Anatomic considerations after commando double valve reconstruction: insights for future valve-in-valve therapies.

OBJECTIVES: The Commando technique for reconstruction of the aortomitral intervalvular fibrous body is effective to facilitate double valve surgery in cases of endocarditis or infiltrative calcification. The length of patch utilized in reconstruction of the intervalvular fibrous body has an important relationship to the geometry of the mitral valve (MV) and aortic valve (AV) and may impact on potential future valve-in-valve (VIV) therapy. Here we report anatomic measurements after Commando reconstruction in a small group of patients and analyse the impact of reconstruction techniques on transcatheter VIV therapies. METHODS: Seven patients from January 2018 to April 2022 who underwent double valve surgery with the Commando technique with postoperative computed tomography (CT) scans were identified. Computed tomographic reconstruction of the AV and MV was performed using 3mensio software and virtual transcatheter valve replacement was performed. Two of these patients who had preoperative imaging was analysed to assess the change in aortomitral geometry resulting from reconstruction. RESULTS: Measurements for each patient post-reconstruction are given in the table. Aortomitral length was grossly inversely proportional to aortomitral angle (AMA). AMA and aortomitral curtain (AMC) length were significantly altered post-Commando in 2 analysed patients with pre- and postoperative computed tomography scan. Transcatheter AV and MV replacements were feasible in all patients post-Commando. The AMA was larger and more favorable for mitral VIV in patients in which the AMC was short. CONCLUSIONS: AMC length, as determined by location of AV annular sutures, may be an important consideration in surgical decision-making for VIV after the Commando procedure.

Elevated preoperative neutrophil:lymphocyte ratio as a predictor of postoperative disease recurrence in esophageal cancer.

BACKGROUND: The prognosis for patients with esophageal cancer is poor, even among those who undergo potentially curative esophagectomy. The neutrophil:lymphocyte ratio (NLR) is hypothesized to reflect the systemic inflammatory response created by a tumor and is possibly predictive of tumor aggressiveness and propensity for metastasis. METHODS: We performed a single-center retrospective analysis of esophageal cancer patients who underwent attempted curative esophagectomy at Weill Cornell Medical Center between 1996 and 2009. We collected data on patient demographics, clinical characteristics, and receipt of neoadjuvant treatment. Preoperative blood tests were used to calculate NLR. Elevated NLR was defined a priori as ≥5.0. Logistic regression modeling was performed to analyze characteristics associated with elevated NLR. We conducted Kaplan-Meier analyses and Cox regression modeling to determine estimates and predictors of disease-free and overall survival. RESULTS: We identified a total of 295 patients who underwent esophagectomy. The median duration of follow-up was 31 months (interquartile range [IQR] 13-61). There were 56 patients (18.9%) who had elevated NLR preoperatively. Receipt of neoadjuvant therapy was independently associated with high NLR (odds ratio [OR] 2.14, 95% confidence interval [95% CI] 1.02-4.51). In multivariable analyses, elevated NLR was associated with significantly worse disease-free (hazard ratio [HR] 2.26, 95% CI 1.43-3.55) and overall survival (HR 2.31, 95% CI 1.53-3.50). CONCLUSIONS: Preoperative NLR is a potential prognostic marker for recurrence and death after esophagectomy. It is unclear whether NLR reflects the degree of inflammatory response to the primary tumor or other patient-specific or tumor characteristics that predispose to recurrence. Further investigation is warranted to clarify the mechanisms explaining the observed associations between elevated NLR and poor outcomes in esophageal cancer.

A Double Whammy: Severe Aortic Stenosis and Cocaine Overwhelm the Mitral Valve.

A 50-year-old man presented with acute onset dyspnea following cocaine use. He had severe aortic stenosis (AS), mild mitral regurgitation (MR) due to mitral valve prolapse, and no coronary artery disease on recent coronary angiography. He was in acute heart failure with signs of impending cardiogenic shock. Urgent bedside echocardiography revealed hyperdynamic left ventricular systolic function with acute severe MR from a ruptured chordae tendineae. The acute cocaine-induced spike of his already elevated left ventricular systolic pressure from severe AS likely precipitated chordal rupture of his vulnerable mitral valve. This patient underwent emergent mitral and aortic valve replacements. Although cocaine use has been associated with a myriad of cardiovascular complications, acute MR due to chordal rupture has not, to our knowledge, been previously reported in this setting. Prompt diagnosis with echocardiography and surgical intervention are of paramount importance in the management of acute MR.

Ratio of positron emission tomography uptake to tumor size in surgically resected non-small cell lung cancer.

BACKGROUND: In patients with non-small cell lung cancer (NSCLC), previous studies have shown a prognostic benefit of maximum standardized uptake (SUV(max)) values on positron emission tomography (PET). Because tumor size is also prognostic and is associated with SUV(max), we sought to better characterize their relationship. We hypothesize that the ratio of SUV(max) to tumor size is a clinically useful measurement. METHODS: A retrospective review was performed for patients (tumors ≥ 1 cm) undergoing resection of NSCLC. Patients were placed into quartiles (SUV(max) and SUV(max) to tumor size ratio) and compared for clinical and pathologic factors. Predictors of SUV(max) and SUV(max) to tumor size ratio on survival were evaluated. RESULTS: Among 530 patients, increasing tumor size (odds ratio [OR], 2.04; confidence interval [CI], 1.68-2.47; p < 0.001) was an independent predictor of higher SUV(max). Patients in quartiles by the ratio of SUV(max) to tumor size demonstrated no significant difference in median tumor size. Those patients with the highest ratios (QR4, 3.21-27.5) more frequently had poorly differentiated tumors (51%; p < 0.001), were likely to have lymph node metastases (30%; p < 0.001), and had poor 3-year disease-free survival (DFS) (58%; p = 0.013). On multivariate analysis, as a continuous variable SUV(max) to tumor size ratio was a stronger independent predictor of survival than SUV(max) alone (hazard ratio [HR], 1.06; CI, 1.00-1.13 versus HR, 1.02; CI, 0.99-1.06). Using cutpoint analysis, a high SUV(max) to tumor size ratio was also a stronger predictor of survival than was high SUV(max) alone, particularly for tumors 1-3 cm (HR, 1.53; CI, 0.93-2.53 versus HR, 1.15; CI, 0.69-1.93). CONCLUSIONS: The ratio of SUV(max) to tumor size may be a more important indicator of prognosis than SUV(max) alone in patients with NSCLC. In particular, the use of the ratio may be appropriate for identifying patients with small tumors who are at high risk for lymph node metastases and poor survival.

Worldwide Oesophageal Cancer Collaboration guidelines for lymphadenectomy predict survival following neoadjuvant therapy.

OBJECTIVES: The Worldwide Oesophageal Cancer Collaboration (WECC) reported recommendations regarding the optimum number of lymph nodes to be removed during oesophagectomy based upon patients undergoing surgery alone. We sought to determine whether these recommendations are relevant in the case of oesophageal cancer (EC) patients receiving neoadjuvant therapy. METHODS: Patients undergoing neoadjuvant chemotherapy followed by transthoracic en bloc oesophagectomy were reviewed. Patients were grouped by optimal versus suboptimal lymphadenectomy per WECC recommendations (pTis/T0/T1 ≥ 10; pT2 ≥ 20; pT3/T4 ≥ 30). Cohorts were compared for factors predicting optimal lymphadenectomy and for overall survival (OS). RESULTS: During the time period, 135 patients (adeno = 100, squamous = 35) met the study criteria, of whom 94 patients (70%) had optimal lymphadenectomy. Optimal lymphadenectomy was more likely for tumours with lower ypT (P ≤ 0.001). Optimal lymphadenectomy predicted the OS (0.50, confidence intervals 0.29-0.85, P = 0.011), although it was collinear with ypT classification, which was also predictive. Patients not down-staged in ypT (n = 66, 49%) particularly experienced a trend towards improved 3-year survival with optimal lymphadenectomy (51 versus 29%, P = 0.144). Similarly, of patients with persistent nodal disease (n = 79, 59%), those who had optimal lymphadenectomy (n = 51) experienced improved 3-year OS compared with those with suboptimal lymphadenectomy (n = 28), (55 versus 36%, P = 0.087). CONCLUSIONS: WECC recommendations regarding lymphadenectomy for EC may be applicable to patients undergoing oesophagectomy following neoadjuvant therapy, particularly those who are not down-staged by pathological tumour depth (T) classification and those with persistent nodal metastases. Techniques to enhance the extent of LAN should be pursued in this patient population.

Survival of patients with clinical stage IIIA non-small cell lung cancer after induction therapy: age, mediastinal downstaging, and extent of pulmonary resection as independent predictors.

BACKGROUND: In clinical stage IIIA non-small cell lung cancer, the role of surgical resection, particularly pneumonectomy, after induction therapy remains controversial. Our objective was to determine factors predictive of survival after postinduction surgical resection. METHODS: We retrospectively reviewed a prospectively collected database of 136 patients who underwent surgical resection after induction chemotherapy (n = 119) or chemoradiation (n = 17) from June 1990 to January 2010. RESULTS: One hundred five lobectomies or bilobectomies and 31 pneumonectomies were performed. There was 1 perioperative death (pneumonectomy). Seventy-one patients had downstaging to N0 or N1 nodal status (52%). There were 2 complete pathologic responses. Median follow-up was 42 months (range, 0.69-136 months). Overall 5-year survival for entire cohort was 33% (36% lobectomy, 22% pneumonectomy, P = .001). Patients with pathologic downstaging to pN0 or pN1 had improved 5-year survival (45% vs 20%, P = .003). For patients with pN0 or pN1 disease, survival after lobectomy was better than after pneumonectomy (48% vs 27%, P = .011). In patients with residual N2 disease, there was no statistically significant survival difference between lobectomy and pneumonectomy (5-year survival, 21% vs 19%; P = .136). Multivariate analysis showed as independent predictors of survival age (hazard ratio, 1.05; P = .002), extent of resection (hazard ratio, 2.01; P = .026), and presence of residual pN2 (hazard ratio, 1.60; P = .047). CONCLUSIONS: After induction therapy for patients with clinical stage IIIA disease, both pneumonectomy and lobectomy can be safely performed. Although survival after lobectomy is better, long-term survival can be accomplished after pneumonectomy for appropriately selected patients. Nodal downstaging is important determinant of survival, particularly after lobectomy.

Clinical T2-T3N0M0 esophageal cancer: the risk of node positive disease.

BACKGROUND: No consensus exists on the optimal treatment strategy for clinical T2-T3N0M0 esophageal cancer. This study was conducted to determine rates of nodal positivity (N+) and to evaluate results of treatment strategies in this cohort. METHODS: Surgically treated patients with cT2-T3N0M0 esophageal cancer were reviewed. Adequacy of lymph node dissection was assessed by guidelines applied to clinical stage. Survival was determined by Kaplan-Meier analysis. Univariate and multivariate analyses were done for predictors of N+ and survival. RESULTS: We identified 102 patients, 51 cT2N0 and 51 cT3N0, 39 (38%) of whom had induction therapy. Despite being clinically node negative, 61 patients (60%) had nodal metastases. Applied to cT classification, adequate nodal dissection was achieved in 64 patients (63%). Transthoracic esophagectomy was more likely than transhiatal esophagectomy to achieve adequate nodal dissection (69% versus 31%, p=0.005). Adequate nodal dissection was more likely to document pN+ disease in both the surgery alone group (70% versus 50%, p=0.13) and induction therapy group (71% versus 33%, p=0.02). Five-year overall survival was 44% with surgery alone and 55% with induction therapy. On multivariate analysis, pN+ was the strongest predictor of overall survival (relative risk 2.73, confidence interval: 1.29 to 5.78). CONCLUSIONS: Most cT2-T3N0M0 patients have pN+ disease. Despite induction therapy, more than 50% have persistent nodal disease. Transthoracic esophagectomy is more likely to detect pN+ disease and more likely to meet criteria of adequate nodal dissection than is transhiatal esophagectomy. Therefore, the majority of patients with cT2-T3N0M0 should be considered for neoadjuvant protocols and should be treated by transthoracic resection whenever possible.

Predictors of recurrence and disease-free survival in patients with completely resected esophageal carcinoma.

OBJECTIVE: The goal of this study was to analyze factors predictive of recurrence and disease-free survival in patients with completely resected esophageal carcinoma. METHODS: We conducted a retrospective review of a prospective database to identify patients with completely resected esophageal carcinoma. Medical records were reviewed. Recurrence rates, time to recurrence, and disease-free survival were analyzed. The Kaplan-Meier method was used for time to event estimation, and multivariate Cox regression models were constructed to analyze factors thought to be significant in determining both freedom from recurrence and disease-free survival. RESULTS: From 1988 to 2009, 465 of 500 patients underwent complete resection for esophageal carcinoma. Median follow-up for living patients was 49 months; 197 patients (42.4%) had recurrence, leading to 175 patients dying of cancer and 22 patients living with recurrent disease. Multivariate regression adjusted for P stage identified the following variables as independent predictors of freedom from recurrence: performance status greater than 0 (hazard ratio [HR], 1.84; 95 confidence interval [CI], 1.35-2.49]; P < .001), poor differentiation (HR, 1.50; CI, 1.12-2.01; P = .006), induction therapy (HR, 1.65; CI, 1.21-2.25]; P = .002), en bloc resection (HR, 0.61; CI, 0.43-0.88; P = .007), and advanced pathologic stages (II/III/IV) (HR, 5.46; CI, 3.05-9.78; P < .001). Independent predictors of disease-free survival adjusted for P stage were performance status greater than 0 (HR, 1.73; CI, 1.34-2.23; P < .001), en bloc resection (HR, 0.63; CI, 0.47-0.84; P = .002), induction therapy (HR, 1.34; CI, 1.02-1.76; P = .033), and advanced pathologic stages (II/III/IV) (HR, 3.16; CI, 2.15-4.65; P < .001). CONCLUSIONS: For patients with completely resected esophageal cancer, independent predictors of improved freedom from recurrence and disease-free survival include good performance status, en bloc resection, and early pathologic stage.

Lobectomy in octogenarians with non-small cell lung cancer: ramifications of increasing life expectancy and the benefits of minimally invasive surgery.

BACKGROUND: As the population ages, clinicians are increasingly confronted with octogenarians with resectable non-small cell lung cancer (NSCLC). We reviewed the outcomes of octogenarians who underwent lobectomy for NSCLC by video-assisted thoracic surgery (VATS) versus open thoracotomy, to determine if there was a benefit to the VATS approach in this group. METHODS: We conducted a retrospective single-institution review of patients age 80 years or greater who underwent a lobectomy for NSCLC from 1998 to 2009. Outcomes including complication rates, length of stay, disposition, and long-term survival were analyzed. RESULTS: One hundred twenty-one octogenarians underwent lobectomy: 40 VATS and 81 through open thoracotomy. Compared with thoracotomy, VATS patients had fewer complications (35.0% vs 63.0%, p = 0.004), shorter length of stay (5 vs 6 days, p = 0.001), and were less likely to require admission to the intensive care unit (2.5% vs 14.8%, p = 0.038) or rehabilitation after discharge (5% vs 22.5%, p = 0.015). In multivariate analysis, VATS was an independent predictor of reduced complications (odds ratio, 0.35; 95% confidence interval, 0.15 to 0.84; p = 0.019). Survival comparisons demonstrated no significant difference between the two techniques, either in univariate analysis of stage I patients (5-year VATS, 76.0%; thoracotomy, 65.3%; p = 0.111) or multivariate analysis of the entire cohort (adjusted hazard ratio, 0.59; 95% confidence interval, 0.27 to 1.28; p = 0.183). CONCLUSIONS: Octogenarians with NSCLC can undergo resection with low mortality and survival among stage I patients, which is comparable with the general lung cancer population. The VATS approach to resection reduces morbidity in this age demographic, resulting in shorter, less intensive hospitalization, and less frequent need for postoperative rehabilitation.

Cumulative radiation dose from medical imaging procedures in patients undergoing resection for lung cancer.

BACKGROUND: Radiation dose from diagnostic imaging procedures is not monitored in patients undergoing surgery for lung cancer. Evidence suggests an increased lifetime risk of malignancy of 1.0% per 100 millisieverts (mSv). As such, recommendations are to restrict healthcare and radiation workers to a maximum dose of 50 mSv per year or to 100 mSv over a three-year period. The purpose of this study was to estimate cumulative effective doses of radiation in patients undergoing lung cancer resection and to determine predictors of increased exposure. METHODS: We identified 94 consecutive patients undergoing resection for non-small cell lung cancer. Radiologic procedures performed from one year prior to resection until two years postresection were recorded. Estimates of effective doses (mSv) were obtained from published literature and institutional records. Predictors of dose greater than 50 mSv per year and greater than 100 mSv per three years were examined statistically. RESULTS: The majority of patients (median age = 67 years) had stage IA cancer (52%). In the three-year period, patients had 1,958 radiologic studies (20.8/patient) including 398 computed tomographic (CT) scans (4.23/patient) and 211 positron emission tomography (PET) scans (2.24 per patient). The three-year median estimated radiation dose was 84.0 mSv (interquartile range, 44.1 to 123.2 mSv). The highest dose was in the preoperative year. In any one year, 66% of patients received more than 50 mSv, while 19% received over 100 mSv. Over the three-year period, 43.6% of patients exceeded 100 mSv. The majority of the radiation (89.8%) was from CT or PET scans. On multivariate analysis, a history of previous malignancy (odds ratio [OR] 3.8; confidence interval [CI] 1.14 to 12.7), postoperative complications (OR 6.16; CI 1.42 to 26.6), and postoperative surveillance with PET-CT (OR 13.2; CI 4.34 to 40.3) predicted exposure greater than 100 mSv over the three-year period. CONCLUSIONS: This study demonstrates that lung cancer patients often receive a higher dose of radiation than that considered safe for healthcare and radiation workers. The median cumulative dose reported in this study could potentially increase the individual estimated lifetime cancer risk by as much as 0.8%. Although risk-benefit considerations are clearly different between these groups, strategies should be in place to decrease radiation doses during the preoperative workup and postoperative period.

Prevalence, outcomes, and a risk-benefit analysis of diaphragmatic hernia admissions: an examination of the National Inpatient Sample database.

OBJECTIVE: Current practice is to repair uncomplicated diaphragmatic hernias (UDHs) to avoid complications such as obstruction or gangrene. However, practice patterns are based on limited data. We analyzed the National Inpatient Sample to compare outcomes of patients with obstructed (ODH) or gangrenous (GDH) diaphragmatic hernias and those who underwent repair of UDHs to perform a risk-benefit analysis of observation versus elective repair. PATIENTS AND METHODS: We queried the National Inpatient Sample for hospitalized patients who underwent a UDH repair as the principal procedure during their admission. To this repair group, we compared the outcomes of those patients who had a diagnosis of GDH or ODH. A risk-benefit analysis of observation versus elective repair was performed based on these data. RESULTS: Over a 10-year period, 193,554 admissions for the diagnosis of diaphragmatic hernia were identified. A UDH was the diagnosis in 161,777 (83.6%) admissions with 38,764 (24.0%) admissions for elective repair. ODH or GDH was the reason for admission in 31,127 (16.1%) and 651 (0.3%), respectively. Compared with patients who underwent elective repair, mortality was higher in patients with ODH or GDH (1% vs 4.5%; P < .001; and 1% vs 27.5%; P < .001). Risk-benefit analysis suggested a small but real benefit to elective repair in patients aged 50 to 70 years or if the operative mortality is 1% or less. CONCLUSIONS: Elective UDH repair is associated with better outcomes than admissions for ODH or GDH with a favorable risk-benefit profile than observation if the operative mortality is low.

Preoperative taxane-based chemotherapy and celecoxib for carcinoma of the esophagus and gastroesophageal junction: results of a phase 2 trial.

PURPOSE: The primary objective of this study was to determine the rate of pathological response after preoperative celecoxib and concurrent taxane-based chemotherapy in patients with cancer of the esophagus and gastroesophageal junction. METHODS: Thirty-nine patients were enrolled in this single-arm, phase II clinical trial. Patients were administered daily celecoxib in combination with two to three cycles of carboplatin and paclitaxel with preoperative intent. Levels of cyclooxygenase (COX)-2 expression in resected tumors were analyzed by immunohistochemistry and correlated with clinical outcome measures. Postoperatively, patients were administered daily celecoxib for 1 year or until documented tumor recurrence. RESULTS: All patients received two to three cycles of chemotherapy plus celecoxib 800 mg/d. Toxicities were as expected. A major clinical response (complete response + partial response) was noted in 22 patients (56%); six patients (15%) had a complete clinical response. Thirty-seven patients underwent esophagectomy. Five patients had a major pathological response (12.8%). Four-year overall and disease-free survivals were 40.9% and 30.3%, respectively. Patients with tumors expressing COX-2 demonstrated a higher likelihood of a major clinical response response (62% versus 50%) and an improved overall survival, compared with patients with COX-2-negative tumors. CONCLUSIONS: Preoperative celecoxib with concurrent chemotherapy demonstrated sufficient effect on pathologic response to warrant further study. Patients with tumors expressing COX-2 demonstrated trends toward improved response to preoperative therapy and improved overall survival compared with nonexpressors.

Predictors of cervical and recurrent laryngeal lymph node metastases from esophageal cancer.

BACKGROUND: Although patients with esophageal cancer (EC) often develop lymph node metastases in the cervical and recurrent laryngeal (CRL) distribution, lymphadenectomy in this field is rarely performed. The purpose of this study was to determine factors associated with CRL node positivity and to determine the appropriate indications to perform a "three field" lymphadenectomy. METHODS: In a retrospective review, EC patients who underwent three-field lymphadenectomy were analyzed. Predictors of positive CRL nodes were examined univariately, then selected for inclusion in a multivariate logistic regression model. RESULTS: From 1994 to 2009, 185 patients had a three-field lymphadenectomy, of whom 46 patients (24.9%) had positive CRL nodes. Final pathology stages (seventh edition) were I in 24 patients, II in 43, III in 109, and IV in 1 patient. Eight patients had a major pathologic response after induction therapy. On univariate analysis, variables significantly associated with positive CRL nodes included squamous cell histology, proximal location, advanced clinical presentation, the presence of clinical nodal disease, higher pT classification, and higher pN classification. There was no reduction in the rate of positive CRL nodes after induction chemotherapy. On multivariate analysis, higher pN classification (adjusted odds ratio 16.25, 95% confidence interval: 5.40 to 48.87; p < 0.0001) and squamous histology (adjusted odds ratio 6.04, 95% confidence interval: 2.21 to 16.56; p < 0.0001) predicted positive CRL nodes. CONCLUSIONS: Complete lymphadenectomy is necessary in esophageal cancer to appropriately stage patients. Low rates of positive CRL nodes are present with early clinical stage, with pT0-2 tumors, and with pN0 classification, particularly in patients with adenocarcinoma and gastroesophageal junction tumors. Dissection of the CRL field should be considered with advanced disease for adenocarcinoma and in all patients with squamous cell cancer.