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Background: Despite the relatively high sensitivity of fluorodeoxyglucose-positron emission tomography (PET) and computed tomography (CT) scans used for staging of non-small cell lung cancer (NSCLC), a subset of patients with peripherally located clinical T1a N0 will be upstaged due to pathologic nodal disease. It is important to study this risk of upstaging, especially if local treatments, such as wedge resection or stereotactic body radiation therapy, are potential treatment modalities. Our aim was to determine the rate of pathologic N1/N2 disease in peripherally located clinical T1a N0 NSCLC and predictive factors for nodal metastasis., Methods: A retrospective review of a prospective database (2000 to 2015) identified 1,342 patients with clinical T1a N0 NSCLC, and 914 (68%) underwent lobectomy. Among this group, 449 patients had peripherally located tumors and were deemed node negative by fluorodeoxyglucose-PET/CT scan. The relationship between clinicopathologic features and the PET maximal-standardized uptake value (SUVmax) of the primary tumor was investigated. Predictors for nodal metastasis were determined by multivariable logistic regression analysis. The receiver operating characteristic curve was used to assess the cutoff value of PET-SUVmax on the incidence of nodal metastasis., Results: Nodal metastasis was detected in 9.6% (43 of 449) of the patients: 4.5% (n = 20) had pN1 and 5.1% (n = 23) had pN2 metastasis. The relationship between SUVmax and development of pathologic nodal metastasis was calculated using the receiver operating characteristic curve with cutoff point at SUVmax of 3.3. In multivariable analysis, PET-SUVmax exceeding 3.3 was the only independent predictor for N1/N2 metastasis (p = 0.016). Disease-free survival showed a trend of poor survival for patients with nodal metastasis (p = 0.068)., Conclusions: High PET-SUVmax of the primary tumor is associated with elevated risk of nodal disease for peripheral T1a N0 NSCLC patients. Further diagnostic procedures, such as endobronchial ultrasound, may be required, especially if wedge resection or stereotactic body radiation therapy are being considered., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Tourette's disorder (TD) and autism spectrum disorder (ASD) share clinical features and possibly an overlapping etiology. The aims of this study were to examine ASD symptom rates in participants with TD, and to characterize the relationships between ASD symptom patterns and TD, obsessive-compulsive disorder (OCD), and attention-deficit/hyperactivity disorder (ADHD)., Method: Participants with TD (n = 535) and their family members (n =234) recruited for genetic studies reported TD, OCD, and ADHD symptoms and completed the Social Responsiveness Scale Second Edition (SRS), which was used to characterize ASD symptoms., Results: SRS scores in participants with TD were similar to those observed in other clinical samples but lower than in ASD samples (mean SRS total raw score = 51; SD = 32.4). More children with TD met cut-off criteria for ASD (22.8%) than adults with TD (8.7%). The elevated rate in children was primarily due to high scores on the SRS Repetitive and Restricted Behaviors (RRB) subscale. Total SRS scores were correlated with TD (r = 0.27), OCD (r = 0.37), and ADHD (r = 0.44) and were higher among individuals with OCD symptom-based phenotypes than for those with tics alone., Conclusion: Higher observed rates of ASD among children affected by TD may in part be due to difficulty in discriminating complex tics and OCD symptoms from ASD symptoms. Careful examination of ASD-specific symptom patterns (social communication vs. repetitive behaviors) is essential. Independent of ASD, the SRS may be a useful tool for identifying patients with TD with impairments in social communication that potentially place them at risk for bullying and other negative sequelae., (Copyright © 2017 American Academy of Child and Adolescent Psychiatry. Published by Elsevier Inc. All rights reserved.)

Background: Patients with persistent N2 disease after induction have poor survival. Many of these patients may have had mediastinoscopy before induction therapy, making reassessment of the mediastinum by repeat mediastinoscopy hazardous and inaccurate. The sensitivity and specificity of endobronchial ultrasonography and nodal fine-needle aspiration in this setting is unclear. In this study, we sought to identify the clinical predictors of persistent N2 disease after induction therapy, which may help in selecting the patients most likely to benefit from surgical resection., Methods: A retrospective review of a prospective database (1990 to 2014) was performed to identify patients who had surgical resection after induction therapy for clinical stage IIIA-N2 non-small cell lung cancer. Multivariable logistic regression analysis was performed to determine independent predictors of persistent N2 disease., Results: 203 patients (56% female; median age 64 years) underwent potentially curative lung resection after induction therapy. Ninety-seven patients (48%) had pathologic nodal downstaging (pN0/N1), which was associated with significantly better overall survival compared with patients with persistent N2 disease (5 years, 56% versus 35%, p = 0.047). Univariate and multivariate analysis showed that upper or middle lobe location and less than 60% reduction of N2 SUVmax were independent predictors of persistent N2 disease., Conclusions: Patients with upper lobe tumors and less than 60% reduction in N2 SUVmax are more likely to have persistent N2 disease, which is often associated with poor survival rates. These clinical prognostic criteria may help surgeons in stratifying patients and properly selecting optimal surgical candidates., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: Sublobar resection is advocated for patients with NSCLC and compromised cardiopulmonary reserve, and for selected patients with early stage disease. Anatomic segmentectomy (AS) has traditionally been considered superior to wedge resection (WR), but well-balanced comparative studies are lacking. We hypothesize that WR and AS are associated with comparable oncologic outcomes for patients with cT1N0 NSCLC., Methods: A retrospective review of a prospective database was performed (2000-2014) for cT1N0 patients, excluding patients with multiple primary tumors, carcinoid tumors, adenocarcinoma in situ, and minimally invasive adenocarcinoma. Demographic, clinical, and pathological data were reviewed. Overall survival (OS) and disease-free survival (DFS) were estimated using the Kaplan-Meier method and differences compared using log-rank test. Multivariable analysis (MVA) of factors affecting DFS was performed by Cox regression analysis. For further comparison of the effect of resection type on survival, propensity score matching (i.e., by age, sex, Charlson comorbidity index, percent forced expiratory volume in 1 second (FEV 1 %), clinical tumor size, and tumor maximum standardized uptake value) was performed to obtain balanced cohorts of patients undergoing WR and AS (n = 76 per group)., Results: Two hundred eighty-nine patients met our selection criteria, including WR in 160 and AS in 129. Poor performance status and limited cardiopulmonary reserve were the primary indications for sublobar resection in 76% of WR patients and in 62% of AS patients (p = 0.011). Thirteen patients (4.5%) had pN1/2 disease. Patients undergoing AS were more likely to have nodal sampling/dissection [123 (95%) versus 112 (70%); p < 0.001], more stations sampled (3 versus 2; p < 0.001), and more total nodes resected (7 versus 4; p = 0.001). However, there was no difference between patients undergoing WR versus AS in local recurrence [15 versus 14; p = 0.68] or 5-year DFS (51% versus 53%; p = 0.7; median follow-up 34 months). Univariate analysis showed no effect of extent of resection on DFS [hazard ratio 1.07 (95% confidence interval 0.74-1.56); p = 0.696]. MVA showed that only tumor maximum standardized uptake value was associated with worse DFS [hazard ratio 1.07 (95% confidence interval 1.01-1.13); p = 0.016]. In the propensity-matched analysis of balanced subgroups, there was also no difference (p = 0.950) in 3- or 5-year DFS in cT1N0 patients undergoing WR (65% and 49%) or AS (68% and 49%)., Conclusions: Our data show that WR and AS are comparable oncologic procedures for carefully staged cT1N0 NSCLC patients. Although AS is associated with a more thorough lymph node dissection, this did not translate to a survival benefit in this patient population with a low rate of nodal metastases., (Copyright © 2016 International Association for the Study of Lung Cancer. Published by Elsevier Inc. All rights reserved.)

Background: In patients with thymic neoplasms, the pleural space is a frequent site of either synchronous or metachronous tumor dissemination after surgical resection. The objective of this study was to identify factors that predict pleural dissemination, which would allow for better surgical planning and consideration of novel adjuvant or surveillance strategies., Methods: A retrospective review of a prospective database (2000 to 2014) was performed to identify patients with thymic tumors (excluding neuroendocrine). Demographic, clinical, and pathologic data were reviewed. Multivariable Cox regression analysis was performed to determine independent predictors of pleural implants (either occult synchronous or metachronous). Univariate predictors (p < 0.20) were selected for inclusion in a multivariable model. Receiver operating characteristic (ROC) curve was used to assess the effect and cutoff value of tumor size on the incidence of pleural metastasis., Results: One hundred sixty-two patients with thymic tumors were identified. Pleural deposits were incidentally identified intraoperatively in 4 patients (2.5%) and developed during follow-up in 15 patients (10%), with a median follow-up of 34 months (interquartile range, 12 to 71). Univariate predictors of pleural metastasis were macroscopic capsular/organ invasion, preoperative core/surgical biopsy, induction therapy, pathologic tumor size, and World Health Organization type B3/C. In the multivariable model, core/surgical biopsy (hazard ratio [HR] 9.45, p = 0.002), macroscopic capsular invasion (HR 10.18, p = 0.008), and larger tumor size (HR 1.34, p = 0.044) were found to be independent predictors of pleural metastasis. The relation between the pathologic tumor size and development of pleural metastasis was further investigated with the ROC curve (area under the curve 0.78, p < 0.001), and the cutoff tumor size that gave the best combined sensitivity and specificity was 6.5 cm. Overall survival of patients with pleural implants was 88% and 50% at 5 and 10 years, respectively. Five- and 10- year disease-free survival for the whole cohort was 80% and 30%, respectively., Conclusions: Development of pleural metastasis is predictable. Pathologic tumor size, an independent predictor of pleural implants, can be assessed intraoperatively. Because preoperative core needle biopsy is also an independent predictor of pleural dissemination, its use and execution should be carefully considered. Pleural exploration at the index operation should be considered in high-risk patients. Further studies are needed to confirm these findings and to assess the role of novel therapeutic strategies in reducing pleural disease., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Because video-assisted thoracic surgery (VATS) lobectomies are increasingly being performed by thoracic surgeons, the adequacy of lymph node clearance by VATS compared with thoracotomy has been questioned, raising the possibility that patients are being understaged. One factor that may be overlooked in published studies is the learning curve of the surgeons and surgical volume in the adoption of VATS lobectomy. This study examined the effect of cumulative institutional VATS lobectomy experience on the adequacy of lymphadenectomy., Methods: We retrospectively reviewed a prospective database to identify 500 consecutive patients who underwent VATS lobectomy for non-small cell lung cancer (NSCLC) at our institution between 2002 and 2012. For comparative purposes, the cohort was divided into halves, with an early group (first 250 cases) vs a late group (next 250 cases). Clinical and pathologic factors were analyzed. A propensity-matching analysis controlling for age, gender, pathologic stage, and percentage of forced expiratory volume in 1 second was done to compare survival and adequacy of lymphadenectomy., Results: Patients operated on in the late group were significantly older (72 vs 69 years, p = 0.001) and had worse pulmonary functions (median forced expiratory volume in 1 second 83% vs 91%, p < 0.001; median diffusion capacity of the lung for carbon monoxide, 76% vs 85%, p < 0.001). Clinical and pathologic tumor sizes were significantly larger in the late group compared with the early group, with a median of 2.0 vs 1.8 cm (p = 0.002) for clinical T size and median of 2.1 vs 2.0 cm (p = 0.003) for pathologic T size. Patients in the late group had significantly more advanced clinical and pathologic stage distribution. The total number of lymph nodes and the number of nodal stations removed were significantly greater in the late group (p = 0.012) than in the early group (p < 0.001), and same results were obtained after propensity matching. No difference was seen in disease-free survival between the propensity-matched early vs late groups at 3 years (82% vs 85%, p = 0.187)., Conclusions: For patients with NSCLC resected by VATS lobectomy, cumulative institutional experience significantly and positively affects the adequacy of lymphadenectomy. This may be related to the initial surgeon's learning curve with VATS lobectomy. As the experience with VATS lobectomy becomes more mature, the procedure is increasingly being performed on older patients, often with more compromised pulmonary function and more advanced stage disease. Despite the expanded inclusion of older and sicker patients for VATS lobectomy, no compromise was seen in their disease-free survival., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: There is rising interest among thoracic surgeons in anatomical segmental resection for early-stage non-small cell lung cancer (NSCLC). In the current study we compared video-assisted thoracoscopic surgery (VATS) and thoracotomy approaches for segmentectomy to explore the safety and oncologic efficacy of VATS for stage I NSCLC., Methods: We retrospectively analyzed all patients who underwent segmentectomy for clinical stage I NSCLC from 2000 to 2013. Perioperative and oncologic outcomes were evaluated. The probabilities of disease-free survival (DFS) and overall survival (OS) were estimated with the Kaplan-Meier method and multivariate Cox regression analysis., Results: We identified 193 segmentectomies, including 91 (47%) performed by VATS and 102 (53%) performed by thoracotomy. Patients who underwent VATS, although older (median age 72 versus 68 years; p = 0.016), had similar sex distribution (63% versus 61% women; p = 0.792) and similar clinical stages as the thoracotomy group (stage IA: VATS, 93.4% versus thoracotomy 87.3%; p = 0.152). No significant differences were found in the final pathologic stages (p = 0.439), total number of lymph nodes (LNs) sampled (7 versus 8; p = 0.104), or median number of mediastinal LN stations sampled (2 versus 2; p = 0.234). VATS was associated with decreased length of stay (4 versus 5 days; p = 0.001) and decreased pulmonary complications (13.2% versus 26.5%; p = 0.022). Five-year DFS and OS favored VATS over thoracotomy (58% versus 47%; p = 0.013 and 75% versus 62%; p = 0.017, respectively). By multivariable analysis, the only predictor of poor DFS or OS was larger tumor size., Conclusions: VATS segmentectomy is a safe and oncologically effective technique for the treatment of stage I NSCLC. Patients who underwent VATS had a shorter length of stay, fewer pulmonary complications, equivalent lymphadenectomy results, and similar oncologic outcomes compared with patients undergoing thoracotomy., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Readmission rates after major procedures are used to benchmark quality of care. We sought to identify readmission diagnoses and factors associated with readmission in patients undergoing pulmonary lobectomy., Methods: Analyzing the State Inpatient Databases (Healthcare Cost and Utilization Project), we reviewed all lobectomies performed from 2009 to 2011 in California, Florida, and New York. The group was subdivided into open (OL) versus minimally invasive lobectomy (MIL; thoracoscopic/robotic). We used unique identifiers to determine 30- and 90-day readmission rates and diagnoses and performed regression analysis to determine factors associated with readmission., Results: A total of 22,647 lobectomies were identified (58.8% OL vs 41.2% MIL; median age, 68 years; median length of stay, 6 days). Most patients (59.8%) had routine discharge home (home health care, 29.4%; transfer to other facility, 8.8%; mortality, 1.9%). The 30-day readmission rate was 11.5% (OL 12.0% vs MIL 10.8%, p = 0.01), while the 90-day readmission rate was 19.8% (OL 21.1% vs MIL 17.9%, p < 0.001). The most common readmission diagnoses were pulmonary (24.1%), cardiovascular (16.3%), and complications related to surgical/medical procedures (15.1%). Preoperative factors associated with readmission included male gender (odds ratio, 1.19), Medicaid payer (odds ratio, 1.29), and several individual comorbidities. Surgical approach and postoperative complications were not independently associated with readmission., Conclusions: Readmission is a frequent event after pulmonary lobectomy and is strongly associated with preoperative demographic factors and comorbidities. Resources and services should be directed to patients at risk for readmission and multicomponent care pathways developed that may circumvent the need for repeat hospitalization., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Pulmonary resections using cardiopulmonary bypass (CPB) are infrequently performed. Their short-term outcomes are not well described. We queried the National Inpatient Sample over a 10-year period (2001 to 2011) to more clearly delineate the short-term outcomes of patients undergoing pulmonary resections on CPB., Methods: We identified all patients 18 years and older who underwent pulmonary lobectomy (LB) or pneumonectomy (PN) on CPB; lung transplantations were excluded. We then grouped these patients based on the setting in which bypass was used: LB/PN with planned CPB (group 1), LB/PN with concomitant on-pump cardiac procedure (group 2), or LB/PN requiring CPB secondary to injury (group 3). Demographic data and inhospital outcomes were obtained for each patient., Results: In all, 843 patients underwent LB or PN on CPB during the study period. Lobectomies were the most commonly performed procedure overall. Inhospital mortality for groups 1, 2, and 3 were 22% (n = 58), 16% (n = 61), and 57% (n = 115), respectively. Complications were prevalent across all groups. Routine discharge was achieved by fewer than half of all patients: 48% of group 1 (n = 128); 34% of group 2 (n = 129); and 18% of group 3 (n = 36). Pneumonectomy (odds ratio 2.74, 95% confidence interval: 1.00 to 7.53, p = 0.049) as well as using CPB either as part of a combined cardiac surgery (odds ratio 1.48, 95% confidence interval: 0.39 to 5.59, p = 0.002) or because of injury (odds ratio 6.52, 95% confidence interval: 2.13 to 19.99, p = 0.002) were found to be significant multivariate predictors of short-term mortality., Conclusions: Pulmonary resections on CPB carry considerable short-term mortality and morbidity, but some risk can be partially mitigated when bypass is planned preoperatively., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Fetal adenocarcinoma is a rare lung malignancy associated with improved outcomes compared to more common adenocarcinoma variants. We describe a case of a 31-year-old woman who presented with right-sided chest pain, and was subsequently diagnosed with an intermediate-grade stage IV fetal adenocarcinoma with chest wall invasion. She was treated with surgical resection and adjuvant radiation., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Patients who present with early stage non-small cell lung cancer and are poor candidates for lobar resection may be offered sublobar resection (commonly wedge) or stereotactic body radiotherapy (SBRT). However, comparing the relative effectiveness of these techniques is difficult because of differences in patient selection. We performed a propensity-matched analysis to compare the different treatment modalities. We compared the overall recurrence, overall survival, disease-free survival, and recurrence-free survival between treatment groups., Methods: A prospectively collected database was reviewed for patients who underwent a wedge resection, a wedge plus brachytherapy, or SBRT for clinical stage IA non-small cell lung cancer from 2001 to 2012. Patients who underwent SBRT were further assessed to confirm operability. Univariate and Cox regression multivariate analysis were performed for predictors of a composite end point of recurrence and mortality., Results: There were 164 patients identified, from which 99 were matched by age, sex, and histology. There were 61 women (62%) and 38 men (38%) with a median age of 73 years. Thirty-eight patients underwent a wedge resection only, 38 patients underwent a wedge with brachytherapy, and 23 patients had SBRT. Median follow-up was 35 months. Overall recurrence (local and distant) was significantly higher after SBRT (wedge, 9%; SBRT, 30%; p = 0.016). Although recurrence-free 3 -year survival was significantly better after wedge resection (88% versus 72%; p = 0.001), there was no difference between the two groups in disease-free 3-year survival (77% versus 59%; p = 0.066). Multivariate regression analysis identified male sex and SBRT as significant predictors for mortality and recurrence., Conclusions: Patients with clinical stage IA non-small cell lung cancer treated by SBRT appear to have higher overall disease recurrence than those treated by wedge resection. However, there was no significant difference in disease-free survival. A randomized trial is needed to define the role of SBRT in the potentially operable patient., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Chordoma is a rare slow-growing neoplasm arising from notochordal remnants. In the United States, the annual incidence of chordoma is 0.08 per 100,000 and is more common in men than in women. The most common locations of chordoma are the cranial (32%), spinal (32.8%), and sacral (29.2%) regions [1]. We report an unusual case of pleural chordoma in a 45-year-old man., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Positron emission tomography scanning is used to assess response to induction therapy after treatment of esophageal cancer. A decrease in standardized uptake value has been correlated with response to therapy, with a standardized uptake value of zero often assumed to indicate complete absence of disease. We hypothesize that a significant number of patients may have residual esophageal cancer despite complete metabolic response (CMR)., Methods: A prospective database was reviewed for esophageal cancer patients receiving induction therapy followed by esophagectomy on whom both preinduction and postinduction positron emission tomography scans were obtained. Patients with a postinduction SUV of 0 (or "no uptake") were categorized as complete metabolic responders. Survival was calculated by the Kaplan-Meier statistic., Results: Among 120 patients, 32 (27%) had postinduction CMR after chemotherapy (21 of 81, 26%) or chemoradiation (11 of 39, 28%). At surgery, 19 patients (59%) with CMR had residual disease, including 12 (38%) with nodal metastases. Even among patients with a negative postinduction biopsy, 4 of 10 (40%) had residual disease. Final pathologic stages of patients with CMR were yp0 (complete pathologic response) in 13 (41%), ypI in 4 (12%), ypII in 9 (28%), and ypIII in 6 (19%). Three-year survival was 83% in the CMR group versus 41% in the remainder of the cohort (p = 0.02)., Conclusions: A CMR on postinduction positron emission tomography scan predicts but should not be assumed to be synonymous with complete pathologic response in esophageal cancer patients. The presence of residual disease should be strongly considered despite CMR and negative biopsy in patients receiving induction therapy., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Video-assisted thoracic surgery (VATS) lobectomy for non-small cell lung cancer (NSCLC) is increasingly popular. However, the oncologic soundness of VATS for patients with NSCLC as measured by long-term survival has not been proven. The objective here is to determine the overall survival (OS) and disease-free survival (DFS) in two well-matched groups of patients with NSCLC resected by VATS or thoracotomy., Methods: We conducted a retrospective review of a prospective database to identify patients who had a lobectomy for NSCLC. A propensity score-matched analysis was done with variables of age, sex, smoking history, Charlson comorbidity index, forced expiratory volume in 1 second, lung diffusing capacity for carbon monoxide, histology, and clinical T and N status. Medical records were reviewed and survival was analyzed., Results: After matching, there were 208 patients in each group. Patient and tumor characteristics were similar. The VATS group had a shorter length of stay. More nodes (14.3 versus 11.3; p=0.001) and more nodal stations (3.8 versus 3.1; p<0.001) were removed by thoracotomy. No differences were seen in OS and DFS. Median follow-up was 36 months. More than 90% of patients had clinical stage I disease, with 3- and 5-year OS of 87.4% and 76.5%, respectively, for VATS, and 81.6% and 77.5%, respectively, for thoracotomy (p=0.672). Both the incidence and distribution of recurrence were similar. Multivariate Cox regression analyses of OS and DFS confirmed the noninferiority of VATS., Conclusions: For patients with clinical stage I NSCLC, VATS lobectomy offered similar OS and DFS compared with thoracotomy. Thoracotomy offers a more thorough lymph node evaluation, and may be appropriate for patients with more advanced clinical disease., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Pulmonary resection for hemoptysis carries an increased risk of death. However, the extent and predictors of risk are poorly characterized and based on institutional case series. We analyzed the Nationwide Inpatient Sample (NIS) database to determine the outcome of patients undergoing anatomic pulmonary resection who were admitted with a diagnosis of hemoptysis., Methods: We queried the NIS for hospitalized patients who were admitted emergently or urgently with hemoptysis as the principal diagnosis or as a secondary or tertiary diagnosis. We examined the outcomes of those patients who underwent lobectomy or pneumonectomy. Logistic regression analysis was used to determine clinical characteristics that were independent risk factors for death., Results: During a 10-year period, 457,523 admissions for the diagnosis of hemoptysis were identified, and 2,671 patients (0.58%) underwent resection, comprising lobectomy in 2,205 and pneumonectomy in 466. The median age was 58 years, and 1,682 (63%) were men. Compared with those patients resected without a diagnosis of hemoptysis, those admitted with a hemoptysis diagnosis had a higher mortality rate after pneumonectomy (15.2% vs 9.7 %, p = 0.320) and lobectomy (6.6% vs 3.0%, p = 0.006). Advanced age, associated bacterial infections, the presence of a lung abscess/necrosis, extent of resection, and associated diagnoses of sarcoidosis and renal failure were multivariable independent risk factors for death., Conclusions: Analysis of this national database with its inherent limitations demonstrates that major lung resection can be performed in the setting of hemoptysis with reasonable mortality rate. Advanced age, extent of resection, systemic illnesses such as renal failure, sarcoidosis, and the presence of a lung abscess are independent predictors of death., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: In patients with non-small cell lung cancer (NSCLC), previous studies have shown a prognostic benefit of maximum standardized uptake (SUV(max)) values on positron emission tomography (PET). Because tumor size is also prognostic and is associated with SUV(max), we sought to better characterize their relationship. We hypothesize that the ratio of SUV(max) to tumor size is a clinically useful measurement., Methods: A retrospective review was performed for patients (tumors ≥ 1 cm) undergoing resection of NSCLC. Patients were placed into quartiles (SUV(max) and SUV(max) to tumor size ratio) and compared for clinical and pathologic factors. Predictors of SUV(max) and SUV(max) to tumor size ratio on survival were evaluated., Results: Among 530 patients, increasing tumor size (odds ratio [OR], 2.04; confidence interval [CI], 1.68-2.47; p < 0.001) was an independent predictor of higher SUV(max). Patients in quartiles by the ratio of SUV(max) to tumor size demonstrated no significant difference in median tumor size. Those patients with the highest ratios (QR4, 3.21-27.5) more frequently had poorly differentiated tumors (51%; p < 0.001), were likely to have lymph node metastases (30%; p < 0.001), and had poor 3-year disease-free survival (DFS) (58%; p = 0.013). On multivariate analysis, as a continuous variable SUV(max) to tumor size ratio was a stronger independent predictor of survival than SUV(max) alone (hazard ratio [HR], 1.06; CI, 1.00-1.13 versus HR, 1.02; CI, 0.99-1.06). Using cutpoint analysis, a high SUV(max) to tumor size ratio was also a stronger predictor of survival than was high SUV(max) alone, particularly for tumors 1-3 cm (HR, 1.53; CI, 0.93-2.53 versus HR, 1.15; CI, 0.69-1.93)., Conclusions: The ratio of SUV(max) to tumor size may be a more important indicator of prognosis than SUV(max) alone in patients with NSCLC. In particular, the use of the ratio may be appropriate for identifying patients with small tumors who are at high risk for lymph node metastases and poor survival., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Local and distant recurrences are frequent after curative resection for esophageal cancer and are considered uniformly fatal. However, some patients may present with isolated recurrences that appear amenable to definitive local therapy either by resection or chemoradiotherapy. We reviewed the clinical outcome of all patients with isolated nodal or distant metastases who were treated with curative intent., Methods: In this retrospective review, all patients (n=561) who underwent curative resection for esophageal cancer from 1988 to 2011 were identified from a prospectively assembled thoracic surgery database. Patients who had any type of recurrence were identified (n=205). In this group, 27 patients were identified with isolated disease defined as single station of nodal disease or isolated distant metastases. Survival was modeled using the Kaplan-Meier method, and subgroup survival estimates were compared by the log rank test. The impact of age, sex, histology, pathology stage, site of recurrence, and treatment modality on mortality were analyzed by logistic regression., Results: Twenty-seven patients (22 male, median age 61 years) had an isolated esophageal cancer recurrence; of those, 15 patients underwent surgical resection and 12 underwent definitive chemoradiation therapy. The sites of isolated recurrence were most commonly nodal. Median overall survival from time of recurrence was 25.2 months; 3-year estimated survival was 33.0% (confidence interval: 13.7 to 52.5). In univariate analysis, no relationship was formed., Conclusions: In appropriately selected patients with isolated esophageal metastases, definitive therapy can prolong survival. A long disease-free interval and recurrence limited to single nodal stations may select patients likely to have longer survival after definitive local therapy., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: As the population ages, clinicians are increasingly confronted with octogenarians with resectable non-small cell lung cancer (NSCLC). We reviewed the outcomes of octogenarians who underwent lobectomy for NSCLC by video-assisted thoracic surgery (VATS) versus open thoracotomy, to determine if there was a benefit to the VATS approach in this group., Methods: We conducted a retrospective single-institution review of patients age 80 years or greater who underwent a lobectomy for NSCLC from 1998 to 2009. Outcomes including complication rates, length of stay, disposition, and long-term survival were analyzed., Results: One hundred twenty-one octogenarians underwent lobectomy: 40 VATS and 81 through open thoracotomy. Compared with thoracotomy, VATS patients had fewer complications (35.0% vs 63.0%, p = 0.004), shorter length of stay (5 vs 6 days, p = 0.001), and were less likely to require admission to the intensive care unit (2.5% vs 14.8%, p = 0.038) or rehabilitation after discharge (5% vs 22.5%, p = 0.015). In multivariate analysis, VATS was an independent predictor of reduced complications (odds ratio, 0.35; 95% confidence interval, 0.15 to 0.84; p = 0.019). Survival comparisons demonstrated no significant difference between the two techniques, either in univariate analysis of stage I patients (5-year VATS, 76.0%; thoracotomy, 65.3%; p = 0.111) or multivariate analysis of the entire cohort (adjusted hazard ratio, 0.59; 95% confidence interval, 0.27 to 1.28; p = 0.183)., Conclusions: Octogenarians with NSCLC can undergo resection with low mortality and survival among stage I patients, which is comparable with the general lung cancer population. The VATS approach to resection reduces morbidity in this age demographic, resulting in shorter, less intensive hospitalization, and less frequent need for postoperative rehabilitation., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Radiation dose from diagnostic imaging procedures is not monitored in patients undergoing surgery for lung cancer. Evidence suggests an increased lifetime risk of malignancy of 1.0% per 100 millisieverts (mSv). As such, recommendations are to restrict healthcare and radiation workers to a maximum dose of 50 mSv per year or to 100 mSv over a three-year period. The purpose of this study was to estimate cumulative effective doses of radiation in patients undergoing lung cancer resection and to determine predictors of increased exposure., Methods: We identified 94 consecutive patients undergoing resection for non-small cell lung cancer. Radiologic procedures performed from one year prior to resection until two years postresection were recorded. Estimates of effective doses (mSv) were obtained from published literature and institutional records. Predictors of dose greater than 50 mSv per year and greater than 100 mSv per three years were examined statistically., Results: The majority of patients (median age = 67 years) had stage IA cancer (52%). In the three-year period, patients had 1,958 radiologic studies (20.8/patient) including 398 computed tomographic (CT) scans (4.23/patient) and 211 positron emission tomography (PET) scans (2.24 per patient). The three-year median estimated radiation dose was 84.0 mSv (interquartile range, 44.1 to 123.2 mSv). The highest dose was in the preoperative year. In any one year, 66% of patients received more than 50 mSv, while 19% received over 100 mSv. Over the three-year period, 43.6% of patients exceeded 100 mSv. The majority of the radiation (89.8%) was from CT or PET scans. On multivariate analysis, a history of previous malignancy (odds ratio [OR] 3.8; confidence interval [CI] 1.14 to 12.7), postoperative complications (OR 6.16; CI 1.42 to 26.6), and postoperative surveillance with PET-CT (OR 13.2; CI 4.34 to 40.3) predicted exposure greater than 100 mSv over the three-year period., Conclusions: This study demonstrates that lung cancer patients often receive a higher dose of radiation than that considered safe for healthcare and radiation workers. The median cumulative dose reported in this study could potentially increase the individual estimated lifetime cancer risk by as much as 0.8%. Although risk-benefit considerations are clearly different between these groups, strategies should be in place to decrease radiation doses during the preoperative workup and postoperative period., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: No consensus exists on the optimal treatment strategy for clinical T2-T3N0M0 esophageal cancer. This study was conducted to determine rates of nodal positivity (N+) and to evaluate results of treatment strategies in this cohort., Methods: Surgically treated patients with cT2-T3N0M0 esophageal cancer were reviewed. Adequacy of lymph node dissection was assessed by guidelines applied to clinical stage. Survival was determined by Kaplan-Meier analysis. Univariate and multivariate analyses were done for predictors of N+ and survival., Results: We identified 102 patients, 51 cT2N0 and 51 cT3N0, 39 (38%) of whom had induction therapy. Despite being clinically node negative, 61 patients (60%) had nodal metastases. Applied to cT classification, adequate nodal dissection was achieved in 64 patients (63%). Transthoracic esophagectomy was more likely than transhiatal esophagectomy to achieve adequate nodal dissection (69% versus 31%, p=0.005). Adequate nodal dissection was more likely to document pN+ disease in both the surgery alone group (70% versus 50%, p=0.13) and induction therapy group (71% versus 33%, p=0.02). Five-year overall survival was 44% with surgery alone and 55% with induction therapy. On multivariate analysis, pN+ was the strongest predictor of overall survival (relative risk 2.73, confidence interval: 1.29 to 5.78)., Conclusions: Most cT2-T3N0M0 patients have pN+ disease. Despite induction therapy, more than 50% have persistent nodal disease. Transthoracic esophagectomy is more likely to detect pN+ disease and more likely to meet criteria of adequate nodal dissection than is transhiatal esophagectomy. Therefore, the majority of patients with cT2-T3N0M0 should be considered for neoadjuvant protocols and should be treated by transthoracic resection whenever possible., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Myoepitheliomas have been described most commonly in salivary glands and have been reported elsewhere but are rare in the lung, with only six previously reported cases. To our knowledge, this represents the first endotracheal myoepithelioma. These tumors have characteristic features that distinguish them from other tumors, and the diagnosis is a pathologic one, based on the morphology and supported by immunohistochemistry. Myoepitheliomas should be considered in the diagnosis of any pulmonary nodule.

Purpose: The primary objective of this study was to determine the rate of pathological response after preoperative celecoxib and concurrent taxane-based chemotherapy in patients with cancer of the esophagus and gastroesophageal junction., Methods: Thirty-nine patients were enrolled in this single-arm, phase II clinical trial. Patients were administered daily celecoxib in combination with two to three cycles of carboplatin and paclitaxel with preoperative intent. Levels of cyclooxygenase (COX)-2 expression in resected tumors were analyzed by immunohistochemistry and correlated with clinical outcome measures. Postoperatively, patients were administered daily celecoxib for 1 year or until documented tumor recurrence., Results: All patients received two to three cycles of chemotherapy plus celecoxib 800 mg/d. Toxicities were as expected. A major clinical response (complete response + partial response) was noted in 22 patients (56%); six patients (15%) had a complete clinical response. Thirty-seven patients underwent esophagectomy. Five patients had a major pathological response (12.8%). Four-year overall and disease-free survivals were 40.9% and 30.3%, respectively. Patients with tumors expressing COX-2 demonstrated a higher likelihood of a major clinical response response (62% versus 50%) and an improved overall survival, compared with patients with COX-2-negative tumors., Conclusions: Preoperative celecoxib with concurrent chemotherapy demonstrated sufficient effect on pathologic response to warrant further study. Patients with tumors expressing COX-2 demonstrated trends toward improved response to preoperative therapy and improved overall survival compared with nonexpressors.

Background: Although patients with esophageal cancer (EC) often develop lymph node metastases in the cervical and recurrent laryngeal (CRL) distribution, lymphadenectomy in this field is rarely performed. The purpose of this study was to determine factors associated with CRL node positivity and to determine the appropriate indications to perform a "three field" lymphadenectomy., Methods: In a retrospective review, EC patients who underwent three-field lymphadenectomy were analyzed. Predictors of positive CRL nodes were examined univariately, then selected for inclusion in a multivariate logistic regression model., Results: From 1994 to 2009, 185 patients had a three-field lymphadenectomy, of whom 46 patients (24.9%) had positive CRL nodes. Final pathology stages (seventh edition) were I in 24 patients, II in 43, III in 109, and IV in 1 patient. Eight patients had a major pathologic response after induction therapy. On univariate analysis, variables significantly associated with positive CRL nodes included squamous cell histology, proximal location, advanced clinical presentation, the presence of clinical nodal disease, higher pT classification, and higher pN classification. There was no reduction in the rate of positive CRL nodes after induction chemotherapy. On multivariate analysis, higher pN classification (adjusted odds ratio 16.25, 95% confidence interval: 5.40 to 48.87; p < 0.0001) and squamous histology (adjusted odds ratio 6.04, 95% confidence interval: 2.21 to 16.56; p < 0.0001) predicted positive CRL nodes., Conclusions: Complete lymphadenectomy is necessary in esophageal cancer to appropriately stage patients. Low rates of positive CRL nodes are present with early clinical stage, with pT0-2 tumors, and with pN0 classification, particularly in patients with adenocarcinoma and gastroesophageal junction tumors. Dissection of the CRL field should be considered with advanced disease for adenocarcinoma and in all patients with squamous cell cancer., (Copyright © 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Distinguishing a metachronous lung cancer from a metastatic or recurrent lesion in patients with a prior history of non-small cell lung cancer is a challenging task. Previous studies have suggested histologic type and disease-free interval as criteria for diagnosing metachronous lung cancer. These factors may not be as relevant now that current imaging allows for earlier detection of tumors and with the rising incidence of adenocarcinoma. The purpose of this study was to reexamine the factors that determine outcomes in patients with a second primary lung cancer., Methods: A retrospective review of a prospective lung cancer database was performed to identify patients with metachronous lung cancer. Metachronous lung cancer was defined as any non-small cell lung cancer occurring after a prior resection regardless of disease-free interval or histologic type. The Kaplan-Meier method was used for survival analysis. The Mantel-Cox method was used to compare overall survival. Cox regression was used for multivariate analysis., Results: Fifty-eight patients had metachronous lung cancer. Overall survival at 5 years was 66% (stage IA, 74%; IB, 59%; all other stages, 0%; p = 0.01). Seventy-two percent (42 of 58 patients) had similar histologic type. There was no difference in overall survival based on similar versus different histologic type (65% versus 73%; p = 0.77). Median disease-free interval was 42 months (range, 8 to 312 months). Disease-free interval was not a significant predictor of overall survival (p = 0.24). The extent of resection included wedge (36%, 21 of 58 patients), segmentectomy (24%, 14 of 58 patients), and lobectomy (40%, 23 of 58 patients), with no difference in overall survival (58% versus 60% versus 75%, respectively; p = 0.32)., Conclusions: These data suggest that early tumor stage is the only significant determinant of survival after surgical treatment of metachronous lung cancer. Neither histologic type nor disease-free interval was of prognostic value. Limited resections may be adequate treatment.

Background: Patients with esophageal carcinoma and celiac, cervical, or other nonregional nodal metastases generally have a poor prognosis after surgical resection. Factors predicting long-term survival are unclear. The goal of this study was to analyze factors predicting long-term survival in this subset of patients., Methods: We conducted a retrospective review of a prospective database over a 20-year period to identify patients with resected esophageal carcinoma with nonregional lymph node metastases. Medical records were reviewed and risk factors were analyzed., Results: Sixty-seven patients underwent esophagectomy for M1a or M1b disease from 1987 to 2007. Esophagectomy was transthoracic in 62 patients and transhiatal in 5. The median number of lymph nodes harvested was 36. Sites of nodal metastases were the following: recurrent nodal chain in 42 patients, celiac in 20, both recurrent and celiac in 4, and paratracheal in 1. Median length of follow-up was 66 months. The 5-year overall survival for the entire cohort was 25%. The 5-year overall survival was significantly higher with earlier T-status, (pathologic tumor [pT]1/T2 vs pT3/T4; 62% vs 15%, p = 0.006). Thirteen patients who had nonregional nodal metastases without involvement of regional nodes (pN0) had a significant improvement in 5-year survival (67% vs 15%; p < 0.001). Patients with squamous cell carcinomas had higher 5-year survival compared with those with adenocarcinomas (42% vs 14%; p = 0.009). Patients treated with induction chemotherapy had prolonged 5-year survival (41%, p = 0.06) compared with those treated with adjuvant chemotherapy (11%) or no therapy (20%). Multivariate analysis demonstrated that chemotherapy treatment, squamous cell type, and early T stage (pT1/T2) are significant positive predictors of survival., Conclusions: Surgical resection for patients with esophageal cancer associated with nonregional nodal metastases results in 25% survival at five years. Squamous histology, earlier T status, and perioperative chemotherapy are independent positive predictors of long-term survival.

Background: The ability to accurately predict clinical and pathological response and survival in patients undergoing preoperative chemotherapy may have a significant impact on treatment strategy for esophageal carcinoma. This study assessed the predictive accuracy of clinical response (CR) and positron emission tomography (PET) scanning in determining pathological downstaging and disease free survival (DFS) after chemotherapy., Methods: This is a retrospective review of patients who underwent chemotherapy prior to complete surgical resection for esophageal carcinoma between 1999 and 2005. Clinical response was correlated with pathological downstaging and survival. For PET scanning, the percent reduction in maxSUV after induction therapy was determined and we identified the optimal threshold of percent reduction in maxSUV for predicting clinical response and pathological downstaging., Results: Sixty-two patients (52 men, median age 62.3) were evaluated. Thirty-nine patients (62.9%) had either a partial (n = 32) or complete clinical response (n = 7) to induction therapy. The sensitivity, specificity, positive, and negative predictive value of an objective clinical response in predicting downstaging in T and (or) N were 85.7%, 55.9%, 61.5%, and 82.6%, respectively. There was no difference in DFS between responders and nonresponders. The PET sensitivity, specificity, positive, and negative predictive values for predicting pathologic downstaging were 77.8%, 52.9%, 56.8%, and 75%, respectively. Thirty-seven patients (59.7%) had a 50% or greater reduction in the maxSUV of their primary tumor and had a significant improvement in DFS compared with patients with a less than 50% reduction in maxSUV (median DFS time: 35.5 months vs 17.9 months, respectively, p = 0.03). Significantly, 11 patients had a 100% reduction in maxSUV despite the presence of residual tumor., Conclusions: Complete response and PET appear equivalent in predicting pathological downstaging. However, a 50% reduction in the maxSUV after induction therapy is more significantly associated with improved DFS than CR or pathological downstaging. Additionally, a complete absence of PET signal cannot be equated with a complete pathological response.

Background: In patients deemed to have clinical stage I for non-small cell lung cancer (NSCLC) after computerized tomography (CT) and positron emission tomography (PET) scans, the utility of mediastinoscopy to detect occult mediastinal metastases is unclear. The goal of this study was to analyze the risk factors for occult mediastinal metastases in this subset of patients., Methods: We conducted a retrospective review during a 7-year period to identify patients with potentially operable clinical stage I NSCLC screened by CT and PET scans. Medical records were reviewed, and the prevalence of pathologic N2 disease was analyzed according to clinical tumor location, size, histology, and PET uptake of the primary tumor., Results: Of 224 patients identified with clinical stage I NSCLC with a CT-negative and PET-negative mediastinum, 16 patients had pathologic N2 disease proven by mediastinoscopy (n = 11) or after resection (n = 5). The overall prevalence of histologically confirmed N2 disease was 6.5% in clinical T1 patients and 8.7% in clinical T2 patients. Central tumors had a higher prevalence of N2 disease compared with peripheral tumors, 21.6% versus 2.9% (p < 0.001). Larger clinical T size predicted a higher prevalence of occult N2 disease (p < 0.001). All 16 patients with occult N2 metastases had adenocarcinoma as the primary tumor cell type. When the PET maximum standardized uptake value (SUV(max)) of the primary tumors was analyzed, patients with occult N2 metastases had a higher median SUV(max) of the primary tumor compared with patients without N2 metastases, 6.0 g/mL versus 3.6 g/mL (p = 0.017)., Conclusions: For patients deemed at clinical stage I NSCLC by CT and PET, the prevalence of missed N2 metastases increased significantly with larger tumor size and central location. Adenocarcinoma cell type and a high PET SUV(max) of the primary tumor were other risk factors. Mediastinoscopy may have improved yield in the select subset of patients with one or more risk factor.

Background: The current international staging system for lung cancer designates intralobar satellites as T4 disease. In this study, we sought to determine the impact of multifocal, intralobar non-small cell lung cancer (NSCLC) on patient survival and its potential relevance to stage designation., Methods: We conducted a retrospective review of our thoracic surgical cancer registry from 1990 to 2005. Included were 53 patients with a resected lung cancer containing intralobar satellites detected preoperatively (n = 8) or in the resected specimen (n = 45). Patients with multicentric bronchioloalveolar cancer were excluded. All patients had an anatomic resection with mediastinal lymph node dissection. Median follow-up for the entire group was 31 months. Survival was calculated by the Kaplan-Meier method. A Cox proportional hazards regression model was performed to examine simultaneously the effects on overall survival of age, gender, nodal disease, number of satellite lesions, lymphatic invasion, and T status., Results: The median age of the 53 patients with multifocal, intralobar (T4) disease was 68 years and 31 were women. Ten patients had more than one satellite lesion. Overall 5-year survival was 47.6% (95% confidence interval [CI], 27.36% to 65.30%) for all patients with resected intralobar satellites. Patients without nodal metastases had a 5-year survival of 58.4% (95% CI, 28.76% to 79.30%). The Cox regression identified female gender (adjusted hazard ratio [HR], 0.31; 95% CI, 0.10 to 0.96; p < 0.04) as a significant prognostic variable but only a trend towards significance for nodal status (adjusted HR, 2.3; 95% CI, .83 to 6.26; p < 0.11)., Conclusions: Patients with intralobar multifocal NSCLC detected in the resected specimen have a more favorable prognosis after surgical resection than might be predicted by their stage T4 designation. Five-year survival rates, especially in T4N0 patients, more closely approximate those with stages IB or II NSCLC.

Background: To determine the eventual outcome of abnormalities detected on surveillance computed tomography (CT) in patients with previously resected nonsmall-cell lung cancer (NSCLC), and to assess the accuracy of CT when used by the thoracic surgeon, and to determine the characteristics of abnormalities on CT that correlate with the development of recurrent NSCLC., Methods: A cohort of patients who had abnormal postoperative CT scans of the chest and upper abdomen in 2002 were followed up into 2005. Abnormalities consisted of pulmonary nodules, pleural effusions, or adenopathy. Data collected included recurrence patterns, the availability of previous scans for comparison, the interval between initial resection and the abnormal CT, nodule size, growth, and multiplicity, as well as progression of pleural effusions or adenopathy., Results: In all, 105 scans in 92 patients were read as abnormal in 2002 by the radiologist. After further investigation or follow-up, or both, for a mean of 3.2 years, 78% of patients who had recurrent NSCLC had their site of first recurrence inside the chest. The negative predictive value of CT when used by the thoracic surgeon was 99%; however, the positive predictive value was only 53%. Abnormalities that correlated with the diagnosis of recurrent cancer included pulmonary nodules that either grew or were larger than 1 cm and pleural effusions that developed after the first postoperative year., Conclusions: Intrathoracic recurrent NSCLC was rarely missed by the surgeon utilizing surveillance CT, but a significant number of negative investigations were generated by its use. Characteristics of abnormal surveillance CT findings exist that correlate with the presence of malignancy.

Background: The purposes of this study were to determine the frequency of downstaging of T or N after neoadjuvant chemotherapy and radical resection in patients with carcinoma of the esophagus, and to evaluate the effect of tumor downstaging on survival., Methods: A cohort of patients who underwent neoadjuvant chemotherapy followed by radical surgical resection for carcinoma of the esophagus was identified from a large, prospectively maintained, single-institution database of esophageal cancer patients. Patients were included if they had an accurate pretreatment clinical stage determined by the authors. Data collected included demographic data, the type of staging regimen, the chemotherapy agents used, clinical and pathologic data and stages, and survival data. Downstaging of T or N was determined by comparing the pretreatment, clinical stage to the postresection, pathologic stage. Downstaging was then evaluated in the context of survival., Results: Seventy-seven patients were identified who had an accurate clinical stage assigned and underwent neoadjuvant chemotherapy followed by radical resection. Patients were clinically staged before treatment using computed tomography, positron emission tomography, and endoscopic ultrasonography. Thirty-seven patients (48%) experienced downstaging of T or N, and this group of patients had a 5-year overall actuarial survival of 63%, compared with 23% for those who were not downstaged (p = 0.002). Three patients had a complete pathologic response to neoadjuvant chemotherapy (3.9%)., Conclusions: Patients who experience downstaging of T or N after neoadjuvant chemotherapy and radical surgical resection for esophageal carcinoma have a significantly higher survival rate compared with those who do not experience downstaging. This enhanced survival is comparable to survival rates reported in complete pathologic responders after neoadjuvant chemoradiation.

Background: Postoperative surveillance with chest computed tomography (CT) is often performed in patients who have undergone resection of non-small cell lung cancer (NSCLC), despite lack of supporting data. This study involves the creation of a decision analysis model to predict the cost effectiveness of postoperative surveillance CT., Methods: A decision analysis model was created in which a hypothetical cohort of patients underwent annual chest CT after resection of a stage IA NSCLC. The incidence of second primary lung cancer (SPLC), sensitivity and specificity of CT, as well as survival after resection of initial primary and SPLC were derived from published literature. The cost of CT and other procedures prompted by a positive finding on CT was calculated from Medicare reimbursement schedules. Cost effectiveness was defined as a cost of less than 60,000 dollars per quality-adjusted life-year gained in the cohort under surveillance compared with controls under no surveillance., Results: In the initial (base case) analysis, the cost of surveillance CT was 47,676 dollars per quality-adjusted life-year gained, implying cost effectiveness. However, factors that rendered surveillance CT cost ineffective were (1) age at entry into the surveillance program greater than 65 years, (2) cost of CT greater than 700 dollars, (3) incidence of SPLC of less than 1.6% per patient per year of follow-up, and (4) a false positive rate of surveillance CT greater than 14%., Conclusions: Surveillance with postoperative CT may be a cost-effective intervention to detect SPLC in selected patients with previously resected stage IA NSCLC.

Background: A purported advantage of the cervical esophagogastrostomy is that drainage is easily accomplished should anastomotic dehiscence occur after esophagectomy. However, support for this statement stems mainly from studies of transhiatal esophagectomy, with little data published when a transthoracic resection is performed. The purpose of this study was to determine the incidence and clinical significance of intrathoracic manifestations of cervical anastomotic leaks after transthoracic esophagectomy., Methods: A retrospective analysis of a prospectively collected esophageal carcinoma database (1988 to 2004) was performed at a single institution. Operative and pathologic data were collected, as well as details concerning the incidence, clinical features, treatment, and outcome of anastomotic leaks. Patients with leaks were further analyzed on the basis of whether or not intrathoracic manifestations of anastomotic leakage were present., Results: Two hundred, forty-two patients underwent transthoracic esophagectomy with a cervical anastomosis during the study period. There were 27 (11.1%) anastomotic leaks. Of these, 14 patients (52%) had intrathoracic manifestations of their cervical leaks, with empyema being the most common. Patients with intrathoracic spread of sepsis had significantly longer in-hospital (p < 0.001) and anastomotic healing times (p < 0.05) and required more drainage procedures (including reoperation; p < 0.005) than those with leaks confined to the neck. However, no difference in operative mortality or long-term survival was appreciated., Conclusions: Intrathoracic manifestations of cervical anastomotic leaks are more common after transthoracic esophagectomy than what has historically been reported for transhiatal esophagectomy. This discrepancy may be due to anatomical or technical differences, or both, between the two procedures. Early diagnosis and aggressive drainage are necessary for achieving a favorable outcome.

Background: Induction therapy is a common treatment modality for patients with stage IIIA non-small cell lung cancer (NSCLC). Although mediastinal nodal downstaging after induction therapy is generally considered a favorable prognostic feature, the benefit of resection in the presence of residual N2 disease is controversial. In this study we analyzed our experience with resection after induction chemotherapy in patients with residual N2 disease to more precisely define the role of surgical resection in this group of patients., Methods: In this retrospective analysis, we reviewed the records of 78 patients with N2 disease who received induction therapy with preoperative intent between 1990 and 2003. All patients had potentially resectable disease. Survival analysis was performed using the Kaplan-Meier method. A Cox proportional hazards regression model was used to evaluate multiple prognostic factors., Results: There were 78 patients (39 men) with a median age of 64 years. Sixty had nonsquamous histology. Resection was performed in 52 patients (47 R0). Hospital mortality was 1.9%. A complete pathologic response occurred in 2 of 52 (3.8%) patients and 19 of 52 (36%) patients had no residual N2 disease. Overall 5-year survival for resected patients was 23%. Overall 5-year survival was 30% for N0-N1 patients and 19% for those with residual N2 disease. Multivariable analysis identified clinical response to therapy (p = 0.0007) and histology (p = 0.01), but not residual N2 disease (p = 0.65), as important prognostic variables., Conclusions: Surgical resection may be a viable option for patients with residual N2 disease after induction chemotherapy, provided an R0 resection can be performed.

Background: As the US population ages, clinicians are increasingly confronted with octogenarians with resectable non-small cell lung cancer. Earlier reports documented substantial risk for surgical resection in this age group., Methods: We reviewed our surgical experience in octogenarians who underwent curative resection from 1990 to 2003., Results: Sixty-one patients underwent resection: 46 lobectomies, 6 segmentectomies, 5 wedge resections, and 4 pneumonectomies. There was one perioperative death (1.6%). The overall complication rate was 38% with a major complication rate of 13%. The average postoperative length of stay was 7 days. Overall 5-year survival was 38%, and 82% for stage IA patients. Patients with more advanced disease had a significantly worse survival., Conclusions: Appropriately selected octogenarians with early stage disease should be offered anatomic surgical resection for cure. These patients can anticipate a long-term survival, and should not be denied an operation on the basis of age alone.