Robert Shen

Clinical outcomes and changes in lung function after segmentectomy versus lobectomy for lung cancer cases

OBJECTIVE We compared the clinical outcomes and changes in pulmonary function test (PFT) results after segmentectomy or lobectomy for non-small cell lung cancer. METHODS The retrospective study included 212 patients who had undergone segmentectomy (group S) and 2336 patients who had undergone lobectomy (group L) from 1997 to 2012. The follow-up and medical record data were collected. We used all the longitudinal PFT data within 24 months postoperatively and performed linear mixed modeling. We analyzed the 5-year overall and disease-free survival in stage IA patients. We used propensity score case matching to minimize the bias due to imbalanced group comparisons. RESULTS During the perioperative period, 1 death (0.4%) in group S and 7 (0.3%) in group L occurred. The hospital stay for the 2 groups was similar (median, 5.0 vs 5.0 days; range, 2-99 vs 2-58). The mean overall and disease-free survival period of those with T1a after segmentectomy or lobectomy seemed to be similar (4.2 vs 4.5 years, P=.06; and 4.1 vs 4.4 years, P=.07, respectively). Compared with segmentectomy, lobectomy yielded marginally significantly better overall (4.4 vs 3.9 years, P=.05) and disease-free (4.1 vs 3.6 years; P=.05) survival in those with T1b. We did not find a significantly different effect on the PFTs after segmentectomy or lobectomy. CONCLUSIONS Both surgical types were safe. We would advocate lobectomy for patients with stage IA disease, especially those with T1b. A retrospective study with a large sample size and more detailed information should be conducted for PFT evaluation, with additional stratification by lobe and laterality.

Bilobectomy Versus Lobectomy for Non-Small Cell Lung Cancer: A Comparative Study of Outcomes, Long-Term Survival, and Quality of Life

BACKGROUND We aimed to compare long-term survival and quality of life (QOL) outcomes after bilobectomy and lobectomy for non-small cell lung cancer patients. METHODS A cohort of 951 consecutive patients was identified from a single treatment institution, of whom 128 underwent bilobectomy and 823, lobectomy. Propensity score matching (1:3) was applied to balance known confounders between the two surgical groups and resulted in 512 patients (matched cohort). Unmatched and matched analyses were performed to compare clinical outcomes between the two groups, including operative mortality rate, morbidity rate, long-term survival, overall QOL, and specific symptoms. RESULTS Operative mortality was higher in the bilobectomy group than in the lobectomy group (2.3% versus 0.5%, p = 0.022). Morbidity rates did not differ significantly between the two groups in either unmatched or matched cohort. In the unmatched analysis, the overall survival (OS [p = 0.003]) and disease-free survival (DFS [p = 0.003]) were significantly lower in the bilobectomy group; whereas in the matched analysis, no significant difference was found in either OS (p = 0.473) or DFS (p = 0.387). Using multivariate analysis, the operation type was not found to be a significant factor for either OS (hazard ratio 1.18; 95% confidence interval: 0.91 to 1.52; p = 0.22) or DFS (hazard ratio 1.22; 95% confidence interval: 0.95 to 1.58; p = 0.13). Patients who underwent bilobectomy appeared to have similar measures of QOL as lobectomy patients, except for coughing and dyspnea. CONCLUSIONS Our findings indicate that patients with non-small cell lung cancer treated with bilobectomy had similar morbidity, OS, DFS, and overall QOL as patients treated with lobectomy, but had higher mortality by matched analysis.

Microbiology specimens obtained at the time of surgical lung biopsy for interstitial lung disease: clinical yield and cost analysis

OBJECTIVES In efforts to obtain complete results, current practice in surgical lung biopsy (LB) for interstitial lung disease (ILD) recommends sending lung tissue samples for bacterial, mycobacterial, fungal, and viral cultures. This study assesses the value of this practice by evaluating the microbiology findings obtained from LB for ILD and their associated costs. METHODS A total of 296 consecutive patients (140 women, 156 men, median age=61 years) underwent LB for ILD from 2002 to 2009. All had lung tissue sent for microbiology examination. Microbiology results and resultant changes in patient management were analyzed retrospectively. A cost analysis was performed based upon nominal hospital charges adjusted on current inflation rates. Cost data included cultures, stains, smears, direct fluorescent antibody studies, and microbiologist consulting fees. RESULTS As many as 25 patients (8.4%) underwent open LB and 271 (91.6%) underwent thoracoscopic LB. A total of 592 specimens were assessed (range 1-4 per patient). The most common pathologic diagnoses were idiopathic pulmonary fibrosis in 122 (41.2%), cryptogenic organizing pneumonia in 31 (10.5%), and respiratory bronchiolitis ILD in 16 (5.4%). Microbiology testing was negative in 174 patients (58.8%). A total of 118 of 122 (96.7%) positive results were clinically considered to be contaminants and resulted in no change in clinical management. The most common contaminants were Propionibacterium acnes (38 patients; 31%) and Penicillium fungus (16 patients; 13%). In only four patients (1.4%), the organism cultured (Nocardia one, Histoplasma one, and Aspergillus fumigatus two) resulted in a change in clinical management. The cost of microbiology studies per specimen was

¿Influyen el número y volumen de las biopsias pulmonares en el rendimiento diagnóstico en la enfermedad pulmonar intersticial? Análisis mediante índice de propensión

984 (€709), with a total cost for the study cohort being

Chondrosarcoma arising within a radiation-induced osteochondroma several years following childhood total body irradiation: case report.

582,000 (€420,000). CONCLUSIONS The yield and impact on clinical management of microbiology specimens from LB for ILD is very low. Its routine use in LB is questionable. We suggest it should be limited to those cases of ILD with a high suspicion of infection. Substantial cost savings are possible with this change in clinical practice.

88P: Use of brain imaging in the management of patients with lymph node negative multifocal lung cancer.

INTRODUCTION Our objective was to evaluate whether the number and volume of surgical lung biopsies (SLB) influence the diagnosis of diffuse interstitial lung disease (ILD). METHODS Retrospective study of SLB for suspected ILD in patients from the Mayo Clinic from January 2002 to January 2010. Data were collected in the institution and analyzed. RESULTS 311 patients were studied. Mean number of biopsies was 2.05 (SD 0.6); 1 biopsy in 50 (16%), 2 in 198 (63.7%), 3 in 59 (19%) and 4 in 4 (1.3%). Histopathologic diagnosis was: definitive (specific): 232 (74.6%), descriptive (non-specific): 76 (24.4%), no diagnosis: 3 (1%). After excluding patients without diagnosis (n=3), there were 50 patients with only 1 biopsy, 196 with 2 and 62 with 3 or 4; the definitive diagnostic yield was similar in all 3 groups (37/50; 74%, 150/196; 77%, and 45/62; 73%) (Chi-square, p value 0.8). The propensity score analysis between patients with 1 SLB and patients with more than 1 SLB also showed no difference in diagnostic yield. Regarding the volume of biopsies, mean total volume was 34.4 cm(3) (SD 46): 41.2 cm(3) (3 cases) in patients with no diagnosis; 33.6 cm(3) (232 cases, SD 47) in patients with specific diagnosis; and 36.6 cm(3) (76 cases, SD 44) in patients with descriptive diagnosis. Biopsy volume had no influence on histopathology yield (ANOVA, p value .8). CONCLUSIONS The number and volume of the biopsy specimens in SLB did not seem to influence diagnosis. Based on our results, we believe a single sample from a representative area may be sufficient for diagnosis. Randomized prospective trials should be performed to optimize SLB for ILD.

Factors influencing length of stay after surgery for benign foregut disease.

Malignant degeneration arising in radiation-induced osteochondromas is extremely rare. We report a case of a 34-year-old man with a chondrosarcoma arising from an osteochondroma of the left posterior eighth rib that developed following total body irradiation received as part of the conditioning regimen prior to bone marrow transplantation at age 8. To our knowledge, this is only the fourth reported case of a chondrosarcoma arising within a radiation-induced osteochondroma and the first case occurring following childhood total body irradiation.

Pseudomyxoma pleuri. A rare manifestation of an uncommon disease.

Y.S. Kim1, S.H. Yoon1, B.S. Son2, D.H. Kim2, K. Kim3, I.-J. Kim4. 1 Pulmonology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea, 2 Thoracic surgery, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea, 3 Nuclear Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea, 4 Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea

Preoperative Pulmonary Rehabilitation before Lung Cancer Resection: Results from two Randomized Studies

OBJECTIVES Length of stay (LOS) is an important measure of quality and healthcare costs. Variation occurs due to individual and institutional practices, case complexity and patient/social factors. Identification of variables affecting LOS may help develop enhanced recovery protocols. This study aims to identify factors influencing LOS following surgery for hiatal hernia, gastro-oesophageal reflux and achalasia. METHODS We identified all patients who underwent benign foregut surgery between August 2013 and July 2014 inclusive. Data from a prospectively maintained database were collected and univariate/multivariable analyses were performed. All patients were contacted to determine their 30-day readmission rate to any hospital. RESULTS One hundred and sixty-five patients were identified in the 12-month period; 68% underwent laparoscopic surgery and 32% open surgery. The rates of laparoscopic conversion to open surgery and operative mortality were zero. Statistically, the most significant predictor of LOS was the surgical approach. The median LOS was 2 days for laparoscopic surgery and 4 days for open surgery. Beyond the surgical approach, the following factors were significant in predicting LOS: for laparoscopic surgery patients, younger age, shorter operative time, nasogastric (NG) tube removal in the operation theatre (OT), OT exit before noon, low postoperative nausea counts and discharge to home rather than a skilled facility were associated with reduced LOS. For open surgery patients, younger age, American Society of Anesthesiologists grade I-II, urinary catheter removal before discharge, discharge to home and discharge on the weekend were associated with reduced LOS. Whether surgery was primary or reoperation did not affect LOS. The overall 30-day readmission rate was 5% (laparoscopic 3% and open 12%; P = 0.003). CONCLUSIONS The laparoscopic surgery approach, where feasible, in the treatment of benign foregut diseases is the strongest predictor of a decreased LOS. Modifiable factors influencing LOS include OT exit time, NG tube removal in the OT, urinary catheter removal in hospital and postoperative nausea control. Any implementation of enhanced recovery pathways to optimize these factors must monitor readmission rates and complications to confirm efficacy.

Unplanned Readmission After Lung Resection: Complete Follow-Up in a 1-Year Cohort With Identification of Associated Risk Factors

A middle-aged man, a never-smoker, was diagnosed with pseudomyxoma peritonei and had undergone several cytoreductive surgical interventions followed by intraperitoneal chemotherapy with mitomycin several years before presentation. He was referred to our institution for progressively worsening shortness of breath and left chest pain. Computed tomography and chest magnetic resonance imaging of the chest (Figures 1 and 2) revealed prominent soft tissue masses involving the entire left pleural space and suggested left transdiaphragmatic tumor infiltration (laterally and inferiorly). Positron emission tomography demonstrated scattered areas of mild fluorodeoxyglucose uptake (Figure 3). A computed tomography–guided biopsy revealed moderately differentiated mucinous adenocarcinoma, consistent with prior biopsies, establishing the diagnosis of pseudomyxoma pleuri. Palliative debulking surgery was performed, removing a large amount of gelatinous material. The patient’s respiratory status improved in spite of significant residual pleural tumor. Figure 1. Axial intravenous enhanced computed tomography shows a large left multiseptated cystic pleural mass with enhancing soft tissue in the periphery of the cysts and along septations. The low-density cysts extend into the pericardial and mediastinal fat. There is near-complete collapse of the left lung and significant mediastinal shift. Figure 2. Coronal non–gadolinium-enhanced two-dimensional balanced steady-state free precession image demonstrates a massive, multiseptated, multicystic mass in the left hemithorax, causing significant mediastinal left to right shift.