Comparing Robotic, Thoracoscopic, and Open Segmentectomy: A National Cancer Database Analysis

INTRODUCTION

Minimally invasive approaches to lung resection have become widely acceptable and more recently, segmentectomy has demonstrated equivalent oncologic outcomes when compared to lobectomy for early-stage non-small cell lung cancer (NSCLC). However, studies comparing outcomes following segmentectomy by different surgical approaches are lacking. Our objective was to investigate the outcomes of patients undergoing robotic, video-assisted thoracoscopic surgery (VATS), or open segmentectomy for NSCLC using the National Cancer Database.

METHODS

NSCLC patients with clinical stage I who underwent segmentectomy from 2010 to 2016 were identified. After propensity-score matching (1:4:1), multivariate logistic regression analyses were performed to determine predictors of 30-d readmissions, 90-d mortality, and overall survival.

RESULTS

22,792 patients met study inclusion. After matching, approaches included robotic (n = 2493; 17%), VATS (n = 9972; 66%), and open (n = 2493; 17%). An open approach was associated with higher 30-d readmissions (7% open versus 5.5% VATS versus 5.6% robot, P = 0.033) and 90-d mortality (4.4% open versus 2.2% VATS versus 2.5% robot, P < 0.001). A robotic approach was associated with improved 5-y survival (50% open versus 58% VATS versus 63% robot, P < 0.001).

CONCLUSIONS

For patients with clinical stage I NSCLC undergoing segmentectomy, compared to the open approach, a VATS approach was associated with lower 30-d readmission and 90-d mortality. A robotic approach was associated with improved 5-y survival compared to open and VATS approaches when matched. Additional studies are necessary to determine if unrecognized covariates contribute to these differences.

Transsternal Approach for Broncho-Pleural Fistula Closure After Right Pneumonectomy

Broncho-pleural fistula (BPF) is an abnormal communication between the bronchial lumen and the pleural space that typically occurs postoperatively. Surgical intervention is typically needed to patch the fistula; however, current literature lacks a gold standard for which treatment to use. With a high mortality rate, there is a clear urgency for quick and successful intervention. This case examines a 59-year-old patient presenting with a BPF 14 years after incidental pneumonectomy during upper lobectomy for invasive aspergillus. A fistula was appreciated during bronchoscopy with contrast injection. The fistula was closed via the transsternal approach through median sternotomy and pericardiotomy. This case report aims to provide a viable option to successfully repair a BPF via the transsternal approach.

Preclinical Synergistic Combination Therapy of Lurbinectedin with Irinotecan and 5-Fluorouracil in Pancreatic Cancer

Pancreatic cancer is a devastating disease with a poor prognosis. Novel chemotherapeutics in pancreatic cancer have shown limited success, illustrating the urgent need for new treatments. Lurbinectedin (PM01183; LY-01017) received FDA approval in 2020 for metastatic small cell lung cancer on or after platinum-based chemotherapy and is currently undergoing clinical trials in a variety of tumor types. Lurbinectedin stalls and degrades RNA Polymerase II and introduces breaks in DNA, causing subsequent apoptosis. We now demonstrate lurbinectedin's highly efficient killing of human-derived pancreatic tumor cell lines PANC-1, BxPC-3, and HPAF-II as a single agent. We further demonstrate that a combination of lurbinectedin and irinotecan, a topoisomerase I inhibitor with FDA approval for advanced pancreatic cancer, results in the synergistic killing of pancreatic tumor cells. Western blot analysis of combination therapy indicates an upregulation of γH2AX, a DNA damage marker, and the Chk1/ATR pathway, which is involved in replicative stress and DNA damage response. We further demonstrate that the triple combination between lurbinectedin, irinotecan, and 5-fluorouracil (5-FU) results in a highly efficient killing of tumor cells. Our results are developing insights regarding molecular mechanisms underlying the therapeutic efficacy of a novel combination drug treatment for pancreatic cancer.

Understanding the Challenges Faced by Esophageal and Gastroesophageal Junction Cancer Survivors

The primary aim of this study is to characterize long-term quality of life (QOL) in patients with esophageal and gastroesophageal junction (EGEJ) cancers who underwent curative intent treatment. EGEJ survivors were recruited to participate in a one-time cross-sectional survey study using validated questionnaires assessing QOL. Chart review was conducted for patient demographics and clinical characteristics. Spearman correlation coefficients, Wilcoxon signed-rank test, and Fisher's exact test were used to assess relationships between patient characteristics and long-term outcomes. QOL was relatively high in this sample, as evidenced by high median scores on the functional scales and low median scores in the symptom domains of the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ)-C30, with an overall median global health score of 75.0 (range 66.7-83.3). Patients using opiates at the time of survey reported lower role functioning (P  =  .004), social functioning (P  =  .052), and overall global health (P  =  .041). Younger patients had significantly higher rates of reflux (P  =  .019), odynophagia (P  =  .045), choking (P  =  .005), and cough (P  =  .007). Patients using opiates or of younger age had lower QOL and higher symptoms in this cohort of long-term EGEJ survivors.

Pulmonary Open, Robotic, and Thoracoscopic Lobectomy (PORTaL) Study: Survival Analysis of 6646 Cases

OBJECTIVE

The aim of this study was to analyze overall survival (OS) of robotic-assisted lobectomy (RL), video-assisted thoracoscopic lobectomy (VATS), and open lobectomy (OL) performed by experienced thoracic surgeons across multiple institutions.

SUMMARY BACKGROUND DATA

Surgeons have increasingly adopted RL for resection of early-stage lung cancer. Comparative survival data following these approaches is largely from single-institution case series or administrative data sets.

METHODS

Retrospective data was collected from 21 institutions from 2013 to 2019. Consecutive cases performed for clinical stage IA-IIIA lung cancer were included. Induction therapy patients were excluded. The propensity-score method of inverse-probability of treatment weighting was used to balance baseline characteristics. OS was estimated using the Kaplan-Meier method. Multivariable Cox proportional hazard models were used to evaluate association among OS and relevant risk factors.

RESULTS

A total of 2789 RL, 2661 VATS, and 1196 OL cases were included. The unadjusted 5-year OS rate was highest for OL (84%) followed by RL (81%) and VATS (74%); P =0.008. Similar trends were also observed after inverse-probability of treatment weighting adjustment (RL 81%; VATS 73%, OL 85%, P =0.001). Multivariable Cox regression analyses revealed that OL and RL were associated with significantly higher OS compared with VATS (OL vs. VATS: hazard ratio=0.64, P <0.001 and RL vs. VATS: hazard ratio=0.79; P =0.007).

CONCLUSIONS

Our finding from this large multicenter study suggests that patients undergoing RL and OL have statistically similar OS, while the VATS group was associated with shorter OS. Further studies with longer follow-up are necessary to help evaluate these observations.

Health-Related Quality of Life Following Robotic-Assisted or Video-Assisted Lobectomy in Patients With Non-Small Cell Lung Cancer: Results From the RVlob Randomized Clinical Trial

BACKGROUND

Robot-assisted lobectomy (RAL) is increasingly used as an alternative to video-assisted lobectomy (VAL) for resectable non-small cell lung cancer (NSCLC). However, there is little evidence of any difference in postoperative health-related quality of life (HRQoL) between these two approaches.

RESEARCH QUESTION

Is RAL superior to VAL in improving quality of life in patients with resectable NSCLC?

STUDY DESIGN AND METHODS

We performed a single-center, open-label randomized clinical trial from May 2017 to May 2020 with 320 enrolled patients undergoing RAL or VAL for resectable NSCLC (RVlob trial; NCT03134534). Postoperative pain was evaluated by visual analog score or numeric rating score on postoperative day 1 and at weeks 4, 24, and 48. The European Organization for Research and Treatment of Cancer (EORTC) Core Quality of Life Questionnaire (QLQ-C30), EORTC Quality of Life Questionnaire in Lung Cancer (QLQ-LC13), and the European Quality of Life 5 Dimensions (EQ-5D) questionnaire were also administered at weeks 4, 24, and 48 after surgery.

RESULTS

One hundred and fifty-seven patients underwent RAL and 163 underwent VAL. The mean pain score of patients after RAL was significantly lower at week 4 (2.097 ± 0.111 vs 2.431 ± 0.108; P = .032). QLQ-C30 and QLQ-LC13 summary scores (P > .05) were similar for both RAL and VAL during the first 48 weeks of follow-up. HRQoL scores assessed with the EQ-5D questionnaire were also comparable between the two groups (P > .05) during the whole study period.

INTERPRETATION

Both RAL and VAL showed satisfactory and comparable HRQoL and postoperative pain up to 48 weeks after surgery, despite some minor statistical differences at week 4.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov; No.: NCT03134534; URL: www.

CLINICALTRIALS

gov.

Abstract 4909: Molecular analysis of small cell lung cancer provides insights into mechanism of action underlying the novel drug combination of lurbinectedin and TIC10/ONC201

We previously explored the combination of novel imipridone TIC10/ONC201 and small molecule RNA polymerase inhibitor lurbinectedin as a potentially effective treatment regimen for small cell lung cancer (SCLC). Data from cell viability experiments demonstrated synergistic killing of SCLC cells with minimal death of healthy control cells. Analysis of intracellular proteins via Western blot indicated that combinatorial treatment induces the integrated stress response, DNA damage/cell cycle checkpoint responses, and increased apoptosis of tumor cells. We have utilized the Luminex 200 platform to perform analyses of cytokine levels in SCLC cell lines with various genetic alterations before and after ONC201 and lurbinectedin treatment. Our results revealed significant changes in cytokine levels following treatment indicating potential immunomodulatory and angioregulatory effects of ONC201 and lurbinectedin. CCL3, known to recruit and activate granulocytes, was found to be elevated by treatment with lurbinectedin, ONC201 and combination versus control. Angiopoietin 1, which contributes to blood vessel maturation, and angiopoietin 2, which promotes neovascularisation, were elevated by all drug treatments in H1882 SCLC cells. Our ongoing studies are further analysing the importance of specific cytokines in tumor vascularity and in recruitment and killing of SCLC cells by immune cells. Results from these experiments are helping to elucidate the molecular mechanisms underlying SCLC, its immune landscape, and treatment response.

Citation Format: Ashley Sanchez Sevilla Uruchurtu, Nicholas Liguori, Leiqing Zhang, Kelsey Huntington, Lanlan Zhou, Young Lee, Abbas E. Abbas, Christopher G. Azzoli, Wafik S. El-Deiry. Molecular analysis of small cell lung cancer provides insights into mechanism of action underlying the novel drug combination of lurbinectedin and TIC10/ONC201. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 4909.

Abstract 2674: Synergistic combinations of lurbinectedin with irinotecan and ONC212 in pancreatic cancer

Pancreatic cancer is a devastating disease with a five-year survival rate below 10% according to the American Cancer Society. Novel chemotherapeutics and targeted therapies in pancreatic cancer have shown limited success, illustrating the urgent need for new treatments. Lurbinectedin is a chemotherapeutic synthetic tetrahydroisoquinoline alkaloid that inhibits active transcription by binding to guanine rich sequences in the minor groove of DNA. Lurbinectedin has been shown to reduce oncogenic transcription by stalling and degrading RNA Polymerase II while also inducing single- and double-stranded breaks to DNA, causing subsequent apoptosis. Lurbinectedin received accelerated FDA approval in 2020 for metastatic small cell lung cancer on or after platinum-based chemotherapy and is currently undergoing clinical trials in a variety of tumor types. We recently described a synergistic interaction between lurbinectedin and ONC201/TIC10, a compound that induces the TRAIL pathway, in killing SCLC cell lines associated with activation of p-Chk1 and the integrated stress response. We now demonstrate lurbinectedin’s efficient killing of pancreatic tumor cells as a single agent in PANC-1, BxPC-3, and HPAF-II cell lines, with IC-50s corresponding to sub-nanomolar concentrations. We also demonstrate that a combination of lurbinectedin and irinotecan, a topoisomerase I inhibitor with FDA approval for advanced pancreatic cancer, results in synergistic killing of pancreatic tumor cells in vitro. We further demonstrate a combination of lurbinectedin and ONC212, an imipridone, the same class of compounds as ONC201, also results in synergistic killing of pancreatic tumor cells. Cell viability was measured using the CellTiterGlo assay at varying drug concentrations. We hypothesize a combination therapy of lurbinectedin and irinotecan or ONC212 can enhance immune cell killing of pancreatic tumor cells. This is being explored by co-culturing CD8+ T lymphoblast cells with pancreatic tumor cells treated with lurbinectedin, irinotecan, ONC212, and combination, along with molecular mechanisms of cell death and effects on cytokines in the tumor microenvironment. Our results are developing insights regarding molecular mechanisms underlying therapeutic efficacy of a novel combination drug treatment for pancreatic cancer.

Citation Format: Tej Tummala, Arielle De La Cruz, Ash Uruchurtu, Nicholas R. Liguori, Abbas E. Abbas, Leiqing Zhang, Christopher G. Azzoli, Lanlan Zhou, Wafik S. El-Deiry. Synergistic combinations of lurbinectedin with irinotecan and ONC212 in pancreatic cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 2674.

Abstract 4457: Post exposure suppression of radiation pneumonitis by TRAIL pathway agonists TLY012 and ONC201

Thoracic therapeutic ionizing radiation is limited by toxicities such as pneumonitis and fibrosis of the lungs. Such limitation restricts therapeutic doses and adversely affects patient quality of life while undergoing and following treatment. ONC201/TIC10 is a small-molecule anti-cancer drug that activates the integrated stress response (ISR) and drives the tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) pathway. Pegylated recombinant long-acting TRAIL (TLY012) has been shown in preclinical models to induce the reversal of fibrosis and currently has orphan drug status for systemic sclerosis and chronic pancreatitis. We show a similar effect of both TLY012 and ONC201 in vivo in protecting from radiation pneumonitis and fibrosis of the lungs. WT and TRAIL-/- C57Bl/6 mice receiving a single 20 Gy thoracic radiation dose with shielding of other organs and treated with 10 mg/kg of TLY012 twice a week showed a significantly reduced alveolar wall thickness and lessened inflammation compared to controls and DR5-/- mice receiving the same treatment upon histological analysis of the lungs conducted 13 days post-irradiation. WT and TRAIL-/- C57Bl/6 mice treated with 100 mg/kg of ONC201 once a week showed similar effect to a lesser extent. Further analysis in C57Bl/6 WT mice bearing orthotopic mammary fat pad e0771 TNBC tumors similarly receiving a single 20 Gy thoracic radiation dose revealed the same pattern of protection from radiation pneumonitis upon TRAIL-pathway agonism through treatment with TLY012 and ONC201 both in combination and alone, while also showing a significant reduction in tumor burden at the experimental endpoint (day 9 post-irradiation) in the combination treated mice. Further, pulse oximetry readings of the hind paw revealed a notable reduction in oxygen saturation in all mice except those treated with TLY012. Cytokinomic profiling of mouse serum upon sacrifice revealed a significant reduction in CCL22/MDC levels in the TLY012 cohort. Additional post-hoc analysis including immunophenotyping, immunostaining, and bulk RNA analysis through Nanostring nCounter technologies is underway. Altogether, these findings suggest a role for TLY012, ONC201, or broader modulation of the TRAIL/DR5 pathway in mitigating adverse effects and outcomes of therapeutic radiation, and may serve as a foundation for safer use of radiation in the clinic.

Citation Format: Jillian R. Strandberg, Anna Louie, Marina Hahn, Praveen Srinivasan, Andrew George, Arielle De La Cruz, Leiqing Zhang, Liz Hernandez Borrero, Kelsey Huntington, Christopher Azzoli, Abbas E. Abbas, Lanlan Zhou, Seulki Lee, Wafik S. El-Deiry. Post exposure suppression of radiation pneumonitis by TRAIL pathway agonists TLY012 and ONC201. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 4457.

Abstract 4185: Inclusive basic and advanced translational laboratory research competencies for research in cancer biology and therapeutics

Our Laboratory was established in 1994 at Univ. of Pennsylvania. Lab members demonstrated initial competencies by performing cell culture, western blots, immunofluorescence, and flow cytometry showing induction of p53/p21(WAF1) in cells treated with chemotherapy. Years later, our Laboratory of Translational Oncology & Experimental Cancer Therapeutics moved to Penn State Univ., Fox Chase Cancer Center/Temple Univ. and then Brown Univ. By 2020, with desire for inclusiveness (everyone succeeds), scientific rigor/reproducibility mandated by NIH, and as a training and mentoring activity (lab scientists/trainees/students mentoring others at High School level and beyond), we established a process for onboarding and training new cancer researchers. By Fall of 2022, there were 17 current Brown University undergraduate students (10 receiving research credit and 7 not receiving credit), HS students, 7 graduate students (PhD, masters, MD/PhD), and 6 medical students working with collaborating faculty at our laboratory at Brown’s Legorreta Cancer Center. After completion of biosafety training, and required trainings such as by IACUC, new lab members complete basic competencies in cell culture, cell viability, and western blot analysis that include technical, presentation quality output, and quantitative/statistical rigor to satisfy current standards for journal publication. For cell culture this includes pathogen free conditions, authentication, attention to details of routine procedures, documentation of morphology, freezing, thawing, passaging, seeding density, and managing cell populations to not run out of cells. Cell viability assessment includes attention to culture conditions, synergy analysis, data robustness, and presentation, and for western blots attention to quality of blots, protein quantification, loading, labeling, antibody specificity and sensitivity controls, presentation at 2022 standards, conventions for splicing, and issues with reproducibility including biological replicates, and generalizability. Additional and advanced competencies include RT-PCR, long-term colony assays, 3-D cultures (spheroids, organoids), transfection (overexpression, knockdown, CRISPR), co-culture and triculture with immune cells and fibroblasts, cytokine profiling, in vivo studies, in vivo imaging, immunohistochemistry, flow cytometric analysis, single cell techniques, viral infection, circulating tumor cell isolation, blood immune and cytokine analysis, and work with transgenic organoids and inducible cancer predisposing alleles. Modeling the tumor microenvironment, relevance to human cancer and translational directions are emphasized. Shared online lab resources, protocols, practices, videos, and manuscripts are available for lab members. The framework herein may be of interest to others involved in similar training programs.

Citation Format: Wafik S. El-Deiry, Andrew George, Francesca Di Cristofano, Praveen Srinivasan, Lindsey Carlsen, Kelsey E. Huntington, Arielle De La Cruz, Leiqing Zhang, Marina Hahn, Shuai Zhao, Attila Seyhan, Bradley D. DeNardo, Aaron W. Maxwell, Dae Hee Kim, Alex Raufi, Hina Khan, Stephanie L. Graff, Don S. Dizon, Christopher Azzoli, Abbas E. Abbas, Roxanne Wood, Rishi R. Lulla, Howard P. Safran, Benedito A. Carneiro, Arunasalam Navaraj, Xiaobing Tian, Shengliang Zhang, Lanlan Zhou. Inclusive basic and advanced translational laboratory research competencies for research in cancer biology and therapeutics. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 4185.

Robotic Belsey Mark IV Repair of the Paraesophageal Hernia

OBJECTIVE

Surgical repair of paraesophageal hernias in patients with hostile abdomen is challenging. Despite its utility as an open procedure, the adoption of the minimally invasive Belsey Mark IV procedure has been limited because of the complexity of using traditional video-assisted thoracoscopic instrumentation. The robotic platform offers additional degrees of freedom, which enables minimally invasive transthoracic approach despite challenging anatomy. The purpose of this article is to describe a technique of robotic approach for the Belsey Mark IV operation.

METHODS

We retrospectively reviewed 5 cases of the robotic Belsey Mark IV procedure completed at a single institution between June 2018 and November 2021. Data were collected from a review of the medical records, including operative reports, anesthesia records, imaging, and clinical notes. The operative technique is described in the present article. There were 4 men and 1 woman. The average age of the patients was 64.4 ± 13.6 years, with an average body mass index of 24.5 kg/m². Three patients had undergone previous transabdominal hiatal hernia repair, and 2 of them had 2 prior repairs. One patient underwent simultaneous pulmonary left lower lobectomy for cancer with the Belsey Mark IV procedure.

RESULTS

The average operative time was 209 ± 95 min (110 to 360 min). The average postoperative length of stay was 4.2 days, and 2 patients experienced complications including bleeding and persistent air leak (after lobectomy). The average blood loss was 67 ± 25 mL.

CONCLUSIONS

The robotic platform enables a transthoracic minimally invasive approach to the Belsey Mark IV operation.

The Scan, the Needle, or the Knife? National Trends in Diagnosing Stage I Lung Cancer

OBJECTIVE

Indeterminate lung nodules have been increasingly discovered since the expansion of lung cancer screening programs. The diagnostic approach for suspicious nodules varies based on institutional resources and preferences. The aim of this study is to analyze factors associated with diagnostic modalities used for early-stage non-small cell lung cancer (NSCLC).

METHODS

The National Cancer Database was queried for all patients with stage I NSCLC from 2004 to 2015. Four diagnostic modalities were identified, including clinical radiography alone (CRA), bronchial cytology (BC), procedural biopsy (PB), and surgical biopsy (SB). A multivariable multinomial logistic regression was used to assess associations of patient demographics, cancer characteristics, and facility characteristics with these modalities.

RESULTS

Of 250,614 patients, 4,233 (1.7%) had CRA, 5,226 (2.1%) had BC, 147,621 (59.9%) had PB, and 93,534 (37.3%) had SB. Older patients were more likely to receive CRA (adjusted odds ratio [ORadj] = 5.3) and less likely to receive SB (ORadj = 0.73). Black patients were less likely to receive SB (ORadj = 0.83) and more likely to receive BC (ORadj = 1.31). Private insurance was associated with SB (ORadj = 1.11), whereas Medicaid was associated with BC (ORadj = 1.21). Patients more than 50 miles from the facility were more likely to undergo SB (ORadj = 1.25 vs PB; ORadj = 1.30 vs CRA; ORadj = 1.38 vs BC). Patients receiving SB had shorter days from diagnosis to treatment (23.0 vs 53.5 to 64.7 for other modalities, P < 0.001).

CONCLUSIONS

Diagnostic SB to confirm early-stage NSCLC was associated with younger age, greater travel distance, and shorter time to treatment in comparison with other modalities. Black race and non-private insurance were less likely to be associated with SB.

A Rare Complication of Esophageal Exclusion: Esophageal Mucocele

Bipolar esophageal exclusion is a "Hail Mary" procedure for control of leak and persistent mediastinal soilage from esophageal injury. Usually, the esophageal remnant scars down without negative consequences. Esophageal mucocele is a rare complication of bipolar esophageal exclusion. This is a case report of an iatrogenic esophageal transection and the subsequent treatment course. A retrospective chart review of the patient's medical and surgical history was performed. After a robotic hiatal hernia repair at an outside institution, the patient suffered an esophageal leak and was surgically treated with esophageal exclusion, wide drainage of the mediastinum, and decortication of the resulting empyema. She subsequently underwent retrosternal gastric conduit for esophageal reconstruction 4 months later. Three years after this, she developed a rare complication of esophageal exclusion, a symptomatic esophageal mucocele that required resection.

Robotic Transgastric Reconstruction of the Double Lumen Esophagus

Double lumen esophagus is an extremely rare condition, developing in most cases as a complication of antireflux procedures or gastroesophageal reflux itself secondary to the severe inflammatory process in and around the lower esophagus. We describe a case of iatrogenic double lumen esophagus after multiple previous Nissen fundoplications for chronic gastroesophageal reflux disease. There is no standard surgical intervention for the management of this complication. We present a first report of successful robot-assisted surgical reconstruction of a double lumen esophagus.

Minimally Invasive Diaphragm Plication for Acquired Unilateral Diaphragm Paralysis: A Systematic Review

Objective: Diaphragm paralysis is a relatively uncommon entity that can be both congenital and acquired in nature. While commonly asymptomatic, it can also cause a significant decrease in pulmonary function and reserve, particularly in patients with underlying pulmonary diseases. Our aim was to summarize the current literature regarding the minimally invasive techniques used in the surgical correction of acquired diaphragm paralysis via traditional and robotic minimally invasive approaches. Methods: We conducted a systematic review of available literature using the Cochrane methodology and reported findings according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards. Results: A total of 6,561 citations were identified through initial database and reference searches, of which 90 articles met the inclusion criteria for review. After further assessment, 33 appropriate full-text studies were selected for the review. Of the selected publications, the majority represented case reports and single-center retrospective studies with level of evidence 4. Only 1 level 2b study (individual cohort study) was identified, comparing minimally invasive and open approaches. Conclusions: Each of the minimally invasive approaches has its unique benefits and disadvantages, which are summarized and delineated in this article. Ultimately, no preferred method of diaphragm plication for diaphragm paralysis can be recommended at this time based on clinical data. The choice of procedure and surgical approach continues to be selected based on the surgeon's experience and preference.

Preclinical studies with ONC201/TIC10 and lurbinectedin as a novel combination therapy in small cell lung cancer (SCLC)

The American Cancer Society estimates that ~15% of all lung cancers are categorized as small cell lung cancer (SCLC) with an overall five-year survival rate of less than 7%. Due to disease aggressiveness, more other malignancies, the standard of care is based on clinical efficacy rather than helpful biomarkers. Lurbinectedin is a small molecule RNA polymerase II inhibitor that binds the minor groove of DNA to induce double-strand breaks. Lurbinectedin has efficacy towards SCLC cells at sub-nM concentration and received accelerated FDA approval in 2020 for metastatic SCLC that progressed on platinum-based therapy. ONC201/TIC10 is a TRAIL pathway-inducing compound that with demonstrated clinical efficacy in H3K27M-mutated diffuse midline glioma and neuroendocrine tumors, in early phase clinical trials. We hypothesized that combining ONC201 and lurbinectedin may yield synergistic and targeted killing of SCLC cells. SCLC cell lines H1048, H1105, H1882, and H1417 were treated with ONC201 and lurbinectedin and cell viability was determined using a CellTiter-Glo assay using varying drug concentrations. Synergistic growth inhibition of SCLC cells was noted with combination of ONC201 and lurbinectedin. Induction of the integrated stress response mediator ATF4 and CHOP was observed with ONC201 and lurbinectedin along with induction of PARP cleavage indicative of apoptosis in response to cellular stress. Additionally, SCLC lines treated with the combination therapy displayed increased DNA breakage-related proteins such as phosphorylated Chk-1, Wee1 and γ-H2AX. Combination index revealed the most potent synergy occurred at the concentrations of 0.16 μM ONC201 and 0.05 nM lurbinectedin in the H1048 cell line, demonstrating highly efficient and selective killing of these tumor cells in vitro. While these therapies showed potency against the cell lines derived from SCLC patients, it is noteworthy that the combination showed significantly less toxicity to healthy human lung epithelial cells. Future studies could explore the combination of ONC201 and lurbinectedin in SCLC cell lines, SCLC patient-derived organoids, other tumor types, including in vivo studies and clinical translation.

Complex anterior chest wall reconstruction after extensive oncologic resections: a narrative review

Objective:

This report serves to showcase four cases of rare, malignant primary neoplasms of the anterior chest wall [chondrosarcoma and basal cell carcinoma (BCC)] that thoracic surgeons may encounter, and different approaches to complex reconstruction that may be necessary following resection.

Background:

Approximately 60% of the anterior chest wall neoplasms are malignant. The most common types of primary sternal tumors are chondrosarcoma and osteosarcoma. While guidelines for resection of these tumors have been previously described in the literature, guidelines regarding reconstructive techniques of the subsequent large defects are infrequently demonstrated.

Methods:

The medical records of four adult patients with primary chest wall tumors who underwent resection of the sternum from October 2016 to March 2021 were retrospectively reviewed. Radical resection with tumor-free surgical margins offers the best chance for survival, but results in a wide full-thickness defect. Hence, closure of the anterior chest wall defect with skeletal reconstruction is an essential step of the procedure and allows us to highlight surgical techniques and materials that have been used over recent years. Methods described herein include skeletal reconstruction with various hardware or allograft, as well as defect coverage using regional flaps, free tissue transfer, and mesh.

Conclusions:

Primary chest wall tumors of the sternum are an extremely rare diagnosis with a high malignancy rate. Full-thickness radical en-bloc resection is the most effective treatment option. Subsequent reconstruction of a wide chest wall defect is the most challenging aspect, though crucial in the preservation of the rigidity of the chest wall and protection of underlying structures. Different techniques and materials have been described without clear guidelines in treatment approaches; this paper serves to delineate and describe techniques that achieved successful outcomes.

Surgical Management of Early Esophageal Cancer

Esophageal cancer is the eighth most common cancer worldwide, and its incidence has been increasing over the past several decades. Esophagectomy currently is the standard of care for more advanced early esophageal cancer and should be performed at centers of excellence with high volumes, appropriate supportive staff, and multidisciplinary expertise.

Surveillance Following Treatment of Esophageal Cancer

We describe the surveillance strategies after esophageal cancer treatment, whether local therapy, induction chemoradiation, or other definitive treatment such as trimodality therapy. We discuss the shortcomings of the different invasive and imaging studies, and the recommended stage-specific surveillance after local and organ-sparing approaches to esophageal cancer treatment.

Peroral endoscopic myotomy: techniques and outcomes

Achalasia is progressive neurodegenerative disorder of the esophagus, resulting in uncoordinated esophageal motility and failure of lower esophageal sphincter relaxation, leading to impaired swallowing. Surgical myotomy of the lower esophageal sphincter, either open or minimally invasive, has been a standard of care for the past several decades. Recently, new procedure-peroral endoscopic myotomy (POEM) has been introduced into clinical practice. This procedure accomplishes the same objective of controlled myotomy only via endoscopic approach. In the current chapter authors review the present state, clinical applications, outcomes and future directions of the POEM procedure.

Learning curve of robotic portal lobectomy for pulmonary neoplasms: A prospective observational study

Background

We aim to assess the learning curve of robotic portal lobectomy with four arms (RPL‐4) in patients with pulmonary neoplasms using prospectively collected data.

Methods

Data from 100 consecutive cases with lung neoplasms undergoing RPL‐4 were prospectively accumulated into a database between June 2018 and August 2019. The Da Vinci Si system was used to perform RPL‐4. Regression curves of cumulative sum analysis (CUSUM) and risk‐adjusted CUSUM (RA‐CUSUM) were fit to identify different phases of the learning curve. Clinical indicators and patient characteristics were compared between different phases.

Results

The mean operative time, console time, and docking time for the entire cohort were 130.6 ± 53.8, 95.5 ± 52.3, and 6.4 ± 3.0 min, respectively. Based on CUSUM analysis of console time, the surgical experience can be divided into three different phases: 1–10 cases (learning phase), 11–51 cases (plateau phase), and >51 cases (mastery phase). RA‐CUSUM analysis revealed that experience based on 56 cases was required to truly master this technique. Total operative time (p < 0.001), console time (p < 0.001), and docking time (p = 0.026) were reduced as experience increased. However, other indicators were not significantly different among these three phases.

Conclusions

The RPL‐4 learning curve can be divided into three phases. Ten cases were required to pass the learning curve, but the mastery of RPL‐4 for satisfactory surgical outcomes requires experience with at least 56 cases.

Tracheobronchoplasty for tracheobronchomalacia

Tracheobronchoplasty (TBP) consists of splinting of the posterior membranous wall of the central airways with the goal of restoring a normal configuration and preventing excessive collapse in patients with tracheobronchomalacia (TBM). Despite some variation in technique, it consists of sewing a mesh on the posterior membranous wall of the trachea and both main stem bronchi. Traditionally performed through a right posterolateral thoracotomy, it should be reserved for cases of severe TBM. Surgical exposure necessitates dissection of the trachea from the thoracic inlet to the carina, as well the right main stem bronchus, bronchus intermedius and left main stem bronchus. Airway management in the operating room requires manipulation of the endotracheal tube (ETT) to allow safe placement of the sutures without puncturing the balloon. Other key technical considerations include downsizing of the airway with the mesh, and appropriate spacing of the sutures to ensure a plicating effect of the posterior membranous wall. More recently the robotic platform was used to perform TBP surgery. Its fine precise wristed motion and excellent visualization offer potential advantages over a thoracotomy and early outcomes of robotic-assisted TBP are encouraging. Longitudinal follow-up is still necessary to ensure the durability of repair in a patient population with significant underlying respiratory co-morbidities.

Specific complications and limitations of robotic esophagectomy

Regardless of the approach to esophagectomy, it is an operation that may be associated with significant risk to the patient. Robotic-assisted minimally invasive esophagectomy (RAMIE) has the same potential for short- and long-term complications as does open and minimally invasive esophagectomy. These complications include among others, the risk for anastomotic leak, gastric tip necrosis, vocal cord palsy, and chylothorax. Moreover, there are additional risks that are unique to the robotic platform such as hardware or software malfunction. These risks are heavily influenced by numerous factors including the patient's comorbidities, whether neoadjuvant therapy was administered, and the extent of the surgical team's experience. The limitations of RAMIE are therefore based on the careful assessment of the patient for operability, the tumor for resectability and the team for surgical ability. This article will tackle the topic of complications and limitations of RAMIE by examining each of these issues. It will also describe the recommended terminology for reporting post-esophagectomy complications.

Thymic Neuroendocrine Tumors and Thymic Carcinoma: Demographics, Treatment, and Survival

OBJECTIVE

Although rare, thymic neuroendocrine tumors (TNET) and thymic carcinoma (TC) are the most common thymic nonthymomatous malignancies; their survival outcomes have not been thoroughly compared. We analyzed the clinical, treatment, and survival characteristics of TNET and TC.

METHODS

We retrospectively identified patients with a histologic diagnosis of TNET or TC in the National Cancer Database (2004 to 2015). Exclusion criteria were age <18 years and unstaged tumors. Descriptive statistics, survival analysis, and multivariable Cox regression analyses were used in elucidating associations.

RESULTS

One thousand four hundred eighty-nine patients were included (TNET: 19.8%). Patients with TNET were significantly younger (57 vs 62.5 years), more likely to be male (70.5% vs 60.0%), and have localized tumors (45.4% vs 32.3%). Patients with TC more frequently underwent chemotherapy (56.1% vs 34.9%), radiation (56.9% vs 39.3%), and trimodality therapy (21.3% vs 11.5%), while resection rates were similar (55.3% vs 58.3%). The 5-year survival was 62% for TNET and 52% for TC, but comparable following multivariable adjustment. Age, stage, and Charlson-Deyo score were negative predictors of survival, while surgery and trimodality therapy were positive predictors. On subanalysis, adjuvant radiation therapy (ART) improved the survival of margin-positive tumors and was an independent predictor of survival for both tumor types (hazard ratio = 0.5).

CONCLUSIONS

Our analysis of the largest series of TNET and TC showed a survival rate surpassing 50% at 5 years. These outcomes seem to be influenced by surgical resection and ART. Standardized staging and surgical protocols including lymph node sampling are still warranted to better elucidate the treatment algorithm of these tumors.

Endoscopic and Surgical Treatments for Achalasia: Who to Treat and How?

Achalasia is a progressive neurodegenerative disorder characterized by failure of relaxation of the lower esophageal sphincter (LES) and altered motility of the esophagus. The traditional, highly effective, surgical approach to relieve obstruction at the LES includes cardiomyotomy. Fundoplication is added to decrease risk of postoperative reflux. Per oral endoscopic myotomy is a new endoscopic procedure that allows division of the LES via transoral route. It has several advantages including less invasiveness, cosmesis, and tailored approach to the length on the myotomy. However, it is associated with increased rate of post-procedural reflux. Various endoscopic interventions are used to address this problem.

Why comprehensive adoption of robotic assisted thoracic surgery is ideal for both simple and complex lung resections

Minimally invasive thoracoscopic surgical techniques have grown increasingly popular due to improved outcome measures compared to conventional rib-spreading thoracotomy. However, video-assisted thoracoscopic surgery (VATS) presents with unique technical challenges that have limited its role in certain cases. Here, we discuss our perspectives on the implementation of a successful robotic thoracic program. We will then present the case for how the adoption of robotic assisted thoracic surgery (RATS) provides the benefits of minimally invasive VATS while still retaining the technical finesse of bimanual articulating instruments and 3-dimensional imaging that is a universal component of any open surgery. We will also discuss how to overcome some of the perceived disadvantages to RATS in regard to the higher cost, lack of tactile feedback and potential safety concerns.

Pneumonectomy is necessary following delayed detection of pulmonary artery compromise

It has been previously suggested that lung tissue remains viable without blood supply from the pulmonary artery (PA). However, our experience demonstrates otherwise. We present 2 cases of accidental left lower lobe PA occlusion during upper lobectomy causing ischaemic changes to the remaining lung tissue. Both patients became septic secondary to necrosis of infarcted lung and required completion pneumonectomy. Development of collateral circulation to bypass the occluded PA may occur but is often insufficient to support the affected lung tissue. Unless the patient is medically unfit, resection of the ischaemic lung should be undertaken.

Outcomes of octogenarians with esophageal cancer: an analysis of the National Cancer Database

The optimal treatment of esophageal cancer in octogenarians is controversial. While the safety of esophagectomy has been demonstrated in elderly patients, surgery and multimodality therapy are still offered to a select group. Additionally, the long-term outcomes in octogenarians have not been thoroughly compared to those in younger patients. We sought to compare the outcomes of esophageal cancer treatment between octogenarians and non-octogenarians in the National Cancer Database (2004-2014). The major endpoints were early postoperative mortality and long-term survival. A total of 107,921 patients were identified [octogenarian-16,388 (15.2%)]. Compared to non-octogenarians, octogenarians were more likely to be female, of higher socioeconomic status, and had more Charlson comorbidities (p < 0.001 for all). Octogenarians were significantly less likely to undergo esophagectomy (11.5% vs. 33.3%; p < 0.001) and multimodality therapy (2.0% vs. 18.5%; p < 0.001), a trend that persisted following stratification by tumor stage and Charlson comorbidities. Both 30-day and 90-day mortality were higher in the octogenarian group, even after multivariable adjustment (p ≤ 0.001 for both). Octogenarians who underwent multimodality therapy had worse long-term survival when compared to younger patients, except for those with stage III tumors and no comorbidities (HR: 1.29; p = 0.153). Within the octogenarian group, postoperative mortality was lower in academic centers, and the long-term survival was similar between multimodality treatment and surgery alone (HR: 0.96; p = 0.62). In conclusion, octogenarians are less likely to be offered treatment irrespective of tumor stage or comorbidities. Although octogenarians have higher early mortality and poorer overall survival compared to younger patients, outcomes may be improved when treatment is performed at academic centers. Multimodality treatment did not seem to confer a survival advantage compared to surgery alone in octogenarians, and more prospective studies are necessary to better elucidate the optimal treatment in this patient population.

Role and safety of fundoplication in esophageal disease and dysmotility syndromes

Gastroesophageal reflux disease (GERD) is quite prevalent worldwide, especially in the western hemisphere. The pathophysiology of GERD is complex, involving an incompetent esophagogastric junction (EGJ) as an anti-reflux barrier, as well as other co-morbid conditions such as gastroparesis, hiatal herniation or hyper acid secretion. Esophageal dysmotility is also frequently encountered in GERD, further contributing to the disease in the form of fragmented peristalsis, ineffective esophageal motility (IEM) or the more severe aperistalsis. The latter is quite common in systemic connective tissue disorders such as scleroderma. The main stay treatment of GERD is pharmacologic with proton pump inhibitors (PPI), with surgical fundoplication offered to patients who are not responsive to medications or would like to discontinue them for medical or other reasons. The presence of esophageal dysmotility that can worsen or create dysphagia can potentially influence the choice of fundoplication (partial or complete), or whether it is even possible. Most of the existing literature demonstrates that fundoplication may be safe in the setting of ineffective or weak peristalsis, and that post-operative dysphagia cannot be reliably predicted by pre-operative manometry parameters. In cases of complete aperistalsis (scleroderma-like esophagus), partial fundoplication can be offered in select patients who exhibit prominent reflux symptoms after a comprehensive multidisciplinary evaluation. Roux-en-Y gastric bypass is an alternative to fundoplication in patients with this extreme form of esophageal dysmotility, after careful consideration of the nutritional status.

Robotic substernal esophageal bypass and reconstruction with gastric conduit-frequently overlooked minimally invasive option

Modern esophagectomy includes the esophageal extirpation with immediate reconstruction of the gastrointestinal (GI) continuity via posterior mediastinal route. In the majority of cases tubularized stomach is chosen as the conduit of choice. Other conduits, such as colon or small bowel can be used for these purposes as well. In rare circumstances use of the alternative route for the conduit placement is required. Authors describe the technique of robotic substernal esophageal bypass and reconstruction of the esophageal continuity.

Carinal resection

Tracheobronchial tumors with involvement of the carina represent a challenging problem in the pulmonary surgery. Carinal resection is referred to removal and reconstruction of the airway itself, whereas concomitant removal of the lung parenchyma (usually a whole lung) is termed as carinal pneumonectomy. Thorough preoperative workup of these patients is mandatory. Meticulous surgical technique and aggressive postoperative management is required for the best outcomes in these difficult cases. In the paper authors review surgical technique, evaluation and management of this challenging patient population.

Nutrition and exercise patterns in survivors of esophageal and gastroesophageal junction (EGEJ) cancers

89

Background: While obesity is a risk factor for EGEJ, malnutrition is common at diagnosis (dx) and can be exacerbated by neoadjuvant therapy (NAT) and esophagectomy. Little is known regarding nutrition and exercise patterns of EGEJ cancer survivors. Methods: A survey of EGEJ survivors > 12 months from esophagectomy was conducted. Pts were identified using institutional tumor registry. The Dillman mailed survey method was used. Questionnaires regarding health behaviors were employed: Godin Leisure-Time Exercise [GLTQ], Cancer Appetite and Symptom [CASQ], Nutritional Self-Efficacy (NSEQ). Chart review included demographics, pt characteristics and therapy received. Spearman correlation, Wilcoxon and Fisher’s tests assessed relationships between groups or variables. Results: Forty one of 140 eligible pts (29%) returned questionnaires and had surgery between 1991-2014. Median age was 69 and 78% were male. Most (83%) had adenocarcinoma. On presentation, 73% had clinical stage II or III disease and 76% received NAT. Median time from dx was 5 years (range 2-25). Mean weight loss from dx to current was 38 lbs. Mean BMI (kg/m2) was 29.52 at dx and 24.15 at most recent clinic visit. Obesity was present in 37% of pts at dx, but only 7% of survivors. Mean health behavior scores (SD): GLTQ 22.10 (22.93), CASQ 31.74 (6.66), and NSEQ 11.39 (4.03). Age, marital status, gender, education, and income were not associated with GLTQ, CASQ or NSEQ. Sedentary lifestyle (SL) with GTLQ score < 14 was present in 46% of survivors and associated with overweight BMI (mean 26.7 for SL vs 23.7 for non-SL; p = 0.04). There was a significant positive correlation between current BMI and NSEQ score (r = 0.68; p = 0.03). Conclusions: Many EGEJ cancer pts present with obesity but subsequently lose weight after curative therapy. The mean CASQ score in our population is similar to other GI cancer populations, suggesting that residual symptoms persist years after treatment ends. There is a high prevalence of SL in survivors which is associated with being overweight. Higher levels of nutrition self-efficacy were also associated with a higher current BMI. Future studies should define strategies to optimize nutrition and exercise habits in EGEJ cancer survivors.

Initial experience of robot-assisted Ivor-Lewis esophagectomy: 61 consecutive cases from a single Chinese institution

This study aims to report the technical details and preliminary outcomes of robot-assisted Ivor-Lewis esophagectomy (RAILE) using two different types of intrathoracic anastomosis from a single institution in China. From May 2015 to October 2017, 61 patients diagnosed with mid-lower esophageal cancer were treated with RAILE. The RAILE procedure was performed in two stages. The first 35 patients underwent circular end-to-end stapled intrathoracic anastomosis (stapled group), and the remaining 26 patients had a double-layered, completely hand-sewn intrathoracic anastomosis (hand-sewn group). Patient characteristics, surgical techniques, postoperative complications, and pathology outcomes were analyzed. The mean operating time and mean blood loss were 315.6 ± 59.4 minutes and 189.3 ± 95.8 mL, respectively. There was one patient who underwent conversion to thoracotomy. The 30-day and in-hospital mortality rates were 0%. Overall complications were observed in 22 patients (36.1%) according to the Clavien-Dindo (CD) and the Esophagectomy Complications Consensus Group (ECCG) classifications, of whom 6 patients (9.8%) had anastomotic leakage (ECCG, Type II). The median length of hospitalization (LOH) was 10 days (IQR, 5 days). Complete (R0) resection was achieved in all cases. The mean tumor size was 3.2 ± 1.5 cm, and the mean number of totally dissected lymph nodes was 19.3 ± 9.2. Regarding the operative outcomes between stapled and hand-sewn groups, there were no significant differences in the operative time (325.4 ± 66.6 vs. 302.3 ± 45.9 min, P = 0.114), blood loss (172.9 ± 74.1 vs. 211.5 ± 117.0 mL, P = 0.147), conversion rate (2.9 vs. 0%, P = 1.000), overall complication rate (37.1 vs. 34.6%, P = 0.839) or LOH (10 vs. 9.5 days, P = 0.415). RAILE using both stapled and hand-sewn intrathoracic anastomosis is safe and technically feasible with satisfactory perioperative outcomes for the treatment of mid-lower thoracic esophageal cancer.