A Prospective Clinical Trial to Evaluate Mesothelin as a Biomarker for the Clinical Management of Patients With Esophageal Adenocarcinoma.

OBJECTIVE: To investigate the utility of serum soluble mesothelin-related peptide (SMRP) and tumor mesothelin expression in the management of esophageal adenocarcinoma (ADC). BACKGROUND: Clinical management of esophageal ADC is limited by a lack of accurate evaluation of tumor burden, treatment response, and disease recurrence. Our retrospective data showed that tumor mesothelin and its serum correlate, SMRP, are overexpressed and associated with poor outcomes in patients with esophageal ADC. METHODS: Serum SMRP and tumoral mesothelin expression from 101 patients with locally advanced esophageal ADC were analyzed before induction chemoradiation (pretreatment) and at the time of resection (posttreatment), as a biomarker for treatment response, disease recurrence, and overall survival (OS). RESULTS: Pre and posttreatment serum SMRP was ≥1 nM in 49% and 53%, and pre and post-treatment tumor mesothelin expression was >25% in 35% and 46% of patients, respectively. Pretreatment serum SMRP was not significantly associated with tumor stage ( P = 0.9), treatment response (radiologic response, P = 0.4; pathologic response, P = 0.7), or recurrence ( P =0.229). Pretreatment tumor mesothelin expression was associated with OS (hazard ratio: 2.08; 95% CI: 1.14-3.79; P = 0.017) but had no statistically significant association with recurrence ( P = 0.9). Three-year OS of patients with pretreatment tumor mesothelin expression of ≤25% was 78% (95% CI: 68%-89%), compared with 49% (95% CI: 35%-70%) among those with >25%. CONCLUSIONS: Pretreatment tumor mesothelin expression is prognostic of OS for patients with locally advanced esophageal ADC, whereas serum SMRP is not a reliable biomarker for monitoring treatment response or recurrence.

Long-term Survival Based on the Surgical Approach to Lobectomy For Clinical Stage I Nonsmall Cell Lung Cancer: Comparison of Robotic, Video-assisted Thoracic Surgery, and Thoracotomy Lobectomy.

OBJECTIVE: To compare the long-term outcomes among robotic, video-assisted thoracic surgery (VATS), and open lobectomy in stage I nonsmall cell lung cancer (NSCLC). BACKGROUND: Survival comparisons between robotic, VATS, and open lobectomy in NSCLC have not yet been reported. Some studies have suggested that survival after VATS is superior, for unclear reasons. METHODS: Three cohorts (robotic, VATS, and open) of clinical stage I NSCLC patients were matched by propensity score and compared to assess overall survival (OS) and disease-free survival (DFS). Univariate and multivariate analyses were performed to identify factors associated with the outcomes. RESULTS: From January 2002 to December 2012, 470 unique patients (172 robotic, 141 VATS, and 157 open) were included in the analysis. The robotic approach harvested a higher number of median stations of lymph nodes (5 for robotic vs 3 for VATS vs 4 for open; P < 0.001). Patients undergoing minimally invasive approaches had shorter median length of hospital stay (4 d for robotic vs 4 d for VATS vs 5 d for open; P < 0.001). The 5-year OS for the robotic, VATS, and open matched groups were 77.6%, 73.5%, and 77.9%, respectively, without a statistically significant difference; corresponding 5-year DFS were 72.7%, 65.5%, and 69.0%, respectively, with a statistically significant difference between the robotic and VATS groups (P = 0.047). However, multivariate analysis found that surgical approach was not independently associated with shorter OS and DFS. CONCLUSIONS: Minimally invasive approaches to lobectomy for clinical stage I NSCLC result in similar long-term survival as thoracotomy. Use of VATS and robotics is associated with shorter length of stay, and the robotic approach resulted in greater lymph node assessment.

Preoperative consolidation-to-tumor ratio and SUVmax stratify the risk of recurrence in patients undergoing limited resection for lung adenocarcinoma ≤2 cm.

PURPOSE: Limited resection is an increasingly utilized option for treatment of clinical stage IA lung adenocarcinoma (ADC) ≤2 cm (T1aN0M0), yet there are no validated predictive factors for postoperative recurrence. We investigated the prognostic value of preoperative consolidation/tumor (C/T) ratio [on computed tomography (CT) scan] and maximum standardized uptake value (SUVmax) on (18)F-fluorodeoxyglucose-positron emission tomography (PET) scan. METHODS: We retrospectively reviewed 962 consecutive patients who underwent limited resection for lung cancer at Memorial Sloan-Kettering between 2000 and 2008. Patients with available CT and PET scans were included in the analysis. C/T ratio of 25 % (in accordance with the Japan Clinical Oncology Group 0201) and SUVmax of 2.2 (cohort median) were used as cutoffs. Cumulative incidence of recurrence (CIR) was assessed. RESULTS: A total of 181 patients met the study inclusion criteria. Patients with a low C/T ratio (n = 15) had a significantly lower 5-year recurrence rate compared with patients with a high C/T ratio (n = 166) (5-year CIR, 0 vs. 33 %; p = 0.015), as did patients with low SUVmax (n = 86) compared with patients with high SUVmax (n = 95; 5-year CIR, 18 vs. 40 %; p = 0.002). Furthermore, within the high C/T ratio group, SUVmax further stratified risk of recurrence [5-year CIR, 22 % (low) vs. 40 % (high); p = 0.018]. CONCLUSIONS: With the expected increase in diagnoses of small lung ADC as a result of more widespread use of CT screening, C/T ratio and SUVmax are widely available markers that can be used to stratify the risk of recurrence among cT1aN0M0 patients after limited resection.

Prospective impact of tumor grade assessment in biopsies on tumor stage and prognostic grouping in gastroesophageal adenocarcinoma: relevance of the seventh edition American Joint Committee on Cancer Staging Manual revision.

BACKGROUND: In the seventh edition of the American Joint Committee on Cancer (AJCC) staging system for esophageal cancer, tumor grade was introduced as an independent determinant of stage grouping in early stage tumors. With the significantly lower prognosis for poorly differentiated early stage adenocarcinomas, patients with these tumors may become candidates for neoadjuvant therapy given an accurate identification of these tumors with preoperative staging. The objective of the current study was to investigate the accuracy of preoperative histopathologic grading and the effect of preoperative grade on tumor stage/prognostic grouping. METHODS: Preoperative tumor grade was compared with postoperative tumor grade in 427 patients who underwent surgery without receiving neoadjuvant therapy for adenocarcinoma of the esophagus. The impact of preoperative tumor grade on stage/prognostic grouping was investigated. RESULTS: The overall accuracy of preoperative tumor grade assessment was 76% when unknown differentiation was regarded as well/moderately differentiated as recommended by the AJCC, whereas accuracy was 73% after the exclusion of tumors with unknown grade. In patients who have tumors classified as T1 or T2 and lymph node-negative (N0) (T1-T2N0) disease, 16% were assigned to a lower stage group based on preoperative pathology, whereas 5% were assigned to a higher stage group. In the T1-T2N0 group, sensitivity for detecting a poorly differentiated tumor was 0.43 (95% confidence interval [CI], 0.30-0.56), whereas specificity was 0.94 (95% CI, 0.90-0.98). CONCLUSIONS: With increasing use of neoadjuvant therapy, the accuracy of preoperative biopsy assessment has become increasingly important. In the current study, the accuracy of preoperative tumor grade assessment was 73%, leading to changes in AJCC stage/prognostic group in 21% of patients with T1-T2N0 esophageal adenocarcinomas. The authors concluded that caution should be exhibited in staging patients with esophageal adenocarcinoma based on preoperative biopsy data.

FDG-PET SUVmax combined with IASLC/ATS/ERS histologic classification improves the prognostic stratification of patients with stage I lung adenocarcinoma.

BACKGROUND: We investigated the association between the newly proposed International Association for the Study of Lung Cancer (IASLC)/American Thoracic Society (ATS)/European Respiratory Society (ERS) classification and (18)F-fluorodeoxyglucose (FDG) uptake on positron emission tomography (PET), and whether the combination of these radiologic and pathologic factors can further prognostically stratify patients with stage I lung adenocarcinoma. METHODS: We retrospectively evaluated 222 patients with pathologic stage I lung adenocarcinoma who underwent FDG-PET scanning before undergoing surgical resection between 1999 and 2005. Patients were classified by histologic grade according to the IASLC/ATS/ERS classification (low, intermediate, or high grade) and by maximum standard uptake value (SUVmax) (low <3.0, high ≥3.0). The cumulative incidence of recurrence (CIR) was used to estimate recurrence probabilities. RESULTS: Patients with high-grade histology had higher risk of recurrence (5-year CIR, 29% [n = 25]) than those with intermediate-grade (13% [n = 181]) or low-grade (11% [n = 16]) histology (p = 0.046). High SUVmax was associated with high-grade histology (p < 0.001) and with increased risk of recurrence compared to low SUVmax (5-year CIR, 21% [n = 113] vs. 8% [n = 109]; p = 0.013). Among patients with intermediate-grade histology, those with high SUVmax had higher risk of recurrence than those with low SUVmax (5-year CIR, 19% [n = 87] vs. 7% [n = 94]; p = 0.033). SUVmax was associated with recurrence even after adjusting for pathologic stage (p = 0.037). CONCLUSIONS: SUVmax on FDG-PET correlates with the IASLC/ATS/ERS classification and can be used to stratify patients with intermediate-grade histology, the predominant histologic subtype, into two prognostic subsets.

The Case of the Vanishing Vessel Loop: Unrecognized Removal Via Laparoscopic Suction Device.

Although the incidence rate of retained surgical items is low, it remains an important cause of patient injury and can lead to harm, death, and waste of time and resources when looking for the missing item. Perioperative counting of equipment is a common method to identify missing surgical items. We present a rare case report of a missing vessel loop that was suctioned by a suction irrigator device. The diagnosis of a retained surgical item is extremely important; special attention should be paid when suctioning body liquids with small surgical items nearby, to prevent incidences of missing items after the surgery.

Pulmonary thermal ablation in patients with prior pneumonectomy.

OBJECTIVE: The purpose of this article is to review the safety and efficacy of thermal ablation of lung malignancies after pneumonectomy. MATERIALS AND METHODS: We reviewed patients who underwent thermal ablation for malignant lung tumors after pneumonectomy between 1999 and 2009. Patient demographics, complications, procedural success, and oncologic outcomes were recorded. Technique effectiveness was evaluated at imaging 4-6 weeks after ablation. The Kaplan-Meier method was used to evaluate overall survival. A cumulative incidence and competing risk method was used to account for progression-free tumors at the time of patient death. RESULTS: Of 619 lung ablations, 17 were performed to treat 13 tumors (nine primary and four metastatic) in 12 patients with a single lung. The median tumor size was 2 cm (range, 1.2-4 cm). Technical success was documented in all 17 cases. Technical effectiveness was documented in 10 of 12 patients. Local tumor progression occurred in five lesions within a median of 12 months (range, 10-22 months) after ablation and was treated with repeat ablation in four lesions. Complications included six (35%) of 17 pneumothoraces requiring thoracostomy. Deaths occurred within 2-12 days after three (19%) of 16 ablation sessions. The median time to primary local tumor progression was 18 months (95% CI, 12 months through not reached), and the median time to assisted (after repeat ablation) local tumor progression was 33 months (95% CI, not reached). Median overall survival was 21 months (95% CI, 18-53 months). After excluding the two early deaths complicating the initial ablation procedure, median overall survival was 37 months. CONCLUSION: Thermal ablation can offer local tumor control after pneumonectomy, despite a relatively high postprocedure clinical risk.

Real-time intraoperative detection of tissue hypoxia in gastrointestinal surgery by wireless pulse oximetry.

OBJECTIVE: Dehiscence or leakage after bowel anastomoses is associated with high morbidity and mortality. Perfusion and local tissue oxygenation (StO2), independent of systemic oxygen saturation, are fundamental determinants of anastomotic viability. Because current technology is limited for monitoring local StO2 at bowel anastomoses, our goal was to construct a wireless pulse oximeter (WiPOX) to monitor real-time intraoperative tissue oxygenation, permitting identification of compromised anastomotic perfusion. METHODS: We have: (a) designed a handheld device capable of real-time monitoring of serosal and mucosal StO2 through endoscopic ports with wireless data transmission to standard intraoperative monitors, (b) constructed the WiPOX using materials meeting FDA regulations for intraoperative use and reuse, (c) performed accuracy testing in humans by comparing the WiPOX to standard pulse oximeters, and (d) tested WiPOX efficacy for detecting early tissue hypoxia in stomach, intestines, and kidneys in anesthetized rats and swine. RESULTS: In humans, WiPOX demonstrated accuracy within 3% compared with commercially available pulse oximeters. Application of the WiPOX in rats and swine demonstrated normal serosal and mucosal StO2 and pulse rates in healthy small bowel and stomach. Within 30 s of compromised perfusion, the WiPOX detected bowel hypoxia over a wide range of oxygen saturation (p<0.005). A greater degree of hypoxia was detected in mucosal versus serosal measurements during early ischemia, despite normal appearance of tissue. The onboard sensor-processor unit permitted noninvasive pulse oximetry and integration with current intraoperative monitoring. The contact pressure-sensing head allowed for consistent, high-quality StO2 waveform readouts despite the presence of body fluids. CONCLUSIONS: We have constructed, validated, and successfully tested a novel wireless pulse oximeter capable of detecting intraoperative tissue hypoxia in open or endoscopic surgery. This device will aid surgeons in detecting anastomotic vascular compromise and facilitate choosing an ideal site for bowel anastomosis by targeting well-perfused tissue with optimal healing capacity.

Two-Year Quality of Life Outcomes After Robotic-Assisted Minimally Invasive and Open Esophagectomy.

BACKGROUND: Robotic-assisted minimally invasive esophagectomy (RAMIE) is a safe alternative to open esophagectomy (OE). However, differences in quality of life (QOL) after these procedures remain unclear. We previously reported short-term QOL outcomes after RAMIE and OE and describe here our results from 2 years of follow-up. METHODS: We conducted a prospective, nonrandomized trial of patients with esophageal cancer undergoing transthoracic resection by RAMIE or OE at a single institution. The primary outcomes were patient-reported QOL, measured by the Functional Assessment of Cancer Therapy-Esophageal (FACT-E), and pain, measured by the Brief Pain Inventory (BPI). Generalized linear models were used to assess the relationship between QOL outcomes and surgery cohort. P values were adjusted (P-adj) within each model using the false discovery rate correction. RESULTS: Esophagectomy was performed in 170 patients (106 OE and 64 RAMIE). The groups did not differ significantly by any measured clinicopathologic variables. After covariates were controlled for, FACT-E scores were higher in the RAMIE cohort than in the OE cohort (parameter estimate [PE], 6.13; P-adj = .051). RAMIE was associated with higher esophageal cancer subscale (PE, 2.72; P-adj = .022) and emotional well-being (PE, 1.25; P-adj = .016) scores. BPI pain severity scores were lower in the RAMIE cohort than in the OE cohort (PE, -0.56; P-adj = .005), but pain interference scores did not differ significantly between groups (P-adj = .11). CONCLUSIONS: During 2 years of follow-up, RAMIE was associated with improved patient-reported QOL, including esophageal symptoms, emotional well-being, and decreased pain, compared with OE.

Optimum lymphadenectomy for esophageal cancer.

OBJECTIVE: Using Worldwide Esophageal Cancer Collaboration data, we sought to (1) characterize the relationship between survival and extent of lymphadenectomy, and (2) from this, define optimum lymphadenectomy. SUMMARY BACKGROUND DATA: What constitutes optimum lymphadenectomy to maximize survival is controversial because of variable goals, analytic methodology, and generalizability of the underpinning data. METHODS: A total of 4627 patients who had esophagectomy alone for esophageal cancer were identified from the Worldwide Esophageal Cancer Collaboration database. Patient-specific risk-adjusted survival was estimated using random survival forests. Risk-adjusted 5-year survival was averaged for each number of lymph nodes resected and its relation to cancer characteristics explored. Optimum number of nodes that should be resected to maximize 5-year survival was determined by random forest multivariable regression. RESULTS: For pN0M0 moderately and poorly differentiated cancers, and all node-positive (pN+) cancers, 5-year survival improved with increasing extent of lymphadenectomy. In pN0M0 cancers, no optimum lymphadenectomy was defined for pTis; optimum lymphadenectomy was 10 to 12 nodes for pT1, 15 to 22 for pT2, and 31 to 42 for pT3/T4, depending on histopathologic cell type. In pN+M0 cancers and 1 to 6 nodes positive, optimum lymphadenectomy was 10 for pT1, 15 for pT2, and 29 to 50 for pT3/T4. CONCLUSIONS: Greater extent of lymphadenectomy was associated with increased survival for all patients with esophageal cancer except at the extremes (TisN0M0 and >or=7 regional lymph nodes positive for cancer) and well-differentiated pN0M0 cancer. Maximum 5-year survival is modulated by T classification: resecting 10 nodes for pT1, 20 for pT2, and >or=30 for pT3/T4 is recommended.

Lean Lobectomy: Streamlining Video-Assisted Lobectomy to Increase the Value of Lung Cancer Care.

PURPOSE: A review of the outcomes of patients who received our video-assisted thoracic surgery (VATS) lung lobectomy in 2015 revealed long lengths of stay, inefficient care transitions, and overuse of resources. Focused process redesign offers a proven method for instituting improvement and changes in health care. We sought to use systems process improvement to streamline VATS lobectomies at our institution, and we targeted cost drivers to optimize quality of care and minimize overuse of resources. METHODS: We performed a retrospective review of perioperative practices between January 2015 and March 2016 for patients undergoing VATS lobectomy that helped establish a value stream map, used a granular cost database, and performed real-time analysis. We used an outcomes database, which allowed us to identify cost drivers, practice variability, and rent seeking. We implemented process redesign with constant review and formal value stream reanalysis at 6-month intervals over a 2-year period. RESULTS: We ultimately experienced an overall 187% reduction of time in the operating room (297 v 159 minutes). Our process redesign also resulted in significantly fewer chest x-rays per patient (mean, 6.7 v 2), laboratory draws (100% v 5.7%), and consultations (100% v 5.7%), which resulted in a 234% reduction in mean length of stay (4.4 v 1.88 days) and an overall cost reduction of 40%. These changes did not have a detrimental effect on patient outcomes: pulmonary complications (16.9% v 8.6%), cardiac complications (13.2% v 8.6%), and readmission rates (13.6% v 2.9%) all decreased. CONCLUSION: By using value stream analysis and process redesign methodologies, closely paired with highly granular cost and outcomes data, we were able to achieve significant improvements in patient outcomes and use of resources.

A prospective trial of intraoperative tissue oxygenation measurement and its association with anastomotic leak rate after Ivor Lewis esophagectomy.

BACKGROUND: Anastomotic leak following Ivor Lewis esophagectomy is associated with increased morbidity/mortality and decreased survival. Tissue oxygenation at the anastomotic site may influence anastomotic leak. Methods for establishing tissue oxygenation at the anastomotic site are lacking. METHODS: Over a 2-year study period, 185 Ivor Lewis esophagectomies were performed. Study participants underwent measurement of gastric conduit tissue oxygenation at the planned anastomotic site using the wireless pulse oximetry device. Associations between anastomotic leaks or strictures and tissue oxygenation levels were analyzed using Wilcoxon rank sum test or Fisher's exact test. RESULTS: Among study participants (n=114), median gastric conduit tissue oxygenation level was 92% (range, 62-100%). There were 8 (7.0%) anastomotic leaks and 3 (2.6%) strictures. Analysis of tissue oxygenation as a continuous variable showed no difference in median tissue oxygenation in patients with and without leaks (98% and 92%; P=0.2) and stricture formation (89% and 92%; P=0.6). Analysis of tissue oxygenation as a dichotomous variable found no difference in anastomotic leak rates [7.5% (n=93) in >80% vs. 0% (n=20) in ≤80%; P=0.3]. There were no significant differences in leak rates in concurrent study nonparticipants. CONCLUSIONS: No significant association was observed between intraoperative tissue oxygenation at the anastomotic site and subsequent anastomotic leak or stricture formation among patients undergoing Ivor Lewis esophagectomy.

Post-treatment endoscopic biopsy is a poor-predictor of pathologic response in patients undergoing chemoradiation therapy for esophageal cancer.

PURPOSE: Endoscopic biopsy after chemoradiation therapy (CRT) for esophageal cancer has been used to determine response to treatment. We wanted to determine if endoscopic biopsy can accurately establish evidence of local pathologic complete response (pCR) in patients undergoing CRT. METHODS: We queried a prospectively maintained database for patients seen at Memorial Sloan-Kettering Cancer Center from 1996 to the present who underwent, (1) CRT for local-regionally advanced esophageal cancer, (2) post-CRT endoscopic biopsy, and (3) esophagectomy. Data points included pathology of post-CRT endoscopy and surgical specimens, tumor histology, and survival. Correlations were analyzed by the chi2 test and one-way analysis of variance. Survival comparisons were assessed using the Kaplan-Meier method and log-rank analysis. RESULTS: One hundred fifty-six patients were identified. Over 80% of patients received cisplatin-based chemotherapy and 5040 cGy of radiation. One hundred eighteen patients had no tumor identified on endoscopic biopsy. A negative biopsy at endoscopy was a poor predictor of pCR (negative predictive value: 31%), with 69% having local disease at esophagectomy. A positive biopsy was predictive of residual disease (positive predictive value: 95%). Negative endoscopic biopsy better predicted a pCR for squamous cell carcinomas versus adenocarcinomas (P[r] < 0.001). Nodal status of surgical specimens was not correlated with post-treatment endoscopic findings. Survival was equivalent after surgery in patients with a negative endoscopic biopsy versus patients with positive pathology. CONCLUSION: A negative endoscopic biopsy is not a useful predictor of a pCR after CRT, final nodal status, or overall survival.

Early Quality of Life Outcomes After Robotic-Assisted Minimally Invasive and Open Esophagectomy.

BACKGROUND: Minimally invasive esophagectomy may improve some perioperative outcomes over open approaches; effects on quality of life are less clear. METHODS: A prospective trial of robotic-assisted minimally invasive esophagectomy (RAMIE) and open esophagectomy was initiated, measuring quality of life via the Functional Assessment of Cancer Therapy-Esophageal and Brief Pain Inventory. Mixed generalized linear models assessed associations between quality of life scores over time and by surgery type. RESULTS: In total, 106 patients underwent open esophagectomy; 64 underwent minimally invasive esophagectomy (98% RAMIE). The groups did not differ in age, sex, comorbidities, histologic subtype, stage, or induction treatment (P = .42 to P > .95). Total Functional Assessment of Cancer Therapy-Esophageal scores were lower at 1 month (P < .001), returned to near baseline by 4 months, and did not differ between groups (P = .83). Brief Pain Inventory average pain severity (P = .007) and interference (P = .004) were lower for RAMIE. RAMIE had lower estimated blood loss (250 vs 350 cm3; P < .001), shorter length of stay (9 vs 11 days; P < .001), fewer intensive care unit admissions (8% vs 20%; P = .033), more lymph nodes harvested (25 vs 22; P = .05), and longer surgical time (6.4 vs 5.4 hours; P < .001). Major complications (39% for RAMIE vs 52% for open esophagectomy; P > .95), anastomotic leak (3% vs 9%; P = .41), and 90-day mortality (2% vs 4%; P = .85) did not differ between groups. Pulmonary (14% vs 34%; P = .014) and infectious (17% vs 36%; P = .029) complications were lower for RAMIE. CONCLUSIONS: RAMIE is associated with lower immediate postoperative pain severity and interference and decreased pulmonary and infectious complications. Ongoing data accrual will assess mid-term and long-term outcomes in this cohort.

Preservation of replaced left hepatic artery during robotic-assisted minimally invasive esophagectomy: A case series.

OBJECTIVE: Finding of a significant replaced left hepatic artery (RLHA) during esophagectomy is relatively rare, with an incidence of approximately 5%. Sparing of the artery may be required to avoid complications of liver ischemia. Robotic assistance during esophagectomy may provide a technically superior method of artery preservation with minimally invasive approaches. METHODS: This is a retrospective case series of patients undergoing robotic-assisted minimally invasive esophagectomy (RAMIE) identified to have a significant RLHA at time of surgery. RESULTS: Five patients with a significant RLHA were identified from a series of over 100 RAMIE operations. Preservation of RLHA was accomplished in all cases without need for conversion, no intra-operative complications, and no post-operative liver dysfunction. The stomach was suitable and used for conduit reconstruction in all patients. CONCLUSIONS: Sparing of the RLHA during RAMIE is feasible and effective. The robotic assisted approach may obviate the need for open conversion during these complex minimally invasive operations.

Unusual late presentation of metastatic extrathoracic thymoma to gastrohepatic lymph node treated by surgical resection.

In advanced stages, thymic tumors tend to spread locally. Distant metastatic disease is rare. We present the first report of single metastatic abdominal lymph node in a 37-year-old female patient and 5 years after an extrapleural pneumonectomy for stage IV thymoma followed by radiotherapy with no other evidence of abdominal disease successfully treated by robotic surgical resection.

Incidence of occult pN2 disease following resection and mediastinal lymph node dissection in clinical stage I lung cancer patients.

Objectives: Early clinical stage (T1 and T2) non-small cell lung cancer (NSCLC) is commonly treated with anatomic lung resection and lymph node sampling or dissection. The aims of this study were to evaluate the incidence and the distribution of occult N2 disease according to tumour location and the short- and long-term outcomes. Methods: We performed a retrospective review of patients with clinical stage I NSCLC who underwent anatomic lung resection and lymphadenectomy. Mediastinal lymphadenectomy (ML) was defined as resection of at least 2 mediastinal stations, always including station 7 lymph nodes. Patients who had a lobe-specific lymphadenectomy were excluded. Results: One thousand six hundred and sixty-seven consecutive patients met inclusion criteria and were included. Overall, 9% (146/1667) of the patients had occult pN2 disease. At multivariable analysis, adenocarcinoma histology and vascular invasion were independently associated with greater risk of occult pN2 disease. In left and right upper lobe tumours, station 7 nodes were involved in 5 and 13% of pN2 positive cases, respectively. Station 5 and station 2/4 nodes were involved in 29 and 18% of left and right lower lobe pN2 tumours, respectively. There was no postoperative mortality, and postoperative morbidity was 28%. The median overall survival was 77.4 months. N0 patients had a median overall survival of 83.7 months vs 48.0 months and 37.9 months in N1 and N2 populations, respectively ( P < 0.001). Conclusions: Sixteen percent of pN2 patients had mediastinal lymph node metastasis beyond the lobe-specific lymphatic drainage. We recommend a complete lymphadenectomy be performed, even in clinical stage I NSCLC.

Early operative outcomes and learning curve of robotic assisted giant paraesophageal hernia repair.

BACKGROUND: We have previously described our technique of robotic-assisted giant paraesophageal hernia repair (RA-GPEHR). The purpose of this study was to report our initial experience, early outcomes and learning curve with RA-GPEHR using a four-arm robotic platform. METHODS: 24 consecutive patients presenting with symptomatic giant paraesophageal hernias (GPEH) underwent RA-GPEHR from April 2011 to February 2014. Peri-operative data and short-term patient outcomes were assessed by retrospective review of a prospectively maintained database. RESULTS: Median age was 62 years (range 44-84). 15 (63%) patients underwent fundoplication and 9 (37%) gastropexy. Median procedure time was 277 min (range: 185-485) and decreased steadily over the experience. There were no intra-operative complications or surgical mortality. No patients experienced dysphagia in the early post-operative period. CONCLUSIONS: RA-GPEHR is safe, with reported short-term operative and functional outcomes similar to conventional laparoscopic approaches. The initial learning curve appears relatively short for experienced minimally invasive esophageal surgeons. Copyright © 2016 John Wiley & Sons, Ltd.

Resected Lung Cancer Patients Who Would and Would Not Have Met Screening Criteria.

BACKGROUND: Current eligibility criteria for lung cancer screening may underestimate the risk of malignancy for some individuals. We compared the predicted risk of lung cancer among patients who would have met screening criteria to those who would not have despite being at moderate-risk. METHODS: A retrospective cohort study of resected lung cancer patients was performed. The screen eligible group was based on criteria provided by the United States Preventive Services Task Force; age 55 to 80 and a 30 or greater pack-year smoking history. The screen ineligible group was based on criteria provided by the National Comprehensive Cancer Network for a moderate-risk individual not recommended screening; age greater than 50 years, greater than 20 pack-year smoking history, and no history of asbestos exposure or chronic obstructive pulmonary disease. A recently validated risk-prediction model was used to compare the risk of lung cancer across eligibility groups based on measured and imputed patient-level variables. RESULTS: Screen ineligible patients (n = 88) had a lower estimated probability of lung cancer than screen eligible patients (n = 419); 1.3% versus 3.1%, p value less than 0.001. However, 20% of screen ineligible patients had a predicted probability of lung cancer greater than or equal to the prevalence of lung cancer (3.7%) among National Lung Screening Trial participants; 17% of screen ineligible patients had a predicted probability of lung cancer greater than or equal to the American Association for Thoracic Surgery threshold (5%) defining high-risk individuals. CONCLUSIONS: Current eligibility criteria for lung cancer screening underestimate the risk of lung cancer for some individuals who might benefit from lung cancer screening.

Endoscopic Management of Esophageal Anastomotic Leaks After Surgery for Malignant Disease.

BACKGROUND: Esophageal anastomotic leaks after cancer surgery remain a major cause of morbidity and mortality. Endoscopic interventions, including covered metal stents (cSEMS), clips, and direct percutaneous endoscopic jejunostomy (dPEJ) tubes are increasingly used despite limited published data regarding their utility in this setting. This study aimed to determine the efficacy and safety of a multimodality endoscopic approach to anastomotic leak management after operation for esophageal or gastric cancer. METHODS: We performed a retrospective review of prospectively maintained databases of gastric and esophageal operations at our hospital between January 2003 and December 2012. Included patients had an operation for esophageal or gastric cancer, demonstrated evidence of an anastomotic leak at the esophageal anastomosis, and underwent attempted endoscopic therapy. Healing was defined as clinical and radiographic leak resolution. RESULTS: Forty-nine patients with leaks underwent endoscopic management. Of the 49 patients, 31 (63%) received cSEMS, 40 (82%) had dPEJ tubes inserted, and 3 (6%) received clips. Twenty-three (47%) patients underwent a combined approach. Overall, 88% of patients achieved healing in a median of 83 days. Twenty-two of 23 patients (96%) who underwent a multimodality endoscopic approach healed. Only 1 patient had a major complication associated with stent erosion into the pulmonary artery, which was successfully treated with operative repair. CONCLUSIONS: Esophageal anastomotic leaks after esophageal and gastric cancer operations can be managed successfully and safely with endoscopic therapy. Combining cSEMS for leak control and dPEJ tube placement for nutritional support was highly effective in achieving healing, without the need for surgical repair.