Mediastinal IgG4-Related Disease Manifesting as Superior Vena Cava Syndrome.

Immunoglobulin G4 (IgG4)-related disease was first identified as a systemic condition in 2003 when extrapancreatic manifestations were identified in patients with autoimmune pancreatitis. Its peak incidence occurs in the fifth or sixth decades of life. Isolated extraaortic mediastinal involvement is extremely rare. This report describes a case of isolated extraaortic mediastinal IgG4-related disease encasing the superior vena cava (SVC) and manifesting as SVC syndrome in a 25-year-old man with no personal or family history of autoimmune disease. Resection with SVC reconstruction was performed.

A model for predicting prolonged length of stay in patients undergoing anatomical lung resection: a National Surgical Quality Improvement Program (NSQIP) database study.

OBJECTIVES: There are currently no studies that have specifically delineated the risk factors for a prolonged length of hospitalization in patients undergoing anatomical lung resection. Knowing these risk factors is important in terms of risk stratification and improving outcomes in the high-risk population. The goal of this study was to identify risk factors associated with a prolonged length of stay (≥14 days) in patients undergoing an anatomical lung resection and to further create a model for predicting the probability of a prolonged length of stay in these patients. METHODS: The NSQIP database (2005-2013) was culled for data on 45 distinct preoperative, intraoperative and postoperative variables among patients undergoing anatomical pulmonary resections. Univariate and multivariate logistic regression analyses were used to determine variables that contributed to a prolonged length of stay. A scoring system was created based on these results and applied to internal and external (a single institution database) validation groups to test for the adequacy of the model through the comparison of receiver operating characteristic curves. RESULTS: Fifteen factors were found to be significant for prolonged length of stay; six were preoperative (age >70 years [P < 0.0001], functional status-dependent [P = 0.0020], chronic obstructive pulmonary disease [P < 0.0001], serum sodium <135 mmol/l [P = 0.0200], ASA Class 3 [P = 0.0070] and ASA Class 4 or 5 [P = 0.0010]), one was intraoperative (open thoracotomy [P < 0.0001]) and eight were postoperative (pneumonia [P < 0.0001], unplanned reintubation [P < 0.0001], prolonged mechanical ventilation [P < 0.0001], urinary tract infection [P < 0.0001], stroke [P = 0.0020], transfusion [P = 0.0010], deep vein thrombosis/thrombophlebitis [P < 0.0001] and return to the operating room [P < 0.0001]). CONCLUSIONS: A simple model for predicting the probability of a prolonged length of stay in patients undergoing anatomical lung resection has been successfully created. This model can allow for better risk stratification of patients preoperatively based on certain existing comorbidities, and can help to predict the impact the development of various postoperative complications will have on overall patient outcomes.

Analyzing Risk Factors for Morbidity and Mortality after Lung Resection for Lung Cancer Using the NSQIP Database.

BACKGROUND: Our goal was to develop a predictive model that identifies how preoperative risk factors and perioperative complications lead to mortality after anatomic pulmonary resections. STUDY DESIGN: This was a retrospective cohort study. The American College of Surgeons NSQIP database was examined for all patients undergoing elective lobectomies for cancer from 2005 through 2012. Fifty-eight pre- and intraoperative risk factors and 13 complications were considered for their impact on perioperative mortality within 30 days of surgery. Multivariate logistic regression and a logistic regression model using least absolute shrinkage and selection operator (LASSO) selection methods were used to identify preoperative risk factors that were significant for predicting mortality, either through or independent of complications. Only factors that were significant under both the multivariate logistic regression and LASSO-selected models were considered to be validated for the final model. RESULTS: There were 6,435 lobectomies identified. After multivariate logistic regression modeling, 28 risk factors and 5 complications were found to be predictors for mortality. This was then tested against the LASSO method. There were 7 factors shared between the LASSO and multivariate logistic regressions that predicted mortality based on comorbidity: age (p = 0.007), male sex (p = 0.011), open lobectomy (p = 0.001), preoperative dyspnea at rest (p < 0.001), preoperative dyspnea on exertion (p = 0.003), preoperative dysnatremia (serum sodium <135 mEq/L or >145 mEq/L) (p = 0.011), and preoperative anemia (p = 0.002). Of these, 3 variables predicted mortality independent of any complications: dyspnea at rest, dyspnea on exertion, and dysnatremia. CONCLUSIONS: The clinical factors that predict postoperative complications and mortality are multiple and not necessarily aligned. Efforts to improve quality after anatomic pulmonary resections should focus on mechanisms to address both types of adverse outcomes.

Resection of oligometastatic lung cancer to the pancreas may yield a survival benefit in select patients--a systematic review.

OBJECTIVES: To conduct a systematic review of the existing literature regarding surgical therapy for oligometastatic lung cancer to the pancreas. METHODS: Data was collected on patients with singular pancreatic metastases from lung cancer from papers published between January 1970 and June 2014. This was performed following the Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) guidelines. Kaplan-Meier and Cox Regression analyses were then used to determine and compare survival. RESULTS: There were 27 papers that fulfilled the search criteria, from which data on 32 patients was collected. Non-small cell lung cancer (NSCLC) was the most prevalent type of primary lung malignancy, and metachronous presentations of metastases were most common. Lesions were most frequently located in the pancreatic head and consequently the most common curative intent metastasectomy was pancreaticoduodenectomy. There was a statistically significant survival benefit for patients whose metastasis were discovered incidentally by surveillance CT as opposed to those whose metastasis were discovered during a work up for new somatic complaints (p = 0.024). The overall median survival for patients undergoing curative intent resection was 29 months, with 2-year and 5-year survivals of 65% and 21% respectively. Palliative surgery or medical only management was associated with a median survival of 8 months and 2-year and 5-year survivals of 25% and 8% respectively. CONCLUSIONS: Curative intent resection of isolated pancreatic metastasis from lung cancer may be beneficial in a select group of patients.