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.
Primary cardiac sarcomas are rare, aggressive, and usually lethal. Surgical management protocols are not defined because of the lack of extensive experience in treating these patients. In this study, ...we reviewed our outcomes with primary cardiac sarcoma, and we make recommendations regarding management.
Review of the Houston Methodist Hospital cardiac tumor database from 1990 to 2015 (25 years) yielded 131 primary cardiac evaluations of possible cardiac sarcoma. From these we identified 95 patients who underwent surgical excision. A computer search of cardiac sarcomas yielded 131 tumors that were coded as primary cardiac sarcoma or possible primary cardiac sarcoma. Retrospective data collection and clinical outcomes were evaluated for all 95 patients. Medical records and follow-up material were requested for all patients through clinic visits and contacting the physician of the patient, the hospital record department, and the cardiac tumor board after previous approval. The procedures were performed using an institutional review board-approved cardiac tumor protocol, and the patients gave full consent.
All 95 patients were diagnosed as having primary cardiac sarcoma by histologic appearance. Age ranged from 15 to 84 years at the time of presentation (mean, 44 years). Male patients made up 57% of the sample. The most common site for the cardiac sarcoma was the right atrium (37 patients) followed by the left atrium (31 patients). Postoperative 1-year mortality was 35% (33 patients). The most common tumor histologic type was angiosarcoma (40%) followed by spindle cell sarcoma (11%).
Primary cardiac sarcoma is a rare but lethal disease. Surgical intervention is associated with acceptable surgical mortality in this high-risk group of patients.
Right-side heart sarcomas tend to be bulky, infiltrative, and difficult to treat. We have previously examined our outcomes with right heart sarcomas. Surgical resection with R0 margins showed better ...survival than positive margins but in only one third of cases could R0 status be achieved. The hypothesis for this study was that preoperative neoadjuvant chemotherapy would shrink the tumor margins and allow an increase in R0 resection, and hence, better survival.
Review of our cardiac tumor database from 1990 to 2015 yielded 133 primary cardiac sarcoma cases. Of these, we identified 44 patients with primary right-side heart sarcomas. Prospective database and retrospective data collection and clinical outcomes were evaluated for all 44 patients. Primary outcomes included 30-day mortality and morbidity and long-term survival. We used univariate and multivariate analyses to identify independent predictors of overall survival.
There were 27 male and 17 female patients with a mean age of 41 ± 12.7 years (range, 15 to 67). Seventy-three percent of the patients (32 of 44) received neoadjuvant chemotherapy. The most common tumor histology was angiosarcoma in 30 of 44 (68%). Thirty-day mortality was 4.5%, and statistically similar between the two groups. The median survival of patients who had R0 resection was 53.5 months compared with 9.5 months for R1. Neoadjuvant chemotherapy led to a doubling of survival (20 versus 9.5 months).
Neoadjuvant chemotherapy followed by radical surgery is a safe and effective strategy in patients with primary right-side heart sarcoma. This multimodality treatment enhances resectability (R0 resection) that translates into improved patient survival.
Outcomes after surgical resection of cardiac sarcoma in the multimodality treatment era Bakaeen, Faisal G., MD; Jaroszewski, Dawn E., MD; Rice, David C., MD ...
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
06/2009, Letnik:
137, Številka:
6
Journal Article
Recenzirano
Odprti dostop
Objective Primary cardiac sarcomas are rare tumors carrying poor prognosis. Resection remains the primary therapy. Especially in recent years, chemotherapy and radiation have been used adjunctively. ...Methods All patients (n = 27) surgically treated for primary cardiac sarcoma at two tertiary referral centers from January 1990 to January 2006 were retrospectively reviewed. Results There were 13 women and 14 men, with 26 resections and 1 palliative debulking performed. Cardiac explantation was necessary in 8 cases because of tumor location. Concomitant valve surgery (repair or replacement) or coronary artery bypass grafting was performed in 9 and 3 patients, respectively. Synchronous or staged resections of associated pulmonary metastases were performed in 6 and 2 patients, respectively. Operative mortality was 7.4% (2/27). Preoperative or postoperative chemotherapy was administered to 16 and 19 patients, respectively. At follow-up (median 22 months, range, 2–119 months), 12 patients were alive, with 7 tumor free. Among patients who underwent resection with curative intent and survived surgery (n = 24), median survival was 23.5 months (range 4–119 months). Patients who underwent surgical resection, radiofrequency ablation, or radiation treatment for tumor recurrence (local or metastatic, n = 7) had median survival of 47 months (range 16–119 months), whereas patients with no further intervention for recurrent disease (n = 7) had median survival of 25 months (range 8–34 months). Conclusions Multimodal therapy can achieve reasonable survival for patients with resected cardiac sarcomas. Patients with local tumor recurrence or metastatic disease may still benefit from aggressive treatment.
Improving the quality of surgical care through accurate measurement of outcomes is an important endeavor. The purpose of this study was to compare data from the American College of Surgeons National ...Surgical Quality Improvement Program (ACS NSQIP) and The Society of Thoracic Surgeons (STS) general thoracic surgery database to determine if a sampling technique (ACS NSQIP) is as effective and accurate as the comprehensive technique (STS database).
A common data abstractor collected and recorded data for the ACS NSQIP and STS database from our institution for the year 2012. The data was completely deidentified and analyzed for demographics, preoperative risk factors, mortality, and morbidity.
The STS database recorded 1,595 (100%) operations for the year 2012, whereas the ACS NSQIP by design collects a limited sample and recorded 308 (19.3%) operations. Postoperative events were recorded in 17.2% of ACS NSQIP operations and in 30.1% of operations reported in the STS database. As more specific operations are examined, errors in the NSQIP data increase significantly. For example, the ACS NSQIP underestimated the pneumonia rate for lobectomy (5.9% versus 10.9%) and overestimated the pneumonia rate for an Ivor Lewis esophagogastrectomy (23.8% vs 18.8%). When the ACS NSQIP was used to compare our institution to the ACS NSQIP national norms, our institution was ranked in the lowest eighth decile for 30-day operative mortality; however, we were better than average when using STS database data (1.2% 2 of 162 procedures vs 1.4% 538 of 37,324 procedures) for pulmonary resections and 3.0% (3 of 100 procedures) vs 3.6% 138 of 3,865 procedures for esophagectomy).
Databases built on partial sampling that do not capture all patients, such as the ACS NSQIP, may be useful for global analyses, but fall short of providing a foundation for meaningful quality improvement initiatives when analyzing data for specific thoracic surgical operations. These results highlight the utility and importance of complete databases such as the STSDB. National comparisons of clinical outcomes for thoracic surgical procedures should be interpreted with caution when using partial databases.
As more women enter the thoracic surgery profession, issues affecting childbearing become increasingly important. We set out to assess birth trends and factors affecting childbearing among thoracic ...surgeons.
A 33-question anonymous survey was sent to women diplomats of American Board of Thoracic Surgery, residents in Thoracic Surgery Residents Association, and members of Women in Thoracic Surgery. Findings were compared with national norms.
There were a total of 113 respondents (88 women, 25 men). Of 69% (61 of 88) of women and 88% (22 of 25) of men who desired children, 98% (60 of 61) of women versus 50% (11 of 22) of men delayed pregnancy (p < 0.0001). Eighty-two percent (72 of 88) of women versus 60% (15 of 25) of men felt their career would be adversely affected, with 6% (54 of 88) of women versus 16% (4 of 25) of men reporting that pregnancy would be viewed unfavorably among peers (p < 0.03 and p < 0.0001, respectively). Of women of childbearing age, 28% (15 of 54) utilized assisted reproductive technology (national average 12%, p < 0.0002). The total fertility rate was 0.6 ± 0.2 children per woman whereas the national rate was 1.9. The average age at first-childbirth was 34.3 ± 0.7 years, while the national norm was 25.4.
Women thoracic surgeons begin their family later in life and have fewer children compared with the national average. These findings are likely related to the perception that their career would be adversely affected and to advanced maternal age. Residency programs and practice groups should strive to develop policies that support childbearing earlier in training as the number of women thoracic surgeons grows.
Complete surgical resection is the optimal treatment for malignant and complex benign left heart tumors. Anatomic inaccessibility and relationship with vital cardiac structures, makes complete ...resection of these complex tumors with standard surgical technique suboptimal. We employ autotransplantation in these cases to allow optimal anatomic exposure for complete resection and accurate reconstruction.
From 1998 to 2013, 35 cardiac autotransplants were done in 34 patients. Demographics, tumor histology, operative notes, hospital data, pathology reports, morbidity, and short and long-term mortality data were analyzed. Mortality follow-up was complete in all patients.
Of the 34 patients, there were 26 primary cardiac sarcomas, 1 isolated malignant melanoma metastasis to the intracavitary left ventricle, and 7 benign cases. The benign group had no operative deaths and 100% 2-year survival. Overall 30-day, 1-year, and 2-year procedural survival was 85%, 59%, and 44%, respectively. For primary malignant tumors, survival at 1 and 2 years was 46% and 28%. Among patients with primary malignant tumors, 19 had isolated cardiac autotransplantation and 7 had autotransplantation plus pneumonectomy. Operative mortality (and median survival) for cardiac autotransplantation with and without pneumonectomy was 43% (55 days) and 11% (378 days), respectively. For primary sarcomas, microscopically positive or negative resection margins did not impact survival.
Cardiac autotransplantation is a feasible and safe technique for resection of complex left-sided tumors when done as an isolated procedure in experienced centers. Addition of concomitant pneumonectomy carries a high rate of mortality and should be avoided. Further studies are needed to validate these results.
Three-dimensional (3D) printing of anatomic models for complex surgical cases improves patient and resident education, operative team planning, and guides the operation. Our group describes two ...additional dimensions.
The process of 5-dimensional (5D) printing was developed for surgical planning. Pretreatment computed tomography and positron emission tomography scans were reformatted and fused. Selected anatomy from these studies, along with posttreatment computed tomography and magnetic resonance images, were coregistered and segmented. This fused anatomy was converted into stereolithography files for 3D printing.
A patient presenting with a complex thoracic tumor was selected for 5D printing. 3D and 5D models were prepared to allow surgical teams to directly evaluate and compare the added benefits of information provided by printing in 5 dimensions.
Printing 5D models in patients with complex thoracic pathology facilitates surgical planning, selecting margins for resection, anticipating potential difficulties, teaching for learners, and education for patients.
The objective of this review is to determine the outcome of patients with sarcomas involving the main pulmonary artery, pulmonic valve, or right ventricular outflow tract. Survival data were analyzed ...using an aggregate series derived from the published literature in conjunction with a current series. Median survival was 36.5 +/- 20.2 months for patients undergoing an attempt at curative resection compared with 11 +/- 3 months for those undergoing incomplete resection. Median survival was 24.7 +/- 8.5 months for patients undergoing multimodality treatment compared with 8.0 +/- 1.7 months for patients having single-modality therapy. A complete review of diagnosis, evaluation, treatment, and surveillance of primary pulmonary artery sarcomas follows.
Resection of pulmonary colorectal carcinoma metastases may provide long-term benefit, but patient selection remains controversial. The objective of this study was to identify preoperative predictors ...of survival and lung recurrence for patients undergoing resection of such lesions.
A prospectively collected database was retrospectively reviewed to identify patients who underwent their first colorectal carcinoma pulmonary metastasectomy. Two multivariate logistic analyses were performed to identify preoperative predictors of survival and lung recurrence. Preoperative factors, pathologic colorectal carcinoma stage, additional sites of metastases, timing of metastatic occurrence, and premetastasectomy disease-free interval were included in the univariate analyses.
From January 2000 to December 2010, 229 patients met inclusion criteria. The mean age was 60 years, and 100 patients (43.7%) were women. The overall median time and 5-year survival rate were 70.1 months and 55.4%, respectively, after the first pulmonary metastasectomy. Median follow-up was 37.2 months. Age older than 60 years (hazard ratio HR, 1.03; 95% confidence interval CI, 1.005 to 1.052; p=0.016), male sex (HR, 1.84; 95% CI, 1.089 to 3.094; p=0.023), and more than three lung metastases (HR, 1.15; 95% CI, 1.024 to 1.282; p=0.018) predicted survival at 5 years in one multivariate analysis. In the second, more than three lung metastases present at first metastasectomy (HR, 1.19; 95% CI, 1.071 to 1.321; p=0.001) and the preoperative disease-free interval of less than 3 years (HR, 0.99; 95% CI, 0.973 to 0.997; p=0.013) predicted lung recurrence.
Older age, male sex, and more lung metastases predict poorer survival after resection of pulmonary colorectal cancer metastases. The number of lung metastases present at the first metastasectomy and the preoperative disease-free interval predicted recurrence in the lung.
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