Thoracic Poster Session IV*
Activity: 103rd Annual Meeting
Indiana University
Zionsville, IN
United States - Contact Me
Dr. Denlinger is a tenured Professor of Surgery at Indiana University who joined the faculty there in 2020. He is a graduate of the Ohio State University College of Medicine and completed his general surgery and thoracic training at the University of Virginia and Washington University. His clinical interests include the treatment of lung and esophageal cancers, benign foregut surgery and lung transplantation. He currently serves as an editorial board member for the Journal of Thoracic and Cardiovascular Surgery as well as the Annals of Thoracic Surgery.
Henry Ford Health System
Detroit, MI
United States - Contact Me
I grew up in Detroit before going to Johns Hopkins University for my undergraduate degree. I did medical school at Washington University in St. Louis, residency at the Cleveland Clinic Foundation and then fellowship at Beth Israel Deaconess Medical Center in Boston.
I specialize in lung and esophageal disease. I perform almost every surgery minimally invasively and have been named to the Super Doctors list for 6 consecutive years.
I have dedicated my life and career to caring for those in need. I started the Okereke Foundation in 2013 to provide care and education to communities in need. In 2016, I began a mentorship program with underrepresented high school students. That program continues, and I now also sponsor a summer internship program for high school students. Our program mentors hundreds of high school students each academic year.
I have an active basic science lab which studies the esophageal microbiome and its association with disease. I have had NIH funding for several consecutive years now. I also perform research on disparities in healthcare in Michigan and across the country.
Monday, May 8, 2023: 3:15 PM - 3:45 PM
Los Angeles Convention Center
Posted Room Name: Exhibit Hall
Track
Thoracic
103rd Annual Meeting
Presentations
P140. Assessing the Accuracy of a Novel Multi-Section Robotic Bronchoscope in Localization & Targeting of Small Pulmonary Lesions
Total Time: 3 Minutes
Objective: In light of the newly adopted lung cancer screening guidelines, the ability to definitively diagnosis early-stage lung cancer within small pulmonary nodules is critical. Despite viable methods such as electromagnetic navigational bronchoscopy (EM-NB), there is still an unmet need for rapid, accurate, and minimally invasive biopsy techniques for patients with small peripheral lung lesions. Robotic bronchoscopy (RB) has emerged as a novel technique to address this issue. The objective of this study was to quantitatively assess the accuracy of a multi-section robotic bronchoscope compared to current standards of care.
Methods: This is a prospective, single-blinded, randomized, comparative study where the accuracy of RB was compared against the accuracy of standard EM-NB during lesion localization and targeting. 5 blinded subjects of varying bronchoscopy experience were recruited to use both RB and EM-NB in a swine lung model. Accuracy of localization and targeting success was measured as the distance from the center of pulmonary targets at each anatomic location. Subjects used both RB and EM-NB to navigate to 4 pulmonary targets assigned using 1:1 block randomization. Differences in accuracy and time between navigation systems were assessed using Wilcoxon Rank Sum test.
Results: Both RB and EM-NB were driven to 4 independent targets twice for a total of 40 attempts each (8 per subject per bronchoscopic modality). Of the 40 total targeting attempts per modality, 90% and 85% attempts were successful when utilizing RB and EM-NB, respectively. No significant differences were found between the two bronchoscopy modalities with regard to total navigation time. Upon targeting completion, RB was found to have a significantly lower median distance to the real-time EM target (1.1 mm, IQR:0.6-2.0mm) compared to EM-NB (2.6mm, IQR:1.6-3.8). Median target displacement resulting from lung deformation was found to be significantly lower when using RB (0.8mm, IQR:0.5-1.2mm) compared to EM-NB (2.6mm, IQR:1.4-6.4mm).
Conclusions: The results of our study highlight the clear advantage of RB compared to standard EM-NB in terms of targeting accuracy. This is likely attributable to the three-section RB which mitigates the large tissue displacement observed with standard EM-NB navigation. As RB development and implementation continues to improve, so will our ability to definitively diagnosis smaller lung cancer nodules-continuing the improvement of patient outcomes.
Methods: This is a prospective, single-blinded, randomized, comparative study where the accuracy of RB was compared against the accuracy of standard EM-NB during lesion localization and targeting. 5 blinded subjects of varying bronchoscopy experience were recruited to use both RB and EM-NB in a swine lung model. Accuracy of localization and targeting success was measured as the distance from the center of pulmonary targets at each anatomic location. Subjects used both RB and EM-NB to navigate to 4 pulmonary targets assigned using 1:1 block randomization. Differences in accuracy and time between navigation systems were assessed using Wilcoxon Rank Sum test.
Results: Both RB and EM-NB were driven to 4 independent targets twice for a total of 40 attempts each (8 per subject per bronchoscopic modality). Of the 40 total targeting attempts per modality, 90% and 85% attempts were successful when utilizing RB and EM-NB, respectively. No significant differences were found between the two bronchoscopy modalities with regard to total navigation time. Upon targeting completion, RB was found to have a significantly lower median distance to the real-time EM target (1.1 mm, IQR:0.6-2.0mm) compared to EM-NB (2.6mm, IQR:1.6-3.8). Median target displacement resulting from lung deformation was found to be significantly lower when using RB (0.8mm, IQR:0.5-1.2mm) compared to EM-NB (2.6mm, IQR:1.4-6.4mm).
Conclusions: The results of our study highlight the clear advantage of RB compared to standard EM-NB in terms of targeting accuracy. This is likely attributable to the three-section RB which mitigates the large tissue displacement observed with standard EM-NB navigation. As RB development and implementation continues to improve, so will our ability to definitively diagnosis smaller lung cancer nodules-continuing the improvement of patient outcomes.
View Submission
Poster Presenter
Fumitaro Masaki, Massachusetts General Hospital - Contact Me Brookline, MAUnited States
P141. Hospital Factors Are More Important than Volume in Predicting Outcome and Failure to Rescue in Medicare Beneficiaries Undergoing Robotic Lobectomy
Total Time: 3 Minutes
OBJECTIVE
Surgical volume is known to influence failure to rescue (FTR), defined as death following a complication. Robotic lung surgery continues to expand despite outcome variability between hospitals. We sought to estimate the contribution of hospital-based factors on outcomes and FTR following robotic lobectomy.
METHODS
Using the Centers for Medicare and Medicaid Services inpatient claims database, we evaluated all patients aged 65 and older with a diagnosis of lung cancer undergoing robotic upper lobectomy between January 2018 and December 2020. We excluded patients who had a segmentectomy, sublobar, wedge and bronchoplastic resections, those with metastatic or non-malignant disease, and those with a history of neoadjuvant chemotherapy. Primary outcomes included FTR rate, length of stay (LOS), readmissions, conversion to open, complications, and costs. We analyzed hospitals by tertiles of volume (Low <9, Medium 9-20; High >20). We utilized the Medicare Mortality index (MMI), a marker of overall hospital performance, and analyzed hospitals by tertile (low <0.04; medium 0.04-0.13; high >0.13). Propensity score models were adjusted for confounding using goodness-of-fit.
RESULTS
Data pertaining to 4,317 patients who underwent robotic resection were analyzed. After propensity score balancing, patients from tertiles of lowest volume and highest MMI had higher costs ($34,222 vs. $30,316, p = 0.006) p < 0.001), as well as higher mortality (OR 7.46; 95% CI 2.67-28.2, p < 0.001) and death within 60 days (OR 17.1; 95% CI 5.43-87.4). Compared to high volume hospitals, low volume centers had the highest incidence of conversion to open, atelectasis, respiratory failure, hemorrhagic anemia, death, length of stay (LOS), and costs (each p<0.001). The C-statistic for volume as a predictor of FTR was 0.6. Hospitals in the highest tertile of MMI had highest incidence of conversion to open surgery (p=0.01), pneumothorax (p=0.02), atelectasis (p<0.001), and respiratory failure (p<0.001). They also had highest mortality, readmissions, LOS, costs (each p<0.001), and shortest survival (p<0.001). The C-statistic for MMI was 0.8. (Figure)
CONCLUSION
The MMI incorporates hospital-based factors in the adjudication of outcomes and may be a more sensitive predictor of FTR rates than volume alone. Combining MMI and volume may provide a metric that can guide quality improvement and cost effectiveness measures in hospitals seeking to implement robotic lung
Surgical volume is known to influence failure to rescue (FTR), defined as death following a complication. Robotic lung surgery continues to expand despite outcome variability between hospitals. We sought to estimate the contribution of hospital-based factors on outcomes and FTR following robotic lobectomy.
METHODS
Using the Centers for Medicare and Medicaid Services inpatient claims database, we evaluated all patients aged 65 and older with a diagnosis of lung cancer undergoing robotic upper lobectomy between January 2018 and December 2020. We excluded patients who had a segmentectomy, sublobar, wedge and bronchoplastic resections, those with metastatic or non-malignant disease, and those with a history of neoadjuvant chemotherapy. Primary outcomes included FTR rate, length of stay (LOS), readmissions, conversion to open, complications, and costs. We analyzed hospitals by tertiles of volume (Low <9, Medium 9-20; High >20). We utilized the Medicare Mortality index (MMI), a marker of overall hospital performance, and analyzed hospitals by tertile (low <0.04; medium 0.04-0.13; high >0.13). Propensity score models were adjusted for confounding using goodness-of-fit.
RESULTS
Data pertaining to 4,317 patients who underwent robotic resection were analyzed. After propensity score balancing, patients from tertiles of lowest volume and highest MMI had higher costs ($34,222 vs. $30,316, p = 0.006) p < 0.001), as well as higher mortality (OR 7.46; 95% CI 2.67-28.2, p < 0.001) and death within 60 days (OR 17.1; 95% CI 5.43-87.4). Compared to high volume hospitals, low volume centers had the highest incidence of conversion to open, atelectasis, respiratory failure, hemorrhagic anemia, death, length of stay (LOS), and costs (each p<0.001). The C-statistic for volume as a predictor of FTR was 0.6. Hospitals in the highest tertile of MMI had highest incidence of conversion to open surgery (p=0.01), pneumothorax (p=0.02), atelectasis (p<0.001), and respiratory failure (p<0.001). They also had highest mortality, readmissions, LOS, costs (each p<0.001), and shortest survival (p<0.001). The C-statistic for MMI was 0.8. (Figure)
CONCLUSION
The MMI incorporates hospital-based factors in the adjudication of outcomes and may be a more sensitive predictor of FTR rates than volume alone. Combining MMI and volume may provide a metric that can guide quality improvement and cost effectiveness measures in hospitals seeking to implement robotic lung
View Submission
Poster Presenter
*J. W. Awori Hayanga, West Virginia University - Contact Me Morgantown, WVUnited States
P142. National Trends, Safety and Effectiveness of Minimally Invasive En-bloc Chest Wall Resection for Locally Advanced Lung Cancer
Total Time: 3 Minutes
Objective: En-bloc chest wall resection for locally advanced lung cancer is traditionally performed via an open approach. Limited case reports and small case series have reported the use of minimally invasive approaches to chest wall resection. The trends of use, safety and effectiveness of this approach nationally are not known.
Methods: We used the National Cancer Database to identify adult patients with locally advanced lung cancer requiring a chest wall resection, between 2010 and 2017. We stratified patients into those undergoing a minimally invasive resection (VATS/robotic) and those undergoing an open approach. To account for conversions, we analyze the data using both intention-to-treat and as-treated classifiers. The main outcomes of interest were length of stay, 90-day mortality, readmissions and overall survival. We used multivariable logistic regression, Kaplan Meier and Cox-Proportional hazards models to identify associations and estimate survival.
Results: Of 2,454 patients with locally advanced lung cancer requiring an en-bloc chest wall resection, 546 (22.3%) were started minimally invasively. There were 170 (31.1%) conversions to open. Year over year, the use of minimally invasive approaches increased from 7% in 2010 to 22.9% in 2017. Patients undergoing a minimally invasive operation were similar in terms of age 64.9+10.1 vs 65.5+10.7, sex, race and Charlson comorbidity score (all p>0.05), but had smaller cancers (5.1+2.8 cm vs 6.1+4.3 cm; p<0.001) compared to the open group. Patients in the minimally invasive group had shorter length of stay 7.9+5.7 days vs 10+9.4 days p<0.001) but similar 90-day mortality at 8.4% vs 8.2% p=0.889, and had similar readmission rates 4.8% vs 6.3%; p=0.271. Overall survival was equivalent between the two groups.
Conclusion: In this first national report on the use of minimally invasive approaches to en-bloc chest wall resection for locally advanced lung cancer, we found that the minimally invasive approach is being utilized more frequently. Although conversions to open are common, this approach is safe, and is associated with shorter hospital stays. Overall survival is equivalent to the open approach.
Methods: We used the National Cancer Database to identify adult patients with locally advanced lung cancer requiring a chest wall resection, between 2010 and 2017. We stratified patients into those undergoing a minimally invasive resection (VATS/robotic) and those undergoing an open approach. To account for conversions, we analyze the data using both intention-to-treat and as-treated classifiers. The main outcomes of interest were length of stay, 90-day mortality, readmissions and overall survival. We used multivariable logistic regression, Kaplan Meier and Cox-Proportional hazards models to identify associations and estimate survival.
Results: Of 2,454 patients with locally advanced lung cancer requiring an en-bloc chest wall resection, 546 (22.3%) were started minimally invasively. There were 170 (31.1%) conversions to open. Year over year, the use of minimally invasive approaches increased from 7% in 2010 to 22.9% in 2017. Patients undergoing a minimally invasive operation were similar in terms of age 64.9+10.1 vs 65.5+10.7, sex, race and Charlson comorbidity score (all p>0.05), but had smaller cancers (5.1+2.8 cm vs 6.1+4.3 cm; p<0.001) compared to the open group. Patients in the minimally invasive group had shorter length of stay 7.9+5.7 days vs 10+9.4 days p<0.001) but similar 90-day mortality at 8.4% vs 8.2% p=0.889, and had similar readmission rates 4.8% vs 6.3%; p=0.271. Overall survival was equivalent between the two groups.
Conclusion: In this first national report on the use of minimally invasive approaches to en-bloc chest wall resection for locally advanced lung cancer, we found that the minimally invasive approach is being utilized more frequently. Although conversions to open are common, this approach is safe, and is associated with shorter hospital stays. Overall survival is equivalent to the open approach.
View Submission
P143. Perceptions of Frailty and Prehabilitation Among Thoracic Surgeons: Findings from a National Survey
Total Time: 3 Minutes
Objectives: Frailty is associated with increased perioperative morbidity and mortality. How thoracic surgeons recognize, measure and mitigate frailty in their daily clinical practice is unknown. We administered a national survey to determine the experiences of thoracic surgeons managing frail surgical patients.
Methods: A 144-question web-based survey designed with input from the University of Chicago Survey Lab assessing perceptions of frailty and prehabilitation was sent to members of CTSnet.org who identified as thoracic surgeons, practiced in the United States, and had publicly available emails. Responses were collected from August to September 2022. Both fully and partially completed surveys were included in a descriptive statistical analysis.
Results: Of 2,796 surveys administered, 286 (10%) were fully and 56 (2%) were partially completed. Surgeons were 76.3% male (261/292), 80.1% white (225/281) and in practice a median of 23 years (range 1-50) at academic (63.4%, 187/295) or community (34.2%, 101/295) centers. Most surgeons were familiar with frailty (92.7%, 317/342) and believed it was important to assess (83.9%, 287/342). Frailty was estimated to be present in a median of 3 new clinic patients (range 0-30) per week. Routine frailty assessment was performed by 28% (97/342) of surgeons, who used observation alone (26.0 %, 89/332) or formal tools (7.9%, 27/342). Barriers to routine frailty assessment included lack of tools (80.0%, 32/40), training (59.0%, 23/39), and staffing (56.4%, 22/39). While most surgeons believed that frailty could be mitigated (72.2%, 247/342), only 49.5% (156/315) prescribed prehabilitation, recommending nutritional supplements (80.0%, 124/155), mild to moderate exercise (64.5%, 100/155), and physical therapy (61.3%, 95/155). Up to 78.7% (203/263) of surgeons would delay or cancel surgery depending on disease etiology (Table 1). Most surgeons favor establishing surgical guidelines for frailty screening and management (69.9%, 239/294). Only 24.1% (71/295) of surgeons work in hospitals that offer specialized perioperative care programs for frail surgical patients.
Conclusions: Thoracic surgeons accept that frailty is an established risk factor for perioperative morbidity and mortality; however, there appears to be high variability in diagnosing and managing frailty. Guidelines are needed to establish best practices for frailty screening and mitigation techniques to optimally treat frail patients.
Methods: A 144-question web-based survey designed with input from the University of Chicago Survey Lab assessing perceptions of frailty and prehabilitation was sent to members of CTSnet.org who identified as thoracic surgeons, practiced in the United States, and had publicly available emails. Responses were collected from August to September 2022. Both fully and partially completed surveys were included in a descriptive statistical analysis.
Results: Of 2,796 surveys administered, 286 (10%) were fully and 56 (2%) were partially completed. Surgeons were 76.3% male (261/292), 80.1% white (225/281) and in practice a median of 23 years (range 1-50) at academic (63.4%, 187/295) or community (34.2%, 101/295) centers. Most surgeons were familiar with frailty (92.7%, 317/342) and believed it was important to assess (83.9%, 287/342). Frailty was estimated to be present in a median of 3 new clinic patients (range 0-30) per week. Routine frailty assessment was performed by 28% (97/342) of surgeons, who used observation alone (26.0 %, 89/332) or formal tools (7.9%, 27/342). Barriers to routine frailty assessment included lack of tools (80.0%, 32/40), training (59.0%, 23/39), and staffing (56.4%, 22/39). While most surgeons believed that frailty could be mitigated (72.2%, 247/342), only 49.5% (156/315) prescribed prehabilitation, recommending nutritional supplements (80.0%, 124/155), mild to moderate exercise (64.5%, 100/155), and physical therapy (61.3%, 95/155). Up to 78.7% (203/263) of surgeons would delay or cancel surgery depending on disease etiology (Table 1). Most surgeons favor establishing surgical guidelines for frailty screening and management (69.9%, 239/294). Only 24.1% (71/295) of surgeons work in hospitals that offer specialized perioperative care programs for frail surgical patients.
Conclusions: Thoracic surgeons accept that frailty is an established risk factor for perioperative morbidity and mortality; however, there appears to be high variability in diagnosing and managing frailty. Guidelines are needed to establish best practices for frailty screening and mitigation techniques to optimally treat frail patients.
View Submission
Poster Presenter
Johnathan Kent, The University of Chicago Medicine - Contact Me Chicago, ILUnited States
P144. Quality of Life and Satisfaction Level Following Thoracoscopic Sympathectomy: A 10 Year Follow-up
Total Time: 3 Minutes
Objectives: Thoracoscopic (VATS) sympathectomy is considered one of the best treatment modalities for primary hyperhidrosis; however, this procedure is still surrounded by controversy with regards to its operative approaches, post-operative complications, and level of satisfaction in patients post-sympathectomy. The purpose of the study is to evaluate post-operative complications and level of satisfaction in 10-year follow-up, post VATS cauterizing sympathectomy.
Methods: this is a retrospective single institute review that enrolled patients undergoing single-staged cauterizing sympathectomy in a tertiary care center over the past 10 years. The rate of short-term, long-term complications was assessed by conducting a chart review. Level of patients' satisfaction was evaluated using quality of life questioner.
Results: total of 47 patients agreed to participate in our study, with males constituting 55.3% of the cohort. Majority of the study group 48.9% had a positive family history of hyperhidrosis in 1st degree relative, and 42.5% had failed a trial of Botox injection to maintain a long symptom-free period. Post-operatively, 31 patients had compensatory hyperhidrosis, mostly were in the back (61.7%) and stomach (48.9%), legs (31.8%); with median time to event of 32 days.
Thirty patients (63.8%) completed pre-operative and 10-year follow up post-operative personalized quality of life assessment, revealing significant improvement in the quality of life in all domains of questionnaire post-operatively (p-value <0.001), except wearing colored cloths.
Conclusion: VATS sympathectomy is a curative treatment in patients with primary hyperhidrosis with limited post-operative complications and significant upgrade in the quality of life post-operatively.
Methods: this is a retrospective single institute review that enrolled patients undergoing single-staged cauterizing sympathectomy in a tertiary care center over the past 10 years. The rate of short-term, long-term complications was assessed by conducting a chart review. Level of patients' satisfaction was evaluated using quality of life questioner.
Results: total of 47 patients agreed to participate in our study, with males constituting 55.3% of the cohort. Majority of the study group 48.9% had a positive family history of hyperhidrosis in 1st degree relative, and 42.5% had failed a trial of Botox injection to maintain a long symptom-free period. Post-operatively, 31 patients had compensatory hyperhidrosis, mostly were in the back (61.7%) and stomach (48.9%), legs (31.8%); with median time to event of 32 days.
Thirty patients (63.8%) completed pre-operative and 10-year follow up post-operative personalized quality of life assessment, revealing significant improvement in the quality of life in all domains of questionnaire post-operatively (p-value <0.001), except wearing colored cloths.
Conclusion: VATS sympathectomy is a curative treatment in patients with primary hyperhidrosis with limited post-operative complications and significant upgrade in the quality of life post-operatively.
View Submission
P145. Safety of Lung Resection Surgery in Patients with History of SARS-CoV-2 Infection in the Post-vaccination Era: A Single Center Experience
Total Time: 3 Minutes
Objective: SARS-CoV-2 pandemic poses an unanticipated challenge in lung resection surgery. Although the number of infection cases has increased, there have been more cases of mild illness recently since the SARS-CoV-2 vaccine has shown great efficacy and effectiveness in real-world data. The purpose of this study was to investigate the postoperative outcomes of lung resection surgery in patients with SARS-CoV-2 infection in order to discover the optimal timing of lung surgery following SARS-CoV-2 in the post-vaccination era.
Methods: This study is a retrospective single-center study, which included patients who underwent lung resection surgery from June 2021 to June 2022. The patients were divided into two groups based on their SARS-CoV-2 infection status before to surgery, and their postoperative outcomes were compared.
Results: A total of 1,197 patients underwent lung resection surgery during this period, of which 79 patients had a history of SARS-CoV-2 infection before surgery. In SARS-CoV-2 group, sixty-six patients (90.4%) received at least one dose of vaccination, and the most common symptoms were cough (52.0%), sore throat (44.0%), and sputum (41.3%). Eight patients had preoperative CT scans that suggested SARS-CoV-2 sequelae, yet surgery was nonetheless performed on them as they had no respiratory symptoms. There was no patient whose surgery was canceled due to SARS-CoV-2 infection. Minimally invasive surgery was performed in 74 patients (93.7%). The types of operation performed included wedge resection (N = 20, 25.3%), segmentectomy (N = 8; 10.1%), lobectomy (N = 47; 59.5%), bilobectomy (N = 3; 3.8%), and pneumonectomy (N = 1; 1.3%). The interval between SARS-CoV-2 infection to surgery was < 4weeks (18 patients), 4-6 weeks (18 patients), 6-8 weeks (11 patients), and > 8 weeks (32 patients). The complication rate (27.8% vs. 44.4% vs. 0 vs. 18.8%) and length of stay (average 5.3 vs. 5.3 vs. 3.1 vs. 5.2 days) were not different according to the interval between infection and surgery. When we compared postoperative outcomes between SARS-CoV-2 group and non-SARS-CoV-2 group, there was no statistical difference regarding major complication rate (6.3 % vs. 6.2%; p = 1.000), respiratory complication rate (19.0% vs. 12.9%; p = 0.122), and length of stays (4.9±3.4 vs. 5.0±6.0; p = 0.955).
Conclusions: In the post-vaccination era, lung resection surgery can be safely performed after SARS-CoV-2 infection, even in a short period of less than 6 weeks after
Methods: This study is a retrospective single-center study, which included patients who underwent lung resection surgery from June 2021 to June 2022. The patients were divided into two groups based on their SARS-CoV-2 infection status before to surgery, and their postoperative outcomes were compared.
Results: A total of 1,197 patients underwent lung resection surgery during this period, of which 79 patients had a history of SARS-CoV-2 infection before surgery. In SARS-CoV-2 group, sixty-six patients (90.4%) received at least one dose of vaccination, and the most common symptoms were cough (52.0%), sore throat (44.0%), and sputum (41.3%). Eight patients had preoperative CT scans that suggested SARS-CoV-2 sequelae, yet surgery was nonetheless performed on them as they had no respiratory symptoms. There was no patient whose surgery was canceled due to SARS-CoV-2 infection. Minimally invasive surgery was performed in 74 patients (93.7%). The types of operation performed included wedge resection (N = 20, 25.3%), segmentectomy (N = 8; 10.1%), lobectomy (N = 47; 59.5%), bilobectomy (N = 3; 3.8%), and pneumonectomy (N = 1; 1.3%). The interval between SARS-CoV-2 infection to surgery was < 4weeks (18 patients), 4-6 weeks (18 patients), 6-8 weeks (11 patients), and > 8 weeks (32 patients). The complication rate (27.8% vs. 44.4% vs. 0 vs. 18.8%) and length of stay (average 5.3 vs. 5.3 vs. 3.1 vs. 5.2 days) were not different according to the interval between infection and surgery. When we compared postoperative outcomes between SARS-CoV-2 group and non-SARS-CoV-2 group, there was no statistical difference regarding major complication rate (6.3 % vs. 6.2%; p = 1.000), respiratory complication rate (19.0% vs. 12.9%; p = 0.122), and length of stays (4.9±3.4 vs. 5.0±6.0; p = 0.955).
Conclusions: In the post-vaccination era, lung resection surgery can be safely performed after SARS-CoV-2 infection, even in a short period of less than 6 weeks after
View Submission
P146. Screening Criteria Evaluation for Expansion in Pulmonary Neoplasias Using Molecular and Immunologic Markers (SCREEN II)
Total Time: 3 Minutes
Objective: The primary objective of SCREEN II was to assess the molecular and immunologic profile of light-or-never-smokers (LONS) and heavy smokers, defined by National Lung Screening Trial (NLST) and by Nederlands–Leuvens Longkanker Screenings Onderzoek (NELSON) criteria, separately. The hypothesis was that molecular and immunologic profiles differ between LONS and heavy smokers.
Methods: A retrospective review of 1,156 lung cancer cases from 2005-2018 at a tertiary Canadian institution was conducted. Multivariable logistic regression was used to compare the rate of KRAS, EGFR, BRAF, PIK3CA, ALK, and PD-L1 (<1%, 1-49%, ≥50%) between LONS and heavy smokers while adjusting for sex, previous cancer history, family history of cancer, symptoms, histological diagnosis, grade, stage, urban or rural environment, and geographic radon levels. Survival differences were assessed between LONS and heavy smokers using multivariate regression while adjusting for clinical, molecular, and immunologic variables.
Results: The cohort was comprised of 45.7% (NLST, n=536) and 63.5% (NELSON, n=745) heavy smokers. LONS had a higher rate of stage I cancer using NELSON criteria [56.3%, (n=240) vs 49.0% (n=365); p = 0.041]. LONS were more likely EGFR-positive in both NLST [OR 0.79, 95% CI 0.21-1.37; p = 0.008] and NELSON [OR 0.79, 95%CI 0.28-1.31; p = 0.002] models. Female LONS were more likely than male LONS to be EGFR-positive in NELSON [OR 0.59, 95% CI = 0.06-1.12; p = 0.031] but not NLST [OR 0.51, 95% CI 0.02-1.05; p = 0.058] models. LONS were more often PIK3CA-positive using NLST [OR 1.33, 95% CI 0.54-2.13; p = 0.001] and NELSON [OR 1.19, 95% CI 0.49-1.90; p = 0.001] models. Heavy smokers were more often KRAS-positive in both NLST [OR 0.35, 95% CI 0.04-0.67; p = 0.029] and NELSON [OR 0.43, 995% CI 0.09-0.76; p = 0.012] models. No differences in ALK, BRAF, and PD-L1 were observed between LONS and heavy smokers using NELSON or NLST models. LONS in the NELSON model were at higher risk for mortality (Figure 1).
Conclusions: When defined by NLST or NELSON criteria, LONS have a higher rate of EGFR and PIK3CA mutations. There was no difference in the rate of ALK, BRAF, or PD-L1 mutations. LONS with non-small-cell lung cancer may be at increased risk for mortality compared to heavy smokers. Molecular profiling, particularly where targeted therapy is available, should be considered in establishing criteria for lung cancer screening.
Methods: A retrospective review of 1,156 lung cancer cases from 2005-2018 at a tertiary Canadian institution was conducted. Multivariable logistic regression was used to compare the rate of KRAS, EGFR, BRAF, PIK3CA, ALK, and PD-L1 (<1%, 1-49%, ≥50%) between LONS and heavy smokers while adjusting for sex, previous cancer history, family history of cancer, symptoms, histological diagnosis, grade, stage, urban or rural environment, and geographic radon levels. Survival differences were assessed between LONS and heavy smokers using multivariate regression while adjusting for clinical, molecular, and immunologic variables.
Results: The cohort was comprised of 45.7% (NLST, n=536) and 63.5% (NELSON, n=745) heavy smokers. LONS had a higher rate of stage I cancer using NELSON criteria [56.3%, (n=240) vs 49.0% (n=365); p = 0.041]. LONS were more likely EGFR-positive in both NLST [OR 0.79, 95% CI 0.21-1.37; p = 0.008] and NELSON [OR 0.79, 95%CI 0.28-1.31; p = 0.002] models. Female LONS were more likely than male LONS to be EGFR-positive in NELSON [OR 0.59, 95% CI = 0.06-1.12; p = 0.031] but not NLST [OR 0.51, 95% CI 0.02-1.05; p = 0.058] models. LONS were more often PIK3CA-positive using NLST [OR 1.33, 95% CI 0.54-2.13; p = 0.001] and NELSON [OR 1.19, 95% CI 0.49-1.90; p = 0.001] models. Heavy smokers were more often KRAS-positive in both NLST [OR 0.35, 95% CI 0.04-0.67; p = 0.029] and NELSON [OR 0.43, 995% CI 0.09-0.76; p = 0.012] models. No differences in ALK, BRAF, and PD-L1 were observed between LONS and heavy smokers using NELSON or NLST models. LONS in the NELSON model were at higher risk for mortality (Figure 1).
Conclusions: When defined by NLST or NELSON criteria, LONS have a higher rate of EGFR and PIK3CA mutations. There was no difference in the rate of ALK, BRAF, or PD-L1 mutations. LONS with non-small-cell lung cancer may be at increased risk for mortality compared to heavy smokers. Molecular profiling, particularly where targeted therapy is available, should be considered in establishing criteria for lung cancer screening.
View Submission
Poster Presenter
Daniel French, Queen Elizabeth II Health Centre - Halifax Infirmary - Contact Me HALIFAX, NSCanada
P147. The Effect of Donor-Recipient Sex Matches on Lung Transplant Survival Rates: An Analysis of the UNOS Database.
Total Time: 3 Minutes
Objective: Due to relatively lower life expectancy post-lung transplantation, research has focused on optimizing donor-recipient (DR) matches to increase survival time. The significance of DR sex matches on survival outcomes still remains inconclusive. The purpose of this study is to investigate this relationship in United Network of Organ Sharing (UNOS) database of lung transplantation recipients.
Methods: We performed a retrospective study of 29,310 lung transplant recipients who were reported in the UNOS database (January 2005- March 2020). Patients were divided into groups based on their respective DR sex match: male to male (MM), male to female (MF), female to female, (FF), and female to male (FM). Survival for each group was assessed using a Kaplan-Meier curve and log-rank tests for 1-, 3-, 5-, and 10- year survival. Cox proportional hazards regression and analysis of maximum likelihood estimates for 15-year survival were also performed using the following variables: recipient age, recipient BMI, recipient height, lung allocation score, transplant type, donor age, and DR sex match. P-values <0.05 were considered significant.
Results: Of the 29,310 patients who received lung transplants, 12772 were MM, 4861 were MF, 7165 were FF, and 4512 were FM. There was a significant difference in 1-, 3-, 5-, and 10- year survival outcomes when comparing the donor-recipient sex matched groups (P < 0.0001). The analysis of maximum likelihood estimates showed older recipient age (Hz = 1.006, 95%CI = 1.004-1.007; p<0.0001), higher lung allocation score (Hz = 1.006, 95%CI = 1.005-1.007; p<0.0001), older donor age (Hz = 1.003, 95%CI = 1.002-1.005; p<0.0001), and FM lung transplants were correlated with poorer survival outcomes. In contrast, taller recipient height (Hz = 0.997, 95%CI= 0.995-0.999; p=0.0053) and double lung transplants (Hz = 0.751, 95%CI= 0.721-0.783; p<0.0001) were associated with better survival outcomes. Recipient BMI (Hz = 1.002, 95%CI= 0.997-1.006; p<0.4093) had no effect on survival outcomes.
Conclusions: Post-lung transplant 1-, 3-, 5-, and 10-year survival outcomes were significantly different between DR sex matched groups. Importantly, female to male lung transplants were associated with the poorest survival outcomes for each survival analysis.
Methods: We performed a retrospective study of 29,310 lung transplant recipients who were reported in the UNOS database (January 2005- March 2020). Patients were divided into groups based on their respective DR sex match: male to male (MM), male to female (MF), female to female, (FF), and female to male (FM). Survival for each group was assessed using a Kaplan-Meier curve and log-rank tests for 1-, 3-, 5-, and 10- year survival. Cox proportional hazards regression and analysis of maximum likelihood estimates for 15-year survival were also performed using the following variables: recipient age, recipient BMI, recipient height, lung allocation score, transplant type, donor age, and DR sex match. P-values <0.05 were considered significant.
Results: Of the 29,310 patients who received lung transplants, 12772 were MM, 4861 were MF, 7165 were FF, and 4512 were FM. There was a significant difference in 1-, 3-, 5-, and 10- year survival outcomes when comparing the donor-recipient sex matched groups (P < 0.0001). The analysis of maximum likelihood estimates showed older recipient age (Hz = 1.006, 95%CI = 1.004-1.007; p<0.0001), higher lung allocation score (Hz = 1.006, 95%CI = 1.005-1.007; p<0.0001), older donor age (Hz = 1.003, 95%CI = 1.002-1.005; p<0.0001), and FM lung transplants were correlated with poorer survival outcomes. In contrast, taller recipient height (Hz = 0.997, 95%CI= 0.995-0.999; p=0.0053) and double lung transplants (Hz = 0.751, 95%CI= 0.721-0.783; p<0.0001) were associated with better survival outcomes. Recipient BMI (Hz = 1.002, 95%CI= 0.997-1.006; p<0.4093) had no effect on survival outcomes.
Conclusions: Post-lung transplant 1-, 3-, 5-, and 10-year survival outcomes were significantly different between DR sex matched groups. Importantly, female to male lung transplants were associated with the poorest survival outcomes for each survival analysis.
View Submission
Poster Presenter
Elizabeth Profozich, Temple University, Lewis Katz School of Medicine, Division of Cardiovascular Surgery - Contact Me Gibsonia, PAUnited States
P148. Underlying Reasons for Failure to Achieve Adequate Lymph Node Staging During Lung Cancer Resection: Results of a Clinical Failure Modes Effects and Criticality Analysis
Total Time: 3 Minutes
Objective:
Surgical resection of the primary tumor combined with mediastinal lymph node staging is the standard of care for the treatment of early-stage non-small cell lung cancer (NSCLC). The ACS Commission on Cancer has defined adequate lymph node staging as the sampling of at least 3 N2 stations and 1 N1 station. However, despite national quality standards, operative lymph node staging has consistently been poor when examining national data. This study sought to define underlying reasons for inadequate nodal staging and to determine their relative contribution .
Methods:
We convened a multidisciplinary panel of thoracic surgeons, pathologists, and operating room nurses and scrub technicians from hospitals participating in the Illinois Cancer Collaborative (ILCC) to conduct a Failure Modes Effectiveness and Criticality Analysis (FMECA) assessment of operative lymph node staging. The panel first considered the process of lymph node staging from preoperative planning through surgical care and finally pathological analysis and reporting. Key steps (figure) were identified and categorized as critical (failure to perform the step could not be overcome by other actions) and non-critical. To validate this construct, we then reviewed surgical resections performed at the participating hospitals over the past 6 months to identify patients where staging was inadequate and categorize failure points.
Results:
The panel identified 6 key steps in nodal staging: preoperative planning, node identification, adequate dissection, operative specimen labelling, pathologic dissection, and pathological reporting. Node identification, dissection, and pathological reporting were identified as critical process steps. Chart review of 200 anatomic lung resections yielded 51 cases of inadequate staging (26%). The most common root cause was failure to dissect the node in 47% (n=24) followed by pathologic documentation errors in 25% (n=13) and specimen labelling errors in 18% (n=9).
Conclusion:
This study identified critical technical and non-technical skills factors which contribute to inadequate lymph node staging during lung cancer resection. While a technical failure to dissect the lymph node station was the most common failure point, several areas of the process may result in failure to adequately stage patients. These steps provide actionable targets for quality improvement.
This work is funded by the AATS Foundation Surgical Investigator Award
Surgical resection of the primary tumor combined with mediastinal lymph node staging is the standard of care for the treatment of early-stage non-small cell lung cancer (NSCLC). The ACS Commission on Cancer has defined adequate lymph node staging as the sampling of at least 3 N2 stations and 1 N1 station. However, despite national quality standards, operative lymph node staging has consistently been poor when examining national data. This study sought to define underlying reasons for inadequate nodal staging and to determine their relative contribution .
Methods:
We convened a multidisciplinary panel of thoracic surgeons, pathologists, and operating room nurses and scrub technicians from hospitals participating in the Illinois Cancer Collaborative (ILCC) to conduct a Failure Modes Effectiveness and Criticality Analysis (FMECA) assessment of operative lymph node staging. The panel first considered the process of lymph node staging from preoperative planning through surgical care and finally pathological analysis and reporting. Key steps (figure) were identified and categorized as critical (failure to perform the step could not be overcome by other actions) and non-critical. To validate this construct, we then reviewed surgical resections performed at the participating hospitals over the past 6 months to identify patients where staging was inadequate and categorize failure points.
Results:
The panel identified 6 key steps in nodal staging: preoperative planning, node identification, adequate dissection, operative specimen labelling, pathologic dissection, and pathological reporting. Node identification, dissection, and pathological reporting were identified as critical process steps. Chart review of 200 anatomic lung resections yielded 51 cases of inadequate staging (26%). The most common root cause was failure to dissect the node in 47% (n=24) followed by pathologic documentation errors in 25% (n=13) and specimen labelling errors in 18% (n=9).
Conclusion:
This study identified critical technical and non-technical skills factors which contribute to inadequate lymph node staging during lung cancer resection. While a technical failure to dissect the lymph node station was the most common failure point, several areas of the process may result in failure to adequately stage patients. These steps provide actionable targets for quality improvement.
This work is funded by the AATS Foundation Surgical Investigator Award
View Submission
Poster Presenter
David Odell, Michigan Medicine - University of Michigan - Contact Me Ann Arbor, MIUnited States
P149. Uptake of Adjuvant Chemotherapy for Stage II-IIIA Non-Small-Cell Lung Cancer in the United States
Total Time: 3 Minutes
OBJECTIVE:
While perioperative immunotherapy has been shown to improve survival in patients with stage II and III non-small cell lung cancer (NSCLC), its relative efficacy in the neoadjuvant vs. adjuvant setting remains unknown. Recently, the ALCHEMIST study attempted to better contextualize the results of adjuvant trials by evaluating the uptake of guideline-concordant adjuvant therapy in patients with NSCLC, finding that only 57% of patients received adjuvant chemotherapy when clinically indicated. Notably, however, this analysis only included clinical trial patients, rendering the real-world uptake of adjuvant therapy still unknown. In this study, we sought to evaluate the use of adjuvant chemotherapy for resected stage II-III NSCLC in the United States using two large, national registries.
METHODS:
Patients in the National Cancer Database (NCDB) and the Surveillance, Epidemiology, and End Results (SEER) database with pathologic stage II-IIIA NSCLC resected between 2004-2018 were separately identified. The proportion of patients who received adjuvant chemotherapy, as well as baseline characteristics of patients who did and did not receive adjuvant chemotherapy, were evaluated. Multivariable-adjusted logistic regression was used in the NCDB to identify factors associated with the receipt of adjuvant chemotherapy.
RESULTS:
Of the 38,259 patients with stage II-IIIA NSCLC identified in the NCDB, 20,856 (55%) received adjuvant chemotherapy. Among these patients, 30% with stage IIA, 54% of with stage IIB, and 65% with stage IIIA received adjuvant chemotherapy. Patients who were younger, healthier, recipients of Medicare or private insurance, and who had higher stage or grade tumors were more likely to receive adjuvant chemotherapy than their counterparts. In the SEER database, 26,998 patients with stage II-III NSCLC were identified and 12,582 (47%) received adjuvant chemotherapy. Among these patients, 26% of with stage IIA, 45% with stage IIB, and 55% with stage IIIA disease received adjuvant chemotherapy.
CONCLUSION:
In this national analysis, we found that only ~50% of patients undergoing upfront surgery for stage II-IIIA NSCLC received adjuvant chemotherapy, suggesting that future adoption of adjuvant immunotherapy in real-world settings may be poor. Given the significant survival benefit associated with this treatment, our findings illustrate the need to identify strategies to maximize adoption of immunotherapy in clinical practice.
While perioperative immunotherapy has been shown to improve survival in patients with stage II and III non-small cell lung cancer (NSCLC), its relative efficacy in the neoadjuvant vs. adjuvant setting remains unknown. Recently, the ALCHEMIST study attempted to better contextualize the results of adjuvant trials by evaluating the uptake of guideline-concordant adjuvant therapy in patients with NSCLC, finding that only 57% of patients received adjuvant chemotherapy when clinically indicated. Notably, however, this analysis only included clinical trial patients, rendering the real-world uptake of adjuvant therapy still unknown. In this study, we sought to evaluate the use of adjuvant chemotherapy for resected stage II-III NSCLC in the United States using two large, national registries.
METHODS:
Patients in the National Cancer Database (NCDB) and the Surveillance, Epidemiology, and End Results (SEER) database with pathologic stage II-IIIA NSCLC resected between 2004-2018 were separately identified. The proportion of patients who received adjuvant chemotherapy, as well as baseline characteristics of patients who did and did not receive adjuvant chemotherapy, were evaluated. Multivariable-adjusted logistic regression was used in the NCDB to identify factors associated with the receipt of adjuvant chemotherapy.
RESULTS:
Of the 38,259 patients with stage II-IIIA NSCLC identified in the NCDB, 20,856 (55%) received adjuvant chemotherapy. Among these patients, 30% with stage IIA, 54% of with stage IIB, and 65% with stage IIIA received adjuvant chemotherapy. Patients who were younger, healthier, recipients of Medicare or private insurance, and who had higher stage or grade tumors were more likely to receive adjuvant chemotherapy than their counterparts. In the SEER database, 26,998 patients with stage II-III NSCLC were identified and 12,582 (47%) received adjuvant chemotherapy. Among these patients, 26% of with stage IIA, 45% with stage IIB, and 55% with stage IIIA disease received adjuvant chemotherapy.
CONCLUSION:
In this national analysis, we found that only ~50% of patients undergoing upfront surgery for stage II-IIIA NSCLC received adjuvant chemotherapy, suggesting that future adoption of adjuvant immunotherapy in real-world settings may be poor. Given the significant survival benefit associated with this treatment, our findings illustrate the need to identify strategies to maximize adoption of immunotherapy in clinical practice.
View Submission
Poster Presenter
Camille Mathey-Andrews, Massachusetts General Hospital - Contact Me Boston, MAUnited States