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Valve-sparing root replacement using reimplantation techniques is increasingly applied to bicuspid aortopathy. Long-term durability of cusp repair is unclear. We analyze midterm results using a conservative approach to cusp repair.From 2006 to 2018, 327 patients underwent valve-sparing reimplantation, 66 with bicuspid valves. Leaflets were analyzed after reimplantation. A majority (51/66) required no cusp repair. Fifteen patients had cusp repair limited to closure of unfused raphe or central plication. Patients were followed by echocardiography.Mean age of patients was 44.7 ± 12.3 years. The cusp repair group had a higher incidence of preoperative moderate (10% vs 40%) or severe (4% vs 33.3%) aortic insufficiency (P .001). There was no operative mortality or major complication. Mean follow-up was 51.6 ± 40.8 months. On postoperative echocardiography, incidence of none, trace, or mild aortic insufficiency was 41.3% (19/46), 43.5% (20/46), and 15.2% (7/46) in the no cusp repair group and 40% (6/15), 40% (6/15), and 20% (3/15) in the cusp repair group, respectively (P = .907). Few patients progressed in degree of aortic insufficiency. No patients required reoperation. At 5 years, freedom from any aortic insufficiency was 46.9% versus 15.8% (P = .013), and freedom from greater than trace aortic insufficiency was 59.1% versus 36.9% (P = .002) due to the higher rate of postoperative trace and mild aortic insufficiency with cusp repair. There was no difference in freedom from greater than mild aortic insufficiency (92.1% vs 100%; P = .33).Valve-sparing root replacement is reliably performed with bicuspid aortic valves whether or not cusp reconstruction is necessary. Few patients progress to greater than mild aortic insufficiency. Need for reoperation is rare in midterm follow-up.

Background Stapling across lung parenchyma may lead to tissue granulation, which could be confused radiographically with recurrence. We sought to define the time course and radiographic characteristics of such thickening and to determine their association with recurrence. Methods Patients who underwent limited resection for non-small cell lung cancer were included. Surveillance computed tomography scans were reviewed to characterize the morphology and size of staple line granulation tissue. Radiological and clinical findings were analyzed and univariate predictors of recurrence were examined. Results We characterized 78 patients for tissue granulation a total of 314 times in serial scans. On initial postoperative scans, 3.8% (n = 3) of staple lines showed no thickening and 17.9% (n = 14) showed thickening less than 2 mm, whereas 78.2% (n = 61) showed thickening 2 mm or greater. Of the 75 staple lines with thickening, soft tissue was characterized as linear in 32.0% (n = 24), focal along the pleura, hilum, or parenchyma in 24.0% (n = 18), and nodular in 44.0% (n = 33). Subsequent scans revealed that 25.3% of these areas (n = 19) did not change in shape or size over time, 58.7% (n = 44) showed regressive changes, and 16.0% (n = 12) showed progressive changes, the thickening of which in all 12 of these patients showed an increase in the largest dimension by 2 mm or greater. Among the 78 patients, 7.7% (n = 6) had biopsy-proven recurrence along the staple line. An increase in the largest dimension by 2 mm or greater (83.3% versus 9.7%; P = .001) and radiologic concern for malignancy (66.7% versus 11.1%; P = .001) predicted staple line recurrence. Conclusions Staple line thickening is a frequent occurrence after pulmonary limited resection, but rarely indicative of recurrence. The characteristics and initial size of granulation tissue do not predict recurrence. Increases in tissue 2 mm or greater at the staple line over time predict local recurrence, which typically occurs after a prolonged time interval.

MINI In patients with esophageal cancer who received neoadjuvant chemoradiation, the total number of resected nodes is a significant determinant of improved survival regardless of clinical nodal status. OBJECTIVES The aim of this study was to explore the potential value of extended nodal-dissection following neoadjuvant chemoradiation (CRT), by analyzing data from the National Cancer Database (NCDB). BACKGROUND A CROSS-trial post-hoc analysis showed that the number of dissected lymph nodes was associated with improved survival in patients undergoing upfront surgery but not in those treated with neoadjuvant CRT. METHODS The NCDB was queried (2004-2014) for patients who underwent esophagectomy following induction CRT. Predictors of overall survival (OS) were assessed. The optimal number of dissected LNs associated with highest survival benefit was determined by multiple regression analyses and receiver-operating characteristic curve analysis. The whole cohort was divided into 2 groups based on the predefined cutoff number. The two groups were propensity-matched (PMs). RESULTS Esophagectomy following induction-CRT was performed in 14,503 patients. The number of resected nodes was associated with improved OS in the multivariable analysis (hazard ratio for every 10 nodes: 0.95 (95% confidence interval: 0.93-0.98). The cutoff number of resected LNs that was associated with the highest survival benefit was 20 nodes. In the PM groups, patients in the "≥20 LNs" group had a 14% relative-increase in OS (P = 0.002), despite having more advanced pathological stages (stage II-IV: 76% vs 72%, P < 0.001), and higher number of positive nodes (0-2 vs 0-1, P < 0.001). CONCLUSIONS The total number of resected nodes is a significant determinant of improved survival following induction CRT in patients with either node negative or node positive disease. In the matched groups, patients with higher number of resected lymph nodes had higher OS rate, despite having more advanced pathological disease and higher number of resected positive lymph nodes.

Background: With antiprogrammed death receptor-1 (anti-PD-L1) therapy, a recent meta-analysis reported higher incidence of cutaneous, endocrine and gastrointestinal complications especially with dual anti-PD-L1 immunotherapy (IMM). Methods: Our primary outcome was assessment of all cardiotoxicity grades in IMM compared with different treatments, thus a systemic review and a meta-analysis on randomized clinical trials (RCTs) were done. Results: We included 11 RCTs with 6574 patients (3234 patients in IMM arm vs 3340 patients in the other arm). Three non-small-cell lung cancer RCTs, seven melanoma RCTs and only one prostatic cancer RCT met the inclusion criteria. There were five RCTs that compared monoimmunotherapy to chemotherapy “(n = 2631 patients)”. No difference exists in all cardiotoxicity grades or high-grade cardiotoxicity (p > 0.05). Lung cancer exhibited a higher response rate and lower mortality in IMM. Conclusion: There was no reported statistically significant cardiotoxicity associated with anti-PD/PD-L1 use. Lung cancer subgroups showed better response and survival rates.

OBJECTIVES: Despite the recent increased rate of adoption of robotic approaches for the resection of thymic tumours, their use is still limited to large-volume academic centres. To date, a large-scale analysis of the robotic approach has not been performed. We assessed the recent trends and outcomes of robotic thymectomies in the United States compared to those of open and video-assisted thoracoscopic surgical (VATS) approaches. METHODS: The National Cancer Database was queried for patients who underwent resection for thymic tumours (2010–2014). Predictors of using the robotic approach were estimated by logistic regression analysis. Propensity matching analysis (robotic versus open and robotic versus VATS) was done (1:1—caliper 0.05), controlling for age, gender, comorbidity index, induction treatment, tumour size and tumour extension. RESULTS: A total of 2558 thymectomies were performed (robotic = 300, VATS = 280, open = 1978). The use of a robotic approach increased from 6% (2010) to 14% (2014). The number of hospitals performing at least 1 robotic thymectomy increased from 22 (2010) to 52 (2014). Independent predictors influencing the choice of a robotic approach included an academic research/integrated cancer programme [odds ratio (OR) 1.66, confidence interval (CI) 1.22–2.27], later year of diagnosis (2014; OR 2.23, CI 1.31–3.80) and a patient’s race (Asian) (OR 1.68, CI 1.05–2.69). A robotic approach was less likely to be utilized in midwestern hospitals (OR 0.65, CI 0.42–0.99), in larger tumours (cm) (OR 0.85, CI 0.80–0.90), with invasion of adjacent organs (OR 0.55, CI 0.37–0.82), thymic carcinoma (OR 0.62, CI 0.40–0.97) and following induction chemotherapy (OR 0.22, CI 0.08–0.61). In a propensity-matched analysis, there were no differences in the incidence of positive margins, nodal dissection, 30-day readmission rates and 30-/90-day mortality rates between the groups. However, a robotic approach was associated with fewer conversions compared to VATS, with a trend towards a shorter length of stay compared to an open approach. There were no differences in the 5-year overall survival rate between the matched groups (robotic 93% vs VATS 94%; P = 0.571; robotic 91% vs open 80%; P = 0.094). CONCLUSIONS: Over a 4-year study period, there was a significant increase in robotic utilization for thymectomies and an increase in the number of hospitals performing the procedure. In a matched analysis, a robotic approach was comparable to a VATS or an open approach. Current trends demonstrate increased robotic utilization for small thymomas with excellent perioperative results.

Fine needle aspiration cytology (FNAC) of mediastinal masses allows for rapid on-site evaluation and the triaging of material for ancillary studies. However, surgical pathology is often considered to be the gold standard for diagnosis. This study examines the sensitivity and specificity of FNAC compared to a concurrent or subsequent surgical pathology specimen in 77 mediastinal lesions. The overall sensitivity for mediastinal mass FNAC was 78% and the overall specificity was 98%. For individual categories the sensitivity and specificity of FNAC was respectively as follows: inflammatory/infectious (33%, 99%), metastatic carcinoma (93%, 100%), lymphoma (84%, 97%), cysts (25%, 100%), soft tissue tumors (100%, 100%), paraganglioma (50%, 100%), germ cell tumor (100%, 99%), thymoma (87%, 94%), thymic carcinoma (60%, 100%), benign thymus (0%, 100%), and indeterminate (100%, 90%). For different locations within the mediastinum the sensitivity and specificity of FNAC was respectively as follows: anterosuperior mediastinum (80%, 98%), posterior mediastinum (33%, 95%), middle mediastinum (100%, 100%), and mediastinum, NOS (79%, 99%). Thus, mediastinal FNAC is fairly sensitive, very specific, and is a valuable technique in the diagnosis of mediastinal masses.

OBJECTIVES: Minimum volume standards for thoracic surgical procedures have been advocated to improve outcomes. However, such standards are controversial within the thoracic surgery literature, and the methodology to determine cut points between high- and low-volume hospitals has been criticized. Furthermore, while multiple studies have examined hospital volume and its relationship with outcomes, there have been very few attempts to study this issue from the perspective of the individual thoracic surgeon. The aim of this study was to determine if surgeon volume is associated with differences in outcomes using a large state-wide database. METHODS: The study utilized the New York State Department of Health Statewide Planning and Research Cooperative (SPARCS) data for analysis. Patients who underwent major lung resections including sublobar resection, lobectomy and pneumonectomy from 1995 to 2014 were included and were categorized into 3 subgroups based on the extent of resection. Patient characteristics included age, gender, race, insurance and comorbidities. Surgeon information was obtained by using a unique identifier. Average annual surgical volumes of sublobar resection, lobectomy and pneumonectomy were calculated separately and grouped into 3 categories based on the tertiles. Demographic data and comorbidities were compared between the various volume groups to analyse the resulting complications. Primary outcomes were in-hospital mortality and 30-day readmission. RESULTS: There were a total of 99 576 major lung resections performed between 1995 and 2014 in the SPARCS database. Among these, the majority were wedge or segmental resections (n = 54 953, 55.2%) followed by lobectomy (n = 40 421, 40.6%) and pneumonectomy (n = 4202, 4.2%). In-hospital mortality was significantly greater for low-volume surgeons compared to high-volume surgeons for all resection groups. Additionally, low-volume surgeons had higher 30-day readmission rates for patients undergoing lobectomy and pneumonectomy. However, low-volume surgeons as a group were more likely to operate on black patients and patients with Medicaid, and black race was an independent predictor of mortality across all resection groups. The vast majority of surgeons performing lobectomy (89.5%) were in the low-volume group. CONCLUSIONS: Low-volume surgeons had higher rates of in-hospital mortality compared to their high-volume counterparts. However, the vast majority of surgeons performing lobectomy (89.5%) were in the low-volume group, and low-volume surgeons operated on higher percentages of black patients. These findings suggest that minimal volume standards would significantly impact the current delivery of thoracic surgery in the US.

Sublobar resection is frequently offered to patients with small, peripheral lung cancers, despite the lack of outcome data from ongoing randomized clinical trials. Sublobar resection may be a particularly attractive surgical strategy for screen-detected lung cancers, which have been suggested to be less biologically aggressive than cancers detected by other means. Using prospective data collected from patients undergoing surgery in the National Lung Screening Trial, we sought to determine whether extent of resection affected survival for patients with screen-detected lung cancer.The National Lung Screening Trial database was queried for patients who underwent surgical resection for confirmed lung cancer. Propensity score matching analysis (lobectomy vs sublobar resection) was done (nearest neighbor, 1:1, matching with no replacement, caliper 0.2). Demographics, clinicopathologic and perioperative outcomes, and long-term survival were compared in the entire cohort and in the propensity-matched groups. Multivariable logistic regression analysis was done to identify factors associated with increased postoperative morbidity or mortality.We identified 1029 patients who underwent resection for lung cancer in the National Lung Screening Trial, including 821 patients (80%) who had lobectomy and 166 patients (16%) who had sublobar resection, predominantly wedge resection (n = 114, 69% of sublobar resection). Patients who underwent sublobar resection were more likely to be female (53% vs 41%, P = .004) and had smaller tumors (1.5 cm vs 2 cm, P .001). The sublobar resection group had fewer postoperative complications (22% vs 32%, P = .010) and fewer cardiac complications (4% vs 9%, P = .033). For stage I patients undergoing sublobar resection, there was no difference in 5-year overall survival (77% for both groups, P = .89) or cancer-specific survival (83% for both groups, P = .96) compared with patients undergoing lobectomy. On multivariable logistic regression analysis, sublobar resection was the only factor associated with lower postoperative morbidity/mortality (odds ratio, 0.63; 95% confidence interval, 0.40-0.98). To compare surgical strategies in balanced patient populations, we propensity matched 127 patients from each group undergoing sublobar resection and lobectomy. There were no differences in demographics or clinical and tumor characteristics among matched groups. There was again no difference in 5-year overall survival (71% vs 65%, P = .40) or cancer-specific survival (75% vs 73%, P = .89) for patients undergoing lobectomy and sublobar resection, respectively.For patients with screen-detected lung cancer, sublobar resection confers survival similar to lobectomy. By decreasing perioperative complications and potentially preserving lung function, sublobar resection may provide distinct advantages in a screened patient cohort.

OBJECTIVES Oesophagectomy following induction chemoradiation therapy (CRT) is technically challenging. To date, little data exist to describe the feasibility of a robotic approach in this setting. In this study, we assessed national trends and outcomes of robotic oesophagectomy following induction CRT compared to the traditional open approach. METHODS The National Cancer Database was queried for patients who underwent oesophagectomy following induction CRT (2010–2014). Trends of robotic utilization were assessed by a Mantel–Haenszel test of trend. Propensity matching controlled for differences in age, gender, comorbidity, stage, histology and tumour location between the robotic and open groups. Overall survival was estimated by Kaplan–Meier analysis and compared by a log-rank test RESULTS Oesophagectomy following induction CRT was performed in 6958 patients. Of them, 555 patients (8%) underwent robotic surgery (5% converted to an open approach). Between 2010 and 2014, utilization of a robotic approach increased from 3% to 11% (Mantel–Haenszel, P CONCLUSIONS Robotic oesophagectomy after induction CRT is feasible and associated with shorter hospitalization compared to an open approach, and does not compromise the adequacy of oncological resection, perioperative outcomes or long-term survival.

Background Recurrent esophageal carcinoma (EC) has a dismal prognosis. However, prior studies showed that selected patients with isolated recurrence may benefit from definitive therapy. The aim of this study was to identify the predictors of postrecurrence survival (PRS) in patients with isolated EC recurrence who were treated with curative intent. Methods A retrospective review of a prospective database (1988 to 2015) was performed to identify all recurrent EC patients after curative esophagectomy. Demographic and clinicopathologic data were reviewed. The probability of PRS was estimated with the Kaplan-Meier method. Predictors of PRS after definitive therapy for isolated EC recurrence were determined by the multivariable Cox proportional hazards model. Results Of the 640 curative esophagectomies, 241 patients (37.7%) experienced recurrences (median follow-up 50 months). Fifty-six patients (9%) received definitive treatment of isolated EC recurrence (31 were treated surgically with or without chemotherapy-radiotherapy [CTRT] and 25 received definitive CTRT alone). Median time to recurrence (TTR) was 19 months. The 1- and 3-year PRSs were 78% and 38% (median survival 26 months). On multivariable analysis; TTR was the only significant independent predictor for survival after recurrence (hazards ratio 0.98, 95% confidence interval: 0.96 to 0.99, p = 0.034). No pronounced difference was found in disease-free survival or in PRS between recurrent patients treated with operation with or without CTRT and patients who received definitive CTRT. Conclusions A select subgroup of patients with isolated EC recurrence can be treated with curative intent. TTR was the best predictor for PRS.

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.

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.

Study Objective. We performed a systematic comparison of high-dose and low-dose opioid anesthesia in cardiac surgery. Design Systematic review and meta-analysis of randomized controlled trials (RCTs). Setting Operating room. Patients 1400 adult patients undergoing cardiac surgery using general anesthesia. Interventions All RCTs comparing the effects of various doses of intravenous opioids (morphine, fentanyl, sufentanil, and remifentanil) during adult cardiac surgery using general anesthesia published until May 2018 (full-text English articles reporting data from human subjects) were included. Measurements Primary outcome was intensive care unit (ICU) length of stay (LOS). Secondary outcomes were ventilation time, use of vasopressors, perioperative myocardial infarction, perioperative stroke, and hospital LOS. Main results Eighteen articles were included (1400 patients). There was no difference in ICU LOS between studies using high or low dose of opioids (both short-acting and long-acting) (standard mean difference [SMD]−0.02, 95%CI: −0.15–0.11, P = 0.74). Similarly, there was no difference in secondary outcomes of ventilation time (SMD−0.27, 95%CI: −0.63–0.09, P = 0.14), use of vasopressors (OR 0.61, 95%CI: 0.29–1.30, P = 0.20), myocardial infarction (risk difference 0.00, 95% CI: −0.02–0.03, P = 0.70), stroke (RD 0.00, 95% CI: −0.01–0.01, P = 0.92) and hospital LOS (SMD 0.03, 95% CI: −0.26–0.33, P = 0.84). At meta-regression, there was no effect of age, gender, or type of opioid on the difference between groups. Conclusions Our data suggest that low-dose opioids, both short acting and long acting, are safe and effective to use in adult cardiac surgery patients, independent of the clinical characteristics of the patients and the type of opioid used. In view of the current opioid epidemic, low-dose opioid anesthesia should be considered for cardiac surgery patients.

Background: This meta-analysis of randomized controlled trials (RCTs) was aimed at comparing coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) for the treatment of unprotected left main coronary disease. Methods: All RCTs randomizing patients to any type of PCI with stents vs. CABG for left main disease (LMD) were included. Primary outcome was a composite of follow-up death/myocardial infarction/stroke/repeat revascularization. Secondary outcomes were peri-procedural mortality and the individual components of the primary outcome. Incidence rate ratio (IRR) or odds ratio (OR) and 95% confidence intervals (CIs) were pooled using a generic inverse variance method with random effects model. Subgroup analyses were done based on: (I) type of PCI [bare metal stents (BMS) vs. drug-eluting stents (DES)] and; (II) mean SYNTAX score tertiles. Leave one-out analysis and meta-regression were performed. Results: Six trials were included (4,700 patients; 2,349 PCI and 2,351 CABG). Follow-up ranged from 2.33 to 5 years. PCI was associated with higher risk of follow-up death/myocardial infarction/stroke/repeat revascularization (IRR =1.328, 95% CI, 1.114–1.582, P=0.002) and of repeated revascularization (IRR =1.754, 95% CI, 1.470–2.093, P

Purpose Previous studies have reported that psychological and social distresses associated with a cancer diagnosis have led to an increase in suicides compared to the general population. We sought to explore lung cancer-associated suicide rates in a large national database compared to the general population, and to the three most prevalent non-skin cancers [breast, prostate and colorectal cancer (CRC)]. Methods The Surveillance, Epidemiology and End Results (SEER) database (1973–2013) was retrospectively reviewed to identify cancer-associated suicide deaths in all cancers combined, as well as for each of lung, prostate, breast or CRCs. Suicide incidence and standardised mortality ratio (SMR) were estimated using SEER*Stat-8.3.2 program. Suicidal trends over time and timing from cancer diagnosis to suicide were estimated for each cancer type. Results Among 3,640,229 cancer patients, 6,661 committed suicide. The cancer-associated suicide rate was 27.5/100,000 person years (SMR = 1.57). The highest suicide risk was observed in patients with lung cancer (SMR = 4.17) followed by CRC (SMR = 1.41), breast cancer (SMR = 1.40) and prostate cancer (SMR = 1.18). Median time to suicide was 7 months in lung cancer, 56 months in prostate cancer, 52 months in breast cancer and 37 months in CRC (p < 0.001). We noticed a decreasing trend in suicide SMR over time, which is most notable for lung cancer compared to the other three cancers. In lung cancer, suicide SMR was higher in elderly patients (70–75 years; SMR = 12), males (SMR = 8.8), Asians (SMR = 13.7), widowed patients (SMR = 11.6), undifferentiated tumours (SMR = 8.6), small-cell lung cancer (SMR = 11.2) or metastatic disease (SMR = 13.9) and in patients who refused surgery (SMR = 13). Conclusion The cancer-associated suicide rate is nearly twice that of the general population of the United States of America. The suicide risk is highest among the patients with lung cancer, particularly elderly, widowed, male patients and patients with unfavourable tumour characteristics. The identification of high-risk patients is of extreme importance to provide proper psychological assessment, support and counselling to reduce these rates.

Background With the advent of bare metal stents and drug-eluting stents, percutaneous coronary intervention has emerged as an alternative to coronary artery bypass grafting surgery for unprotected left main disease. However, whether the evolution of stents technology has translated into better results after percutaneous coronary intervention remains unclear. We aimed to compare coronary artery bypass grafting with stents of different generations for left main disease by performing a Bayesian network meta-analysis of available randomized controlled trials. Methods All randomized controlled trials with at least 1 arm randomized to percutaneous coronary intervention with stents or coronary artery bypass grafting for left main disease were included. Bare metal stents and drug-eluting stents of first- and second-generation were compared with coronary artery bypass grafting. Poisson methods and Bayesian framework were used to compute the head-to-head incidence rate ratio and 95% credible intervals. Primary end points were the composite of death/myocardial infarction/stroke and repeat revascularization. Results Nine randomized controlled trials were included in the final analysis. Six trials compared percutaneous coronary intervention with coronary artery bypass grafting (n = 4654), and 3 trials compared different types of stents (n = 1360). Follow-up ranged from 6 months to 5 years. Second-generation drug-eluting stents (incidence rate ratio, 1.3; 95% credible interval, 1.1-1.6), but not bare metal stents (incidence rate ratio, 0.63; 95% credible interval, 0.27-1.4), and first-generation drug-eluting stents (incidence rate ratio, 0.85; 95% credible interval, 0.65-1.1) were associated with a significantly increased risk of death/myocardial infarction/stroke when compared with coronary artery bypass grafting. When compared with coronary artery bypass grafting, the highest risk of repeat revascularization was observed for bare metal stents (hazard ratio, 5.1; 95% confidence interval, 2.1-14), whereas first-generation drug-eluting stents (incidence rate ratio, 1.8; 95% confidence interval, 1.4-2.4) and second-generation drug-eluting stents (incidence rate ratio, 1.8; 95% confidence interval, 1.4-2.4) were comparable. Conclusions The introduction of new-generation drug-eluting stents did not translate into better outcomes for percutaneous coronary intervention when compared with coronary artery bypass grafting.

Recent studies have suggested that lobectomy and segmentectomy hold equivalent oncologic outcomes, particularly for small, peripheral, subsolid nodules. However, for hypermetabolic nodules that are frequently associated with high rates of nodal disease, recurrence, or mortality, the optimum oncologic procedure was not assessed. We hypothesize that for hypermetabolic, cT1 N0 adenocarcinoma, lobectomy and segmentectomy are associated with comparable outcomes.A prospectively collected database was queried for patients with clinical stage IA lung adenocarcinoma who underwent lobectomy or segmentectomy (2000 to 2016) for hypermetabolic tumors (maximum standard uptake value [SUVmax] ≥ 3g/dL). To obtain balanced groups of patients, a propensity matching analysis was done.A total of 414 patients had hypermetabolic tumors and underwent lobectomy or segmentectomy. Patients were propensity matched (4:1) (lobectomy: n = 156, segmentectomy: n = 46). Patients in the lobectomy group had a higher rate of pathologic nodal upstaging (17% versus 7%, p = 0.085) and a higher pathologic upstaging rate (38% versus 26%, p = 0.143) than the segmentectomy group. In addition, the lobectomy group had a higher number of resected lymph nodes than the segmentectomy group (median lymph nodes resected: 14 versus 7, p0.001). No differences were found in in 5-year recurrence-free survival (RFS; 72% versus 69%, p = 0.679) or in 5-year cancer-specific survival (CSS; 92% versus 83%, p = 0.557) between patients who underwent lobectomy or segmentectomy, respectively.Our data show that lobectomy and segmentectomy are comparable oncologic procedures for patients with carefully staged cT1 N0 lung adenocarcinoma with hypermetabolic tumors (SUVmax ≥ 3g/dL). Although lobectomy was associated with a more thorough lymph node dissection, this did not translate into a higher rate of RFS or CSS compared with segmentectomy.

Controversy exists over the optimal neoadjuvant therapy in patients with locally advanced esophageal cancer (EC). Although most groups favor neoadjuvant chemoradiation (nCRT), some prefer preoperative chemotherapy (nCT) without radiation. The objective of this study was to compare outcomes in EC patients undergoing either regimen, followed by surgery.We reviewed a prospectively collected database of EC patients undergoing esophagectomy after nCT or nCRT from 1989 to 2016. Choice of therapy was at the discretion of the multidisciplinary team. Disease-free survival (DFS) and cancer-specific survival (CSS) were compared by the Kaplan-Meier log-rank test. Independent predictors of CSS were estimated by Cox regression analysis.Among 700 EC patients 338 patients were treated with nCRT (n = 112) or nCT (n = 226) followed by surgery. Patients were well matched for age, gender, and clinical stage, although patients with squamous cell carcinoma were more likely to receive nCRT (49% vs 26%, p0.001). At surgery 90% and 91% of nCRT and nCT patients, respectively, underwent transthoracic esophagectomy. nCRT, in comparison with nCT, was associated with similar rates of Calvien-Dindo grade III/IV complications (34% vs 33%, p = 0.423) but with a trend toward higher perioperative mortality (5% vs 1%, p = 0.064). Among adenocarcinoma patients (n = 239) the use of nCRT was associated with higher rates of complete clinical response (18% vs 7.4%), pathologically negative lymph nodes (52% vs 30%, p = 0.001), and complete pathologic response (21% vs 5.1%, p0.001). However, there was no difference between nCRT and nCT for 5-year DFS (28% vs 31%, p = 0.636) or CSS (51% vs 52%, p = 0.824) among adenocarcinoma patients. For patients with squamous cell carcinoma (n = 98), nCRT and nCT had similar rates of complete clinical response (31% vs 26%, p = 0.205), but the rates of negative nodes (65% vs 46%, p = 0.064) and of complete pathologic response (42% vs 12%, p0.05) were higher with nCRT. For these patients nCRT was associated with no statistical difference in 5-year DFS (57% vs 40%, p = 0.595) but with improved 5-year CSS (87% vs 68%, p = 0.019) compared with nCT. On multivariable analysis for CSS, nCRT predicted improved survival for patients with squamous cell carcinoma (hazard ratio, 0.242; 95% confidence interval, 0.071-0.830) but not for those with adenocarcinoma (univariate hazard ratio, 0.940; 95% confidence interval, 0.544-1.623).For adenocarcinoma patients undergoing surgery for EC, nCRT leads to increased local tumor response compared with nCT alone but with no difference in survival. For squamous carcinoma patients nCRT appears to improve CSS compared with nCT. For patients with locally advanced EC targeted neoadjuvant regimens should be used depending on tumor histology.

Background Pulmonary carcinoid tumors are often considered indolent tumors. The prognostic significance of lymph node (LN) metastases and the need for mediastinal dissection is controversial. We sought to determine the incidence, risk factors, and prognosis of LN metastases in resected carcinoid patients. Methods Patients undergoing lung resection for carcinoid and removal of ≥10 LNs were identified in the National Cancer Database from 2004 to 2014. Typical (TCs) and atypical carcinoids (ACs) were included. Clinical and pathologic LN status was assessed. Overall survival (OS) was analyzed using log-rank test and Cox hazard regression analysis. Results A total of 3,335 patients (TC 2,893; AC 442), underwent resection (lobectomy/bilobectomy 84%, pneumonectomy 8%, sublobar resection 8%). LN involvement was present in 21% of patients (N1 15%, N2 6%) and increased with tumor size and AC histology. Tumor size was an independent predictor of LN disease. The rate of nodal upstaging was 13% (TC 11%, AC 24%). Independent predictors of OS were AC type (HR 3.25 [95% CI 2.19-4.78]) and LN metastases (HR 2.3 [1.49-3.58]). LN disease was associated with worse survival for TC > 2 cm (5-year OS 87% versus 94%, p = 0.005) and AC (58% versus 88%, p = 0.001), but not for small (≤ 2 cm) TC patients (5-year OS 93% versus 92%, p = 0.67). Conclusions A substantial number of well-staged carcinoid patients had LN metastases. Large tumor size is a valuable predictor of carcinoid nodal disease. LN involvement was an independent predictor of worse survival. Nodal dissection in tumors > 2 cm and in atypical subtype can yield important prognostic information.

Background Cerebrospinal-fluid (CSF) drainage is recommended by current guidelines for spinal protection during open and endovascular repairs of thoracic and thoraco-abdominal aortic aneurysms. In the published literature, great variability exists in the rate of CSF-related complications and morbidity. Herein, we perform a systematic review and meta-analysis on the incidence of CSF drainage-related complications, and compare the complication rates between open and endovascular repairs. Methods The systematic review was conducted according to the Meta-Analysis of Observational Studies in Epidemiology guidelines. Thirty-four studies (4714 patients) were included in the quantitative analysis. The CSF drainage-related complications were categorised as mild, moderate, and severe. Pooled event rates for each complication category were estimated using a random-effect model. Random-effect uni- and multivariable meta-regression analyses were used to assess the effect of aortic-repair approach (open vs endovascular) and the CSF drainage criteria on CSF drainage-related complications. Results The pooled event rates were 6.5% [95% confidence interval (CI): 4.3–9.8%] for overall complications, 2% (95% CI: 1.1–3.4%) for minor complications, 3.7% (95% CI: 2.5–5.6%) for moderate complications, and 2.5% (95% CI: 1.6–3.8%) for severe complications. The drainage-related-mortality pooled event rate was 0.9% (95% CI: 0.6–1.4%). The uni- and multivariable meta-regression analyses showed no difference in complication rates between the open and endovascular approaches, or between the different CSF drainage protocols. Conclusion The complication rate for CSF drainage is not negligible. Our results help define a more accurate risk–benefit ratio for CSF drain placement at the time of repair of thoracic and thoraco-abdominal aneurysms.

OBJECTIVES Historically, surgical resection has been the mainstay of treatment for T1N0 oesophageal cancer (OC). More recently, oesophageal sparing endoscopic techniques have shown value for local control in a large institutional series. However, the effect of their utilization upon survival rates in large population series is largely unknown. METHODS The surveillance, epidemiology, and end results (SEER) database was queried for T1N0M0-OC patients (1988-2013). Patients with multiple treatment types were excluded. Time periods were divided by 5-year increments. Overall survival and cancer-specific survival (CSS) were compared in the group as a whole and in propensity-matched subgroups. Independent predictors of cancer-specific mortality were studied by the Cox proportional hazard models. RESULTS We identified 5497 patients with cT1N0M0 OC. Treatment modalities used were changed significantly over time. The ratio of oesophagectomy when compared with local therapy decreased from 15:1 in 1998-92 to 1.4:1 in 2008-13. The proportion of patients treated with radiation slightly increased (35% vs 41%) between 1988-92 and 2008-13. In the propensity-matched groups, 5-year CSS was similar in patients treated with oesophagectomy and local therapy (81% vs 89%; P = 0.257) (n = 216 in each group), whereas oesophagectomy had superior 5-year CSS compared with radiation alone (73% vs 38%; P

Recently, robotic-assisted thymectomy (RAT) has emerged as an alternative to either, an open transsternal approach or to a video-assisted thoracoscopic approach, for both thymic tumors and benign lesions. We have reviewed our early experience with RAT to assess the associated learning curve as well as the short-term perioperative outcomes.A prospectively collected database was reviewed for patients who underwent RAT for all causes in the period 2012-2016. Robotic thymectomy cases were stratified and compared according to the number of cases performed by each surgeon (≤15 versus15 cases). A propensity score matching was done to compare perioperative outcomes in patients undergoing robotic and transsternal resection of thymomas.Seventy patients (47 females) with a median age of 52, underwent RAT. The median operative time was 102 min with 5 conversions to an open approach for local invasion (n = 3) or for complete pleural symphysis (n = 2). There were 2 rib fractures and 1 recurrent laryngeal nerve palsy. Median length of chest tube drainage and length of stay were 1 and 3 days, respectively. Operative time and estimated blood loss plateaued after surgeon's initial 15-20 cases, which may reflect the initial learning curve. A comparison between early and late robotic cases showed that with the growing experience, the operative time becomes shorter (94 versus 107 min, P = .018). Propensity score analysis between robotic and transsternal resection of thymoma (n = 22 in each group) showed no significant differences in operative time (P = .79), intraoperative complications (P = .99), or postoperative complications (P = .99).Robotic thymectomy is feasible and safe, and is associated with comparable perioperative outcomes to the traditional transsternal approach in patients undergoing thymomectomy. An initial learning curve of 15-20 robotic thymectomy cases may be required by the surgeons to adequately perform this relatively novel technique.

Background Robotic-assisted thymectomy (RAT) is increasingly performed for resection of thymomas. Its application for large tumors remains controversial. In this study, we evaluated the safety and feasibility of RAT for large thymomas in comparison with transsternal thymectomy (ST). Methods A single institution database was reviewed for patients who underwent RAT for thymoma of 4 cm or larger between 2004 and 2016. Propensity scores were applied to match RAT with ST patients, based on age, sex, tumor size, and Masaoka stage. Perioperative outcomes were compared. Results Twenty patients (15 women and 5 men, median age 59 years) underwent RAT for a large thymoma (median size 6.0 cm). A right-sided approach was used in 14 patients (70%). A control group of 34 ST patients (median size 6.7 cm) had similar Masaoka staging ( p = 0.64). Combined resection of adjacent structures, including pericardium, lung, and phrenic nerve, were frequently performed in both groups (50% RAT versus 47% ST, p = 0.83). RAT patients had lower blood loss (25 mL versus 150 mL, p = 0.001), were more frequently managed with a single chest tube (85% versus 56%, p = 0.027), and had a shorter median length of stay (3 days versus 4 days, p = 0.034). There were no perioperative deaths and no major vascular injuries. Three RAT patients (15%) were converted to open approach. Overall complication rates were similar between RAT and ST patients (15% versus 24%, p = 0.45). No difference was seen in R0 resection rates (90% versus 85%, p = 0.62). Conclusions RAT can be performed safely and effectively in a radical fashion for large thymomas. Future studies are necessary to determine long-term oncologic outcomes.

Introduction Surgical data from the National Lung Screening Trial (NLST) has yet to be closely examined. We sought to analyze surgical procedures and complications from the NLST to determine their relevance to modern surgical practice. Methods The NLST database was queried for patients who underwent surgical resection for confirmed lung cancer, specifically evaluating postoperative complications. Numerical variables were compared using the Mann–Whitney U test. Categorical variables were compared using the χ2 test. Logistic regression uni- and multivariable analysis of independent risk factors of postoperative complications was performed. Results At operation, 80% of patients (n = 821) had lobectomy, 4.1% (n = 42) had pneumonectomy, and 16.1% (n = 166) had sublobar resection, among whom 69% (n = 114) had wedge resection. Only 29.6% (n = 305) of the cohort had a thoracoscopic resection. Although the overall rate of surgical patients with any complication was 31% (n = 318), only 15.5% of patients (n = 160) had major complications, most commonly prolonged air leaks (n = 67, 6.5%). Respiratory failure (n = 28, 2.7%), prolonged ventilation (n = 9, 0.9%), myocardial infarction or cardiac arrest (n = 7, 0.7%), and stroke (n = 2, 0.2%) were rare events. Overall 30-day mortality in patients undergoing resection was 1.7% (n = 18). On multivariable analysis, greater smoking pack history (odds ratio [OR], 1.01; 95% confidence interval [CI], 1.001-1.01) and pulmonary comorbidities (OR, 1.34; 95% CI, 0.98-1.82) were significant or approached significance for an association with complications/death, whereas sublobar resection (OR, 0.59; 95% CI, 0.38-0.94) and video-assisted thoracoscopic surgery approach (OR, 0.76; 95% CI, 0.56-1.04) were significant or approached significance for an association with decreased rates of complications/death. Conclusions Operative mortality and postoperative morbidity were very low in patients undergoing resection for screen-detected lung cancer. Increased use of sublobar resection and minimally invasive surgical approaches may be associated with fewer complications.

Recent advances in lung cancer screening have encouraged many clinicians to apply computed tomography screening principles to their resected patients. These patients represent a high-risk cohort for the development of either recurrent disease or a metachronous second lung primary. 1,2 Often with current imaging, cytology, and genetic analysis the distinction can be challenging and the surgeon would offer definitive local therapy for patients who clinically present with local disease. The exact incidence of second primaries and which local therapy is superior is not well understood. Taioli et al. 3 performed an analysis of the Surveillance, Epidemiology, and End Results database for patients with second primary lung cancers discovered 6 months or more after potentially curative resection of stage-one disease. Despite the non-randomized nature and the dearth of information on how treatment was assigned, the study highlights several important points. Overall, 5.4% of patients who undergo curative resection for stage I disease would develop a second cancer, the most of which are apparent before 3 years. This represents a significant risk and supports close monitoring of our resected patients. In addition, only 58.5% of these second primaries were stage I. The improvements in radiation therapy, particularly stereotactic body radiation therapy (SBRT), have encouraged radiation oncologists to offer definitive radiation to early-stage lung cancer patients who are deemed medically inoperable. SBRT has achieved good local control for this high-risk group and has encouraged some to question whether it should be offered to the medically operable as well. Unfortunately, 2 randomized trials comparing SBRT to lobectomy, closed due to the slow accrual. 4 So, what should be the optimum therapy offered for second lung primaries? Perhaps, the best therapy is the same as for first primaries. We performed a retrospective, propensity-matched

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.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 (p0.20) 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.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, p0.001), 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.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.

e12516Background: Primary prophylactic Granulocyte Colony Stimulating Factor (PP-GCSF) is recommended for patients receiving single agent docetaxel (SAD) and docetaxel combination regimens (DCR) to...

Objectives For patients undergoing lobectomy for non-small cell lung cancer (NSCLC), a survival benefit exists with increased number of lymph nodes (LNs) resected. We sought to evaluate the associations of LN removal with outcomes in clinical stage I lung cancer patients undergoing wedge resection. Methods We evaluated all patients undergoing wedge resection for peripheral, clinical stage IA NSCLC and grouped patients into those with and without LN assessment. Data were compared and survival analysed using Kaplan-Meier, with differences compared using log-rank. Propensity score matching controlling for age, gender, Charlson comorbidity index, patient tolerability of lobectomy, surgery year, tumour size and surgical approach was done (51 patients in each group, caliper 0.2). Results We identified196 patients undergoing wedge resection, of whom 138 patients (70%) had LNs resected (median = 4 nodes), while the remaining 58 patients (30%) had none. There were no significant differences in the clinical or pathologic characteristics between the two groups. There was no difference in terms of OR time, estimated blood loss, chest tube duration or length of stay. Median pT size was 1.5 cm in each group ( P = 0.73). Among patients with LNs removed, 6 (4.3%) had positive nodes Patients in the LN assessed group had higher probability of freedom from loco-regional recurrence compared to the no lymph node (NLN) group (5-year: 92 vs 74%, P = 0.025).In propensity matched groups, patients who underwent LN dissection also had higher probability of freedom from local recurrence ( P = 0.024). Conclusions Accompanying wedge resection for lung cancer, LN sampling adds no morbidity and does not increase length of stay. Positive nodes are identified in 4.3% of patients thought eligible for wedge resection. LN removal appears to decrease locoregional recurrence and may be associated with a survival benefit.