Frank O. Velez-Cubian

Tumor-to-tumor metastasis: an unusual case of breast cancer metastatic to a solitary fibrous tumor

Solitary fibrous tumor (SFT) is a rare mesenchymal neoplasm that most commonly involves the visceral or parietal pleura, but that has also been described arising from virtually all organs. This neoplasm exhibits rich vascularity, a characteristic it shares with renal cell carcinoma, making these tumors especially suitable for harboring metastases. We present a case of a 64-year-old woman with history of right breast cancer treated six years previously and who presents with a left pulmonary SFT containing metastatic invasive ductal breast carcinoma as well as a synchronous contralateral primary adenocarcinoma of the lung. The literature on tumor-to-tumor metastasis is then reviewed.

Effect of small body habitus on peri-operative outcomes after robotic-assisted pulmonary lobectomy: retrospective analysis of 208 consecutive cases

BACKGROUND Patients with smaller body surface area (BSA) have smaller pleural cavities, which limit visualization and instrument mobility during video-assisted thoracoscopic surgery (VATS). We investigated the effects of BSA on outcomes with robotic-assisted VATS lobectomy. METHODS We analyzed 208 consecutive patients who underwent robotic-assisted lobectomy over 34 months. Patients were separated into group A (BSA ≤1.65 m(2)) and group B (BSA >1.65 m(2)). Operative times, estimated blood loss (EBL), conversions to thoracotomy, complications, hospital length of stay (LOS), and in-hospital mortality were compared. RESULTS Group A had 40 patients (BSA 1.25-1.65 m(2)), and group B had 168 patients (BSA 1.66-2.86 m(2)). Median skin-to-skin operative times [± standard error of the mean (SEM)] were 169±16 min for group A and 176±6 min for group B (P=0.34). Group A had median EBL of 150±96 mL compared to 200±24 mL for group B (P=0.37). Overall conversion rate to thoracotomy was 8/40 (20.0%) in group A versus 12/168 (7.1%) in group B (P=0.03); while emergent conversion for bleeding was 2/40 (5.0%) in group A versus 5/168 (3.0%) in group B (P=0.62). Postoperative complications occurred in 12/40 (30.0%) in group A, compared to 66/168 (39.3%) in group B (P=0.28). Patients from both groups had median hospital LOS of 5 days (P=0.68) and had similar in-hospital mortality. CONCLUSIONS Patients with BSA ≤1.65 m(2) have similar perioperative outcomes and complication risks as patients with larger BSA. Patients with BSA ≤1.65 m(2) have a higher overall conversion rate to thoracotomy, but similar conversion rate for bleeding as patients with larger BSA. Robotic-assisted pulmonary lobectomy is feasible and safe in patients with small body habitus.

Effect of gender on perioperative outcomes after robotic-assisted pulmonary lobectomy

BACKGROUND Female gender has been associated with worse outcomes after cardiovascular surgery and critical illness. We investigated the effect of gender on perioperative outcomes following robotic-assisted pulmonary lobectomy. METHODS We retrospectively analyzed 282 consecutive patients who underwent robotic-assisted pulmonary lobectomy by one surgeon over 53 months. Perioperative outcomes and clinically significant intraoperative and postoperative complications, including respiratory and cardiovascular events, were noted. Chi-Square (χ2), Fishers exact test, Analysis of Variance (ANOVA), Students t-test, and Kruskal-Wallis or Moods median test were used to compare variables, with significance at P≤0.05. RESULTS There were 128 men (mean age, 68.8 yr) and 154 women (mean age, 65.9 yr; P=0.02). Women had higher preoperative forced expiratory volume in 1 second as percent of predicted (FEV1%; P=0.001). There were more former smokers in the male cohort (P=0.03) and more nonsmokers in the female cohort (P<0.001). Women had smaller tumors (3.0±0.1 vs. 3.5±0.2 cm, P=0.04), lower estimated blood loss (EBL) (150±34 vs. 250±44 mL, P<0.001), and shorter operative time (168±6 vs. 196±7 min, P=0.01). Rates of intraoperative complications (7.1% vs. 8.6%, P=0.65) and of conversion to open lobectomy (7.8% vs. 8.6%; P=0.81) were similar between genders. Postoperative complications were fewer in women (27.9% vs. 44.5%; P=0.004), the most common of which, in both women and men, were prolonged air leak for ≥7 days (13.0% vs. 22.7%, P=0.03), atrial fibrillation (7.1% vs. 14.8%, P=0.04), and pneumonia (7.8% vs. 10.2%, P=0.49). Hospital length of stay (LOS) (4±0.3 vs. 5±0.5 days) was also shorter for women (P=0.02). Despite the higher postoperative complication rate in men, in-hospital mortality did not differ between genders (P=0.23). Multivariable analyses did not identify female gender as an independent predictor of post-operative complications. CONCLUSIONS Female gender was associated with rates of intraoperative complications and of conversion to open lobectomy as low as those for men, but with better perioperative outcomes, lower risk of intraoperative bleeding, and fewer postoperative complications. Thus, robotic-assisted pulmonary lobectomy is feasible and safe for women.

Robotic-Assisted Videothoracoscopic Surgery of the Lung.

BACKGROUND Despite initial concerns about the general safety of videothoracoscopic surgery, minimally invasive videothoracoscopic surgical procedures have advantages over traditional open thoracic surgery via thoracotomy. Robotic-assisted minimally invasive surgery has expanded to almost every surgical specialty, including thoracic surgery. Adding a robotic-assisted surgical system to a videothoracoscopic surgical procedure corrects several shortcomings of videothoracoscopic surgical cameras and instruments. METHODS We performed a literature search on robotic-assisted pulmonary resections and compared the published robotic series data with our experience at the H. Lee Moffitt Cancer Center & Research Institute. All perioperative outcomes, such as intraoperative data, postoperative complications, chest tube duration, hospital length of stay (LOS), and in-hospital mortality rates were noted. RESULTS Our literature search found 23 series from multiple surgical centers. We divided the literature into 2 groups based on the year published (2005-2010 and 2011-2014). Operative times from earlier studies ranged from 150 to 240 minutes compared with 90 to 242 minutes for later studies. Conversion rates (to open lung resection) from the earlier studies ranged from 0% to 19% compared with 0% to 11% in the later studies. Mortality rates for the earlier studies ranged from 0% to 5% compared with 0% to 2% for the later studies. Since 2010, our group has performed more than 600 robotic-assisted thoracic surgical procedures, including more than 200 robotic-assisted pulmonary lobectomies, which we also divided into 2 groups. Our median skin-to-skin operative time improved from 179 minutes for our early group (n = 104) to 172 minutes for our later group (n = 104). The overall conversion rate was 9.6% and the emergent conversion rate (for bleeding) was 5% for our robotic-assisted lobectomies. The most common postoperative complications in our cohort were prolonged air leak (> 7 days; 16.8%) and atrial fibrillation (12%). Hospital LOS for the early series ranged from 3 to 11 days compared with 2 to 6 days for the later series. Median hospital LOS decreased from 6 to 4 days. Our mortality rate was 1.4%; 3 in-hospital deaths occurred in the early 40 cases. Mediastinal lymph node (LN) dissection and detection of occult mediastinal LN metastases were improved during robotic-assisted lobectomy for non-small-cell lung cancer, as demonstrated by an overall 30% upstaging rate, including a 19% nodal upstaging rate, in our cohort. CONCLUSIONS Robotic-assisted videothoracoscopic pulmonary lobectomy appears to be as safe as conventional videothoracoscopic surgical lobectomy, which has decreased perioperative complications and a shorter hospital LOS than open lobectomy. Both mediastinal LN dissection and the early detection of occult mediastinal LN metastatic disease were improved by robotic-assisted videothoracoscopic surgical compared with conventional videothoracoscopic surgical or open thoracotomy.

Robotic resection of Stage III lung cancer: an international retrospective study

OBJECTIVES Minimally invasive surgery is accepted for early-stage lung cancer, but its role in locally advanced disease is controversial, especially using a robotic platform. The aim of this retrospective study was to assess the safety and effectiveness of robot-assisted resection in patients with Stage IIIA non-small-cell lung cancer (NSCLC) or carcinoid tumours in the series as a whole and in different subgroups according to adjuvant treatment. METHODS This was a retrospective multicentre study of consecutive patients with clinically evident or occult N2 disease (210 NSCLC and 13 carcinoid) who, in 2007-2016, underwent robot-assisted resection at 7 high-volume centres. Perioperative outcomes, recurrences and overall survival were assessed. RESULTS N2 disease was diagnosed preoperatively in 72 (32%) patients and intraoperatively in 151 (68%) patients. Surgical margins were negative in 98.4% of cases with available data. Thirty-four (15.2%) patients received neoadjuvant treatment, 140 (63%) patients received postoperative treatment, and 49 (22%) patients underwent surgery only. There were 22 (9.9%) conversions to thoracotomy, 23 (10.3%) had serious (Grades III-IV) postoperative morbidity and the mean hospital stay was 5.3 days. Complications and outcomes did not differ significantly between treatment groups. Of the 34 patients who were given neoadjuvant chemotherapy, all had R0 resection, 5 (15%) patients required conversion but none required conversion because of bleeding and 4 (12%) patients had Grade III or IV postoperative complications. After a median of 18 (interquartile range 8-33) months, 3-year overall survival in NSCLC patients was 61.2% and 60.3% (P = 0.6) of patients in the subgroup were given induction treatment. However, overall survival was significantly better (P = 0.012) in NSCLC patients with ≤2 positive nodes (vs >2). Nineteen (8.5%) patients developed local recurrence. CONCLUSIONS Robot-assisted lobectomy is safe and effective in patients with Stage III NSCLC or carcinoid tumours with low conversions and complications. Among patients with NSCLC, including those who were given induction chemotherapy, survival was similar to that reported for open surgery.

Surgical outcomes associated with postoperative atrial fibrillation after robotic-assisted pulmonary lobectomy: retrospective review of 208 consecutive cases

BACKGROUND In this study, we sought to investigate the effect of post-operative atrial fibrillation (POAF) after robotic-assisted video-thoracoscopic pulmonary lobectomy on comorbid postoperative complications, chest tube duration, and hospital length of stay (LOS). METHODS We retrospectively analyzed prospectively collected data from 208 consecutive patients who underwent robotic-assisted pulmonary lobectomy by one surgeon for known or suspected lung cancer. Postoperatively, 39 (18.8%) of these patients experienced POAF during their hospital stay. The occurrence of postoperative complications other than POAF, chest tube duration, and hospital LOS were analyzed in patients with POAF and without POAF. Statistical significance (P≤0.05) was determined by unpaired Students t-test or by Chi-square test. RESULTS Of patients with POAF, 46% also had other concurrent postoperative complications, while only 31% of patients without POAF experienced complications. The average number of postoperative complications experienced by patients with POAF was significantly higher than that experienced by those without POAF (0.9 vs. 0.4, P<0.05). Median chest tube duration in POAF patients (6 days) was significantly higher than in patients without POAF (4 days). A similar result was also seen with hospital LOS, with the median hospital LOS of 8 days in POAF patients being significantly longer than in those without POAF, whose median hospital LOS was 4 days. No other significant difference was detected between the two groups of patients. CONCLUSIONS This study demonstrated the association between the incidence of POAF and a more complicated hospital course. Further studies are needed to determine whether confounders were involved in this association.

Transient Aphonia After Mediastinoscopy

The most common adverse event after cervical mediastinoscopy is recurrent laryngeal nerve (RLN) injury, which has an incidence of 0.6% [1]. We report the case of a 68-year-old man with non-small cell lung cancer (NSCLC) who experienced transient bilateral vocal cord paralysis after mediastinoscopy, which manifested in complete aphonia. This patients ability to maintain his airway was carefully followed up, but neither endotracheal intubation nor tracheostomy was required. The vocal cord paralysis resolved without intervention after 5 hours. To our knowledge, this is the first reported case in which bupivicaine used at the end of a cervical mediastinoscopy diffused through the freshly dissected planes to paralyze both RLNs along the tracheoesophageal grooves.

Effect of Obesity on Perioperative Outcomes After Robotic-Assisted Pulmonary Lobectomy: Retrospective Study of 287 Patients

Objective. We investigated whether higher body mass index (BMI) affects perioperative and postoperative outcomes after robotic-assisted video-thoracoscopic pulmonary lobectomy. Methods. We retrospectively studied all patients who underwent robotic-assisted pulmonary lobectomy by one surgeon between September 2010 and January 2015. Patients were grouped according to the World Health Organization’s definition of obesity, with “obese” being defined as BMI >30.0 kg/m2. Perioperative outcomes, including intraoperative estimated blood loss (EBL) and postoperative complication rates, were compared. Results. Over 53 months, 287 patients underwent robotic-assisted pulmonary lobectomy, with 7 patients categorized as “underweight,” 94 patients categorized as “normal weight,” 106 patients categorized as “overweight,” and 80 patients categorized as “obese.” Because of the relatively low sample size, “underweight” patients were excluded from this study, leaving a total cohort of 280 patients. There was no significant difference in intraoperative complication rates, conversion rates, perioperative outcomes, or postoperative complication rates among the 3 groups, except for lower risk of prolonged air leaks ≥7 days and higher risk of pneumonia in patients with obesity. Conclusions. Patients with obesity do not have increased risk of intraoperative or postoperative complications, except for pneumonia, compared with “normal weight” and “overweight” patients. Robotic-assisted pulmonary lobectomy is safe and effective for patients with high BMI.

Effect of advanced age on peri-operative outcomes after robotic-assisted pulmonary lobectomy: Retrospective analysis of 287 consecutive cases

OBJECTIVES We investigated whether advanced age affects peri-operative outcomes after robotic-assisted pulmonary lobectomies. MATERIALS AND METHODS We retrospectively analyzed patients who underwent robotic-assisted lobectomy by one surgeon over a 5-year period. Rates of postoperative complications were compared according to age group. Other outcomes, such as intraoperative complications, hospital length of stay (LOS), and in-hospital mortality, were also compared. RESULTS A total of 287 patients were included (mean age 67.1yr). Group A had 65 patients of advanced age≥75yr (range 75-87yr; 37 men, 28 women); Group B had 222 patients aged <75yr (range 29-74yr; 95 men, 127 women). Group A had 10/65 (15.4%) patients with robotic-related intraoperative complications, compared to 10/222 (4.5%) for Group B (p=0.002), with the most frequent intraoperative complications being bleeding from a pulmonary vessel (10.8% vs. 4.5%, p=0.06), bronchial injury (3.1% vs. 0.9%, p=0.18), and injury to the phrenic or recurrent laryngeal nerve (1.5% vs. 0.4%, p=0.33). There were 28/65 (43.1%) patients in Group A with postoperative complications compared to 76/222 (34.2%) in Group B (p=0.19). While operative times were similar (p=0.42), Group A had longer median hospital LOS of 6±0.9days compared to 4±0.3days for Group B (p=0.02). CONCLUSION While younger patients have lower risk of robotic-related intraoperative complications and shorter hospital LOS, elderly patients do not have increased overall or emergent conversion rates to open lobectomy, overall postoperative complications rates, or in-house mortality compared to younger patients. Thus, robotic-assisted pulmonary lobectomy is feasible and relatively safe for patients of advanced age.