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Michael R Folkert,
Gil'ad N Cohen,
Abraham J Wu,
Hans Gerdes,
Mark A Schattner,
Arnold J Markowitz,
Emmy Ludwig,
David H Ilson, Manjit S Bains,
Michael J Zelefsky,
Karyn A Goodman
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ABSTRACT: PURPOSE: The management of superficial primary and recurrent esophageal cancer (EC) in medically inoperable patients is complex. Endoluminal high-dose-rate (HDR) brachytherapy has shown mixed results in terms of toxicity and local control. In this study, we examined the outcomes and toxicities in a set of patients with superficial primary and recurrent EC treated with a consistent HDR technique. METHODS AND MATERIALS: Between 8/2008 and 7/2011, 14 patients were treated with HDR intraluminal brachytherapy, 10 (71.4%) with recurrent disease, and 4 (28.6%) with previously unirradiated lesions. Patients received three weekly fractions to a median dose of 12 Gy (range, 10-15 Gy); dose was prescribed to 7-mm median depth with mucosal dose limited to 8-10 Gy using a 12-14-mm applicator. RESULTS: Median followup was 15.4 months. Overall freedom from failure (OFFF) and overall survival (OS) at 18 months were 30.8% (95% confidence interval [CI]: 5.2, 56.4) and 72.7% (95% CI: 45.3, 100), respectively. For patients with recurrent disease, OFFF and OS at 18 months were 11.1% (95% CI: 0, 32.1) and 55.6% (95% CI: 15.4, 95.8), respectively. For patients with previously unirradiated disease, OFFF and OS at 18 months were 75.0% (95% CI: 31.6, 100) and 100.0%, respectively. Eight (57.1%) patients had Grade 1 acute adverse effects; 6 (42.9%) patients had chronic Grade 1 adverse effects; 1 (7.1%) patient developed Grade 2 stricture. Grade 3 tracheoesophageal fistula occurred in 1 (7.1%) patient. One patient died before completion of treatment of unrelated causes. CONCLUSIONS: HDR endoluminal brachytherapy is a well-tolerated treatment for superficial primary and recurrent EC in medically inoperable patients.
Brachytherapy 02/2013; · 1.47 Impact Factor
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ABSTRACT: OBJECTIVES: This study reports an early, single-institution experience of combined thoracoscopic and laparoscopic robotic-assisted minimally invasive esophagectomy (RAMIE) using a four-arm robotic platform, with special attention given to the pitfalls and complications during procedure development. METHODS: We conducted a prospective, single-cohort, observational study of patients undergoing RAMIE at a single institution. RESULTS: A total of 21 patients (median age, 62 years [range, 37-83 years]) underwent RAMIE with a four-arm robotic platform (17 by Ivor Lewis and 4 by McKeown). Of the patients, 17 (81%) had a complete (R0) resection, and 16 (76%) received induction treatment, the majority (14/21 [67%]) with combined chemoradiation. The median operative time was 556 min (range, 395-807 min), which decreased to 414 min (range, 405-543 min) for the last 5 cases in the series. The median estimated blood loss was 307 cm(3) (range, 200-500 cm(3)), and the median length of hospital stay was 10 days (range, 7-70 days). The median number of lymph nodes resected was 20 (range, 10-49). Five (24%) patients were converted to open procedures. Five patients (24%) had major complications. One (5%) died of complications on postoperative Day 70, and 3 (14%) had clinically significant anastomotic leaks (Grade II or greater, by Common Terminology Criteria for Adverse Events version 3.0). Three patients (14%) in this early experience developed airway fistulas. CONCLUSIONS: While four-arm RAMIE may offer advantages over standard minimally invasive esophagectomy approaches, its adoption in a structured program, with critical evaluation of adverse events and subsequent adjustment of technique, is paramount to maximize patient safety, minimize complications and improve the conduct of operation early in the learning curve. Particular technical consideration should be given to prevention of airway complications.
European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 01/2013; · 2.40 Impact Factor
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ABSTRACT: Postoperative atrial fibrillation (POAF) complicating general thoracic surgery is a marker of increased morbidity and stroke risk. Our goal was to determine whether increased preoperative brain natriuretic peptide (BNP) levels are able to stratify patients by the risk of POAF.
Using a prospective database of 415 patients aged 60 years or older, who had undergone lung or esophageal surgery during a 1-year period, the preoperative clinical data, including BNP levels, were compared between patients who developed POAF lasting longer than 5 minutes during hospitalization and those who did not.
POAF occurred in 65 (16%) of the 415 patients and was more frequent among patients who had undergone esophagectomy or anatomic lung resection (22% or 58 of 269) compared with those who did not (5% or 7 of 146; P < .0001). After esophagectomy or anatomic lung resection, 46 (34%) of the 135 patients with BNP levels greater than the median (≥30 pg/mL) developed POAF compared with only 12 (9%) of 134 patients with BNP levels less than 30 pg/mL (P < .0001). The rates of POAF in patients undergoing other thoracic procedures were low and not associated with the BNP levels. Multivariate logistic regression analysis showed that in patients undergoing esophagectomy or anatomic lung resection, older age (5-year increments, odds ratio [OR], 1.28; 95% confidence interval [CI], 1.01-1.61; P = .04), male gender (OR, 2.61; 95% CI, 1.12-4.17; P = .02), and BNP level 30 pg/mL or greater (OR, 4.52; 95% CI, 2.19-9.32; P < .0001) were independent risk factors for POAF. The length of hospital stay was significantly increased in patients who developed POAF compared with those who did not (P < .0001).
Among patients undergoing anatomic lung resection or esophagectomy, increased age, male gender, and preoperative BNP level of 30 pg/mL or greater were significant risk factors for the development of POAF. The identification of patients who are more likely to develop POAF will allow the development of trials assessing prevention strategies aimed at reducing this complication.
The Journal of thoracic and cardiovascular surgery 07/2012; 144(5):1249-53. · 3.41 Impact Factor
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Raja M Flores,
Ugonna Ihekweazu,
Joseph Dycoco,
Nabil P Rizk,
Valerie W Rusch, Manjit S Bains,
Robert J Downey,
David Finley,
Prasad Adusumilli,
Inderpal Sarkaria,
James Huang,
Bernard Park
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ABSTRACT: Large case series have demonstrated that video-assisted thoracoscopic surgery (VATS) lobectomy is feasible and safe. However, catastrophic intraoperative complications during VATS lobectomy requiring thoracotomy can be overlooked and are not reported in the current literature. We reviewed our experience to determine the frequency, management, and outcome of these complications.
A systematic review of a prospective database was performed after institutional review board approval. All patients who underwent VATS lobectomy or a combination of any VATS procedure plus a thoracotomy were identified. A catastrophic complication was defined as an event that resulted in an additional unplanned major surgical procedure other than the planned lobectomy.
From 2002 to 2010, a total of 633 VATS lobectomies were performed and 610 patients had any VATS procedure plus a thoracotomy. Thirteen catastrophic complications were identified in 12 (1%) patients. We included all cases in which a VATS was performed as well as a thoractomy since this would include conversions as well. These cases included 3 main pulmonary arterial and 1 main pulmonary venous transection requiring reanastomosis, 3 unplanned pneumonectomies, 1 unplanned bilobectomy, 1 tracheoesophageal fistula, 1 membranous airway injury to the bronchus intermedius, 1 complete staple line disruption of the inferior pulmonary vein injury to the azygos/superior vena cava junction, and 1 splenectomy. There were no intraoperative deaths.
Catastrophic intraoperative complications of VATS lobectomy are uncommon. However, awareness of the possibility of such injuries is critical to avoid them, and development of specific management strategies is necessary to limit morbidity should they occur.
The Journal of thoracic and cardiovascular surgery 12/2011; 142(6):1412-7. · 3.41 Impact Factor
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ABSTRACT: We previously reported a high mortality after induction therapy and pneumonectomy for non-small cell lung cancer. Recent reports suggest that operative mortality in these patients is declining. We analyzed our contemporary results to define operative mortality and factors determining surgical risk.
Eligible patients were identified from our prospective surgical database. Complications were graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events 3.0. Uni- and multivariate logistic regression models assessed the association of preoperative tests and clinical characteristics with outcome. Receiver operating characteristic curves and area under the receiver operating characteristic curve (AUC) statistics were calculated in a leave-one-out crossvalidation scheme to evaluate the predictive value of various models.
From January 2000 to December 2006, 549 patients underwent surgery after induction therapy. Median patient age was 64 years (range: 30-86), and 54% were women (298/549). All received chemotherapy, and 17% also had radiation. Lobectomy (388/549, 71%) and pneumonectomy (70/549, 13%) were the most common procedures. Complications occurred in 250 patients (46%), with grade 3 or higher in 23% (126/549). Inhospital mortality was 1.8% (10/549), with only one death after right pneumonectomy (1/30, 3%). Multivariate analysis showed that predicted postoperative (PPO) pulmonary function was associated with postoperative morbidity. By receiver operating characteristic curves, PPO product (AUC = 0.75, p < 0.001), PPO diffusion capacity (AUC = 0.70, p < 0.001), and preoperative % predicted PPO diffusion capacity (AUC = 0.66, p < 0.001) predicted mortality.
Our current experience shows that resection of non-small cell lung cancer after induction therapy, including pneumonectomy, is associated with low mortality. PPO pulmonary function is the strongest predictor of operative risk and should be used to select patients for surgery.
Journal of thoracic oncology: official publication of the International Association for the Study of Lung Cancer 09/2011; 6(9):1530-6. · 4.55 Impact Factor
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ABSTRACT: Surgical resection of residual tumor mass in responders to platinum-based chemotherapy has evolved as the preferred treatment of primary mediastinal nonseminomatous germ cell tumors (PMNGCTs). We reviewed a single institution's operative experience with these rare tumors.
We reviewed charts of patients resected for PMNGCT at Memorial Sloan-Kettering Cancer Center between July 1980 and April 2008. Analyses included Kaplan-Meier survival with univariate log-rank comparisons and Cox multivariate regression.
Fifty-seven patients were identified and followed up for a median of 5.3 years. Fifty-four of them received platinum-based preoperative chemotherapy, and 28 (49%) had limited stage I/II disease. Preoperative tumor markers normalized or decreased in 79% of patients. The most common surgical approach was anterolateral thoracotomy with partial sternotomy ("hemiclamshell," 38.6%). An R0 resection was achieved in 91% of the patients with a major morbidity of 17.5% and no postoperative deaths. The median overall survival was 31.5 months. Factors correlating with better survival on univariate analyses were necrosis or teratoma versus residual cancer on final pathology (p = 0.001), R0 resection (p = 0.03), normalized or decreased postchemotherapy/preoperative tumor markers (p < 0.001), normalized postoperative tumor markers (p = 0.004), stage I/II disease (p = 0.03), and surgery after 2000 versus 1980-1999 (p = 0.01). An exploratory multivariate analysis suggests that normalized or decreased postchemotherapy/preoperative tumor markers is the strongest independent predictor of improved survival.
In a cohort of PMNGCT patients in which 91% of the patients underwent complete posttherapy resection, response to chemotherapy, measured by normalized or decreased preoperative tumor markers, was the strongest predictor of improved survival.
Journal of thoracic oncology: official publication of the International Association for the Study of Lung Cancer 05/2011; 6(7):1236-41. · 4.55 Impact Factor
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ABSTRACT: The purpose of this report is to introduce a technique of direct lymphangiography to enable chylothorax treatment. Using a hybrid computed tomography (CT) and fluoroscopy imaging system, a 21-gauge needle was placed under CT guidance into the cisterna chyli to allow contrast lymphangiography and CT lymphangiography in two patients with presumed postoperative chylothorax. Water-soluble contrast media injection demonstrated the thoracic duct anatomy in both patients. Further successful needle disruption of the cisterna chyli was performed in one patient to interrupt lymph flow and stop the chylous leak, with subsequent resolution of the chylothorax.
CardioVascular and Interventional Radiology 02/2011; 34 Suppl 2:S240-4. · 2.09 Impact Factor
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Raja M Flores,
Ugonna N Ihekweazu,
Nabil Rizk,
Joseph Dycoco, Manjit S Bains,
Robert J Downey,
Prasad Adusumilli,
David J Finley,
James Huang,
Valerie W Rusch,
Inderpal Sarkaria,
Bernard Park
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ABSTRACT: Reports have questioned the oncologic efficacy of video-assisted thoracoscopic surgery when compared with thoracotomy despite similar survival results. In response, we investigated the pattern of recurrent disease and the incidence of second primary tumors after lobectomy by means of video-assisted thoracoscopic surgery and thoracotomy.
All patients who underwent lobectomy for clinical stage IA lung cancer determined by means of computed tomographic and positron emission tomographic analysis were identified from a prospective database at a single institution. All patients were selected for video-assisted thoracoscopic surgery or thoracotomy by an individual surgeon. Patients' characteristics, perioperative results, recurrences, and second primary tumors were recorded. Variables were compared by using Student's t test, the Pearson χ(2) test, and Fisher's exact test. A logistic regression model was constructed to identify variables influencing the development of recurrent disease or metachronous tumors.
From 2002 to 2009, 520 patients underwent lobectomy by means of video-assisted thoracoscopic surgery, and 652 underwent lobectomy by means of thoracotomy. Final pathological stage was similar in the video-assisted thoracoscopic surgery and thoracotomy groups. Logistic regression demonstrated a lower risk (odds ratio, 0.65; P = .01) of recurrent disease in patients undergoing video-assisted thoracoscopic surgery after adjusting for age, stage, sex, histology, tumor location, and synchronous primary tumors.
Recurrence rates for video-assisted thoracoscopic surgery appear to be at least equivalent to those for thoracotomy. This study supports lobectomy by means of video-assisted thoracoscopic surgery as an oncologically sound technique.
The Journal of thoracic and cardiovascular surgery 11/2010; 141(1):59-64. · 3.41 Impact Factor
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ABSTRACT: Nael Martini was one of the leading academic general thoracic surgeons of the late 20th century. His most notable contributions related to the surgical and multimodality treatment of lung cancer.
The Annals of thoracic surgery 03/2010; 89(3):1006-9. · 3.74 Impact Factor
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ABSTRACT: Distinguishing synchronous primary lung cancers (SPLCs) from advanced disease is important because prognosis and treatments are very different and a surgical approach to SPLC may result in survival similar to solitary cancers. Determining this distinction with certainty, however, is challenging. We reviewed our experience with surgical resection of presumed SPLC to analyze outcomes and identify factors associated with prolonged survival.
A retrospective review identified patients treated for presumptive SPLC. Cases were defined using modified criteria set forth by Martini and Melamed and histologic subtyping. Survival was estimated using the Kaplan-Meier method, and factors associated with survival were evaluated using a log-rank test or Cox proportional hazards model for categorical and continuous variables, respectively.
From January 1995 to July 2006, 175 patients met study criteria and underwent complete resection. Tumors were more often in different lobes of an ipsilateral chest (55 of 175, 31%) or contralateral lesions (45 of 175, 26%). More than half (104 of 175, 59%) of the patients underwent a single operation. Median follow-up was 50.3 months (4.8-164.7); median overall survival (OS) for the group was 67.4 months (46.4-80.0) with a 3-year OS of 64%. On multivariable analysis controlling for stage, only female gender was a significant predictor of better OS (p = 0.001).
An aggressive surgical approach to patients with apparent SPLC can result in survival that is comparable with patients with single lung cancers of similar stage. The Martini and Melamed criteria and histologic subtyping can identify appropriate patients for resection. Female gender was associated with superior OS.
Journal of thoracic oncology: official publication of the International Association for the Study of Lung Cancer 02/2010; 5(2):197-205. · 4.55 Impact Factor
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ABSTRACT: Thymic carcinomas are considered to be more aggressive than thymomas and carry a worse prognosis. We reviewed our recent experience with the surgical management of thymic tumors and compared the outcomes and patterns of relapse between patients with thymic carcinoma and those with thymoma.
We performed a single-institution retrospective cohort study. Data included patient demographics, stage, treatment, pathologic findings, and postoperative outcomes.
During the period 1995-2006, 120 patients with thymic tumors underwent surgical intervention, including 23 patients with thymic carcinoma and 97 patients with thymoma, as classified according to the World Health Organization 2004 histologic classification. The overall 5-year survival was significantly different between patients with thymic carcinoma and those with thymoma (thymic carcinoma, 53%; thymoma, 89%; P = .01). Data on relapse were available for 112 patients. The progression-free 5-year survival was also significantly different between patients with thymic carcinoma and those with thymoma (thymic carcinoma, 36%; thymoma, 75%; P < .01). Using multivariate analysis, thymic carcinoma and incomplete resection were found to be independent predictors of progression-free survival. Relapses in patients with thymic carcinoma tended to occur earlier, and occurred significantly more frequently at distant sites than in patients with thymoma (60% vs 13%, P = .01).
Patterns of relapse differ significantly between patients with thymic carcinoma and those with thymoma, with lower progression-free survival, earlier onset, and more distant relapses in patients with thymic carcinoma. Given the greater propensity for distant failures, the inclusion of systemic therapy in the treatment of thymic carcinoma might take on greater importance. Despite significantly higher rates of distant relapse, good overall survival in patients with thymic carcinoma can be achieved.
The Journal of thoracic and cardiovascular surgery 08/2009; 138(1):26-31. · 3.41 Impact Factor
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ABSTRACT: We have previously shown that in early clinical stage esophageal adenocarcinoma, a positron emission tomography standardized uptake values (PET SUVmax) of <4.5 is associated with earlier pathologic stage and predicts better survival. In this study, we analyze the impact of the pretreatment PET SUVmax in patients with locally advanced esophageal adenocarcinoma who undergo preoperative chemoradiotherapy.
We performed a retrospective analysis, selecting patients with adenocarcinoma of the esophagus who had a pretreatment PET scan and who received chemoradiotherapy before esophagectomy. Data recorded included demographics, PET SUVmax, treatment details, pathologic details, and survival data. Comparison of categorical variables was done by chi analysis, continuous variables by t test, survival analysis by the Kaplan-Meier method, and comparisons of survival using the log-rank test.
Between January 1996 and September 2007, 189 patients were appropriate for this analysis. The initial PET SUVmax was <4.5 in 28 patients and >or=4.5 in 161 patients. The two groups were similar with regards to demographics and treatment details. Patients in the low SUV group were less likely to show evidence of treatment response after chemoradiotherapy, including a higher likelihood of residual nodal disease and a lower likelihood of a pathologic complete response and estimated treatment response. However, both groups had similar survival.
Although the initial PET SUVmax does not predict survival in patients with locally advanced esophageal adenocarcinoma who receive preoperative chemoradiotherapy, patients with a high initial SUVmax respond better to preoperative therapy. These results can be used to better select esophageal cancer patients for combined modality treatment.
Journal of thoracic oncology: official publication of the International Association for the Study of Lung Cancer 07/2009; 4(7):875-9. · 4.55 Impact Factor
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Mark W Onaitis,
Rebecca P Petersen,
John C Haney,
Leonard Saltz,
Bernard Park,
Raja Flores,
Nabil Rizk, Manjit S Bains,
Joseph Dycoco,
Thomas A D'Amico,
David H Harpole,
Nancy Kemeny,
Valerie W Rusch,
Robert Downey
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ABSTRACT: This study was undertaken to review a large series of resections of colorectal pulmonary metastases in the era of modern chemotherapy.
A retrospective chart review of prospectively maintained thoracic surgery databases identified 378 patients who underwent pulmonary resection for colorectal cancer metastases with curative intent from 1998 to 2007.
The primary site of disease was rectum (52%), left colon (26%), right colon (16%), and unknown (6%). Before thoracic recurrence, 166 patients (44%) had previously undergone resection of extrathoracic metastases. Median disease-free interval (DFI) was 24 months from the time of the primary operation. The number of metastatic deposits resected was one in 60%, two in 20%, three in 10%, and four or more in 10%. Chemotherapy was administered to 87 patients (23%) before resection and to 169 patients (45%) after resection. Three-year recurrence-free survival was 28%, and 3-year overall survival was 78%. Multivariable analysis revealed age younger than 65 years, female sex, DFI less than 1 year, and number of metastases greater than three as independent predictors of recurrence. Of 44 patients with three or more lesions and less than 1 year DFI, none was cured by operation. By contrast, recurrence-free survival was 49% at 3 years for those with one lesion and DFI greater than 1 year.
Age younger than 65 years, female sex, DFI less than 1 year, and number of metastases greater than three predict recurrence. Medical management alone should be considered standard for patients who have both three or more pulmonary metastases and less than 1 year DFI.
The Annals of thoracic surgery 07/2009; 87(6):1684-8. · 3.74 Impact Factor
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ABSTRACT: OBJECTIVE: The objective of our study was to illustrate the potential for phrenic nerve injury during percutaneous lung ablation, to discuss the importance of this complication, and to review the expected location of the phrenic nerve on chest CT. CONCLUSION: Knowledge of the expected location of the phrenic nerve-a structure that is usually not visible on imaging but is important-is essential for avoiding injury to the nerve during pulmonary ablation.
American Journal of Roentgenology 08/2008; 191(2):565-8. · 2.78 Impact Factor
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ABSTRACT: The optimal procedure for resection of malignant pleural mesothelioma is controversial, partly because previous analyses include small numbers of patients. We performed a multi-institutional study to increase statistical power to detect significant differences in outcome between extrapleural pneumonectomy and pleurectomy/decortication.
Patients with malignant pleural mesothelioma who underwent extrapleural pneumonectomy or pleurectomy/decortication at 3 institutions were identified. Survival and prognostic factors were analyzed by the Kaplan-Meier method, log-rank test, and Cox proportional hazards analysis.
From 1990 to 2006, 663 consecutive patients (538 men and 125 women) underwent resection. The median age was 63 years (range, 26-93 years). The operative mortality was 7% for extrapleural pneumonectomy (n = 27/385) and 4% for pleurectomy/decortication (n = 13/278). Significant survival differences were seen for American Joint Committee on Cancer stages 1 to 4 (P < .001), epithelioid versus non-epithelioid histology (P < .001), extrapleural pneumonectomy versus pleurectomy/decortication (P < .001), multimodality therapy versus surgery alone (P < .001), and gender (P < .001). Multivariate analysis demonstrated a hazard rate of 1.4 for extrapleural pneumonectomy (P < .001) controlling for stage, histology, gender, and multimodality therapy.
Patients who underwent pleurectomy/decortication had a better survival than those who underwent extrapleural pneumonectomy; however, the reasons are multifactorial and subject to selection bias. At present, the choice of resection should be tailored to the extent of disease, patient comorbidities, and type of multimodality therapy planned.
The Journal of thoracic and cardiovascular surgery 04/2008; 135(3):620-6, 626.e1-3. · 3.41 Impact Factor
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ABSTRACT: The purpose of this study was to determine if the utilization of video-assisted thoracic surgery (VATS) for lobectomy for clinical stage I non-small cell lung cancer in elderly patients results in decreased complications compared with lobectomy by thoracotomy (THOR).
A retrospective, matched case-control study was performed evaluating the perioperative outcomes after lobectomy by VATS versus THOR performed in elderly patients (age > or = 70 years) at a single institution. All complications were graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events version 3.0 (http://ctep.cancer.gov/reporting/ctc.html).
Between May 1, 2002 and December 31, 2005 333 patients (245 THOR, 88 VATS) 70 years old or greater underwent lobectomy for clinical stage I non-small cell lung cancer. After matching based on age, gender, presence of comorbid conditions, and preoperative clinical stage, there were 82 patients in each group. Patients had similar preoperative characteristics. A VATS approach resulted in a significantly lower rate of complications compared with THOR (28% vs 45%, p = 0.04) and a shorter median length of stay (5 days, range 2 to 20 vs 6 days, range 2 to 27, p < 0.001). No patients undergoing VATS lobectomy had higher than grade 2 complications, whereas 7% of complications in the THOR group were grade 3 or higher. There were no perioperative deaths in the VATS patients compared with an in-hospital mortality rate of 3.6% (3 of 82) for THOR patients.
A VATS approach to lobectomy for clinical stage I non-small cell lung cancer in the elderly was associated with fewer and overall reduced severity of complications as well as a shorter hospital stay compared with thoracotomy.
The Annals of thoracic surgery 02/2008; 85(1):231-5; discussion 235-6. · 3.74 Impact Factor
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ABSTRACT: Extended resections for advanced-stage thymomas are not commonly performed because of the potential morbidity in the face of unclear survival or palliative benefit. We reviewed our experience with multimodality treatment for Masaoka stage IVA thymomas for feasibility and outcomes.
We conducted a retrospective review of a single-institution surgical database. Data included patient demographics, preoperative staging and treatment, perioperative events, pathologic findings, and postoperative outcomes.
During the period from 1996 to 2006, 18 patients who had Masaoka stage IVA thymoma underwent surgical resection. All patients received preoperative chemotherapy. Four patients with extensive pleural involvement underwent concomitant extrapleural pneumonectomy and postoperative hemithoracic radiation. Complete resection was achieved in 12 (67%) patients. There was no operative mortality. With a median follow-up of 32.2 months (range 1.4-129.9 months), 3-year, 5-year, and 10-year survivals were 91%, 78%, and 65%, respectively, and median survival has not yet been reached.
Multimodality therapy including extended surgical resection can be performed in select patients with stage IVA thymoma with low morbidity and mortality and can result in excellent long-term survival.
The Journal of thoracic and cardiovascular surgery 01/2008; 134(6):1477-83; discussion 1483-4. · 3.41 Impact Factor
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ABSTRACT: In a previous study of prognostic factors in patients with loco-regionally advanced adenocarcinoma of the esophagus treated with chemo-radiotherapy (CRT) followed by resection, we found that residual nodal disease was most prognostic of outcome. In this study, we evaluated prognostic factors among patients with squamous cell carcinoma (SCC) of the esophagus who have undergone a similar treatment regimen.
A retrospective review of patients with SCC of the esophagus who received CRT before esophagectomy. Data collected included demographics, CRT details, pathologic findings, and survival. Statistical methods included recursive partitioning and Kaplan-Meier analyses.
From 1996 to 2006, 91 patients were appropriate for this analysis. Complete pathologic response in the primary tumor (pt-pCR) occurred in 49 patients (53.8%), including 10 of 91 (10.9%) who had a pt-pCR but residual nodal disease. Recursive partitioning analysis identified three prognostic groups: (1) group 1 (n = 52), patients with minimal residual local disease (pt-pCR and T1-N any); (2) group 2 (n = 28), patients with residual T2 disease (N0 and N1) and patients with T3-4N0 disease; and (3) group 3 (n = 11), patients with residual T3-4N1 disease. Three-year survival was 68.4% in group 1, 45.6% in group 2, and 0 % in group 3 (p < 0.001).
Unlike adenocarcinoma, in which residual nodal disease after CRT is the most significant predictor of survival, in SCC of the esophagus, pt-pCR or minimal residual local disease after CRT predicts the best survival. These findings aid the design of future clinical trials.
Journal of thoracic oncology: official publication of the International Association for the Study of Lung Cancer 12/2007; 2(12):1117-23. · 4.55 Impact Factor
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ABSTRACT: Endoscopic ultrasound (EUS) is the most accurate locoregional staging tool for gastroesophageal junction (GEJ) adenocarcinoma, and it may allow pretreatment risk stratification. The purpose of this study was to compare preoperative EUS staging with postoperative pathologic staging and to assess the ability of EUS to predict survival after resection for GEJ adenocarcinoma.
Patients with GEJ adenocarcinoma, who had preoperative staging with EUS followed by resection, were identified from a prospectively maintained database. Patients receiving neoadjuvant therapy were excluded. EUS stage was compared with pathologic stage. Survival analyses were performed in patients who underwent complete gross resection.
From 1985 through 2003, 209 patients underwent preoperative EUS followed by surgery without neoadjuvant therapy for GEJ adenocarcinoma. EUS correlated with pathologic T stage in 128 of 209 (61%) patients and with pathologic nodal stage in 154 of 206 (75%) patients. EUS accurately stratified patients into "early" (T0-2 N0) or "advanced" (T3-4 or N1) disease categories in 173 (83%) patients. Curative (R0) resection was performed in 184 patients: EUS "early" (n=84) and "advanced" (n=122) stages were associated with R0 rates of 100% and 82%, respectively (p=0.001). EUS "early" versus "advanced" stage was highly predictive of outcomes (p < 0.0001). The 5-year disease-specific survival for EUS "early" patients was 65% compared with 34% for EUS "advanced" stage.
EUS accurately predicts pathologic stage. In addition, EUS is predictive of outcomes after complete gross resection without neoadjuvant treatment for GEJ adenocarcinoma and identifies a high-risk population that might benefit from preoperative therapy.
Journal of the American College of Surgeons 11/2007; 205(4):593-601. · 4.55 Impact Factor
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ABSTRACT: Lung injury, defined as acute hypoxemia accompanied by radiographic pulmonary infiltrates without a clearly identifiable cause, is a major cause of morbidity and mortality after major anatomic pulmonary resection. Our objective was to identify the incidence and risk factors for the development of postoperative lung injury.
A retrospective case-control study of consecutive patients undergoing resection for lung cancer at a single institution was performed. The severity of lung injury was defined using the American European Consensus Conference on ARDS (acute respiratory distress syndrome) criteria and the National Cancer Institute Common Terminology Criteria for Adverse Events version 3.0 (http://ctep.cancer.gov/reporting/ctc.html). Patients with lung injury were compared with matched control patients, based on age, sex, and extent of resection, for examination of a priori defined risk factors.
From January 2001 to June 2004, 1,428 patients underwent attempted curative lung cancer resection. Postoperative lung injury occurred in 76 (5.3%) cases, 44 (3.1%) of which met criteria for acute lung injury or acute respiratory distress syndrome. After matching, there were no differences between cases and control patients with respect to use of induction therapy, perioperative transfusions, or tumor laterality. After univariate and multivariate analysis, increasing perioperative fluid administration and decreasing postoperative predicted lung function were significant risk factors for the development of lung injury. The overall mortality for patients with lung injury was 25%, compared with 2.6% for the control group.
Lung injury after lung resection has a high mortality. Lower predicted postoperative lung function, especially diffusion capacity, in combination with greater perioperative fluid administration were significant predictors of postoperative lung injury.
The Annals of thoracic surgery 11/2007; 84(4):1085-91; discussion 1091. · 3.74 Impact Factor
