Jon O. Wee

2014 AATS guidelines for the prevention and management of perioperative atrial fibrillation and flutter for thoracic surgical procedures

PREAMBLE Our mission was to develop evidence-based guidelines for the prevention and treatment of perioperative/postoperative atrial fibrillation and flutter (POAF) for thoracic surgical procedures. Sixteen experts were invited by the American Association for Thoracic Surgery (AATS) leadership: 7 cardiologists and electrophysiology specialists, 3 intensivists/ anesthesiologists, 1 clinical pharmacist, joined by 5 thoracic and cardiac surgeons who represented AATS (see Online Data Supplement 1 for the list of members and Online Data Supplement 2 for the conflict of interest declaration online).

Cost-effectiveness analysis of stereotactic body radiotherapy and radiofrequency ablation for medically inoperable, early-stage non-small cell lung cancer.

PURPOSE The standard management of medically inoperable Stage I non-small-cell lung cancer (NSCLC) conventionally has been fractionated three-dimensional conformal radiation therapy (3D-CRT). The relatively poor local control rate and inconvenience associated with this therapy have prompted the development of stereotactic body radiotherapy (SBRT), a technique that delivers very high doses of irradiation typically over 3 to 5 sessions. Radiofrequency ablation (RFA) has also been investigated as a less costly, single-day therapy that thermally ablates small, peripheral tumors. The cost-effectiveness of these three techniques has never been compared. METHODS AND MATERIALS We developed a Markov model to describe health states of 65-year-old men with medically inoperable NSCLC after treatment with 3D-CRT, SBRT, and RFA. Given their frail state, patients were assumed to receive supportive care after recurrence. Utility values, recurrence risks, and costs were adapted from the literature. Sensitivity analyses were performed to model uncertainty in these parameters. RESULTS The incremental cost-effectiveness ratio for SBRT over 3D-CRT was

Low Incidence of Chest Wall Pain with a Risk-Adapted Lung Stereotactic Body Radiation Therapy Approach Using Three or Five Fractions Based on Chest Wall Dosimetry

6,000/quality-adjusted life-year, and the incremental cost-effectiveness ratio for SBRT over RFA was

Outcomes by Tumor Histology and KRAS Mutation Status After Lung Stereotactic Body Radiation Therapy for Early-Stage Non–Small-Cell Lung Cancer

14,100/quality-adjusted life-year. One-way sensitivity analysis showed that the results were robust across a range of tumor sizes, patient utility values, and costs. This result was confirmed with probabilistic sensitivity analyses that varied local control rates and utilities. CONCLUSION In comparison to 3D-CRT and RFA, SBRT was the most cost-effective treatment for medically inoperable NSCLC over a wide range of treatment and disease assumptions. On the basis of efficacy and cost, SBRT should be the primary treatment approach for this disease.

Image-guided video assisted thoracoscopic surgery (iVATS) - phase I-II clinical trial

Purpose To examine the frequency and potential of dose-volume predictors for chest wall (CW) toxicity (pain and/or rib fracture) for patients receiving lung stereotactic body radiotherapy (SBRT) using treatment planning methods to minimize CW dose and a risk-adapted fractionation scheme. Methods We reviewed data from 72 treatment plans, from 69 lung SBRT patients with at least one year of follow-up or CW toxicity, who were treated at our center between 2010 and 2013. Treatment plans were optimized to reduce CW dose and patients received a risk-adapted fractionation of 18 Gy×3 fractions (54 Gy total) if the CW V30 was less than 30 mL or 10–12 Gy×5 fractions (50–60 Gy total) otherwise. The association between CW toxicity and patient characteristics, treatment parameters and dose metrics, including biologically equivalent dose, were analyzed using logistic regression. Results With a median follow-up of 20 months, 6 (8.3%) patients developed CW pain including three (4.2%) grade 1, two (2.8%) grade 2 and one (1.4%) grade 3. Five (6.9%) patients developed rib fractures, one of which was symptomatic. No significant associations between CW toxicity and patient and dosimetric variables were identified on univariate nor multivariate analysis. Conclusions Optimization of treatment plans to reduce CW dose and a risk-adapted fractionation strategy of three or five fractions based on the CW V30 resulted in a low incidence of CW toxicity. Under these conditions, none of the patient characteristics or dose metrics we examined appeared to be predictive of CW pain.

Extending Indications for Radiofrequency Ablation of Lung Tumors Through an Intraoperative Approach

BACKGROUND We analyzed outcomes after lung stereotactic body radiotherapy (SBRT) for early-stage non-small cell lung-carcinoma (NSCLC) by histology and KRAS genotype. PATIENTS AND METHODS We included 75 patients with 79 peripheral tumors treated with SBRT (18 Gy × 3 or 10 to 12 Gy × 5) at our institution from 2009 to 2012. Genotyping for KRAS mutations was performed in 10 patients. Outcomes were analyzed by the Kaplan-Meier method/Cox regression, or cumulative incidence method/Fine-Gray analysis. RESULTS The median patient age was 74 (range, 46 to 93) years, and Eastern Cooperative Oncology Group performance status was 0 to 1 in 63%. Tumor histology included adenocarcinoma (44%), squamous cell carcinoma (25%), and NSCLC (18%). Most tumors were T1a (54%). Seven patients had KRAS-mutant tumors (9%). With a median follow-up of 18.8 months among survivors, the 1-year estimate of overall survival was 88%, cancer-specific survival (CSS) 92%, primary tumor control 94%, and freedom from recurrence (FFR) 67%. In patients with KRAS-mutant tumors, there was a significantly lower tumor control (67% vs. 96%; P = .04), FFR (48% vs. 69%; P = .03), and CSS (75% vs. 93%; P = .05). On multivariable analysis, histology was not associated with outcomes, but KRAS mutation (hazard ratio, 10.3; 95% confidence interval, 2.3-45.6; P = .0022) was associated with decreased CSS after adjusting for age. CONCLUSION In this SBRT series, histology was not associated with outcomes, but KRAS mutation was associated with lower FFR on univariable analysis and decreased CSS on multivariable analysis. Because of the small sample size, these hypothesis-generating results need to be studied in larger data sets.

The 3-Hole Minimally Invasive Esophagectomy: A Safe Procedure Following Neoadjuvant Chemotherapy and Radiation

To facilitate localization and resection of small lung nodules, we developed a prospective clinical trial (ClinicalTrials.gov number NCT01847209) for a novel surgical approach which combines placement of fiducials using intra‐operative C‐arm computed tomography (CT) guidance with standard thoracoscopic resection technique using image‐guided video‐assisted thoracoscopic surgery (iVATS).

Metastatic carcinoid tumor of the heart.

BACKGROUND Radiofrequency ablation (RFA) is a means of local destruction of lung tumors. The role of this technique in regards to improved survival or quality of life has yet to be well defined. RFA can be performed through an intraoperative or percutaneous route. Percutaneous RFA can be performed without single-lung ventilation under local anesthesia with sedation and is often the preferred route of ablation. We detail instances of RFA in patients who were either not candidates for percutaneous RFA or in whom the tumor was found to be unresectable at operation. METHODS Ten patients with either primary or secondary lung tumors who underwent operation with consideration of intraoperative RFA were reviewed. Patients were followed up with chest computed tomography scans at least every 6 months. Preoperative characteristics, intraoperative techniques, complications, and tumor response were noted. RESULTS The median patient age was 60 years (range, 40 to 85 years). Six patients had lung cancer, 4 had cancer metastatic to the lung, and 5 patients had hilar lesions. Combined lung resection and RFA was done in 4 patients; 6 underwent RFA only. The average size of the ablated lesion was 3.0 cm (range, 1.0 to 5.8 cm). No serious intraoperative or perioperative complications were noted. No immediate or delayed hemorrhage or hemoptysis has been noted. Of patients at least 6 months out from ablation, 4 had no growth of the ablated tumor at an average of 13.5 months (range, 8 to 23 months) after ablation, and 5 have had growth of the tumor first noted at an average of 12.8 months (range, 9 to 14) after ablation. CONCLUSIONS Intraoperative RFA is useful (1) when the lesion is near vital structures such as the great vessels, hilum, or heart, (2) if resectability can only be determined at the time of operation, and (3) when used in patients with secondary tumors of the lung combined with limited resection to preserve lung parenchyma.

Endoscopic management of gastroesophageal reflux disease: A review

Induction therapy followed by esophagectomy has become standard for treatment of intermediate-stage esophageal cancer in many centers. Herein we evaluate the feasibility and safety of the 3-hole minimally invasive esophagectomy (3HMIE) approach in patients who received induction radiation and chemotherapy. Between 2003 and 2012, the records of 119 consecutive patients with esophageal cancer who underwent 3HMIE were reviewed for perioperative complications and long-term outcomes. Comparison was made between procedures performed for patients receiving neoadjuvant chemoradiation and patients who were treated with only surgery. Of them, 78 patients received neoadjuvant chemoradiation and 41 patients were treated with only surgery. Tumor locations were upper (2), middle (16), distal (64), and gastroesophageal junction (37). In all, 76 patients were at clinical stage IIA or above at presentation. Increased requirement for blood replacement in the induction therapy group was significant compared with the surgery-only group. Operative time, estimated blood loss, proximal and distal margin lengths, and length of stay were not significantly different between the cohorts. There was a 30-day perioperative death (0.8%), and this patient was from the surgery-only group. No conduit necrosis or need for diversion was recorded. Overall, 5-year survival was 62% among the 107 patients with early-stage esophageal cancer. 3HMIE is feasible with low mortality and acceptable morbidity even in patients with locally advanced esophageal cancer who received neoadjuvant radiochemotherapy. Overall perioperative and survival outcomes are similar to or better than those reported in the published literature on esophagectomy after induction therapy.

Early Experience of Robot-Assisted Esophagectomy With Circular End-to-End Stapled Anastomosis.

Although carcinoid heart disease has been well described in the literature, metastatic implantation in the heart is rare. We describe a 79-year-old man with no previous history of cancer who presented with progressive dyspnea. He was found to have a septal implantation of a previously undiagnosed metastatic carcinoid tumor. He underwent successful resection with an uneventful postoperative course.