A thoracic surgery clinic dedicated to indeterminate pulmonary nodules: Too many scans and too little pathology?

ObjectiveWidespread application of computed tomographic scans has increased detection of asymptomatic pulmonary nodules. A dedicated clinic was established to encourage referral and manage large numbers of patients with such nodules.MethodsPatients were evaluated periodically by a nurse practitioner with surgeon oversight, and follow-up imaging was centralized. Patients were rescanned at intervals on the basis of radiologist recommendation.ResultsA total of 414 patients, 189 male and 225 female with a median age of 60.2 years (20.7–84.1 years), were evaluated since April 2000. Median follow-up was 1.51 years (0–6.65 years). Thirty-seven percent (153/414) were older than 60 years with at least 10 pack-years of tobacco use, whereas 30% (123/414) had never smoked. A total of 286 patients completed at least 2 years of follow-up computed tomographic evaluation. After 2 years, 24.2% (69/286) were deemed in stable condition and were discharged from further follow-up, whereas 22.4% (64/286) of patients were followed up longer than 2 years owing to the development of new nodules. Forty-five percent (127/286) of patients did not complete their recommended follow-up at our clinic. Overall, 3% (13/414) of our patients have been shown to have a malignant tumor. Only 5 patients underwent curative resection of a primary lung cancer.ConclusionIn a population of patients with indeterminate nodules in routine clinical practice, few patients required intervention and few cancers were detected. Although the benefits of a “nodule” clinic may include patient reassurance and convenience to referring physicians, a significant number of patients did not complete their follow-up in our clinic

Adjuvant chemotherapy for patients with pathologic node-positive esophageal cancer after induction chemotherapy is associated with improved survival

The study objectives were to identify variables associated with the use of adjuvant chemotherapy among patients with node-positive esophageal cancer who received induction therapy and to evaluate its relationship with overall survival. Treatment data for patients with esophageal cancer receiving induction chemotherapy ± radiotherapy and esophagectomy were abstracted from the National Cancer Data Base. Pathologic node-positive patients were dichotomized by whether they received 2 or more cycles of adjuvant chemotherapy or none. Kaplan–Meier survival curves were generated, and a Cox proportional hazards model was done to identify factors associated with overall survival. From 2006 to 2012, 3100 patients had pathologic positive nodes after induction therapy and esophagectomy. A total of 2625 patients (84.7%) did not receive adjuvant chemotherapy, and 475 patients (15.3%) did. N3 nodal stage was associated with an increased likelihood of receiving adjuvant chemotherapy (reference: N1, odds ratio, 1.82, 95% confidence interval, 1.15-2.97, P = .01), whereas increasing age (by year, odds ratio, 0.97, confidence interval, 0.96-0.98, P < .001), induction chemoradiation therapy (reference: induction chemotherapy, odds ratio, 0.39, confidence interval, 0.30-0.52, P < .001), and increasing inpatient length of stay after esophagectomy (per day: odds ratio, 0.98, confidence interval, 0.97-0.99, P = .007) were associated with a decreased likelihood. Patients receiving adjuvant chemotherapy had improved overall survival at each pathologic nodal stage: 31.6 months versus 22.7 months for N1 disease (P < .001), 32.4 months versus 19.2 months for N2 disease (P = .035), and 19.5 months versus 10.4 months for N3 disease (P < .001). Adjuvant therapy was independently associated with decreased mortality hazard (hazard ratio, 0.69, 95% confidence interval, 0.57-0.83, P < .001). Patients receiving adjuvant chemotherapy after induction therapy and esophagectomy show a survival benefit at all positive nodal stages. Prospective studies may help further delineate this benefit

Absence of deterioration of vascular function of the donor limb at late follow-up after radial artery harvesting

ObjectiveRadial artery harvesting has been questioned because of purported long-term circulatory consequences. Previous midterm Doppler ultrasonographic results are inconsistent regarding ulnar arterial effects. Flow-mediated vasodilatation more sensitively measures response to shear stress as index of arterial reactivity and function.MethodsWe contacted 231 patients who had undergone radial artery harvesting at least 10 years previously (mean follow-up, 12.9 ± 0.8 years). Subcohort of 25 volunteers (mean age, 69.2 ± 8.4 years) underwent ultrasonographic evaluation of ipsilateral (harvest) and contralateral (control) ulnar arteries. Flow-mediated vasodilatation compared changes in ulnar arterial diameters before and after occlusion.ResultsIn subcohort, peak systolic velocity of harvest ulnar artery was 0.82 ± 0.15 m/s, versus 0.63 ± 0.23 m/s on control side (P < .001), with no differences in intimomedial thickness (P = .763) or presence of atherosclerotic plaques (P = .364). Baseline diameter of harvest ulnar artery was 3.0 ± 0.5 mm, versus 2.7 ± 0.6 mm on control side (P = .007). Postocclusion diameter of harvest ulnar artery was 3.2 ± 0.5 mm, versus 2.9 ± 0.6 mm on control side (P = .001). No differences were seen in preocclusion and postocclusion absolute and percentage changes in ulnar arterial diameter (Table 1).ConclusionsDespite increased shear stress, no deterioration in either ulnar arterial structure or functional reactivity was measured by flow-mediated vasodilatation more than 10 years after radial artery harvesting. With appropriate preoperative evaluation, radial arterial grafting for coronary artery bypass grafting is not associated with long-term donor limb vascular insufficiency

Clinical T2N0 Esophageal Cancer: Identifying Pretreatment Characteristics Associated With Pathologic Upstaging and the Potential Role for Induction Therapy

BACKGROUND: While studies have suggested standard therapy for clinical T2N0 esophageal cancer should be primary surgery, we hypothesize there is a subgroup for whom induction therapy may result in improved overall survival (OS). METHODS: cT2N0 esophageal cancer patients receiving induction therapy or upfront esophagectomy (UE) were identified in the National Cancer Data Base (NCDB). UE patients were dichotomized as 1) pathologically upstaged or 2) same-or down-staged. Logistic regression models identified variables associated with upstaging and Kaplan-Meier analysis compared median OS. RESULTS: From 2006–2012, 932 (52.2%) cT2N0 patients received UE, while 853 (47.8%) received induction therapy first. 326/713 (45.7%) UE patients were upstaged. 87/326 (26.7%) patients had T upstaging, 98/326 (30.1%) had N upstaging, and 141/326 (43.3%) had both. Patients upstaged after UE had a higher tumor grade (35.1% versus 57.1% Grade 3), and a higher rate of lymphovascular invasion (LVI, 57.1% versus 17.7%), both p<0.001. Variables associated with upstaging included LVI (OR 6.0, 95% CI 2.9 – 12.5, p<0.001) and tumor grade 3 (OR 9.4, 1.8 – 48.4, p=0.007). Of upstaged UE patients, only 144 (44.2%) received adjuvant therapy. The median OS for cT2N0 patients upstaged after UE was 27.5 ± 2.5 months versus 43.9 ± 2.9 months for induction therapy patients (any resultant pathologic stage, p<0.001). CONCLUSIONS: Half of all cT2N0 patients were pathologically upstaged after UE with worse survival compared to patients receiving induction therapy. Refining an upstaging model would help select patients for induction therapy and increase the rate of chemotherapy in patients at risk for systemic disease