Clinical predictors of donor antibody titre and correlation with recipient antibody response in a COVID-19 convalescent plasma clinical trial.

BACKGROUND: Convalescent plasma therapy for COVID-19 relies on transfer of anti-viral antibody from donors to recipients via plasma transfusion. The relationship between clinical characteristics and antibody response to COVID-19 is not well defined. We investigated predictors of convalescent antibody production and quantified recipient antibody response in a convalescent plasma therapy clinical trial. METHODS: Multivariable analysis of clinical and serological parameters in 103 confirmed COVID-19 convalescent plasma donors 28 days or more following symptom resolution was performed. Mixed-effects regression models with piecewise linear trends were used to characterize serial antibody responses in 10 convalescent plasma recipients with severe COVID-19. RESULTS: Donor antibody titres ranged from 0 to 1 : 3892 (anti-receptor binding domain (RBD)) and 0 to 1 : 3289 (anti-spike). Higher anti-RBD and anti-spike titres were associated with increased age, hospitalization for COVID-19, fever and absence of myalgia (all P < 0.05). Fatigue was significantly associated with anti-RBD (P = 0.03). In pairwise comparison amongst ABO blood types, AB donors had higher anti-RBD and anti-spike than O donors (P < 0.05). No toxicity was associated with plasma transfusion. Non-ECMO recipient anti-RBD antibody titre increased on average 31% per day during the first three days post-transfusion (P = 0.01) and anti-spike antibody titre by 40.3% (P = 0.02). CONCLUSION: Advanced age, fever, absence of myalgia, fatigue, blood type and hospitalization were associated with higher convalescent antibody titre to COVID-19. Despite variability in donor titre, 80% of convalescent plasma recipients showed significant increase in antibody levels post-transfusion. A more complete understanding of the dose-response effect of plasma transfusion amongst COVID-19-infected patients is needed.

ISDE Presidential Biography: David B. Skinner, MD.

Dr. David Skinner, the 4th President of the ISDE, was a world-renowned surgeon, educator, scholar, and leader. He participated in the formation of the ISDE, hosted two international congresses in 1983 and 1989, and made important advances in the ISDE during his presidential tenure 1992-1995.

The 2018 ISDE achalasia guidelines.

Achalasia is a relatively rare primary motor esophageal disorder, characterized by absence of relaxations of the lower esophageal sphincter and of peristalsis along the esophageal body. As a result, patients typically present with dysphagia, regurgitation and occasionally chest pain, pulmonary complication and malnutrition. New diagnostic methodologies and therapeutic techniques have been recently added to the armamentarium for treating achalasia. With the aim to offer clinicians and patients an up-to-date framework for making informed decisions on the management of this disease, the International Society for Diseases of the Esophagus Guidelines proposed and endorsed the Esophageal Achalasia Guidelines (I-GOAL). The guidelines were prepared according the Appraisal of Guidelines for Research and Evaluation (AGREE-REX) tool, accredited for guideline production by NICE UK. A systematic literature search was performed and the quality of evidence and the strength of recommendations were graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Given the relative rarity of this disease and the paucity of high-level evidence in the literature, this process was integrated with a three-step process of anonymous voting on each statement (DELPHI). Only statements with an approval rate >80% were accepted in the guidelines. Fifty-one experts from 11 countries and 3 representatives from patient support associations participated to the preparations of the guidelines. These guidelines deal specifically with the following achalasia issues: Diagnostic workup, Definition of the disease, Severity of presentation, Medical treatment, Botulinum Toxin injection, Pneumatic dilatation, POEM, Other endoscopic treatments, Laparoscopic myotomy, Definition of recurrence, Follow up and risk of cancer, Management of end stage achalasia, Treatment options for failure, Achalasia in children, Achalasia secondary to Chagas' disease.

Extremes of body mass index and postoperative complications after esophagectomy.

Obesity has been variously associated with reduced or similar rates of postoperative complications compared to normal weight patients undergoing esophagectomy for cancer. In contrast, little is known about esophagectomy risks in the underweight population. The relationship between the extremes of body mass index (BMI) and postoperative complications after esophagectomy was evaluated. Consecutive esophagectomy patients (2000-2013) were reviewed. The patients were stratified based on BMI at the time of diagnosis: underweight (<18.5), normal (18.5-24.9), overweight (25-29.9), obese I (30-34.9), and obese II or III (≥35). Hospital length of stay as well as postoperative complications and their accordion severity grading were evaluated according to the BMI category. Of 388 patients, 78.6% were male with a median age of 62 years at the time of operation. Pathologic cancer stage was 0 to I in 53%. BMI distribution was as follows: 5.6% underweight, 28.7% normal, 31.4% overweight, 22.8% obese I, and 11.5% obese II or III. Performance status was 0 or 1 in 99.2%. Compared to normal BMI patients, underweight patients had increased pulmonary complications (odds ratio (OR) 3.32, P = 0.014) and increased other postoperative complications (OR 3.00, P = 0.043). Patients who were overweight did not have increased complications compared to normal BMI patients. BMI groups did not differ in mortality rates or complication accordion severity grading. Hospital length of stay trended toward a longer duration in the underweight population (P = 0.06). Underweight patients are at increased risk for postoperative pulmonary and other complications. Underweight patients may benefit from preoperative nutritional repletion and mitigation for sarcopenia. Aggressive postoperative pulmonary care may help reduce complications in these patients. In contrast, the operative risk in overweight and obese patients is similar to normal BMI patients.

Worldwide Esophageal Cancer Collaboration: pathologic staging data.

We report data-simple descriptions of patient characteristics, cancer categories, and non-risk-adjusted survival-for patients with pathologically staged cancer of the esophagus and esophagogastric junction after resection or ablation with no preoperative therapy from the Worldwide Esophageal Cancer Collaboration (WECC). Thirty-three institutions from six continents submitted de-identified data using standard definitions: demographics, comorbidities, clinical cancer categories, and all-cause mortality from first management decision. Of 13,300 patients, 5,631 had squamous cell carcinoma, 7,558 adenocarcinoma, 85 adenosquamous carcinoma, and 26 undifferentiated carcinoma. Patients were older (62 years) men (80%) with normal body mass index (51%), little weight loss (1.8 kg), 0-2 ECOG performance status (83%), and a history of smoking (70%). Cancers were pT1 (24%), pT2 (15%), pT3 (50%), pN0 (52%), pM0 (93%), and pG2-G3 (78%); most involved distal esophagus (71%). Non-risk-adjusted survival for both squamous cell carcinoma and adenocarcinoma was monotonic and distinctive across pTNM. Survival was more distinctive for adenocarcinoma than squamous cell carcinoma when pT was ordered by pN. Survival for pTis-1 adenocarcinoma was better than for squamous cell carcinoma, although monotonic and distinctive for both. WECC pathologic staging data is improved over that of the 7th edition, with more patients studied and patient and cancer variables collected. These data will be the basis for the 8th edition cancer staging manuals following risk adjustment for patient, cancer, and treatment characteristics, and should direct 9th edition data collection. However, the role of pure pathologic staging as the principal point of reference for esophageal cancer staging is waning.

Worldwide Esophageal Cancer Collaboration: clinical staging data.

To address uncertainty of whether clinical stage groupings (cTNM) for esophageal cancer share prognostic implications with pathologic groupings after esophagectomy alone (pTNM), we report data-simple descriptions of patient characteristics, cancer categories, and non-risk-adjusted survival-for clinically staged patients from the Worldwide Esophageal Cancer Collaboration (WECC). Thirty-three institutions from six continents submitted data using variables with standard definitions: demographics, comorbidities, clinical cancer categories, and all-cause mortality from first management decision. Of 22,123 clinically staged patients, 8,156 had squamous cell carcinoma, 13,814 adenocarcinoma, 116 adenosquamous carcinoma, and 37 undifferentiated carcinoma. Patients were older (62 years) men (80%) with normal body mass index (18.5-25 mg/kg2 , 47%), little weight loss (2.4 ± 7.8 kg), 0-1 ECOG performance status (67%), and history of smoking (67%). Cancers were cT1 (12%), cT2 (22%), cT3 (56%), cN0 (44%), cM0 (95%), and cG2-G3 (89%); most involved the distal esophagus (73%). Non-risk-adjusted survival for squamous cell carcinoma was not distinctive for early cT or cN; for adenocarcinoma, it was distinctive for early versus advanced cT and for cN0 versus cN+. Patients with early cancers had worse survival and those with advanced cancers better survival than expected from equivalent pathologic categories based on prior WECC pathologic data. Thus, clinical and pathologic categories do not share prognostic implications. This makes clinically based treatment decisions difficult and pre-treatment prognostication inaccurate. These data will be the basis for the 8th edition cancer staging manuals following risk adjustment for patient characteristics, cancer categories, and treatment characteristics and should direct 9th edition data collection.

Worldwide Esophageal Cancer Collaboration: neoadjuvant pathologic staging data.

To address uncertainty of whether pathologic stage groupings after neoadjuvant therapy (ypTNM) for esophageal cancer share prognostic implications with pathologic groupings after esophagectomy alone (pTNM), we report data-simple descriptions of patient characteristics, cancer categories, and non-risk-adjusted survival-for pathologically staged cancers after neoadjuvant therapy from the Worldwide Esophageal Cancer Collaboration (WECC). Thirty-three institutions from six continents submitted data using variables with standard definitions: demographics, comorbidities, clinical cancer categories, and all-cause mortality from first management decision. Of 7,773 pathologically staged neoadjuvant patients, 2,045 had squamous cell carcinoma, 5,686 adenocarcinoma, 31 adenosquamous carcinoma, and 11 undifferentiated carcinoma. Patients were older (61 years) men (83%) with normal (40%) or overweight (35%) body mass index, 0-1 Eastern Cooperative Oncology Group performance status (96%), and a history of smoking (69%). Cancers were ypT0 (20%), ypT1 (13%), ypT2 (18%), ypT3 (44%), ypN0 (55%), ypM0 (94%), and G2-G3 (72%); most involved the distal esophagus (80%). Non-risk-adjusted survival for yp categories was unequally depressed, more for earlier categories than later, compared with equivalent categories from prior WECC data for esophagectomy-alone patients. Thus, survival of patients with ypT0-2N0M0 cancers was intermediate and similar regardless of ypT; survival for ypN+ cancers was poor. Because prognoses for ypTNM and pTNM categories are dissimilar, prognostication should be based on separate ypTNM categories and groupings. These data will be the basis for the 8th edition cancer staging manuals following risk adjustment for patient, cancer, and treatment characteristics and should direct 9th edition data collection.

Phase II study of neoadjuvant therapy with docetaxel, cisplatin, panitumumab, and radiation therapy followed by surgery in patients with locally advanced adenocarcinoma of the distal esophagus (ACOSOG Z4051).

BACKGROUND: Preoperative chemoradiotherapy (CRT) improves outcomes in patients with locally advanced but resectable adenocarcinoma of the esophagus. ACOSOG Z4051 evaluated CRT with docetaxel, cisplatin, and panitumumab (DCP) in this patient group with a primary end point of a pathologic complete response (pCR) ≥35%. PATIENTS AND METHODS: From 15 January 2009 to 22 July 2011, 70 patients with locally advanced but resectable distal esophageal adenocarcinoma were enrolled. Patients received docetaxel (40 mg/m(2)), cisplatin (40 mg/m(2)), and panitumumab (6 mg/kg) on weeks 1, 3, 5, 7, and 9 with RT (5040 cGy, 180 cGy/day × 28 days) beginning week 5. Resection was planned after completing CRT. PCR was defined as no viable residual tumor cells. Secondary objectives included near-pCR (≤10% viable cancer cells), toxicity, and overall and disease-free survival. Adverse events were graded using the CTCAE Version 3.0. RESULTS: Five of 70 patients were ineligible. Of 65 eligible patients (59 M; median age 61), 11 did not undergo surgery, leaving 54 assessable. PCR rate was 33.3% and near-pCR was 20.4%. Secenty-three percent of patients completed DCP (n = 70) and 92% completed RT. 48.5% had toxicity ≥grade 4. Lymphopenia (43%) was most common. Operative mortality was 3.7%. Adult respiratory distress syndrome was encountered in two patients (3.7%). At median follow-up of 26.3 months, median overall survival was 19.4 months and 3-year overall survival was 38.6% (95% confidence interval 24.5% to 60.8%). CONCLUSIONS: Neoadjuvant CRT with DCP is active (pCR + near-pCR = 53.7%) but toxicity is significant. Further evaluation of this regimen in an unselected population is not recommended. CLINICALTRIALSGOV IDENTIFIER: NCT00757172.

Pathologic response rates following definitive dose image-guided chemoradiotherapy and resection for locally advanced non-small cell lung cancer.

INTRODUCTION: Treatment of technically operable, medically fit locoregionally advanced non-small cell lung cancer (NSCLC) patients is a controversial therapeutic challenge. Our group routinely uses a trimodality approach. Recent advances in radiotherapy allow for improved tumor targeting and daily patient positioning. We hypothesized that these technologies would improve pathologic response rates. We analyzed consecutively treated stage IIIA/IIIB NSCLC patients undergoing chemoradiotherapy before major lung resection, with particular attention paid to the impact of advanced technologies. METHODS: Locoregionally advanced NSCLC patients (N2) staged in a multidisciplinary forum with mediastinoscopy were planned to receive platinum-based chemotherapy and 60Gy and major lung resection. Four-dimensional CT (4DCT) and image-guided radiotherapy (IGRT) were used as available. Survival endpoints were estimated using the Kaplan-Meier method and compared using the log-rank test. Multivariate analysis was performed using Cox proportional hazards models. RESULTS: We identified 53 patients from 2/1999 to 2/2010. Median RT dose was 59Gy. 68% underwent lobectomy. Forty-three patients were downstaged pathologically (81%), 38 experienced mediastinal sterilization (72%), and 21 (40%) had complete pathologic response (pCR). 1 and 2 year OS were 85.5% and 61.6%. Superior OS and DFS were associated with nodal downstaging and mediastinal sterilization (pN0). Treatment with IGRT/4DCT in 10 patients resulted in high rates of nodal downstaging (100% vs 77%, p=0.0452), mediastinal sterilization (90% vs 67%, p=0.0769), and pCR (60% vs 35%, p=0.0728). CONCLUSIONS: In selected patients, definitive dose CRT followed by major lung resection results in promising DFS and OS. The use of advanced radiotherapy techniques (4DCT and IGRT) appears to result in promising pathologic response rates.

Assessment of a scoring system for predicting complications after esophagectomy.

Complications occur frequently after esophagectomy. Identifying the risk of complications preoperatively may help in patient selection and postoperative management. We performed a retrospective review of patients who underwent esophagectomy between 1980 and 2009. A previously reported scoring system was used to estimate risk, and its ability to predict complications was assessed. A total of 514 patients (382 men; 74%) with a mean age of 59.0 ± 12.5 years underwent esophagectomy for cancer (398; 77%) or benign disease. Minor complications occurred in 224 patients (44%) and severe complications occurred in 134 patients (26%). The calculated risk score was based on weighted values for age, coronary artery disease, cerebrovascular disease, type of operation, and forced expiratory volume in the first second expressed as a percent of predicted (FEV1%). Increasing risk score was associated with a linear increase in the incidence of complications (P < 0.001 for either severe complications or any complications). The scoring system predicted severe complications with an accuracy of 65.3% (P < 0.001). Score groups identified an incremental risk of severe complications (0 to 6 = 12%; 7 to 13 = 18%; 14 to 20 = 28%; 21 to 27 = 36%; >27 = 52%; P < 0.001). Complications are frequent after esophagectomy and can be predicted using a previously reported scoring system. This scoring system may assist in patient selection for esophagectomy and in providing appropriate resources for postoperative management of higher risk patients.

ERS/ESTS clinical guidelines on fitness for radical therapy in lung cancer patients (surgery and chemo-radiotherapy).

A collaboration of multidisciplinary experts on the functional evaluation of lung cancer patients has been facilitated by the European Respiratory Society (ERS) and the European Society of Thoracic Surgery (ESTS), in order to draw up recommendations and provide clinicians with clear, up-to-date guidelines on fitness for surgery and chemo-radiotherapy. The subject was divided into different topics, which were then assigned to at least two experts. The authors searched the literature according to their own strategies, with no central literature review being performed. The draft reports written by the experts on each topic were reviewed, discussed and voted on by the entire expert panel. The evidence supporting each recommendation was summarised, and graded as described by the Scottish Intercollegiate Guidelines Network Grading Review Group. Clinical practice guidelines were generated and finalized in a functional algorithm for risk stratification of the lung resection candidates, emphasising cardiological evaluation, forced expiratory volume in 1 s, systematic carbon monoxide lung diffusion capacity and exercise testing. Contrary to lung resection, for which the scientific evidences are more robust, we were unable to recommend any specific test, cut-off value, or algorithm before chemo-radiotherapy due to the lack of data. We recommend that lung cancer patients should be managed in specialised settings by multidisciplinary teams.

Survival outcomes of resected patients who demonstrate a pathologic complete response after neoadjuvant chemoradiation therapy for locally advanced esophageal cancer.

A variety of strategies, using chemotherapy, radiation therapy, and surgical resection have been employed in the treatment of locally advanced esophageal cancer. No strategy has proven superior, and poor long-term survival is anticipated. A survival benefit has been suggested for patients who achieve a pathologic complete response (pCR) following neoadjuvant chemoradiation therapy. We examined the collective results at three institutions of patients who achieved a pCR following neoadjuvant chemoradiation therapy. A retrospective, chart-based review was conducted. Kaplan-Meier calculations were used to determine overall and disease-free survival. Between 1995 and 2002, 229 patients were treated with neoadjuvant chemoradiation followed by surgery as a planned approach for locally advanced esophageal cancer. Forty-one patients (18%) demonstrated pCR and were the focus of this study. Histology was adenocarcinoma in 29, squamous in 10, and adenosquamous/undifferentiated in two patients. Forty patients were staged by endoscopic ultrasound prior to neoadjuvant therapy and all demonstrated a T-stage of 2 or higher, while 19 had evidence of nodal metastasis. Four patients died in the perioperative period. The remaining patients have been followed for an average of 46 months. Overall survival at 5 years was 56.4% and a median survival has not been reached. Esophageal cancer patients who demonstrate a pCR following neoadjuvant chemoradiation are a select subset who demonstrate excellent long-term survival. Identification of clinical variables or biomarkers predictive of pCR may therefore optimize treatment strategies of patients with locally advanced esophageal cancer.

Influence of buried hydrogen-bonding groups within monolayer films on gas-surface energy exchange and accommodation.

Self-assembled monolayers (SAMs) of carbonyl-containing alkanethiols on gold are employed to explore the influence of hydrogen-bonding interactions on gas-surface energy exchange and accommodation. H-bonding, COOH-terminated SAMs are found to produce more impulsive scattering and less thermal accommodation than non-H-bonding, COOCH3-terminated monolayers. For carbamate-functionalized SAMs of the form Au/S(CH2)16OCONH(CH2)(n-1)CH3, impulsive scattering decreases and accommodation increases as the H-bonding group is positioned farther below the terminal CH3.

Laparoscopic management of giant paraesophageal herniation.

BACKGROUND: Many surgeons have found laparoscopic fundoplication effective management of medically recalcitrant gastroesophageal reflux disease (GERD) associated with sliding type I hiatal hernias. The anatomic distortion and technical difficulty inherent with repair has limited the use of laparoscopy for repair of "giant" paraesophageal hernias (gPH). METHODS: Since July 1993, we have accomplished laparoscopic repair of paraesophageal hiatal hernias in 54 of 60 (90%) patients. Five patients had classic type II hernias with total intrathoracic stomachs, and 53 patients had large sliding/paraesophageal type III herniation. Two patients had true parahiatal hernias. None had gastric incarceration. Median age was 53 years and 28 of 60 (47%) were women. Chest pain and dysphagia were primary complaints from 39 of 60 (65%). Heartburn with or without regurgitation was present in 52 of 60 (85%). Preoperative manometry and prolonged pH testing were obtained on 43 of 60 (72%) and 44 of 60 (73%) patients, respectively. Principles of repair included reduction of the hernia, excision of the sac, crural approximation, and fundoplication over a 54F bougie (Nissen, 41; Dor, 1; Toupet, 18) to "pexy" the stomach within the abdomen and to control postoperative reflux. RESULTS: Mean operative time was 202+/-81 minutes. Conversion to "open" repair was required in 6 patients (iatrogenic esophageal injury in 2 patients and difficult hernia sac dissection in 4 patients). One postoperative mortality occurred as a result of sepsis and multiorgan failure after an intraoperative esophageal perforation. Follow-up barium swallow performed in 44 of 60 patients demonstrated recurrent hiatal hernias in 3 patients. Preoperative symptoms have been relieved in all but 3 patients. Reoperation for recurrent paraesophageal herniation has been required in these latter 3 patients. CONCLUSIONS: Although technically challenging, laparoscopic repair of paraesophageal hiatal hernias is a viable alternative to "open" surgical approaches. Control of the herniation and the patient's symptoms are equivalent and hospitalization and return to full activity are shorter.

Long-term outcome after resection for bronchial carcinoid tumors.

OBJECTIVES: We sought to determine the long-term survival of patients treated for bronchial carcinoid tumors and whether lesser resections have had an effect on outcomes. METHODS: We conducted a retrospective, multi-institutional review of patients treated surgically for primary bronchial carcinoid tumors since 1980. Operative approach, pathologic stage, histology, surgical complications, tumor recurrence, and long-term survival were assessed. RESULTS: There were 50 men and 89 women with a mean age of 52.2+/-17.4 and 58.9+/-13.3 years, respectively (P=0.021). Men were more likely to be current or former smokers than were women. Operations included lobectomy or bilobectomy in 110, pneumonectomy in four, wedge resection in 22, and bronchial sleeve resection only in three patients; resection was performed thoracoscopically in six patients. One patient died postoperatively. Stages were I, 121; II, nine; III, six; and IV, three. Typical carcinoid tumors were stage I in 100 and more advanced (stages II-IV) in nine, whereas atypical carcinoid tumors were stage I in 18 and more advanced in eight (P=0. 002). Median follow-up was 43 months (range 1-149) during which 21 (15%) patients died (four from recurrent cancer) and 19 patients (14%) were lost to follow-up. Recurrent cancer developed in 2/98 patients with typical and 5/25 patients with atypical subtypes (P<0. 001; log-rank test). The likelihood of recurrence was related to histological subtype (relative risk 7.9 for atypical carcinoid; 95% confidence interval 1.4-43.5). Five-year survival was 88% for stage I patients and was 70% for patients with more advanced stages. When stratified by stage, survival was related to age (relative risk=1.9 for a 10 year increase in age; 95% confidence interval 1.2-2.9) and possibly to the histological subtype, but not to patient gender, year of operation, or type of operation performed. CONCLUSIONS: Either major lung resection or wedge resection is appropriate treatment for patients with early stage typical bronchial carcinoid tumors. Survival is favorable for early stage tumors regardless of histological subtype. Local recurrence is more common among patients with atypical subtypes, suggesting that a formal resection may improve long-term outcome.

Measurement of flow characteristics during individual contractions in bovine mesenteric lymphatic vessels.

We developed a novel technique for measuring flow characteristics during individual contractions in lymph vessels. Bovine mesenteric lymph vessel segments (n = 15) were mounted in organ baths and allowed to equilibrate for 1 hr. Transmural pressure was subsequently increased by 2 cm H2O increments at 15 min intervals and vessel outputs were collected during the final 10 min of each period and measured. Flow also was continuously recorded with an in-line Doppler transducer connected to a flow analyzer, and flow characteristics were analyzed. The two methods of flow measurement correlated well (r2 = 0.92). Mean flow increased with increasing transmural pressure and reached a maximum of 0.5 +/- 0.1 ml/min at a transmural pressure of 8 cm H2O. The rate of spontaneous contractions, the peak flow during a contraction-induced wave, and the total volume of flow during a wave also increased with increasing transmural pressure and reached maximums of 12.4 +/- 1.0 min-1, 8.2 +/- 1.6 ml/min, and 0.21 +/- 0.06 ml, respectively. Wave duration changed little in response to changes in transmural pressure. Continuous in-line flow measurement is an accurate technique for assessing flow characteristics during individual contractions in lymph vessels in vitro. Transmural pressure regulates flow by influencing spontaneous contraction frequency and total and peak flows during contraction-induced waves.

Does pneumonectomy for lung cancer adversely influence long-term survival?

OBJECTIVE: The increased operative mortality associated with pneumonectomy has stimulated the use of lung-sparing operations such as sleeve lobectomy. Whether pneumonectomy adversely affects long-term outcome after lung resection is unknown. METHODS: We reviewed the cases of patients who underwent lobectomy/bilobectomy or pneumonectomy because of non-small cell lung cancer between January 1980 and June 1998. Survival curves were compared by the log-rank test. Covariates were determined for operative mortality and survival using logistic regression analysis and Cox proportional hazards estimation, respectively. RESULTS: There were 259 men and 183 women who underwent lobectomy/bilobectomy (340) or pneumonectomy (102). Operative mortality was 36 (8.1%) patients overall, 24 (7.0%) for lobectomy/bilobectomy and 12 (12%) for pneumonectomy. Mean follow-up was 41 months (range 0-222 months). Median survival was worse for pneumonectomy (stage II: 17.9 vs 36.3 months, log-rank P =. 05; stage III: 11.7 vs 21.3 months, log-rank P =.07). However, important covariates for survival were age, primary tumor status, regional nodal status, and forced expiratory volume in 1 second. After adjusting for these covariates, survival did not differ significantly between the types of operations (hazard ratio for pneumonectomy 1.21; 95% CI 0.88-1.68). CONCLUSIONS: We did not detect a significant long-term adverse influence of pneumonectomy on survival after adjusting for other prognostic factors, but randomized clinical trials would be needed to definitively address this issue.

Sex-associated differences in survival of patients undergoing resection for lung cancer.

BACKGROUND: The increasing incidence of lung cancer among women prompted us to assess whether sex-associated differences exist in the presentation and survival of patients who undergo major lung resection for lung cancer. METHODS: We performed a retrospective review of patients who had major lung resection for lung cancer from January 1980 to June 1998. RESULTS: There were 265 men and 186 women. Women were younger (60.7+/-0.8 versus 63.6+/-0.6 years; p = 0.005). Adenocarcinoma was more common among women (48% versus 40%; p = 0.001). Pathologic stages for men were: I = 43%, II = 26%, IIIA = 25%, IIIB or IV = 6%, and for women: I = 52%, II = 20%, IIIA = 22%, IIIB or IV = 6% (p = 0.146). Median survival was better for women (41.8 versus 26.9 months; p = 0.006). This was due both to a difference in stage at presentation and to a better median survival rate for adenocarcinoma compared with squamous cell cancer. The data suggest an association between sex and survival, although this failed to reach statistical significance. Sex influenced survival with a relative risk for women of 0.67 (95% confidence interval 0.35 to 1.29; p = 0.231 adjusted for stage, cell type, age, and spirometry). CONCLUSIONS: There are sex-associated differences in the presentation and possibly in the survival of patients with lung cancer. This finding has possible implications regarding the selection of patients for therapy and for the design of randomized therapeutic trials.

Combined laminectomy and thoracoscopic resection of a dumbbell neurofibroma: technical case report.

OBJECTIVE AND IMPORTANCE: We describe combined laminectomy and thoracoscopic surgery for removal of a dumbbell thoracic spinal tumor to demonstrate the feasibility of such an approach. CLINICAL PRESENTATION: We present the case of a 29-year-old man who developed chest pain and spinal cord compression from a thoracic dumbbell neurofibroma. TECHNIQUE: Surgical approaches for benign nerve sheath tumors that extend from the spinal cord into the thoracic cavity include combined laminectomy and thoracotomy either in one or two stages, or a lateral extracavitary approach involving laminectomy, facetectomy, and rib resection in a single stage. We performed a combination laminectomy and thoracoscopic tumor resection in a single stage with good results. CONCLUSION: This technique has not been reported previously in the literature. It has the advantage of avoiding the potential morbidity of a thoracotomy, as well as the extensive muscle dissection and pain associated with the lateral extracavitary approach.