How Much Delay Matters? How Time to Treatment Impacts Overall Survival in Early Stage Lung Cancer.

OBJECTIVES: The aim of this study was to identify drivers of time from diagnosis to treatment (TTT) of surgically resected early stage non-small cell lung cancer (NSCLC) and determine the effect of TTT on post-resection survival. SUMMARY BACKGROUND DATA: Large database studies that lack relevant comorbidity data have identified longer TTT asa driver of worse overall survival. METHODS: From January 1, 2014 to April 1, 2018, 599 patients underwent lung resection for clinical stage I and II NSCLC. Random forest classification, regression, and survival were used to estimate likelihood of TTT = 0 (tissue diagnosis obtained at surgery), >0 (diagnosis obtained pre-resection), and effect of TTT on all-cause mortality. RESULTS: Patients with TTT > 0 (n = 413) had median TTT of 42 days (25-75 th percentile: 27-59 days). Patients with TTT = 0 (n = 186) had smaller tumors and higher percent predicted forced expiratory volume in 1 second (FEV 1 %). Patients with history of stroke, oncology consultation, invasive mediastinal staging, low and high extremes of FEV 1 % had longer TTT. Higher clinical stage, lack of preoperative stress test, anemia, older age, lower FEV1% and diffusion lung capacity, larger tumor size, and longer TTT were the most important predictors of all-cause mortality. One- and 5-year overall survival decreased when TTT was >50 days. CONCLUSIONS: Preoperative physiologic workup and multidisciplinary evaluation were the predominant drivers of longer TTT. Patients with TTT = 0have more favorable presentation and should be considered in TTT analyses for early stage lung cancer populations. The time needed to clinically stage and optimize patients for resection is not deleterious to overall survival until resection is performed after 50 days from diagnosis.

Airway Injury Caused by Aspiration of Iron Sulfate Pills: A Series of 11 Cases.

It is not widely recognized that iron (ferrous sulfate) pill aspiration causes airway damage. Clinical diagnosis is challenging because patients are often unaware that they have aspirated a pill. The literature on this entity consists mainly of case reports. The aim of this study is to describe the clinical and pathologic features of iron pill aspiration in a series of 11 patients. A retrospective review of our pathology archives was performed to identify cases of iron pill aspiration (2013-2023). All available histologic and cytologic material was rereviewed. Clinical information was collected from the electronic medical record, and imaging studies were rereviewed. Eighteen endobronchial biopsies were identified from 11 patients (7 women and 4 men; mean age, 70 years; range, 44-82 years). Eight patients had corresponding cytology (20 specimens). Medication history was available in 9 of 11 patients, all of whom were taking iron sulfate pills. Two patients reported possible aspiration episodes; 4 had risk factors for aspiration. The diagnosis of iron pill aspiration was suspected prior to biopsy in only 1 case. Histologically, iron pill particles were yellow, golden brown, or gray, were elongated and crystal or fiber like, and stained strongly with an iron stain. Common histologic findings included mucosal ulceration, acute and/or chronic inflammation, fibrosis, and squamous metaplasia. Iron pill particles were also identified in 11 cytology specimens from 6 patients. On Papanicolaou staining, iron pill particles were yellow to golden, fiber like, refractile, and crystalline. Reactive epithelial cells, squamous metaplasia, and acute inflammation were common. The combination of iron pill intake and discolored mucosa on bronchoscopy is a potential clue to the diagnosis of iron pill aspiration. Pathologists should familiarize themselves with the appearance of iron pill particles in endobronchial biopsies and cytology specimens from the respiratory tract as this diagnosis is seldom suspected on clinical grounds, and most patients lack a history of aspiration.

Harmonized Outcome Measures for Use in Non-Small Cell Lung Cancer Patient Registries and Clinical Practice.

BACKGROUND: Lung cancer is the leading cause of cancer-related death in the United States and globally, and many questions exist about treatment options. Harmonizing data across registries and other data collection efforts would yield a robust data infrastructure to help address many research questions. The purpose of this project was to develop a minimum set of patient and clinician relevant harmonized outcome measures that can be collected in non-small cell lung cancer (NSCLC) patient registries and clinical practice. METHODS: Seventeen lung cancer registries and related efforts were identified and invited to submit outcome measures. Representatives from medical specialty societies, government agencies, health systems, health information technology groups, patient advocacy organizations, and industry formed a stakeholder panel to categorize the measures and harmonize definitions using the Agency for Healthcare Research and Quality's supported Outcome Measures Framework (OMF). RESULTS: The panel reviewed 66 outcome measures and identified a minimum set of 8 broadly relevant measures in the OMF categories of patient survival, clinical response, events of interest, and resource utilization. The panel harmonized definitions for the 8 measures through in-person and virtual meetings. The panel did not reach consensus on 1 specific validated instrument for capturing patient-reported outcomes. The minimum set of harmonized outcome measures is broadly relevant to clinicians and patients and feasible to capture across NSCLC disease stages and treatment pathways. A pilot test of these measures would be useful to document the burden and value of the measures for research and in clinical practice. CONCLUSIONS: By collecting the harmonized measures consistently, registries and other data collection systems could contribute to the development research infrastructure and learning health systems to support new research and improve patient outcomes.

Intercostal Blocks with Liposomal Bupivacaine in Thoracic Surgery: A Retrospective Cohort Study.

OBJECTIVE: Assess the efficacy of adding liposomal bupivacaine (LB) to bupivacaine-containing intercostal nerve blocks (ICNBs) to improve analgesia and decrease opioid consumption and hospital length of stay compared with bupivacaine-only ICNBs. DESIGN: This retrospective, observational investigation compared pain intensity scores and cumulative opioid consumption within the first 72 postoperative hours in patients who received ICNBs with bupivacaine plus LB (LB group) versus bupivacaine only (control group) after minimally invasive anatomic pulmonary resection. LB was tested for noninferiority on pain scores and opioid consumption. If LB was noninferior, superiority of LB was tested on both outcomes. SETTING: Academic tertiary care medical center. PARTICIPANTS: Adult patients undergoing minimally invasive anatomic pulmonary resection. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: For the secondary analysis, hospital length of stay was compared through the Cox regression model. Of 396 patients, 178 (45%) received LB and 218 (55%) did not. The mean (standard deviation) pain score was three (one) in the LB group and three (one) in the control group, with a difference of -0.10 (97.5% confidence interval [-0.39 to 0.18]; p = 0.41). The mean (standard deviation) cumulative opioid consumption (intravenous morphine equivalents) was 198 (208) mg in the LB group and 195 (162) mg in the control group. Treatment effect in opioid consumption was estimated at a ratio of geometric mean of 0.94 (97.5% confidence interval [0.74-1.20]; p = 0.56). Pain control and opioid consumption were noninferior with LB but not superior. Hospital discharge was not different between groups. CONCLUSIONS: LB with bupivacaine in ICNBs did not demonstrate superior postoperative analgesia or affect the rate of hospital discharge.

Intraoperative Percutaneous Microcoil Localization of Small Peripheral Pulmonary Nodules Using Cone-Beam CT in a Hybrid Operating Room.

OBJECTIVE. Thoracoscopic surgical resection of small peripheral pulmonary nodules can be challenging, and often preoperative localization techniques are needed to avoid conversion to open thoracotomy. In this article, we show the feasibility and benefits of performing intraoperative percutaneous microcoil localization with C-arm cone-beam CT in a hybrid operating room immediately before video-assisted thoracoscopic surgery for wedge resection of a small pulmonary nodule. CONCLUSION. This technique can provide safe and accurate localization while minimizing patient discomfort and thus enhancing the patient's experience.

Correction to: Largely Unchanged Annual Incidence and Overall Survival of Pleural Mesothelioma in the USA.

The following disclaimer is missing from the original article.

Largely Unchanged Annual Incidence and Overall Survival of Pleural Mesothelioma in the USA.

BACKGROUND: Projections based on regulations curtailing asbestos use in the USA suggest that peak incidence of pleural mesothelioma would occur between 2000 and 2005 and then decline. We analyzed the National Cancer Database (NCDB) to assess current trends in disease incidence, patient demographics, cancer treatment, and survival. METHODS: The NCDB was queried to identify patients diagnosed with pleural mesothelioma from 2004 through 2014. Clinical and pathologic characteristics, treatments, and survival were analyzed. Risk factors for death were identified by multivariable Cox regression. RESULTS: A total of 20,988 patients with pleural mesothelioma were reported to the NCDB. The number of cases per year increased from 1783 to 1961, accounting for roughly 0.3% of all reported cancers each year. The proportion of elderly patients increased from 75 to 80%, but distribution by sex remained constant (20% female). The proportion of patients undergoing treatment increased from 34 to 54%. One-year survival increased from 37 to 47% and 3-year survival from 9 to 15% (p < 0.001). Factors associated with improved survival included younger age, female sex, epithelioid histology, treatment in an academic center, health insurance, higher income, and multimodality therapy. CONCLUSIONS: The annual incidence of mesothelioma has not declined this century and remains stable. Reporting of histologic and clinical staging has improved. National trends suggest that survival is slowly increasing despite an aging cohort. Multimodal therapy and treatment at academic centers are modifiable risk factors associated with improved survival.

Video-Assisted Thoracic Surgery Resection without Intraoperative Fluoroscopy after CT-Guided Microcoil Localization of Peripheral Pulmonary Nodules.

The aim of this brief report is to determine the safety and reliability of minimally invasive video-assisted thoracic surgery (VATS) resection without the aid of intraoperative fluoroscopy after computed tomography (CT)-guided microcoil localization of small peripheral pulmonary nodules. Twenty patients with peripheral lung nodules underwent percutaneous needle localization with a microcoil that was tagged back to the visceral pleural surface. Same-day VATS resection was performed without the use of intraoperative fluoroscopy. All 20 nodules were successfully localized in the CT procedure room, and all 20 nodules were resected with negative margins and no major complications.

Novel Repair of Clamshell Thoracotomy Sternal Dehiscence after Lung Transplant: A Case Report.

Bilateral transverse thoracosternotomy, or "clamshell" thoracotomy, can be complicated by dehiscence. A 65-year-old male underwent lung transplantation via clamshell thoracotomy, with subsequent sternal dehiscence on postoperative day 11. Upon repair, the previous sternal wires had pulled through, so a Sternal Talon connected to a Recon Talon was utilized to re-approximate the inferior sternum. On follow-up at 3 months, the patient recovered well. Use of the Sternal Talon provides an effective technique for repairing transverse sternal dehiscence.

Development and validation of a universal esophageal patient-reported outcome measure: The Cleveland Clinic Esophageal Questionnaire (CEQ).

OBJECTIVE: Currently, there is no validated patient-reported outcome measure (PROM) applicable to all esophageal diseases. Our objective was to create a psychometrically robust, validated universal esophageal PROM that can also objectively assess patients' quality of life (QoL). METHODS: The pilot PROM constructed based on expert opinions, literature review, and previous unpublished institutional research had 27 items covering 8 domains. It was completed by 30 patients in the outpatient clinic followed by a structured debriefing interview, which allowed for refining the PROM. The final PROM: Cleveland Clinic Esophageal Questionnaire (CEQ) included 34 items across 6 domains (Dysphagia, Eating, Pain, Reflux & Regurgitation, Dyspepsia, Dumping), each accompanied by a corresponding QoL component. Further psychometric assessment of the PROM was conducted by evaluating (1) acceptability, (2) construct validity, (3) reliability, and (4) responsiveness. RESULTS: Five hundred forty-six unique patients (median 63.7 years [54.3-71.7], 53% male [287], 86% White) completed CEQ at >90% completion within 5 minutes. Construct validity was demonstrated by differentiating scores across esophageal cancer (n = 146), achalasia (n = 170), hiatal hernia (n = 160), and other diagnoses (n = 70). Internal reliability (Cronbach alpha 0.83-0.89), and test-retest reliability (intraclass correlation coefficients 0.63-0.85) were strong. Responsiveness was demonstrated through CEQ domains improving for 53 patients who underwent surgery for achalasia or hiatal hernia (Cohen d 0.86-2.59). CONCLUSIONS: We have constructed a psychometrically robust, universal esophageal PROM that allows concise, consistent, objective quantification of symptoms and their effect on the patient. The CEQ is valuable in prognostication and tracking of longitudinal outcomes in both benign and malignant esophageal diseases.

Clinical T2 N0 M0 Esophageal Cancer: Identifying Predictive Factors of Upstaging.

BACKGROUND: Inaccuracy of clinical staging renders management of clinical T2 N0 M0 (cT2 N0 M0) esophageal cancer difficult. When an underlying advanced-stage disease is understaged to cT2 N0 M0, patients miss the opportunity to gain the potential benefits of neoadjuvant therapy. This study aimed to identify preoperative factors that predict underlying advanced-stage esophageal cancer. METHODS: From 2000 to 2020, 1579 patients with esophageal cancer underwent esophagectomy. Sixty patients who underwent upfront surgery for cT2 N0 M0 esophageal cancer were included in this study. The median age was 62.5 years, and 78% (n = 47) of these patients were male. Radiologic, clinical, and endoscopic factors were evaluated as preoperative markers. The Fisher exact and the Wilcoxon rank sum tests were used for categoric and continuous variables, respectively. Random forest classification was used to identify preoperative factors for predicting upstaging and downstaging. RESULTS: Of the 60 patients, 8 (13%) were found to have pathologic T2 N0 M0 esophageal cancer. Sixteen (27%) patients had cancer that was pathologically downstaged, and 36 (60%) had upstaged disease. Seven (19%) patients had upstaged cancer on the basis of the pathologic T stage, 14 (39%) had upstaging on the basis of the pathologic N stage, and 15 (42%) had upstaging on the basis of both T and N stages. Dysphagia (P = .003) and tumor maximum standardized uptake value (P = .048) were predictors of upstaging, with a combined predictive value of up to 75%. CONCLUSIONS: The presence of dysphagia and of high maximum standardized uptake value (≥5) of the tumor is predictive of more advanced underlying disease for patients with cT2 N0 M0 esophageal cancer, and these patients should be considered for neoadjuvant therapy.

The Society of Thoracic Surgeons Expert Consensus Document on the Management of Pleural Drains After Pulmonary Lobectomy: Expert Consensus Document.

The Society of Thoracic Surgeons Workforce on Evidence-Based Surgery provides this document on management of pleural drains after pulmonary lobectomy. The goal of this consensus document is to provide guidance regarding pleural drains in 5 specific areas: (1) choice of drain, including size, type, and number; (2) management, including use of suction vs water seal and criteria for removal; (3) imaging recommendations, including the use of daily and postpull chest roentgenograms; (4) use of digital drainage systems; and (5) management of prolonged air leak. To formulate the consensus statements, a task force of 15 general thoracic surgeons was invited to review the existing literature on this topic. Consensus was obtained using a modified Delphi method consisting of 2 rounds of voting until 75% agreement on the statements was reached. A total of 13 consensus statements are provided to encourage standardization and stimulate additional research in this important area.

Preoperative predictors of spread through air spaces in lung cancer.

OBJECTIVE: Spread through air spaces (STAS) is a new histologic feature of invasion of non-small cell lung cancer that lacks sensitivity and specificity on frozen sections and is associated with higher recurrence and worse survival with sublobar resections. Our objective is to identify preoperative characteristics that are predictive of STAS to guide operative decisions. METHODS: From January 2018 through December 2021, 439 cT1-3N0 M0 patients with non-small cell lung cancer and a median age of 68 years, 255 (58%) women, who underwent primary surgery at our institution were included. Patients who received neoadjuvant therapy and whose STAS status was not documented were excluded. Age, sex, smoking status, tumor size, ground-glass opacities, maximum standardized uptake values, and molecular markers on preoperative biopsy were evaluated as preoperative markers. Comparisons between groups were conducted using standardized mean differences and random forest classification was used for prediction modeling. RESULTS: Of the 439 patients, 177 had at least 1 STAS-positive tumor, and 262 had no STAS-positive tumors. Overall, 179 STAS tumors and 293 non-STAS tumors were evaluated. Younger age (50 years or younger), solid tumor, size ≥2 cm, and maximum standardized uptake value ≥2.5 were independently predictive of STAS with prediction probabilities of 50%, 40%, 38%, and 40%, respectively. STAS tumors were more likely to harbor KRAS mutations and be PD-L1 negative. CONCLUSIONS: Young age (50 years or younger), larger (≥2 cm) solid tumors, high maximum standardized uptake values, and presence of KRAS mutation, are risk factors for STAS and can be considered for lobectomy. Smoking status and gender are still controversial risk factors for STAS.

Non-iatrogenic esophageal trauma: a narrative review.

Background and Objective: Non-iatrogenic esophageal trauma is a rare entity that has a high morbidity and mortality. The diagnosis can often be quite challenging, however is critical to perform in a timely manner. The workup and management of non-iatrogenic trauma continues to evolve, with new innovative approaches available for both diagnosis and treatment. The aim of this narrative review is to comprehensively describe the incidence, presentation, workup, treatment approaches and outcomes of non-iatrogenic esophageal trauma. Methods: A thorough literature review was performed using full length articles available in English via PubMed between January 1, 1960 to September 30, 2021, focusing on the epidemiology, workup and treatment of non-iatrogenic esophageal trauma, including current surgical techniques. Key Content and Findings: Injuries to the cervical esophagus are more common than injuries to the thoracic esophagus, occurring more in young males, with significant racial disparity. Penetrating trauma via gunshot wounds are the most common forms of injury, followed by stab wounds and blunt trauma. Workup is multimodal and involves a combination of plain radiographs, computed tomography (CT) scans, endoscopy and fluoroscopy depending of the stability of the patient and associated injuries. Conclusions: Workup and management of non-iatrogenic esophageal trauma depends on the location and extent of esophageal injury, and can include observation, debridement and drainage, esophageal diversion, endoscopic approaches or esophagectomy, with indications, techniques and outcomes described in further detail in this review.

Multidisciplinary Approach to Isolated Pulmonary Vein Compression by an Enlarging Vertebral Osteophyte.

Compression of mediastinal structures by vertebral osteophytes is rare. We report a case of pulmonary vein compression by a vertebral osteophyte that failed stenting. A minimally invasive approach to osteophyte removal with subsequent re-expansion angioplasty yielded an optimal outcome, negating the need for cardiopulmonary bypass, stent removal, and pulmonary venoplasty. (Level of Difficulty: Intermediate.).

Select octogenarians with stage IIIa non-small cell lung cancer can benefit from trimodality therapy.

Objectives: Currently, more than 36% of patients diagnosed with lung cancer are 75 years of age or older. Management of stage IIIA cancer is variable, especially for octogenarians who might not be offered surgery because of questionable benefit. In this study we investigated the outcomes of definitive chemoradiotherapy (CR) and trimodality therapy (TM) management (CR and surgery) for clinical stage IIIA non-small cell lung cancer (NSCLC) in patients 80 years of age or older. Methods: The National Cancer Data Base was queried for stage IIIA NSCLC in patients 80 years of age or older between 2004 and 2015. Patients were divided according to treatment type: definitive CR and TM. Patient demographic characteristics, facility type, Charlson-Deyo score, final tumor pathology, and survival data were extracted. Univariate analysis was performed, followed by 3:1 propensity matching to analyze overall survival differences. Unadjusted and adjusted Kaplan-Meier survival analyses were performed. Results: From the database, 6048 CR and 190 TM octogenarians were identified. Patients in the TM group were younger (82 years old [TM] vs 83 years old [CR]; P < .0001), more likely to be treated at an academic/research institution (36% [TM] vs 26% [CR]; P = .003), had greater proportion of adenocarcinoma (52% [TM] vs 34% [CR]; P < .001), and a smaller tumor size (38 mm [TM] vs 33 mm [CR]; P = .025). After 3:1 matching, the 5-year overall survival for the TM group was 29% (95% CI, 22%-38%) versus 15% (95% CI, 11%-20%) for the CR group. Conclusions: Selected elderly patients with stage IIIa NSCLC can benefit from an aggressive TM approach.

Impact of Chest Wall Resection on Mortality After Lung Resection for Non-Small Cell Lung Cancer.

BACKGROUND: Lung cancer invading the chest wall is treated with concomitant en bloc lung and chest wall resection (CWR). It is unclear how CWR affects postoperative outcomes of lung resection. We hypothesized that CWR would be associated with increased risk of adverse outcomes after lung cancer resection. METHODS: We performed a retrospective analysis of The Society of Thoracic Surgeons (STS) General Thoracic Surgery Database from 2016-2019. Patients with superior sulcus tumors were excluded. Patient demographic and operative outcomes were compared between those with and without CWR. Chest wall resection was added to existing STS lung risk models to determine the association with a composite adverse outcome, which included major morbidity and death. RESULTS: Among 41 310 lung resections, 306 (0.74%) occurred with concomitant CWR. Differences between those with and without CWR included demographic and comorbidities. Patients undergoing CWR were more likely to have the composite adverse outcome (64 of 306 [20.9%] vs 3128 of 41 004 [7.6%] for non-CWR resections, P < .001). Mortality was also increased among the CWR cohort (2.9% vs 1.1%, P = .003). CWR was associated with an increased risk of adverse composite outcome among all lung resection patients in a multivariable model (odds ratio 1.74, P = .0003) and the lobectomy subgroup (odds ratio 2.35, P < .0001). Among institutions with ≥10 lung resections, 49.1% performed lung resections with CWR. CONCLUSIONS: Concomitant CWR adds risk of adverse outcomes after lung cancer resection. As a subset of intuitions perform CWR, quality assessments should control for CWR. This variable will be incorporated into the STS lung cancer and lobectomy quality composite measures.

Spontaneous Chest Wall Herniation in Centrally Obese Patients: A Single-Center Experience of a Rare Problem.

BACKGROUND: Spontaneous rib fractures, especially in association with chest wall herniation, represent an uncommon pathology. As such, there are little data analyzing approaches to treatment or regarding the success of intervention. The goal of this study was to analyze our cumulative experience with this unusual condition. METHODS: A case series of 12 patients was gathered from a single institution based on outpatient visits between February 2015 and October 2018. Each chart was retrospectively reviewed with particular attention to age, gender, BMI, area of injury, and smoking history. Patients presented with complaints of dyspnea or pain related to rib fractures with or without intercostal neuralgia. Each of these patients was noted to have rib fractures with lung herniation either on imaging, outside hospital records, or physical exam. A thorough medical history was obtained with attempts to find common predisposing factors as well as data regarding any previous surgical intervention for their herniation. RESULTS: Nine of the 12 patients reviewed had recent or prior surgical intervention. Every patient seen in the clinic with a spontaneous fracture and herniation incidentally had a BMI >30 and was therefore classified as obese. Additionally, every patient who had a recurrence after their first surgical attempt at repair had a BMI greater than or equal to 35. All 12 patients seen at our institution were males. The failure rate of operative intervention was 66%. CONCLUSIONS: Obesity was a prevalent comorbidity in the patient population we reviewed. Given the role obesity plays in abdominal and hiatal hernia repair success rates, it should be considered that obesity is a significant contributor to chest wall herniation if rib fractures occur. With 66% chest wall repair failure, patient selection is critical in the success of surgical intervention. Perhaps additional patient optimization, especially weight loss, should be considered prior to surgery.