Lisa M. Brown

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.

Work-life balance: The female cardiothoracic surgeon's perspective.

The American Board of Thoracic Surgery (ABTS) certified its first women as diplomats in 1961, with the number climbing to 10 by the year 1980. However, during the ensuing 35 years, the presence of women in the field of cardiothoracic surgery has grown dramatically. As we mark the 30th anniversary of the formation of the Women in Thoracic Surgery, our cohort of double-X chromosomes has climbed the ranks, made waves, and achieved positions of prominence in cardiothoracic surgery. 1 However, despite these strides, as of 2015, women account for only approximately 3% of the total number of ABTS diplomats ever certified and comprise a small minority of practicing cardiothoracic surgeons. 2 This issue carries global significance, as female representation among thoracic surgeons in Canada and Europe is similar to the gender distribution in the United States. 3 Through professional networking, mutual support, and committed advocacy from male sponsors and major thoracic professional organizations, women in thoracic surgery have seized numerous opportunities to achieve professional advancement. Although the prospects for women in this field have exploded in recent years, ongoing challenges and tribulations have not vanished. Certainly, it is true that we all have chosen a unique field, full of stressors and uphill battles, regardless of one’s gender. In traversing a long and arduous career path, individuals may face a variety of adversities, related to financial stressors, social support, racial and religious inequities, and barriers related to sexual preferences. Even without any specific barriers, we recognize that all of our colleagues in this specialty have faced formidable challenges and demonstrated feats of endurance, courage, and compassion to join this very special field. However, we contend that there are some particular aspects of identifying oneself as both ‘‘woman’’ and ‘‘cardiothoracic surgeon’’ that bring forth a set of experiences that may be unique; we also would argue that carrying these two, previously considered oxymoronic identifiers, brings the bearer access to a world of personal and professional joy, pride, and satisfaction.

Improvement in TNM staging of pulmonary neuroendocrine tumors requires histology and regrouping of tumor size

Objective Neuroendocrine tumors of the lung are currently staged with the 7th edition TNM non–small cell lung cancer staging system. This decision, based on data analysis without data on histology or disease‐specific survival, makes its applicability limited. This study proposes a specific staging system for these tumors. Methods We retrospectively analyzed 510 consecutive patients (female/male, 313/197; median age, 61 years; interquartile range, 51‐70) undergoing lung resection for a primary neuroendocrine tumor between 2000 and 2015 in 8 centers. Multivariable analysis was performed using a Cox proportional hazard model to identify factors associated with disease‐specific survival. A new staging system was proposed on the basis of the results of this analysis. Kaplan–Meier disease‐specific survival was analyzed by stage using the proposed and the 7th TNM staging system. Results Follow‐up was completed in 490 of 510 patients at a median of 51 months (interquartile range, 18‐99). Histology (G1‐typical carcinoid vs G2‐atypical carcinoid vs G3‐large‐cell neuroendocrine carcinoma) and pT were independently associated with survival, but pN was not. After regrouping histology and pT, we proposed the following staging system: IA (pT1‐2G1), IB (pT3G1, pT1G2), IIA (pT4G1, pT2‐3G2, pT1G3), IIB (pT4G2, pT2‐3G3), and III (pT4G3). The 5‐year survivals were 97.9%, 81.0%, 69.1%, 51.8%, and 0%, respectively. By using the 7th TNM, 5‐year survivals were 95.0%, 92.3%, 67.7%, 70.9%, and 65.1% for stage IA, IB, IIA, IIB, and III, respectively. Conclusions Incorporating histology and regrouping tumor stage create a unique neuroendocrine tumor staging system that seems to predict survival better than the 7th TNM classification.

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

Endobronchial ultrasound-guided transbronchial needle aspiration for staging of non-small cell lung cancer

Accurate staging for non-small cell lung cancer (NSCLC) is essential to guide therapy. While computed tomography (CT) and positron emission tomography (PET) scan can indicate whether mediastinal lymphadenopathy is present, histologic confirmation is required to complete the staging evaluation. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive technique associated with similar diagnostic yield and improved postoperative pain and complication rates compared to mediastinoscopy. We share the surgical technique for EBUS-TBNA based on our experience. An 81-year-old man underwent EBUS-TBNA for concurrent tissue diagnosis and mediastinal staging of a hypermetabolic left lower lobe mass and subcarinal lymph node. Our patient had no perioperative complications and was discharged home on the same day. Histologic evaluation demonstrated squamous cell carcinoma in the left lower lobe and subcarinal lymph node. EBUS-TBNA provides histologic confirmation of suspicious mediastinal lymph nodes seen on imaging. Clinicians should consider EBUS-TBNA as a mediastinal staging modality for patients with NSCLC.

Preventing Recurrence: Optimal Surgical and Medical Management of Catamenial Pneumothorax

The authors describe the successful surgical and medical management of a young woman with recurrent catamenial pneumothoraxes. A 34-year-old woman was referred to thoracic surgery clinic for recurrent episodes of dyspnea. She stopped taking oral contraceptive pills at the age of 30, shortly after which she began having recurrent episodes of dyspnea, cough, and dysmenorrhea. She underwent a diagnostic laparoscopy with evidence of pelvic endometriosis. She was found to have a right pneumothorax and had a chest tube placed. The pneumothorax persisted and she underwent a VATS blebectomy and decortication at an outside hospital.Full article available at: https://www.ctsnet.org/article/preventing-recurrence-optimal-surgical-and-medical-management-catamenial-pneumothorax Images: Figure 1. Selected images of the patient’s preoperative computed tomography imaging showing her right apical and basilar pneumothoraxes and pigtail thoracostomy tube. Figure 2. The patient’s 14-month postoperative chest x-ray showing no recurrence of her pneumothorax.

Is there a role for traditional nuclear medicine imaging in the management of pulmonary carcinoid tumours

OBJECTIVES The clinical utility of fluorodeoxyglucose-positron emission tomography (FDG-PET) and somatostatin receptor scintigraphy (SRS) in pulmonary carcinoids staging is unclear. This study aims to determine the role of FDG-PET and SRS in detecting hilar-mediastinal lymph node metastasis from these tumours. METHODS We retrospectively collected the data of 380 patients who underwent lung resection for primary pulmonary carcinoid in seven centres between 2000 and 2015. Patients without nodal sampling ( n  = 78) were excluded. In 302 patients [35% men, median age 58 (interquartile range 47-68) years] the results of preoperative computed tomography (CT) scan, FDG-PET and SRS were analysed and compared to the pathological findings after resection to determine the respective utility of these two nuclear tests. RESULTS The sensitivity, specificity and negative predictive value in detecting N1 and N2 disease were respectively 33% and 46%, 93% and 90%, 88% and 95% for computed-tomography-scan, 38% and 60%, 93% and 95%, 88% and 95% for FDG-PET, 22% and 33%, 95% and 98%, 84% and 87% for SRS. The diagnostic accuracy for N1 and N2 disease of CT scan was not significantly different from that of FDG-PET ( P  =   1.0 and P  =   0.37 for N1 and N2 disease respectively) and of SRS ( P  =   0.47 and P  =   0.35 for N1 and N2 disease respectively). The sensitivity and specificity of these imaging tests were also similar when analysed by typical vs atypical histology. CONCLUSIONS CT scan, FDG-PET and SRS showed similar performance in terms of nodal staging for pulmonary carcinoid. These findings suggest that additional nuclear imaging beyond CT scan is not required as long as a lymphadenectomy or nodal sampling is completed at resection.

Video-assisted thoracoscopic surgery: pneumonectomy for synchronous primary lung malignancies

BACKGROUND Although video-assisted thoracoscopic surgery (VATS) initially demonstrated slow adoption amongst thoracic surgeons, VATS is now widely accepted and the techniques are associated with equivalent nodal dissection and, improved perioperative morbidity and, in some cases, superior perioperative survival compared to thoracotomy. Using a video-assisted, minimal access technique that requires marginal or no rib spreading, VATS provides improved postoperative pain and decreased time-to-recovery after surgery. However, complex resective cases, such as pneumonectomy, are not commonly accomplished minimally invasively. We share the surgical technique for VATS pneumonectomy based on our experience. METHODS A 71-year-old patient underwent VATS pneumonectomy for synchronous, ipsilateral primary non-small cell lung cancer (NSCLC). RESULTS Our patient had no perioperative complications and was discharged to home on postoperative day 4. The patients pain was managed with oral analgesics. Greater than ten lymph nodes were examined, all margins were negative for residual tumor. The patient did not require adjuvant radiation or chemotherapy. CONCLUSIONS VATS pneumonectomy is a safe and effective procedure that provides many clinical benefits to the patient. Our results suggest that clinicians should consider VATS pneumonectomy for primary treatment of patients with synchronous primary lung cancers when appropriate.

PS01.25: Large Cell Neuroendocrine Carcinoma of the Lung: Prognostic Factors of Survival and Recurrence After R0 Surgical Resection: Topic: Surgery

Maria Cattoni, Eric Vallieres, Lisa M. Brown, Amir A. Sarkeshik, Stefano Margaritora, Alessandra Siciliani, Pier Luigi Filosso, Francesco Guerrera, Andrea Imperatori, Nicola Rotolo, Farhood Farjah, Grace Wandell, Kimberly Costas, Catherine Mann, Michal Hubka, Stephen Kaplan, Alexander S. Farivar, Ralph W. Aye, Brian Louie Swedish Cancer Institute, Seattle, WA/United States of America, UC Davis Medical Center, Sacramento, CA/United States of America, Catholic University ‘Sacred Heart’, Rome/Italy, San Giovanni Battista Hospital, Torino/Italy, University of Insubria, Ospedale di Circolo, Varese/Italy, University of Washington Medical Center, Seattle, WA/United States of America, Providence Regional Medical Center, Everett, WA/United States of America, Virginia Mason Hospital & Seattle Medical Center, Seattle, WA/United States of America