Jennifer L. Sullivan

Electromagnetic Navigation Bronchoscopy for Identifying Lung Nodules for Thoracoscopic Resection

BACKGROUND Pulmonary nodules smaller than 1 cm can be difficult to identify during minimally invasive resection, necessitating conversion to thoracotomy. We hypothesized that localizing nodules with electromagnetic navigation bronchoscopy and marking them with methylene blue would allow minimally invasive resection and reduce conversion to thoracotomy. METHODS We retrospectively identified all patients who underwent electromagnetic navigation bronchoscopy followed by minimally invasive resection of a pulmonary nodule from 2011 to 2014. Lung nodules smaller than 10 mm and nodules smaller than 20 mm that were also located more than 10 mm from the pleural surface were localized and marked with methylene blue. Immediately after marking, all patients underwent resection. RESULTS Seventy patients underwent electromagnetic navigation bronchoscopy marking followed by minimally invasive resection. The majority of patients (68/70, 97%) had one nodule localized; 2 patients (2/70, 3%) had two nodules localized. The median nodule size was 8 mm (range, 4-17 mm; interquartile range, 5 mm). The median distance from the pleural surface was 6 mm (range, 1-19 mm; interquartile range, 6 mm). There were no conversions to thoracotomy. Nodule marking was successful in 70 of 72 attempts (97.2%); two nodules were identified by palpation. The nodules were most commonly metastases from other sites (31/70, 44.3%). There were no adverse events related to electromagnetic navigation bronchoscopy-guided marking or wedge resection, and minimal adverse events after resections that were more extensive. CONCLUSIONS Localizing and marking small pulmonary nodules using electromagnetic navigation bronchoscopy is safe and effective for nodule identification before minimally invasive resection.

Resection of thymoma should include nodal sampling

OBJECTIVE Thymoma is best treated by surgical resection; however, no clear guidelines have been created regarding lymph node sampling at the time of resection. Additionally, the prognostic implications of nodal metastases are unclear. The aim of this study was to analyze the prognostic implications of nodal metastases in thymoma. METHODS The Surveillance, Epidemiology, and End Results database was queried for patients who underwent surgical resection of thymoma with documented pathologic examination of lymph nodes. The impact of nodal status on survival and thymoma staging was examined. RESULTS We identified 442 patients who underwent thymoma resection with pathologic evaluation of 1 or more lymph nodes. A median of 2 nodes were sampled per patient. Fifty-nine patients (59 of 442, 13.3%) had ≥ 1 positive node. Patients with positive nodes were younger and had smaller tumors than node-negative patients. Median survival in the node-positive patients was 98 months, compared with 144 months in node-negative patients (P = .013). In multivariable analysis, the presence of positive nodes had a significant, independent, adverse impact on survival (hazard ratio 1.945, 95% confidence interval 1.296-2.919, P = .001). The presence of nodal metastases resulted in a change in classification to a higher stage in 80% of patients, the majority from Masaoka-Koga stage III to stage IV. CONCLUSIONS Nodal status seems to be an important prognostic factor in patients with thymoma. Until the prognostic significance of nodal metastases is better understood, surgical therapy for thymoma should include sampling of regional lymph nodes.

Impact of Positive Nodal Metastases in Patients with Thymic Carcinoma and Thymic Neuroendocrine Tumors

Introduction: Thymic carcinomas and thymic neuroendocrine tumors are rare diseases often treated with surgical resection. Currently, there are no guidelines regarding nodal dissection at the time of tumor resection. Moreover, the prognostic significance of nodal metastases is unclear. The goal of this study was to define the incidence and prognostic relevance of nodal metastases in patients with thymic carcinoma and thymic neuroendocrine tumors. Methods: The Surveillance, Epidemiology and End Results database was queried for patients who underwent surgical resection of thymic carcinoma or a thymic neuroendocrine tumor with documented pathological examination of lymph nodes. The incidence of nodal metastases and the impact on survival were examined. Results: We identified 176 patients with thymic carcinoma and 53 with thymic neuroendocrine tumors. A median of three lymph nodes was sampled per patient. Positive metastasis to at least one lymph node was identified in 92 patients (40.2%). Nodal metastasis was more common in patients with thymic neuroendocrine tumors than in patients with thymic carcinoma (62.3% versus 33.5%). In multivariate analysis, nodal metastasis was more likely in patients with thymic neuroendocrine tumors and with more advanced tumors. The presence of nodal metastases had significant, independent, adverse impact on survival (hazard ratio, 2.933, 95% confidence interval, 1.903–4.521, p = 0.001). Median survival was 47 months in patients with nodal metastasis and 124 months in patients without nodal metastases (p < 0.001). Conclusions: Nodal status seems to be an important prognostic factor in patients with thymic carcinoma and thymic neuroendocrine tumors. Nodal sampling should be performed during resection of these thymic malignancies.

Using the National Cancer Database to create a scoring system that identifies patients with early-stage esophageal cancer at risk for nodal metastases

Objectives: Endoscopic resection is gaining popularity as a treatment for early‐stage esophageal adenocarcinoma, particularly for T1a tumors. The goal of this study was to create a scoring system to reflect the risk of nodal metastases in early‐stage esophageal adenocarcinoma to be used after endoscopic resection to better individualize treatment. Methods: The National Cancer Database was queried for patients with T1a or T1b esophageal adenocarcinoma who underwent esophagectomy. We identified variables affecting nodal metastases using multivariable logistic regression, which we then used to create a scoring system. We stratified the model for T1a or T1b tumors, tested model discrimination, and validated the models by refitting in 1000 bootstrap samples. C‐statistics greater than 0.7 were considered relevant. Results: We identified 1283 patients with T1a or T1b tumors; 146 had nodal metastases (11.4%). Tumor category (pT1a vs pT1b), grade, and size and the presence of angiolymphatic invasion significantly affected the risk of nodal metastases. We assigned points to each variable and added them to get a risk score. In patients with T1a tumors, less than 3% of patients with a risk score of 3 or less had nodal metastases, whereas 16.1% of patients with a risk score of 5 or greater had nodal metastases. In patients with T1b tumors, less than 5% of patients with a risk score of 2 or less had nodal metastases, whereas 41% of patients with a score of 6 or greater had nodal metastases (c‐statistic = 0.805). Conclusions: The proposed scoring system seems to be useful in discriminating risk of nodal metastases in patients with T1a or T1b esophageal adenocarcinoma and may be useful in directing patients who received endoscopic resection to esophagectomy or careful follow‐up.

Racial and Ethnic Differences in Lung Cancer Surgical Stage: An STS Database Study

BACKGROUND Racial and ethnic differences in lung cancer care have been previously documented. These differences may be related to access to care, cultural differences, or fewer patients presenting with operable lung cancer. The relationship between race and pathologic stage of patients who undergo lung cancer resection has not been defined. This study estimates racial disparities in lung cancer stage among patients who undergo surgical resection. METHODS The Society of Thoracic Surgeons (STS) database was queried for patients who underwent resection of non-small cell lung cancer and had complete pathologic staging and racial identification. Univariate and multivariate analyses were performed. Study end point was the pathologic stage and we evaluated its association with the racial and ethnic origins of the patients. RESULTS Of 19,173 eligible patients with non-small cell lung cancer of known pathological stage who underwent surgery between 2002 and 2008, the majority were Caucasian (17,148, 89.4%), 1,502 (7.8%) were African-American, 273 (1.4%) were Asian, and 250 (1.3%) were Hispanic. In univariate analysis, significantly more Caucasian and African-American patients underwent resection of stage I/II lung cancer (13,929, 81.2% and 1,217, 81%, respectively) as compared with the Asian (207, 75.2%) and Hispanic (188, 75.8%) patients (p = 0.007). Stage at operation did not differ between Caucasians and African-Americans. Multivariate analysis confirmed these findings (p = 0.03) after adjustment for age, gender, tobacco use, diabetes, and year of surgery. CONCLUSION Within the STS database, patients identified as Asian or Hispanic had a significantly higher pathologic stage at the time of resection than Caucasian or African-American patients. The causes of these differences in the treatment of potentially curable lung cancer are unknown and require further investigation.

Esophagectomy versus endoscopic resection for patients with early-stage esophageal adenocarcinoma: A National Cancer Database propensity-matched study

Objectives: Endoscopic resection has been rapidly adopted in the treatment of early‐stage esophageal tumors. We compared the outcomes after esophagectomy or endoscopic resection for stage T1a adenocarcinoma. Methods: We queried the National Cancer Database for patients with T1a esophageal adenocarcinoma who underwent esophagectomy or endoscopic resection and generated a balanced cohort with 735 matched pairs using propensity‐score matching. We then performed a multivariable Cox regression analysis on the matched and unmatched cohorts. Results: We identified 2173 patients; 1317 (60.6%) underwent esophagectomy, and 856 (39.4%) underwent endoscopic resection. In the unmatched cohort, patients who underwent esophagectomy were younger, more often not treated in academic settings, and more likely to have comorbidities (30.4% vs 22.5%, P = .002). They had longer hospital stays and more readmissions than patients who underwent endoscopic resection. Factors positively affecting overall survival were younger age, resection at an academic medical center, and lower Charlson–Deyo comorbidity score. In the matched cohort, patients who underwent esophagectomy had longer hospital stays and were more likely to be readmitted within 30 days (7.0% vs 0.6%, P < .001). When a time period–specific partition was applied, endoscopic resection had a lower death hazard 0 to 90 days after resection (hazard ratio, 0.15; P = .003), but this was reversed for survival greater than 90 days (hazard ratio, 1.34; P = .02). Conclusions: In patients with early‐stage esophageal adenocarcinoma, survival appears equivalent after endoscopic resection or esophagectomy, but endoscopic resection is associated with shorter hospital stays, fewer readmissions, and less 90‐day mortality. In patients surviving more than 90 days, esophagectomy may provide better overall survival.

Neuroendocrine Tumors of the Thymus: Analysis of Factors Affecting Survival in 254 Patients.

BACKGROUND Neuroendocrine tumors of the thymus (NETT) constitute less than 5% of all anterior mediastinal masses but are aggressive and lead to poor overall survival. This study was designed to evaluate factors that influence the prognosis of patients with NETT and the role of surgical intervention in survival. METHODS We analyzed the Surveillance, Epidemiology, and End Results cancer database to identify patients with NETT. We performed univariate and multivariate analyses to identify prognostic factors among demographic, tumor, and treatment variables. RESULTS In 254 patients identified with NETT, the median overall survival time was 73 months, with a 5-year survival rate of 56%. Patients who underwent surgical therapy had a significantly longer median survival time than did those who did not undergo surgical therapy (109 months vs 46 months, p < 0.001). In multivariate analysis, surgical resection, Masaoka-Koga stage, and tumor size were significant predictors of survival. CONCLUSIONS Our study found that surgical resection, Masaoka-Koga stage, and tumor size are significant prognostic factors in patients with NETT. Complete surgical resection continues, rightfully, to be the mainstay in the treatment of this rare disease.

Adjuvant chemotherapy improves survival in patients with completely resected T3N0 non–small cell lung cancer invading the chest wall

Objective: Adjuvant chemotherapy prolongs survival in patients with non–small cell lung cancer with N1 disease or tumors larger than 4 cm. Patients with T3N0 disease due to chest wall invasion often receive adjuvant chemotherapy because their disease is classified as stage II non–small cell lung cancer. This study evaluated whether chemotherapy improves survival after complete resection of T3N0 non–small cell lung cancer with invasion of the chest wall. Methods: Patients who underwent complete resection of N0 non–small cell lung cancer with invasion of the chest wall were identified in the National Cancer Database. We performed propensity matching of patients who received adjuvant chemotherapy and patients who did not and examined survival. Results: We identified 2326 eligible patients; 1050 patients (45%) received adjuvant chemotherapy, and 1276 patients (55%) did not. Patients who received chemotherapy after surgery had significantly better median survival than patients who did not (71 vs 39 months, P < .001). We identified 772 matched pairs. In the matched cohort, patients who received chemotherapy after surgery also had significantly better median survival (68 vs 39 months without chemotherapy, P < .001). Conclusions: In this large database study, adjuvant chemotherapy significantly improved survival in patients with T3 (chest wall) N0 non–small cell lung cancer after complete resection. Further studies are required to confirm our findings.

Esophageal Actinomycoses Mimicking Malignancy

Actinomycosis is caused by anaerobic bacteria and rarely affects the esophagus. We present a case of esophageal actinomycosis in a 55-year old woman that mimicked malignancy. The patient presented with dysphagia and weight loss. Preoperative esophagogastroscopic biopsy revealed purulent material, but was inconclusive. Endoscopic ultrasonography suggested esophageal cancer, and chest computed tomography showed a mass in the lower esophagus surrounded by inflammation. The patient underwent esophagogastrectomy, and histopathology examination of the specimen revealed distal esophageal actinomycosis. Preoperative diagnosis of esophageal actinomycosis is difficult, but clinicians should be aware of its unusual presentations and its ability to mimic malignancy.

Navigational bronchoscopy-guided dye marking to assist resection of a small lung nodule

Electromagnetic navigational bronchoscopy (ENB) can be used to dye mark nodules that are difficult to identify during minimally invasive lung resection thoracic surgery. This case report describes the technique of ENB to identify and resect a suspicious small pulmonary nodule in a patient undergoing resection of lung adenocarcinoma.