Pulmonary squamous cell carcinoma with a lepidic-pagetoid growth pattern.

We report a rare case of a peripheral squamous cell carcinoma (SCC) of the lung in which most of the tumor displayed a "lepidic" growth pattern. The tumor cells also appeared to grow along the alveolar walls between the overlying pneumocytes and underlying basement membrane, a form reminiscent of the "pagetoid" mode of spread. The neoplastic cells were positive for the squamous markers p63 and p40. TTF-1 and CK7 highlighted residual non-neoplastic pneumocytes, which either covered the lepidic tumor cells or lined pseudoglandular formations created by the filling of alveolar spaces by the tumor. CK7 also stained the tumor cells, albeit focally and weakly, a not uncommon finding in peripheral lung SCC. The tumor cells were negative for TTF-1 (clone 8G7G3/1), but did show focal weak reactivity with the less specific clone SPT24. The invasive area measured 2.5 mm while the overall size of the tumor including the lepidic-pagetoid component was 9.0 mm. Even though the invasive component was < 0.5 cm, the only option according to existing staging criteria was to stage it as pT1a. Since the current staging system does not account for the non-invasive lepidic component of pulmonary SCC, the increasing awareness of this variant may require its inclusion within the classification and pathological staging of lung carcinoma.

Long-term Outcomes After Lung Cancer Resection in Smokers: Analysis of the National Lung Screening Trial.

BACKGROUND: Smoking is a known risk factor for perioperative complications after lung resection; however, little data exists looking at the impact of smoking status (current versus former) on long-term oncologic outcomes after lung cancer surgery. We sought to compare overall survival (OS), progression-free survival (PFS), and cancer-specific mortality (CSM) in current and former smokers using data from the National Lung Screening Trial (NLST). Additionally, we performed subset analysis in current smokers in order to evaluate the effect of modern surgical techniques on long-term outcomes. METHODS: Patients with clinical stage IA or IB NSCLC who underwent upfront resection within 180 days of diagnosis were identified in the NLST database. Cox proportional hazard regression models were used to assess differences in patient and treatment characteristics with respect to OS and PFS, with a cause-specific hazard model used for CSM. RESULTS: A total of 593 patients were included in the study (269 former smokers, 324 current smokers). Lobar resection (LR) was performed more often than sublobar resection (SLR) (481 vs. 112), and thoracotomy was performed more often than thoracoscopy (482 vs. 86). Comparison of current versus former smokers showed no difference in OS or PFS after resection. Higher CSM was seen in current smokers (p = 0.049). Subset analysis of current smokers revealed no difference in OS or PFS between sub-lobar and lobar resection or thoracotomy and thoracoscopy. Although higher CSM was associated with thoracoscopy versus thoracotomy in this group, this finding was limited by a relatively small thoracoscopy sample size of 44 patients (p = 0.026). CONCLUSION: Our analysis of the NLST database shows no significant difference in OS and PFS when comparing current and former smokers undergoing resection for stage I NSCLC. Active smoking status was associated with higher CSM. Subset analysis of current smokers showed no difference in OS or PFS between sub-lobar and lobar resection or thoracotomy and thoracoscopy. Higher CSM was seen in current smokers who underwent thoracoscopy compared to thoracotomy; however, this finding was limited by a small sample size.

Impact of postoperative complications on long-term survival after esophagectomy in older adults: A SEER-Medicare analysis.

BACKGROUND: Esophagectomy is a complex procedure associated with a high rate of postoperative complications. It is not clear whether postoperative complications effect long-term survival. Most studies report the results from single institutions. METHODS: We examined the Surveillance, Epidemiology and End Results (SEER)-Medicare database to assess whether long-term overall and cancer-specific mortality of patients undergoing esophagectomy for cancer is impacted by postoperative complications. RESULTS: Nine hundred and forty patients underwent esophagectomy from 2007 to 2014, of which 50 died, resulting in a cohort of 890 patients. Majority were males (n = 764, 85.8%) with adenocarcinoma of the lower esophagus. Almost 60% of the group had no neoadjuvant therapy. Four hundred and fifty-five patients had no major complications (51.1%), while 285 (32.0%) and 150 (16.9%) patients had one, two, or more major complications, respectively. Overall survival at 90 days was 93.1%. Multivariate analysis of patients followed up for a minimum of 90 days demonstrated that the number of complications was significantly associated with decreased overall survival but no impact on cancer-specific survival. CONCLUSIONS: Our population-based analysis with its inherent limitations suggests that patients undergoing esophagectomy who experience complications have worse overall survival but not cancer-specific survival if they survive at least 90 days from the date of surgery.

Pagetoid involvement of bronchioles by metastatic breast carcinoma.

We report a case of a 36-year-old female with endobronchiolar spread of breast carcinoma in the lung. The patient had recently been diagnosed with invasive ductal breast carcinoma and imaging of the lungs revealed bilateral lung nodules. She then underwent a wedge resection of a lung nodule. The biopsy revealed a subpleural metastatic nodule of invasive ductal carcinoma with an intra-alveolar pattern of spread at its advancing edge. Several smaller foci of intra-alveolar tumor were noted as well as pagetoid spread of tumor cells along a 0.9 mm wide bronchiole. The neoplastic cells were TTF-1 negative, GATA3 positive and ER positive. This is the third reported case of pagetoid spread of metastatic breast carcinoma along the bronchial tree. This case emphasizes the importance of examining not only bronchi but also bronchioles to detect this unusual pattern of spread of metastatic breast carcinoma in lung resection specimens.

Effect of On-Site Cardiac Surgery Program on General Thoracic Surgery Outcomes.

OBJECTIVE: Limited data exist exploring the relationship between multispecialty surgical collaboration and outcomes in general thoracic surgery. To address this, the Nationwide Inpatient Sample (NIS) was analyzed to determine whether the presence of an on-site cardiac surgery program is associated with improved general thoracic surgery outcomes. METHODS: The NIS (1999-2008) was utilized to identify 389,959 patients who had a lobectomy, pneumonectomy, or esophagectomy. Short-term outcomes of patients undergoing these procedures were compared between hospitals with and without an on-site cardiac surgery program. Univariate and multivariate analyses were performed to determine patient and hospital predictors of mortality and morbidity. RESULTS: During the study period, patients undergoing lobectomy (n = 314,130), pneumonectomy (n = 34,860), or esophagectomy (n = 40,969) were identified. Univariate analysis demonstrated lower mortality for lobectomy (P < 0.001) and esophagectomy (P < 0.001) but not pneumonectomy (P = 0.344) in hospitals with a cardiac surgery program. All-cause morbidity was significantly lower for all 3 procedures in hospitals with a cardiac surgery program. However, multivariate analysis demonstrated that a cardiac surgery program was not an independent predictor when adjusted for known confounders, particularly procedure volume and hospital academic teaching status. CONCLUSIONS: The presence of an on-site cardiac surgery program is not in and of itself associated with improved general thoracic surgery outcomes. The presence of a cardiac surgery program is likely a surrogate for other known predictors of improved outcomes such as hospital teaching status and procedure volume.

Morbidity and mortality after general surgery in heart and lung transplant patients.

BACKGROUND: Heart and lung transplant patients can develop conditions necessitating general surgery procedures. Their postoperative morbidity and mortality remain poorly characterized and limited to case series from select centers. METHODS: The National Inpatient Sample (1998-2015) was used to identify 6433 heart and 3015 lung transplant patient admissions for general surgery procedures. For a comparator group, we identified 23,764,164 nontransplant patient admissions for the same procedures. Patient morbidity and mortality after general surgery were compared between transplant patients and nontransplant patients. Data were analyzed with frequency tables, χ 2 analysis, and a mixed-effects multivariate regression. RESULTS: Overall mortality was higher and length of stay longer in the transplant group compared to the nontransplant group. Analysis revealed that hospital size and comorbidities were predictors of mortality for patients undergoing certain general surgery procedures. Transplant status alone did not predict mortality. CONCLUSION: Our findings demonstrate that heart and lung transplant patients, compared to nontransplant patients, have more complications and a higher length of stay after certain general surgery procedures.

A Comparative Analysis of Long-Term Survival of Robotic Versus Thoracoscopic Lobectomy.

BACKGROUND: Minimally invasive lobectomy can be performed robotically or thoracoscopically. Short-term outcomes between the 2 approaches are reported to be similar; however, the comparative oncological effectiveness is not known. We sought to compare long-term survival after robotic and thoracoscopic lobectomy. METHODS: We performed a propensity-matched analysis of SEER (Surveillance, Epidemiology and End Results)-Medicare patients with non-small cell lung cancer from 2008 to 2013 who underwent minimally invasive lobectomy using either a thoracoscopic (n = 3881) or a robotic-assisted (n = 426) approach. Patients in the 2 groups were propensity matched 1:1 based on demographics, comorbidities, treatment, and tumor characteristics. We compared the overall survival (OS) and cancer-specific mortality (CSM) between the 2 groups. RESULTS: Within the matched cohort (n = 409 per group), the median age at surgery was 73 (range, 65-91) years, with a median follow-up of 35 months postsurgery. There was no difference in OS or CSM between the thoracoscopic and robotic-assisted groups (OS: 71.4% vs 73.1% at 3 years, overall P = .366; CSM: 16.6% vs 14.9% at 3 years, overall P = .639). CONCLUSIONS: Our propensity-matched analysis demonstrates that patients undergoing robotic-assisted lobectomy have similar OS and CSM compared with those patients undergoing thoracoscopic lobectomy. Oncologic outcomes are similar between the 2 minimally invasive approaches. These results demonstrate that further investigation is needed in the form of a randomized control trial, its variations, or additional large-scale registry analyses to verify these results.

Disparities in utilization of services for racial and ethnic minorities with hepatocellular carcinoma associated with hepatitis C.

BACKGROUND: Hepatitis C affects racial minorities disproportionately and is greatest among the black population. The incidence of hepatocellular carcinoma has increased with the largest increase observed in black and Hispanic populations, but limited data remain on whether hepatitis C hepatocellular carcinoma in racial-ethnic minorities have the same utilization of services compared with the white population. METHODS: We used the database of the National Inpatient Sample to identify hepatitis C-hepatocellular carcinoma patients (N = 200,163) who underwent liver transplantation (n = 11,491), liver resection (n = 4,896), or ablation of liver lesions (n = 6,933) from 2005 to 2015. We estimated utilization over time and assessed differences in utilization and inpatient mortality across patient characteristics. RESULTS: In multivariate analysis, factors associated with utilization of services included treatment year, sex, race, insurance status, hospital type, and comorbidity burden, with black and Hispanic patients having statistically significantly decreased utilization. Factors associated with inpatient mortality included treatment year, sex, race, insurance status, hospital type, hospital region, and comorbidity burden, with black patients having a statistically significantly greater risk of inpatient mortality. CONCLUSION: We identified racial and socioeconomic factors which were associated with utilization of services and inpatient mortality for patients with hepatitis C hepatocellular carcinoma. Blacks were especially disadvantaged in the receipt of care. Further work to abrogate these findings is imperative to ensure equitable provision of surgical therapies.

Fibrosing Mediastinitis Requiring Multimodality Treatment to Maintain Pulmonary Vein Patency.

Fibrosing mediastinitis is a rare condition with limited epidemiologic data. We detail a case of a 43-year-old female with no past medical history, who presented with chest pain and dyspnea on exertion. Chest computed tomography revealed a large mediastinal mass that was invading into the anterior chest as well as encasing the pulmonary hilum. Surgical pathology returned as dense hyaline fibrosis tissue with focal histiocytic aggregates and giant cells consistent with fibrosing mediastinitis. Treatment with rituximab and steroids showed a reduction in the size of her mass.

Decrease in Hospital Admissions for Acute Surgical Conditions During the COVID-19 Pandemic.

MINI-ABSTRACT: The nature of emergency room admissions for acute surgical conditions changed during the COVID-19 pandemic with less admissions for potentially life threatening conditions.

Disparities in Follow-Up After Low-Dose Lung Cancer Screening.

The National Lung Cancer Screening Trial (NLST) demonstrated an improvement in overall survival with lung cancer screening. Achieving follow-up for a positive screen is essential to impact early intervention for lung cancer. The objective of this study was to determine predictors of follow-up after a positive lung cancer screening test. The NLST database was queried for participants with a positive lung cancer screening exam. This cohort was then subdivided into patients who had follow-up and those who did not. Pairwise comparison was performed within different subgroups. A logistic regression model was then utilized to identify predictive factors associated with follow-up. Of the 53,454 patients who participated in the study, we identified 14,000 patients who had a positive lung cancer screening test. Of those patients, 12,503 followed up appropriately (89.3%). Women had a statistically higher follow-up rate compared to men (90% vs 88.8%, P ≤ 0.05). Patients reported as married or living as married also showed a higher rate of follow-up compared to patients reported as never married, divorced, separated, or widowed (90.2% vs 87.5%, P ≤ 0.05). The rate of follow-up among African-American patients was 82.8%, while those in white patients was 89.6%, this was statistically significant (P ≤ 0.05). Education level was not a significant factor in follow-up rates. Current smokers followed up at lower rates compared to former smokers (87.9 % vs 90.6%, P ≤ 0.05). Logistic regression determined gender, marital status, race, and smoking status to be predictors of follow-up. Follow-up rates after a positive lung cancer screening test were associated with a patient's gender, marital status, race, and smoking status.

Modified Blood Patch Used to Treat a High Output Chyle Leak After McKeown Esophagectomy.

Chyle leaks after esophagectomy are associated with significant morbidity and mortality. High-output fistulas are particularly difficult to manage, as the likelihood of spontaneous closure with conservative management is low. Leaks that fail to resolve with conservative management are referred for thoracic duct ligation or embolization. Some patients, however, are not candidates for these procedures or have persistent output despite intervention. We report a case of a post-McKeown esophagectomy patient with a high-output chyle leak despite intraoperative thoracic duct ligation. Treatment was successful with a modified blood patch through a neck drain.

Outcomes Following Major Oncologic Operations for Non-AIDS-Defining Cancers in the HIV Population: A Matched Comparison to the General Population.

INTRODUCTION: Human immunodeficiency virus (HIV) patients are living longer due to the availability of antiretroviral therapies, and non-AIDS-defining cancers are becoming more prevalent in this patient population. A paucity of data remains on post-operative outcomes following resection of non-AIDS-defining cancers in the HIV population. METHODS: The National Inpatient Sample was utilized to identify patients who underwent surgical resection for malignancy from 2005 to 2015 (HIV, N = 52,742; non-HIV, N = 11,885,184). Complications were categorized by international classification of disease (ICD)-9 diagnosis codes. Cohorts were matched on insurance, household income, zip code and urban/rural setting. Logistic regression assessed whether HIV was an independent predictor of post-operative complications. RESULTS: Descriptive statistics found HIV patients to have an increased rate of complications following select oncologic surgical resections. Univariate and multivariate logistic regression found HIV to only be an independent predictor of complications following pulmonary lobectomy (p = 0.011; OR 2.93, 95% CI 1.29-6.73). Length of stay was statistically longer following colectomy (2.61 days, 95% CI 1.98-3.44) in those with HIV. CONCLUSIONS: Our findings are hypothesis generating and highlight the potential safety of major cancer surgery in the HIV population. However, care providers need be cognizant of the potential increased risk of post-operative complications following pulmonary lobectomy and the potential for increased length of stay. These findings are an initial insight into quality of care and outcomes metrics on HIV patients undergoing major cancer operations.

Improving Self-Reported Preoperative Anxiety Through a Preoperative Education Program: A Quality Improvement Project.

BACKGROUND: Preoperative education is an important component of preparing patients for surgery. Preoperative anxiety is one of the most important problems for patients, because it causes emotional and psychiatric problems as well as physical problems. Anxiety has been associated with several pathophysiological responses such as hypertension and dysrhythmias, which can increase perioperative morbidity. Estimates suggest that between 11% and 80% of adult presurgical patients experience heightened levels of anxiety. OBJECTIVE: The purpose of this pilot project was to develop a preoperative education program for thoracic surgery patients and to assess the effectiveness of the program in decreasing patient's self-reported anxiety levels using the validated Patient-Reported Outcomes Measurement Information System (PROMIS) tool. METHODS: This quality improvement project used a pre- and posttest improvement design to evaluate patient's self-reported anxiety levels at three different timepoints during the preoperative and postoperative period. A total of 15 patients from a thoracic surgery practice participated in the study. RESULTS: The study showed no statistically significant change in patients' self-reported anxiety levels after completion of the preoperative education program (p = .538). Patients reported improvements in parameters such as expectations, pain, and preparedness. CONCLUSIONS: Although some studies have found that preoperative patient education decreases anxiety, this study supports others that indicate that anxiety is not affected by or associated with educational preparation prior to thoracic surgery. Though no statistical improvement in anxiety levels was demonstrated in this study, a majority of patients reported improvements in parameters such as expectations, pain, and preparedness. IMPLICATIONS FOR NURSING: As patient education is largely provided by the nursing profession, this article will help the profession to better understand what is important for patients to know in the preoperative setting. Setting patient expectations has a great impact on the patient's recovery and satisfaction with their surgical experience. As this is a pilot study, the goal is for continued research in the area of decreasing preoperative anxiety and preparing patients for surgery.