Elizabeth A. David

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.

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

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.

Risk of Pneumonitis After Stereotactic Body Radiation Therapy in Patients With Previous Anatomic Lung Resection.

BACKGROUND Stereotactic body radiation therapy (SBRT) has emerged as a standard treatment of early-stage, medically inoperable lung cancer. Limited data have evaluated the radiation pneumonitis (RP) risk with SBRT after previous anatomic lung resection (ALR). We assessed the incidence of RP and all pulmonary toxicity (PT) in patients who underwent lung SBRT after ALR and compared them with those of patients without previous ALR. MATERIALS AND METHODS We reviewed the medical records of 84 consecutively treated patients with stage T1-T2b non-small-cell lung cancer (NSCLC) treated with 88 courses of SBRT for 94 lung tumors from January 2007 to December 2014, including 17 patients with previous ALR. The rates of RP and all PT were compared between the patients with and without previous ALR. RESULTS At a median follow-up duration of 18.3 months (range, 1.8-85.6 months), the crude grade 2+ RP rate was 5.9% and 2.8% for patients with and without previous ALR, respectively (P = .51). The corresponding 2-year estimates of freedom from RP were 89% and 97% (P = .51). The crude rate of all grade 2+ PT was 11.8% and 2.8% for those with and without previous ALR (P = .11), with 2-year estimates of freedom from PT of 97% and 84% (P = .11), respectively. The 2 cohorts were well matched by the mean lung dose, percentage of lung volume receiving 20 Gy (P = .86), and prescribed dose (P = .75). The 2-year estimates of local control, cause-specific survival, and overall survival were similar between the 2 cohorts. CONCLUSION The observed rates of PT were low among all patients, with a trend toward increased grade 2 and 3 lung toxicity among patients with previous ALR. Previous ALR did not increase the risk of grade 4 and 5 RP, and SBRT appears safe and effective in this population.

The Role of Thoracic Surgery in the Therapeutic Management of Metastatic Non–Small Cell Lung Cancer

Introduction: In most patients with NSCLC, the disease is diagnosed in an advanced stage, the prognosis is poor, and survival is typically measured in months. Standard therapeutic treatment regimens for patients with stage IV NSCLC typically include chemotherapy and palliative radiation. Despite newer regimens that may include molecularly targeted therapy and immunotherapy, the overall 5‐year survival for stage IV disease remains low at 4% to 6%. Although therapeutic surgery is performed in a minority of cases, accumulating data suggest that thoracic surgery may play several beneficial roles for these patients. Methods: In this narrative review, we summarize the literature on surgical intervention in the multimodality management of stage IV NSCLC, focusing on the potential evidence for and against therapeutic or curative intent procedures to affect outcomes for patients with oligometastatic disease and pleural metastasis. Results: In selected patients, surgical resection can result in a 5‐year survival rate of 30% to 50%, but this is heavily influenced by the presence of mediastinal nodal disease, which should be evaluated before therapeutic surgical procedures are undertaken. Additionally, diagnostic or palliative surgical procedures can play an important role in the personalized management of stage IV disease. These data suggest that for carefully selected patients with advanced stage NSCLC, surgical intervention can be an important component of combined modality treatment. Conclusions: Given the advances in molecular targeted therapy and immunotherapy, further studies should focus on the possible use of surgery as a strategy of therapeutic “consolidation” for appropriately selected patients with stage IV NSCLC who are receiving combined modality care.

Reviewing Scientific Manuscripts: A Comprehensive Guide for Peer Reviewers

86 The abstract provides the authors with an opportun ity to summarize the objectives, methods, 87 results and conclusions for the journal readers. It i oftentimes the first, and perhaps only, section 88 of the manuscript that will be read as it is typica lly freely available through reference databases. 89 The abstract should provide a clear statement of th e study objectives, which must match what is 90 stated in the introduction and other summary statem ents regarding the study. This is oftentimes 91 not the case and the astute reviewer will identify the discrepancy for the authors to correct. While 92 brief in length, the abstract methods must define t he study group, stratification variables if any, 93 and provide a general overview of the analysis plan . The results should provide data that directly 94 address the stated objectives and support the abstr act conclusions. Conclusions which are not 95 directly supported by the data provided in the abst r ct results should not be included in the 96 abstract; these conclusions belong in the manuscrip t discussion or the appropriate data added to 97 the abstract results. It is often the case that the abstract is excessively wordy without added 98 M AN US CR IP T AC CE PT ED ACCEPTED MANUSCRIPT meaning. Authors often reply to reviewers that the word count restricts the information that can 99 be provided, but this can typically be addressed th rough language simplification and removal of 100 extraneous words. If this is the case, the reviewer will advise the authors to revise accordingly. 101

Reviewing scientific manuscripts: A comprehensive guide for peer reviewers

The abstract provides the authors with an opportunity to summarize the objectives, methods, results, and conclusions for the journal readers. It is oftentimes the first, and perhaps only, section of the manuscript that will be read, as it is typically freely available through reference databases. The abstract should provide a clear statement of the study objectives, which must match what is stated in the introduction and other summary statements regarding the study. This is oftentimes not the case, and the astute reviewer will identify the discrepancy for the authors to correct. Although brief in length, the abstract methods must define the study group, stratification variables if any, and provide a general overview of the analysis plan. The results should provide data that directly address the stated 1610 The Journal of Thoracic and Cardiovascular Sur objectives and support the abstract conclusions. Conclusions that are not directly supported by the data provided in the abstract results should not be included in the abstract; these conclusions belong in the manuscript discussion or the appropriate data added to the abstract results. It is often the case that the abstract is excessively wordy without added meaning. Authors often reply to reviewers that the word count restricts the information that can be provided, but this typically can be addressed through language simplification and removal of extraneous words. If this is the case, the reviewer will advise the authors to revise accordingly. INTRODUCTION The introduction succinctly defines the scope of the problem and justification for further investigation. It should be

The Society of Thoracic Surgeons General Thoracic Surgery Database: 2017 Update on Research

The outcomes research efforts based on The Society of Thoracic Surgeons (STS) General Thoracic Surgery Database include two established research programs with dedicated task forces and with data analyses conducted at the STS data analytic center: (1) The STS-sponsored research by the Access and Publications program, and (2) grant and institutionally funded research by the Longitudinal Follow-Up and Linked Registries Task Force. Also, the STS recently introduced the research program enabling investigative teams to apply for access to deidentified patient-level General Thoracic Surgery Database data sets and conduct related analyses at their own institution. Last years General Thoracic Surgery Database-based research publications and the new Participant User File research program are reviewed.

Lung resection is safe and feasible among stage IV cancer patients: An American College of Surgeons National Surgical Quality Improvement Program analysis

Background. Operative resection can be associated with improved survival for selected patients with stage IV malignancies but may also be associated with prohibitive acute morbidity and mortality. We sought to evaluate rates of acute morbidity and mortality after lung resection in patients with disseminated malignancy with primary lung cancer and non–lung cancer pulmonary metastatic disease. Methods. For 2011–2012, 6,360 patients were identified from the American College of Surgeons National Surgical Quality Improvement Program undergoing lung resections, including 603 patients with disseminated malignancy. Logistic regression analyses were used to compare outcomes between patients with and without disseminated malignancy. Results. After controlling for preoperative and intraoperative differences, we observed no statistically significant differences in rates of 30‐day overall and serious morbidity or mortality between disseminated malignancy and non–disseminated malignancy patients (P > .05). Disseminated malignancy patients were less likely to have a prolonged duration of stay and be discharged to a facility compared to non–disseminated malignancy patients (P < .05). Subgroup analyses by procedure type and diagnosis showed similar results. Conclusion. Disseminated malignancy patients undergoing lung resections experienced low rates of overall morbidity, serious morbidity, and mortality comparable to non–disseminated malignancy patients. These data suggest that lung resections may be performed safely on carefully selected, disseminated malignancy patients with both primary lung cancer and pulmonary metastatic disease, with important implications for multimodality care.

Special considerations of military cardiothoracic surgeons

From the Department of Surgery–Cardiothoracic, San AntonioMilitary Medical Center, Joint Base; Department of Surgery–Cardiothoracic, Audie L. Murphy Veterans Affairs Medical Center, San Antonio, Tex; Heart Lung Vascular Center, David Grant Medical Center, Travis Air Force Base; Section of General Thoracic Surgery, University of California, Davis, Medical Center, Sacramento, Calif; and Department of Surgery–Cardiothoracic, Walter Reed National Military Medical Center, Bethesda, Md. This editorial is an independent expression of the authors and does not represent the view of the US Government, the US Army, the US Air Force, or the US Navy. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication Oct 15, 2015; revisions received March 22, 2016; accepted for publication April 28, 2016; available ahead of print June 14, 2016. Address for reprints: LTC Bryan S. Helsel, MD, Department of Surgery–Cardiothoracic, San Antonio Military Medical Center, 3551 Roger Brooke Dr, San Antonio, TX 78234 (E-mail: deltaguns@aol.com). J Thorac Cardiovasc Surg 2016;152:664-6 0022-5223/