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Lung cancer screening with low-dose computed tomography has demonstrated at least a 20% decrease in lung cancer-specific mortality, but it has the potential harm of unnecessary invasive procedures performed because of false-positive results. This study reports the outcomes of a structured multidisciplinary lung cancer screening program in an area of endemic histoplasmosis.A retrospective review of patients undergoing lung cancer screening from December 2012 to March 2019 was conducted. Findings suggestive of lung cancer were presented to a multidisciplinary thoracic tumor board. Patients were assigned to interval imaging follow-up, additional diagnostic imaging, or referral for an invasive procedure. Invasive procedures were then compared between benign and malignant diseases.A total of 4087 scans were performed on 2129 patients; 372 (9.1%) were suspicious and were presented to a multidisciplinary thoracic tumor board. Ultimately, 108 procedures were performed: 55 bronchoscopies, 7 percutaneous biopsies, and 46 operations. A total of 25 patients (1.2%) underwent bronchoscopy resulting in benign pathologic findings, significantly associated with an indication of an endobronchial lesion (P = .01). All percutaneous biopsy specimens revealed malignancy. Five patients (0.2%) who underwent resection had benign disease. Lung cancer was diagnosed in 67 patients (3.1% of the entire cohort), 46 of whom had stage I or II disease.Lung cancer screening in a structured, multidisciplinary program successfully identifies patients with early-stage lung cancer with limited unnecessary surgical interventions. Patients with isolated endobronchial lesions should undergo short interval imaging follow-up to avoid bronchoscopy for benign disease. Future studies to minimize unnecessary procedures could incorporate biomarkers and advanced imaging analysis into risk assessment models.

Background Granulomas caused by infectious lung diseases can present as indeterminate pulmonary nodules (IPN). This study aims to validate an enzyme immunoassay (EIA) for Histoplasma immunoglobulin G (IgG) and immunoglobulin M (IgM) for diagnosing benign IPN in areas with endemic histoplasmosis. Methods Prospectively collected serum samples from patients at Vanderbilt University Medical Center (VUMC [n = 204]), University of Pittsburgh Medical Center (n = 71), and University of Cincinnati (n = 51) with IPN measuring 6 to 30 mm were analyzed for Histoplasma IgG and IgM with EIA. Diagnostic test characteristics were compared with results from the VUMC pilot cohort (n = 127). A multivariable logistic regression model was developed to predict granuloma in IPN. Results Cancer prevalence varied by cohort: VUMC pilot 60%, VUMC validation 65%, University of Pittsburgh Medical Center 35%, and University of Cincinnati 75%. Across all cohorts, 19% of patients had positive IgG titers, 5% had positive IgM, and 3% had positive both IgG and IgM. Of patients with benign disease, 33% were positive for at least one antibody. All patients positive for both IgG and IgM antibodies at acute infection levels had benign disease (n = 13), with a positive predictive value of 100%. The prediction model for granuloma in IPN demonstrated an area under the receiver-operating characteristics curve of 0.84 and Brier score of 0.10. Conclusions This study confirmed that Histoplasma EIA testing can be useful for diagnosing benign IPN in areas with endemic histoplasmosis in a population at high risk for lung cancer. Integrating Histoplasma EIA testing into the current diagnostic algorithm where histoplasmosis is endemic could improve management of IPN and potentially decrease unnecessary invasive biopsies.

Background Integrated thoracic surgery (I-6) programs have become popular over traditional general surgery (GS) pathways since their inception in 2007. However the effect of I-6 programs on GS resident training remains unknown. The purpose of this study was to evaluate the effect of I-6 programs on the thoracic operative experience of co-located GS residents. Methods Thoracic surgery cases recorded by residents in GS programs co-located with I-6 programs until 2019 were analyzed. Cases were reviewed 5 years before (TSR-5) through 5 years after (TSR-5) the matriculation of the first thoracic resident in the co-located I-6 program. To contextualize the overall trends in the field Accreditation Council for Graduate Medical Education GS resident case logs from 1990 to 2018 were analyzed and total thoracic surgery cases recorded. Statistical analysis was performed with linear regression. Results Residents in 19 GS programs with co-located I-6 programs showed an increase in total thoracic cases from 3710 to 4451 (Δ/year of +85.05 cases a year; P = .03) balanced by an increase in GS residents from 107 to 126 (Δ/year of +1.45; P = .01) with no significant overall change in the median thoracic operative case volume (31.00 at both thoracic residency before and after 5 years). Nationally from 1990 to 2018 there was no change in the total thoracic operative experience for GS graduates. Conclusions The introduction of I-6 programs did not negatively impact thoracic operative experience for residents in co-located GS programs. Adequate training of both I-6 and GS residents at the same institution is feasible.

Background Individualized prediction of outcomes may help with therapy decisions for patients with non-small cell lung cancer. We developed a nomogram by analyzing 17 clinical factors and outcomes from a randomized study of sublobar resection for non-small cell lung cancer in high-risk operable patients. The study compared sublobar resection alone with sublobar resection with brachytherapy. There were no differences in primary and secondary outcomes between the study arms, and they were therefore combined for this analysis. Methods The clinical factors of interest (considered as continuous variables) were assessed in a univariate Cox proportional hazards model for significance at the 0.10 level for their impact on overall survival (OS), local recurrence-free survival (LRFS), and any recurrence-free survival (RFS). The final multivariable model was developed using a stepwise model selection. Results Of 212 patients, 173 had complete data on all 17 risk factors. Median follow-up was 4.94 years (range, 0.04 to 6.22). The 5-year OS, LRFS, and RFS were 58.4%, 53.2%, and 47.4%, respectively. Age, baseline percent diffusing capacity of lung for carbon monoxide, and maximum tumor diameter were significant predictors for OS, LRFS, and RFS in the multivariable model. Nomograms were subsequently developed for predicting 5-year OS, LRFS, and RFS. Conclusions Age, baseline percent diffusing capacity of lung for carbon monoxide, and maximum tumor diameter significantly predicted outcomes after sublobar resection. Such nomograms may be helpful for treatment planning in early stage non-small cell lung cancer and to guide future studies.

Background Sublobar resection (SR) in high-risk operable patients may result in a long-term decrease in pulmonary function. We previously reported 3-month pulmonary function outcomes from a randomized phase III study of SR alone compared with SR with brachytherapy in patients with non-small cell lung cancer. We now report long-term pulmonary function after SR. Methods Pulmonary function was measured at baseline and at 3, 12, and 24 months. A decline of 10% or more from baseline in the percentage predicted forced expiratory volume of 1 percentage or in the diffusion capacity of the lung for carbon monoxide was considered clinically meaningful. The effect of study arm, tumor location, size, approach (video-assisted thoracoscopic surgery vs thoracotomy), and SR type (wedge vs segmentectomy) on pulmonary function was assessed using a Wilcoxon rank sum test. A generalized estimating equation model was used to assess the effect of each factor on longitudinal data, including all four time points. Results Complete pulmonary function data at all time points was available in 69 patients. No significant differences were observed in pulmonary function between SR and SR with brachytherapy, thus the study arms were combined for all analyses. A decline of 10% or more ( p = 0.02) in the percentage predicted forced expiratory volume in 1 second was demonstrated for lower-lobe resections at 3 months but was not at 12 or 24 months. A decline of 10% or more ( p = 0.05) in the percentage predicted diffusion capacity of the lung for carbon monoxide was seen for thoracotomy at 3 months but was not at 12 or 24 months. Conclusions Clinically meaningful declines in pulmonary function occurred after lower lobe resection and after thoracotomy at 3 months but subsequently recovered. This study suggests that SR does not result in sustained decreased pulmonary function in high-risk operable patients.

Background When the stomach is not available, long-segment esophageal reconstruction remains a surgical challenge. Since 2005, we have used a "supercharged" isoperistaltic colon interposition conduit for long-segment esophageal reconstruction that reestablishes a dual blood supply. Methods An institutional database search of 449 patients who underwent esophagectomy from 2005 to 2012 identified 11 consecutive patients who underwent long-segment esophageal reconstruction using an isoperistaltic supercharged right (n = 9) or left (n = 2) colon conduit. All conduits were routed through the anterior mediastinum, maintaining the middle colic (right) or ascending left colic vessels (left) in situ, with reimplantation of the ileocolic vessels (right) or middle colic vessels (left) into the left internal thoracic artery and brachiocephalic vein to improve distal conduit blood flow. Results Patients were a mean age of 64 years (range, 47 to 76 years). Seven patients had a history of malignancy and 4 had a benign process. The stomach was unavailable for reconstruction due to prior gastric operations (n = 9) or neoplastic involvement (n = 2). All reimplanted vessels demonstrated excellent flow by Doppler evaluation. Esophagocolonic healing was successful in all patients; however, 1 patient required a temporary stent. Conclusions Supercharged isoperistaltic colon interposition appears to be an excellent option for the challenging situation where long-segment esophageal reconstruction is needed and the stomach is not available. The additional effort required to reestablish a dual blood supply appears justified to minimize ischemic-related morbidity. Unlike long-segment small bowel "supercharged" techniques, adequate blood supply to the distal conduit may still be present in case thrombosis of the reimplanted vessels occurs.

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.

Patients with early-stage lung cancer and limited pulmonary reserve may not be appropriate candidates for lobectomy. In these situations, sublobar resection (wedge or segmentectomy) is generally performed. Many physicians believe that segmentectomy is superior because it allows for an improved parenchymal margin and nodal sampling.We performed an analysis using operative and pathology reports collected as part of planned data collection for American College of Surgeons Surgical Oncology Group (ACOSG) Z4032. This was a prospective trial in which patients with clinical stage I lung cancer and limited pulmonary function were randomized to sublobar resection with or without brachytherapy. The operative approach (video-assisted thoracic surgery [VATS] vs thoracotomy), extent of resection, and degree of lymph node evaluation were at the discretion of the individual surgeon. The primary aim of this analysis was to compare the parenchymal margin achieved between segmentectomy and wedge resection. Secondary aims included the extent of nodal staging and whether the operative approach (VATS vs open) had an effect on margin status and nodal evaluation.Among 210 patients, 135 (64%) underwent a VATS approach and 75 (36%) a thoracotomy. A segmentectomy was performed in 57 patients (27%) and a wedge resection in 153 patients (73%). There were no significant differences in the degree of nodal upstaging, stations sampled, or parenchymal margin obtained between VATS and thoracotomy. However, significant differences were observed between patients who underwent a segmentectomy and those who underwent a wedge resection with regard to parenchymal margin (1.5 cm vs 0.8 cm, p = 0.0001), nodal upstaging (9% vs 1%, p = 0.006), and nodal stations sampled (3 vs 1, p0.0001) . Notably, 41% of patients treated by wedge resection had no nodes sampled at the time of operation compared with 2% of those who underwent segmentectomy (p0.0001).In ACOSG Z4032, wedge resection, regardless of the approach, was associated with a smaller parenchymal margin and a lower yield of lymph nodes and rate of nodal upstaging when compared with segmentectomy.

Five-year survival for early-stage lung cancer despite complete surgical resection is approximately 50%. Adjuvant chemotherapy has been shown to improve survival in some patients. Older cancer patients do not always receive standard therapy. The purpose of this study was to determine if there were age-related biases concerning the use of adjuvant chemotherapy after lobectomy for elderly patients with non-small cell lung cancer (NSCLC).A prospective lung cancer outcomes database was queried for all patients undergoing lobectomy for NSCLC pathologic stage IB and higher between April 2006 and October 2010. Patients who received neoadjuvant treatment or who died within 30 days of operation were excluded. Ninety-nine patients met the inclusion criteria. Patients were divided into 2 groups based on age (70 or ≥70 years). The use of adjuvant chemotherapy was compared between groups.Sixty-nine patients (70%) were younger than 70 years and 30 (30%) were 70 years or older. There was a significant difference in the use of adjuvant chemotherapy between the 2 groups, with 46 (66.7%) of the younger patients and 7 (25%) of the elderly patients receiving adjuvant treatment (p0.01). The difference persisted when analyzed by stage, with older patients less likely to receive chemotherapy among all patients with stage IB disease, stage II or more advanced disease, and stage IB lesions greater than or equal to 4 cm plus stage II or more advanced disease. In multivariate analysis of preoperative and postoperative factors, age remained the only independent predictor of chemotherapy use.Patients undergoing lobectomy who were 70 years of age or older received adjuvant chemotherapy less often than did younger patients.

Background Patients with stage I lung cancer undergoing a complete resection have a 25% risk of recurrence. Factors predictive for recurrence are critically needed. In the present study, we prospectively examined clinical and molecular factors that may predict a poor outcome. Methods Patients with stage I non-small cell lung cancer undergoing surgical resection were enrolled into an institutional registry. Clinical demographics and outcomes data were prospectively collected. Patients who received neoadjuvant therapy or patients who died within 30 days of surgery were excluded from this analysis. Molecular factors involved in cell proliferation, cell cycle control, apoptosis, and angiogenesis were analyzed. The primary endpoint was recurrence-free survival. Results One hundred and two patients were enrolled between March 2006 and April 2009. There were 25 (25%) documented recurrences. In univariate analysis, male sex, increased tumor standard uptake value, tumor size, final pathology stage, arterial invasion, percent nuclear phosphorylated AKT, vascular endothelial growth factor score, negative cyclin D1 protein expression, and percent nuclear cyclin D1 expression were predictive of decreased recurrence-free survival. All factors with a p value of 0.1 or less were included in multivariate analysis. Male sex, final pathology stage, vascular endothelial growth factor score, and percent nuclear cyclin D1 expression were significant independent predictors for poor prognosis. Conclusions Four clinical and molecular factors were associated with prognosis in a prospective study of stage I non-small cell lung cancer.