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Whereas current guidelines recommend staging laparoscopy for most patients with potentially resectable gastric cancer, such a recommendation for patients with adenocarcinoma of the gastroesophageal junction (AEG) is lacking. This study sought to identify baseline clinicopathologic characteristics associated with peritoneal metastasis (PM) among patients with Siewert II AEG. Trimodality therapy–eligible patients with Siewert II AEG (2000-2015, single institution) were retrospectively identified. A composite PM outcome was defined as follows: (1) PM at staging laparoscopy; (2) PM diagnosed during neoadjuvant chemoradiation; or (3) PM ≤6 months postoperatively. Logistic regression was used to identify features associated with PM; bootstrapped analysis (Youden J) identified the distal tumor extension that best discriminated the composite outcome. Of 188 patients, a composite PM outcome was observed in 26 of 188 (13.8%); 12 of 26 had positive staging laparoscopy, 10 of 26 experienced PM during chemoradiation, and 4 of 26 had PM ≤6 months postoperatively. Tumor extension below the GEJ was greater in patients with PM (median, 4.0 cm [interquartile range, 3.0-5.0] vs 3.0 cm [interquartile range, 2.0-3.0]; P <.001). All patients with PM had cT3 to cT4 tumors. Among patients with cT3 to cT4 tumors (n = 168 of 188; 89.4%), distal tumor extent (odds ratio, 1.67/cm; 95% CI, 1.23-2.28; P =.001) was independently associated with increased odds of PM. Gastric tumor extension ≥4 cm remained independently associated with PM (OR, 5.14; 95% CI, 2.11-12.53; P <.001) after adjustment for signet ring cell status. Distal tumor extent beyond the GEJ is independently associated with increased odds of PM in patients with Siewert II AEG. Patients with extensive gastric involvement should therefore be considered for staging laparoscopy before trimodality therapy. [ABSTRACT FROM AUTHOR]

For extrathoracic malignant neoplasms that have metastasized to the lungs, previous investigations have demonstrated both oncologic and survival benefits after pulmonary and repeated metastasectomy. Little is known about the feasibility of incrementally increasing numbers of subsequent metastasectomy procedures. We conducted a retrospective review of patients who underwent ≥3 pulmonary resection procedures for recurrent, metachronous metastatic disease of nonlung primary malignant neoplasms at a single institution between 1992 and 2020. Primary outcomes collected pertained to safety and feasibility, including estimated blood loss (EBL), hospital length of stay, and details of postoperative complications. There were 117 patients who met inclusion criteria, having undergone at least 3 metastasectomy operations, with 55 (47.1%) undergoing a fourth operation and 20 (17.1%) undergoing a fifth operation. EBL did not differ between first and second operations (106.6 mL vs 102.5 mL; P =.76). It was, however, significantly greater at third operations (102.5 mL vs 238.7 mL; P =.000016). We noted an increase in wound complications between the second and third operations (0.9% vs 6.8%; P =.02) and incremental increases in likelihood of prolonged air leak with each subsequent operation. The need for reoperation was low for all and similar between operations. Importantly, hospital length of stay was similar for all procedures, as were the frequencies of hospital readmission. Third-time redo pulmonary metastasectomy can be performed safely and feasibly in select patients. Further repeated resection should remain a therapeutic option for patients, although risks for potentially longer operating time, greater EBL, and prolonged air leaks may be anticipated. [ABSTRACT FROM AUTHOR]

In retrospective studies the definition of salvage esophagectomy has been inconsistent and is a source of bias. We sought to describe how variability in the definition of salvage affects comparative outcomes of trimodality therapy (TMT) and bimodality therapy (BMT). Patients with locally advanced esophageal squamous cell carcinoma who completed chemoradiation therapy (CRT) from 2002 to 2017 were identified. TMT included patients who had a planned esophagectomy after CRT. BMT included patients treated with CRT only plus salvage esophagectomy, variably defined as an esophagectomy occurring (A) 3 months after CRT; (B) 3 months after CRT, excluding delayed recovery; (C) 3 months after CRT, excluding delayed workup; or (D) 6 months after CRT. Long-term survival outcomes between the TMT and BMT groups were compared for each definition of salvage esophagectomy. Time to surgery was included a priori in a multivariable model for overall survival. Of 143 patients, 90 (63%) underwent esophagectomy and 53 (37%) received CRT only. Although the total patients remained the same, the composition of the TMT and BMT groups varied by salvage definitions A through D. Various definitions resulted in different 5-year survival rates for TMT vs BMT groups: (A) 56% vs 39%, (B) 61% vs 34%, (C) 50% vs 42%, and (D) 51% vs 39%. In a Cox multivariable analysis age and proximal/middle esophageal tumors were associated with worse postoperative survival, but time to surgery was not. Slight variations in the definition of salvage esophagectomy can influence the interpretation of TMT and BMT outcomes. Future studies should consistently define treatment groups. [ABSTRACT FROM AUTHOR]

The assumption that increased [18F] fluoro-2-deoxy- d -glucose (FDG) uptake in hilar nodes on positron emission tomography/computed tomography (PET/CT) imaging is indicative of distant metastasis can result in palliative rather than curative care in patients with esophageal cancer. This study aimed to determine the significance of increased FDG uptake in hilar nodes in patients with potentially curable, locally advanced disease at initial staging. We included patients with biopsy specimen-proven esophageal carcinoma who had pretreatment FDG-PET/CT at initial staging and follow-up imaging >1 year. We excluded patients with distant hematogeneous metastases. Hilar nodes were considered concerning for metastatic disease when the maximum standardized uptake value was >2.5 or FDG uptake was visually greater than the mediastinal background. We reviewed FDG-PET CT scans from 806 patients treated for esophageal cancer from 2010 to 2018 and identified 42 patients with FDG-avid hilar adenopathy. Thirteen patients underwent histologic assessment, and 29 were monitored with imaging. None of the 42 patients had distant metastatic disease on the initial workup, and all were treated curatively. In follow-up, 2 of 42 patients eventually manifested hilar nodal metastases after treatment; 1 who had a biopsy specimen-negative hilar node at initial staging and another who did not have a biopsy of the hilar node. Increased FDG uptake in hilar nodes in patients with localized esophageal cancer was not indicative of nonregional nodal metastasis. Patients in these situations should be approached with curative intent. The need for biopsy of FDG-avid hilar nodes in this cohort should be carefully considered due to the low diagnostic utility. [ABSTRACT FROM AUTHOR]

Traditional journal clubs address individual articles and are limited in terms of breadth and depth of content covered. The present study describes the outcomes of a novel debate-style journal club in a multiinstitutional setting. Participating institutions were recruited through the Thoracic Education Cooperative Group. The distributed curriculum included instructions, debate scenarios, suggested article lists, moderator slides, debate scoresheets, exams, and feedback surveys. Six institutions participated in the study (2015-2019), consisting of a total of 10 years' worth of cumulative debates. Cardiothoracic surgery trainees participated in 10 monthly debates over each academic year. Trainee performance on the written examination in the realm of evidence-based medicine and critical appraisal improved over the course of the academic year (beginning 55.2% vs end 76.3%; P =.040). Importantly, written examination after debates revealed a significant improvement in scores on questions relating to topics that were debated as compared with those that were not (+27.1% vs +2.5%; P =.006), emphasizing the importance of the debates as compared with other sources of knowledge gain. Surveys completed by trainees and faculty overall favored the debate-style journal club as compared with the traditional journal club in gaining familiarity with seminal literature in the field, improving on oral presentation skills, and applying published literature to questions encountered clinically. In this multiinstitutional prospective study, we demonstrate that the novel debate-style cardiothoracic surgery journal club is an effective educational intervention for cardiothoracic surgical trainees to acquire, retain, and gain practice in applying literature-based evidence to case-based scenarios. [Display omitted] [ABSTRACT FROM AUTHOR]

Although smokers are at an increased risk for postoperative pulmonary complications after thoracic surgery, the relationship between cessation timing and postoperative pulmonary complications has not been explored in an era of enhanced recovery protocols and active tobacco cessation programs. Because a strong preference exists among thoracic surgeons to delay surgery to continued smokers, we sought to evaluate this relationship in a modern era. Patients undergoing lung resection for a diagnosis of non-small cell lung cancer from 2012 to 2017 were identified. Multivariable logistic regression was used to evaluate preoperative tobacco cessation timing to determine the impact on postoperative pulmonary complications. In all, 1038 ever smokers were identified. Patients were current smokers in 30 (3%) instances, and among former smokers, the preoperative cessation interval was 0 to 14 days in 10% (104), more than 14 days to 1 month in 6% (62), more than 1 month to 1 year in 18% (189), more than 1 to 5 years in 10% (107), and more than 5 years in 53% (546). Pulmonary complications occurred in 269 patients (26%). Multivariable analysis revealed that no group of recent or long-term quitters had superior outcomes in terms of pulmonary complications when evaluating various periods of abstinence in comparison with continued smokers and active quitters. In an era of enhanced recovery protocols, minimally invasive surgery, and active tobacco cessation programs that may help patients to cut back, our data do not support the practice of delaying or denying surgery to patients who have difficulty quitting completely. Perioperative cessation counseling should be aimed at long-term benefits, including reduction of disease recurrence and secondary malignancies. [ABSTRACT FROM AUTHOR]

This study aimed to investigate the maximum standardized uptake value (SUV max) as a predictor of recurrence and timing of recurrence after resection of early-stage non-small cell lung cancer. The study retrospectively reviewed patients from a single institution who underwent lobectomy for stage I to IIa non-small cell lung cancer from 2013 to 2018. Exclusion criteria included preoperative therapy and neuroendocrine histologic type. The study investigators collected recurrence and follow-up data, as well as preoperative SUV max. A receiver operating characteristic curve was used to identify the optimal SUV max for predicting recurrence. Kaplan-Meier curves and Cox regression analyses were used to identify predictors of freedom from recurrence (FFR). The study included 238 patients, 30 (12.6%) of whom had disease recurrence. The receiver operating characteristic curve had an area under the curve of 0.671 and identified 4.93 as the optimal SUV max cutoff. Patients were stratified into groups on the basis of this value; each group included 119 patients. High SUV max was associated with larger tumor size, poor differentiation, lymphovascular invasion, and shorter FFR. The proportion of patients without recurrence at 5 years in the low- and high-SUV max groups were 92.4% and 73.4%, respectively (P <.001). On univariate analysis, poor differentiation (hazard ratio [HR],2.35; 95% confidence interval [CI], 1.04 to 5.31; P =.04), lymphovascular invasion (HR, 3.19; 95% CI, 1.37 to 7.44; P =.007), visceral pleural invasion (HR, 2.33; 95% CI, 1.05 to 5.20; P =.04), and SUV max 4.93 or greater (HR, 4.51; 95% CI, 1.84 to 11.03; P =.001) predicted FFR. On multivariable analysis, only SUV max 4.93 or greater remained significant (HR, 5.36; 95% CI, 1.50 to 19.17; P =.01). SUV max is independently associated with a risk of recurrence after resection of early-stage lung cancer. SUV max may be a valuable tool for stratifying patients with early-stage lung cancer for adjuvant therapy and surveillance frequency. [Display omitted] [ABSTRACT FROM AUTHOR]

Whether robotic segmentectomies are advantageous is unclear. We describe our experience with the robot, comparing patient populations and outcomes with video-assisted thoracoscopic surgery (VATS) and open resection. Patients who underwent anatomic segmentectomy from 2004 to 2019 were reviewed. Resection methods were categorized as robotic, VATS, or open. Segmentectomies were categorized as simple or complex. Baseline characteristics and perioperative outcomes were analyzed from 2015 to 2019 due to implementation of the Enhanced Recovery After Surgery pathway for all thoracic surgery patients and to thus minimize confounders resulting from the Enhanced Recovery After Surgery protocol. Since 2004, an increase has occurred in segmentectomies, including robotic and complex segmentectomies. Of the 222 segmentectomies performed from 2015 to 2019, 77 (35%) were robotic, 40 VATS (18%), and 105 open (47%). More complex segmentectomies were performed in the robotic group compared with VATS and open (45% vs 15% vs 22%; P <.001). Operative time for robotic resections were longer compared with VATS and open (205 vs 147 vs 147 minutes; P <.001) but had lower blood loss (50 vs 75 vs 100 mL; P <.001) and shorter chest tube days (2 vs 2 vs 3 days; P =.004) and lengths of stay (3 vs 3 vs 4 days; P <.001). Perioperative mortality was low in all groups. No robotic segmentectomy was converted to open compared with 7.5% for VATS (P =.038). Prolonged air leak was lower for robotic compared with open (4% vs 13%; P =.038). Robotic segmentectomy has increased in our institution, with a concurrent rise in atypical segmentectomies. Despite performing more complex procedures, there were no conversions and low perioperative morbidity and mortality. Our results suggest that the robotic platform can facilitate performance of complex anatomic segmentectomies. [Display omitted] [ABSTRACT FROM AUTHOR]

Psychiatric comorbidities (PCs) have been associated with poor surgical outcomes in several malignancies. However, the impact of PCs on surgical outcomes for non-small cell lung cancer (NSCLC) remains largely unknown. NSCLC patients who underwent pulmonary resection at a single institution between 2006 and 2017 were included. Presence of preoperative PCs was identified by documented diagnostic codes. Demographic, histopathologic, perioperative, and survival data were analyzed. Categorical variables were compared using the χ2 or Fisher exact test. Overall and disease-free survival was analyzed using Kaplan-Meier method. Univariable and multivariable logistic regression analyses were performed for 30-day readmission. Among 2907 patients, PCs were present preoperatively in 180 (6%), including anxiety, 130 (72%); depression, 52 (29%); adjustment disorder, 28 (16%); alcohol abuse, 16 (9%); sleep disorder, 8 (4%); and schizophrenia, 3 (2%). Patients with PCs were younger, with fewer cardiovascular complications. There were no differences in length of stay. However, PCs led to increased 30-day readmission (12% vs 6%, P =.004). Reasons for readmission did not differ between groups (P =.679). Multivariable analysis showed PCs independently predicted 30-day readmission (odds ratio, 2.00; P =.005). Importantly, there were no differences in 30- or 90-day mortality (P =.495 and P =.748, respectively), overall survival (P =.439), or disease-free survival (P =.924). NSCLC patients with and without PCs experienced similar perioperative and long-term outcomes, suggesting that individuals should not be denied surgical care on the basis of such comorbidities. However, further research should seek to identify reasons for increased risk of readmission for patients with PCs and validate these findings in other settings. [ABSTRACT FROM AUTHOR]

Whether extrapleural pneumonectomy (EPP) or extended pleurectomy/decortication (P/D) is the optimal resection for malignant pleural mesothelioma remains controversial. We therefore compared perioperative outcomes and long-term survival of patients who underwent EPP versus P/D. Patients with the diagnosis of malignant pleural mesothelioma who underwent either EPP or P/D from 2000 to 2019 were identified from our departmental database. Propensity score matching was performed to minimize potential confounders for EPP or P/D. Survival analysis was performed by the Kaplan-Meier method and Cox multivariable analysis. Of 282 patients, 187 (66%) underwent EPP and 95 (34%) P/D. Even with propensity score matching, perioperative mortality was significantly higher for EPP than for P/D (11% vs 0%; P =.031); when adjusted for perioperative mortality, median overall survival between EPP and P/D was 15 versus 22 months, respectively (P =.276). Cox multivariable analysis for the matched cohort identified epithelioid histology (hazard ratio [HR], 0.56; P =.029), macroscopic complete resection (HR, 0.41; P =.004), adjuvant radiation therapy (HR, 0.57; P =.019), and more recent operative years (HR, 0.93; P =.011)—but not P/D—to be associated with better survival. Asbestos exposure (HR, 2.35; P =.003) and pathologic nodal disease (HR, 1.61; P =.048) were associated with worse survival. In a multimodality treatment setting, P/D and EPP had comparable long-term oncologic outcomes, although P/D had much lower perioperative mortality. The goal of surgical cytoreduction should be macroscopic complete resection achieved by the safest operation a patient can tolerate. [ABSTRACT FROM AUTHOR]

We have previously demonstrated that Enhanced Recovery After Surgery protocols are associated with a reduction in pulmonary complications. As a component of enhanced recovery pathways, intercostal nerve blocks with liposomal bupivacaine are increasingly utilized, but the extent to which this element may contribute to such outcomes has not been evaluated. Patients undergoing lung resection for stage I to III non-small cell lung cancer at a single institution from 2006 to 2017 were examined for major postoperative pulmonary morbidity, defined as pneumonia, acute respiratory distress syndrome, respiratory arrest, reintubation, bronchoscopy, or need for discharge with oxygen. Pharmacy records were queried for administration of liposomal bupivacaine via posterior intercostal nerve block. Patients treated with and without liposomal bupivacaine were compared in a logistic regression to determine the impact on pulmonary morbidity. A total of 2865 patients were identified, including 860 (30%) who were treated with liposomal bupivacaine via posterior intercostal block. Pulmonary morbidity occurred in 455 (16%). Adoption of liposomal bupivacaine analgesia occurred over several years, beginning in 2012 to full adoption by 2017. Liposomal bupivacaine management was associated with a reduction in pulmonary complications, as compared with nonuse (odds ratio, 0.63; P =.006). Additional factors associated with the occurrence of pulmonary morbidity were age, body mass index, smoking, spirometry values, and operative blood loss. As a component of an active enhanced recovery program, liposomal bupivacaine is associated with a reduction in major pulmonary complications, and utilization should be evaluated on a hospital-by-hospital basis. [ABSTRACT FROM AUTHOR]

As strategies promoting enhanced recovery protocols and opioid minimization techniques are increasingly prioritized, use of nonsteroidal antiinflammatory drugs continues to rise. Whether this prevalent use poses increased risk for bleeding or renal dysfunction in surgical populations after extensive dissection and fluid shifts is unclear. We reviewed records of patients undergoing esophagectomy for a diagnosis of esophageal adenocarcinoma at a single institution from 2006 to 2018 for ketorolac administration during the postoperative hospital admission, as well as the occurrence of postoperative events, defined as the need for blood product transfusion and/or acute kidney injury. We identified 1019 patients, 123 of whom experienced postoperative events (12%). Ketorolac was administered to 686 (67%). Furthermore, ketorolac use steadily increased over the study period; 36 of 72 patients received this medication in 2006 (49%), and 76 of 83 in 2018 (92%). Multivariable logistic regression failed to identify a relationship between ketorolac administration (assessed as a binary covariate) and postoperative events (P =.657). Additional examination for a dose-response relationship using the cumulative total dose from the time of surgery to discharge also did not demonstrate a relationship with postoperative events (P =.829). In an effort to evaluate a more homogeneous population, we performed a subgroup analysis using only patients treated with trimodality therapy, which showed similar findings. Ketorolac has become a staple of multimodal postesophagectomy analgesic regimens. Importantly, this medication does not pose risk for acute kidney injury or bleeding after surgery. [ABSTRACT FROM AUTHOR]

Surgeons have shifted away from the practice of en bloc esophagectomy, particularly in the era of neoadjuvant therapies. Although some still advocate for this radical approach, contemporary data establishing its superiority are sparse. We hypothesized that a more complete, radical resection could be completed in the setting of chemoradiation without adding morbidity. Patients undergoing esophagectomy after neoadjuvant chemoradiation for esophageal adenocarcinoma from 2006-2018 were evaluated. Outcomes after right transthoracic en bloc esophagectomy were compared with standard esophagectomy to determine the impact on outcomes. A Cox proportional hazard model was evaluated, and logistic regression was performed to determine the impact of en bloc resection on postoperative morbidity. A total of 604 patients were identified, including 133 (22%) who underwent modified en bloc esophagectomy. Positive margins were most likely to occur in standard esophagectomy (35 of 471, 7%) vs en bloc (3 of 133, 2%) (P =.026). En bloc resection yielded a greater lymph node harvest (27; interquartile range, 22-36), as compared to standard esophagectomy (22; interquartile range, 17-28), P <.001. Multivariable analysis demonstrated prolonged progression-free survival with en bloc resection (hazard ratio, 0.74; P =.041), with 3-year freedom from locoregional recurrences of 78% and 90% for standard and en bloc approaches (P =.044). There were no differences in cardiopulmonary, gastrointestinal, or wound complications, as well as leak or chylothorax. Our experience demonstrates improved locoregional disease control with en bloc esophagectomy, with equivalent morbidity. Although these results may be multifactorial, including adequate clearance of both primary tumor and nodal micrometastases, this approach is safe and feasible. [ABSTRACT FROM AUTHOR]

Websites are primary sources of information for prospective trainees. However, little is known regarding the information deemed most important to cardiothoracic (CT) surgery interviewees when evaluating a program. The objectives of this study were to (1) report informational content important to CT surgery interviewees on a fellowship website and (2) improve the quality of a specific program's website. Study investigators conducted a survey of interviewees at a traditional 2-year CT surgery fellowship program. Questions were asked to elicit what information interviewees considered important to include in a program website and to identify gaps in the website's content. After administering the survey to 2018 fellowship interviewees, the website was redesigned, and the survey was readministered to 2019 fellowship interviewees. A total of 49 interviewees completed the survey (response rate, 90.7%); 45 (91.8%) of these interviewees had previously visited the program's website. Interviewees reported that the most important information they sought when accessing fellowship websites included faculty profiles (n = 47), rotation schedules (n = 33), current fellows' profiles (n = 29), and past fellows' profiles (n = 26). The website was revamped to include content across each of these domains. After website redesign, there was significant improvement in interviewees reporting that they found the information they sought (mean score, 3.56 to 4.64; P <.001) and that the website was useful (mean score, 3.67 to 4.77; P <.001) compared with the previous year. CT surgery fellowship websites are accessed by the majority of interviewees and are a critical source of program information. Optimizing website design and content on the basis of survey feedback objectively improved the usefulness of the program website to interviewees. [ABSTRACT FROM AUTHOR]

High tumor mutational burden (TMB) and programmed death ligand 1 (PD-L1) expression are leading biomarkers in metastatic non-small cell lung cancer (NSCLC) and predict favorable response to checkpoint inhibitors. We sought to identify clinicopathologic characteristics associated with elevated TMB and PD-L1 expression among patients who underwent resection for NSCLC. NSCLC patients undergoing primary resection (2016-2018) were prospectively enrolled in an immunogenomic profiling project. Multiplex immunofluorescence quantified densities (cells/mm2) of CD3+, CD3+CD8+, CD3+CD8+PD-1+, malignant cells (MCs), MCsPD-L1+, CD68+, CD68+PD-L1+, and CD20+ cells. Whole-exome sequencing quantified TMB (mutations/megabase). TMB and MCsPD-L1+ were dichotomized according to the median of each. A total of 55 patients completed multiplex immunofluorescence and whole-exome sequencing profiling. In this sample, 41.8% (23 of 55) had pathologic stage I disease. Median TMB and MCsPD-L1+ were 3.91 and 0.62 cells/mm2, respectively. TMB was higher among smokers (P =.001) and tumors with lymphovascular invasion (LVI) (P =.051). TMB was positively correlated with densities of MCsPD-L1+ (r = 0.293, P =.030), CD68+PD-L1+ (r = 0.289, P =.033), and CD20+ (r = 0.310, P =.043) cells. The density of MCsPD-L1+ was associated with increased CD3+CD8+ (r = 0.319, P =.018) and CD68+PD-L1+ (r = 0.371, P =.005) cells. Patients with PD-L1HighTMBHigh tumors (30.9%, 17 of 55) had higher intratumoral densities of CD3+, CD3+CD8+, CD68+, CD68+PD-L1+, and CD20+ cells. On multivariable analysis LVI was associated with synchronous elevated TMB and PD-L1 expression (odds ratio 3.53, P =.039). NSCLC tumors with elevated TMB and PD-L1 expression are associated with LVI and increased intratumoral immune cell infiltration. These findings may potentially improve patient selection for checkpoint inhibitor therapy trials in the adjuvant setting. [ABSTRACT FROM AUTHOR]

Advances in perioperative and operative management hold great promise for improving perioperative outcomes in patients undergoing resection for early stage non-small cell lung cancer (NSCLC). The objective of this study was to evaluate time trends in the incidence of perioperative outcomes and to identify predictors of pulmonary complication in early stage NSCLC resection patients. An institutional database was reviewed to identify patients with primary, clinical stage I and II NSCLC who underwent resection from 1998 to 2016. Rates of perioperative pulmonary complication, pneumonia, and cardiovascular complication; and 30-day and 90-day mortality were calculated for each year. Joinpoint regression was used to calculate annual percentage change (APC) and to evaluate time trends in rates of these outcomes. Multivariable logistic regression was conducted to identify predictors of pulmonary complication. Of the 3045 patients identified, 80% had stage I and 20% had stage II NSCLC. From 1998 to 2016, there was no trend in the rate of pulmonary complication, but there was a significant downward trend in the rates of pneumonia (APC −3.7), cardiovascular complication (APC −3.5), 30-day mortality (APC −9.8), and 90-mortality (APC −7.4). Older age, male sex, smoking status, percentage of predicted forced expiratory volume in 1 second and percentage of diffusion capacity of lung for carbon monoxide, and intraoperative blood transfusion were identified as predictors of pulmonary complication. Decrease in the rates of perioperative outcomes parallels improvements in patient selection and perioperative management of early stage NSCLC resection patients. Predictors of pulmonary complication could be used to improve selection criteria for surgery and to reduce the incidence of pulmonary complication in these patients. [ABSTRACT FROM AUTHOR]

Adenocarcinoma of the gastroesophageal junction (AEG) poses a management challenge, as preoperative prediction of occult mediastinal nodal metastasis is difficult. We sought to identify factors predictive of mediastinal involvement among patients undergoing trimodality therapy. Patients undergoing trimodality therapy for Siewert II and III AEG at a single institution between 2000 and 2015 were identified. Mediastinal involvement was defined as pathologic nodal involvement after neoadjuvant chemoradiation (ypN+) in mediastinal stations or mediastinal recurrence 2 years or less after resection. Maximal χ2 analysis and Youden's J index were used to identify the pretreatment proximal tumor extent that best discriminated mediastinal involvement. In all, 204 patients (151 [74%] AEG II, 53 [26%] AEG III) were included, of whom 47 (23%) had clinical evidence of thoracic nodal disease. Thirty-one of the 204 patients (15%) met criteria for mediastinal involvement (24 of 31 ypN+, 10 of 31 mediastinal recurrence). Patients with mediastinal involvement had greater proximal tumor extent (median 2 cm [interquartile range, 1.0 to 3.0 cm] vs 1.4 cm [interquartile range, 0.7 to 3.0 cm], P =.030), were more frequently Siewert II lesions (27 of 31 [87.1%] vs 124 of 173 [71.7%], P =.071), and were more often observed to have clinical thoracic nodal metastasis (cN) evidence (13 of 31 [42%] vs 34 of 173 [20%], P =.007) than patients who did not. On multivariable analysis of patients with intrathoracic cN0, esophageal extent of 1.5 cm or greater was independently predictive of mediastinal involvement (odds ratio 5.46, P =.011), whereas Siewert classification was not (Siewert II odds ratio 3.48, P =.116). Pretreatment proximal tumor extent, rather than Siewert classification, is an independent predictor of mediastinal involvement among AEG II/III patients without clinical evidence of mediastinal metastasis and should be considered during treatment planning. [ABSTRACT FROM AUTHOR]

Although specialty outreach clinics have been associated with improved outcomes and access to care, their role for patients with non-small cell lung cancer (NSCLC) has not been described. We sought to characterize perceptions of the utility of a specialty outreach clinic among patients with suspected NSCLC. Surveys were administered to patients who were suspected to have NSCLC and were seen at an outreach thoracic surgery clinic (2016 to 2017). The clinic was located approximately 20 miles from the academic cancer center. Sixty-nine patients completed surveys. The median distance traveled to the clinic was 43.5 miles (interquartile range: 5.0 to 111.3 miles). Among patients traveling 50 miles or more, the overwhelming majority (27 of 32 patients, 84.4%) cited physician expertise as the primary benefit of treatment at the clinic. Moreover, compared with patients living in closer proximity, they were more willing to travel 100 miles or more to have surgery (71.0% versus 26.7%, p = 0.001) or to consult with a surgeon (71.0% versus 25.8%, p < 0.001). Patients for whom it was very important to receive care close to home (33 of 68 patients, 48.5%) were less willing to travel 100 miles or more for consultation (surgeon: 33.3% versus 65.6%, p = 0.011; medical oncologist: 33.3% versus 65.6%, p = 0.011; radiation oncologist: 33.3% versus 64.5%, p = 0.015) and for treatment (surgery: 33.3% versus 65.6%, p = 0.011; chemotherapy: 36.7% versus 60.7%, p = 0.067; radiotherapy: 33.3% versus 64.3%, p = 0.018). Many patients value receiving oncologic care close to home and are sensitive to distance required to travel for care. Thoracic surgical outreach clinics may provide a benefit for patients with lung cancer in the settings of initial consultation, preoperative care, and postoperative care. [ABSTRACT FROM AUTHOR]

It is unclear whether the enhanced dexterity and visualization of the surgical robot lessens morbidity and influences staging or survival. We compared outcomes of robotic-assisted lobectomy (RAL) with thoracoscopic video-assisted lobectomy (VAL) or open lobectomy (OL) of non-small cell lung cancer. Using a prospective surgical database, perioperative and cancer-related outcomes of patients who received a lobectomy for non-small cell lung cancer from 2011 to 2017 were analyzed. Outcomes between each surgical approach were compared using inverse probability of treatment weighting generated from the inverse of the propensity score. There were 831 patients: 106 RAL, 301 VAL, and 424 OL. More RAL patients than VAL received neoadjuvant therapy (16% vs 6%, P =.001), but less than OL (28% vs 16%, P =.014). After adjustment, RAL was associated with longer operative times, less blood loss, and improved nodal harvest (all P <.02). There were no differences in morbidity, nodal upstaging, or mortality between surgical approaches. Length of stay was shorter with RAL vs OL (P <.01). Unadjusted cost was higher after RAL vs VAL (P =.003), but after adjustment, cost differences disappeared. Robotic-assisted lobectomy was associated with improved nodal harvest and less blood loss as compared with VAL or OL. Length of stay was shorter with RAL as opposed to OL. Unexpectedly, cost was not higher with RAL. The profile of patients who received RAL more closely approximated OL, suggesting RAL may allow typical thoracotomy patients to receive minimally invasive surgery after adequate training and experience. [ABSTRACT FROM AUTHOR]

Microwave ablation is a therapeutic option for patients with lung malignancies who are not surgical candidates. However, reports on local recurrence have been limited to small case series or retrospective reports. This review was conducted to synthesize the evidence regarding local recurrence and adverse events after microwave ablation for primary non–small cell lung cancer or pulmonary metastases. The PubMed, Embase, and Scopus databases were searched to identify peer-reviewed studies investigating microwave ablation of lung malignancies with local recurrence or adverse events as a primary outcome. Articles were appraised using the Critical Appraisal Skills Programme criteria. Twelve studies met the eligibility criteria, representing 985 patients and 1,336 treated lung nodules. Studies were limited by infrequent reporting of censoring and by short follow-up. Estimates of local recurrence by the end of the study varied substantially, from 9% to 37%. Tumor size was consistently shown to increase the risk of local recurrence. Among four studies that stratified results by tumor size, local recurrence among tumors smaller than 3 to 4 cm was 5% to 19%. Studies with accrual after 2011 showed recurrence rates between 9% and 26%, whereas earlier studies showed recurrence rates between 22% and 37%. The most common complication was pneumothorax, with grade III or higher complications infrequently encountered. Microwave ablation of primary and secondary lung malignancies is a reasonable therapeutic approach for select patients. Estimates of local failure after treatment are highly variable, with newer reports and smaller tumors having more favorable treatment efficacy rates. [ABSTRACT FROM AUTHOR]

Background Ground glass opacities (GGOs) on computed tomography (CT) have gained significant recent attention, with unclear incidence and epidemiologic patterns. Natural language processing (NLP) is a powerful computing tool that collects variables from unstructured data fields. Our objective was to characterize trends of GGO detection using NLP. Methods Patients were identified at a large quaternary referral center who underwent chest CT from 2000 to 2016 via query of institutional databases. NLP was used to identify imaging reports with GGOs and to obtain additional demographic data. Incidence of reported GGOs was tracked over time. Multivariate regression was used to identify predictors of GGOs identified on chest CT. Results A total of 244,391 chest CTs were included, with 35,386 (14.5%) revealing GGOs. There was a significant relationship between advancing year of chest CT and likelihood of reported GGOs (p < 0.001). GGOs were more likely to occur in older subjects (60.5 vs 58.5 years, p < 0.001), males (54.6% vs 51.5%, p < 0.001), and nonwhite races (21.2% Asian, 15.6% Hispanic, 14.4% black, 14.0% white; p < 0.001). Certain occupational histories predicted more frequent GGOs (p < 0.001), including transportation labor (47.4%), metal workers (42.3%), iron workers (33.3%), cabinetry (32.6%), and foremen (29.6%). Multivariate regression revealed age, sex, nonsmokers, increasing year of chest CT, and race as significant independent predictors of identifying GGOs. Conclusions NLP explored a large cohort of patients who underwent chest CT over the study period. Demographic features predicting reported GGOs include age, sex, race, and occupation. GGO recognition continues to increase with time, and further studies investigating etiology and prognostic implications are necessary. [ABSTRACT FROM AUTHOR]

Background Induction chemoradiation for resectable N2 non-small cell lung cancer (NSCLC) is used with the intent to optimize locoregional control, whereas induction chemotherapy given in systemic doses is meant to optimally target potential distant disease. However, the optimal preoperative treatment regimen is still unknown and practice patterns continue to vary widely. We compared multiinstitutional oncologic outcomes for N2 NSCLC from 4 experienced lung cancer treatment centers. Methods This collaborative retrospective study unites 4 major thoracic oncology centers. Patients with N2 NSCLC undergoing surgical resection after induction chemotherapy (CxT) or concurrent chemoradiation (CxRT) were included. Primary outcomes were overall and disease-free survival (OS and DFS). Results 822 patients were identified (CxT = 662 and CxRT = 160). There were no differences in 5-year OS (CxT 39.9% versus CxRT 42.9%, p = 0.250) nor in DFS (CxT 28.7% versus 29.8%, p = 0.207). Recurrence rates (CxT 46.8% versus CxRT 51.6%, p = 0.282) and recurrence patterns were not significantly different (Local: CxT 9.8% versus CxRT 9.7%; and Distant: CxT 30.4% versus CxRT 33.1%, p = 0.764). There was no difference in perioperative mortality. In the analyses of patients who underwent pretreatment invasive mediastinal staging (n = 555), there were still no significant differences in OS (p = 0.341) and DFS (p = 0.455) between the 2 treatment strategies. Conclusions Both treatment strategies produce equivalent and better than expected outcomes compared with historical controls for N2 NSCLC, with no differences in recurrence patterns. How these conventional therapeutic strategies will compare with those involving immunotherapy combined with surgical locoregional disease control for N2 disease remains to be determined. [ABSTRACT FROM AUTHOR]

Background Previous studies have highlighted important biologic and survival-related differences among men and women with non-small cell lung cancer (NSCLC). However, differences in perioperative or short-term outcomes have not been as well characterized. In this study, we investigated differences in the perioperative period and postoperative emergency department (ED) visits among men and women after lobectomy for stage I NSCLC. Methods A retrospective review was performed of patients who underwent a lobectomy for clinical stage I NSCLC at a single institution from 2010 to 2015. Results We identified 559 patients for inclusion, including 293 women (52%) and 266 men (48%). Women were more likely to present with clinical T1 status (p = 0.005) and to undergo a minimally invasive operation (p = 0.058). To reduce confounding, 206 case-matched pairs were identified. After matching, no differences were found in length of stay (p = 0.551) or pulmonary complications (p = 0.509); however, men experienced more cardiac complications (18% versus 7%, p = 0.001). Of importance, although rates of 30- and 90-day ED visits between sexes were similar (p = 0.531, p = 0.890, respectively) and no sex-related differences were found in presenting symptom on return to the ED (p = 0.478), women were more likely to be readmitted after presenting to the ED within 30 days (p = 0.038). Conclusions Women demonstrated an increased likelihood of being admitted after presenting to the ED within 30 days after discharge, indicating important differences between men and women in the short-term period after lobectomy. Further research will be required to further understand the cause for these differences. Visual Abstract [ABSTRACT FROM AUTHOR]

Background Ground glass opacities pose diagnostic challenges, and even after malignancy is confirmed, prognosis is often unclear. We sought to identify clinicoradiographic features that could predict aggressive tumor biology in lung adenocarcinoma with associated ground glass components. Methods A retrospective review of patients with resected lung adenocarcinoma from 2008 to 2013 was performed. Detailed radiographic features were reviewed by two radiologists. Logistic regression was used to identify risks of poor differentiation or a composite outcome of nodal metastases and lymphovascular invasion. Results In all, 79 patients met criteria for analysis. Larger tumor size ( p = 0.04), increasing solid component ( p = 0.01), pleural tags ( p = 0.03), spiculation ( p = 0.01), lobulation ( p < 0.05), history of coronary artery disease ( p = 0.04), and increasing number of pack-years smoking ( p < 0.05) were associated with poorly differentiated tumors. However, after adjustment for size of the solid component, the associations between pleural tags, spiculation, and lobulation with poorly differentiated tumors were negated, whereas number of pack-years and history of coronary artery disease remained statistically significant ( p = 0.01 and p = 0.03, respectively). There were no identified clinical or radiographic features associated with lymphovascular invasion/nodal metastasis. Conclusions Several radiographic features were associated with aggressive tumor biology, a well-known finding. However, we found that none of these radiographic features remained relevant after we adjusted for the size of the solid component, indicating that radiographic features are not as important as previously believed. Further research will be required to identify reliable markers associated with favorable tumor biology. These studies will ultimately be critical in informing prognosis or guiding extent of resection. [ABSTRACT FROM AUTHOR]

Background Enhanced recovery after surgery (ERAS) pathways aim to improve postoperative recovery through evidence-based practices, including early ambulation, multimodal opioid-sparing analgesia, and reduction of surgical stress. This study evaluated outcomes after implementation of ERAS in patients undergoing resection for pulmonary malignancy. Methods A retrospective review compared outcomes for patients undergoing pulmonary resection for primary lung cancer. Analysis was performed between three periods: pre-ERAS (January 1, 2006, to December 31, 2011), transitional period with elements of ERAS (January 1, 2012, to August 31, 2015), and full implementation of ERAS (September 1, 2015, to December 31, 2016). Results We analyzed 2,886 lung resections (pre-ERAS, n = 1615; transitional, n = 929; ERAS, n = 342). For all patients, length of stay decreased in the ERAS and transitional periods compared with pre-ERAS (4 [3] versus 4 [3] versus 5 [3] days, p < 0.001). Pulmonary complications were decreased with ERAS compared with transitional and pre-ERAS (19.9% versus 28.2% versus 28.7%, p = 0.004). Cardiac complications decreased with ERAS (12.3% versus 13.1% versus 18.1%, p = 0.001). There was less thoracic epidural use (2.9% versus 44.5% versus 75.5%, p < 0.001). There were no differences in hospital readmission ( p = 0.772) or mortality rates ( p = 0.417). After thoracotomy, ERAS was associated with decreased length of stay, fewer intensive care unit readmissions, and decreased frequency of pneumonia, atrial arrhythmias, and need for home oxygen (all p < 0.05). ERAS was independently associated with decreased pulmonary ( p = 0.046) and cardiac ( p = 0.001) complications on logistic regression after thoracotomy but not minimally invasive operations. Conclusions ERAS was associated with improved postoperative outcomes, including decreased length of stay and pulmonary and cardiac morbidity after thoracotomy, but not after minimally invasive operations. ERAS safety was demonstrated by low rates of adverse events without effect on hospital readmission or perioperative deaths. [ABSTRACT FROM AUTHOR]

Background Immune checkpoint inhibitors that target the programmed cell death protein ligand 1 (PD-L1) pathway have shown benefit for the treatment of metastatic non-small cell lung cancer (NSCLC). However, the prognostic value of PD-L1 independent of immunotherapy is still unclear, with conflicting results reported between PD-L1 expression and patient survival. Our aim was to correlate PD-L1 mRNA level with clinical and pathologic factors and to investigative the prognostic value of PD-L1 mRNA in all stages of NSCLC. Methods Gene expression and clinical data were obtained from public repositories in The Cancer Genome Atlas from the National Cancer Institute. Genotype-Tissue Expression was used to compare with normal tissue expression analysis. Results A total of 985 patients met inclusion criteria, among whom 79.6% were stage I to II, 16.5% were stage III, and 3.5% were stage IV, representing 495 adenocarcinoma and 490 squamous cell carcinoma (SCC). PD-L1 mRNA gene expression in lung cancers was higher than in most other tumor and normal tissue types and was significantly higher in lung SCC than adenocarcinoma ( p < 0.001). PD-L1 mRNA expression was associated with pathologic stage in SCC and with smoking status in adenocarcinoma of the lung. However, none of the cutoff values of PD-L1 mRNA expression were prognostic of overall survival. Conclusions Our results suggest that the value of PD-L1 mRNA in prognosticating outcome in lung cancer is limited. Further studies are needed to identify novel prognostic biomarkers other than PD-L1 that are associated with improved patient survival. Identification of further prognostically important biomarkers may prove useful in identifying patients suitable for immunotherapy. [ABSTRACT FROM AUTHOR]

Background Among patients with previous lung cancer, the malignant potential of subsequent ground-glass opacities (GGOs) on computed tomography remains unknown, with a lack of consensus regarding surveillance and intervention. This study sought to describe the natural history of GGO in patients with a history of lung cancer. Methods A retrospective review was performed of 210 patients with a history of lung cancer and ensuing computed tomography evidence of pure or mixed GGOs between 2007 and 2013. Computed tomography reports were reviewed to determine the fate of the GGOs, by classifying all lesions as stable, resolved, or progressive over the course of the study. Multivariable analysis was performed to identify predictors of GGO progression and resolution. Results The mean follow-up time was 13 months. During this period, 55 (26%) patients’ GGOs were stable, 131 (62%) resolved, and 24 (11%) progressed. Of the 24 GGOs that progressed, three were subsequently diagnosed as adenocarcinoma. Patients of black race (odds ratio [OR], 0.26) and other races besides white (OR, 0.89) had smaller odds of GGO resolution ( p = 0.033), whereas patients with previous lung squamous cell carcinoma (OR, 5.16) or small cell carcinoma (OR, 5.36) were more likely to experience GGO resolution ( p < 0.001). On multivariable analysis, only a history of adenocarcinoma was an independent predictor of GGO progression (OR, 6.9; p = 0.011). Conclusions Among patients with a history of lung cancer, prior adenocarcinoma emerged as a predictor of GGO progression, whereas a history of squamous cell carcinoma or small cell carcinoma and white race were identified as predictors of GGO resolution. [ABSTRACT FROM AUTHOR]

Background Data from meta-analyses support the use of induction or adjuvant platinum-based chemotherapy for locally advanced non-small cell lung cancers (NSCLCs). This phase 2 study assessed the role of induction cisplatin and docetaxel followed by surgery in patients with resectable stage I to III NSCLCs, followed by 12 months of adjuvant erlotinib. Methods Patients with resectable stage I to III NSCLCs received cisplatin 80 mg/m 2 , docetaxel 75 mg/m 2 every 21 days for 3 cycles, followed by surgery, followed by adjuvant erlotinib for 12 months. The primary endpoint included safety. Long-term efficacy outcomes and exploratory analysis of intermediary endpoints are also reported ( NCT00254384 ). Results Forty-seven eligible patients received a median of 3 cycles of induction treatment, 37 underwent surgical resection, and only 21 received adjuvant erlotinib. Two patients died in the perioperative period (1 sepsis during chemotherapy, 1 acute respiratory distress syndrome postoperatively). Most common grade 3 to 5 toxicities during chemotherapy included hypokalemia (8%), infection (7%), and granulocytopenia (25%). During adjuvant erlotinib, 14% of patients experienced grade 2 rash. Median overall survival was 3.4 years. Major pathologic responses in the primary tumor were observed in 19% (7 of 37) of patients and correlated with improved long-term overall survival. Complete pathologic response in mediastinal/hilar nodes also correlated with superior survival. Conclusions Induction cisplatin and docetaxel was well tolerated. Adjuvant erlotinib did not improve outcomes compared with historical controls. Major pathologic response predicted for improved long-term survival and is a suitable intermediary endpoint for future phase 2 studies. [ABSTRACT FROM AUTHOR]

Background Surgical skill assessment tools frequently reflect the opinions of small groups of surgeons. That raises concerns over their generalizability as well as their utilization when applied broadly. A Delphi approach could engage a broad group of experts to identify key elements for a checklist assessing coronary anastomotic skill, improving generalizability. Methods Expert surgeons in North America (10 or more years in practice, actively teaching coronary artery surgery) were contacted randomly to participate. Consenting surgeons first provided items they believed were mandatory when performing a coronary artery bypass. These were then entered into a three-round Delphi. Positive consensus was reached when 75% or more of participants ranked an item mandatory. Results Sixteen faculty consented to participate. Each participant provided 25 ± 10 items. The 407 items provided were condensed, resulting in 146 items in the final list, divided into six sections based on the conduct of the operation. Twenty-three items reached consensus in the first round, 14 in the second, and 3 in the third. These 40 items represented only 27% of the initial 146 items. Agreement within sections varied widely, from 0% for “management of assistants” to 47% for “testing and final steps.” Conclusions A randomly selected group of experts using a Delphi approach can generate a checklist to assess construction of a coronary artery bypass. Considerable disagreement among experts regarding what steps are mandatory calls into question the generalizability of any locally developed checklist. [ABSTRACT FROM AUTHOR]

Background Perioperative management of antiplatelet therapy for patients undergoing pulmonary resection must balance the risk of cardiovascular events with that of hemorrhage. An optimal approach has not been defined in this population. We sought to characterize outcomes of patients undergoing pulmonary lobectomy on antiplatelet therapy with clopidogrel. Methods A prospective institutional database was retrospectively reviewed to identify all patients undergoing pulmonary lobectomy from 2007 to 2015 who received perioperative clopidogrel. Patients were grouped according to the timing of clopidogrel discontinuation before operation: group I, 5 days or less; group II, 6 to 14 days; and group III, more than 14 days. Analyses were performed to assess the effect of timing of discontinuation on adverse events. Results Sixty-two patients were identified and included in the analysis. The indication for clopidogrel was coronary artery disease in 44 patients (71%), 35 (56%) of whom had prior stent placement. The overall incidences of transfusion and major cardiovascular events were 16% (10 of 62) and 6.5% (4 of 62), respectively. Non-ST elevation myocardial infarctions occurred in 4 patients. Three were in patients with stents, all placed more than 1 year before the operation. There were no significant differences identified in estimated blood loss, operative duration, or perioperative deaths. Conclusions No significant outcome differences in perioperative cardiovascular or hemorrhagic events were identified among the groups. Although these findings suggest that clopidogrel may be discontinued shortly before the operation with limited risk of bleeding, we also found that holding therapy for more than 14 days preoperatively may be safe in appropriately selected patients. [ABSTRACT FROM AUTHOR]

Background Traditional journal clubs addressing single articles are limited by the lack of a standardized process for conduct and evaluation. We developed a novel, debate-style journal club for trainees to use best available evidence to address controversial topics in cardiothoracic surgery through discussion of realistic patient scenarios. Methods After implementation of our new curriculum, trainee knowledge acquisition and retention were assessed by a summative test of published literature and standardized debate scoring. Feedback was additionally obtained by trainee and faculty surveys. Results Cardiothoracic surgery trainees (n = 4) participated in five debates each over 10 monthly sessions. Written examination results after debate revealed a nonsignificant improvement in scores on topics that were debated compared with topics that were not (+9.8% versus −4.2%, p = 0.105). Trainee ability to sway the debate position supported by the attendee strongly correlated with trainee use of supporting literature ( r = 0.853), moderately correlated with persuasiveness ( r = 0.465), and overall effect of the debate ( r = 0.625). Surveys completed by trainees and faculty unanimously favored the debate-style journal club as compared to the traditional journal club in gaining familiarity and applying published literature to questions encountered clinically. Conclusions Our novel debate-style cardiothoracic surgery journal club is an effective educational intervention for cardiothoracic surgery trainees to acquire, retain, and gain practice in applying specialty-specific literature-based evidence to controversial case-based issues. Evaluation by multi-institutional expansion is needed to validate our preliminary findings in this initial trainee cohort. [ABSTRACT FROM AUTHOR]

Background We aimed to evaluate the impact of collagen matrix in the reconstruction of the diaphragm. Methods We queried the electronic medical record for patients who had resection of the diaphragm and simultaneous pulmonary resection between 1999 and 2016. All reconstructions were performed with either polytetrafluoroethylene or acellular dermal matrix. We evaluated the rate of empyema and herniation in each group. Results A total of 208 patients met inclusion criteria. Polytetrafluoroethylene was used in 168 cases (80.8%) and dermal matrix in 40 cases (19.2%). Dermal matrix was used in 8 extrapleural pneumonectomies (5.4%), in 26 pleurectomy decortications (55.3%), and in 6 other types of resections (40%). Follow-ups were for a median of 15.0 months in the polytetrafluoroethylene group and 11.6 months in the dermal matrix group. Patients in the dermal matrix group had a chest tube for a median of 2.5 days longer than patients with polytetrafluoroethylene ( p = 0.006). Empyema occurred in 11 polytetrafluoroethylene reconstructions (6.5%) and 3 dermal matrix reconstructions (7.5%) ( p = 0.735). Seven patients (63.6%) with polytetrafluoroethylene infection required removal of the graft, whereas none in the dermal matrix group needed removal ( p = 0.351). There were nine herniations in the polytetrafluoroethylene group and four in the dermal matrix group ( p = 0.281), all were acute and due to anchorage failure. Conclusions Although infection rates were similar between polytetrafluoroethylene and acellular dermal matrix, re-operation for removal was not necessary in the latter. The use of a thick acellular dermal matrix may be a reasonable option when diaphragmatic reconstruction is potentially associated with a higher risk of infection. [ABSTRACT FROM AUTHOR]

Background Since 2010, the Joint Council on Thoracic Surgery Education, Inc (JCTSE) has sponsored an annual “Educate the Educators” (EtE) course. The goal is to provide United States academic cardiothoracic surgeons (CTS) the fundamentals of teaching skills, educational curriculum development, and using education for academic advancement. This report describes the course development and evaluation along with attendee’s self-assessment of skills through the first 5 years of the program. Methods The content of this 2½-day course was based on needs assessment surveys of CTS and residents attending annual meetings in 2009. From 2010 to 2014, EtE was offered to all CTS at training programs approved by the Accreditation Council for Graduate Medical Education. Course content was evaluated by using end-of-course evaluation forms. A 5-point Likert scale (1 = poor, 5 = excellent) was used to obtain composite assessment mean scores for the 5 years on course variables, session presentations, and self-assessments. Results With 963 known academic CTS in the United States, 156 (16.3%) have attended, representing 70 of 72 training programs (97%), and 1 international surgeon attended. There were also 7 program coordinators. Ratings of core course contents ranged from 4.4 to 4.8, accompanied with highly complementary comments. Through self-assessment, skills and knowledge in all content areas statistically improved significantly. The effect of the course was evaluated with a follow-up survey in which responders rated the program 4.3 on the usefulness of the information for their career and 3.9 for educational productivity. Conclusions The EtE program offers an excellent opportunity for academic CTS to enhance their teaching skills, develop educational activities, and prepare for academic promotion. With its unique networking and mentorship environment, the EtE program is an important resource in the evolution of cardiothoracic surgical training in the United States. [ABSTRACT FROM AUTHOR]

Background Emerging technologies for prosthetic reconstruction after chest wall resection have yielded a wide variety of reconstructive options for thoracic surgeons. The ideal chest wall reconstruction and its impact on perioperative outcomes has not been well defined. Our goal was to determine whether mesh characteristics such as rigidity or absorbability altered perioperative pulmonary and infectious outcomes. Methods Our institutional database was queried for patients who underwent chest wall resection and reconstruction for primary or secondary chest wall tumors between the years 1998 and 2013. A focused chart review supplied clinical and perioperative variables. The main study outcomes focused on perioperative pulmonary and wound/implant infectious complications. Univariate and multivariate analyses were performed to identify variables associated with outcome. Results We identified 1,096 patients who underwent chest wall resection during the study period, of which 427 required chest wall reconstruction. Pulmonary complications occurred in 24% (n = 102 of 427) of patients. We observed no significant difference in pulmonary complications between those that had a rigid versus flexible chest wall reconstruction ( p = 0.401; OR, 1.43; 95% CI, 0.83–2.43). The odds of pulmonary complications increased with each additional resected rib (OR, 1.43; 95% CI, 1.2–1.71). Multivariable analysis identified the number of resected ribs (OR, 1.26; 95% CI, 1.00–1.59) and concomitant lobectomy (OR, 3.59; 95% CI, 1.62–7.92) as variables associated with perioperative pulmonary morbidity. Infectious complications occurred in 13 patients and were not predicted by the use of permanent versus absorbable prosthetic materials ( p = 0.575). Conclusions The type of reconstructive material, whether with rigid, flexible, permanent, or biologic characteristics, does not appear to influence perioperative pulmonary or infectious wound complications. Rather, the number of resected ribs and the concomitant lung parenchymal resection predict pulmonary morbidity following chest wall resection. Depending on the circumstances, an effective chest wall reconstruction can be achieved with either rigid or flexible prosthetic material. [ABSTRACT FROM AUTHOR]

Background The feasibility and efficacy of a web-based curriculum in supplementing thoracic surgical training was previously shown. However, the impact of curricular participation on validated knowledge tests remains unknown. We compared in-service training examination (ITE) results among trainees, stratified by curricular use. Methods The national online curriculum was implemented in August 2013. We retrospectively reviewed trainees who participated in thoracic surgical training programs in both 2012 to 2013 and 2013 to 2014. Scores from the 2013 and 2014 ITEs were obtained, and curricular usage data were collected from site analytics. Trainees were separated into three groups according to 2013 ITE scores; within each group, changes in score for high- versus low-volume users were compared. Results 187 trainees took the ITE both years, with exposure to the online curriculum during only the second year. High-volume users’ scores trended toward greater improvement than scores of low-volume users (+18.2% versus +13.0%, p = 0.199). When stratified by 2013 score, the lowest scoring quartile improved substantially, and the highest scoring quartile improved modestly, regardless of curricular use. However, for those individuals who achieved mid-range scores in 2013, there was a trend toward much greater improvement in score with heavier use of the curriculum (+17.0% versus +7.0%, p = 0.094). Conclusions Among trainees who had access to the novel online curriculum during the second of 2 consecutive years, we evaluated the impact of curricular participation on ITE scores. The effect appears to be most pronounced in individuals with mid-range scores, in whom high curricular use led to the greatest improvement. [ABSTRACT FROM AUTHOR]

Background After hospital discharge, patients may have questions or complaints that surface or remain inadequately addressed. However, the dominant concerns and indications for further intervention among recently discharged patients after pulmonary resection have not been well described. The aims of this study were to characterize dominant concerns of pulmonary resection patients after discharge and to elucidate any relevant risk factors for their development. Methods A single-institution, retrospective review was conducted of all patients who underwent pulmonary resection over a 12-month period and included records of standardized, nurse-initiated follow-up phone calls to discharged patients. Records of postdischarge telephone calls were reviewed, and data collected pertaining to complaints requiring counseling over the phone or escalation to higher care level. Demographic, operative, and hospital data were examined by multivariate analyses to assess predictors of need for counseling or escalation of care. Results In all, 523 patients underwent pulmonary resection during the study, and 245 (46.8%) had nursing-documented telephone conversations at 4.6 days (±0.18) days after discharge. Among those reached, 81 (33.1%) had problems requiring counseling during the call; 31 (12.7%) reported concerns requiring escalation of care, handled by subsequent telephone call for 7 (22.6%), clinic appointment for 22 (71.0%), or emergency room referral for 2 (6.5%). Age, sex, race, and residential proximity to the hospital did not predict need for counseling nor escalation of care. Conclusions Patient complaints after pulmonary resection were frequent, with most problems resolved by telephone counseling. Despite highly prevalent concerns, predictors of need for counseling or care escalation were not identified, suggesting ongoing utility in the practice of telephoning all patients. Further, this study serves as a needs assessment, highlighting the importance of patient education and discharge planning. [ABSTRACT FROM AUTHOR]

Background To facilitate deliberate practice, we developed and evaluated a three-dimensional multistation cardiovascular simulator with low-fidelity, anatomically correct materials. Methods Surgical educators and senior fellows at several national institutions who are a part of the Thoracic Education Cooperative Group completed expert validation surveys that feature a self-report rating scale, ranging from 0 (don’t know) to 4 (highly realistic, no changes needed), and a global recommendation rating scale, ranging from 0 to 3. To analyze the survey results, we used paired Student t tests and a many-facet Rasch model. Results We analyzed the results of 18 expert validation surveys (completed by 9 senior fellows and by 9 staff surgeons). The overall realism-of-experience rating for the simulator was 3.23 (of 4), suggesting adequate realism with room remaining for improvement. Senior fellows rated the aortic graft replacement station and overall physical attributes more favorably than staff. Staff surgeons favored the simulator for realism of the mitral valve annuloplasty station and the cannulation station and for its use as a training tool. The overall global recommendation rating for the simulator was 2.38 (of 3), suggesting that the simulator can be considered for use in cardiovascular surgery training programs with minor improvements. Conclusions This three-dimensional multistation cardiovascular simulator has adequate realism and can be considered for use in cardiovascular training programs. Platforms such as this may facilitate deliberate home practice and reinforcement of technical skills. [ABSTRACT FROM AUTHOR]

Background Cardiothoracic surgery is rapidly evolving to adapt to a changing health care environment and a wider application of innovative techniques. The Society of Thoracic Surgeons Workforce on Thoracic Surgery Resident Issues Transition to Practice Task Force sought to identify new or existing gaps of training in contemporary thoracic surgery residency training programs. Methods A voluntary survey consisting of 24 questions was distributed to recent graduates of thoracic surgery residency programs in the United States during the 2014 American Board of Thoracic Surgery oral examination application process. Fifty-five of 132 applicants anonymously participated. Results The majority of respondents admitted that they needed more instruction or lacked confidence with the following specific cardiothoracic procedures: minimally invasive cardiac operations (25/52, 48%), robotic cardiac operations (29/52, 55.8%), endovascular operations (28/52, 53.8%), robotic pulmonary operations (29/52, 55.8%), minimally invasive esophageal operations (24/52, 46.2%), robotic esophageal operations (32/52, 61.5%), and operations on congenital cardiac conditions (31/52, 59.6%). The respondents further declared either a need for more instruction or lack of confidence in employment contracting (17/21, 81.0%), negotiating terms of employment (17/21, 81.0%), and professional service agreements (16/21, 76.2%). Conclusions Further exposure to minimally invasive robotic procedures, operations on congenital conditions, and issues of practice management appear to be needed in contemporary cardiothoracic training in the United States. These identified gaps may assist cardiothoracic surgery residency programs to optimally prepare future graduates for our evolving specialty. [ABSTRACT FROM AUTHOR]

Background The American Joint Committee on Cancer Cancer Staging Manual 7th Edition esophageal cancer staging was derived from outcomes of patients undergoing esophagectomy alone and eliminated nodal location from its schema. A limitation of this staging system is that it has not been validated in the setting of multimodality therapy for esophageal cancer. In addition, nodal location continues to influence treatment decisions. The aim of our study was to evaluate outcomes of patients with distal esophageal or gastroesophageal junction (GEJ) adenocarcinoma undergoing trimodality therapy and assess the effect of nodal location on survival. Methods This multiinstitutional retrospective study assessed patients with clinically node-positive (cN+) distal esophageal/GEJ adenocarcinoma treated with trimodality therapy between January 2002 and December 2011. Nodal stations were classified as paratracheal, subcarinal, celiac, lower esophageal, paraaortic, supraclavicular, or perigastric/perihepatic. Overall survival (OS) was estimated by the Kaplan-Meier method. Univariate and multivariate analyses were performed to identify variables associated with OS. Results A total of 196 cN+ patients met the study criteria. The most prevalent metastatic nodal location was in the perigastric region, present in 141 patients (72%); paratracheal nodal involvement was present in 19 patients (10%). None of the nodal stations was significantly associated with OS on univariable analysis. Multivariable analysis identified age (hazard ratio [HR], 1.036; p = 0.001), male sex (HR, 2.39; p = 0.003), pathologic ypT3 (HR, 1.81; p = 0.048), and ypN3 (HR, 2.93; p = 0.003) as being significantly associated with survival. Conclusions The location of cN+ regional node disease in patients with distal esophageal or GEJ adenocarcinoma was not predictive of survival after trimodality therapy. Age, sex, pathologic tumor depth, and the number of involved nodes were independent predictors of survival. Patients with cN+ cancers should not be deprived of potentially curative surgical resection based solely on the location of regional nodal disease. [ABSTRACT FROM AUTHOR]

Background Management of superior sulcus non-small cell lung cancer (NSCLC) continues to evolve, with preoperative chemoradiotherapy (CXRT) followed by surgical intervention supported by several studies. Rates of pathologic complete response (pCR) have varied, and previous attempts to identify clinical predictors of pCR have been unsuccessful. We analyzed our experience with resected superior sulcus NSCLC to elucidate clinical features suggestive of pCR among patients after preoperative treatment. Methods A multiinstitutional retrospective review was performed in patients who underwent resection for superior sulcus NSCLC between January 1988 and July 2013. Data pertaining to comorbidities, staging, therapy, imaging, and outcomes were collected. Logistic regression was performed to identify predictors of survival and pCR. Results During the study, 102 patients underwent preoperative therapy, consisting of CXRT in 75 (73.5%), chemotherapy in 15 (14.7%), and radiotherapy in 12 (11.8%). After median follow-up of 18.0 months, overall and disease-free survivals were 51.0% and 45.1%, respectively. On multivariate regression, independent predictors of survival included pCR ( p = 0.001; hazard ratio [HR], 0.243; 95% confidence interval [CI], 0.106–0.555) and age ( p = 0.007; HR, 1.049; CI, 1.013–1.085). Among those who received CXRT, 24 of 75 (32%) achieved pCR. Multivariate regression analysis of the CXRT group revealed that pCR was independently predicted by extent of size reduction on imaging ( p = 0.015; HR, 1.042; CI, 1.008–1.078), with histologic examination showing a trend toward significance ( p = 0.073). Conclusions Preoperative chemoradiation frequently resulted in pCR, and treatment response on imaging was associated with the likelihood of achieving pCR. Future investigations are warranted to further predict pCR from preoperative clinical variables such as symptom resolution, as identification of accurate predictors may ultimately permit the application of selective surgical intervention in superior sulcus NSCLC. [ABSTRACT FROM AUTHOR]

Background The definitive use of 18F-2-deoxy- d -glucose positron emission tomography (FDG-PET) to detect nodal metastasis in patients with early-stage non-small cell lung cancer (NSCLC) being evaluated for local nonsurgical management, such as stereotactic body radiation therapy and minimally invasive percutaneous ablative therapies, underscores the importance of diagnosing N1 disease by FDG-PET. The purpose of this study was to evaluate FDG-PET in the detection of N1 disease and to determine if FDG-PET–positive N1 disease predicts poor survival in patients with pathologic stage II-N1 NSCLC. Methods We reviewed all patients who underwent surgical resection for lung cancer at MD Anderson Cancer Center from 2000 to 2011 who had pathologic stage T1 to T2 and N1 disease and a preoperative FDG-PET. We compared the clinicopathologic characteristics and survival of patients who had PET-positive N1 and PET-negative N1 disease. Results A total of 104 patients met the inclusion criteria. The pathologic stage in 87 patients was IIA (T1a N1, T1b N1 or T2a N1) and in 17 patients was IIB (T2b N1). Only 25 of 104 patients (24%) had PET-positive N1 disease. There was no clinical or pathologic difference between the patients who had PET-positive N1 and PET-negative N1 disease. No significant difference was found in the survival rates between patients from the PET-positive N1 and the PET-negative N1 groups ( p = 0.9). Conclusions FDG-PET has poor sensitivity in detecting N1 disease, and N1-positive disease on FDG-PET does not have an effect on survival. FDG-PET should not be used alone to determine management in patients with early-stage non-small cell lung cancer being evaluated for local nonsurgical management. [ABSTRACT FROM AUTHOR]

Background Cardiothoracic surgical education faces numerous challenges, including reduced duty hours and diminishing prioritization of teaching, in the setting of rapidly advancing knowledge, skills, and case complexity. Pass rates on the American Board of Thoracic Surgery exam remain suboptimal, and new training formats are being evaluated. We hypothesize that Internet-based courses can be developed and implemented to supplement learning of basic topics in cardiothoracic surgery. Methods After a needs assessment, 4 online self-study courses were developed by content experts using a Moodle [modular object-oriented dynamic learning environment] platform. As a pilot cohort, students from 4 thoracic surgery training programs participated, accessing courses at their own pace. Each course included general and detailed readings, multimedia content, discussion forum, and a question-bank supported quiz (90% required to pass, multiple attempts allowed). Utilization and exam data were tracked electronically. The t tests were used to compare first versus final-year traditional track trainees. Post-course surveys collected data on trainee attitudes. Results Nineteen students completed 4 courses on tracheal disease. Mean time spent per course and quiz attempts to pass were 1.35 hours and 2.86, respectively. Scores improved with successive attempts. Senior trainees showed a trend toward less time per course and fewer quiz attempts. Post-course surveys uniformly demonstrated perceived benefits from the content and quizzes in an easy-to-navigate format. Conclusions Online courses can be developed and integrated within cardiothoracic training programs. This pilot demonstrates evidence of active learning as shown through the embedded assessments. Internet-based courses may serve as a means of supplementing modern thoracic surgical training. Further development and evaluation are warranted. [ABSTRACT FROM AUTHOR]

Background: Postesophagectomy diaphragmatic hernia (PDH) is a recognized but severely under-reported and potentially hazardous event. Information regarding the natural course of this condition and guidelines regarding indications for reoperative intervention are lacking. In this study we aim to describe the frequency, predictors of incidence, and indications for repair. Methods: Cross-sectional imaging (computed tomography scan) from patients who underwent esophagectomy between January 2001 and December 2007 at a single center were reviewed by two radiologists blinded to previous reports and clinical outcomes. Patients with PDH were compared with a similar cohort who did not have hernia. Patient characteristics, outcomes, and hernia descriptors including longitudinal progression were recorded. Multivariable logistic regression analyses identified predictors of PDH and need for repair. Results: Of a total of 440 patients who underwent esophagectomy, 67 (15%) were radiologically diagnosed with PDH. Of these, only 7 of 67 cases (10%) were prospectively reported by the radiologist. Median time interval from esophagectomy to hernia was 2 years. Type of esophagectomy was an independent predictor for hernia developing (p = 0.027). Patients with high body mass index were less prone to have PDH (p = 0.043). Thus far, 9 patients (2%) have required surgical intervention, all for hernia-related symptoms or progression. Despite mesh repair, 4 of 9 have recurred and 2 were re-repaired. There was 1 PDH-associated death, 8 years after transhiatal resection. Conclusions: Variables contributing to PDH are both technical and patient dependent. Whereas the majority of patients with PDH have not required repair, a small portion who became symptomatic or had large, progressive hernia required remedial surgery. Postesophagectomy patients require long-term surveillance for PDH. [Copyright &y& Elsevier]

Background. Visceral pleural invasion (VPI) is used as an indicator of adverse prognosis in non-small cell lung cancer (NSCLC). The purpose of this retrospective study was to evaluate the impact of VPI on disease-free survival (DFS) and overall survival (OS) in patients with node-negative NSCLC. Methods. Between 1998 and 2009, 1,166 patients with pathologic NOM0 NSCLC underwent surgical resection by lobectomy. Two hundred fourteen patients with VPI were compared with 952 patients without VPI. Results. Median follow-up was 59 months. In multivariate analysis, VPI, larger tumor size, older age, female sex, and poor performance status were significantly associated with decreased OS. In contrast, larger tumor size, female sex, and poor performance, but notably not VPI, were associated with decreased DFS. After examining interactive effects of VPI and T stage subgroups, found that VPI did not significantly affect either OS or DFS in the subgroups of patients with smaller tumor sizes--stage T1a, stage T1b, or stage T2a. In contrast, a deleterious effect of VPI on DFS was seen for tumors larger than 5 cm--stages T2b and T3--with the VPI-stage T3 interaction effect being statistically significant for DFS but not for OS. Conclusions. The effect of VPI on survival in NSCLC varies greatly with tumor size, with VPI not strongly associated with OS or DFS in tumors smaller than 5 cm, but showing large negative effects on DFS for stage T2b and stage T3 tumors. Using VPI to upstage T1 tumors to a higher T stage is not warranted because it would misrepresent these VPI-T stage subgroup effects. [ABSTRACT FROM AUTHOR]

Background: Resection of pulmonary colorectal carcinoma metastases may provide long-term benefit, but patient selection remains controversial. The objective of this study was to identify preoperative predictors of survival and lung recurrence for patients undergoing resection of such lesions. Methods: A prospectively collected database was retrospectively reviewed to identify patients who underwent their first colorectal carcinoma pulmonary metastasectomy. Two multivariate logistic analyses were performed to identify preoperative predictors of survival and lung recurrence. Preoperative factors, pathologic colorectal carcinoma stage, additional sites of metastases, timing of metastatic occurrence, and premetastasectomy disease-free interval were included in the univariate analyses. Results: From January 2000 to December 2010, 229 patients met inclusion criteria. The mean age was 60 years, and 100 patients (43.7%) were women. The overall median time and 5-year survival rate were 70.1 months and 55.4%, respectively, after the first pulmonary metastasectomy. Median follow-up was 37.2 months. Age older than 60 years (hazard ratio [HR], 1.03; 95% confidence interval [CI], 1.005 to 1.052; p = 0.016), male sex (HR, 1.84; 95% CI, 1.089 to 3.094; p = 0.023), and more than three lung metastases (HR, 1.15; 95% CI, 1.024 to 1.282; p = 0.018) predicted survival at 5 years in one multivariate analysis. In the second, more than three lung metastases present at first metastasectomy (HR, 1.19; 95% CI, 1.071 to 1.321; p = 0.001) and the preoperative disease-free interval of less than 3 years (HR, 0.99; 95% CI, 0.973 to 0.997; p = 0.013) predicted lung recurrence. Conclusions: Older age, male sex, and more lung metastases predict poorer survival after resection of pulmonary colorectal cancer metastases. The number of lung metastases present at the first metastasectomy and the preoperative disease-free interval predicted recurrence in the lung. [ABSTRACT FROM AUTHOR]

Background: Outcomes of salvage esophagectomy after definitive chemoradiation (CRT) for squamous cell carcinoma are well defined. Previous reports of salvage esophagectomy in patients with recurrent adenocarcinoma after definitive CRT are limited by small numbers and high morbidity and mortality rates. Methods: We reviewed our experience of 65 patients with esophageal adenocarcinoma treated from 1997 to 2010 who underwent salvage esophagectomy after failed definitive CRT. We then compared this group to 65 matched patients of 521 total patients with esophageal adenocarcinoma who received preoperative CRT followed by planned esophagectomy. Propensity matching and multivariable analysis were performed. Results: Median time to surgery from completion of therapy for the salvage group was 216 days. Major postoperative events (major pulmonary event, conduit loss, leak, readmission to intensive care unit) occurred in 35% (23 of 65) of salvage patients and 31% (20 of 65) of the planned resection matched group. Anastomotic leak occurred in 18.5% (12 of 65) and 11.3 (59 of 521) of salvage and planned groups, respectively. Thirty-day mortality was 3.1% (2 of 65) after salvage resection and 4.6% (3 of 65) after planned resection. There was no difference in 3-year overall or median survival between the two groups of patients (32 months, 48% salvage, versus 40 months, 57% planned resection). Multivariable analysis did not identify salvage strategy or time from completion of therapy to resection as a predictor of major event or death. Conclusions: Postoperative morbidity, mortality, and overall survival of patients after salvage esophagectomy are comparable to matched patients after planned resection. These results suggest that patients with esophageal adenocarcinoma who fail definitive CRT and recur locoregionally should be considered for salvage esophagectomy at experienced esophageal centers. [ABSTRACT FROM AUTHOR]

Background: Esophageal continuity after esophagectomy can be established without a viable stomach conduit by using the colon or jejunum. The current study evaluated the technical outcomes of the long-segment supercharged jejunal (SPJ) interposition. Methods: A database was developed to capture patient characteristics, operative technique, and outcomes for patients with an SPJ interposition at 2 institutions from 2000 to 2010. A multivariable analysis was performed to determine predictors of leak and graft loss. A selective prospective manometric analysis was performed to describe peristalsis of the SPJ. Results: Of the 60 patients undergoing SPJ reconstruction, 44 (73%) were men, and the median age was 57 years (range, 28 to 76 years). The operation in 23 patients (38%) was performed to reverse esophageal discontinuity, and 57 (95%) patients underwent reconstruction for cancer. Early complications included 18 instances (30%) of pneumonia, 19 anastomotic leaks (32%), and 5 instances of graft loss with diversion (8%). Three patients (5%) died in the hospital or within 30 days. After jejunal reconstruction, 50 patients (83%) were able to return to a regular diet. The 90-day mortality rate was 10% (n = 6). Characteristic postoperative manometric findings included segmental peristalsis, as is typical for in situ jejunum. Median survival was 28 months and the 5-year survival rate was 30%. Conclusions: An SPJ conduit can reestablish or maintain gastrointestinal continuity in high-risk patients when the stomach is unavailable. This is our preferred conduit for reconstruction of the esophagus over the colon. [ABSTRACT FROM AUTHOR]

Background: Clinical factors predicting pulmonary complications after lung resection have been well described, whereas the role of genetics is unknown. The vascular endothelial growth factor (VEGF) signaling pathway has been linked to acute lung injury. We hypothesized that genetic variations in this pathway may be associated with postoperative pulmonary complications after lung resection. Methods: One hundred ninety-six single nucleotide polymorphisms (SNPs) in 17 genes in the VEGF pathway were genotyped in a discovery set of 264 patients and a replication set of 264 patients who underwent lobectomy for lung cancer. Multivariable analysis adjusting for baseline clinical factors was used to identify SNPs associated with pulmonary complications. Cumulative and classification and regression tree (CART) analyses were used to further stratify risk groups. Results: The overall number of pulmonary complications was 164/528 (31%). The effects of 6 SNPs were consistent in the discovery and replication sets (pooled p value < 0.05). The rs9319425 SNP in the VEGF receptor gene FLT1 resulted in a 1.50-fold increased risk (1.15–1.96; p = 0.003). A cumulative effect for the number of risk genotypes and complications was also evident (p < 0.01). Patients carrying 5 risk genotypes had a 5.76-fold increase in risk (2.73–12.16; p = 4.44 × 10–6). Regression tree analysis identified potential gene-gene interactions between FLT1:rs9319425 and RAF1:rs713178. The addition of the 6 SNPs to the clinical model increased the area under the receiver operating characteristic curve by 6.8%. Conclusions: Genetic variations in the VEGF pathway are associated with risk of pulmonary complications after lobectomy. This may offer insight into the underlying biological mechanisms of pulmonary complications. [ABSTRACT FROM AUTHOR]