Donna E. Maziak

The Management of Thymoma: A Systematic Review and Practice Guideline

Introduction: Thymoma is a rare tumor for which there is little randomized evidence to guide treatment. Because of the lack of high-quality evidence, a formal consensus-based approach was used to develop recommendations on treatment. Methods: A systematic refview of the literature was performed. Recommendations were formed from available evidence and developed through a two-round modified Delphi consensus approach. Results: The treatment recommendations are summarized as follows: Stage I—complete resection of the entire thymus without neoadjuvant or adjuvant therapy. Stage II—complete resection of the entire thymus with consideration of adjuvant radiation for high-risk tumors. Stage IIIA—surgery either initially or after neoadjuvant therapy, or surgery followed by adjuvant therapy. Stage IIIB—treatment may include a combination of chemotherapy, radiation, and/or surgery, or if technically possible, surgery in combination with chemoradiotherapy (concurrent cisplatin based). For bulky tumors, consideration should be given to sequential chemotherapy followed by radiation. Stage IVA—as per stage III, with surgery only if metastases can be resected. Stage IVB—treatment on an individual case basis (no generic recommendations). Recurrent disease—consider surgery, radiation, and/or chemoradiation. Chemoradiation should be considered in all medically inoperable and technically inoperable patients. Conclusion: Consensus was achieved on these recommendations, which serve to provide practical guidance to the physician treating this rare disease.

Circulation of the spinal cord: An important consideration for thoracic surgeons

The spinal cord has significant thoracic arterial watershed areas rendering it vulnerable to intraoperative ischemic damage, clearly mandating a need for postoperative neurologic monitoring. Mechanisms of hypoperfusion include aortic cross-clamping, rib retraction, intercostal artery interruption, and costovertebral junction bleeding. We report cases of primary lung cancer resection, resection of pulmonary metastasis adherent to the thoracic aorta, resection of cartilaginous tumor with chest wall invasion, and esophagomyotomy for achalasia-all complicated by postoperative paraplegia. We review spinal cord circulation, describe mechanisms and patterns of neurologic dysfunction of susceptible watershed areas, and outline roles of preoperative spinal angiography and intraoperative evoked potentials.

Surgical staple metalloptysis after apical bullectomy: a reaction to bovine pericardium?

Palliation of symptomatic emphysema may include bullous resection to improve function of the remaining lung. Buttressing staple lines with bovine pericardium partially alleviates postoperative air leak, but can promote inflammation and infection. We report a patient expectorating staples and pericardium 5 years after bilateral apical bullectomy. Previous reporting of this complication in lung volume reduction operation also involved both pericardium and staples, and we propose that an ongoing local inflammatory reaction to these materials may facilitate delayed erosion into airways.

Incidence, severity and perioperative risk factors for atrial fibrillation following pulmonary resection

OBJECTIVESnPostoperative atrial fibrillation (PAF) occurs commonly following pulmonary resection. Our aims were to quantify the incidence and severity of PAF using the Thoracic Morbidity & Mortality classification system, and identify risk factors for PAF.nnnMETHODSnAll consecutive patients undergoing pulmonary resection at a single centre (January 2008 - April 2010) were enrolled. PAF was defined as postoperative, electrocardiographically documented and requiring initiation of pharmacological therapy. Univariate and multivariate analyses of risk factors associated with the development of PAF were conducted.nnnRESULTSnThe incidence of PAF was 11.8% (n = 43) of 363 pulmonary resections (open: n = 173; 47.7%; video-assisted: n = 177; 48.8%; converted: n = 13; 3.6%): sublobar (n = 93; 25.6%), lobectomy (n = 237; 65.3%), bilobectomy (n = 7; 1.9%) and pneumonectomy (n = 24; 6.6%). Twenty-eight cases (65.1%) were uncomplicated/transient, and 15 cases (34.9%) were complicated/persistent PAF, defined as lasting for >7 days (40.0%), requiring cardioversion (13.3%), vasopressors (33.3%), in-hospital use of anticoagulants (46.7%) and/or anticoagulants on discharge (26.7%). Patients with PAF had increased mean lengths of hospital stay (10.5 days vs 6.9 days; P = 0.04). Peak onset of PAF occurred 2.5 (standard deviation (SD) ± 1.3) days after pulmonary resection, lasting for 1.8 ± 2.8 (mean, ±SD) days. Multivariate analysis identified (relative risk; 95% confidence interval): age ≥70 years (2.3; 1.1-5.1), history of angioplasty/stents/angina (4.0; 1.4-11.3), thoracotomy (3.6; 1.4-9.3), conversion to open thoracotomy (16.5; 2.2-124.0) and extent of surgery/stage (7.1; 1.0-49.4) as predictors of PAF.nnnCONCLUSIONSnWhile the majority of PAF is uncomplicated and transient, one-third of cases lead to persistence or major intervention. Age, coronary artery disease and extent of surgery/stage increase the risk of PAF following pulmonary resection. Identifying patients with elevated risk may lead to targeted prophylaxis to reduce the incidence of PAF.

Risk of Pneumonectomy After Induction Therapy for Locally Advanced Non-Small Cell Lung Cancer

BACKGROUNDnRecent data from prospective multimodality trials have documented an unacceptable early mortality with pneumonectomy after induction chemotherapy. This finding has raised skepticism toward pneumonectomy as a surgical option for patients with regionally advanced nonsmall-cell lung cancer. In the current study, perioperative outcomes after pneumonectomy with or without neoadjuvant therapy are compared to determine the impact of induction therapy on perioperative mortality in this setting. Variables associated with increased perioperative risk are identified.nnnMETHODSnA review of 315 nonsmall-cell lung cancer patients (196 male [62%]) undergoing pneumonectomy over a 15-year period was undertaken. Patients were well matched for clinical variables other than receiving induction chemotherapy. Complications and operative mortality were analyzed for associations with laterality and induction chemotherapy.nnnRESULTSnMedian age was 64 years, (range, 25 to 82). Age was predictive of mortality in 13 of 86 patients (15%) more than 70 years old, compared with 16 of 229 patients (7%) less than 70 years old (hazard ratio = 1.77, p = 0.046). Overall operative mortality was 9.2% (29 of 315). There were 115 left-sided (37%) and 200 right-sided (63%) pneumonectomies. Sixty-eight patients (22% [left = 31, right = 37]) received induction chemotherapy. Surgery alone was performed in 247 patients. Mortality among patients undergoing induction chemotherapy was 21% (odds ratio = 4.01; p = 0.0007). After induction chemotherapy, postoperative bronchopleural fistula associated with respiratory failure was predictive of operative mortality (hazard ratio = 148, p = 0.0001). Left-side pneumonectomy did appear to a have a greater incidence of postoperative arrhythmia.nnnCONCLUSIONSnMorbidity and mortality after pneumonectomy is substantial. Patients greater than 70 years old appear to be at increased risk. Induction chemotherapy also increases the risk of operative mortality after pneumonectomy. Patients should be advised of this increased operative risk, and the multidisciplinary team must consider this when pneumonectomy appears necessary after induction therapy for locally advanced nonsmall-cell lung cancer.

Measuring Surgical Quality: Comparison of Postoperative Adverse Events with the American College of Surgeons NSQIP and the Thoracic Morbidity and Mortality Classification System

BACKGROUNDnMonitoring surgical outcomes is critical to quality improvement; however, different data-collection methodologies can provide divergent evaluations of surgical outcomes. We compared postoperative adverse event reporting on the same patients using 2 classification systems: the retrospectively recorded American College of Surgeons (ACS) NSQIP and the prospectively collected Thoracic Morbidity and Mortality (TM&M) system.nnnSTUDY DESIGNnUsing the TM&M system, complications and deaths were documented daily by fellows and reviewed weekly by staff for all thoracic surgical cases conducted at our institution (April 1, 2010 to December 31, 2011). The ACS NSQIP recording was performed 30 to 120 days after index surgery by trained surgical clinical reviewers on a systemic sampling of major cases during the same time period. Univariate analyses of the data were performed.nnnRESULTSnDuring the study period, 1,788 thoracic procedures were performed (1,091 were designated major, as per ACS NSQIP inclusion criteria). The ACS NSQIP evaluated 182 of these procedures, representing 21.1% and 16.7% of patients and procedures, respectively. Mortality rates were 1.4% in TM&M vs 2.2% in ACS NSQIP (p = 0.42). Total patients and procedures with complications reported were 24.4% and 31.1% by TM&M vs 20.2% and 39.0% by ACS NSQIP (p = 0.23 and 0.03), respectively. Rates of reported cardiac complications were higher in TM&M vs ACS NSQIP (5.8% vs 1.1%; p = 0.01), and wound complications were lower (2.5% vs 6.0%; p = 0.01).nnnCONCLUSIONSnAlthough overall rates were similar, significant differences in collection, definitions, and classification of postoperative adverse events were observed when comparing TM&M and ACS NSQIP. Although both systems offer complementary value, harmonization of definitions and severity classification would enhance quality-improvement programs.

Pre- and postresection thoracic washings in non-small cell carcinoma of the lung: A cytological study of 44 patients without pleural effusion

The presence of malignant pleural effusion in patients with non‐small cell bronchogenic cancer has a poor prognostic significance and is indicative of advanced disease (T4, IIIB). The present study will investigate the role of cytology and identify the various cellular components seen in thoracic washings, in the absence of an effusion, and will identify the potential pitfalls in diagnosing these specimens. The sensitivity, specificity, and positive and negative predictive values will be determined, as well as the associated predictive factors. From November 1996 to July 1997, 96 thoracic washings were performed on 44 patients with non‐small cell carcinoma of the lung prior to and following resection. The specimens were processed routinely. To assess the false‐negative or false‐positive cases, all cases were rescreened and then correlated with the surgical pathology. Seven (15.9%) patients had positive findings detected on the pre‐ and/or postresection thoracic washings. One (2.3%) patient had a negative preresection, but cytologically atypical cells were found on the postresection. Thirty‐six (81.8%) patients had negative pre‐ and postresection thoracic washings. There were no false‐positive diagnoses in the study; however, two false‐negative diagnoses were made. The finding of positive cytology in 7 of 44 (15.9%) patients appears significant. Thoracic washings may provide evidence of cancer beyond the pleura in patients without pleural effusion which may be indicative of advanced disease. Diagn. Cytopathol. 2000; 22:218–222.

Impact of Adverse Events and Length of Stay on Patient Experience After Lung Cancer Resection

BACKGROUNDnPostoperative adverse events (AEs), prolonged length of stay (PLOS), and patient experience are common quality measures after thoracic surgical procedures. Our objective was to investigate the relationship of postoperative AEs on patient experience and hospital length of stay (LOS) after lung cancer resection.nnnMETHODSnAEs (using Thoracic Morbidity and Mortality system based on Clavien-Dindo schema) and LOS were prospectively collected for all patients undergoing lung cancer resection. A 21-item questionnaire, retrospectively asking about patient experience, was mailed to patients twice (October 2015 and January 2016). The impact of AEs on experience was investigated and stratified by hospital LOS, with PLOS defined as the 75th percentile. Univariate analysis used parametric (t test) and nonparametric (Mann-Whitney) tests according to test conditions.nnnRESULTSnOf 288 patients who responded to the survey (70% response rate), 175 (61%) had no AEs, 113 (39%) hadxa0experienced at least one AE, and 52 (18%) had experienced PLOS. Lung cancer patients who experienced PLOS showed significantly decreased experience on several questionnaire items, including their impression of comprehensiveness of surgeons information provision during inpatient period (pxa0= 0.008), inpatient recovery from operation (pxa0= 0.001), quality of life 30 days after operation (pxa0= 0.032), follow-up care, (pxa0= 0.022), and satisfaction with outcome 1 year after operation during follow-up care (pxa0= 0.022). The presence of postoperative AEs led only to reduced impression about inpatient recovery from the operation (pxa0= 0.01).nnnCONCLUSIONSnIn this cohort, postoperative AEs were minimally associated with negative patient experience. However, patients who experienced PLOS demonstrated a marked reduction in experience after thoracic surgical procedures.