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Background Breast cancer is the most common malignancy among women in the USA. Improved survival has resulted in increasing incidence of second primary malignancies, of which lung cancer is the most common. The United States Preventive Services Task Force (USPSTF) guidelines for lung-cancer screening do not include previous malignancy as a high-risk feature requiring evaluation. The aim of this study was to compare women undergoing resection for lung cancer with and without a history of breast cancer and to assess whether there were differences in stage at diagnosis, survival and eligibility for lung-cancer screening between the two groups. Methods Women who underwent lung-cancer resection between 2000 and 2017 were identified. Demographic, clinicopathological, treatment and outcomes data were compared between patients with a history of breast cancer (BC-Lung) and patients without a history of breast cancer (P-Lung) before lung cancer. Results Of 2192 patients included, 331 (15.1 per cent) were in the BC-Lung group. The most common method of lung-cancer diagnosis in the BC-Lung group was breast-cancer surveillance or work-up imaging. Patients in the BC-Lung group had an earlier stage of lung cancer at the time of diagnosis. Five-year overall survival was not statistically significantly different between groups (73.3 per cent for both). Overall, 58.4 per cent of patients (1281 patients) had a history of smoking, and 33.3 per cent (731 patients) met the current criteria for lung-cancer screening. Conclusion Differences in stage at diagnosis of lung cancer and treatment selection were observed between patients with and without a history of breast cancer. Overall, there were no statistically significant differences in genomic or oncogenic pathway alterations between the two groups, which suggests that lung cancer in patients who previously had breast cancer may not be affected at the genomic level by the previous breast cancer. The most important finding of the study was that a high percentage of women with lung cancer, regardless of breast-cancer history, did not meet the current USPSTF criteria for lung-cancer screening., Differences in stage at diagnosis of lung cancer and treatment selection were observed between patients with and without a history of breast cancer. Overall, there were no statistically significant differences in genomic or oncogenic pathway alterations between the two groups, which suggests that lung cancer in patients who previously had breast cancer may not be affected at the genomic level by the previous breast cancer. The most important finding of the study was that a high percentage of women with lung cancer, regardless of breast cancer history, did not meet the current USPSTF criteria for lung cancer screening.

The incidence of esophagogastric junction (EGJ) adenocarcinoma is increasing worldwide. Management of these tumors remains controversial given their unique location between the esophagus and the stomach. Debate surrounding the optimal therapy for EGJ adenocarcinoma has often centered around the tumor origin as defined by the Siewert classification system. However, the optimal surgical management should focus on adhering to important surgical principles that will allow for the best outcomes and prognosis regardless of tumor location including resection with appropriate and negative histological margins, adequate lymphadenectomy, minimization of morbidity and mortality, and preservation of quality‐of‐life. In this article, we provide a discussion of the controversy surrounding EGJ adenocarcinoma within the framework of these concepts.

Objective We sought to evaluate the performance of two commonly used prediction models for postoperative morbidity in patients undergoing open and minimally invasive esophagectomy. Summary background data Patients undergoing esophagectomy have a high risk of postoperative complications. Accurate risk assessment in this cohort is important for informed decision-making. Methods We identified patients who underwent esophagectomy between January 2016 and June 2018 from our prospectively maintained database. Predicted morbidity was calculated using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Surgical Risk Calculator (SRC) and a 5-factor NSQIP-derived frailty index. Performance was evaluated using concordance index (C-index) and calibration curves. Results In total, 240 consecutive patients were included for analysis. Most patients (85%) underwent Ivor Lewis esophagectomy. The observed overall complication rate was 39%; the observed serious complication rate was 33%. The SRC did not identify risk of complications in the entire cohort (C-index, 0.553), patients undergoing open esophagectomy (C-index, 0.569), or patients undergoing minimally invasive esophagectomy (C-index, 0.542); calibration curves showed general underestimation. Discrimination of the SRC was lowest for reoperation (C-index, 0.533) and highest for discharge to a facility other than home (C-index, 0.728). Similarly, the frailty index had c-index of 0.513 for discriminating any complication, 0.523 for serious complication, and 0.559 for readmission. Conclusions SRC and frailty index did not adequately predict complications after esophagectomy. Procedure-specific risk-assessment tools are needed to guide shared patient-physician decision-making in this high-risk population.

Although opioids are frequently prescribed in the postoperative setting, the call for increased opioid stewardship among surgeons has only recently become more urgent. Recent studies have shown that opioids are overprescribed postoperatively (1,2). Given that the risk of chronic opioid use and consequently, misuse and abuse, has been demonstrated to increase with longer duration and higher dosage prescriptions, it is time for surgeons to have a proactive role in mitigating the opioid crisis (3,4). Most of the current literature to date on postoperative opioid prescribing has focused on general, gynecologic, and orthopedic surgery (1-3,5,6). Opioid prescribing patterns and implications for thoracic surgery remain mostly undefined.

Node dissection during esophagectomy is an important aspect of esophageal cancer staging. Controversy remains as to how many nodes need to be resected in order to properly stage a patient and whether the removal of more nodes carries a stage-independent survival benefit. A review of the literature performed by a group of experts in the subject may help define a minimum accepted number of lymph nodes to be resected in both primary surgery and post-induction therapy scenarios. The existing evidence generally supports the goal of obtaining a minimum of 15 lymph nodes for pathological examination in both primary surgery and post-induction therapy scenarios.

There are limited data regarding optimal surveillance after curative resection for esophageal cancer. Once disease recurrence is diagnosed, the prognosis is poor. The purpose of this article was to characterize disease recurrence in patients with early esophageal adenocarcinoma.Two hundred sixty patients were identified from a prospective institutional database with pathologic T1 and T2 node-negative disease therapy treated with curative esophagectomy alone for esophageal adenocarcinoma between 1995 and 2017. Competing risk analysis was used to analyze factors associated with recurrence.The 5-year cumulative incidence of recurrence was 12%. Predictive factors for increased risk of recurrence included increasing tumor size, poor differentiation, and pathologic T2 disease (P.05), whereas presence of Barrett's esophagus on pathology was protective. Recurrence within 2 years was 2.5%, 6.1%, and 12% for T1a, T1b, and T2 disease, respectively. At 5 years cumulative incidence of recurrence was 8.2%, 11.5% and 22.2%, respectively. Median overall survival after recurrence was 1.04 years (95% confidence interval, 0.7-2.4). There were 14 subclinical and 13 symptomatic recurrences; patients with symptomatic recurrence had a significantly shorter overall survival after recurrence occurred (0.31 vs 0.71 years, P = .018).Among early node-negative patients with esophageal cancer undergoing curative resection, 5-year recurrence was 12%. Survival after recurrence was poor, and only a few patients had isolated locoregional recurrence at time of diagnosis, suggesting that scheduled surveillance may have an important role.

OBJECTIVE: Esophageal squamous cell carcinoma (ESCC-R) is a rarely encountered sequela of chest radiation. Treatment is limited by toxicity with reirradiation and complex surgical dissection in a previously radiated field. The clinical presentation, prognosis and treatment selection of ESCC-R remains undefined. METHODS: A retrospective review was performed of patients with esophageal squamous cell carcinoma at a single institution between 2000 to 2017 to identify patients with previous radiation therapy (≥ 5 years delay). Clinicopathologic characteristics, treatment and outcomes of ESCC-R (n=69) patients were compared to patients with primary esophageal squamous cell carcinoma (ESCC) (n=827). Overall survival (OS) and cumulative incidence of recurrence (CIR) were compared using log rank and Gray’s tests, respectively. RESULTS: Median time from radiation to ESCC-R was 18.2 years. The majority of ESCC-R patients was female, and presented with earlier disease and decreased behavioral risk factors. ESCC-R treated with surgery alone had worse OS than ESCC (5-year 15% vs 33, p=0.045). Patients with ESCC-R that received neoadjuvant treatment had higher risk of postoperative in-house mortality (16.7% vs 4.2, p=0.032). Patients with ESCC-R treated with surgery alone and definitive chemoradiation had higher recurrence risk than neoadjuvant+surgery (5-year recurrence 55% and 45 vs 15%, p=0.101). CONCLUSION: Neoadjuvant chemotherapy or chemoradiation should be used whenever possible for ESCC-R as it is associated with lower risk of recurrence. The improved survival benefits of aggressive treatment must be weighed against the higher associated postoperative risks.