Objective To determine the response rate, toxicity, and rate of complete resection after induction chemoradiotherapy for locally advanced thymic tumors, which were defined by specific radiographic ...criteria. Methods A single-arm, pilot trial was conducted at 4 institutions. Patients with thymoma or thymic carcinoma who met specific criteria on computed tomography were accrued. Induction therapy consisted of 2 cycles of cisplatin and etoposide combined with 45 Gy of thoracic radiotherapy. Patients underwent computed tomography and positron emission tomography before and after induction therapy and then resection was attempted. Postoperative chemoradiotherapy was administered in selected patients. The primary endpoint was the pathologic response to induction therapy. The secondary endpoints were toxicity, surgical complications, radiographic response, and the rate of R0 resection. Results A total of 22 patients were accrued during a 5-year period (1 patient withdrew before starting induction therapy). Of the 22 patients, 21 completed induction therapy, and 9 (41%) experienced grade 3 or 4 toxicity. A total of 10 patients had a partial radiographic response and 11 had stable disease. Of the 21 patients, 17 (77%) underwent an R0 resection, 3 (14%) an R1 resection, and 1 (5%) underwent debulking. Eight patients sustained surgical complications (36%), and two patients (9%) died postoperatively. Of the 21 patients, 13 (62%) had either thymic carcinoma or B3 thymoma and 15 (71%) had either Masaoka stage III or IV disease. No patient had a complete pathologic response, but 5 specimens (24%) had <10% viable tumor. Conclusions The present induction chemoradiotherapy protocol, which used specific computed tomography inclusion criteria to successfully select locally advanced thymic tumors, appeared to be tolerable and resulted in a high rate of complete surgical resection.
Objectives To determine if there are advantages to transitioning to robotics by a surgeon who is already proficient in performing video-assisted thoracic surgical (VATS) lobectomy. Methods A single ...surgeon proficient in VATS lobectomy initiated a robotic lobectomy program, and a retrospective review was conducted of his patients undergoing minimally invasive lobectomy (robotics or VATS) for lung cancer between 2011 and 2012. Data collected included patient/tumor characteristics, morbidity, mortality, operative times, and length of hospital stay. Results Over a 24-month period, a total of 69 patients underwent minimally invasive lobectomy (35 robotic, 34 VATS). Patients in each group were similar in age and clinical stage. Robotic upper lobectomy operative times were longer than VATS (172 vs 134 minutes; P = .001), with no significant difference in lower lobectomies noted (140 vs 123 minutes; P = .1). Median length of stay was 3 days in both groups, and the median number of lymph nodes harvested was 18 (robotic) versus 16 (VATS; P = .42). Morbidity and mortality for robotic versus VATS were 11% versus 18% ( P = .46) and 0% versus 3% ( P = .49), respectively. Conclusions There does not seem to be a significant advantage for an established VATS lobectomy surgeon to transition to robotics based on clinical outcomes. The learning curve for robotic upper lobectomies seems to be more significant than that for lower lobectomies.
Background Recent multiinstitutional published data have demonstrated increased pathologic nodal upstaging by robotic lobectomy compared with historical video-assisted thoracic surgery (VATS) ...lobectomy data. To eliminate potential variability from multiple surgical techniques, we compared the rate of nodal upstaging at a single institution where robotic and VATS lobectomy are both performed. Methods We retrospectively reviewed clinically node-negative patients with lung cancer undergoing VATS or robotic lobectomy. Clinical data were recorded in concordance with The Society of Thoracic Surgeons database elements. The rates of pathologic nodal upstaging as well as disease-free and overall survival were calculated. Results A total of 211 patients underwent anatomic lobectomy by VATS (n = 158) or robotics (n = 53) from 2009 to 2014. The two groups were statistically similar in their clinical stage, tumor size, location, and histologic evaluation. Within the VATS group, 24 patients experienced nodal upstaging (15.2%), with 13 patients having pN1 disease, and 11 patients having pN2 disease. The robotics group contained 7 patients (13.2%) with nodal upstaging, with 5 patients exhibiting pN1 disease and 2 patients with pN2 disease. When VATS and robotics were compared, there was no significant difference in pathologic upstaging ( p = 0.72), 2-year overall survival (88% vs 95%, respectively; p = 0.40), or 2-year disease-free survival (83% vs 93%, respectively; p = 0.48). Conclusions In this comparison of robotic and VATS lobectomy for clinically node-negative lung cancer that was managed with consistent surgical technique and pathologic evaluation, the rate of nodal upstaging achieved by robotics appears similar to VATS. In addition, there were no appreciable differences in disease-free or overall survival.
Objective Invasive mediastinal biopsy is often necessary in the evaluation of non–small cell lung cancer (NSCLC), and mediastinoscopy has long been considered the reference standard. However, the ...emergence of endobronchial ultrasound–guided transbronchial needle aspiration (EBUS-TBNA) has resulted in controversy regarding it represents a suitable replacement for mediastinoscopy. We chose to determine the utility of EBUS-TBNA in evaluating the mediastinum in patients with NSCLC. Methods The present study was a retrospective review of a prospective database of consecutive patients with NSCLC who underwent EBUS-TBNA for mediastinal evaluation from 2009 to 2011. The sensitivity, specificity, negative predictive value, and accuracy of EBUS-TBNA are reported. Also reported are the size of the lymph nodes biopsied and the number of instances in which EBUS-TBNA obviated the need for cervical mediastinoscopy. Results A total of 73 patients had a total of 140 mediastinal stations biopsied using EBUS-TBNA. Of the 73 patients, 30 had benign findings and underwent surgical resection, 1 of whom was found to have stage N2 disease. Of the remaining patients, 42 had a positive result and 1 had nondiagnostic biopsy findings for which malignancy was confirmed by mediastinoscopy. Mediastinoscopy would have changed the tumor stage and treatment planning in only 2 (2.7%) of the 73 patients. Overall, EBUS-TBNA had a sensitivity of 95%, a specificity of 100%, a negative predictive value of 94%, and an accuracy of 97%. Conclusions EBUS-TBNA might be a feasible option for most patients with NSCLC for whom histologic assessment of the mediastinum is necessary. The rates of nondiagnostic and false-negative biopsy findings using EBUS-TBNA were low, small subcentimeter nodes could be routinely biopsied, and most patients with a radiographically positive mediastinum had their disease pathologically confirmed.
Abstract This study examined the effect of patient attributes on expectations before total knee arthroplasty (TKA). A total of 1943 patients completed an Expectations Survey before TKA. Demographics, ...surgical history, baseline Medical Outcomes Study Short Form 36 (SF-36) score, Knee injury and Osteoarthritis Outcome Score (KOOS), and Lower Extremity Activity Scale score were obtained. On univariate analysis, expectations (mean score, 77.6) correlated with SF-36 General Health, age, SF-36 Vitality, KOOS Quality-of-Life, and Lower Extremity Activity Scale. Living alone and history of joint arthroplasty were associated with significantly lower expectations, whereas male sex and white race were associated with higher expectations. On multivariate regression analysis, age, living situation, history of joint arthroplasty, SF-36 General Health, and KOOS Quality-of-Life remained significant predictors of expectations. Our results suggest that high, possibly unrealistic, expectations of TKA are common and should be moderated to maintain patient satisfaction.
Objective Radiofrequency ablation can eradicate Barrett’s esophagus successfully in the majority of cases. We sought to determine (1) how often intestinal metaplasia is detected during follow-up ...endoscopy after successful ablation and (2) patterns of persistent/recurrent intestinal metaplasia. Methods Patients ablated successfully during a phase II clinical trial of radiofrequency ablation for Barrett’s esophagus were followed using endoscopic surveillance according to a defined protocol. Systematic biopsies were performed in all patients throughout the neosquamous epithelium as well as at the gastroesophageal junction, and patterns of recurrent or persistent intestinal metaplasia were documented. Results Fifty-three patients were ablated successfully during this single-institution clinical trial. A total of 151 follow-up endoscopies were performed (range, 1-5 endoscopies per patient) and 2492 biopsies were obtained, of which 604 (24%) were from the gastroesophageal junction. The median follow-up period was 18 months (range, 3-50 months). Recurrent/persistent intestinal metaplasia was detected in 14 patients (26%) in 3 distinct patterns: endoscopically invisible intestinal metaplasia underneath the neosquamous epithelium (buried glands) in 3 patients, visible recurrence in the tubular esophagus in 3 patients, and intestinal metaplasia of the gastroesophageal junction (with a squamous-lined tubular esophagus) in 10 patients. Dysplasia or cancer was not detected in any patient during the follow-up period. Conclusions Recurrent/persistent intestinal metaplasia after successful radiofrequency ablation of Barrett’s esophagus is relatively common. This finding has implications for the continued surveillance of patients who are ablated successfully.
Objective Our objectives were 3-fold: to define the correlation between automated volumetric and 2-dimensional measurements of pulmonary nodule growth and prospectively; to determine whether ...volumetric growth analysis represents a useful addition to 2-dimensional measurements; and to evaluate growth rates over time of biopsy-proven lung cancers using automated volumetric software. Methods Nodule growth on consecutive 2-dimensional computed tomographic scans was measured, and a decision regarding nodule biopsy was made. Automated volumetric software was then used to determine nodule growth, growth rates obtained from the 2 techniques were correlated, and the decision to perform a biopsy was reassessed. Biopsy-proven lung cancer growth rates were then documented over time. Results Growth rates measured using volumetric software were highly correlated with 2-dimensional measurements ( r = 0.69; P < .00001). This correlation was affected by nodule type (irregular r = .63 versus smooth r = 0.84; P = .02) as well as the interval between scans (<100 days r = .5 versus >100 days r = 0.76; P = .02). The addition of volumetric growth analysis changed the decision to perform a biopsy after only a minority (6.2%) of scan comparisons; however, lung cancer was diagnosed in 43% of these cases. Growth curves for individual cancers were highly variable, with 45% of tumors showing at least 1 period of shrinkage. Conclusions Automated volumetric software influences biopsy decisions in only a minority of cases in a dedicated pulmonary nodule clinic, but seems to be useful in detecting lung cancer in this minority. Radiographically determined nodule growth rates, in general, need to be questioned as the sole determinate of the need to perform a biopsy.
Objective Hiatal hernia is common in patients with Barrett’s esophagus. We sought to evaluate the effect of hiatal hernia size and initial columnar segment length on the success of radiofrequency ...ablation of Barrett’s esophagus. Methods A phase II clinical trial was conducted aimed at evaluating the success of radiofrequency ablation in eradicating Barrett’s esophagus. Success was defined as complete replacement of the columnar lining with squamous mucosa and lack of intestinal metaplasia using light microscopy. Hiatal hernia size and columnar segment length were measured endoscopically. Results Sixty-seven patients were accrued to the protocol. In the 55 patients who completed radiofrequency ablation (43 successes, 12 failures), the mean hiatal hernia size was 3.3 cm (range, 0–10 cm), and the mean columnar segment length was 5.4 cm (range, 1–18 cm). The median length of the columnar segment was 3 cm in the successful cases and 8.5 cm in the failed cases ( P = .002). Although the median hiatal hernia size was identical in the successful and failed cases (3 cm, P = .38), the median hiatal hernia size was 7 cm ( P = .001) in the 6 patients who experienced nonhealing after the initial ablation. Patients who were successfully ablated but had larger hiatal hernias and longer columnar segment lengths required significantly more radiofrequency ablation sessions than those with smaller hernias and shorter segments ( P = .003 and P = .007, respectively). Conclusions Patients with larger hiatal hernias and longer columnar segments are more likely to experience failure or nonhealing after radiofrequency ablation. These patients also require more radiofrequency ablation treatments to achieve successful eradication of Barrett’s esophagus.
Background Studies of quality of life (QOL) in children with juvenile idiopathic arthritis (JIA) have focused on changes in musculoskeletal function secondary to arthritis. The role of visual ...functionality as a result of JIA-associated uveitis and its complications has not been examined. We evaluated the individual impact of physical and visual disability on QOL in children with and without uveitis. Methods We administered patient-based questionnaires that measured visual function, physical function, and overall QOL to 27 children with JIA or idiopathic uveitis. Demographic data, assessed joint involvement, and reviewed medical records were recorded. Groups with and without uveitis were compared for differences in arthritis and uveitis disease characteristics with use of the Wilcoxon-Mann-Whitney, χ2 , and Fisher exact tests. Associations between physical or visual function, and overall QOL were measured with use of Pearson's correlation coefficient. Results Of 27 patients, 85.2% had had arthritis and 51.9% had had uveitis. The group without uveitis had increased morning stiffness ( p = 0.036). Patients with uveitis reported more eye redness ( p = 0.033) and photophobia ( p = 0.013) than those without uveitis. We observed moderate associations between overall QOL and visual function in the uveitis group ( r = −0.579) and overall QOL and physical function in the nonuveitis group ( r = −0.562). Conclusions This study demonstrates that visual impairment is an important component of QOL in children with uveitis. It suggests that QOL studies should incorporate both visual and physical function measures in their analyses, especially because many children with JIA also suffer from uveitis and visual impairment.
Background Very little data exist regarding patients’ preoperative expectations of the outcome of total shoulder arthroplasty. We hypothesized that younger patients and patients with worse function ...and worse general health would have greater expectations of total shoulder arthroplasty. Methods Ninety-eight patients who underwent unilateral primary total shoulder arthroplasty at one institution were studied prospectively. The preoperative evaluation included the American Shoulder and Elbow Surgeons (ASES) score, Shoulder Activity Scale, Short Form-36 (SF-36), and visual analog scale scores for shoulder pain, fatigue, and general health. Expectations were evaluated with use of the Hospital for Special Surgery's Shoulder Surgery Expectations Survey. Results Relief of daytime pain, relief of nighttime pain, and improvement of shoulder range of motion were very important to 86%, 82%, and 84% of the patients, respectively. Expectations were not associated with education, history of previous joint replacement, or comorbidities. Greater expectations were associated with younger age, worse general health on the visual analog scale, and worse ASES scores (p < 0.05 for all), with correlation coefficients ranging from 0.25 to 0.28. Multivariate analysis showed that younger age was the only independent predictor of greater expectations (p < 0.05). Conclusions Younger patients had greater expectations of total shoulder arthroplasty, which may have implications for outcome and implant longevity.
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