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Objective: Despite declining lung cancer mortality in the United States, survival differences remain among racial and ethnic minorities in addition to those with limited health care access. Improvements in lung cancer treatment can be obtained through clinical trials, yet there are disparities in clinical trial enrollment of other cancer types. This study aims to evaluate disparities in lung cancer clinical trial enrollment to inform future enrollment initiatives., Methods: We analyzed patients with non-small cell lung cancer from the National Cancer Database (2004-2018), categorizing them as enrolled or not enrolled in clinical trials based on "rx&#95;summ&#95;other" data element. Clinical, demographic, and institutional factors associated with trial enrollment were assessed using bivariate and multivariate analysis, adjusting for institutional-level clustering., Results: A total of 1924 (0.12%) patients with lung cancer were enrolled in clinical trials. Enrolled patients were predominantly non-Hispanic White (82%), with greater socioeconomic status, treated at academic programs (67%), and had private insurance (42%) or Medicare (44%). They also traveled further for treatment compared with unenrolled patients (56 vs 27 miles, P < .001). After adjusting for demographic and clinical factors, lung cancer trial enrollment was significantly less likely among Black (odds ratio, 0.55; 95% confidence interval, 0.5-0.7, P < .001) and Hispanic (0.66; 95% confidence interval, 0.5-0.9, P = .01) patients. Patients with Medicaid or uninsured, in the lowest socioeconomic status group, and those treated at community-based cancer programs were the least likely to enroll., Conclusions: Enrollment in lung cancer trials disproportionally excludes minority patients, those in the lowest socioeconomic status, community cancer programs, and the underinsured. These disparities in demographic and access for trial participation show a need for improved enrollment strategies., Competing Interests: Conflict of Interest Statement C.W.T. is a consultant for Zimmer Biomet, AtriCure, Astra Zeneca, and Bristol Myers Squibb. C.W.T. also discloses research finding and nonfinancial research support from Zimmer Biomet and Medtronic. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: To determine whether discriminatory performance of a computational risk model in classifying pulmonary lesion malignancy using demographic, radiographic, and clinical characteristics is superior to the opinion of experienced providers. We hypothesized that computational risk models would outperform providers., Methods: Outcome of malignancy was obtained from selected patients enrolled in the NAVIGATE trial (NCT02410837). Five predictive risk models were developed using an 80:20 train-test split: univariable logistic regression model based solely on provider opinion, multivariable logistic regression model, random forest classifier, extreme gradient boosting model, and artificial neural network. Area under the receiver operating characteristic curve achieved during testing of the predictive models was compared to that of prebiopsy provider opinion baseline using the DeLong test with 10,000 bootstrapped iterations., Results: The cohort included 984 patients, 735 (74.7%) of which were diagnosed with malignancy. Factors associated with malignancy from multivariable logistic regression included age, history of cancer, largest lesion size, lung zone, and positron-emission tomography positivity. Testing area under the receiver operating characteristic curve were 0.830 for provider opinion baseline, 0.770 for provider opinion univariable logistic regression, 0.659 for multivariable logistic regression model, 0.743 for random forest classifier, 0.740 for extreme gradient boosting, and 0.679 for artificial neural network. Provider opinion baseline was determined to be the best predictive classification system., Conclusions: Computational models predicting malignancy of pulmonary lesions using clinical, demographic, and radiographic characteristics are inferior to provider opinion. This study questions the ability of these models to provide additional insight into patient care. Expert clinician evaluation of pulmonary lesion malignancy is paramount., Competing Interests: Conflict of Interest Statement Dr Towe is a consultant for Zimmer Biomet, Astra Zeneca, Bristol Myers Squibb, Atricure, and Medtronic and is a grant recipient from Zimmer Biomet. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Thoracoscopic pneumonectomy commonly requires conversion to thoracotomy. We hypothesize that conversion would lead to worse short- and long-term outcomes compared with operations completed thoracoscopically., Methods: The National Cancer Database identified patients who underwent a pneumonectomy from 2010 to 2016. Trends in conversion were described using linear regression. Multivariable regression of factors associated with conversion was performed. Short-term outcomes included duration of stay, number of lymph nodes harvested, margin status, readmission, and 90-day mortality. Long-term outcome was evaluated as overall survival., Results: A total of 8,037 patients underwent a pneumonectomy. The rate of attempted thoracoscopic pneumonectomies increased from 11% to 22% (P < .001) and the rate of conversion decreased from 39% to 33% (P = .011). On multivariable analysis, a greater patient comorbidity index and pathologic nodal-stage 2 disease were associated with an increased rate of conversion. The mean number of lymph nodes evaluated was greater as was the duration of stay in the conversion group, but conversion to open thoracotomy was not associated with positive surgical margins, readmission rate, 90-day mortality, or survival., Conclusion: Thoracoscopic pneumonectomy is performed with increasing frequency and decreasing conversion rate. Conversion is associated with a greater duration of stay but other short- and long-term outcomes are similar. This observation suggests minimal harm in conversion from minimally invasive to open pneumonectomy., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: Although minimally invasive techniques have led to shorter hospitalizations, discharge on postoperative day 1 is still uncommon. We hypothesized that day 1 discharge could be performed safely and that there might be significant variation in day 1 discharge rates between hospitals., Methods: We identified patients with lung cancer who underwent lobectomy and segmentectomy in the Society of Thoracic Surgeons Database from 2012 to 2017. The 10% longest hospital stay outliers were excluded. A multivariable regression model was created to assess for factors associated with day 1 discharge and readmission., Results: A total of 46,325 patients were examined, and 1821 patients (3.9%) were discharged on day 1. This rate increased from 3.4% to 5.3% over the course of the study (P < .0001). In multivariable analysis, factors associated with day 1 discharge included age, Zubrod score, body mass index greater than 25, forced expiration value at 1 second, middle or upper lobectomy, minimally invasive technique, and procedure time. Outpatient 30-day mortality was similar (0.3% vs 0.4%, P = .472). Patients discharged on day 1 were not at increased risk of readmission. Readmission after day 1 discharge was associated with male sex, coronary artery disease, chronic obstructive pulmonary disease, and longer procedure time. There was substantial variation in day 1 discharge rate between institutions, with 11 centers (4.0%) discharging more than 20% of their patients on day 1, whereas 102 centers (36.7%) had no day 1 discharges., Conclusions: Day 1 discharge after anatomic lung resection is uncommon but is becoming more common. Carefully selected patients may be discharged on day 1 without an increased risk of readmission or death., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: We analyzed the Society of Thoracic Surgeons' Database to describe the results of surgical decortication., Methods: A review of patients undergoing pulmonary decortication, excluding hemothorax and malignancy, from 2009 to 2016 was performed. Preoperative factors, length of stay, discharge status, readmission, morbidity, and mortality were compared between open and video-assisted thoracoscopic surgery approaches. Multivariable models identified risk factors for morbidity and mortality., Results: Of 7316 patients undergoing decortication, 6961 (95.2%) had a primary diagnosis of empyema. Video-assisted thoracoscopic surgery was used in 4435 patients (60.6%) and increased during the study period. Median length of stay was 4 days (interquartile range, 2-7) preoperatively and 7 days (interquartile range, 5-11) postoperatively. Mortality occurred in 228 patients (3.1%). Complications occurred in 2875 patients (39.3%), and major morbidity occurred in 1138 patients (15.6%). Transitional care after discharge occurred in 1922 patients (26.3%). Readmission within 30 days occurred in 452 patients (8.7%). Compared with video-assisted thoracoscopic surgery, mortality, major morbidity, prolonged length of stay, and discharge to other than home were higher with thoracotomy. In multivariable analysis, age, estimated glomerular filtration rate less than 60, chronic obstructive pulmonary disease, body mass index, American Society of Anesthesiologists level, Zubrod score, and thoracotomy were associated with increased mortality, morbidity, discharge to transitional care, and prolonged length of stay. Each additional preoperative hospital day (up to 5 days) increased mortality. Readmission, major morbidity, prolonged length of stay, and discharge to transitional care were all higher when preoperative hospitalization extended beyond 5 days., Conclusions: Surgeons participating in the Society of Thoracic Surgeons General Thoracic Surgery Database perform decortication for parapneumonic empyema and pleural effusion with limited mortality despite substantial postoperative morbidity. Further study is required to describe selection criteria for video-assisted thoracoscopic surgery and determine indications for surgical intervention to reduce delays in operative intervention., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Five-year survival after the diagnosis of non-small cell lung cancer is the most common benchmark used to evaluate long-term survival. Data on survival beyond 5 years are sparse. We sought to elucidate variables affecting 10- to 18-year survival., Methods: A total of 31,206 patients alive at least 5 years after diagnosis of non-small cell lung cancer who were registered in the Surveillance, Epidemiology, and End Results database from 1988 to 2001 were examined. Primary end points were disease-specific survival and overall survival. Survival analysis was performed with Kaplan-Meier estimates, multivariable Cox proportional hazards regression, and competing risk models., Results: Overall survival at 10, 15, and 18 years was 55.4%, 33.1%, and 24.3%, respectively. Disease-specific survival at 10, 15, and 18 years was 76.6%, 65.4%, and 59.4%, respectively. In multivariable regression analysis, squamous cell cancers had a disease-specific survival advantage (hazard ratio, 0.88; P < .0001) but an overall survival disadvantage (hazard ratio, 1.082; P = .0002) compared with adenocarcinoma. Pneumonectomy (hazard ratio, 0.44) and lobectomy (hazard ratio, 0.474) had improved disease-specific survival compared with no surgery (P < .0001). Left-sided tumors (hazard ratio, 0.723; P = .036) and node-negative cancers (hazard ratio, 0.562; P < .001) also had a better disease-specific survival and, to a lesser extent, overall survival advantage., Conclusions: Five-year survivors of non-small cell lung cancer have a persistent risk of death from lung cancer up to 18 years from diagnosis. More than one half of all deaths in 5-year survivors are related to lung cancer. In multivariable regression analysis, age, node-negative disease, and lobar or greater resection were strong predictors of long-term survival (ie, 10-18 years)., (Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objectives: CyberKnife stereotactic body radiosurgery is a potentially curative option for medically inoperable Stage I lung cancer. Fiducial marker placement in or near the tumor is required. Transthoracic placement using computed tomography guidance has been associated with a high risk of iatrogenic pneumothorax. Electromagnetic navigation bronchoscopy offers a safer method of placing markers; however, previous studies using linear markers have shown at least a 10% dislocation rate. We describe the use of coil-spring fiducial markers placed under moderate sedation in an outpatient bronchoscopy suite., Methods: A total of 52 consecutive nonoperative patients with isolated lung tumors underwent fiducial placement using electromagnetic navigation bronchoscopy. Of the 52 patients, 4 received 17 linear fiducial markers, and 49 patients with 56 tumors received 217 coil-spring fiducial markers. The procedures were considered successful if the fiducial markers had been placed in or near the tumors and had remained in place without migration, allowing radiosurgery without the need for additional fiducial markers., Results: A total of 234 fiducial markers were successfully deployed in 52 patients with 60 tumors (mean diameter 23.7 mm). Of these 60 tumors, 35 (58%) were adjacent to the pleura. At CyberKnife planning, 8 (47%) of 17 linear fiducial markers and 215 (99%) of 217 coil-spring fiducial markers (P = .0001) were still in place. Of the 4 patients with linear fiducial markers, 2 required additional fiducial placements; none of the patients with coil fiducial markers required additional procedures. Three pneumothoraces (5.8%) occurred in peripheral lesions (2 were treated with a pig-tail chest tube and 1 with observation only)., Conclusions: Deployment of coil spring fiducial markers using navigation bronchoscopy can safely be performed with the patient under moderate sedation with almost no migration and a 5.8% rate of pneumothorax., (Copyright © 2010 The American Association for Thoracic Surgery. All rights reserved.)

Objective: Using a national cancer registry, we determined the postoperative survival of patients with stage IA non-small cell lung cancer in the United States from 1988 to 1997 and identified factors that affect survival., Methods: Within the Surveillance, Epidemiology, and End Result Program database, 10,761 patients were identified as having stage IA non-small cell lung cancer and underwent curative surgical resection from 1988 to 1997. Univariate analyses were performed by the log-rank test to determine predictors of survival, and multivariable analysis was performed by a Cox regression model., Results: Overall 5-year survival was 58%. On univariate analysis, tumor size, gender, age, and extent of resection were significant predictors of survival. Five-year survival of patients with tumors 2.1 to 3.0 cm was lower than that for patients with tumors 2.0 cm or smaller: 55% versus 60% (P < .0001). Men faired significantly worse than women, with a 5-year survival of 53% versus 63% (P < .0001). Patients older than the median age of 67 years had worse 5-year survival than had those under the median age: 52% versus 65% (P < .0001). Patients undergoing sublobar resections showed poorer 5-year survival than patients undergoing anatomic resections: 44% versus 61% (P < .0001). On multivariable analysis with a Cox regression model, all 4 variables remained statistically significant., Conclusion: The survival of patients with stage IA non-small cell lung cancer within the United States is significantly worse than survival reported from single-institution studies. This study identifies 4 factors that may affect survival in resected stage IA non-small cell lung cancer: tumor size, gender, age, and extent of resection.

Objective: There is a strong association between reflux and end-stage lung disease, especially idiopathic pulmonary fibrosis. The presence of reflux after lung transplantation might predispose to the development of bronchiolitis obliterans. We evaluated the risk and physiologic effect of laparoscopic fundoplication in patients on the lung transplant waiting list., Methods: One hundred forty-nine patients on the lung transplant waiting list between March 2001 and January 2005 were evaluated. Nineteen were found to have a history of reflux, continued symptoms, and severe reflux by means of pH and manometric studies and underwent laparoscopic fundoplication. The postoperative course of these 19 patients, including lung function, was retrospectively reviewed. Postoperatively, the lung function of the 14 patients with idiopathic pulmonary fibrosis who underwent the laparoscopic Nissen procedure was compared with that of 31 patients with idiopathic pulmonary fibrosis on the transplant waiting list who did not undergo fundoplication., Results: There were no perioperative complications and no decrease in lung function over the 15-month average follow-up. Exercise capacity remained stable, as determined on the basis of 6-minute walk distance. Patients with idiopathic pulmonary fibrosis treated with fundoplication had stable oxygen requirements, whereas control patients with idiopathic pulmonary fibrosis on the waiting list had a statistically significant deterioration in oxygen requirement., Conclusions: Laparoscopic fundoplication can be performed safely in patients with end-stage lung disease awaiting lung transplantation. Overall, these patients maintained stable lung function during the follow-up period. When compared with a control group of patients with idiopathic pulmonary fibrosis not undergoing fundoplication, there was stabilization of oxygen requirement. A larger prospective trial evaluating the effect of laparoscopic fundoplication on underlying lung function in this patient population is warranted.