David T. Cooke

Survival Comparison of Adenosquamous, Squamous Cell, and Adenocarcinoma of the Lung After Lobectomy

BACKGROUND Primary adenosquamous carcinoma (ASC) of the lung is a rare tumor that may carry a poor prognosis. We examined a national database to see if ASC exhibited distinct clinical behavior from squamous cell (SC) and adenocarcinoma (AC) of the lung. METHODS This is a retrospective study querying the Surveillance, Epidemiology, and End Results database to identify 872 surgical patients diagnosed with ASC, 7888 with SC, and 12,601 with AC of the lung from 1998 to 2002. Analysis characterized clinical variables to determine patterns of presentation and compared survival among the above three histologic groups after lobectomy for stage I and II disease. RESULTS ASC represented 4.1% of the 21,361 patients examined. ASC tended toward right side (56.9%) laterality and upper lobe (60.0%) location. Compared with AC, patients with ASC and SC were more likely to be male (p < 0.0001), and ASC patients had worse histologic grade (p< 0.0001). Survival after lobectomy for stage I and II disease was significantly reduced in ASC and SC compared with AC (p < 0.0001). ASC had a significantly increased hazard ratio of 1.35 and 1.27 relative to AC and SC, respectively. Other significant negative predictors of survival included tumor grade of III and IV, stage II, age, and black ethnicity. CONCLUSIONS This large review demonstrates that ASC is an uncommon tumor with distinct clinical behavior and worse prognosis than AC and SC. Further insight into the molecular profile of ASC is needed to determine the cause of its biologic aggressiveness.

The Society of Thoracic Surgeons Expert Consensus Statement: A Tool Kit to Assist Thoracic Surgeons Seeking Privileging to Use New Technology and Perform Advanced Procedures in General Thoracic Surgery

Division of General Thoracic Surgery, Mayo Clinic, Rochester, Minnesota; Section of General Thoracic Surgery, University of California, Davis Medical Center, Sacramento, California; Division of Thoracic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Division of Thoracic Surgery, WellStar Health System, Marietta, Georgia; Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama; Division of Cardiothoracic Surgery, University of Washington, Seattle, Washington; National Cancer Institute, Pascale Foundation, Naples, Italy; Division of Thoracic Surgery, Memorial Hospital-University of Colorado Health, Colorado Springs, Colorado; Department of Surgery, Southern Illinois University, Springfield, Illinois; Division of Thoracic Surgery, NorthShore University Health System, Evanston, Illinois; Esophageal Center of Excellence, Virginia Mason Medical Center, Seattle, Washington; Division of Thoracic Surgery, Brigham and Women’s Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts; Department of Cardiothoracic Surgery, Stanford University, Stanford, California; Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina; Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts; and Division of Thoracic Surgery, University of Calgary, Foothills Medical Centre, Calgary, Alberta, Canada

Who Performs Complex Noncardiac Thoracic Surgery in United States Academic Medical Centers

BACKGROUND We hypothesized that general thoracic surgeons (GTS) predominantly perform complex noncardiac thoracic surgery in academic hospitals compared with cardiac surgeons (CS), general surgeons, and surgical oncologists. METHODS Fiscal year 2007-2008 to 2009-2010 coding and work relative value unit data from the University Health System Consortium and Association of American Medical Colleges Faculty Practice Solutions Center database, which includes 86 academic institutions, was analyzed. Procedural groups for pneumonectomy, other pulmonary resection (including lobectomy, bilobectomy, segmentectomy, sleeve lobectomy, and video-assisted thoracoscopic surgery lobectomy-segmentectomy), and esophagectomy were evaluated. RESULTS Of the 1,989,055.3 total work relative value units generated for complex noncardiac thoracic surgical procedures during the study period, 77.5% were generated by GTS, compared with 9.9% by CS, 8.9% by general surgeons, and 3.7% by surgical oncologists (p<0.001). General thoracic surgeons averaged 2.1 pneumonectomies, 51.1 other pulmonary resections, and 12.2 esophagectomies per year compared with 2.1 pneumonectomies, 9.4 other pulmonary resections, and less than 1 esophagectomy per year for CS. General surgeons and surgical oncologists averaged no more than 1.6 cases per year for all categories (all p<0.001, except for pneumonectomy, in which GTS versus CS was not significantly different). To determine the use of parenchymal-sparing operations, we looked at the ratio of sleeve lobectomy to pneumonectomy and found higher usage of parenchymal-sparing techniques by GTS, relative to pneumonectomy, compared with all other groups (p<0.001). General thoracic surgeons averaged 16.0 video-assisted thoracoscopic surgery lobectomies per year compared with approximately 1 per year for all other groups (p<0.001). General thoracic surgeons had a 47.1% increase in video-assisted thoracoscopic surgery lobectomies per year compared with 27.4% for CS. CONCLUSIONS In academic hospitals, noncardiac thoracic surgery is performed mostly by GTS, supporting academic GTS as a distinct specialty. These results may help determine hospital referral and credentialing policies, and plan general and cardiothoracic surgery residency curriculum.

Investigation of metabolomic blood biomarkers for detection of adenocarcinoma lung cancer

Background: Untargeted metabolomics was used in case–control studies of adenocarcinoma (ADC) lung cancer to develop and test metabolite classifiers in serum and plasma as potential biomarkers for diagnosing lung cancer. Methods: Serum and plasma were collected and used in two independent case–control studies (ADC1 and ADC2). Controls were frequency matched for gender, age, and smoking history. There were 52 adenocarcinoma cases and 31 controls in ADC1 and 43 adenocarcinoma cases and 43 controls in ADC2. Metabolomics was conducted using gas chromatography time-of-flight mass spectrometry. Differential analysis was performed on ADC1 and the top candidates (FDR < 0.05) for serum and plasma used to develop individual and multiplex classifiers that were then tested on an independent set of serum and plasma samples (ADC2). Results: Aspartate provided the best accuracy (81.4%) for an individual metabolite classifier in serum, whereas pyrophosphate had the best accuracy (77.9%) in plasma when independently tested. Multiplex classifiers of either 2 or 4 serum metabolites had an accuracy of 72.7% when independently tested. For plasma, a multimetabolite classifier consisting of 8 metabolites gave an accuracy of 77.3% when independently tested. Comparison of overall diagnostic performance between the two blood matrices yielded similar performances. However, serum is most ideal given higher sensitivity for low-abundant metabolites. Conclusion: This study shows the potential of metabolite-based diagnostic tests for detection of lung adenocarcinoma. Further validation in a larger pool of samples is warranted. Impact: These biomarkers could improve early detection and diagnosis of lung cancer. Cancer Epidemiol Biomarkers Prev; 24(11); 1716–23. ©2015 AACR.

Large-Bore and Small-Bore Chest Tubes: Types, Function, and Placement

Chest tubes are placed in the pleural space, either surgically or percutaneously to evacuate abnormal fluid and air. Indications for chest tubes include therapeutic drainage of pleural conditions such as pneumothorax, hemothorax, empyema, chylothorax, and malignant effusions, as well as prophylaxis drainage of air, blood, and other fluids after chest surgery. This article characterizes the types of chest tubes, reviews the basic techniques for insertion, and describes the comparative effectiveness between large-bore and small-bore chest tubes.

Update on Cardiothoracic Surgery Resident Job Opportunities

BACKGROUND Concerns regarding ample employment opportunities for graduating cardiothoracic surgery residents may affect perceptions of the field and recruitment into residency programs. We present the results of the Thoracic Surgery Residents Association/Thoracic Surgery Directors Association (TSRA/TSDA) 2008 Resident Survey, and compare them with the 2007 TSRA/TSDA survey and the 2006 interim report of the Society of Thoracic Surgeons Task Force on Job Opportunities. METHODS In April 2008, the TSRA/TSDA conducted an anonymous survey, linked to the cardiothoracic surgery resident online In-training Exam, with questions germane to resident job seeking and perceptions of the specialty. Results were compared with resident surveys from 2007 and 2006. RESULTS Response rates for the 2008 and 2007 surveys were 100%, and 54.2% for 2006. Of graduating residents looking for employment, 61.6% had one or more job offers, compared with 64.6% and 83.5% from the 2007 and 2006 surveys, respectively. Of the respondents completing their job search, 24.5% entered private practice and 26.3% academia, compared with 12.1% and 30.1%, respectively, in the 2007 survey. Overall, 57.7% of all respondents had more than

Surgery in high-volume hospitals not commission on cancer accreditation leads to increased cancer-specific survival for early-stage lung cancer.

50,000 education-related debt, compared with 54.2% of 2007 respondents. However, 71.5% of all 2008 respondents would recommend cardiothoracic surgery to a potential trainee, compared with 63.7% and 46.0% from 2007 and 2006 survey respondents, respectively. CONCLUSIONS The 2008 survey suggests that although the majority of respondents found employment on completing residency, the percentage is less than 65%, reinforcing a need for formal networking programs or changes in residency training. Despite continued limited employment opportunities, resident impressions of cardiothoracic surgery have improved from 2006 to 2008.

Quality Indicators for the Evaluation of Patients With Lung Cancer

BACKGROUND Quality of oncologic outcomes is of paramount importance in the care of patients with non-small cell lung cancer (NSCLC). We sought to evaluate the relationship of hospital volume for lobectomy on cancer-specific survival in NSCLC patients treated in California, as well as the influence of Commission on Cancer (CoC) accreditation. METHODS The California Cancer Registry was queried from 2004 to 2011 for cases of Stage I NSCLC and 8,345 patients were identified. Statistical analysis was used to determine prognostic factors for cancer-specific survival. RESULTS A total of 7,587 patients were treated surgically. CoC accreditation was not significant for cancer-specific survival, but treatment in high-volume centers was associated with longer survival when compared with low- and medium-volume centers (hazard ratio 1.77, 1.474 to 2.141 and hazard ratio 1.23, 1.058 to 1.438). CONCLUSION These data suggest that surgical treatment in high-volume hospitals is associated with longer cancer-specific survival for early-stage NSCLC, but that CoC accreditation is not.

Increasing Rates of No Treatment in Advanced-Stage Non-Small Cell Lung Cancer Patients: A Propensity-Matched Analysis.

BACKGROUND Ideally, quality indicators are developed with the input of professional groups involved in the care of patients. This project, led by the Thoracic Oncology Network and Quality Improvement Committee of the American College of Chest Physicians (CHEST), had the goal of developing quality indicators related to the evaluation and staging of patients with lung cancer. METHODS Evidence-based guidelines were used to generate a list of process-of-care quality indicators, and project members revised the content and wording of this list. A survey of the Steering Committee of the Thoracic Oncology Network was performed to rate the validity, feasibility, and relevance of the indicators. Predefined thresholds were used to select indicators from the list. This process was repeated for the selected indicators through a survey available to all members of the Thoracic Oncology Network. Three academic medical centers determined if the surviving indicators were feasible and relevant within their practices. RESULTS Eighteen quality indicators were drafted. Eleven survived the first round of voting, and seven survived the second round of voting. One was related to tissue acquisition for molecular testing, four were related to staging and stage documentation, one was related to smoking cessation counseling, and one was related to documentation of a performance status measure. The indicators were feasible and relevant within the practices assessed. CONCLUSIONS We have defined seven process-of-care quality indicators related to the evaluation and staging of patients with lung cancer, which are felt to be valid, feasible, and relevant by lung cancer specialists.

Rise in microsurgical free-flap breast reconstruction in academic medical practices.

Introduction: Variation in treatment and survival outcomes for NSCLC is high among patients with stage III or IV disease, but patients with untreated NSCLC have not been critically analyzed to evaluate for improvable outcomes. We evaluated treatment trends and their association with oncologic outcomes for NSCLC, hypothesizing that there are a substantial number of untreated patients who are similar to patients who undergo treatment. Methods: Linear regression was used to calculate trends in utilization of treatment. Kaplan‐Meier and Cox regression modeling were used to determine predictors of receiving treatment. Propensity matching was used to compare survival among subsets of treated versus untreated patients. Results: Patients with primary NSCLC were identified from the National Cancer Data base from 1998 to 2012, and 21% of patients (190,539) received no treatment. For stage IIIA and IV, the proportion of untreated patients increased over the study period by 0.21% and 0.4%, respectively (p = 0.003 and p < 0.0001). Regardless of stage, untreated patients had significantly shorter overall survival (OS) (p < 0.0001). Propensity‐matched analyses of 6144 stage IIIA patient pairs treated with chemoradiation versus no treatment confirmed shorter OS for untreated patients (median 16.5 versus 6.1 months, p < 0.0001). For 19,046 stage IV patient pairs treated with chemotherapy versus no treatment, similar results were obtained (median OS 9.3 versus 2.0 months, p < 0.0001). Conclusions: The proportion of untreated patients with stage IIIA and IV disease is increasing. Survival outcomes among patients with advanced‐stage disease are superior with treatment, independent of selection bias. The benefits and risks of treatment should be carefully assessed before choosing to forego treatment.