS: Resection with VATS increased significantly after 2007, from 17.7 to 35 % (p = 0.03). The rate of complications increased after 2007 (p = 0.03), which was apparent in non-VATS patients (p = 0.03). The use of magnetic resonance imaging (MRI) decreased from 29 to 15.5 % (p = 0.02) and positron emission tomography (PET)-computed tomography (CT) use increased from 1.6 to 25.2 % (p < 0.001). CONCLUSIONS: We identified a paradigm shift in mediastinal mass surgery. PET-CT became a more preferred diagnostic method and MRI became less preferred. The rate of VATS resection doubled and sternotomy decreased. Complication rates increased in non-VATS due to an increase in extended resections.

Factors associated with pulmonary recurrence after pulmonary metastasectomy for sarcomatous disease.

PURPOSE: To analyze the factors associated with survival and pulmonary recurrence after complete metastasectomy for patients with sarcomatous disease. METHODS: Among the 51 patients who underwent complete pulmonary metastasectomy at our hospital between January 2002 and November 2010, 30 (58.8 %) suffered pulmonary recurrence in an ipsilateral hemithorax. We analyzed the factors affecting survival and recurrence after complete metastasectomy. RESULTS: The 51 patients who underwent pulmonary metastasectomy comprised 33 male and 18 female patients, with a median age of 22 years (range 11-61 years). The median survival was 24 months. Multivariate analysis revealed recurrence (p = 0.016) and the type of tumor (p = 0.024) as independent predictors of survival. Recurrence developed in 30 (58.8 %) patients. The risk of recurrence was higher in patients with a DFI <12 months and >1 metastasis resected during the initial metastasectomy. CONCLUSIONS: Based on the findings of our analysis, patients with a DFI <12 months and >1 metastases resected during initial surgery have a higher risk of recurrence. We recommend postoperative follow-up at frequent intervals and reconsideration of oncological treatment after complete resection.

Costal margin reconstruction for slipping rib syndrome: Outcomes of more than 500 cases and advancements beyond earlier sutured repair technique.

Objectives: To evaluate results of sutured repair for slipping rib syndrome (SRS), identify failure points, and discuss technique modifications to improve outcomes through costal margin reconstruction (CMR). Methods: Patients undergoing repair of SRS between February 2019 and February 2024 at an academic referral institution were retrospectively analyzed. Pain scores, quality of life, pain medication use, and reoperations were evaluated pre- and postoperatively at 1 and 6 months. In patients failing sutured repair we identified specific failure points and devised a new CMR technique to overcome them. Subsequent CMR patients were followed at 1, 6, 12, 18, and 24 months using the same outcome measures. Results: Four hundred forty-nine patients underwent repair. Two hundred forty-one patients underwent sutured repair with revision required in 66. Median time to revision was 14 months. CMR was developed and performed in 247 patients. In CMR patients, preoperative mean pain score of 7.5 out of 10 dropped postoperatively to 4.0, 2.5, 1.9, 1.3, and 0.9 at 1, 6, 12, 18, and 24 months, respectively (P < .001). Mean quality of life of 38% improved to 73%, 83%, 88%, 93%, and 95% at the same intervals (P < .001). Preoperatively, 29% of patients chronically used opioid medications. Opioid use dropped postoperatively to 11%, 4%, 4%, 0%, and 0% at the same intervals. Use of nonopioid medications followed a similar pattern. One CMR patient required full revision. Conclusions: SRS is a debilitating, but correctable disorder. Improved pain and quality of life, reduction in chronic opioid use, and freedom from revision surgery suggest that CMR should be considered the standard operation for SRS.

Potential Survival Benefit of Upfront Surgery for Lung Tumors Unconfirmed but Highly Suspicious for Stage I Lung Cancer.

Background: Patients with early-stage lung tumors that are highly suspicious for malignancy typically undergo a preoperative diagnostic workup, primarily through bronchoscopy or transthoracic biopsy. Those without a preoperative diagnosis may alternatively be treated with upfront surgery, contingent upon the potential for intraoperative diagnosis. Previous studies have yielded conflicting results regarding the impact of upfront surgery on the survival of these patients. Our study aimed to elucidate the effect of upfront surgery on the survival outcomes of patients undergoing surgery for early-stage lung cancer without a preoperative diagnosis. Methods: We analyzed the survival rate of 158 consecutive patients who underwent pulmonary resection for stage I lung cancer, either with or without a preoperative diagnosis. Results: A total of 86 patients (54%) underwent upfront surgery. This approach positively impacted both disease-free survival (p=0.031) and overall survival (p=0.017). However, no significant differences were observed across subgroups based on sex, smoking status, forced expiratory volume in 1 second, histologic tumor size, or histologic subtype. Univariate analysis identified upfront surgery (p=0.020), age (p=0.002), maximum standardized uptake value (SUVmax) exceeding 7 (p=0.001), and histological tumor size greater than 20 mm (p=0.009) as independent predictors. However, multivariate analysis indicated that only SUVmax greater than 7 (p=0.011) was a significant predictor of unfavorable survival. Conclusion: Upfront surgery does not appear to confer a survival advantage in patients with stage I lung cancer undergoing surgical intervention.

The surgical outcome of standard lobectomy versus sleeve lobectomy in patients with non-small cell lung cancer: propensity score matching.

OBJECTIVES: The goal of this study was to compare the patients who underwent standard or sleeve lobectomy for non-small cell lung cancer in terms of postoperative outcomes, prognostic factors and overall survival. METHODS: Between January 2002 and January 2020, the patients with squamous cell carcinoma or adenocarcinoma who underwent standard lobectomy or sleeve lobectomy by thoracotomy in our clinic were analysed retrospectively. Standard and sleeve groups were compared after propensity score matching in terms of age, comorbidity, T status, N status and pathological stage. Primary outcomes were morbidity and mortality; the secondary outcome was overall survival. RESULTS: The study included 476 patients, and sleeve lobectomy was performed in 196 (41.1%) patients. Multivariable analysis revealed that age over 61 years (P = 0.003 and P = 0.005, respectively), forced expiratory volume in 1 s (FEV1) below 84% (P = 0.013 and P = 0.205, respectively) and the presence of perineural invasion (P = 0.052 and P = 0.001, respectively) were poor prognostic factors in the standard lobectomy and the sleeve groups. The propensity matching analysis included 276 patients (138 sleeve lobectomy and 138 standard lobectomy). Complications occurred in 96 (69.6%) and 92 (66.7%) patients in the standard and sleeve groups, respectively (P = 0.605). Three (2.2%) patients in the standard group and 5 (3.6%) patients in the sleeve group died within 90 days postoperatively (P = 0.723). CONCLUSIONS: Bronchial sleeve lobectomy is a safe procedure that can be applied in oncologically suitable cases without causing higher mortality than a standard lobectomy.

Tracheobronchoplasty for severe tracheobronchomalacia: a case-series of patients with acute and chronic critical comorbidities.

OBJECTIVES: There are little data within the literature regarding tracheobronchoplasty in the setting of the acute and chronically ill, morbidly obese or ventilator-dependent patients with tracheobronchomalacia. Short- and long-term outcomes are studied. METHODS: The series represents 12 tracheobronchomalacia patients with American Society of Anesthesiologists (ASA) physical status scores of 3-5. Candidacy was based on bronchoscopic findings during spontaneous respirations with >90% collapse of the trachea and both mainstem bronchi. We used dynamic computed tomography scan as an adjunct in those not mechanically ventilated. Our operative approach was a complete portal robotic approach for those outpatients (wheelchair dependent) and right thoracotomy for those who were already mechanically ventilated with 100% fraction of inspired oxygen with high pressure. Extracorporeal support was used in 2 patients. RESULTS: Patients who underwent robotic repair were discharged without complications. Two patients who were critically ill and required extracorporeal support for their surgeries were separated from extracorporeal membrane oxygenation on postoperative day 2. Three patients died at the follow-up. In 1 patient, the prolene mesh migrated into trachea and caused obstruction of the trachea and required removal with endobronchial techniques. CONCLUSIONS: The repair of tracheobronchomalacia in patients with multiple comorbidities and with severe life-threatening problems in or outside the intensive care unit may have improvement due to the ability to wean from positive pressure ventilation. Surgical technique and the utilization of mesh support in tracheobronchoplasty operations may need to be debated due to duration of the surgery in patients with severe comorbidities.

Mortality index is more accurate than volume in predicting outcome and failure to rescue in Medicare beneficiaries undergoing robotic right upper lobectomy.

Background: Surgical volume is known to influence failure to rescue (FTR), defined as death following a complication. Robotic lung surgery continues to expand and there is variability in outcomes among hospitals. We sought to estimate the contribution of hospital-based factors on outcomes and FTR following robotic right upper lobectomy (RRUL). Methods: Using the Centers for Medicare and Medicaid Services inpatient claims database, we evaluated all patients age ≥65 years with a diagnosis of lung cancer who underwent RRUL between January 2018 and December 2020. We excluded patients who had undergone segmentectomy, sublobar, wedge, or bronchoplastic resection; had metastatic or nonmalignant disease; or had a history of neoadjuvant chemotherapy. Primary outcomes included FTR rate, length of stay (LOS), readmissions, conversion to open surgery, complications, and costs. We analyzed hospitals by tertiles of volume and Medicare Mortality Index (MMI). Defined as the institutional number of deaths per number of survivors, MMI is a marker of overall hospital performance and quality. Propensity score models were adjusted for confounding using goodness of fit. Results: Data for 4317 patients who underwent robotic right upper lobectomy were analyzed. Hospitals were categorized by volume of cases (low, <9; medium, 9-20; high, >20) and MMI (low, <0.04; medium, 0.04-0.13; high, >0.13). After propensity score balancing, patients from tertiles of lowest volume and highest MMI had higher costs ($34,222 vs $30,316; P = .006), as well as higher mortality (odds ratio, 7.46; 95% confidence interval, 2.67-28.2; P < .001). Compared to high-volume centers, low-volume centers had higher rates of conversion to open surgery, respiratory failure, hemorrhagic anemia, and death; longer LOS; and greater cost (P < .001 for all). The C-statistic for volume as a predictor of overall mortality was 0.6, and the FTR was 0.8. Hospitals in the highest tertile of MMI had the highest rates of conversion to open surgery (P = .01), pneumothorax (P = .02), and respiratory failure (P < .001). They also had the highest mortality and rate of readmission, longest LOS, and greatest costs (P < .001 for all) and the shortest survival (P < .001). The C-statistic for MMI as a predictor of overall mortality was 0.8, and FTR was 0.9. Conclusions: The MMI incorporates hospital-based factors in the adjudication of outcomes and is a more sensitive predictor of FTR rates than volume alone. Combining MMI and volume may provide a metric that can guide quality improvement and cost-effectiveness measures in hospitals seeking to implement robotic lung surgery programs.

Intersection of Race, Rurality, and Income in Defining Access to Minimally Invasive Lung Surgery.

BACKGROUND: Race is a potent influencer of health care access. Geography and income may exert equal or greater influence on patient outcomes. We sought to define the intersection of race, rurality, and income and their influence on access to minimally invasive lung surgery in Medicare beneficiaries. METHODS: Centers for Medicare and Medicaid Services data were used to evaluate patients with lung cancer who underwent right upper lobectomy, by open, robotic-assisted thoracic surgery (RATS), or video-assisted thoracic surgery (VATS) between 2018 and 2020. International Classification of Diseases, 10th Edition, was used to define diagnoses and procedures. We excluded sublobar, segmental, wedge, bronchoplasty, or reoperative patients with nonmalignant or metastatic disease or a history of neoadjuvant chemotherapy. Risk adjustment was performed using inverse probability of treatment weighting (IPTW) propensity scores with generalized linear models and Cox proportional hazards models. RESULTS: The cohort comprised 13,404 patients, 4291 open (32.1%), 4317 RATS (32.2%), and 4796 VATS (35.8%). Black/urban patients had significantly higher RATS and VATS rates (P < .001), longer long-term survival (P = .007), fewer open resections (P < .001), and lower overall mortality (P = .007). Low-income Black/urban patients had higher RATS (P = .002), VATS (P < .001), longer long-term survival (P = .005), fewer open resections (P < .001), and lower overall mortality compared with rural White patients (P = .005). CONCLUSIONS: Rural White populations living close to the federal poverty line may suffer a burden of disparity traditionally observed among poor Black people. This suggests a need for health policies that extend services to impoverished, rural areas to mitigate social determinants of health.

The Role of [18F]FDG PET/CT in the Characterization of Thymic Epithelial Tumors at Initial Stage.

Purpose: The aim of this study was to evaluate the potential role of [18F]FDG positron emission tomography/computed tomography (PET/CT) in the characterization of thymic epithelial tumors (TETs). Materials and Methods: A total of 73 patients who underwent preoperative [18F]FDG PET/CT were included in this study. Visual total score (VTS), maximum standard uptake values (SUVmax), metabolic tumor volume (MTV), total lesion glycolysis (TLG), and heterogeneity index (HI) parameters were analyzed to investigate the prediction of histopathologic grade and advanced stage. Results: The cohort included 26 patients with low-grade thymoma (LGT), 36 patients with high-grade thymoma (HGT), and 11 patients with thymic carcinoma (TC). Ninety-one percent of TC had VTS >2, whereas 31% of LGT and 75% of HGT had VTS >2. SUVmax, MTV, and TLG were statistically significantly higher in the TC group than in both thymoma and HGT. Using the cutoff value of 7.25 for SUVmax, TC was differentiated from thymomas with 91% sensitivity and 74% specificity. TC had significantly lower HI values than thymomas. HI parameters showed good diagnostic ability to differentiate TC from thymoma and TC from HGT. SUVmax, MTV, and TLG were significantly higher in advanced-stage disease than in early-stage disease. Conclusions: Visual and quantitative parameters can reliably predict both advanced disease and the grade of primary tumor in TETs. Therefore, as a promising metabolic imaging method, [18F]FDG PET/CT makes important contributions to preoperative evaluation in routine clinical practice.

It is feasible to operate on pathological Masaoka stage I and II thymoma patients with video-assisted thoracoscopy: analysis of factors for a successful resection.

BACKGROUND: The objectives of this study were to evaluate the feasibility of video-assisted thoracoscopic (VATS) thymoma resection and to analyze the factors contributing to a successful perioperative period. METHODS: Fifty-one patients with thymoma underwent VATS with the aim of thymoma resection. Four patients underwent minithoracotomy [due to technical difficulties, including small chest cavity, high body mass index (BMI), and disintegration of the capsule] and three patients underwent sternotomy (due to invasion of major vascular structures). The seven open-converted patients and seven other patients who underwent complete VATS thymoma resection but experienced prolonged hospital stay (≥7 days) formed Group B (n = 14), namely, the unsuccessful group, while successful VATS thymoma resection patients formed Group A (n = 37). The groups were compared with each other in terms of the characteristics of patients, tumors, and perioperative period. RESULTS: Patients' characteristics, tumor size, WHO histologic type, and complications were similar in both Groups A and B (p > 0.05). Patients with Masaoka stage I and II thymomas were significantly more frequent in Group A (p < 0.01). Tumor size was a statistically insignificant variable for the determination of a successful VATS thymoma resection (p = 0.3). Masaoka stage and the size of the thymoma did not have any correlation with each other (p > 0.05). CONCLUSIONS: The size of the thymoma was not observed to be correlated with Masaoka stage and it was not noted to be an important factor in successful VATS thymoma resection. A higher Masaoka stage (III and IVa) was found to be the only variable that predicted unsuccessful situations. Thus, Masaoka stage, rather than the size of the thymoma, should be the main concern for the surgeon.