Todd L. Demmy

Non-small cell lung cancer.

Most patients with non-small cell lung cancer (NSCLC) are diagnosed with advanced cancer. These guidelines only include information about stage IV NSCLC. Patients with widespread metastatic disease (stage IV) are candidates for systemic therapy, clinical trials, and/or palliative treatment. The goal is to identify patients with metastatic disease before initiating aggressive treatment, thus sparing these patients from unnecessary futile treatment. If metastatic disease is discovered during surgery, then extensive surgery is often aborted. Decisions about treatment should be based on multidisciplinary discussion.

Video-Assisted Thoracic Surgery Lobectomy: Report of CALGB 39802—A Prospective, Multi-Institution Feasibility Study

PURPOSE To evaluate the technical feasibility and safety of video-assisted thoracic surgery (VATS) lobectomy for small lung cancers. PATIENTS AND METHODS The Cancer and Leukemia Group B 39802 trial was a prospective, multi-institutional study designed to elucidate the technical feasibility of VATS in early non-small-cell lung cancer (NSCLC) using a standard definition for VATS lobectomy (one 4- to 8-cm access and two 0.5-cm port incisions) that mandated videoscopic guidance and a traditional hilar dissection without rib spreading. Between 1998 and 2001, 128 patients with peripheral lung nodules < or = 3 cm in size with suspected NSCLC were prospectively registered for VATS lobectomy. RESULTS One hundred twenty-seven patients (66 males and 61 females; median age, 66 years; range, 37 to 86 years), with a performance status of 0 (74%) or 1 (26%), underwent surgery. Patients with lymph nodes more than 1 cm by computed tomography scan underwent mediastinal lymph node sampling to rule out N2 disease. One hundred eleven patients (87%) had stage I lung cancer, and 96 (86.5%) of these 111 patients underwent successful VATS lobectomies. The median procedure length was 130 minutes (range, 47 to 428 minutes), and median chest tube duration was 3 days (range, 1 to 14 days). Fifty-eight (60%) of 97 patients underwent diagnostic biopsy at lobectomy. Within 30 days, three (2.7%) of 111 patient deaths occurred, none of which were directly related to VATS technique; seven (7.4%) of 95 patients had grade 3 or greater complications, with only one case of bleeding. CONCLUSION A standardized approach to VATS lobectomy as specifically defined with avoidance of rib spreading is feasible.

Minimally invasive lobectomy directed toward frail and high-risk patients: a case-control study ☆

BACKGROUND To compare minimally invasive video-assisted thoracic surgery (VATS) with thoracotomy, cases were matched from a pool of pulmonary lobectomies performed by one surgeon who offered VATS for patients with unfavorable risk factors. METHODS A thoracotomy case was paired to each of 19 VATS cases by age, sex, lobe, side, and forced expiratory volume in 1 second. Eleven VATS and 5 thoracotomy patients with severe activity impairments or reduced forced expiratory volume in 1 second (< 1.5 L or 50% predicted) were classified as higher risk than the others. RESULTS Despite more high-risk cases, VATS yielded shorter hospitalizations (5.3+/-3.7 versus 12.2+/-11.1 days, p = 0.02), chest tube durations (4.0+/-2.8 versus 8.3+/-8.9 days, p = 0.06), and earlier returns to full preoperative activities (2.2+/-1.0 versus 3.6+/-1.0 months, p < 0.01). The VATS operations had no intraoperative complications and lasted 229+/-59 minutes. Pain 3 weeks later was dramatically better for the VATS group (none or mild, 63% versus 6%; severe, 6% versus 63%; p < 0.01). Six complications or deaths occurred in each group and were related to forced expiratory volume in 1 second, steroid usage, age, active smoking, and upper lobe resection (p < 0.01). Three VATS deaths occurred only in elderly, performance status 3 patients, with two caused by gastrointestinal-related problems masked by steroid use. CONCLUSIONS A VATS lobectomy is less painful and may offer faster recovery for the frail or high-risk patient. Further study, particularly of its safety in severely activity-impaired patients, is warranted.

Recent experience with major sternal wound complications

During a recent 1-year period, 31 patients sustained a major sternal wound infection and sternal dehiscence developed in 6 patients. Multiple potential risk factors were tabulated in these patients and in a control group selected from 1,521 patients undergoing sternotomy during the same time period. The overall infection rate was 2.1%, and the mortality rate in the patients with sternal infection or dehiscence was 16.2%. Chronic obstructive pulmonary disease, prolonged intensive care unit stay, respiratory failure, connective tissue disease, and male sex were significantly higher in the group with sternal infection or dehiscence (p less than 0.05). Advanced age and low cardiac output episodes were more frequent in this group, but only approached statistical significance. Although several risk factors may have been interrelated, male sex and the presence of pulmonary disease were statistically independent predictors of sternal wound infection. Risk factors may be helpful in identifying high-risk patients for additional prophylactic measures.

Is Video-Assisted Thoracic Surgery Lobectomy Better? Quality of Life Considerations

Video-assisted thoracic surgery lobectomy has controversial advantages over traditional open surgical approaches. Subjective concerns such as pain, dyspnea, physical functioning, and overall satisfaction generally favor VATS but vary depending on survey timing. Independence, a major quality of life component, favors video-assisted thoracic surgery because fewer objective hospital and discharge resources are needed because pulmonary function, activity level, muscle strength, and walking capacity are better. Video-assisted thoracic surgery often hastens return to work and facilitates adjuvant chemotherapy or subsequent urgent surgical procedures. Video-assisted thoracic surgery-related quality of life benefits are amplified by advanced age (or other frailties) and reduced by advanced cancer stage or comorbid illness.

Multicenter VATS experience with mediastinal tumors

BACKGROUND The use of video-assisted thoracic surgery for diagnosis and treatment of mediastinal tumors in a multiinstitution patient population is not well understood. METHODS We studied 48 cases from Cancer and Leukemia Group B thoracic surgeons. Of 21 men and 27 women, aged 41 +/- 16 years, 22 patients were asymptomatic. In the others, 92% of tumor-related symptoms improved or resolved after treatment. Five tumors involved the anterior compartment, 19 the middle, and 24 the posterior compartment. Diagnoses were typical for each compartment but also included uncommon problems such as superior vena cava hemangioma and a histoplasmosis cyst causing hoarseness. Of the lesions, a biopsy of 12 was done without excision and the rest were excised completely. Fifteen were cystic and 10 were malignant (8 biopsy only). Maximal dimensions were 5.2 +/- 3.3 cm. RESULTS Operations were briefer for 24 posterior (93 +/- 41 min) than 5 anterior (195 +/- 46 min, p < 0.01) or 19 middle mediastinal tumors (170 +/- 78 min, p < 0.01). Although 96% had vital mediastinal relations, only six open conversions were performed because of bleeding (n = 3), large size, impaired exposure, or rib attachments, and no patient had morbidity beyond that expected for the thoracotomy. Postoperative stay was shorter for the nonconversion group (3.2 +/- 2.8 versus 5.5 +/- 2.1 days, p = 0.05), as was chest tube duration (1.7 +/- 1.4 days versus 3.2 +/- 1.9 days, p = 0.03). There were no postoperative deaths or major complications, but 7 patients had minor complications. During a mean of 20 months of surveillance (range, 1 to 52 months), one cyst recurred (asymptomatic) as did one sarcoma that was excised. CONCLUSIONS Video-assisted thoracic surgery is a safe technique for benign mediastinal tumors, typically those in the middle and posterior mediastinum.

Outcomes of sarcomatoid carcinoma of the lung: a Surveillance, Epidemiology, and End Results Database analysis.

BACKGROUND Sarcomatoid lung carcinomas are unusual, and reports from small single institution case series suggest poor survival rates. We sought to study the clinical characteristics of this form of non-small cell lung cancer using the Surveillance Epidemiology, End Results database. METHODS The Surveillance, Epidemiology, and End Results database was queried for respiratory tract malignancies of sarcomatoid histology. The demographic information and oncologic characteristics of this population were examined. A propensity score-matched analysis of patients was performed to test the hypothesis that patients with sarcomatoid cancers undergoing lobectomies perform worse that those with other non-small cell lung cancers. RESULTS Of 878,810 patients with lung cancer, only 3,647 patients had a diagnosis of sarcomatoid cancer (0.4%). For the additional analyses of outcomes, only patients with lifetime incidence of a single cancer, known Surveillance, Epidemiology, and End Results historic stage and inpatient reporting were selected (n = 1,921). Demographics, tumor characteristics, and outcomes of these patients were described. Non-small cell lung cancer cohorts (with and without sarcomatoid cancer propensity-matched on age, gender, race, year of diagnosis, grade, and Surveillance, Epidemiology, and End Results historic stage) that underwent lobectomies or pneumonectomies were selected (n = 758). Univariate (hazard ratio, 1.60; 95% confidence interval, 1.31-1.97) and multivariate analysis (hazard ratio, 1.67; 95% confidence interval, 1.36-2.05) revealed a significantly worse overall survival for patients with sarcomatoid cancer compared to matched nonsarcomatoid lung cancer controls. CONCLUSION Sarcomatoid cancer is a rare form of lung malignancy with outcomes significantly worse than other forms of non-small cell lung cancer. Novel multimodality treatment strategies are necessary to improve outcomes of this disease.

Coronary revascularization in the elderly: Determinants of operative mortality

Over a 13-year period, 668 patients 70 years of age or older underwent isolated primary coronary artery bypass grafting at our institution. There were 472 men and 196 women, ranging from 70 to 90 years of age (median age, 74 years). Hospital mortality was 5.2% (35/668). In patients 70 to 79 years of age, hospital mortality was 4.2% (25/600), whereas in patients 80 years of age or older, mortality was 14.7% (10/68; p < 0.001). Twenty-seven clinical or hemodynamic variables hypothesized as predictors of operative mortality were examined. Mortality was higher in women than in men (9% versus 3.6%; p = 0.006). Those who died were a mean of 3 years older (77 versus 74 years old; p < 0.05) and were more likely to have unstable angina or Canadian class III or IV angina (p < 0.01). Patients requiring urgent operations, preoperative intraaortic balloon assist, intravenous nitroglycerin, or inotropic agents, and those with preoperative hypotension or cardiac arrest were most likely to die in the hospital (p < 0.001). Multivariate logistic regression analysis revealed advancing age, female sex, bypass time, urgency of operation, preoperative cardiac arrest, and unstable angina as primary determinants of mortality (p < 0.05). Although mortality after coronary artery bypass grafting increases with age, the greatest risk of death is in the acutely ill patient with few options for management other than surgical intervention.

Incidence and predictors of supraventricular dysrhythmias after pulmonary resection.

BACKGROUND Patients undergoing pulmonary resection were evaluated prospectively in an effort to determine the incidence of and predictors for the development of postoperative supraventricular dysrhythmias. Specifically, we wished to test the hypothesis that the incidence of postoperative supraventricular dysrhythmias is dependent on the magnitude of pulmonary resection. METHODS One hundred sixteen patients undergoing pulmonary resection had continuous Holter monitoring preoperatively, the day of operation, and the second postoperative day, as well as continuous cardiac monitoring throughout hospitalization. Holter interpretation was blinded to extent of resection. RESULTS Twenty-six patients underwent pneumonectomy, 7 bilobectomy, 47 lobectomy, and 36 wedge resection. Twenty-six patients (22.4%) had supraventricular dysrhythmias, all atrial fibrillation +/- flutter. The incidence of atrial fibrillation with pneumonectomy, bilobectomy, single lobectomy, and wedge resection was 46.1%, 14.3%, 17.0%, and 13.8%, respectively (p < 0.005 pneumonectomy versus others). Overall, 31% of patients having pneumonectomy required pharmacologic therapy for dysrhythmia compared with 16% of patients having lesser resections, (p = 0.03). The peak incidence of onset of atrial fibrillation occurred on postoperative days 2 and 3 and lasted for less than 1 to 7 days, average 2.5 days. The average age of patients with dysrhythmias (64 years) was greater than those without (58 years) (p = 0.039). Thirty pre- and postoperative variables tested were not found to be significant predictors for development of postoperative atrial fibrillation. CONCLUSIONS Atrial fibrillation occurs commonly after pulmonary resections but is not predictable. Development of atrial fibrillation is not dependent on the magnitude of pulmonary resection but is associated with the procedure pneumonectomy for reasons not elucidated.

Intraoperative Sentinel Node Mapping with Technitium-99 in Lung Cancer: Results of CALGB 140203 Multicenter Phase II Trial

Introduction: Sentinel node mapping with radioactive technetium in non-small cell lung cancer has been shown to be feasible in several single institution reports. The Cancer and Leukemia Group B designed a phase II trial to test a standardized method of this technique in a multi-institutional setting. If validated, the technique could provide a more accurate and sensitive way to identify lymph node metastases. Methods: Patients with clinical stage I non-small cell lung cancer amenable to resection were candidates for this trial. Intraoperatively, tumors were injected with technetium sulfur colloid (0.25 mCi). The tumor and lymph nodes were measured in vivo with a hand held Geiger counter and resection of the tumor and nodes was carried out. Sentinel nodes, all other nodes and the tumor were analyzed with standard histologic assessment. Negative sentinel nodes were also evaluated with immunohistochemistry. Results: In this phase II trial, 8 surgeons participated (1-13 patients enrolled per surgeon), and 46 patients (out of a planned 150) were enrolled. Of these, 43 patients had cancer and an attempted complete resection, and 39 patients underwent sentinel node mapping. One or more sentinel nodes were identified in 24 of the 39 patients (61.5%). The sentinel node(s) were found to be accurate (no other nodes were positive for cancer if the sentinel node was negative) in 20/24 patients (83.3%). In the overall group the sentinel node mapping procedure was found to be accurate in 20/39 patients (51.2%). Conclusions: Intraoperative sentinel node mapping in lung cancer with radioisotope yielded lower accrual and worse accuracy than expected. The multi-institutional attempt at validating this technique was unsuccessful.