Lung cancer in nonsmokers- A risk factor analysis.

INSTITUTIONS: STONY BROOK MEDICAL CENTERRATIONALE: Lung Cancer screening for the high-risk smoking population has been proven to save lives. However, in 2022, 20% of newly diagnosed lung cancers (47,300) were in nonsmokers. These patients were found to be diagnosed at later stages. This may be at least partly due to not meeting criteria for and participating in current lung cancer screening. This study aims to describe characteristics of a never smoker patient population to help identify common risk factors which might merit inclusion in lung cancer screening and thus improve patient outcomes. METHODS: This retrospective single center study included never-smoker patients diagnosed with lung nodules and never-smoker patients diagnosed with lung cancer from 2016 to 2022. Data was obtained from the Stony Brook Medical Center electronic medical record. 16,056 patients were identified as never-smokers who were asked by the medical assistant if they ever smoked in their lifetime. Patients were eliminated if they had any smoking history up to first diagnosis date. Demographics, radiology, histology, diagnosis dates, comorbidities, smoking status, and exposures collected through ICD10 codes and not self-reported, were investigated. RESULTS: Of 16,056 never-smoking patients, 9315 (58.02%) were females diagnosed with lung nodules and 6741 (41.98%) were males diagnosed with lung nodules. The univariate analysis showed significant differences between gender, age at nodule diagnosis, and patients with and without comorbidities including chronic obstructive pulmonary disease (COPD), hypertension (HTN), and family history (FHX) of lung cancer. The percentage of lung cancer patients among females was significantly higher than among males. Patients having lung cancer were older. The percentages of lung cancer patients with these comorbidities were significantly higher than those without. However, there was no significant difference found between patients with and without diabetes mellitus (DM). The multivariable logistic regression suggested that age at nodule diagnosis and comorbidities including COPD (which included asthma, emphysema and chronic bronchitis) and family history of lung cancer were significantly associated with lung cancer. Older patients and patients with those comorbidities had a higher risk of developing cancer than those who were younger or without those comorbidities. The study excluded HTN and included age at nodule diagnosis in the logistic regression model as HTN was found to be protective against lung cancer due to age at lung nodule diagnosis. Please refer to the appendix for further details. CONCLUSION: Never-smoker patients who were older and with COPD and Family History of lung cancer had higher risk of developing lung cancer than younger patients without these comorbidities. In this study, gender had no impact on outcome.

Foreign Body Aspiration Mimicking an Endobronchial Neoplasm: A Case Report and Review of the Literature.

Foreign body aspiration (FBA) is infrequently encountered in the adult population, with major risk factors including advancing age, intoxication, and disorders of the central nervous system. Here, we present a case of FBA in an adult undergoing routine lung cancer screening to review imaging findings and highlight potential pitfalls for the practicing radiologist. A low-dose chest computed tomography (CT) scan was performed for lung cancer screening in a 57-year-old male with a one-month history of worsening dyspnea and cough. An endobronchial lesion was identified in the right bronchus intermedius. A follow-up 18F-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG PET-CT) revealed hypermetabolic activity in the region of interest, raising concern for malignancy. Bronchoscopy was performed, revealing a nodular mass adjacent to a foreign body in the bronchus intermedius. Histopathologic analysis of the tissue sample revealed the presence of an aspirated foreign body with squamous metaplasia of the respiratory epithelium. Adult FBA is an uncommon clinical entity that may be incidentally observed on a screening chest CT. Relevant multimodality imaging findings are discussed here, along with a review of the accompanying pathologic changes seen with chronic airway impaction.

Morphologic Severity of Atypia Is Predictive of Lung Cancer Diagnosis.

In cytologic analysis of lung nodules, specimens classified as atypia cannot be definitively diagnosed as benign or malignant. Atypia patients are typically subject to additional procedures to obtain repeat samples, thus delaying diagnosis. We evaluate morphologic categories predictive of lung cancer in atypia patients. This retrospective study stratified patients evaluated for primary lung nodules based on cytologic diagnoses. Atypia patients were further stratified based on the most severe verbiage used to describe the atypical cytology. Logistic regressions and receiver operator characteristic curves were performed. Of 129 patients with cytologic atypia, 62.8% later had cytologically or histologically confirmed lung cancer and 37.2% had benign respiratory processes. Atypia severity significantly predicted final diagnosis even while controlling for pack years and modified Herder score (p = 0.012). Pack years, atypia severity, and modified Herder score predicted final diagnosis independently and while adjusting for covariates (all p < 0.001). This model generated a significantly improved area under the curve compared to pack years, atypia severity, and modified Herder score (all p < 0.001) alone. Patients with severe atypia may benefit from repeat sampling for cytologic confirmation within one month due to high likelihood of malignancy, while those with milder atypia may be followed clinically.

Cannulate, extubate, ambulate approach for extracorporeal membrane oxygenation for COVID-19.

OBJECTIVE: We compared outcomes in patients with severe COVID-19 versus non-COVID-19-related acute respiratory distress syndrome (ARDS) managed using a dynamic, goal-driven approach to venovenous extracorporeal membrane oxygenation (ECMO). METHODS: We performed a retrospective, single-center analysis of our institutional ECMO registry using data from 2017 to 2021. We used Kaplan-Meier plots, Cox proportional hazard models, and propensity score analyses to evaluate the association of COVID-19 status (COVID-19-related ARDS vs non-COVID-19 ARDS) and survival to decannulation, discharge, tracheostomy, and extubation. We also conducted subgroup analyses to compare outcomes with the use of extracorporeal cytoreductive techniques (CytoSorb [CytoSorbents Corp] and plasmapheresis). RESULTS: The sample comprised 128 patients, 50 with COVID-19 and 78 with non-COVID-19 ARDS. Advancing age was associated with decreased probability of survival to decannulation (P = .04). Compared with the non-COVID-19 ARDS group, patients with COVID-19 had a greater probability of survival to extubation (P < .01) and comparable survival to discharge (P = .14). CONCLUSIONS: Patients with COVID-19 managed with ECMO had comparable outcomes as patients with non-COVID ARDS. A strategy of early extubation and ambulation might be a safe and effective strategy to improve outcomes and survival, even for patients with severe COVID-19.

Variations in mortality in Medicare recipients on extracorporeal membrane oxygenation.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is a rescue modality against severe cardiac and pulmonary compromise. We sought to assess variation in mortality and associated environmental and infrastructural predictors among Medicare beneficiaries on ECMO. METHODS: We used Medicare claims data to evaluate hospitalizations between 2017 and 2019 during which beneficiaries required ECMO. The primary outcome of interest was mortality. We evaluated the influence on mortality of Medicare Case Mix Index (CMI), Medicare Wage Index, hospital size, ECMO cannulations, cardiology volume, region, and gender and modeled necessity and sufficiency relations involving ECMO volume, hospital size, cardiology volume, US region, and the mortality index through qualitative comparative analysis (QCA). RESULTS: 5368 ECMO cases were performed at 306 hospitals. Compared to institutions with a mortality index equal to or below 2, those above this threshold had statistically significant higher number of beds, cardiology volumes, and lower survival percentages (p < 0.05). Moreover, we observed a smaller proportion of institutions with an ECMO volume < 20 (78.3% vs 63.4%), which had mortality index > 2. The QCA analysis indicated that low cardiology volume and central/east location are necessary but not sufficient conditions for a mortality index above 2. CONCLUSION: Trends in mortality are influenced by prevailing socioeconomic, utilization, infrastructural characteristics, and volume. As such, ECMO mortality may be more accurately predicted by models that account for more factors than clinical parameters alone.

Mortality and cost of post-cardiotomy extracorporeal support in the United States.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) has been used increasingly for cardiopulmonary rescue. Despite recent advances however, post-cardiotomy shock (PCS)-ECMO survival remains comparatively poor. We sought to evaluate outcomes and define factors that predict in-hospital mortality. METHODS: We used the Nationwide Inpatient Sample (NIS) to evaluate adult hospitalizations with a primary procedure code for coronary artery bypass grafting (CABG), and/or valve procedures performed between 2013 and 2018, which also required post cardiotomy ECMO support. Patient-related factors and hospital costs were evaluated to identify those associated with in-hospital mortality. RESULTS: There were 1,247,835 admissions for cardiac surgical procedures during the study period. Post-cardiotomy shock-ECMO support was provided in 4475 (0.3%) within the study cohort. A total of 2000 (44.7%) hospitalizations involved isolated valvular procedures, 1700 (38.0%) isolated CABG, and 775 (17.3%) involved a combination of both. Overall, in-hospital mortality was 42.1% (n = 1880). Factors significantly associated with in-hospital mortality included patients with multiple comorbidities (> 7) and those undergoing combination of valve and CABG procedures. Only 26.6% of those who survived to discharge, were discharged home independently. CONCLUSION: Survival to independent home discharge is rare following PCS-ECMO. Its high mortality is associated with multiple comorbidities and combination of CABG and valve surgery.

Superior Vena Cava Reconstruction in Masaoka Stage III and IVa Thymic Epithelial Tumors.

BACKGROUND: We present here a case series of patients who underwent resection for Masaoka stage III and IVa thymic epithelial tumors (TETs) with invasion into the superior vena cava (SVC). METHODS: A total of 29 patients with stage III and IVa TETs were treated surgically in 3 institutions. Operative resections involved replacing the SVC from one of the innominate veins (n = 18) or via reconstruction by truncal replacement (n = 2) or patch plasty (n = 9). RESULTS: Fifteen patients underwent neoadjuvant treatment. Thirty- and 90-day mortality rates were 3.4% and 10.3%, respectively. For stage III patients, the median overall survival and disease-free survival (DFS) were 39 and 30 months, respectively. The median overall survival and DFS in patients with Masaoka stage IVa disease were 67 and 21 months, respectively. Undergoing only preoperative chemotherapy (P = .007) or receiving no chemotherapy (P = .009) had a DFS that was significantly higher than receiving both preoperative and postoperative chemotherapy. CONCLUSIONS: SVC resection and reconstruction in Masoaka stage III and IVa TETs can be performed with acceptable morbidity and mortality. Stage IVa patients with SVC involvement can be treated with similar results as stage III patients with multimodality treatment.

Outcome and Cost of Nurse-Led vs Perfusionist-led Extracorporeal Membrane Oxygenation.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is a resource-intense modality of care whose use has grown exponentially. We examined volume and utilization trends to identify the financial break-even point that might serve to dichotomize between nurse specialist-led and perfusionist-led ECMO programs. METHODS: Data pertaining to patients who required ECMO support between 2018 and 2019 were reviewed. ECMO staffing costs were estimated based on national trends and modeled by annual utilization and case volume. A break-even point was derived from a comparison between nurse specialist-led and perfusionist-led models. For each scenario, direct medical costs were calculated based on utilization, which was in turn defined by "low" (4 days), "average" (10 days), and "high" (30 days) duration of time spent on ECMO. RESULTS: Within the study time frame, there was a total of 107 ECMO cases with a mean ECMO duration of 11 days. Overall, ECMO nursing personnel costs were less than those for perfusionists ($108,000 vs $175,000). Programmatic costs were higher in the perfusionist-led vs nurse specialist-led model when annual utilization was greater than 10 cases and ECMO duration was longer than a mean of 9.7 days. There was no difference in survival between the 2 models. CONCLUSIONS: Use of a perfusionist-led ECMO model may be more cost-conscious in the context of low utilization, smaller case volume and shorter ECMO duration. However, once annual case volume exceeds 10 and mean ECMO duration exceeds 10 days, the nurse specialist-led model may be more cost-conscious.

Incremental effect of complications on mortality and hospital costs in adult ECMO patients.

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) is a resource-intense modality whose usage is expanding rapidly. It is a costly endeavor and best conducted in a multidisciplinary setting. There is a growing impetus to mitigate the mortality and costs associated with ECMO. We sought to examine the impact of complications on mortality and hospital costs in patients on ECMO. METHODS: Using the NIS database, we performed multivariable logistic regression to assess the influence of complications on the primary outcome, in-hospital mortality. Similarly, we performed multivariable survey linear regression analysis to evaluate the effect of the complications on hospital costs. RESULTS: Of the 12,637 patients supported using ECMO between 2004 and 2013, 9836 (78%) developed at least one complication. The three most common complications were acute kidney injury (32.8%), bloodstream infection (31.8%), and bleeding (27.8%). An ECMO hospitalization with no complications was associated with median costs of $53,470, a single complication with costs of $97,560, two complications with costs of $139,035, and three complication with costs of $162,284. A single complication was associated with a 165% increase in odds of mortality. Two or three complications resulted in 375% or 627% higher odds of mortality, respectively. Having one, two, or three complications was associated with 24%, 38%, or 38% increase in median costs respectively (Figure 1). Complications associated with the highest median costs were central line-associated bloodstream infection $217,751; liver failure $176,201; bloodstream infection $169,529. CONCLUSION: In-hospital mortality and costs increase with each incremental complication in patients on ECMO. Accurate prediction and mitigation of complications is likely to improve outcomes and cost.

Persistent N2 After Induction Is Not a Contraindication to Surgery for Lung Cancer.

BACKGROUND: Surgical management for potentially resectable stage IIIA-N2 non-small cell lung cancer (NSCLC) is controversial. For some, persistent N2 disease after induction therapy is a contraindication to resection. We examined outcomes of a well-selected surgical cohort of postinduction IIIA-N2 NSCLC patients with persistent N2 disease. METHODS: We retrospectively reviewed all resected clinical IIIA-N2 NSCLC patients from 2001 to 2018. Thorough preoperative staging, including invasive mediastinal staging, was performed. Those with nonbulky N2 disease, appropriate restaging, and potential for a margin-negative resection were included. After resection, patients were classified as having persistent N2 disease or mediastinal downstaging (N2 to >N0/N1). Persistent N2 patients were further classified as uncertain resection (R[un]) or complete resection (R0) according to the International Association for the Study of Lung Cancer definition. Kaplan-Meier survival analysis was used. RESULTS: Fifty-four patients met inclusion criteria. After induction, 31 patients (57%) demonstrated persistent N2 disease, and 23 patients (43%) had mediastinal downstaging. Preinduction invasive mediastinal staging was performed in 98.1%. Most had clinical single-station N2 disease (75.9%). Margin-negative resections were performed in 100%. Eight patients were reclassified as R(un) due to positive highest sampled mediastinal station. The median overall survival for persistent N2 was 26 months for R(un) and 69 months for R0. Overall survival for the downstaged group was 67 months (P = .31). CONCLUSIONS: Overall survival for patients with non-R(un) or persistent N2 (true R0) was similar to those with mediastinal downstaging. Well-selected patients with persistent N2 disease experience reasonable survival after resection and should have surgery considered as part of their multimodality treatment. This study underscores the importance of classifying the extent of mediastinal involvement for persistent N2 patients, supporting the proposed International Association for the Study of Lung Cancer R(un) classification.

Difficult Decisions in Minimally Invasive Surgery of the Thymus.

A minimally invasive resection of thymomas has been accepted as standard of care in the last decade for early stage thymomas. This is somewhat controversial in terms of higher-staged thymomas and myasthenia gravis patients due to the prognostic importance of complete resections and the indolent characteristics of the disease process. Despite concerted efforts to standardize minimally invasive approaches, there is still controversy as to the extent of excision, approach of surgery, and the platform utilized. In this article, we aim to provide our surgical perspective of thymic resection and a review of the existing literature.

Robotic thymectomy for myasthenia gravis surgical techniques and outcomes.

Myasthenia gravis (MG) is an autoimmune disorder in which antibodies are produced against post-synaptic acetylcholine receptors, thereby causing impairment of neuromuscular transmission. Diagnosis of MG is confirmed with the AChR antibody test and via an Electromyography. Although medical treatment with acetylcholinesterase inhibitors remains the main treatment of MG, in recent years thymectomy has become an integral part of the treatment algorithm. Numerous factors such as the Patient's age, presence of AChR antibodies, or MuSK antibody, the severity of disease affect the decision of preforming the thymectomy. Historically thymectomy was preformed via sternotomy associated with significant morbidity. Advancement in the minimally invasive approaches to thymic resection has led to more acceptance of thymectomy in the management of MG. Among these approaches, robotic thymectomy is gaining popularity across the globe due to the unique advantages of the robotic platform like 3D visibility, enhanced dexterity, and wrist like articulating movements of instruments. This has led to less post-operative pain and morbidity; faster recovery and shorter hospital stay. Successful treatment of MG requires a multi-modality approach, which has led to the formation of MG teams in most academic centers, comprising of a specialist neurologist, intensivist, and thoracic surgeon. In this article, we describe the techniques and outcomes of the robotic thymectomy for MG.

Robotic assisted cryothermic biatrial Cox-Maze.

INTRODUCTION: Robotic cryothermic Cox-Maze (CM) IV is a minimally invasive procedure that reliably replicates the biatrial lesion set of the CM III by utilizing cryothermia as a single power source. METHODS: Herein we describe a step by step creation of the biatrial CM III lesion sets utilizing the minimally invasive robotic platform. RESULTS: Technical details are reviewed for this single incision, single stage, highly effective option for stand-alone or concomitant surgical ablation of atrial fibrillation (AF). CONCLUSION: Robotic cryothermic CM IV can be safely performed as a stand-alone or concomitant procedure, and offers a comprehensive surgical ablation solution for patients with AF.

Tracheotomy, closure of long-term tracheostomy and standard tracheal segmental resections.

Tracheotomy is a surgical procedure commonly employed to establish stable and long-term airway access. Iatrogenic airway injury post procedure may have serious consequences with limited treatment options. Tracheostoma or long standing tracheostomies require special closing techniques. Tracheotomies, tracheostomies, complications of these and treatment options, long standing tracheostomy closure techniques, and standard tracheal segmental resections are discussed.