Faculty Bibliography
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385
Annals of thoracic surgery. 2014:97(6):1878-83; discussion 1883.DOI: 10.1016/j.athoracsur.2014.02.049
The safety and efficacy of mediastinoscopy when performed by general thoracic surgeons
BACKGROUND: Previous publications suggest that mediastinoscopy only obtains a biopsy of lymph node tissue in about 50% of patients; however, those data included results from nonthoracic surgeons. METHODS: A retrospective cohort study was performed using a database of a consecutive series of patients who underwent mediastinoscopy or video mediastinoscopy by general thoracic surgeons only. RESULTS: Between January 1997 and September 2013, 1,970 patients underwent mediastinoscopy (video mediastinoscopy in the last 243). The indications were staging for known or suspected lung cancer in 68.5%. Morbidity occurred in 25 patients (1.3%). Significant bleeding occurred in 5 patients (0.25%): 2 patients required sternotomy, and bleeding in the other 3 was controlled with packing alone. No patients required transfusion. There were no 30-day operative deaths. Median operative time was 18 minutes, and 96.1% of operations were performed as outpatient procedures. Lymph node tissue was obtained from all patients, and biopsy specimens from at least two mediastinal stations were obtained for 98% who had non-small cell lung cancer. The false-negative rate for N2 lymph nodes that were accessible by mediastinoscopy was 8.2% when lymph nodes dissected at the time of pulmonary resection were used as the reference standard. CONCLUSIONS: In the hands of general thoracic surgeons mediastinoscopy provides lymph node tissue from multiple stations essentially 100% of the time; has minimal morbidity and essentially no deaths; and is a short outpatient procedure. Specialty-specific data (and not national databases) should be used when the efficacy of mediastinoscopy is compared with endobronchial ultrasound.
PMID: 24751152
ISSN: 1552-6259
CID: 2538512
Total port approach for robotic lobectomy
Robotic surgery is safe and efficient, with similar survival rates to the open and video-assisted thoracoscopic surgery (VATS) approaches. The surgeon can provide an R0 resection in patients with cancer. Technical modifications lead to decreased operative times and may improve the ability to teach. The capital cost, service contract costs, and equipment costs have to be carefully considered and studied, and patient selection is critical. There are few achievable benefits of using a robotic system compared with VATS when performing a sympathotomy for patients with hyperhidrosis or a pulmonary wedge resection for tissue diagnosis for patients with interstitial lung disease.
PMID: 24780418
ISSN: 1558-5069
CID: 2538502
Journal of thoracic & cardiovascular surgery. 2014:147(4):1160-1163.e1.DOI: 10.1016/j.jtcvs.2013.12.016
Satisfaction and compensatory hyperhidrosis rates 5 years and longer after video-assisted thoracoscopic sympathotomy for hyperhidrosis
OBJECTIVE: The objective of the present study was to determine the long-term fate and factors of compensatory hyperhidrosis (CH) in patients who have undergone video-assisted thoracoscopic sympathotomy for focal hyperhidrosis. METHODS: The same quality-of-life survey was administered 6 months postoperatively and then annually to all patients who underwent video-assisted thoracoscopic sympathotomy for hyperhidrosis. A second rib (R2)/R3 sympathotomy was most commonly performed until September 2007 and then R4/R5 sympathotomy was used. RESULTS: From January 1999 until December 2012, 193 patients underwent video-assisted thoracoscopic sympathotomy for hyperhidrosis, of whom, 173 had provided >/=1 year of postoperative survey information. No operative mortalities occurred. Of the 173 patients, 133 (77%) reported "clinically bothersome" CH. This rate had decreased to an average of 35% at 5 and 12 years postoperatively. Univariate analysis showed the CH incidence was significantly greater for the patients who had undergone R2/R3 versus R4/R5 sympathotomy (P < .001), had had multiple sites of sweating at presentation (P < .001), had used oral medication to control hyperhidrosis preoperatively (P = .022), or were female (P = .002). On multivariate analysis, only R2/R3 versus R4/R5 sympathotomy (P < .021) and multiple sites of sweating at presentation (P < .037) remained statistically significant. Twelve patients (6.2%) regretted having the operation for CH. CONCLUSIONS: Patients who undergo sympathotomy for hyperhidrosis will commonly report "clinically bothersome" compensatory hyperhidrosis. CH will more likely if R2/R3 sympathetic interruption has been performed instead of R4/R5 and in patients who present with multiple areas of sweating. The severity of clinically bothersome CH decreased during the first 3 years postoperatively.
PMID: 24507405
ISSN: 1097-685x
CID: 2538552
Accuracy of fluorodeoxyglucose-positron emission tomography within the clinical practice of the American College of Surgeons Oncology Group Z4031 trial to diagnose clinical stage I non-small cell lung cancer
BACKGROUND: Fluorodeoxyglucose-positron emission tomography (FDG-PET) is recommended for diagnosis and staging of non-small cell lung cancer (NSCLC). Meta-analyses of FDG-PET diagnostic accuracy demonstrated sensitivity of 96% and specificity of 78% but were performed in select centers, introducing potential bias. This study evaluates the accuracy of FDG-PET to diagnose NSCLC and examines differences across enrolling sites in the national American College of Surgeons Oncology Group (ACOSOG) Z4031 trial. METHODS: Between 2004 and 2006, 959 eligible patients with clinical stage I (cT1-2 N0 M0) known or suspected NSCLC were enrolled in the Z4031 trial, and with a baseline FDG-PET available for 682. Final diagnosis was determined by pathologic examination. FDG-PET avidity was categorized into avid or not avid by radiologist description or reported maximum standard uptake value. FDG-PET diagnostic accuracy was calculated for the entire cohort. Accuracy differences based on preoperative size and by enrolling site were examined. RESULTS: Preoperative FDG-PET results were available for 682 participants enrolled at 51 sites in 39 cities. Lung cancer prevalence was 83%. FDG-PET sensitivity was 82% (95% confidence interval, 79 to 85) and specificity was 31% (95% confidence interval, 23% to 40%). Positive and negative predictive values were 85% and 26%, respectively. Accuracy improved with lesion size. Of 80 false-positive scans, 69% were granulomas. False-negative scans occurred in 101 patients, with adenocarcinoma being the most frequent (64%), and 11 were 10 mm or less. The sensitivity varied from 68% to 91% (p=0.03), and the specificity ranged from 15% to 44% (p=0.72) across cities with more than 25 participants. CONCLUSIONS: In a national surgical population with clinical stage I NSCLC, FDG-PET to diagnose lung cancer performed poorly compared with published studies.
PMCID:4008142
PMID: 24576597
ISSN: 1552-6259
CID: 2538532
Innovations : technology & techniques in cardiothoracic & vascular surgery. 2014:9(1):10-5.DOI: 10.1097/IMI.0000000000000043
Comparing robotic lung resection with thoracotomy and video-assisted thoracoscopic surgery cases entered into the Society of Thoracic Surgeons database
OBJECTIVE: The use of robotic lung surgery has increased dramatically despite being a new, costly technology with undefined benefits over standard of care. There is a paucity of published comparative articles justifying its use or cost. Furthermore, outcomes regarding robotic lung resection are either from single institutions with in-house historical comparisons or based on limited numbers. We compared consecutive robotic anatomic lung resections performed at two institutions with matched data from The Society of Thoracic Surgeons (STS) National Database for all open and video-assisted thoracoscopic surgery (VATS) resections. We sought to define any benefits to a robotic approach versus national outcomes after thoracotomy and VATS. METHODS: Data from all consecutive robotic anatomic lung resections were collected from two institutions (n = 181) from January 2010 until January 2012 and matched against the same variables for anatomic resections via thoracotomy (n = 5913) and VATS (n = 4612) from the STS National Database. Patients with clinical N2, N3, and M1 disease were excluded. RESULTS: There was a significant decrease in 30-day mortality and postoperative blood transfusion after robotic lung resection relative to VATS and thoracotomy. The patients stayed in the hospital 2 days less after robotic surgery than VATS and 4 days less than after thoracotomy. Robotic surgery led to fewer air leaks, intraoperative blood transfusions, need for perioperative bronchoscopy or reintubation, pneumonias, and atrial arrhythmias compared with thoracotomy. CONCLUSIONS: This is the first comparative analysis using national STS data. It suggests potential benefits of robotic surgery relative to VATS and thoracotomy, particularly in reducing length of stay, 30-day mortality, and postoperative blood transfusion.
PMID: 24553055
ISSN: 1559-0879
CID: 2538542
Comprehensive molecular profiling of lung adenocarcinoma
ISI:000339566300025
ISSN: 0028-0836
CID: 5270632
Robotic Pulmonary Resection Using a Completely Portal Four-Arm Technique
New York, NY : Springer, 2014
pp. ?-?
ISBN: 9781461487388
CID: 4070102
Stereotactic body radiation therapy (SBRT) for lung malignancies: preliminary toxicity results using a flattening filter-free linear accelerator operating at 2400 monitor units per minute
BACKGROUND: Flattening filter-free (FFF) linear accelerators (linacs) are capable of delivering dose rates more than 4-times higher than conventional linacs during SBRT treatments, causing some to speculate whether the higher dose rate leads to increased toxicity owing to radiobiological dose rate effects. Despite wide clinical use of this emerging technology, clinical toxicity data for FFF SBRT are lacking. In this retrospective study, we report the acute and late toxicities observed in our lung radiosurgery experience using a FFF linac operating at 2400 MU/min. METHODS: We reviewed all flattening filter-free (FFF) lung SBRT cases treated at our institution from August 2010 through July 2012. Patients were eligible for inclusion if they had at least one clinical assessment at least 30 days following SBRT. Pulmonary, cardiac, dermatologic, neurologic, and gastrointestinal treatment related toxicities were scored according to CTCAE version 4.0. Toxicity observed within 90 days of SBRT was categorized as acute, whereas toxicity observed more than 90 days from SBRT was categorized as late. Factors thought to influence risk of toxicity were examined to assess relationship to grade > =2 toxicity. RESULTS: Sixty-four patients with >30 day follow up were eligible for inclusion. All patients were treated using 10 MV unflattened photons beams with intensity modulated radiation therapy (IMRT) inverse planning. Median SBRT dose was 48 Gy in 4 fractions (range: 30-60 Gy in 3-5 fractions). Six patients (9%) experienced > = grade 2 acute pulmonary toxicity; no non-pulmonary acute toxicities were observed. In a subset of 49 patients with greater than 90 day follow up (median 11.5 months), 11 pulmonary and three nerve related grade > =2 late toxicities were recorded. Pulmonary toxicities comprised six grade 2, three grade 3, and one each grade 4 and 5 events. Nerve related events were rare and included two cases of grade 2 chest wall pain and one grade 3 brachial plexopathy which spontaneously resolved. No grade > =2 late gastrointestinal, skin, or cardiac toxicities were observed. Tumor size, biologically effective dose (BED10, assuming alpha/beta of 10), and tumor location (central vs peripheral) were not significantly associated with grade > =2 toxicity. CONCLUSIONS: In this early clinical experience, lung SBRT using a FFF linac operating at 2400 MU/min yields minimal acute toxicity. Preliminary results of late treatment related toxicity suggest reasonable rates of grade > =2 toxicities. Further assessment of late effects and confirmation of the clinical efficacy of FFF SBRT is warranted.
PMCID:3842766
PMID: 24256563
ISSN: 1748-717x
CID: 2538562
SBRT Lung: Fiducial Migration Based on Fiducial Type and Anatomic Location [Meeting Abstract]
ISI:000324503602019
ISSN: 1879-355x
CID: 2540702
Quality of life after pulmonary resections
Quality of life (QOL) is an important component of the conversation between any physician and patient. It is especially important between a surgeon and an operative candidate when considering treatment of lung cancer. Patients want reassurance that after removal of part of their lung that not only will they be cancer-free but also that they will be able to breathe well even when active. They do not want to be left physically or mentally handicapped. Recent studies have also shown the correlation between QOL and survival after resection. In this article the literature concerning QOL after pulmonary resection is reviewed.
PMID: 23931026
ISSN: 1558-5069
CID: 2538572
