Faculty Bibliography

Recent advances in the surgical treatment of early stage non-small cell lung cancer (NSCLC) have focused heavily on making procedures less invasive, less radical, and better tolerated. Advances in accuracy and increased utilization of cross-sectional imaging allows for diagnosis of smaller and more indolent tumors and preinvasive lesions. Similar to advanced disease, early-stage treatment is now being tailored to individual patients and their tumors. Sublobar resections are gaining acceptance as an oncologically equivalent approach to lobectomy in well-selected stage I patients. Minimally invasive approaches either by video-assisted thoracoscopic surgery (VATS) or robotic-assisted thoracic surgery are becoming the procedures of choice for anatomic NSCLC resections and provide decreased perioperative complications and increased tolerability, especially in the elderly and medically high-risk patients. Reports of even less invasive techniques including uniportal VATS and nonintubated lobar resections are now appearing in the literature.

Despite a prospective randomized trial that reported decreased locoregional recurrence for the intentional use of sublobar resection for stage IA non-small cell lung cancer, it continues to be a point of considerable debate. Improved imaging techniques have introduced a large group of smaller and more indolent tumors than what was studied 20 years ago by the Lung Cancer Study Group. Multiple single-institution and population-based analyses suggest that sublobar resections may have equivalent outcomes to lobectomy in well-selected patients with small (<2 cm) resections, and in whom an adequate resection margin can be achieved.

PURPOSE: Prognostic models for pleural mesothelioma (MPM) are needed to prevent potentially futile outcomes. We combined MPM plasma biomarkers with validated clinical prognostic indices to determine whether stratification of risk for death in 194 MPM patients improved. PATIENTS AND METHODS: Individuals were recruited from three different centers: a discovery cohort (83 MPM) created by combining patients from two US centers and a separate, independent cohort from Canada (111 MPM). Univariable/multivariable analyses were performed on the initial discovery and independent cohorts separately. In multivariable analyses, prognostic factors were adjusted for the Mesothelioma EORTC Prognostic Index (PI). The prognostic significance of adding plasma biomarker data to the PI was determined using the likelihood ratio test, comparing models with and without the addition of biomarker to the clinical PI. The predictive ability of the biomarker was then assessed formally using Harrell's c-index by applying the fitted model variables of the discovery cohort to the second, independent cohort, including and not including the biomarker with the PI. RESULTS: Higher levels of osteopontin and mesothelin were individually associated with worse prognosis after adjusting for the PI. In the independent cohort, incorporating either plasma osteopontin or mesothelin into the baseline predictive PI model substantively and statistically significantly improved Harrell's c-statistic. In the final prognostic model, log-osteopontin, EORTC CPI, and hemoglobin remained as independently significant predictors, and the entire prognostic model improved the optimism-corrected Harrell's c-index significantly from 0.718 (0.67-0.77) to 0.801 (0.77-0.84). CONCLUSION: These data suggest a possible role for preoperative plasma biomarkers to improve prognostic capability of the MPM EORTC PI.

Women in Thoracic Surgery was founded in 1986, with 2016 marking its 30th anniversary. Reflecting back on the last 3 decades of history, accomplishments, and enormous strides in our field, we review the past, present, and future of this organization. Although women still constitute a small minority of practicing surgeons in our field today, opportunities currently abound for women in thoracic surgery. Owing much to the early female pioneers in the field and to the support of male sponsors and our national societies, Women in Thoracic Surgery has grown and prospered, as have its members and the global community of female thoracic surgeons as a whole. In celebration of our 30th anniversary, we share with the readership the rich history of Women in Thoracic Surgery and its goals for the future.

Distant metastasis is common in non-small cell lung cancer (NSCLC) and typically associated with poor prognosis. Aggressive local therapy including surgery and/or radiation for limited metastatic disease from colorectal cancer and sarcoma is associated with survival benefit and has become part of the standard of care. In this article, we review the literature and ongoing studies concerning surgery, radiation, and radiofrequency ablation for oligometastatic NSCLC.

Subcutaneous emphysema frequently occurs after pulmonary resection, but is usually mild and self-limiting. Patients can, however, develop severe symptomatic subcutaneous emphysema despite adequate thoracic drainage. There is a paucity of efficacious treatments for subcutaneous emphysema that does not respond to chest tube drainage. Previous reports have suggested that thoracoscopy may be an efficacious treatment, but is unfavourable due to the risks associated with reoperation. We present a case of a patient who developed severe subcutaneous emphysema after pulmonary lobectomy that was quickly and effectively treated using a commercially available negative pressure wound therapy dressing.

The treatment algorithm for locally advanced non-small cell lung cancer is complex and may best be described as chemotherapy-based multimodality therapy, but there is little consensus as to what constitutes the optimal approach to localized therapy in this setting. The extent of mediastinal lymph node involvement is the principal factor dictating the benefit that can be derived from resection. Surgery is reserved for those with occult N2 disease or discrete resectable N2 involvement. Debate exists over which patients with potentially resectable N2 should undergo resection and how to best integrate resection with chemotherapy and radiation.