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Simple Summary The optimal way to treat central (CLT) and ultracentral (UCLT) lung tumors with curative radiation is unclear. We evaluated 83 patients with CLT and UCLT who underwent a curative radiotherapy technique called stereotactic body radiation therapy (SBRT). On statistical analysis, patients with UCLT had worse overall survival. Using a cohort of patients matched for relevant variables such as gender and performance status, we evaluated radiation doses to critical central structures such as the airway and heart. In this group, patients with UCLT were more likely to exceed dose constraints as compared CLT, particularly constraints regarding the airway. Additionally, patients had worse non-cancer associated survival when radiation doses were higher than 18 Gy to 4cc’s of either the trachea or proximal bronchial tree. Based on these findings, patients with UCLT have worse outcomes which could be secondary to higher radiation doses to the trachea and proximal bronchial tree. Abstract The preferred radiotherapeutic approach for central (CLT) and ultracentral (UCLT) lung tumors is unclear. We assessed the toxicity and outcomes of patients with CLT and UCLT who underwent definitive five-fraction stereotactic body radiation therapy (SBRT). We reviewed the charts of patients with either CLT or UCLT managed with SBRT from June 2010–April 2019. CLT were defined as gross tumor volume (GTV) within 2 cm of either the proximal bronchial tree, trachea, mediastinum, aorta, or spinal cord. UCLT were defined as GTV abutting any of these structures. Propensity score matching was performed for gender, performance status, and history of prior lung cancer. Within this cohort of 83 patients, 43 (51.8%) patients had UCLT. The median patient age was 73.1 years with a median follow up of 29.9 months. The two most common dose fractionation schemes were 5000 cGy (44.6%) and 5500 cGy (42.2%) in five fractions. Multivariate analysis revealed UCLT to be associated with worse overall survival (OS) (HR = 1.9, p = 0.02) but not time to progression (TTP). Using propensity score match pairing, UCLT correlated with reduced non-cancer associated survival (p = 0.049) and OS (p = 0.03), but not TTP. Within the matched cohort, dosimetric study found exceeding a D4cc of 18 Gy to either the proximal bronchus (HR = 3.9, p = 0.007) or trachea (HR = 4.0, p = 0.02) was correlated with worse non-cancer associated survival. In patients undergoing five fraction SBRT, UCLT location was associated with worse non-cancer associated survival and OS, which could be secondary to excessive D4cc dose to the proximal airways.

BACKGROUND Despite occurring commonly, the prognoses of second early-stage non-small cell lung cancers (NSCLC) are not well known. METHODS The authors retrospectively reviewed the charts of inoperable patients who underwent thoracic stereotactic body radiation therapy (SBRT) from February 2007 to April 2019. Those with previous small cell lung cancers or SBRT treatments for tumors other than NSCLC were excluded. Multivariate Cox regression and a matched pair cohort analyses evaluated the prognoses of patients undergoing definitive SBRT for a new second primary. RESULTS Of 438 patients who underwent definitive SBRT for NSCLC, 84 had previously treated NSCLC. Univariate log-rank tests identified gender, Karnofksy performance status (KPS), prior lung cancer, anticoagulation use, and history of heart disease to correlate with overall survival (OS) (P

With the complexity of cancer treatment rising, the role of multidisciplinary conferences (MDCs) in making diagnostic and treatment decisions has become critical. This study evaluated the impact of a thoracic MDC (T-MDC) on lung cancer care quality and survival.Lung cancer cases over 7 years were identified from the Roswell Park cancer registry system. The survival rates and treatment plans of 300 patients presented at the MDC were compared with 300 matched patients. The National Comprehensive Cancer Network (NCCN) guidelines were used to define the standard of care. The compliance of care plans with NCCN guidelines was summarized using counts and percentages, with comparisons made using the Fisher exact test. Survival outcomes were summarized using Kaplan-Meier methods.There was improvement in median overall survival (36.9 vs 19.3 months; P.001) and cancer-specific survival (48 vs 28.1 months; P.001) for lung cancer patients discussed at the T-MDC compared with controls. These differences were statistically significant in patients with stages III/IV disease but not in patients with stages I/II disease. The NCCN guidelines compliance rate of treatment plans improved from 80% to 94% (P.001) after MDC discussion. MDC recommendations resulted in treatment plan changes in 123 of 300 patients (41%).Our results suggest that lung cancer patients have a survival benefit from MDC discussion compared with controls. Patients with advanced disease (stages III and IV) benefited the most. Further research is necessary to understand the precise mechanisms that drive these results.

Background Studies of shared (patient-provider) decision making for elective surgical care have examined both the decision whether to have surgery and patients' understanding of treatment options. We consider shared decision making applied to case scheduling, since implementation would reduce labor costs. Methods Study questions were presented in sequence of waiting times, starting with 4 workdays. "Assume the consultant surgeon (ie, the surgeon in charge) you met in clinic did not have time available to do your surgery within the next 4 workdays, but his/her colleague would have had time to do your surgery within the next 4 workdays. Would you have wanted to discuss with a member of the surgical team (eg, the scheduler or the surgeon) the availability of surgery with a different, equally qualified surgeon at Mayo Clinic who had time available within the next 4 workdays, on a date of your choosing?" There were 980 invited patients who underwent lung resection or cholecystectomy between 2011 and 2016; 135 respondents completed the study and 6 respondents dropped out after the study questions were displayed. Results The percentages of patients whose response to the study questions was "4 days" were 58.8% (40/68) among lung resection patients and 58.2% (39/67) among cholecystectomy patients. The 97.5% 2-sided confidence interval for the median maximum wait was 4 days to 4 days. Patients' choices for the waiting time sufficient to discuss having another surgeon perform the procedure did not differ between procedures (P = .91). Results were insensitive to patients' sex, age, travel time to hospital, or number of office visits before surgery (all P ≥ .20). Conclusions Our results indicate that bringing up the option with the patient of changing surgeons when a colleague is available and has the operating room time to perform the procedure sooner is being respectful of most patients' individual preferences (ie, patient-centered).

Mediastinoscopy is considered the gold standard for preresectional staging of lung cancer. We sought to examine the effect of concomitant mediastinoscopy on postoperative pneumonia (POP) in patients undergoing lobectomy. All patients in our institutional database (2008–2015) undergoing lobectomy who did not receive neoadjuvant therapy were included in our study. The relationship between mediastinoscopy and POP was examined using univariate (Chi square) and multivariate analyses (binary logistic regression). In order to validate our institutional findings, lobectomy data in the National Surgical Quality Improvement Program (NSQIP) from 2005 to 2014 were analyzed for these associations. Of 810 patients who underwent a lobectomy at our institution, 741 (91.5%) surgeries were performed by video-assisted thoracic surgery (VATS) and 487 (60.1%) patients underwent concomitant mediastinoscopy. Univariate analysis demonstrated an association between mediastinoscopy and POP in patients undergoing VATS [odds ratio (OR) 1.80; p = 0.003], but not open lobectomy. Multivariate analysis retained mediastinoscopy as a variable, although the relationship showed only a trend (OR 1.64; p = 0.1). In the NSQIP cohort (N = 12,562), concomitant mediastinoscopy was performed in 9.0% of patients, with 44.5% of all the lobectomies performed by VATS. Mediastinoscopy was associated with POP in patients having both open (OR1.69; p

BACKGROUND We examined type I and II error rates for analysis of (1) mean hospital length of stay (LOS) versus (2) percentage of hospital LOS that are overnight. These 2 end points are suitable for when LOS is treated as a secondary economic end point. METHODS We repeatedly resampled LOS for 5052 discharges of thoracoscopic wedge resections and lung lobectomy at 26 hospitals. RESULTS Unequal variances t test (Welch method) and Fisher exact test both were conservative (ie, type I error rate less than nominal level). The Wilcoxon rank sum test was included as a comparator; the type I error rates did not differ from the nominal level of 0.05 or 0.01. Fisher exact test was more powerful than the unequal variances t test at detecting differences among hospitals; estimated odds ratio for obtaining P < .05 with Fisher exact test versus unequal variances t test = 1.94, with 95% confidence interval, 1.31-3.01. Fisher exact test and Wilcoxon-Mann-Whitney had comparable statistical power in terms of differentiating LOS between hospitals. CONCLUSIONS For studies with LOS to be used as a secondary end point of economic interest, there is currently considerable interest in the planned analysis being for the percentage of patients suitable for ambulatory surgery (ie, hospital LOS equals 0 or 1 midnight). Our results show that there need not be a loss of statistical power when groups are compared using this binary end point, as compared with either Welch method or Wilcoxon rank sum test.

Case Presentation A 51-year-old woman was found to have a new 14 × 6 mm soft tissue mass under the right serratus muscle on a CT scan of the chest performed for routine surveillance due to her history of stage I lung cancer. A follow-up CT scan performed 4 months later showed that the mass had increased in size to 22 × 8 mm. The patient presents to the oncology clinic to discuss the results of the CT scan. She has no pain or swelling on the right lateral chest and no cough, fever, or shortness of breath. She is at her baseline health with good appetite and functional status.

Accurate staging of the mediastinum is a critical element of therapeutic decision making in non-small cell lung cancer. We sought to determine the utility of transcervical extended mediastinal lymphadenectomy (TEMLA) in staging non-small cell lung cancer for large central tumors and after induction therapy.A retrospective record review was performed of all patients who underwent TEMLA at our institution from 2010 to 2015. Clinical stage as assessed by positron emission tomography integrated with computed tomography (PET-CT), stage as assessed by TEMLA, final pathologic stage, lymph node yield, and clinical characteristics of tumors were assessed along with TEMLA-related perioperative morbidity. Accuracy of staging by TEMLA for restaging the mediastinum after neoadjuvant therapy was compared with that of PET-CT.Of 164 patients who underwent TEMLA, 157 (95.7%) were completed successfully. Combined surgical resection along with TEMLA was performed in 138 of these patients, with 131 (94.2%) undergoing a video-assisted thoracoscopic resection. The recurrent laryngeal nerve injury rate was 6.7%. TEMLA was performed in 118 of 164 patients for restaging after neoadjuvant therapy, and 101 of these patients were also restaged by PET-CT. Based on TEMLA, 7 patients did not go on to have resection. Of the 101 patients who did have a resection, TEMLA was more accurate than PET-CT in staging the mediastinum (95% vs 73%, p0.0001). However, the pneumonia rate in this subgroup of patients was 13%.TEMLA is a safe procedure and superior to PET-CT for restaging of the mediastinum after neoadjuvant therapy for non-small cell lung cancer. However, this increased accuracy comes with a high postoperative pneumonia rate.

We considered whether senior hospital managers and department chairs need to be concerned that small reductions in average hospital length of stay (LOS) may be associated with greater rates of re-admission, use of home health care, and/or transfers to short-term care facilities. The 2013 United States Nationwide Readmissions Database was used to study surgical Diagnosis Related Groups (DRG) with 1) national median LOS ≥3 days and 2) ≥10 hospitals in the database that each had ≥100 discharges for the DRG. Dependent variables were considered individually: 1) re-admission within 30 days of discharge, 2) discharge disposition to home health care, and/or 3) discharge disposition of transfer to short-term care facility (i.e., inpatient rehabilitation hospital or skilled nursing facility). While controlling for DRG, each one-day decrease in hospital median LOS was associated with an odds of re-admission nationwide of 0.95 (95% confidence interval [CI] 0.92–0.99; P=0.012), odds of disposition upon discharge being home care of 0.95 (95% CI 0.83–1.10; P=0.64), and odds of transfer to short-term care facility of 0.68 (95% CI 0.54–0.85; P=0.0008). Results were insensitive to the addition of patient-specific data. In the USA, patients at hospitals with briefer median LOS across multiple common surgical procedures did not have a greater risk for either hospital re-admission within 30 days of discharge or transfer to an inpatient rehabilitation hospital or a skilled nursing facility. The generalisable implication is that, across many surgical procedures, DRG-based financial incentives to shorten hospital stays seem not to influence post–acute care decisions.

OBJECTIVE/BACKGROUND: Insomnia occurs in 50 to 80% of lung cancer survivors. Cognitive behavioral therapy is the standard treatment for insomnia (CBTI); however, treatment length and lack of psychologists trained in CBTI limits access. Brief Behavioral Treatment for Insomnia (BBTI), a nurse-delivered modified CBTI, is proposed. This feasibility pilot study sought to compare the BBTI intervention to attention control Healthy Eating Program (HEP) for insomnia in lung cancer survivors. PARTICIPANTS: The participants comprised adults, 21 years of age or older with insomnia and stage I/II non-small cell lung cancer, more than 6 weeks from surgery and living in Western NY. METHODS: Participants (n=40) were randomly assigned to an experimental (BBTI) or attention control condition (Healthy Eating Program). Thirty participants completed the study. RESULTS: Participants were 66 years of age (± 7.6; range 53–82), 40% (n=16) male, 87.5% (n=35) Caucasian, 50% (n=20) married, BMI 27.7 (± 5.8), and 12% (n=5) never smokers. Baseline sleep diary sleep efficiency, ISI and other baseline covariates were balanced between the groups. Sleep efficiency improved ≥85% in BBTI group (p=.02), but not in HEP control group (p=1.00). Mean ISI for BBTI and attention control were 6.40 ± 4.98 and 14.10 ± 4.48 (p=.001) respectively. In addition, BBTI group mean total FACT-L score improved by 6.66 points from baseline while HEP group score worsened (p=0.049). CONCLUSIONS: BBTI is a practical, evidence-based, clinically relevant intervention that improved sleep and quality of life in lung cancer survivors with insomnia. Additional research to evaluate efficacy, duration, and implementation strategies are essential.

BACKGROUND The optimal treatment for patients with brain metastases remains controversial as the use of stereotactic radiosurgery (SRS) alone, replacing whole-brain radiation therapy (WBRT), has increased. This study determined the patterns of care at multiple institutions before 2010 and examined whether or not survival was different between patients treated with SRS and patients treated with WBRT. METHODS This study examined the overall survival of patients treated with radiation therapy for brain metastases from non–small cell lung cancer (NSCLC; initially diagnosed in 2007-2009) or breast cancer (initially diagnosed in 1997-2009) at 5 centers. Propensity score analyses were performed to adjust for confounding factors such as the number of metastases, the extent of extracranial metastases, and the treatment center. RESULTS Overall, 27.8% of 400 NSCLC patients and 13.4% of 387 breast cancer patients underwent SRS alone for the treatment of brain metastases. Few patients with more than 3 brain metastases or lesions ≥ 4 cm in size underwent SRS. Patients with fewer than 4 brain metastases less than 4 cm in size (n = 189 for NSCLC and n = 117 for breast cancer) who were treated with SRS had longer survival (adjusted hazard ratio [HR] for NSCLC, 0.58; 95% confidence Interval [CI], 0.38-0.87; P = .01; adjusted HR for breast cancer, 0.54; 95% CI, 0.33-0.91; P = .02) than those treated with WBRT. CONCLUSIONS Patients treated for fewer than 4 brain metastases from NSCLC or breast cancer with SRS alone had longer survival than those treated with WBRT in this multi-institutional, retrospective study, even after adjustments for the propensity to undergo SRS. Cancer 2016;122:2091–100. © 2016 American Cancer Society.

Purpose This study determined practice patterns in the staging and treatment of patients with stage I non-small cell lung cancer (NSCLC) among National Comprehensive Cancer Network (NCCN) member institutions. Secondary aims were to determine trends in the use of definitive therapy, predictors of treatment type, and acute adverse events associated with primary modalities of treatment. Methods and Materials Data from the National Comprehensive Cancer Network Oncology Outcomes Database from 2007 to 2011 for US patients with stage I NSCLC were used. Main outcome measures included patterns of care, predictors of treatment, acute morbidity, and acute mortality. Results Seventy-nine percent of patients received surgery, 16% received definitive radiation therapy (RT), and 3% were not treated. Seventy-four percent of the RT patients received stereotactic body RT (SBRT), and the remainder received nonstereotactic RT (NSRT). Among participating NCCN member institutions, the number of surgeries-to-RT course ratios varied between 1.6 and 34.7 ( P P =.01). Significant variations were also observed in staging practices, with brain imaging 0.33 (0.25-0.43) times as likely and mediastinoscopy 31.26 (21.84-44.76) times more likely for surgical patients than for RT patients. Toxicity rates for surgical and for SBRT patients were similar, although the rates were double for NSRT patients. Conclusions The variations in treatment observed among NCCN institutions reflects the lack of level I evidence directing the use of surgery or SBRT for stage I NSCLC. In this setting, research of patient and physician preferences may help to guide future decision making.

Background Because the traditional open lung approach with en bloc chest wall resection carries substantial risk for complications and death, we studied our thoracoscopic approach for this operation. Methods From 2007 to 2013, all consecutive video-assisted thoracoscopic (VATS) and open chest wall resections at a comprehensive cancer center were tabulated retrospectively. Data were analyzed by approach, type, and cause of early major morbidity and mortality. Lung cancer cases (the largest subset, T3) were analyzed separately. Statistical tests included the Kruskal-Wallis test for continuous variables and the χ 2 for categoric variables. Survival data were analyzed by the Kaplan-Meier method and log-rank tests. Results Of 47 chest wall resections performed, 17 (36%) were performed by VATS with no conversions. Resections were performed for primary non-small cell lung cancer (15 VATS and 16 thoracotomy), sarcoma (11), metastatic disease from a separate primary (2), and benign conditions (3). Patients undergoing a VATS approach were older (76 vs 56 years, p = 0.003), and the operative times, blood loss, and ribs resected were similar between groups. Patients undergoing VATS had shorter intensive care unit and hospital lengths of stay, but both groups had high hospital morbidity and mortality, largely resulting from postoperative pneumonia or respiratory systemic inflammatory response syndrome (n = 5), stroke (n = 2), and postoperative colon ischemia (n = 1). Groups had a 90-day mortality of 26.7% and 25% respectively. Stage-matched survival curves for both approaches were superimposable ( p =0.88). Conclusions Thoracoscopic chest wall resection was feasible, expanded our case selection, and reduced prosthetic reconstruction. It did not, however, protect frail, elderly patients reliably. Briefer, less traumatic operations may be needed for this cohort.

Background: As screening for lung cancer rises, an increase in the diagnosis of early stage lung cancers is expected. Lobectomy remains the standard treatment, but there are alternatives, consideration of which requires an estimation of the risk of surgery. Sarcopenia, irrespective of body mass index, confers a worse prognosis in many groups of patients including those undergoing surgery. Here we examine the association of muscle mass with outcomes for patients undergoing lobectomy. Methods: Consecutive patients undergoing lobectomy were retrospectively reviewed. Preoperative computed tomography scans were reviewed, and cross-sectional area of the erector spinae muscles and pectoralis muscles was determined and normalized for height. Univariate and multivariate analyses were then done to examine for an association of muscle mass with morbidity and short- and long-term mortality. Results: During the study period, there were 299 lobectomies, 278 of which were done by video assisted thoracoscopic surgery. The average age of the patients was 67.5±10.6 years. Overall complication rate was 52.2%, pneumonia rate was 8.7%, and the 30-day mortality rate was 1.3%. Mean height adjusted-erector spinae muscle cross-sectional area was 10.6±2.6 cm 2 /m 2 , and mean height adjusted-pectoralis muscle cross sectional area was 13.3±3.8 cm 2 /m 2 . The height adjusted cross sectional areas of the erector spinae and pectoralis muscles were not associated with overall complication rate, rate of pneumonia, readmission, or intensive care unit length of stay. The height adjusted-erector spinae muscle cross sectional area was inversely correlated with 30-day mortality risk, odds ratio 0.77 (95% CI, 0.60–0.98, P=0.036). Mean length of stay was 7.0 days (95% CI, 5.5–8.4 days). Multivariate analysis demonstrated a significant inverse association of the height adjusted-erector spinae muscle cross sectional area with length of stay (P=0.019). Conclusions: The height adjusted-erector spinae muscle cross sectional area was significantly associated with 30-day mortality and length of stay in the hospital. Measurement of muscle mass on preoperative computed tomography imaging may have a role to help predict risk of morbidity and mortality prior to lobectomy.

OBJECTIVES: Neoadjuvant therapy has emerged as a favoured treatment paradigm for patients with clinical N2 disease undergoing surgical resection for non-small-cell lung cancer. It is unclear whether such a treatment paradigm affects perioperative outcomes. We sought to examine the National Cancer Database (NCDB) to assess the impact of neoadjuvant therapy on perioperative outcomes and long-term survival in these patients. METHODS: All patients with a history of non-small-cell lung cancer undergoing anatomical resection between 2004 and 2014 were included. Thirty-day and 90-day mortality of all patients having neoadjuvant therapy versus those who did not were compared. In addition, the impact of neoadjuvant therapy on the overall survival of patients with clinical N2 disease was examined. RESULTS: Of the 134 428 selected patients, 9896 (7.4%) patients had neoadjuvant chemotherapy. Patients undergoing neoadjuvant therapy had a higher 30-day (3% vs 2.6%; P

We consider whether there should be greater priority of information sharing about postacute surgical resources used: (1) at skilled nursing facilities or inpatient rehabilitation hospitals to which patients are transferred upon discharge (when applicable) versus (2) at different hospitals where readmissions occur. Obtaining and storing data electronically from these 2 sources for Perioperative Surgical Home initiatives are dissimilar; both can be challenging depending on the country and health system.Using the 2013 US Nationwide Readmissions Database, we studied discharges of surgical diagnosis-related group (DRG) with US national median length of stay (LOS) ≥ 3 days and ≥ 10 hospitals each with ≥ 100 discharges for the Medicare Severity DRG.Nationwide, 16.15% (95% confidence interval [CI], 15.14%-17.22%) of discharges were with a disposition of "not to home" (ie, transfer to a skilled nursing facility or an inpatient rehabilitation hospital). Within 30 days, 0.88% of discharges (0.82%-0.95%) were followed by readmission and to a different hospital than the original hospital where the surgery was performed. Among all discharges, disposition "not to home" versus "to home" was associated with greater odds that the patient would have readmission within 30 days and to a different hospital than where the surgery was performed (2.11, 95% CI, 1.96-2.27; P.0001). In part, this was because disposition "not to home" was associated with greater odds of readmission to any hospital (1.90, 95% CI, 1.82-1.98; P.0001). In addition, among the subset of discharges with readmission within 30 days, disposition "not to home" versus "to home" was associated with greater odds that the readmission was to a different hospital than where the surgery was performed (1.20, 95% CI, 1.11-1.31; P.0001). There was no association between the hospitals' median LOS for the DRG and the odds that readmission was to a different hospital (P = .82). The odds ratio per each 1 day decrease in the hospital median LOS was 1.01 (95% CI, 0.91-1.12).Departments and hospitals wishing to demonstrate the value of their Perioperative Surgical Home initiatives, or to calculate risk assumption contracts, should ensure that their informatics priorities include obtaining accurate data on resource use at postacute care facilities such as skilled nursing facilities. Although approximately a quarter of readmissions are to different hospitals than where surgery was performed, provided that is recognized, obtaining those missing data is of less importance.

Early stage lung cancer is being detected at a higher frequency with the implementation of screening programs. At the same time, medically complex patients with multiple comorbidities are presenting for surgery, with a concomitant rise in rates of sublobar resection. We sought to examine the effect of sampling lymph nodes on the outcomes of patients who undergo sublobar resection for small (2 cm) stage I non-small cell lung cancer (NSCLC).All patients in the Surveillance, Epidemiology, and End Results database from 2004 to 2013 with small (2 cm) stage I NSCLC who underwent sublobar resection (wedge/segmentectomy) and no other cancer history were included. The association of the number of lymph nodes examined (LNE; categories none, 1-3, 4-6, 7-9,9) with the overall survival as well as disease-specific survival were examined using univariate as well as multivariate analyses while controlling for covariates such as age, size (1 cm,1 cm), grade, histology (adenocarcinoma vs others), and extent of resection (wedge/segmentectomy).Data from 3916 eligible patients were analyzed. Seven hundred fifteen patients (18.3%) had segmentectomy. No lymph nodes were examined in 49% and 23% of wedge resection and segmentectomy patients, respectively. Among all eligible patients, 1132 (29%), 474 (12%), 228 (6%), and 328 (8%) patients had 1 to 3, 4 to 6, 7 to 9 and 9 LNE, respectively. Univariate analyses showed significant associations between overall and disease-specific survivals with age, grade, histology, sex, extent of surgery, and LNE. The association between the number of LNE and survival remained significant even after adjusting for significant covariates including extent of sublobar resection (hazard ratio for groups with LNE 1-3, 4-6, 7-9, and9 compared with 0 LNE were 0.79, 0.77, 0.68, and 0.45 for overall survival; P .001) and 0.85, 0.77, 0.71, and 0.44 for disease-specific survival (P .05), respectively. In multivariate modeling, LNE was retained as a significant variable and extent of resection was not. In patients in whom at least 1 lymph node was examined, extent of resection was not predictive of outcome.Many patients having sublobar resection for early stage NSCLC in the United States do not have a single lymph node removed for pathologic examination. The number of LNE is associated with improved survival, presumably due to avoidance of mis-staging. This association seems greater than the association with extent of resection (segmentectomy vs wedge resection). Appropriate lymph node examination remains an important part of resection for lung cancer even if the resection is sublobar.

Background Definitive surgical and radiation therapy (RT) treatments are evolving rapidly for stage I non-small cell lung cancer (NSCLC). We hypothesized that utilization of definitive therapies increased between 2000 and 2010 and that survival improved for stage I NSCLC patients over the same time period. Secondary objectives were determining trends in patterns of care and predictors of utilization. Methods Population-based, observational, comparative effectiveness study used Surveillance, Epidemiology, and End Results-18 data from 2000 to 2010. The main outcome measure was 2-year risk of death for stage I NSCLC. Results Between 2000 and 2010, 40,589 patients (62%) underwent surgery, 10,048 (15%) received RT, 2,130 (3%) received both surgery and RT, and 11,537 (18%) received neither surgery nor RT. Annually, the odds of receiving either definitive RT or undergoing surgery increased relative to the odds of receiving no treatment (odds ratio [OR] radiation 1.04, 95% confidence interval [CI]: 1.03 to 1.05; OR surgery 1.05, 95% CI: 1.04 to 1.05). Among surgical patients, the proportion of sublobar resections steadily increased from 12.9% to 17.9%. For all patients, the 2-year risk of death decreased by 3.5% each year (hazard ratio [HR] 0.965, 95% CI: 0.962 to 0.969), driven primarily by improved survival for surgical (annualized HR 0.959, 95% CI: 0.954 to 0.964) and RT (annualized HR 0.942, 95% CI: 0.935 to 0.949) patients. Conclusions Between 2000 and 2010, stage I NSCLC patients were more likely to receive definitive treatment with either surgery or RT, leading to a decline in the number of untreated patients. Survival also improved substantially for stage I NSCLC patients, with the largest survival improvements observed in patients undergoing definitive RT.

BACKGROUND It is unclear whether thoracoscopic (video-assisted thoracoscopic surgery [VATS]) pneumonectomy improves outcomes compared with open approaches. METHODS One hundred seven consecutive pneumonectomies performed at an experienced center from January 2002 to December 2012 were studied retrospectively. Forty cases were open, and 50 successful VATS and 17 conversions were combined (intent-to-treat [ITT] analysis). RESULTS The VATS cohort had more preoperative comorbidities (three vs two, P = .003), women (57% vs 30%, P = .009), and older ages (65 years vs 63 years, P = .07). Although advanced clinical stage was less for VATS (26% vs 50% stage III, P = .035), final pathologic staging was similar (25% vs 38%, P = .77). Pursuing a VATS approach yielded similar complications (two vs two, median, P = .73) with no catastrophic intraoperative events like bleeding. Successful VATS pneumonectomy rates rose from 50%-82% by the second half of the series ( P P = .03). Conversions resulted in longer ICU stays (4 days vs 2 days, P = .01). Advanced clinical stage (III-IV) ITT VATS had longer median overall survival (OS) (42 months vs 13 months, log-rank P = .042). Successful VATS cases with early pathologic stage (0-II) had a median OS of 80 vs 16 months for converted and 28 months for open (log rank = 0.083). CONCLUSIONS Attempting thoracoscopic pneumonectomy at an experienced center appears safe but does not yield the early pain/complication reductions observed for VATS lobectomy. There may be long-term pain/survival advantages for certain stages that warrant further study and refinement of this approach.

BACKGROUND Tobacco assessment and cessation support are not routinely included in cancer care. An automated tobacco assessment and cessation program was developed to increase the delivery of tobacco cessation support for cancer patients. METHODS A structured tobacco assessment was incorporated into the electronic health record at Roswell Park Cancer Institute to identify tobacco use in cancer patients at diagnosis and during follow-up. All patients who reported tobacco use within the past 30 days were automatically referred to a dedicated cessation program that provided cessation counseling. Data were analyzed for referral accuracy and interest in cessation support. RESULTS Between October 2010 and December 2012, 11,868 patients were screened for tobacco use, and 2765 were identified as tobacco users and were referred to the cessation service. In referred patients, 1381 of those patients received only a mailed invitation to contact the cessation service, and 1384 received a mailing as well as telephone contact attempts from the cessation service. In the 1126 (81.4%) patients contacted by telephone, 51 (4.5%) reported no tobacco use within the past 30 days, 35 (3.1%) were medically unable to participate, and 30 (2.7%) declined participation. Of the 1381 patients who received only a mailed invitation, 16 (1.2%) contacted the cessation program for assistance. Three questions at initial consult and follow-up generated over 98% of referrals. Tobacco assessment frequency every 4 weeks delayed referral in

Objective The aim of this report is to describe technical maneuvers used to complete minimally invasive resections of the chest wall successfully. Methods Case videos of advanced thoracoscopic chest wall resections performed at a comprehensive cancer center were reviewed, as were published reports. These were analyzed for similarities and also categorized to summarize alternative approaches. Results Limited chest wall resections en bloc with lobectomy can be accomplished with port placement similar to that used for typical thoracoscopic anatomic resections, particularly when the utility incision is close to the region of excision. Generally, chest wall resection precedes lobectomy. Ribs can be transected with Gigli saws, endoscopic shears, or high-speed drills. Division of bone and overlying soft tissue can be planned precisely using thoracoscopic guidance. Isolated primary chest wall masses may require different port position and selective reconstruction using synthetic materials. Patch anchoring can be accomplished by devices that facilitate laparoscopic port site fascial closure. Conclusions Thoracoscopic chest wall resections have been accomplished safely using tools and maneuvers summarized here. Further outcomes research is necessary to identify the benefits of thoracoscopic chest wall resection over an open approach.

Background The non–small cell lung cancer TNM classification system uses only the anatomic extent of lymph node (LN) metastases to define the N category. The number of LNs resected and the ratio of positive LNs to total examined LNs are prognostic in other solid tumors. We used the Surveillance, Epidemiology and End Results database to investigate the effect of these factors on the overall survival of non–small cell lung cancer. Methods All patients with non–small cell lung cancer in the Surveillance, Epidemiology and End Results database from 1988 through 2007 who had curative resections and had at least one LN examined were included. The prognostic value of age, race, sex, tumor size, histologic grade, number of examined LNs, and ratio of positive LNs to total examined LNs was assessed using a multivariate Cox proportional hazards model for overall survival. The number of LNs examined was categorized into four levels. The percentage of positive LNs was stratified into three levels. Results Among patients with localized disease, fewer LNs examined corresponded with a worse prognosis. Prognosis improved as more LNs were examined. For patients with regional disease, the differences were significant only at the extremes. Older patients, males, and those with higher grade or larger tumors did worse. Patients with low or moderate ratios of positive to total LNs had better prognoses than those with high ratios. Conclusions More LNs resected and lower ratios of positive LNs to total examined LNs are associated with better patient survival after non–small cell lung cancer resection independent of age, sex, grade, tumor size, and stage of disease.

The existing guidelines for extent of resection of carcinoid tumors are based on other, more malignant non-small cell lung cancers. Because of the small number of patients in any single institution, we analyzed the Surveillance Epidemiology and End Results (SEER) database to study the effect of the extent of resection of these tumors on overall survival.All patients with lung cancer in the SEER database from 1973 to 2006 with carcinoid tumors as their only cancer were included. Variables examined included age, race (white, black, others), gender, histologic type (atypical versus typical carcinoid), stage (localized, regional, and distant), extent of resection (sublobar resection, lobectomy, or more extensive) and survival. Univariate analyses (Kaplan-Meier method) were used to select variables for multivariate analysis (Cox regression analysis). Associations were considered significant with an alpha error5%. In addition, propensity score-matched Cox regression analysis was performed for patients with typical carcinoid disease.Most patients with carcinoid tumors did not acquire any other cancers (4,785/6,819; 70.2%). Of these, 797 patients had sublobar resection and 2,681 patients had lobectomy or more extensive resections. On univariate analysis, gender (p = 0.014), race (p0.001), stage (p0.001), histologic type (p0.001) and extent of resection (p = 0.04) were associated with overall survival. Multivariate analysis demonstrated that age, gender, race, stage, and histologic type remain statistically associated with overall survival and disease-specific survival, whereas extent of resection is not. Propensity score-matched analysis demonstrates that for typical carcinoid, extent of resection is not associated with overall survival when adjusted for age, gender, race, and stage.Sublobar resection of carcinoid tumors did not compromise oncologic outcomes in a large population-based database. Lobectomy for typical carcinoid tumors is not mandatory as long as complete resection and adequate mediastinal staging are performed.

Multiple logistic regression studies frequently are performed with duration (e.g., operative time) included as an independent variable. We use narrative review of the statistical literature to highlight that when the association between duration and outcome is presumptively significant, the procedure itself (e.g., video-assisted thoracoscopic lobectomy or thoracotomy lobectomy) needs to be tested for inclusion in the logistic regression. If the procedure is a true covariate but excluded in lieu of category of procedure (e.g., lung resection), estimates of the odds ratios for other independent variables are biased. In addition, actual durations are sometimes used as the independent variable, rather than scheduled (forecasted) durations. Only the scheduled duration is known when a patient would be randomized in a trial of preoperative or intraoperative intervention and/or meets with the surgeon and anesthesiologist preoperatively. By reviewing the literature about logistic regression and about predicting case duration, we show that the use of actual instead of scheduled duration can result in biased logistic regression results.

Background Although a common clinical pairing, the epidemiology and prognosis of lung cancer (LC) after head and neck cancer (HNC) is not well described. Methods Data from the database of the Surveillance, Epidemiology and End Results (SEER) Program were used to study the epidemiology and survival of patients with LC after HNC. These data were compared with those from our institutional cancer registry. Results Of all patients with a history of HNC in the SEER database, 8,225 (5%) patients went on to develop LC. This was more than three times the incidence of second primary lung cancers (1.5%). Subsequent LCs in patients with a history of HNC were more common among those with hypopharyngeal and laryngeal cancer and those with localized HNC. Patients with HNC followed by LC had poorer overall survival than did the overall population of patients with LCs in the SEER database. Overall survival after the onset of LC was dismal (median survival, 8 months). Survival was not affected by histologic concordance between HNC and LC. An analysis of 72 patients with LC after HNC reported in our institutional tumor registry over the past 37 years yielded similar results. Conclusions Of patients who survive LC or HNC, the latter are much more likely to develop a new pulmonary malignancy. Lung cancers that develop after HNC have a poor prognosis. This phenomenon is not explained by misclassified metastases, because histologically discordant cases behave just as poorly. Enhanced surveillance and chemoprevention strategies are needed to detect and prevent subsequent primary LC in survivors of HNC.

Background Mediastinal lymph node dissection (MLND) is an integral component of complete resection for non-small cell lung cancer (NSCLC). This study analyzed the National Comprehensive Cancer Network's (NCCN) NSCLC Database to compare the efficacy of MLND during lobectomy by video-assisted thoracoscopy surgery (VATS) and thoracotomy (open). Methods The NCCN NSCLC Database was queried to identify patients who underwent lobectomy to analyze the adequacy of MLND by the number of LN stations. The percentage of patients with at least three N2 stations, the number of N2 LN stations, and the total number of LN stations (N1 + N2) resected was compared by approach. Results Of 4215 patients with NSCLC (January 2007 to September 2010), 388 patients underwent lobectomy (199 VATS and 189 open) and met entry criteria. The groups were similar in age, sex, comorbidities, performance status, and histology. MLN assessment was similar in both groups as measured by number of N2 stations (median, 3 stations; p = 0.12). At least three MLN stations were assessed in 130 patients (66%) in the VATS group vs 107 patients (58%) in the open group ( p = 0.12). The total number of N1 + N2 stations resected for each group was also similar (median, 4 in both groups ( p = 0.06). Conclusions The NCCN database indicates at least three MLN stations were assessed in most patients who underwent lobectomy by either approach. As evaluated by the number of LN stations, there was no difference in the efficacy of MLN dissection by approach.

BackgroundPreoperative pulmonary function tests are used to assess operability for either lobectomy or pneumonectomy. Current guidelines for defining high-risk patients for anatomic lung resection on the basis of these tests were developed in the era of open thoracotomy. We studied the outcomes of such high-risk patients after video-assisted thoracoscopic surgical resections to assess the performance of these guidelines.MethodsRecords of all patients who underwent anatomic resection from 2001 to 2009 at a single institution were queried for pulmonary function and perioperative outcomes. Patients with predicted postoperative forced expiratory volume in 1 second or predicted postoperative lung carbon dioxide diffusing capacity less than 40% were considered to have limited pulmonary reserve. Perioperative outcomes of patients with limited pulmonary reserve who underwent thoracoscopic resection were documented and compared with those of similar patients who underwent open resection.ResultsOf 600 patients assessed, 70 had limited pulmonary reserve according to our criteria. Forty-seven of them underwent thoracoscopic resection. This cohort had excellent outcomes, with mortality of 2.1%, pneumonia rate of 4.3%, and discharge independence rate of 95.7%. Relative to contemporary patients undergoing open resection (N = 23, including 12 conversions), patients undergoing thoracoscopic resection had lower incidence of pneumonia (4.3% vs. 21.7%, P

Background Surgeon estimates of case durations are important for operating room (OR) management decision making because many cases are rare combinations of procedures with few or no historical data. Thoracic and spine surgeons updated their scheduled OR times on the day of surgery just before the "time out" in the OR. Methods All elective (scheduled) general thoracic (n = 39) and spine surgery (n = 48) cases at 1 hospital were studied over 3-month and 1.5-month periods, respectively. Results Among cases with a change in predicted duration, most changes were made based on updates to the surgical or anesthetic procedures (thoracic 85%, spine 86%). For thoracic surgery, there was overall no significant median reduction in absolute prediction error (median 0 minutes, 95% confidence interval [CI] 0-0 minutes). Among the 37% of cases with changed predicted durations, there was a significant reduction in absolute error (median 38 minutes, 95% CI >7.5 minutes). For spine surgery, there was overall no reduction in the absolute error (median 0 minutes, 95% CI 0-0 minutes). Among the 29% of cases with changed predicted durations, absolute error was no worse, but not significantly better (point estimate of median reduction 34 minutes, 95% CI >0 minutes). Secondary observations made were no effect of updates on bias, frequent rounding of scheduled durations to the nearest half hour, and increased predictive error caused by decisions that reduced expected overutilized OR time. Conclusions A systematic program of routinely and/or always asking for updated case duration predictions will not substantively improve OR management decision making. However, when a change in surgical approach, surgical procedure, or anesthetic procedure is identified (e.g., at the intraoperative briefing before case start), the updated estimate of case duration should be used, because such updates are not worse and often better than original estimates.

Predictive variability of operating room (OR) times influences decision making on the day of surgery including when to start add-on cases, whether to move a case from one OR to another, and where to assign relief staff. One contributor to predictive variability is process variability, which arises among cases of the same procedure(s). Another contributor is parameter uncertainty, which is caused by small sample sizes of historical data.Process variability was quantified using absolute percentage errors of surgeons' bias-corrected estimates of OR time. The influence of procedure classification on process variability was studied using a dataset of 61,353 cases, each with 1 to 5 scheduled and actual Current Procedural Terminology (CPT) codes (i.e., a standardized vocabulary). Parameter uncertainty's sensitivity to sample size was quantified by studying ratios of 90% prediction bounds to medians. That studied dataset of 65,661 cases was used previously to validate a Bayesian method to calculate 90% prediction bounds using combinations of surgeons' scheduled estimates and historical OR times.(1) Process variability differed significantly among 11 groups of surgical specialty and case urgency (P0.0001). For example, absolute percentage errors exceeded the overall median of 22% for 57% of urgent spine surgery cases versus 42% of elective spine surgery cases. (2) Process variability was not increased when scheduled and actual CPTs differed (P = 0.23 without and P = 0.47 with stratification based on the 11 groups), because most differences represented known (planned) options inherent to procedures. (3) Process variability was not associated with incidence of procedures (P = 0.79), after excluding cataract surgery, a procedure with high relative variability. (4) Parameter uncertainty from uncommon procedures (0-2 historical cases) accounted for essentially all of the uncertainty in decisions dependent on estimates of OR times. The Bayesian method moderated the effect of small sample sizes on uncertainty in estimates of OR times. In contrast, from prior work, the use of broad categories of procedures reduces parameter uncertainty but at the expense of increased process variability.For procedures with few historic data, the Bayesian method allows for effective case duration prediction, permitting use of detailed procedure descriptions. Although fine resolution of scheduling procedures increases the chance of performed procedure(s) differing from scheduled procedure(s), this does not increase process variability. Future studies need both to address differences in process variability among specialties and accept the limitation that findings from one may not apply to others.

Summary Advances in technology have changed the treatment of patients with early stage non-small-cell lung cancer who are not healthy enough for standard surgical resection. Previously, patients with severe underlying cardiopulmonary dysfunction were often dissuaded from pursuing definitive therapy, even though most patients died from their lung cancer and not as a result of comorbid medical illness. Recent advances in the technology to treat early stage disease have led to new-found enthusiasm for treating and studying high-risk patients. This Review focuses on the management of these patients, including use of conformal radiotherapy, stereotactic body radiation therapy, sublobar resection, intraoperative brachytherapy, and radiofrequency ablation. Ongoing challenges are presented and prospective data are emphasised.

Purpose: Lung cancer remains the leading cause of cancer death in both men and women. A substantial number of patients with early stage non-small cell lung cancer (NSCLC) are unfit for standard surgery due to cardiopulmonary dysfunction and/or other comorbidity. The appropriate management for this population has not been defined. Methods: Retrospective analysis of patients with clinical stage I NSCLC judged to be unsuitable for lobectomy between 1996 and 2005. Results: Ninety-six patients, representing 23% of all patients treated for clinical stage I NSCLC were included in this analysis. The median age was 73 years and most patients were female. Patients underwent limited resection (LR, n = 45), primary radiotherapy (RT, n = 39) or radiofrequency ablation ( n = 12). With median follow-up of 30 months, 61 patients remain alive. Actuarial 3-year survival is 65% following LR and 60% after primary RT. Local tumor relapse and distant metastases were observed with approximate equal probability following either LR or RT. Conclusion: Medical inoperability does not necessarily correspond to poor survival in patients with early stage NSCLC. A nihilistic approach is not warranted towards this population, and prospective trials are needed to better define optimal treatment strategies.

Previous studies of operating room (OR) information systems data over the past two decades have shown how to predict case durations using the combination of scheduled procedure(s), individual surgeon and assistant(s), and type of anesthetic(s). We hypothesized that the accuracy of case duration prediction could be improved by the use of other electronic medical record data (e.g., patient weight or surgeon notes using standardized vocabularies).General thoracic surgery was used as a model specialty because much of its workload is elective (scheduled) and many of its cases are long. PubMed was searched for thoracic surgery papers reporting operative time, surgical time, etc. The systematic literature review identified 48 papers reporting statistically significant differences in perioperative times.There were multiple reports of differences in OR times based on the procedure(s), perioperative team including primary surgeon, and type of anesthetic, in that sequence of importance. All such detail may not be known when the case is originally scheduled and thus may require an updated duration the day before surgery. Although the use of these categorical data from OR systems can result in few historical data for estimating each case's duration, bias and imprecision of case duration estimates are unlikely to be affected. There was a report of a difference in case duration based on additional information. However, the incidence of the procedure for the diagnosis was so uncommon as to be unlikely to affect OR management.Matching findings of prior studies using OR information system data, multiple case series show that it is important to rely on the precise procedure(s), surgical team, and type of anesthetic when estimating case durations. OR information systems need to incorporate the statistical methods designed for small numbers of prior surgical cases. Future research should focus on the most effective methods to update the prediction of each case's duration as these data become available. The case series did not reveal additional data which could be cost-effectively integrated with OR information systems data to improve the accuracy of predicted durations for general thoracic surgery cases.

INTRODUCTION: Most surgical and anesthesia groups are interested in expanding their practices and recruiting more patients. Methods have been developed to help hospitals identify surgical specialties with the potential for growth by determining whether the hospital is performing fewer of certain types of procedures than expected in a given specialty. However, these methods are not appropriate for physicians who may practice at more than one hospital and want to determine the potential for growth in their regions. METHODS: We examined potential markets for growth of surgical and anesthesia practices in Iowa and New York State using state discharge abstract data. Several patient demographic groups and several surgical specialties were examined. Each state was divided into regions, and data were analyzed three ways: (1) A similarity index compared each region to the rest of the state. (2) The number of procedures performed on patients who left their home regions for care was determined. (3) A similarity index compared procedures performed on patients who left their home regions for care with procedures performed on patients who remained within their home regions. RESULTS: The methods successfully identified several geographic regions with previously unrecognized growth potential. Access to care was limited in these regions. The methods correctly showed few opportunities for growth in geographic regions where expansion was already known to be unlikely. CONCLUSIONS: A count of the number of procedures performed on patients who left their home regions, in combination with the similarity index, is a useful method for screening state discharge abstract data to identify geographic regions where surgical and anesthesia practices could grow.

Inpatient and outpatient data were used to create market segments consisting of hierarchical combinations of surgical procedure, then type of payer, and then location of patients' residences. The competitive effect of one hospital's caseload for a given surgical specialty on the caseload of another hospital was determined from the numbers of patients in each segment. Earlier methods for estimating surgical competition that ignored market segments over-estimated the competitive effects of one hospital on another. Thus, results differed from those obtained previously for all types of hospital admissions. When actual market segments with homogeneous groups of patients are used, competitive effects of hospitals in the same market area are far less than expected.

Recent studies suggest that radiation therapy (RT) dose escalation in early-stage non-small-cell lung cancer (NSCLC) is feasible when 3-dimensional therapy is used. However, the accompanying prolongation of the treatment course when standard fractionation is used could be suboptimal from a practical and biologic standpoint. We report results of a compressed course of RT for patients with pathologically documented clinical stage 1 NSCLC who were unsuitable for curative surgery because of pulmonary dysfunction or other medical comorbidities. Thirty-one lesions were treated with dose-intensive RT (eg, fraction>or=2.25 Gy and nominal total dose>or=60 Gy) and have been followed up for >or=6 months from the completion of treatment. All patients completed therapy without interruption. Three patients developed grade 3 pulmonary toxicity 1-3 months after therapy. The overall tumor response rate was 88% (35% complete response and 53% partial response), whereas in-field tumor progression was documented for 5 of 31 lesions. Actuarial median survival was 38 months and 3-year overall survival was 60%, and most deaths were secondary to intercurrent disease. Moderately accelerated single daily fractionated RT is feasible for high-risk patients with early-stage NSCLC and merits further investigation.

Age is sometimes used as an excuse not to resect lung cancer. Nugent et al [10] noted that, although only 6% of patients younger than 45 years had stage I or II disease, 33% underwent surgical resection. In contrast, of the 33% of elderly patients who had stage I or II disease, only 6% underwent surgical resection. The elderly patients who are carefully selected for lung resection are undoubtedly stronger physiologically than others their same age. Patients with adequate predicted postoperative lung function, no contraindications from other medical problems, good performance status, and social support should be offered standard resection for early-stage NSCLC. Lung cancer resection in elderly patients is justified and has decreasing morbidity and mortality rates. Careful patient selection and operative planning are necessary, however. It is wise to have a diagnosis and staging done before the patient arrives in the operating suite. The surgeon should avoid extended resections when possible. In addition, elderly patients should be ambulated as soon as possible and adequate pain control should be ensured. Finally, the stage of the cancer and occurrence of cardiopulmonary complications are the main determinants of outcome.

In this issue of Shanghai Chest , Kostoulas and Papagiannopoulos discuss “ Mediastinal lymph node dissection in open thoracic surgery ” giving a useful and concise review during thoracotomy approach for non-small cell lung cancer (NSCLC) resection.

A 69-year-old man with presumed solid gastric mass determined by computed tomography, endoscopic ultrasonography, and fine-needle aspiration underwent videoscopic excision of what resulted in a cystic structure consistent with intra-abdominal esophageal duplication cyst. Esophageal duplication cysts are rare congenital lesions that are difficult to diagnose. They seldom occur entirely below the diaphragm, and occurrence in adults is unusual. Only six such cases are reported in the literature. When diagnosis is made, treatment decisions are not always straight forward, although excision is frequently pursued. The current case describes this unique finding and presents laparoscopic excision as a safe treatment alternative.

It is unclear whether thoracoscopic (video-assisted thoracoscopic surgery [VATS]) pneumonectomy improves outcomes compared with open approaches.One hundred seven consecutive pneumonectomies performed at an experienced center from January 2002 to December 2012 were studied retrospectively. Forty cases were open, and 50 successful VATS and 17 conversions were combined (intent-to-treat [ITT] analysis).The VATS cohort had more preoperative comorbidities (three vs two, P = .003), women (57% vs 30%, P = .009), and older ages (65 years vs 63 years, P = .07). Although advanced clinical stage was less for VATS (26% vs 50% stage III, P = .035), final pathologic staging was similar (25% vs 38%, P = .77). Pursuing a VATS approach yielded similar complications (two vs two, median, P = .73) with no catastrophic intraoperative events like bleeding. Successful VATS pneumonectomy rates rose from 50%-82% by the second half of the series (P.001). Completion pneumonectomy cases (13.4% VATS, 7.5% open) had similar outcomes. Having similar initial discomforts as patients undergoing open surgery, more patients undergoing VATS were pain-free at 1 year (53% vs 19%, P = .03). Conversions resulted in longer ICU stays (4 days vs 2 days, P = .01). Advanced clinical stage (III-IV) ITT VATS had longer median overall survival (OS) (42 months vs 13 months, log-rank P = .042). Successful VATS cases with early pathologic stage (0-II) had a median OS of 80 vs 16 months for converted and 28 months for open (log rank = 0.083).Attempting thoracoscopic pneumonectomy at an experienced center appears safe but does not yield the early pain/complication reductions observed for VATS lobectomy. There may be long-term pain/survival advantages for certain stages that warrant further study and refinement of this approach.

Pneumonectomy is commonly performed via thoracotomy, although some centers are performing thoracoscopic pneumonectomy. Longer follow-up is needed to determine whether thoracoscopic pneumonectomy is equivalent or superior to pneumonectomy via thoracotomy. Robotic pneumonectomy has been reported in a handful of patients. However, it may be performed more frequently as more surgeons become proficient with thoracic robotic surgery and appropriate robotic instrumentation is developed.

Negative pressure transients (NPT) recorded in a single closing event of mechanical valves in the mitral position in an in vitro setup are compared with data recorded in the left atrium in vivo with the valves implanted in the mitral position in an animal model. The loading at valve closure (dP/dt_CL) computed from the in vivo ventricular pressure recording (ranging from 700 to 2300 mm Hg/s) agreed with the magnitudes predicted in our earlier in vitro experiments (750-3000 mm Hg/s). The NPT signals and the corresponding power spectral density plots from the in vivo data were in qualitative agreement with those recorded in vitro. The NPT magnitudes were found to be below the vapor pressure for blood in mechanical valves with rigid occluders suggesting a potential for the valve to cavitate in vivo. Our in vivo results also suggest that the valves with flexible occluders are less likely to cavitate. The correlation of the in vitro and in vivo data also suggests that the flexibility of valve housing used in the in vitro studies is not an important factor in the dynamics of mechanical valve closure in vivo. © 1998 Biomedical Engineering Society. PAC98: 8745Hw, 8790+y

One etiology of unilateral lobar pulmonary edema is mitral regurgitation. Echocardiography is able to demonstrate the retrograde flow of blood into the pulmonary veins and allows timely diagnosis and treatment planning. Correction of mitral regurgitation is followed by resolution of the radiographic abnormality.

Background Since the randomized, controlled study that favored lobectomy for resection of stage I non–small cell lung cancers (NSCLCs) by the Lung Cancer Study Group, there have been improvements in staging. The liberal use of computed tomography also may have altered the types of early lung cancer diagnosed. Studies published since then have drawn contradictory conclusions on the benefit of lobectomy over sublobar resections for early-stage NSCLC. We examined the Surveillance Epidemiology End Results database to test our hypothesis that the relationship between extent of resection and outcome has changed since the Lung Cancer Study Group study was published. Methods We examined stage I NSCLCs ≤2 cm in size over three periods: 1988–1998 (Early), 1999–2004 (Intermediate), and 2005–2008 (Late). For each period, we assessed overall and disease-specific survivals and their associations with the extents of resection, by univariate and multivariate analyses. Sublobar resections in the Early group could not be categorized into segmentectomies and wedge resections because these were not coded separately. Results The proportion of NSCLCs ≤2 cm increased from 0.98% in 1988 to 2.2% in 2008. Multivariate analyses showed that sublobar resection was inferior to lobectomy in the Early period (hazard ratio [HR], 1.41; 95% confidence interval [CI], 1.21–1.65). This effect decreased in the Intermediate period, in which segmentectomies but not wedge resections were equivalent to lobectomies (wedge versus lobectomy HR, 1.19; 95% CI, 1.01–1.41; segmentectomy versus lobectomy HR, 1.04; 95% CI, 0.8–1.36). The difference disappeared in the Late period, when both wedge resections and segmentectomies were equivalent to lobectomy (wedge versus lobectomy HR, 1.09; 95% CI, 0.79–1.5; segmentectomy versus lobectomy HR, 0.83; 95% CI, 0.47–1.45). Trends for both overall survival and disease-specific survival were identical. Conclusions The survival benefit of lobectomy over sublobar resection decreased over the past 2 decades with no discernible difference in the most contemporary cases. These results support reevaluation of lobectomy as the standard of care for small (≤2-cm) NSCLCs.