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Studies the diversity of gene expression in adenocarcinoma of the lung. Morphological classification of the tumors into squamous, large cell, small cell, and adenocarcinoma; Discussion of gene expression analysis.

A persistent problem in cardiothoracic surgery, as in all of medicine, is when to offer or to withhold expensive technologies. The ethical requirement of balancing harms and benefits is often difficult to achieve. The use of LVADs is an example of such technologies, and when to offer it is explored in this paper., (Copyright © 2022 Elsevier Inc. All rights reserved.)

A subset of patients with marginal ulcers after Roux-en-Y gastric bypass (RNYGB) is refractory to medical management. Here we report a retrospective review of a single institution cohort (N = 10) of video- or robotic-assisted thoracoscopic (VATS or RATS) truncal vagotomies performed between 2013 and 2018. All patients had recurrent marginal ulcers following RNYGB complicated by bleeding or perforation, refractory to medical management for a median of 3.5 months prior to undergoing truncal vagotomy. With a median of 23 months' follow-up, only three patients had continued symptoms (70% symptom resolution) post-operatively. Only one patient who had repeat endoscopy after the procedure had documented endoscopic evidence of recurrent marginal ulcer (83% endoscopic resolution). VATS or RATS truncal vagotomy is a safe and effective method to treat complicated marginal ulceration after RNYGB. After an average duration of unsuccessful medical treatment lasting three months, vagotomy led to successful resolution in 70-83% of patients.

Background: The sensitivity of fluoroscopic esophagography with oral administration of contrast material to exclude anastomotic leak after esophagectomy is not well documented, and the consequences of missing a leak in this setting have not been previously described., Methods: We performed a retrospective cohort study of a prospectively maintained institutional database of patients undergoing esophagectomy with esophagogastric anastomosis from 2008 to 2020. Relevant details of leaks, management, and outcomes were obtained from the database and formal chart review. Statistical analysis was performed to compare patients with and without leaks and those with false-negative vs positive esophagrams., Results: There were 384 patients who underwent esophagectomy with gastric reconstruction; the majority were Ivor-Lewis (82%), and 51% were wholly or partially minimally invasive. By use of a broad definition of leak, 55 patients (16.7%) developed an anastomotic leak. Of the 55 patients, 27 (49%) who ultimately were found to have a leak initially had a normal esophagram result (performed on average on postoperative day 6). Those with a normal initial esophagram result were more likely to have an uncontained leak (81% vs 29%; P < .01), to require unplanned readmission (70% vs 39%; P = .02), and to undergo reoperation (44% vs 11%; P < .01)., Conclusions: Early postoperative esophagrams intended to evaluate anastomotic integrity have a low sensitivity of 51%, and leaks missed on the initial esophagram have greater clinical consequences than those identified on the initial esophagram. These findings suggest that a high index of suspicion must be maintained even after a normal esophagram result and call into question the common practice of using this test to triage patients for diet advancement., (Copyright © 2023 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Despite demonstration of its clear benefits relative to open approaches, a video-assisted thoracic surgery technique for pulmonary lobectomy has not been universally adopted. This study aims to overcome potential barriers by establishing the essential components of the operation and determining which steps are most useful for simulation training., Methods: After randomly selecting experienced thoracic surgeons to participate, an initial list of components to a lower lobectomy was distributed. Feedback was provided by the participants, and modifications were made based on anonymous responses in a Delphi process. Components were declared essential once at least 80% of participants came to an agreement. The steps were then rated based on cognitive and technical difficulty followed by listing the components most appropriate for simulation., Results: After 3 rounds of voting 18 components were identified as essential to performance of a video-assisted thoracic surgery for lower lobectomy. The components deemed the most difficult were isolation and division of the basilar and superior segmental branches of the pulmonary artery, isolation and division of the lower lobe bronchus, and dissection of lymphovascular tissue to expose the target bronchus. The steps determined to be most amenable for simulation were isolation and division of the branches of the pulmonary artery, the lower lobe bronchus, and the inferior pulmonary vein., Conclusions: Using a Delphi process a list of essential components for a video-assisted thoracic surgery for lower lobectomy was established. Furthermore 3 components were identified as most appropriate for simulation-based training, providing insights for future simulation development., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: An excessive amount of nonurgent pages may disrupt patient care, reduce efficiency, and contribute to burnout. We present detailed paging data to analyze frequency, content, and urgency of pages received by surgery residents to provide recommendations to reduce resident distractions and fatigue., Design: Prospective review of pages received by surgery residents over 15 weeks in 2019. Pages were analyzed by content and urgency (routine, important, emergent) by author consensus and compared among day and night shifts, and page senders' profession., Setting: University tertiary-care hospital PARTICIPANTS: Seventeen junior surgery residents (PGY-1 and PGY-2) RESULTS: Total 1,740 resident-hours yielded 1,871 pages. Residents working day and night shift received a median of 11 (IQR 7-14) and 13 (IQR 6-22) pages, respectively. Pages from nurses were most common for both shifts but constituted a significantly increased proportion at night (71.3% vs 36.7%, p < 0.00005). Most pages during day shift were routine (74.4%) and pertained to plan of care and order request (38.4% and 15.7%, respectively). Emergent and important pages were more common at night (8.9% and 24.7% vs 1.8 and 14.8%, p < 0.00005) which paralleled an increase in pages reporting change in patient condition compared to day shift (19.7 from 6.7%, p < 0.00005). Routine pages pertaining care plan and order requests remained common at night (26.5 and 28%, respectively)., Conclusions: Over half of pages received by residents contain routine communications about care plan and request for non-urgent orders, even during night shift. Resident-nurse collaboration and support from technology services might optimizing communication pathways., (Copyright © 2021. Published by Elsevier Inc.)

In the last several decades, the U.S. Health care industry has undergone a massive consolidation process that has resulted in the formation of large delivery networks. However, the integration of these networks into a unified operational system faces several challenges. Strategic problems, such as ensuring access, allocating resources and capacity efficiently, and defining case-mix in a multi-site network, require the correct modeling of network costs, network trade-offs, and operational constraints. Unfortunately, traditional practices related to cost accounting, specifically the allocation of overhead and labor cost to activities as a way to account for the consumption of resources, are not suitable for addressing these challenges; they confound resource allocation and network building capacity decisions. We develop a general methodological optimization-driven framework based on linear programming that allows us to better understand network costs and provide strategic solutions to the aforementioned problems. We work in collaboration with a network of hospitals to demonstrate our framework applicability and important insights derived from it., (© 2021. The Author(s).)

In Ireland long waits for public hospital services are a feature of the healthcare system, with limited evidence that waits for private hospital services (delivered in both public and private hospitals) are shorter. In 2008, in an attempt to ensure more equitable access to hospital-based services, a 'common waiting list' for all patients within public hospitals was proposed. The aim of this paper is to analyse waiting times in Ireland for hospital services for patients with and without private health insurance (PHI) and to examine whether the 2008 reform reduced the differential in waiting. The analysis used data from the 2007 and 2010 health module of the Quarterly National Household survey (QNHS). The impact of insurance status on waiting times was analysed for the period before and after the reforms. A higher proportion of those without PHI were waiting more than three months for hospital services relative to those with PHI. There was no evidence that the 2008 reforms reduced the differential. Anecdotal evidence suggests that the proposals were not fully implemented, although expansion of capacity for private patients' treatment in private hospitals is a possible confounding factor., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Stereotactic body radiotherapy (SBRT) had become a therapeutic modality in patients with primary tumors, locally recurrent as well as oligometastasis involving the lung. Some modalities of SBRT require fiducial marker (FM) for dynamic tumor tracking. Previous studies have focused on evaluating bronchoscopic-guided FM placement for peripheral lung nodules. We describe the safety and feasibility of placing FM using real-time convex probe endobronchial ultrasound (CP-EBUS) for SBRT in patients with centrally located hilar/mediastinal masses or lymph nodes., Methods: This is a retrospective review of patients who were referred to Beth Israel Deaconess Medical Center's multidisciplinary thoracic oncology program for FM placement to pursue SBRT., Results: Thirty-seven patients who underwent real-time CP-EBUS were included. Patients had a median age of 71 years [interquartile range (IQR), 59.5 to 80.5]. The median size of the lesion was 2.2 cm (IQR, 1.4 to 3.3 cm). The median distance from the central airway was 2.4 cm (IQR, 0 to 3.4 cm). A total of 51 FMs (median of 1 per patient) were deployed in 37 patients. At the time of SBRT planning, 46 (90.2%) were confirmed radiologically in 32 patients. Patients with unsuccessful fiducial deployment (n=5) underwent a second procedure using the same technique. Of those, 3 patients had a successful fiducial placement via bronchoscopy, 1 patient required FM placement by percutaneous computed tomography-guided approach and 1 patient required FM placement through EUS by gastroenterology., Conclusion: CP-EBUS-guided FM placement for patients with malignant lymph nodes and central parenchymal lung lesions appears to be safe and feasible.

Background: Overlapping surgery is highly contentious, both in terms of the safety of the practice and the degree to which patients should be informed. However, no study has surveyed attitudes of the general public toward overlapping surgery and willingness to consent to such a procedure., Study Design: A survey on overlapping surgery was completed by participants using Amazon Mechanical Turk, an online crowd-sourcing worksite. Responders completed a 51-question survey on their knowledge of overlapping surgery, expectations on disclosure during the informed consent process, and their willingness to participate in such a procedure. In addition, responders completed the Health Care System Distrust Scale., Results: The survey was completed by 1,454 respondents. Median age was 33 years (range 21 to 74 years). Only 56 respondents (3.9%) had any knowledge of the practice of overlapping surgery. Overall, 440 respondents (31%) supported or strongly supported this practice. The majority of respondents believed that the attending surgeon should inform them in advance of overlapping surgery (94.7%), define what the critical components of the operation are (95.6%), and document what portion of the operation he or she was present for (91.5%)., Conclusions: A small minority of the general public is aware of the practice of overlapping surgery. The majority of responders were not supportive of the practice, although would consider it acceptable in specific circumstances. However, responders consistently reported that the practice of overlapping surgery should be disclosed during the informed consent process., (Copyright © 2017 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

We compared VO2 max values from ACCP Guidelines and from NETT's homogenous NULPD surrogate for predicting operative mortalities. Estimated mid and long-term non-cancer related survival in NETT's subset was also obtained. NETT and ACCP Guideline VO2 max values were similar in the "low" and "mid" risk operative mortality categories but NETT's "high" risk subset showed lower mortality (14% vs. 26%). Estimated non-cancer related survival in NETT "low", "mid" and "high" risk VO2 max categories at two and eight years were 100%, 74%, 59% and 48%, 26%, 14%, respectively. The lower predicted risk in NETT's "high- risk" subset raises the possibility of extending indications for potential curative resection in selected patients. The NETT surrogate also provides hitherto unavailable estimate on long-term non-cancer related survival after potential curative resection of NSCLC and suggests that the operation does not shorten eight-year longevity., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Rationale: Endobronchial valves are a potential alternative to lung volume reduction surgery for advanced emphysema. The greatest improvements in pulmonary function are seen in patients with complete pulmonary fissures, as determined by computed tomography (CT). However, the accuracy of CT to predict completeness of pulmonary fissures has not been compared with the reference standard of direct observation during thoracic surgery., Objectives: To determine the accuracy of CT scans to predict completeness of pulmonary fissures., Methods: We conducted a double-blind, prospective trial in which completeness of pulmonary fissures was evaluated by direct observation during thoracic surgery. Preoperative CT scans were independently reviewed by two dedicated thoracic radiologists and completeness of the fissures was recorded and compared with intraoperative findings., Measurements and Main Results: The fissures of 46 patients were evaluated. The positive predictive value of CT scan to detect a complete fissure was 100% for the right major fissure and 75% for the left fissure, but only 33% for the right minor fissure. CT scans had a negative predictive value of 29% in evaluation of the right major fissure., Conclusions: CT scans overestimate completeness of the right minor fissure and underestimate completeness of the right major fissure. These findings may have implications for the use of CT scans to select patients for endobronchial valve insertion.

Rationale: Rigid bronchoscopy-guided (RBG) percutaneous tracheostomy has been used in patients with morbid obesity, prior neck surgery, distorted airway anatomy, and uncorrected coagulopathy where standard percutaneous dilational tracheostomy (PDT) is relatively contraindicated., Objectives: This study aims to describe a standardized approach to incorporate RBG-PDT in clinical practice., Methods and Measurements: Retrospective case series of patients who underwent RBG-PDT from 2008 to 2012 at Beth Israel Deaconess Medical Center. Patient medical records were reviewed for demographics, comorbid conditions, American Society of Anesthesiologists classification, indication for tracheostomy, duration of procedure, and periprocedural complications., Main Results: A total of 35 patients underwent RBG-PDT, including 24 men, with a mean age of 66 years (±11 yr; range, 42-88 yr). The mean body mass index was 34 kg/m(2). The mean procedure time was 32 (±10) minutes, with a median of 33 minutes. The most common indication for tracheostomy was failure to wean from mechanical ventilation, followed by tracheal stenosis and tracheobronchomalacia. The most common indications for RBG-PDT were complex airway, obesity, and coagulopathy. There were no periprocedural complications of consequence, or mortality associated with the procedure., Conclusions: RBG-PDT is safe and effective in a population of high-risk patients who are otherwise not considered good candidates for standard PDT.

Background: Thymectomy is often performed on the basis of computed tomography scan findings that are suspicious for thymoma. However, the final diagnosis may be a condition such as thymic hyperplasia or lymphoma for which thymectomy is not therapeutic. The present analysis was undertaken to determine the prevalence of a "nontherapeutic" thymectomy., Methods: The Nationwide Inpatient Sample from 2000 through 2009 was queried to identify patients who underwent a thymectomy. Only adult patients who underwent a total thymectomy without other associated procedures were analyzed. Patients with a diagnosis of myasthenia were excluded. A nontherapeutic thymectomy was defined as a patient who underwent thymectomy with an International Classification of Diseases, Ninth Revision diagnosis code of lymphoma, thymic hyperplasia, thymic cyst, or other benign diseases of the thymus., Results: A total of 1,306 patients were identified. Overall, 72.2% (n = 943) of thymectomies were therapeutic and 27.8% (n = 363) were nontherapeutic. The most common diagnosis in the nontherapeutic group was thymic hyperplasia (n = 174). Mortality (0.32% versus 0%; p = 0.083) and overall complication rates (25% versus 17%; p < 0.001) were higher in the therapeutic group. Patients in the nontherapeutic group were younger (median age, 41 versus 56 years; p < 0.001) and more likely to undergo a video-assisted thoracoscopic surgery thymectomy (28% versus 19%; p = 0.085)., Conclusions: In this study, 27.8% of thymectomies were nontherapeutic, and most patients underwent an open approach. The most common benign diagnosis was thymic hyperplasia, a condition for which magnetic resonance imaging has a high predictive value. Consequently, further studies are warranted to determine the optimal evaluation of patients undergoing thymectomy for presumed thymoma., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: To date, reports on outcomes after robotic-assisted pulmonary resection have been confined to small, single-institution case series. Furthermore, no comparison has been made between robotic, open, and video-assisted thoracic surgery (VATS) procedures. We sought to compare the outcomes between these approaches using the State Inpatient Databases (SID)., Methods: Using the 2008 to 2010 SID, we identified patients who underwent an open, VATS, or robotic lobectomy from 8 states. Patients who underwent segmentectomy were also included. A comparison of outcomes was performed using a propensity-matched analysis., Results: We identified a total of 33,095 patients (open: 20,238; VATS: 12,427; robotic: 430). Case volumes for robotic resections increased over the study period from 0.2% in 2008 to 3.4% in 2010. Robotic resections were performed in all 8 states, and 38% were conducted in a community hospital. In propensity-matched analysis, robotic resections were associated with significant reductions in mortality (0.2% vs 2.0%, p = 0.016), length of stay (5.9 vs 8.2 days, p < 0.0001), and overall complication rates (43.8% vs 54.1%, p = 0.003) when compared with open thoracotomy. Robotic resection was also associated with reductions in mortality (0.2% vs 1.1%, p = 0.12), length of stay (5.9 days vs 6.3 days, p = 0.45), and overall complication rates (43.8% vs 45.3%, p = 0.68) when compared with VATS; however, none of these differences were statistically significant., Conclusions: Case volume for robotic pulmonary resections has increased significantly during the study period, and thoracic surgeons have been able to adopt the robotic approach safely. Robotic resection appears to be an appropriate alternative to VATS and is associated with improved outcomes compared with open thoracotomy., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Neoadjuvant chemoradiation (CRT) is an accepted treatment for locally advanced esophageal carcinoma. A survival benefit has not been definitively established, and there is concern that chemoradiation may increase postoperative morbidity and mortality., Methods: A retrospective review was made of 138 patients treated for esophageal carcinoma between January 1999 and December 2009. Fifty-four patients who underwent CRT followed by esophagectomy were compared with 84 patients who underwent esophagectomy alone., Results: The chemoradiation and esophagectomy alone cohorts were well matched on all preoperative variables. There was a higher percentage of Ivor Lewis procedures in the esophagectomy alone cohort (82.0%) compared with the CRT cohort (59.3%; p = 0.006). Thirty-five percent of the CRT group underwent transhiatal esophagectomy. Thirty-day mortality was 6.0% (5 of 84) in the esophagectomy alone cohort compared with 1.9% (1 of 54) in the CRT cohort (p = 0.5). Similarly, mean intensive care unit stay (4.7 versus 6.5 days; p = 0.5), ventilator time (2.4 versus 4.2 days; p = 0.5), and length of stay (13.5 versus 17 days; p = 0.2) did not differ significantly between the groups. The overall major complication rates were similar in the CRT and esophagectomy alone cohorts: 57.4% versus 56% (p = 0.98). Multivariate analysis determined that coronary artery disease (p = 0.01; odds ratio 3.5) and transthoracic esophagectomy (p = 0.05; odds ratio 1.4) were predictive of development of postoperative complications. Only cervical anastomotic location (p = 0.04; odds ratio 3.0) was predictive of anastomotic leak on multivariate analysis., Conclusions: Neoadjuvant chemoradiation does not appear to increase postoperative morbidity or mortality after esophagectomy. Major postoperative complications are associated with the transthoracic approach and preoperative coronary artery disease., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The optimal treatment of locally advanced non-small-cell lung cancer (NSCLC) remains controversial. We hypothesized that using a trimodality approach in selected patients with stage IIIA/IIIB disease would be both feasible and efficacious with reasonable toxicity., Patients/methods: We enrolled 13 patients with resectable stage III NSCLC on a prospective phase II trial of trimodality therapy. Induction treatment consisted of weekly docetaxel 20 mg/m(2) and weekly carboplatin at an area under curve (AUC) of 2 concurrent with 45 Gy thoracic radiotherapy. Resection was performed unless felt to be unsafe or if patients had progressive disease. Postoperative consolidation consisted of docetaxel 75 mg/m(2) and carboplatin at an AUC of 6 every 3 weeks for 3 cycles with growth factor support., Results: All patients responded to induction chemoradiotherapy as measured by total gross tumor volume reductions of 43% on average (range, 27%-64%). Twelve patients underwent resection of the tumor and involved nodes, yielding a resectability rate of 92%. The primary endpoint of 2-year overall survival (OS) was 72% (95% confidence interval [CI], 36%-90%), and 2-year progression-free survival (PFS) was 36% (95% CI, 9%-64%). The maximal toxicity observed per patient was grade II in 5 patients (38%); grade III in 7 patients (54%); grade IV in 1 patient (8%); and grade V in none., Conclusion: This trimodality approach resulted in promising outcomes with reasonable toxicity in carefully selected patients with stage III NSCLC at a single institution., (Copyright © 2011. Published by Elsevier Inc.)

Background: A fall in the postpneumonectomy fluid level is considered a sign of bronchopleural fistula (BPF) requiring surgical intervention. We have discovered however that in rare asymptomatic patients, this event may not require aggressive surgical treatment., Methods: After seeing a case of benign emptying of the postpneumonectomy space (BEPS), we surveyed 28 surgeons to determine its incidence and characteristics., Results: Forty-four cases of BEPS were reported by 23 survey respondents. Among 7 fully documented cases from 4 institutions, we defined the following criteria: the patient must be asymptomatic (no fever, white cell count elevation, or fluid expectoration), negative culture results if fluid sampled (patient not receiving antibiotics), no BPF at bronchoscopy or ventilation scintigraphy scan (or both), and recovery without drainage, or retrospective assessment that the intervention was unnecessary. BEPS occurred between 5 days and 152 days after pneumonectomy (6 cases right pneumonectomy and 1 case left pneumonectomy). Four patients underwent no treatment, 1 patient underwent thoracoscopic exploration (sterile) and closure after antibiotic irrigation, 1 patient underwent thoracoscopic exploration alone, and 1 patient underwent open window thoracostomy (sterile) with eventual closure. In all 7 patients (except the patient who underwent the open window procedure) the space refilled within 8 weeks; no patient experienced a subsequent empyema/BPF. Four patients who met the initial criteria for BEPS went on to experience empyema. The incidence of BEPS appears related to pneumonectomy volume, particularly extrapleural pneumonectomy. Using surgeon volume assumptions, the incidence of BEPS is 0.65%., Conclusions: To our knowledge, BEPS is a previously unreported occurrence. We hypothesize that it results from postoperative intrapleural pressure shifts, with or without a microscopic BPF, that drive fluid out of the pleural space while failing to cause contamination. Awareness of BEPS' existence may allow surgeons to safely avoid open drainage procedures occasionally in patients who experience an asymptomatic fall in fluid level., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: The role of trimodality therapy for locally advanced non-small cell lung cancer (NSCLC) continues to be defined. We hypothesized that imaging parameters on pre- and postradiation positron emission tomography (PET)-computed tomography (CT) imaging are prognostic for outcome after preoperative chemoradiotherapy (CRT)/resection/consolidation chemotherapy and could help risk-stratify patients in clinical trials., Methods: We enrolled 13 patients on a prospective clinical trial of trimodality therapy for resectable locally advanced NSCLC. PET-CT was acquired for radiation planning and after 45 Gy. Gross tumor volume (GTV) and standardized uptake value were measured at pre- and post-CRT time points and correlated with nodal pathologic complete response, loco-regional and/or distant progression, and overall survival. In addition, we evaluated the performance of automatic deformable image registration (ADIR) software for volumetric response assessment., Results: All patients responded with average total GTV reductions after 45 Gy of 43% (range: 27-64%). Pre- and post-CRT GTVs were highly correlated (R² = 0.9), and their respective median values divided the patients into the same two groups. ADIR measurements agreed closely with manually segmented post-CRT GTVs. Patients with GTV ≥ median (137 ml pre-CRT and 67 ml post-CRT) had 3-year progression-free survival (PFS) of 14% versus 75% for GTV less than median, a significant difference (p = 0.049). Pre- and post-CRT PET-standardized uptake value did not correlate significantly with pathologic complete response, PFS, or overall survival., Conclusions: Preoperative CRT with carboplatin/docetaxel/45 Gy resulted in excellent response rates. In this exploratory analysis, pre- and post-CRT GTV predicted PFS in trimodality therapy, consistent with our earlier studies in a broader cohort of NSCLC. ADIR seems robust enough for volumetric response assessment in clinical trials.

Lung cancer remains the most common cause of cancer-related deaths in the United States, and although surgery remains the standard treatment for early-stage tumors, stereotactic radiation is gaining an increasing role as an alternative form of therapy. Initially a form of treatment designed for neurosurgical applications, during the past decade stereotactic radiosurgery (SRS) has gone from a novel treatment for patients deemed to be prohibitive candidates for surgical resection to the point that there is now an international, randomized, multicenter trial to compare SRS to lobectomy in otherwise-healthy patients. This article reviews the history of SRS as applied to lung tumors, summarizes the currently available data on efficacy and toxicity, and describes some of the current controversial aspects of this treatment., (Copyright 2010 Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to report initial results of a phase I study using single-fraction stereotactic radiotherapy (RT) in patients with inoperable lung tumors., Methods: Eligible patients included those with inoperable T1-2N0 non-small cell lung cancer (NSCLC) or solitary lung metastases. Treatments were delivered by means of the CyberKnife. All patients underwent computed tomography-guided metallic fiducial placement in the tumor for image-guided targeting. Nine to 20 patients were treated per dose cohort starting at 15 Gy/fraction followed by dose escalation of 5 to 10 Gy to a maximal dose of 30 Gy/fraction. A minimal 3-month period was required between each dose level to monitor toxicity., Results: Thirty-two patients (21 NSCLC and 11 metastatic tumors) were enrolled. At 25 Gy, pulmonary toxicity was noted in patients with prior pulmonary RT and treatment volumes greater than 50 cc; therefore, dose escalation to 30 Gy was applied only to unirradiated patients and treatment volume less than 50 cc. Ten patients received doses less than 20 Gy, 20 received 25 Gy, and two received 30 Gy. RT-related complications were noted for doses greater than 25 Gy and included four cases of grade 2 to 3 pneumonitis, one pleural effusion, and three possible treatment-related deaths. The 1-year freedom from local progression was 91% for dose greater than 20 Gy and 54% for dose less than 20 Gy in NSCLC (p = 0.03). NSCLC patients had significantly better freedom from relapse (p = 0.003) and borderline higher survival than those with metastatic tumors (p = 0.07)., Conclusions: Single-fraction stereotactic RT is feasible for selected patients with lung tumors. For those with prior thoracic RT, 25 Gy may be too toxic. Higher dose was associated with improved local control. Longer follow-up is necessary to determine the treatment efficacy and toxicity.

Background: Heart-lung transplant recipients, when compared with heart transplant recipients, are relatively spared from allograft coronary artery disease. This study was undertaken to investigate whether heart-lung transplant recipients are also spared from experiencing bronchiolitis obliterans syndrome (BOS) when compared with double-lung transplant recipients. In addition, the risk factors for developing BOS after lung transplantation were analyzed., Methods: Heart-lung and bilateral sequential double-lung transplant recipients were reviewed retrospectively from 1990 to 2000 using the Stanford Transplant Database. The heart-lung transplant group consisted of 77 heart-lung transplant recipients and the double-lung transplant group consisted of 51 double-lung transplant recipients. The rates of BOS, survival, acute rejection, and cytomegalovirus infection at 1, 3, and 5 years were measured., Results: There were no significant differences in patient demographics between the two groups. Rates of survival and acute rejection were similar in the two transplant groups. The incidence of cytomegalovirus infection was significantly higher in heart-lung transplant recipients. Freedom from BOS was similar in the two transplant groups. Risk factors for the development of BOS in the heart-lung and double-lung transplant recipients included male donor, younger recipient age, a diagnosis other than cystic fibrosis, nonuse of cardiopulmonary bypass, and the use of OKT3 induction therapy., Conclusions: Heart-lung transplant recipients exhibit BOS at a rate similar to double-lung transplant recipients. The immunoprotective effect the lung allograft presumably provides the heart is not reciprocated by the heart in preventing the development of BOS.