Cassivi, Stephen D.

Abstract Background The objective of this study was to analyze the induction therapy regimens employed since publication of CROSS Trial in patients treated with locally advanced EGJ cancer in terms of toxicity, complications, survival and recurrence. Methods Retrospective chart review all patients in single institution prospective database who had neoadjuvant CRT→Surgery 2012–2015. Complications during CRT and after surgery graded using National Cancer Institute CTCAE. Cox-proportion hazard ratios were used to compare the primary outcomes of overall survival (OS) and disease-free survival (DFS). Results 288 patients, 237 men and 51 women were identified. 246 were adenocarcinoma, 38 squamous cell carcinoma, and 4 had other histologic types. 4 distinct neoadjuvant regimens were observed: 50.4 Gy radiation with 5-fluorouracil and cisplatin (N = 22), CROSS regimen (41.4 Gy with carboplatin & paclitaxel) (N = 44), 50.4 Gy with carboplatin and paclitaxel (N = 152), and ‘Other’ which include 27 distinct regimens (N = 70). There were no differences in treatment related complications or postoperative complications between regimens. There was no difference in pathologic complete response rate, OS, or DFS between regimens. Conclusion Since the publication of the CROSS Trial, there is a significant heterogenity in the neoadjuvant chemoradiation treatment regimen employed for patients with locally advanced EGJ tumors. Does not appear to be any differences in treatment related complications or postoperative complications between regimens. There was also no difference in pCR, overall survival or disease-free survival. Disclosure All authors have declared no conflicts of interest.

54 Background: After diagnosis and treatment, lung cancer survivors do not return to a health-related quality of life (QOL) and function comparable to pre-diagnosis levels as observed in other adult cancer survivors. We hypothesize that inadequate attention has been paid to addressing and improving QOL and function among lung cancer survivors. Our primary goal is to evaluate existing symptoms and QOL deficits among lung cancer survivors. Methods: We are evaluating patterns of QOL deficits (scored 5 or less on the scale from 0 [worst] to 10 [best]) in relation to time of lung cancer diagnosis, treatments, progression and/or recurrence, and health-related conditions. We are collecting and analyzing relevant health care utilization for selected QOL deficits, and identifying availability, accessibility, and effectiveness of evidence-based interventions. The expected outcomes will be new knowledge on patterns of QOL deficits, quality-adjusted life years in relation to the availability, accessibility, and adequacy of needed care and the effectiveness of interventions targeting improvement in QOL and symptoms. Results: In our initial analysis, among 3,707 lung cancer survivors who were diagnosed in 1999 to 2010, post-cancer treatment, and followed through 2011, 39% (1,442) reported deficits in overall QOL, 71% fatigue, 60% dyspnea, 41% being sedentary, 17% low spiritual well-being (SWB), and 10% currently smoking cigarettes. Among the 1,442 lung cancer survivors with a deficit in overall QOL, 97.5% reported severe fatigue or dyspnea, being sedentary or smoking, or having low SWB. In the remaining 36 of the 1,442, 24 had pain, cough, poor appetite, or other symptoms; only 12 (<1%) did not report deficit in any of the measured QOL domains. Analyses are ongoing. Conclusions: Based on evidence gained to date, we are developing and testing interventions targeting symptoms and QOL deficits. We expect to gain strong evidence for recommendations in redefining and delivering care and support that are necessary for improving the health and QOL of lung cancer survivors.

Abstract Management of recurrent bronchopleural fistula (BPF) after pneumonectomy remains a challenge. Although a variety of devices and techniques have been described, definitive management usually involves closure of the fistula tract through surgical intervention. Standard surgical approaches for BPF incur significant morbidity and mortality and are not reliably or uniformly successful. We describe the first-in-human application of an autologous mesenchymal stem cell (MSC)-seeded matrix graft to repair a multiply recurrent postpneumonectomy BPF. Adipose-derived MSCs were isolated from patient abdominal adipose tissue, expanded, and seeded onto bio-absorbable mesh, which was surgically implanted at the site of BPF. Clinical follow-up and postprocedural radiological and bronchoscopic imaging were performed to ensure BPF closure, and in vitro stemness characterization of patient-specific MSCs was performed. The patient remained clinically asymptomatic without evidence of recurrence on bronchoscopy at 3 months, computed tomographic imaging at 16 months, and clinical follow-up of 1.5 years. There is no evidence of malignant degeneration of MSC populations in situ, and the patient-derived MSCs were capable of differentiating into adipocytes, chondrocytes, and osteocytes using established protocols. Isolation and expansion of autologous MSCs derived from patients in a malnourished, deconditioned state is possible. Successful closure and safety data for this approach suggest the potential for an expanded study of the role of autologous MSCs in regenerative surgical applications for BPF. Significance Bronchopleural fistula is a severe complication of pulmonary resection. Current management is not reliably successful. This work describes the first-in-human application of an autologous mesenchymal stem cell (MSC)-seeded matrix graft to the repair of a large, multiply recurrent postpneumonectomy BPF. Clinical follow-up of 1.5 years without recurrence suggests initial safety and feasibility of this approach. Further assessment of MSC grafts in these difficult clinical scenarios requires expanded study.

The following, from the 12th OESO World Conference: Cancers of the Esophagus, includes commentaries on the role of the nurse in preparation of esophageal resection (ER); the management of patients who develop high‐grade dysplasia after having undergone Nissen fundoplication; the trajectory of care for the patient with esophageal cancer; the influence of the site of tumor in the choice of treatment; the best location for esophagogastrostomy; management of chylous leak after esophagectomy; the optimal approach to manage thoracic esophageal leak after esophagectomy; the choice for operational approach in surgery of cardioesophageal crossing; the advantages of robot esophagectomy; the place of open esophagectomy; the advantages of esophagectomy compared to definitive chemoradiotherapy; the pathologist report in the resected specimen; the best way to manage patients with unsuspected positive microscopic margin after ER; enhanced recovery after surgery for ER: expedited care protocols; and long‐term quality of life in patients following esophagectomy.

Objectives although video-assisted thoracoscopic surgery for pulmonary resection appears to be associated with more favorable postoperative outcomes than thoracotomy, no reports have discussed its benefit at subsequent reoperative pulmonary resection. Methods between January 2000 and December 2009, 144 patients underwent reoperative pulmonary resections for benign and malignant nodules at the Mayo Clinic, Rochester. Their data were evaluated retrospectively. Twenty-three (16%) patients had prior video-assisted thoracoscopic surgery, and 121 (84%) had undergone a prior open thoracotomy. Intraoperative and short-term postoperative outcomes were analyzed and compared between the two groups, using the chi-square test or Mann-Whitney test. Results overall reoperative mortality was 1.38% and morbidity was 49.3%. Intraoperative factor analysis showed that the prior video-assisted thoracoscopic surgery group more often underwent anatomical resection ( p = 0.0011) and showed a tendency towards a lower conversion rate from video-assisted thoracoscopic surgery to thoracotomy at reoperative pulmonary resection ( p = 0.051). Short-term postoperative outcomes showed that the prior video-assisted thoracoscopic surgery group had a significantly lower morbidity rate ( p = 0.013), significantly shorter hospital stay ( p = 0.002), and a tendency for a shorter duration of chest tube drainage ( p = 0.09). Conclusion our results suggest that prior video-assisted thoracoscopic surgery may lead to improved postoperative outcomes at subsequent reoperative pulmonary resection. Video-assisted thoracoscopic surgery may be favored for future potential reoperative pulmonary resections.

Objective Although robotic technology has addressed many of the limitations of traditional videoscopic surgery, robotic surgery has not gained widespread acceptance in the general thoracic community. We report our initial robotic surgery experience and propose a structured, competency-based pathway for the development of robotic skills. Methods Between December 2008 and February 2012, a total of 79 robot-assisted pulmonary, mediastinal, benign esophageal, or diaphragmatic procedures were performed. Data on patient characteristics and perioperative outcomes were retrospectively collected and analyzed. During the study period, one surgeon and three residents participated in a triphasic, competency-based pathway designed to teach robotic skills. The pathway consisted of individual preclinical learning followed by mentored preclinical exercises and progressive clinical responsibility. Results The robot-assisted procedures performed included lung resection (n = 38), mediastinal mass resection (n = 19), hiatal or para-esophageal hernia repair (n = 12), and Heller myotomy (n = 7), among others (n = 3). There were no perioperative mortalities, with a 20% complication rate and a 3% readmission rate. Conversion to a thoracoscopic or open approach was required in eight pulmonary resections to facilitate dissection (six) or to control hemorrhage (two). Fewer major perioperative complications were observed in the later half of the experience. All residents who participated in the thoracic surgery robotic pathway perform robot-assisted procedures as part of their clinical practice. Conclusions Robot-assisted thoracic surgery can be safely learned when skill acquisition is guided by a structured, competency-based pathway.