Hanghang Wang

Management and Outcomes of Relapse After Treatment for Thymoma and Thymic Carcinoma

BACKGROUND Although surgery is the mainstay of treatment for thymic tumors, recurrence is common despite resection. The optimal approach to the management of disease relapse after treatment for thymic tumors remains unclear. METHODS This study is a retrospective analysis of a single-institution experience assessing treatment patterns and outcomes in patients with recurrence or disease progression after surgical treatment for thymic tumors. Data included demographics, stage, treatment, pathologic findings, and postoperative outcomes. RESULTS From 1995 to 2006, 120 patients had initial resection of a thymic tumor at our institution, of which 112 had recurrence data available. Twenty-five patients developed recurrence or progression of disease after their initial resection (10 thymic carcinoma, 15 thymoma). Median follow-up was 51.4 months. Higher Masaoka stages predominated (I: 0; II: 4; III: 8; IV: 13). Eleven patients (44%) underwent surgery for their relapse with curative intent, while 14 (56%) were managed nonsurgically. Surgery was considered when disease was intrathoracic, unilateral, and technically resectable. The 11 patients receiving surgery had a total of 16 reoperations (range 1 to 4). An R0 re-resection was obtained in half of cases (8 of 16, 50%) but the majority of operative patients (9 of 11, 82%) recurred again. The 5-year overall survival of the 25 patients with recurrent or persistent disease was 58% (median survival = 82 months). Kaplan-Meier curves demonstrate a trend (p = 0.08) toward improved overall survival in patients treated with surgery versus those treated nonoperatively (median survival = 156 months versus 50 months). Patients with thymoma demonstrated a trend (p = 0.12) toward improved survival for over thymic carcinoma (median survival = 90 months versus 35 months). CONCLUSIONS Treatment of patients with recurrent or progressive thymic tumors is associated with long-term survival. Despite the historical enthusiasm for re-resection, the majority of patients will recur again, therefore reoperation should be considered only in selected patients.

Evolving practice pattern changes and outcomes in the era of hybrid aortic arch repair

OBJECTIVE The role of hybrid repair in the management of aortic arch pathology, and long-term outcomes with these techniques, remains uncertain. We report a decade of experience with hybrid arch repair (HAR) and assess institutional practice patterns with regard to the use of hybrid and open techniques. METHODS Hybrid and open total and distal arch procedures performed between July 2005 and January 2015 were identified from a prospectively maintained, institutional aortic surgery database. Perioperative morbidity and mortality, freedom from reintervention, and long-term survival were calculated. Hybrid and open procedural volumes over the study period were assessed to evaluate for potential practice pattern changes. RESULTS During the study period 148 consecutive procedures were performed for repair of transverse and distal aortic arch pathology, including 101 hybrid repairs and 47 open total or distal arch repairs. Patients in the hybrid repair group were significantly older with a greater incidence of chronic kidney disease, peripheral vascular disease, and chronic lung disease. Perioperative mortality and outcomes were not significantly different between the hybrid and open groups, aside from decreased median length of stay after hybrid repair. Need for subsequent reintervention was significantly greater after hybrid repair. Unadjusted long-term survival was superior after open repair (70% 5-year survival open vs 47% hybrid; P = .03), although aorta-specific survival was similar (98% 5-year aorta-specific survival open vs 93% hybrid; P = .59). Institutional use of HAR decreased over the final 3 years of the study, with an associated increased use of open total or distal arch repairs. This was primarily the result of decreased use of native zone 0 hybrid procedures. Concurrent with this apparent increased stringency around patient selection for HAR, perioperative morbidity and mortality was reduced, including avoidance of retrograde type A dissection. CONCLUSIONS HAR remains a viable option for higher-risk patients with transverse arch pathology with perioperative outcomes and long-term aorta-specific survival similar to open repair, albeit at a cost of increased reintervention. This observational single-institution study would suggest decreased use in more recent years in favor of open repair due to avoidance of native zone 0 hybrid procedures. This decline in the institutional use of native zone 0 hybrid repairs was associated with improved perioperative outcomes.

Efficacy of mediastinal lymph node dissection during thoracoscopic lobectomy

While the first description of thoracoscopy occurred as early as 1910 (1), the first successful attempts of video-assisted thoracoscopic (VATS) lobectomy for non-small cell lung cancer (NSCLC) did not take place until the early 1990s (2). As VATS lobectomy continues to gain acceptance as the less invasive alternative to open thoracotomy, extensive research has been conducted to compare its efficacy, postoperative outcomes and oncologic effectiveness to thoracotomy. Despite its many proven advantages, concerns regarding the oncologic effectiveness of VATS lobectomy remain as one of the major obstacles to its wider adoption (3). As an important assessment for accurate staging of NSCLC, adequate evaluation of lymph nodes, especially mediastinal lymph nodes, has been the center of the controversy.

Cough-Induced Bilateral Spontaneous Pneumothorax

We report an otherwise healthy man who presented with bilateral spontaneous pneumothorax, pneumomediastinum, pneumopericardium, and subcutaneous emphysema induced by a bout of coughing. Although this condition is rare, most patients can be treated nonsurgically with the expectation of full recovery.

Use of Cervicothoracic Anatomy as a Guide for Directed Drainage of Descending Necrotizing Mediastinitis

Descending necrotizing mediastinitis is a potentially lethal infection originating from the oropharynx. Adequate abscess drainage is crucial to successful treatment. We present novel management of descending necrotizing mediastinitis using a series of anterior mediastinal incisions adjoined by Penrose drains. The success of this treatment was dependent on radiographic documentation of infection confined to the anterior cervicothoracic plane.

Use of human fibrinogen concentrate during proximal aortic reconstruction with deep hypothermic circulatory arrest

OBJECTIVE Human fibrinogen concentrate (HFC) is approved by the Food and Drug Administration for use at 70 mg/kg to treat congenital afibrinogenemia. We sought to determine whether this dose of HFC increases fibrinogen levels in the setting of high-risk bleeding associated with aortic reconstruction and deep hypothermic circulatory arrest (DHCA). METHODS This was a prospective, pilot, off-label study in which 22 patients undergoing elective proximal aortic reconstruction with DHCA were administered 70 mg/kg HFC upon separation from cardiopulmonary bypass (CPB). Fibrinogen levels were measured at baseline, just before, and 10 minutes after HFC administration, on skin closure, and the day after surgery. The primary study outcome was the difference in fibrinogen level immediately after separation from CPB, when HFC was administered, and the fibrinogen level 10 minutes following HFC administration. Additionally, postoperative thromboembolic events were assessed as a safety analysis. RESULTS The mean baseline fibrinogen level was 317 ± 49 mg/dL and fell to 235 ± 39 mg/dL just before separation from CPB. After HFC administration, the fibrinogen level rose to 331 ± 41 mg/dL (P < .001) and averaged 372 ± 45 mg/dL the next day. No postoperative thromboembolic complications occurred. CONCLUSIONS Administration of 70 mg/kg HFC upon separation from CPB raises fibrinogen levels by approximately 100 mg/dL without an apparent increase in thrombotic complications during proximal aortic reconstruction with DHCA. Further prospective study in a larger cohort of patients will be needed to definitively determine the safety and evaluate the efficacy of HFC as a hemostatic adjunct during these procedures.

Impact of Timing of Lobectomy on Survival for Clinical Stage IA Lung Squamous Cell Carcinoma

BACKGROUND: Because the relationship between the timing of surgery following diagnosis of lung cancer and survival has not been precisely described, guidelines on what constitutes a clinically meaningful delay of resection of early‐stage lung cancer do not exist. This study tested the hypothesis that increasing the time between diagnosis and lobectomy for stage IA squamous cell carcinoma (SCC) would be associated with worse survival. METHODS: The association between timing of lobectomy and survival for patients with clinical stage IA SCC in the National Cancer Data Base (2006–2011) was assessed using multivariable Cox proportional hazards analysis and restricted cubic spline (RCS) functions. RESULTS: The 5‐year overall survival of 4,984 patients who met study inclusion criteria was 58.3% (95% CI, 56.3–60.2). Surgery was performed within 30 days of diagnosis in 1,811 (36%) patients, whereas the median time to surgery was 38 days (interquartile range, 23, 58). In multivariable analysis, patients who had surgery 38 days or more after diagnosis had significantly worse 5‐year survival than patients who had surgery earlier (hazard ratio, 1.13 [95% CI, 1.02–1.25]; P = .022). Multivariable RCS analysis demonstrated the hazard ratio associated with time to surgery increased steadily the longer resection was delayed; the threshold time associated with statistically significant worse survival was ˜90 days or greater. CONCLUSIONS: Longer intervals between diagnosis of early‐stage lung SCC and surgery are associated with worse survival. Although factors other than the timing of treatment may contribute to this finding, these results suggest that efforts to minimize delays beyond those needed to perform a complete preoperative evaluation may improve survival.

Apolipoprotein L1 Genetic Variants Are Associated with Chronic Kidney Disease but Not with Cardiovascular Disease in a Population Referred for Cardiac Catheterization

Background: While the association between APOL1 genetic variants and chronic kidney disease (CKD) has been established, their association with cardiovascular disease (CVD) is unclear. This study sought to understand CKD and cardiovascular risk conferred by APOL1 variants in a secondary cardiovascular prevention population. Methods: Two risk variants in APOL1 were genotyped in African-Americans (n = 1,641) enrolled in the CATHGEN biorepository, comprised of patients referred for cardiac catheterization at Duke University Hospital, Durham, NC, USA (2001-2010). Individuals were categorized as noncarriers (n = 722), heterozygote (n = 771), or homozygote carriers (n = 231) of APOL1 risk alleles. Multivariable logistic regression and Cox proportional hazards models adjusted for CVD risk factors were used to assess the association between APOL1 risk variants and prevalent and incident CKD, prevalent coronary artery disease (CAD), incident CVD events, and mortality. Results: The previously identified association between APOL1 variants and prevalent CKD was confirmed (OR: 1.85, 95% CI: 1.33-2.57, p = 0.0002). No statistically significant associations were detected between APOL1 variants and incident CKD or prevalent CAD, incident CVD events or mortality. Age, type 2 diabetes, and ejection fraction at baseline were significant clinical factors that predicted the risk of incident CKD in a subgroup analysis of APOL1 homozygous individuals. Conclusion:APOL1 genetic variants are not associated with CAD or incident CVD events in a cohort of individuals with a high burden of cardiometabolic risk factors. In individuals with homozygous APOL1 status, factors that predicted subsequent CKD included age, presence of type 2 diabetes, and ejection fraction at baseline.

Impact of delayed lymphoscintigraphy for sentinel lymphnode biopsy for breast cancer

Despite universal adoption of sentinel lymph node biopsy (SLNB) for breast cancer, there remains no standardized protocol for preoperative lymphoscintographic assessment of sentinel nodes. Both immediate and delayed lymphoscintigraphy are currently utilized, although it is unclear how delayed imaging impacts SLN identification.

Outcomes of Reoperation After Acute Type A Aortic Dissection: Implications for Index Repair Strategy.

Background The optimal surgical approach for management of acute type A aortic dissection remains controversial. This study aimed to assess outcomes of reoperation after acute type A dissection repair to help guide decision making around index operative strategy. Methods and Results All aortic reoperations (n=129) at a single referral institution from August 2005 to April 2016 after prior acute type A dissection repair were reviewed. The primary outcome was 30‐day or in‐hospital mortality. Secondary outcomes included organ‐specific morbidity and 1‐ and 5‐year outcomes as estimated using the Kaplan–Meier method. The majority of initial reoperations were proximal aortic (aortic valve, aortic root, or ascending) or aortic arch procedures (62.5%, n=55); most initial reoperations were performed in the elective setting (83.1%, n=74). Additional nonstaged second or more reoperations were required in 21 patients (23.6%) after the initial reoperation, during a median follow‐up of 2.5 years after the initial reoperation. Thirty‐day or in‐hospital mortality for all reoperations was 7.0% (elective: 6.3%; nonelective: 11.1%) with acceptable rates of organ‐specific morbidity, given the procedural complexity. One‐ and 5‐year overall survival after initial reoperation was 85.9% and 64.9%, respectively, with aorta‐specific survival of 88% at 5 years. Conclusions Reoperation after acute type A aortic dissection repair is associated with low rates of mortality and morbidity. These data support more limited index repair for acute type A dissection, especially for patients undergoing index repair in lower volume centers without expertise in extensive repair, because reoperations, if needed, can be performed safely in referral aortic centers.