Management of clinical T2N0 esophageal cancer: a review

While management of locally advanced esophageal cancer has mostly involved multimodality therapy, management of clinical T2N0 patients has been more controversial, primarily as a result of inaccurate clinical staging with existing modalities. This review article examines current literature on this topic and provides recommendations for management of individual patients

Substernal reconstruction following esophagectomy: operation of last resort?

Background: The posterior mediastinum is the preferred location for reconstruction following esophagectomy. Occasionally alternative routes are required. We examined patient outcomes of esophageal reconstruction in order to determine whether substernal reconstruction (SR) is an equivalent alternative to orthotopic placement. Methods: Following IRB approval, we performed a retrospective review of all patients who underwent an esophagectomy from 1988-2014. Only patients reconstructed with a gastric conduit and cervical anastomosis by either substernal or posterior mediastinal (PM) routes were included in the study. Endpoints assessed included anastomotic leak rate, post-operative complications, reoperation, hospital length of stay, and 30- and 90-day mortality. Results: Thirty-three patients underwent SR and 182 had a PM gastric conduit with cervical anastomosis. The SR pathology was predominantly benign while PM was mostly malignant. Sixteen SR patients had a delayed reconstruction after prior diversion. Mean hospital LOS was longer in the SR group (P<0.001). There was no significant difference in 30- and 90-day mortality. PM patients had significantly fewer respiratory complications (P<0.04), reoperations (P<0.04), and transfusions (P<0.0001) and a trend towards fewer anastomotic leaks (17.1% vs. 30.3%; P<0.09). Conclusions: This single institution experience demonstrated no significant difference in mortality between substernal and PM reconstruction following esophagectomy. However, SR was associated with significantly increased LOS and morbidity, including a trend toward increased anastomotic leaks. SR reconstruction should probably be considered an option of last resort

“Show me the Data”: A Recipe for Quality Improvement Success in an Academic Surgical Department

Background Surgeons in academic medical centers have traditionally taken a siloed approach to reducing postoperative complications. We initiated a project focusing on transparency and sharing of data in order to engage surgeons in collaborative quality improvement. Its key features were the development of a comprehensive Department Quality Dashboard and the creation of a Clinical Operations Council that oversaw quality. The purpose of this study was to assess the impact of those efforts. Study Design We compared inpatient outcomes before and after our intervention, allowing one quarter as the diffusion period. The outcomes analyzed were: risk-adjusted length of stay (LOS), mortality and direct cost and unadjusted incidence of complications and 30-day all-cause readmissions, as determined by the Vizient Clinical Database. We examined the outcomes of three groups: Group 1 (Surgery), Group 2 - all other surgical departments (Other Surgery) and Group 3 - all other patients (Non-Surgery). Two-tailed Students’s t-test was used for analysis and a p value of <0.05 considered statistically significant. Results Group 1 demonstrated statistically significant improvements in mortality (p=0.01), LOS (p=0.002), cost (p=0.0001) and complications (p=0.02) while the all-cause readmission rate was unchanged, resulting in mean decrease of 0.55 LOS days and direct cost savings of $2300 per surgical admission. The comparison groups had only modest decreases in some of the analyzed outcomes and an increase in complication rates. Conclusions These data suggest that a collaborative, data-driven and transparent approach to assessing the quality of surgical care can yield significant improvements in patient outcomes

Hypercalcemic Crisis Caused by a Parathyroid Mass Requiring Thoracoscopic Resection

Objective: To describe the presentation, work up, and treatment of a giant parathyroid adenoma presenting as hypercalcemic crisis that ultimately weighed 57 g and extended into the mediastinum, requiring hand-assisted thoracoscopic resection. Methods: The patient is a 68-year-old man with a prior history of parathyroidectomy, who initially presented with a severe hypercalcemia of 16.3 mg/dL and a parathyroid hormone (PTH) level of 2692 pg/mL on routine labs. Results: Diagnostic and staging work up revealed a 7.2-cm mass extending from just superior to the sternal notch into the right posterior mediastinum to the carina, causing esophageal displacement. No evidence of local invasion or distant metastasis was observed on further imaging, and cytology demonstrated hypercellular parathyroid tissue. The PTH level of the aspirate was >5000 pg/mL. The patient subsequently underwent a right hand-assisted video-assisted thoracoscopic resection of the intrathoracic mass. Final pathology identified a 7.0-cm, 57-g parathyroid adenoma, without any pathologic findings suspicious for malignancy. However, the endocrine surgery team plans for annual laboratory assessment to ensure no recurrence. Conclusion: Primary hyperparathyroidism is most commonly caused by a single adenoma. However, in the setting of severe hypercalcemia and elevated PTH, one must have a high suspicion for malignancy, and care should be taken to remove the mass en bloc. For extremely large adenomas extending into the mediastinum, a minimally invasive, hand-assisted, thoracoscopic approach is a safe and effective method of resection

Coping Skills Practice and Symptom Change: A Secondary Analysis of a Pilot Telephone Symptom Management Intervention for Lung Cancer Patients and their Family Caregivers

Context Little research has explored coping skills practice in relation to symptom outcomes in psychosocial interventions for cancer patients and their family caregivers. Objectives To examine associations of coping skills practice to symptom change in a telephone symptom management (TSM) intervention delivered concurrently to lung cancer patients and their caregivers. Methods This study was a secondary analysis of a randomized pilot trial. Data were examined from patient-caregiver dyads (n=51 dyads) that were randomized to the TSM intervention. Guided by social cognitive theory, TSM involved four weekly sessions where dyads were taught coping skills including: a mindfulness exercise, guided imagery, pursed lips breathing, cognitive restructuring, problem solving, emotion-focused coping, and assertive communication. Symptoms were assessed, including patient and caregiver psychological distress and patient pain interference, fatigue interference, and distress related to breathlessness. Multiple regression analyses examined associations of coping skills practice during the intervention to symptoms at 6 weeks post-intervention. Results For patients, greater practice of assertive communication was associated with less pain interference (β=-0.45, p=0.02) and psychological distress (β=-0.36, p=0.047); for caregivers, greater practice of guided imagery was associated with less psychological distress (β=-0.30, p=0.01). Unexpectedly, for patients, greater practice of a mindfulness exercise was associated with higher pain (β=0.47, p=0.07) and fatigue interference (β=0.49, p=0.04); greater practice of problem solving was associated with higher distress related to breathlessness (β=0.56, p=0.01) and psychological distress (β=0.36, p=0.08). Conclusion Findings suggest the effectiveness of TSM may have been reduced by competing effects of certain coping skills. Future interventions should consider focusing on assertive communication training for patients and guided imagery for caregivers

Randomized Pilot Trial of a Telephone Symptom Management Intervention for Symptomatic Lung Cancer Patients and Their Family Caregivers

Context Lung cancer is one of the most common cancers affecting both men and women and is associated with high symptom burden and psychological distress. Lung cancer patients’ family caregivers also show high rates of distress. However, few interventions have been tested to alleviate significant problems of this population. Objectives This study examined the preliminary efficacy of telephone-based symptom management (TSM) for symptomatic lung cancer patients and their family caregivers. Methods Symptomatic lung cancer patients and caregivers (N=106 dyads) were randomly assigned to 4 sessions of TSM consisting of cognitive-behavioral and emotion-focused therapy or an education/support condition. Patients completed measures of physical and psychological symptoms, self-efficacy for managing symptoms, and perceived social constraints from the caregiver; caregivers completed measures of psychological symptoms, self-efficacy for helping the patient manage symptoms and managing their own emotions, perceived social constraints from the patient, and caregiving burden. Results No significant group differences were found for all patient outcomes and caregiver self-efficacy for helping the patient manage symptoms and caregiving burden at 2 and 6-weeks post-intervention. Small effects in favor of TSM were found regarding caregiver self-efficacy for managing their own emotions and perceived social constraints from the patient. Study outcomes did not significantly change over time in either group. Conclusion Findings suggest that our brief telephone-based psychosocial intervention is not efficacious for symptomatic lung cancer patients and their family caregivers. Next steps include examining specific intervention components in relation to study outcomes, mechanisms of change, and differing intervention doses and modalities

Impact of the development of an endoscopic eradication program for Barrett's esophagus with high grade dysplasia or early adenocarcinoma on the frequency of surgery

Background and aims  The impact of the advent of an institutional endoscopic eradication therapy (EET) program on surgical practice for Barrett's esophagus (BE)-associated high grade dysplasia (HGD) or suspected T1a esophageal adenocarcinoma (EAC) is unknown. The aims of this study are to evaluate the different endoscopic modalities used during development of our EET program and factors associated with the use of EET or surgery for these patients after its development. Methods  Patients who underwent primary endoscopic or surgical treatment for BE-HGD or early EAC at our hospital between January 1992 and December 2014 were retrospectively identified. They were categorized by their initial modality of treatment during the first year, and the impact over time for choice of therapy was assessed by multivariable logistic regression. Results  We identified 386 patients and 80 patients who underwent EET and surgery, respectively. EET included single modality therapy in 254 (66 %) patients and multimodal therapy in 132 (34 %) patients. Multivariable logistic regression showed that, for each subsequent study year, EET was more likely to be performed in patients who were older ( P  = 0.0009), with shorter BE lengths ( P  < 0.0001), and with a pretreatment diagnosis of HGD ( P  = 0.0054) compared to surgical patients. The diagnosis of EAC did not increase the utilization of EET compared to surgery as time progressed ( P  = 0.8165). Conclusion  The introduction of an EET program at our hospital increased the odds of utilizing EET versus surgery over time for initial treatment of patients who were older, had shorter BE lengths or the diagnosis of BE-HGD, but not in patients with EAC

Support service use and interest in support services among lung cancer patients

This study examined support service use and interest in support services among lung cancer patients (N = 165) at two comprehensive medical centers in the midwestern United States

Development of a Multidisciplinary Program to Expedite Care of Esophageal Emergencies

Background Level 1 programs have improved outcomes by expediting the multidisciplinary care of critically ill patients. We established a novel level 1 program for the management of esophageal emergencies. Methods After institutional review board approval, we performed a retrospective analysis of patients referred to our level 1 esophageal emergency program from April 2013 through November 2015. A historical comparison group of patients treated for the same diagnosis in the previous 2 years was used. Results Eighty patients were referred and transported an average distance of 56 miles (range, 1–163 miles). Median time from referral to arrival was 2.4 hours (range, 0.4-12.9 hours). Referrals included 6 (7%) patients with esophageal obstruction and 71 (89%) patients with suspected esophageal perforation. Of the patients with suspected esophageal perforation, causes included iatrogenic (n = 26), Boerhaave’s syndrome (n = 32), and other (n = 13). Forty-six percent (n = 33) of patients were referred because of pneumomediastinum, but perforation could not be subsequently demonstrated. Initial management of patients with documented esophageal perforation included operative treatment (n = 25), endoscopic intervention (n = 8), and supportive care (n = 5). Retrospective analysis demonstrated a statistically significant difference in mean Pittsburgh severity index score (PSS) between esophageal perforation treatment groups (p < 0.01). In patients with confirmed perforations, there were 3 (8%) mortalities within 30 days. More patients in the esophageal level 1 program were transferred to our institution in less than 24 hours after diagnosis than in the historical comparison group (p < 0.01). Conclusions Development of an esophageal emergency referral program has facilitated multidisciplinary care at a high-volume institution, and early outcomes appear favorable

Barriers to mental health service use and preferences for addressing emotional concerns among lung cancer patients

OBJECTIVE: This study examined barriers to mental health service use and preferences for addressing emotional concerns among lung cancer patients (N=165) at two medical centers in the Midwestern United States. METHODS: Lung cancer patients completed an assessment of anxiety and depressive symptoms, mental health service use, barriers to using these services, and preferences for addressing emotional concerns. RESULTS: Only 45% of distressed patients received mental health care since their lung cancer diagnosis. The most prevalent patient-reported barriers to mental health service use among non-users of these services (n=110) included the desire to independently manage emotional concerns (58%) and inadequate knowledge of services (19%). In addition, 57% of distressed patients who did not access mental health services did not perceive the need for help. Seventy-five percent of respondents (123/164) preferred to talk to a primary care physician if they were to have an emotional concern. Preferences for counseling, psychiatric medication, peer support, spiritual care, or independently managing emotional concerns also were endorsed by many patients (range=40-50%). Older age was associated with a lower likelihood of preferring to see a counselor. CONCLUSIONS: Findings suggest that many distressed lung cancer patients underuse mental health services and do not perceive the need for such services. Efforts to increase appropriate use of services should address patients' desire for autonomy and lack of awareness of services