Richard Mark Kirkner

So-called “skip metastasis” of lung cancer to the lymph nodes – when the cancer “skips” over the N1 bronchopulmonary or hilar stage to N2 ipsilateral mediastinal metastasis – may be associated with distinct histological characteristics that can further help understand its association with longer survival and better prognosis in advanced resectable lung adenocarcinoma, according to a small study from China.

Researchers at Fudan (Shanghai ) University Cancer Center published their findings online ahead of print for the October issue of the Journal of Thoracic and Cardiovascular Surgery (2015 July 6 [doi: 10.1016/j.jtcvs.2015.03.067]). In all, they enrolled 177 patients with N2 adenocarcinoma, 45 (25.4%) of whom had skip N2 metastasis.

They reported that patients with skip metastasis had considerably better 5-year recurrence-free survival rates of 37.4% vs. 5.7% and better overall survival rates of 60.7% vs. 32.1% when compared with those with non-skip involvement.

Courtesy of AATS/JTCVS

“There are distinct differences in clinicopathological features and prognosis in patients with or without skip N2 metastasis,” Dr. Haiquan Chen and his colleagues said. “Considering the results of our study, subclassifications of mediastinal lymph nodes metastases would have potential clinical significance for patients with lung adenocarcinoma.”

Dr. Chen and his colleagues sought to identify specific histological features that characterized the association between skip N2 metastasis and adenocarcinoma subtypes and prognosis. “Skip N2 patients have more cases that are acinar adenocarcinoma subtype, well differentiated and located in the right lung than [do] non-skip patients,” they said.

In fact, they found the predictive value of skip N2 was more significant in patients with right-lung disease, with 5-year recurrence-free survival of 36.6% vs. 0% and overall survival of 57.2% vs. 28% in non–right-lung lesions. They also reported that tumor size of 3 cm or smaller in skip N2 was associated with significantly improved survival rates – 43% vs. 6.7% recurrence-free survival and 74.6% vs. 27.6% for overall survival, compared with patients with larger tumors.

The skip N2 lung adenocarcinoma patients had “remarkably lower incidence” of vascular invasion of the lymph nodes, Dr. Chen and his coauthors wrote. Skip N2 patients also had lower, but not statistically significant, rates of pleural invasion. The Fudan University researchers also reported that the incidence of non-skip N2 metastasis was “significantly high” in patients with papillary-predominant subtype.

“Considering our results, skip N2 should not be recognized as [a] predictor for better survival in all lung adenocarcinoma cases, but in [a] more specific group of patients,” Dr. Chen and his coauthors said.

A multivariate analysis confirmed the predictive significance of skip N2 for recurrence-free survival, but not so much for overall survival. Single N2 metastasis was also an independent predictor for better recurrence-free and overall survival, Dr. Chen and his colleagues said.

The study received funding from the Key Construction Program of the National “985” Project, Ministry of Science and Technology of China; the National Natural Science Foundation of China; the Science and Technology Commission of Shanghai Municipality; and Shanghai Hospital Development Center.

The authors had no disclosures.

So-called “skip metastasis” of lung cancer to the lymph nodes – when the cancer “skips” over the N1 bronchopulmonary or hilar stage to N2 ipsilateral mediastinal metastasis – may be associated with distinct histological characteristics that can further help understand its association with longer survival and better prognosis in advanced resectable lung adenocarcinoma, according to a small study from China.

Researchers at Fudan (Shanghai ) University Cancer Center published their findings online ahead of print for the October issue of the Journal of Thoracic and Cardiovascular Surgery (2015 July 6 [doi: 10.1016/j.jtcvs.2015.03.067]). In all, they enrolled 177 patients with N2 adenocarcinoma, 45 (25.4%) of whom had skip N2 metastasis.

They reported that patients with skip metastasis had considerably better 5-year recurrence-free survival rates of 37.4% vs. 5.7% and better overall survival rates of 60.7% vs. 32.1% when compared with those with non-skip involvement.

Courtesy of AATS/JTCVS

“There are distinct differences in clinicopathological features and prognosis in patients with or without skip N2 metastasis,” Dr. Haiquan Chen and his colleagues said. “Considering the results of our study, subclassifications of mediastinal lymph nodes metastases would have potential clinical significance for patients with lung adenocarcinoma.”

Dr. Chen and his colleagues sought to identify specific histological features that characterized the association between skip N2 metastasis and adenocarcinoma subtypes and prognosis. “Skip N2 patients have more cases that are acinar adenocarcinoma subtype, well differentiated and located in the right lung than [do] non-skip patients,” they said.

In fact, they found the predictive value of skip N2 was more significant in patients with right-lung disease, with 5-year recurrence-free survival of 36.6% vs. 0% and overall survival of 57.2% vs. 28% in non–right-lung lesions. They also reported that tumor size of 3 cm or smaller in skip N2 was associated with significantly improved survival rates – 43% vs. 6.7% recurrence-free survival and 74.6% vs. 27.6% for overall survival, compared with patients with larger tumors.

The skip N2 lung adenocarcinoma patients had “remarkably lower incidence” of vascular invasion of the lymph nodes, Dr. Chen and his coauthors wrote. Skip N2 patients also had lower, but not statistically significant, rates of pleural invasion. The Fudan University researchers also reported that the incidence of non-skip N2 metastasis was “significantly high” in patients with papillary-predominant subtype.

“Considering our results, skip N2 should not be recognized as [a] predictor for better survival in all lung adenocarcinoma cases, but in [a] more specific group of patients,” Dr. Chen and his coauthors said.

A multivariate analysis confirmed the predictive significance of skip N2 for recurrence-free survival, but not so much for overall survival. Single N2 metastasis was also an independent predictor for better recurrence-free and overall survival, Dr. Chen and his colleagues said.

The study received funding from the Key Construction Program of the National “985” Project, Ministry of Science and Technology of China; the National Natural Science Foundation of China; the Science and Technology Commission of Shanghai Municipality; and Shanghai Hospital Development Center.

The authors had no disclosures.

So-called “skip metastasis” of lung cancer to the lymph nodes – when the cancer “skips” over the N1 bronchopulmonary or hilar stage to N2 ipsilateral mediastinal metastasis – may be associated with distinct histological characteristics that can further help understand its association with longer survival and better prognosis in advanced resectable lung adenocarcinoma, according to a small study from China.

Researchers at Fudan (Shanghai ) University Cancer Center published their findings online ahead of print for the October issue of the Journal of Thoracic and Cardiovascular Surgery (2015 July 6 [doi: 10.1016/j.jtcvs.2015.03.067]). In all, they enrolled 177 patients with N2 adenocarcinoma, 45 (25.4%) of whom had skip N2 metastasis.

They reported that patients with skip metastasis had considerably better 5-year recurrence-free survival rates of 37.4% vs. 5.7% and better overall survival rates of 60.7% vs. 32.1% when compared with those with non-skip involvement.

Courtesy of AATS/JTCVS

“There are distinct differences in clinicopathological features and prognosis in patients with or without skip N2 metastasis,” Dr. Haiquan Chen and his colleagues said. “Considering the results of our study, subclassifications of mediastinal lymph nodes metastases would have potential clinical significance for patients with lung adenocarcinoma.”

Dr. Chen and his colleagues sought to identify specific histological features that characterized the association between skip N2 metastasis and adenocarcinoma subtypes and prognosis. “Skip N2 patients have more cases that are acinar adenocarcinoma subtype, well differentiated and located in the right lung than [do] non-skip patients,” they said.

In fact, they found the predictive value of skip N2 was more significant in patients with right-lung disease, with 5-year recurrence-free survival of 36.6% vs. 0% and overall survival of 57.2% vs. 28% in non–right-lung lesions. They also reported that tumor size of 3 cm or smaller in skip N2 was associated with significantly improved survival rates – 43% vs. 6.7% recurrence-free survival and 74.6% vs. 27.6% for overall survival, compared with patients with larger tumors.

The skip N2 lung adenocarcinoma patients had “remarkably lower incidence” of vascular invasion of the lymph nodes, Dr. Chen and his coauthors wrote. Skip N2 patients also had lower, but not statistically significant, rates of pleural invasion. The Fudan University researchers also reported that the incidence of non-skip N2 metastasis was “significantly high” in patients with papillary-predominant subtype.

“Considering our results, skip N2 should not be recognized as [a] predictor for better survival in all lung adenocarcinoma cases, but in [a] more specific group of patients,” Dr. Chen and his coauthors said.

A multivariate analysis confirmed the predictive significance of skip N2 for recurrence-free survival, but not so much for overall survival. Single N2 metastasis was also an independent predictor for better recurrence-free and overall survival, Dr. Chen and his colleagues said.

The study received funding from the Key Construction Program of the National “985” Project, Ministry of Science and Technology of China; the National Natural Science Foundation of China; the Science and Technology Commission of Shanghai Municipality; and Shanghai Hospital Development Center.

The authors had no disclosures.

NEW YORK – Combined transcatheter mitral valve interventions with the potential to have results as good as cardiac surgery are beginning to emerge in Europe, where cardiac surgeons are also getting early experience with newer transcatheter systems that offer alternatives to existing mitral valve treatments, said Dr. Francesco Maisano.

Surgeons in Europe are investigating for mitral valve repair, as alternatives to the MitraClip (Abbott Vascular) percutaneous mitral valve system, and developers of these devices have met their share of challenges, Dr. Maisano of the University Hospital Zurich (Switzerland) said at the 2015 Mitral Valve Conclave, sponsored by the American Association for Thoracic Surgery.

“This list was much longer in the past, but some of the companies have lost their way in the past few years,” he said. “This is because it is difficult to pursue such a tremendous effort of doing a transcatheter repair that is competing with a device that has been commercially available.”

The NeoChord system (NeoChord) has been approved in Europe and has been implanted in about 200 patients so far. It is implanted through a small (2-3–inch) left thoracotomy and deploys implantation of multiple neochordae. “This is slowly getting into practice,” Dr. Maisano said. “The main problem with this technology is that it still is a hybrid procedure; it requires general anesthesia. It’s still doubtful what the role will be for this procedure in the spectrum of mitral interventions.”

The Carillon Mitral Contour System (Cardiac Dimension Inc.) is “the only coronary sinus annuloplasty technology that survived in these years,” he said. The device is in clinical trials in Europe and Australia. However, he noted, efficacy with the device “doesn’t happen at the implant, but it happens over time.” Group outcomes data is pending. “Enthusiasm around coronary sinus annuloplasty never took, so a lot of physicians are still reluctant to embrace this technology,” he said. Nonetheless, in some patients the device has show results ”as good as other procedures.”

Meanwhile, three other percutaneous systems that aim to reproduce surgical annuloplasty are in development: the Mitralign (Mitralign), a percutaneous system that selectively plicates the annulus using pledget sutures; the Accucinch (Guided Delivery Systems) which completes a full-seal annuloplasty using suture-connected mitral anchors; and Cardioband (ValtechCardio), which can perform surgery-like annuloplasty without sutures. Dr. Maisano said Mitralign is hopeful to get CE-mark approval possibly as early as this year, and the Cardioband has been implanted in 42 patients in Europe with an average 22% reduction in septal dimensions – “good outcomes in terms of reduction of mitral regurgitation and improvement of symptoms,” he said.

Helping to advance the development of percutaneous procedures and the promise of combining those procedures to replicate surgery is the integration of multimodal imaging in the cardiac suite, Dr. Maisano said.

“There are many problems to be solved” in pursuing combined percutaneous procedures to replicate surgical results, he said. “It’s not easy from a regulatory standpoint or from an economical standpoint, but there is the potential to simulate what is done today in surgery-associated procedures. This is something that is happening in Europe, which is land of freedom in terms of utilizing devices.”

He related the story of a patient in whom he implanted two mitral valve clips and then, to stop leakage, used a vascular plug to fill the gap in the subcommissure. European cardiac surgeons have pondered or attempted transcatheter aortic implantation (TAVI) in combination with other procedures, including left atrial appendage closure (LAAC) and mitral clip insertion in varied combinations. “This is still feasible and something that is getting done more in Europe in experienced centers,” Dr. Maisano said. Although feasibility, safety, and efficacy of such approaches need to be proved in larger series, combination therapy will evolve in the future, in an attempt to reproduce surgical standards, he said.

Findings were presented on behalf of the European Society of Cardiology. Dr. Maisano is a consultant for Abbott Vascular and ValtechCardio, among other companies. He receives royalties from Edwards Lifesciences.

NEW YORK – Combined transcatheter mitral valve interventions with the potential to have results as good as cardiac surgery are beginning to emerge in Europe, where cardiac surgeons are also getting early experience with newer transcatheter systems that offer alternatives to existing mitral valve treatments, said Dr. Francesco Maisano.

Surgeons in Europe are investigating for mitral valve repair, as alternatives to the MitraClip (Abbott Vascular) percutaneous mitral valve system, and developers of these devices have met their share of challenges, Dr. Maisano of the University Hospital Zurich (Switzerland) said at the 2015 Mitral Valve Conclave, sponsored by the American Association for Thoracic Surgery.

“This list was much longer in the past, but some of the companies have lost their way in the past few years,” he said. “This is because it is difficult to pursue such a tremendous effort of doing a transcatheter repair that is competing with a device that has been commercially available.”

The NeoChord system (NeoChord) has been approved in Europe and has been implanted in about 200 patients so far. It is implanted through a small (2-3–inch) left thoracotomy and deploys implantation of multiple neochordae. “This is slowly getting into practice,” Dr. Maisano said. “The main problem with this technology is that it still is a hybrid procedure; it requires general anesthesia. It’s still doubtful what the role will be for this procedure in the spectrum of mitral interventions.”

The Carillon Mitral Contour System (Cardiac Dimension Inc.) is “the only coronary sinus annuloplasty technology that survived in these years,” he said. The device is in clinical trials in Europe and Australia. However, he noted, efficacy with the device “doesn’t happen at the implant, but it happens over time.” Group outcomes data is pending. “Enthusiasm around coronary sinus annuloplasty never took, so a lot of physicians are still reluctant to embrace this technology,” he said. Nonetheless, in some patients the device has show results ”as good as other procedures.”

Meanwhile, three other percutaneous systems that aim to reproduce surgical annuloplasty are in development: the Mitralign (Mitralign), a percutaneous system that selectively plicates the annulus using pledget sutures; the Accucinch (Guided Delivery Systems) which completes a full-seal annuloplasty using suture-connected mitral anchors; and Cardioband (ValtechCardio), which can perform surgery-like annuloplasty without sutures. Dr. Maisano said Mitralign is hopeful to get CE-mark approval possibly as early as this year, and the Cardioband has been implanted in 42 patients in Europe with an average 22% reduction in septal dimensions – “good outcomes in terms of reduction of mitral regurgitation and improvement of symptoms,” he said.

Helping to advance the development of percutaneous procedures and the promise of combining those procedures to replicate surgery is the integration of multimodal imaging in the cardiac suite, Dr. Maisano said.

“There are many problems to be solved” in pursuing combined percutaneous procedures to replicate surgical results, he said. “It’s not easy from a regulatory standpoint or from an economical standpoint, but there is the potential to simulate what is done today in surgery-associated procedures. This is something that is happening in Europe, which is land of freedom in terms of utilizing devices.”

He related the story of a patient in whom he implanted two mitral valve clips and then, to stop leakage, used a vascular plug to fill the gap in the subcommissure. European cardiac surgeons have pondered or attempted transcatheter aortic implantation (TAVI) in combination with other procedures, including left atrial appendage closure (LAAC) and mitral clip insertion in varied combinations. “This is still feasible and something that is getting done more in Europe in experienced centers,” Dr. Maisano said. Although feasibility, safety, and efficacy of such approaches need to be proved in larger series, combination therapy will evolve in the future, in an attempt to reproduce surgical standards, he said.

Findings were presented on behalf of the European Society of Cardiology. Dr. Maisano is a consultant for Abbott Vascular and ValtechCardio, among other companies. He receives royalties from Edwards Lifesciences.

NEW YORK – Combined transcatheter mitral valve interventions with the potential to have results as good as cardiac surgery are beginning to emerge in Europe, where cardiac surgeons are also getting early experience with newer transcatheter systems that offer alternatives to existing mitral valve treatments, said Dr. Francesco Maisano.

Surgeons in Europe are investigating for mitral valve repair, as alternatives to the MitraClip (Abbott Vascular) percutaneous mitral valve system, and developers of these devices have met their share of challenges, Dr. Maisano of the University Hospital Zurich (Switzerland) said at the 2015 Mitral Valve Conclave, sponsored by the American Association for Thoracic Surgery.

“This list was much longer in the past, but some of the companies have lost their way in the past few years,” he said. “This is because it is difficult to pursue such a tremendous effort of doing a transcatheter repair that is competing with a device that has been commercially available.”

The NeoChord system (NeoChord) has been approved in Europe and has been implanted in about 200 patients so far. It is implanted through a small (2-3–inch) left thoracotomy and deploys implantation of multiple neochordae. “This is slowly getting into practice,” Dr. Maisano said. “The main problem with this technology is that it still is a hybrid procedure; it requires general anesthesia. It’s still doubtful what the role will be for this procedure in the spectrum of mitral interventions.”

The Carillon Mitral Contour System (Cardiac Dimension Inc.) is “the only coronary sinus annuloplasty technology that survived in these years,” he said. The device is in clinical trials in Europe and Australia. However, he noted, efficacy with the device “doesn’t happen at the implant, but it happens over time.” Group outcomes data is pending. “Enthusiasm around coronary sinus annuloplasty never took, so a lot of physicians are still reluctant to embrace this technology,” he said. Nonetheless, in some patients the device has show results ”as good as other procedures.”

Meanwhile, three other percutaneous systems that aim to reproduce surgical annuloplasty are in development: the Mitralign (Mitralign), a percutaneous system that selectively plicates the annulus using pledget sutures; the Accucinch (Guided Delivery Systems) which completes a full-seal annuloplasty using suture-connected mitral anchors; and Cardioband (ValtechCardio), which can perform surgery-like annuloplasty without sutures. Dr. Maisano said Mitralign is hopeful to get CE-mark approval possibly as early as this year, and the Cardioband has been implanted in 42 patients in Europe with an average 22% reduction in septal dimensions – “good outcomes in terms of reduction of mitral regurgitation and improvement of symptoms,” he said.

Helping to advance the development of percutaneous procedures and the promise of combining those procedures to replicate surgery is the integration of multimodal imaging in the cardiac suite, Dr. Maisano said.

“There are many problems to be solved” in pursuing combined percutaneous procedures to replicate surgical results, he said. “It’s not easy from a regulatory standpoint or from an economical standpoint, but there is the potential to simulate what is done today in surgery-associated procedures. This is something that is happening in Europe, which is land of freedom in terms of utilizing devices.”

He related the story of a patient in whom he implanted two mitral valve clips and then, to stop leakage, used a vascular plug to fill the gap in the subcommissure. European cardiac surgeons have pondered or attempted transcatheter aortic implantation (TAVI) in combination with other procedures, including left atrial appendage closure (LAAC) and mitral clip insertion in varied combinations. “This is still feasible and something that is getting done more in Europe in experienced centers,” Dr. Maisano said. Although feasibility, safety, and efficacy of such approaches need to be proved in larger series, combination therapy will evolve in the future, in an attempt to reproduce surgical standards, he said.

Findings were presented on behalf of the European Society of Cardiology. Dr. Maisano is a consultant for Abbott Vascular and ValtechCardio, among other companies. He receives royalties from Edwards Lifesciences.

Many patients with aortic valve disease still undergo conventional aortic valve replacement (AVR) with standard full sternotomy or seek out alternative treatments like transcatheter aortic valve insertion (TAVI). But a minimally invasive approach that uses a sutureless prostheses may reduce operation times and put AVR within reach of more frail patients.

Investigators from G. Pasquinucci Heart Hospital in Massa, Italy, reported on 593 patients who had AVR through right anterior minithoracotomy (RAMT) over 10 years at their institution (J Thorac Cardiovasc Surg. 2015. doi: 10.1016/j.jtcvs.2015.06.045). In 302 of the patients, the researchers used a sutureless or rapidly implantable biological prosthesis.

“More surgeons should enrich their armamentarium by RAMT AVR,” lead author Dr. Mattia Glauber and his coauthors said. “Sutureless prostheses can increase adoption of RAMT AVR.”

The authors acknowledged that minimally invasive approaches to AVR, including partial sternotomy, require longer operation times than open surgery despite reduced aortic cross-clamping and cardiopulmonary bypass times, but have resulted in better outcomes and lower death rates.

A new generation of aortic valve prostheses, including sutureless devices, have emerged in an attempt to further reduce operative times and improve outcomes, so the Italian investigators designed their study to compare early and midterm outcomes after minimally invasive AVR using sutured and sutureless repair at their institution between 2004 and 2014.

In 302 (50.9%) patients, sutureless or rapidly implantable biological prosthesis was used, 23 (3.9%) had a mechanical prosthesis, and the remainder received a conventional biological prosthesis.

The investigators determined patients were suitable for RAMT if CT scan showed specific anatomic features, including rightward positioning of the ascending aorta at the level of the main pulmonary artery. Once the sutureless prostheses became available in 2011, every patient undergoing AVR via RAMT was considered a potential candidate, although the investigators decided that patients with type 1 and 2 bicuspid aortic valves without raphe and asymmetric aortic root were not suitable for the sutureless approach.

The subgroup that underwent sutureless repair tended to be older and sicker than the overall study population and had a higher prevalence of tricuspid aortic valve and aortic stenosis, a slightly higher body mass index, and a higher propensity to be obese. The sutureless subgroup also had fewer smokers.

Cardiopulmonary bypass time averaged 88 minutes and aortic cross-clamping times 55 minutes in the sutureless subgroup vs. 107 and 74 minutes, respectively, in the overall RAMT study subgroup.

The death before discharge rate of patients who had RAMT repair was 1%, and the 30-day in-hospital death rate was 1.5%. Overall, 97% of patients who had RAMT did not require reoperation at 5 years.

Between the sutured and sutureless subgroups, hospital and intensive care unit lengths of stay were similar, as were bleeding rates and in-hospital mortality. One measure in which the two subgroups deviated was prolonged ICU stay – a rate of 11.3% in the sutureless subgroup and 6.6% in the sutured subgroup.

“To the best of our knowledge, this is the largest up-to-date single-center experience on minimally invasive AVR through RAMT,” Dr. Glauber and coauthors said. “Our data along with earlier reports confirm that minimally invasive AVR through RAMT is safe and reproducible. It is associated with low perioperative mortality and morbidity.”

Dr. Glauber and coauthor Dr. Marco Solinas disclosed a commercial/financial relationship with Sorin Group.

Many patients with aortic valve disease still undergo conventional aortic valve replacement (AVR) with standard full sternotomy or seek out alternative treatments like transcatheter aortic valve insertion (TAVI). But a minimally invasive approach that uses a sutureless prostheses may reduce operation times and put AVR within reach of more frail patients.

Investigators from G. Pasquinucci Heart Hospital in Massa, Italy, reported on 593 patients who had AVR through right anterior minithoracotomy (RAMT) over 10 years at their institution (J Thorac Cardiovasc Surg. 2015. doi: 10.1016/j.jtcvs.2015.06.045). In 302 of the patients, the researchers used a sutureless or rapidly implantable biological prosthesis.

“More surgeons should enrich their armamentarium by RAMT AVR,” lead author Dr. Mattia Glauber and his coauthors said. “Sutureless prostheses can increase adoption of RAMT AVR.”

The authors acknowledged that minimally invasive approaches to AVR, including partial sternotomy, require longer operation times than open surgery despite reduced aortic cross-clamping and cardiopulmonary bypass times, but have resulted in better outcomes and lower death rates.

A new generation of aortic valve prostheses, including sutureless devices, have emerged in an attempt to further reduce operative times and improve outcomes, so the Italian investigators designed their study to compare early and midterm outcomes after minimally invasive AVR using sutured and sutureless repair at their institution between 2004 and 2014.

In 302 (50.9%) patients, sutureless or rapidly implantable biological prosthesis was used, 23 (3.9%) had a mechanical prosthesis, and the remainder received a conventional biological prosthesis.

The investigators determined patients were suitable for RAMT if CT scan showed specific anatomic features, including rightward positioning of the ascending aorta at the level of the main pulmonary artery. Once the sutureless prostheses became available in 2011, every patient undergoing AVR via RAMT was considered a potential candidate, although the investigators decided that patients with type 1 and 2 bicuspid aortic valves without raphe and asymmetric aortic root were not suitable for the sutureless approach.

The subgroup that underwent sutureless repair tended to be older and sicker than the overall study population and had a higher prevalence of tricuspid aortic valve and aortic stenosis, a slightly higher body mass index, and a higher propensity to be obese. The sutureless subgroup also had fewer smokers.

Cardiopulmonary bypass time averaged 88 minutes and aortic cross-clamping times 55 minutes in the sutureless subgroup vs. 107 and 74 minutes, respectively, in the overall RAMT study subgroup.

The death before discharge rate of patients who had RAMT repair was 1%, and the 30-day in-hospital death rate was 1.5%. Overall, 97% of patients who had RAMT did not require reoperation at 5 years.

Between the sutured and sutureless subgroups, hospital and intensive care unit lengths of stay were similar, as were bleeding rates and in-hospital mortality. One measure in which the two subgroups deviated was prolonged ICU stay – a rate of 11.3% in the sutureless subgroup and 6.6% in the sutured subgroup.

“To the best of our knowledge, this is the largest up-to-date single-center experience on minimally invasive AVR through RAMT,” Dr. Glauber and coauthors said. “Our data along with earlier reports confirm that minimally invasive AVR through RAMT is safe and reproducible. It is associated with low perioperative mortality and morbidity.”

Dr. Glauber and coauthor Dr. Marco Solinas disclosed a commercial/financial relationship with Sorin Group.

Many patients with aortic valve disease still undergo conventional aortic valve replacement (AVR) with standard full sternotomy or seek out alternative treatments like transcatheter aortic valve insertion (TAVI). But a minimally invasive approach that uses a sutureless prostheses may reduce operation times and put AVR within reach of more frail patients.

Investigators from G. Pasquinucci Heart Hospital in Massa, Italy, reported on 593 patients who had AVR through right anterior minithoracotomy (RAMT) over 10 years at their institution (J Thorac Cardiovasc Surg. 2015. doi: 10.1016/j.jtcvs.2015.06.045). In 302 of the patients, the researchers used a sutureless or rapidly implantable biological prosthesis.

“More surgeons should enrich their armamentarium by RAMT AVR,” lead author Dr. Mattia Glauber and his coauthors said. “Sutureless prostheses can increase adoption of RAMT AVR.”

The authors acknowledged that minimally invasive approaches to AVR, including partial sternotomy, require longer operation times than open surgery despite reduced aortic cross-clamping and cardiopulmonary bypass times, but have resulted in better outcomes and lower death rates.

A new generation of aortic valve prostheses, including sutureless devices, have emerged in an attempt to further reduce operative times and improve outcomes, so the Italian investigators designed their study to compare early and midterm outcomes after minimally invasive AVR using sutured and sutureless repair at their institution between 2004 and 2014.

In 302 (50.9%) patients, sutureless or rapidly implantable biological prosthesis was used, 23 (3.9%) had a mechanical prosthesis, and the remainder received a conventional biological prosthesis.

The investigators determined patients were suitable for RAMT if CT scan showed specific anatomic features, including rightward positioning of the ascending aorta at the level of the main pulmonary artery. Once the sutureless prostheses became available in 2011, every patient undergoing AVR via RAMT was considered a potential candidate, although the investigators decided that patients with type 1 and 2 bicuspid aortic valves without raphe and asymmetric aortic root were not suitable for the sutureless approach.

The subgroup that underwent sutureless repair tended to be older and sicker than the overall study population and had a higher prevalence of tricuspid aortic valve and aortic stenosis, a slightly higher body mass index, and a higher propensity to be obese. The sutureless subgroup also had fewer smokers.

Cardiopulmonary bypass time averaged 88 minutes and aortic cross-clamping times 55 minutes in the sutureless subgroup vs. 107 and 74 minutes, respectively, in the overall RAMT study subgroup.

The death before discharge rate of patients who had RAMT repair was 1%, and the 30-day in-hospital death rate was 1.5%. Overall, 97% of patients who had RAMT did not require reoperation at 5 years.

Between the sutured and sutureless subgroups, hospital and intensive care unit lengths of stay were similar, as were bleeding rates and in-hospital mortality. One measure in which the two subgroups deviated was prolonged ICU stay – a rate of 11.3% in the sutureless subgroup and 6.6% in the sutured subgroup.

“To the best of our knowledge, this is the largest up-to-date single-center experience on minimally invasive AVR through RAMT,” Dr. Glauber and coauthors said. “Our data along with earlier reports confirm that minimally invasive AVR through RAMT is safe and reproducible. It is associated with low perioperative mortality and morbidity.”

Dr. Glauber and coauthor Dr. Marco Solinas disclosed a commercial/financial relationship with Sorin Group.

While single-center studies have supported the advantages of multiple arterial grafts over venous grafts in coronary artery bypass surgery, an analysis of patients in the international and multicenter SYNTAX trial has shown that, on propensity matching, rates of cardiac events and death are actually similar between the two groups.

These findings of the SYNTAX investigators, led by Dr. Catalina Parasca of Erasmus University in Rotterdam, the Netherlands, were published online in the Journal of Thoracic and Cardiovascular Surgery (doi:10.1016/j.jtcvs.2015.05.010).

The SYNTAX trial compared percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) in patients with left main or three-vessel coronary artery disease (Lancet. 2013;381[9867]:629-38).

In the latest report, the SYNTAX investigators found that patients in unmatched groups who received arterial grafts in addition to an arterial graft of the left anterior descending artery (LAD) had noticeably lower rates of death and a composite endpoint of death-stroke-MI than did those who received a second venous graft. However, when the researchers applied propensity matching, the outcomes between the two groups were similar.

Coutresy of JTCVS/American Association for Thoracic Surgery

Because large randomized trials have yet to prove the superiority of multiarterial grafts, the adoption rate has been low, Dr. Parasca and colleagues said. “The objective of this study was to assess the effect of using a second arterial graft on 5-year outcomes in patients who underwent CABG in the SYNTAX trial and registry,” they said.

They looked at 1,322 SYNTAX trial patients who had CABG with 5-year follow-up. In unmatched groups, the safety endpoint of the death-stroke-MI composite was 13.3% in the multiarterial group vs. 18.7% in the vein graft group. Although the incidence of stroke, MI, and graft occlusion was similar between the unmatched groups, the second-graft arterial group had a higher revascularization rate at 5 years, 12.6% vs. 9.6%, mainly due to repeat PCI. The element of the composite where the two unmatched groups deviated was the all-cause death rate at 5 years: 8.9% in the second-graft arterial group and 13.1% in the venous group.

However, when the investigators applied propensity matching, the differences between the two groups were insignificant.

“The results of the present study must be seen in the light of a multicenter CABG cohort with complex coronary disease, where revascularization was performed according to surgeon’s personal experience and local practices,” Dr. Parasca and coauthors noted. “The result was a high heterogeneity of CABG techniques, which shows different understanding of the best ‘graft-target match’ across centers.”

While the SYNTAX analysis demonstrates the variation in patient selection and operator technique with regard to arterial revascularization typical of a multicenter study, “extended follow-up beyond 5 years is required to estimate its impact on long-term outcomes,” Dr. Parasca and colleagues said.

Boston Scientific supported the trial. Coauthor Keith Dawkins is employed by Boston Scientific and coauthor Ted Feldman has received consulting fees from the company. The other authors reported no disclosures.

While single-center studies have supported the advantages of multiple arterial grafts over venous grafts in coronary artery bypass surgery, an analysis of patients in the international and multicenter SYNTAX trial has shown that, on propensity matching, rates of cardiac events and death are actually similar between the two groups.

These findings of the SYNTAX investigators, led by Dr. Catalina Parasca of Erasmus University in Rotterdam, the Netherlands, were published online in the Journal of Thoracic and Cardiovascular Surgery (doi:10.1016/j.jtcvs.2015.05.010).

The SYNTAX trial compared percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) in patients with left main or three-vessel coronary artery disease (Lancet. 2013;381[9867]:629-38).

In the latest report, the SYNTAX investigators found that patients in unmatched groups who received arterial grafts in addition to an arterial graft of the left anterior descending artery (LAD) had noticeably lower rates of death and a composite endpoint of death-stroke-MI than did those who received a second venous graft. However, when the researchers applied propensity matching, the outcomes between the two groups were similar.

Coutresy of JTCVS/American Association for Thoracic Surgery

Because large randomized trials have yet to prove the superiority of multiarterial grafts, the adoption rate has been low, Dr. Parasca and colleagues said. “The objective of this study was to assess the effect of using a second arterial graft on 5-year outcomes in patients who underwent CABG in the SYNTAX trial and registry,” they said.

They looked at 1,322 SYNTAX trial patients who had CABG with 5-year follow-up. In unmatched groups, the safety endpoint of the death-stroke-MI composite was 13.3% in the multiarterial group vs. 18.7% in the vein graft group. Although the incidence of stroke, MI, and graft occlusion was similar between the unmatched groups, the second-graft arterial group had a higher revascularization rate at 5 years, 12.6% vs. 9.6%, mainly due to repeat PCI. The element of the composite where the two unmatched groups deviated was the all-cause death rate at 5 years: 8.9% in the second-graft arterial group and 13.1% in the venous group.

However, when the investigators applied propensity matching, the differences between the two groups were insignificant.

“The results of the present study must be seen in the light of a multicenter CABG cohort with complex coronary disease, where revascularization was performed according to surgeon’s personal experience and local practices,” Dr. Parasca and coauthors noted. “The result was a high heterogeneity of CABG techniques, which shows different understanding of the best ‘graft-target match’ across centers.”

While the SYNTAX analysis demonstrates the variation in patient selection and operator technique with regard to arterial revascularization typical of a multicenter study, “extended follow-up beyond 5 years is required to estimate its impact on long-term outcomes,” Dr. Parasca and colleagues said.

Boston Scientific supported the trial. Coauthor Keith Dawkins is employed by Boston Scientific and coauthor Ted Feldman has received consulting fees from the company. The other authors reported no disclosures.

While single-center studies have supported the advantages of multiple arterial grafts over venous grafts in coronary artery bypass surgery, an analysis of patients in the international and multicenter SYNTAX trial has shown that, on propensity matching, rates of cardiac events and death are actually similar between the two groups.

These findings of the SYNTAX investigators, led by Dr. Catalina Parasca of Erasmus University in Rotterdam, the Netherlands, were published online in the Journal of Thoracic and Cardiovascular Surgery (doi:10.1016/j.jtcvs.2015.05.010).

The SYNTAX trial compared percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) in patients with left main or three-vessel coronary artery disease (Lancet. 2013;381[9867]:629-38).

In the latest report, the SYNTAX investigators found that patients in unmatched groups who received arterial grafts in addition to an arterial graft of the left anterior descending artery (LAD) had noticeably lower rates of death and a composite endpoint of death-stroke-MI than did those who received a second venous graft. However, when the researchers applied propensity matching, the outcomes between the two groups were similar.

Coutresy of JTCVS/American Association for Thoracic Surgery

Because large randomized trials have yet to prove the superiority of multiarterial grafts, the adoption rate has been low, Dr. Parasca and colleagues said. “The objective of this study was to assess the effect of using a second arterial graft on 5-year outcomes in patients who underwent CABG in the SYNTAX trial and registry,” they said.

They looked at 1,322 SYNTAX trial patients who had CABG with 5-year follow-up. In unmatched groups, the safety endpoint of the death-stroke-MI composite was 13.3% in the multiarterial group vs. 18.7% in the vein graft group. Although the incidence of stroke, MI, and graft occlusion was similar between the unmatched groups, the second-graft arterial group had a higher revascularization rate at 5 years, 12.6% vs. 9.6%, mainly due to repeat PCI. The element of the composite where the two unmatched groups deviated was the all-cause death rate at 5 years: 8.9% in the second-graft arterial group and 13.1% in the venous group.

However, when the investigators applied propensity matching, the differences between the two groups were insignificant.

“The results of the present study must be seen in the light of a multicenter CABG cohort with complex coronary disease, where revascularization was performed according to surgeon’s personal experience and local practices,” Dr. Parasca and coauthors noted. “The result was a high heterogeneity of CABG techniques, which shows different understanding of the best ‘graft-target match’ across centers.”

While the SYNTAX analysis demonstrates the variation in patient selection and operator technique with regard to arterial revascularization typical of a multicenter study, “extended follow-up beyond 5 years is required to estimate its impact on long-term outcomes,” Dr. Parasca and colleagues said.

Boston Scientific supported the trial. Coauthor Keith Dawkins is employed by Boston Scientific and coauthor Ted Feldman has received consulting fees from the company. The other authors reported no disclosures.

A surgeon’s comfort level with a favored operation for non–small cell lung cancer can strongly influence whether the patient will have that operation, which, in turn, can affect the patient’s outcome and long-term survival, according to an analysis of a population-linked database. For patients whose surgeons have lower levels of experience, that could mean a greater chance they will have more invasive total lung removal rather than more difficult operations that spare part of the affected lung, according to investigators at McMaster University in Hamilton, Ontario.

“If a surgeon with high surgical volumes is less likely to perform higher-risk pneumonectomy procedures than one with lower volumes, this may translate to a significant reduction in adverse events,” said lead author Dr. Christian Finley and coauthors online in the Journal of Thoracic and Cardiovascular Surgery (2015 Jun 30 [doi: 10.1016/j.jtcvs.2015.04.060]). “Surgeon volume should be considered an important component in how care is delivered in this population.”

The McMaster investigators evaluated 8,070 patients in an Ontario population-based linked database who underwent surgical resection for non–small cell lung cancer during 2004-2011, including pneumonectomy, or total lung removal (842 patients), lobectomy (6,212 patients), and wedge resection (1,002 patients). Over the years of the study, the proportion of patients who underwent pneumonectomy fell by more than half, from 14.8% in 2004 to 7.6% in 2011.

Of the three procedures, pneumonectomy carries a threefold greater mortality and while the procedure is often avoidable, there may be cases where it’s necessary because of the location of the tumor, Dr. Finley and his colleagues said. Lobectomy is desirable because it spares the parenchyma and has lower recurrence rates than laser resections.

The study investigators aimed to explore the hypothesis that surgeons with less expertise are more inclined to perform the higher-risk pneumonectomy or sublobar resections such as a segmentectomy or a wedge resection than a lobectomy, the rationale being that these procedures can be less challenging than a standard or sleeve lobectomy. The study analyzed results from 124 different physicians at 45 institutions in Ontario.

Data analysis showed that physician volume, age, year of procedure, sex, and comorbidities were predictive of the surgeon performing a pneumonectomy. “Adjusting for these variables, the results indicated that for each 10-unit increase in physician volume, the relative risk of performing a pneumonectomy decreased by 9.1%,” Dr. Finley and his colleagues wrote. They also found no significant difference in stage distribution among low-, medium-, and high-volume surgeons.

“This is meaningful as pneumonectomy is known to have the highest mortality rate of lung cancer resection, found in this study to be 12.6%, demonstrating a potentially large impact on patient survival,” Dr. Finley and his colleagues said.

This analysis cites an earlier study that surgeon volume for many procedures was a key determinant in the link between hospital volume and operative mortality (N Engl J Med. 2003 Nov 27;349[2]:2117-27.). “This study suggests that a patient may improve their chance of survival substantially, even at high-volume institutions, by selecting surgeons who perform operations more frequently,” Dr. Finley and his colleagues said.

They said that despite their study’s limitations, the findings on how surgeon experience can influence the choice of lung resection for cancer warrant further study.

McMaster University, Division of Thoracic Surgery, provided funding for the study. The study authors had no disclosures.

A surgeon’s comfort level with a favored operation for non–small cell lung cancer can strongly influence whether the patient will have that operation, which, in turn, can affect the patient’s outcome and long-term survival, according to an analysis of a population-linked database. For patients whose surgeons have lower levels of experience, that could mean a greater chance they will have more invasive total lung removal rather than more difficult operations that spare part of the affected lung, according to investigators at McMaster University in Hamilton, Ontario.

“If a surgeon with high surgical volumes is less likely to perform higher-risk pneumonectomy procedures than one with lower volumes, this may translate to a significant reduction in adverse events,” said lead author Dr. Christian Finley and coauthors online in the Journal of Thoracic and Cardiovascular Surgery (2015 Jun 30 [doi: 10.1016/j.jtcvs.2015.04.060]). “Surgeon volume should be considered an important component in how care is delivered in this population.”

The McMaster investigators evaluated 8,070 patients in an Ontario population-based linked database who underwent surgical resection for non–small cell lung cancer during 2004-2011, including pneumonectomy, or total lung removal (842 patients), lobectomy (6,212 patients), and wedge resection (1,002 patients). Over the years of the study, the proportion of patients who underwent pneumonectomy fell by more than half, from 14.8% in 2004 to 7.6% in 2011.

Of the three procedures, pneumonectomy carries a threefold greater mortality and while the procedure is often avoidable, there may be cases where it’s necessary because of the location of the tumor, Dr. Finley and his colleagues said. Lobectomy is desirable because it spares the parenchyma and has lower recurrence rates than laser resections.

The study investigators aimed to explore the hypothesis that surgeons with less expertise are more inclined to perform the higher-risk pneumonectomy or sublobar resections such as a segmentectomy or a wedge resection than a lobectomy, the rationale being that these procedures can be less challenging than a standard or sleeve lobectomy. The study analyzed results from 124 different physicians at 45 institutions in Ontario.

Data analysis showed that physician volume, age, year of procedure, sex, and comorbidities were predictive of the surgeon performing a pneumonectomy. “Adjusting for these variables, the results indicated that for each 10-unit increase in physician volume, the relative risk of performing a pneumonectomy decreased by 9.1%,” Dr. Finley and his colleagues wrote. They also found no significant difference in stage distribution among low-, medium-, and high-volume surgeons.

“This is meaningful as pneumonectomy is known to have the highest mortality rate of lung cancer resection, found in this study to be 12.6%, demonstrating a potentially large impact on patient survival,” Dr. Finley and his colleagues said.

This analysis cites an earlier study that surgeon volume for many procedures was a key determinant in the link between hospital volume and operative mortality (N Engl J Med. 2003 Nov 27;349[2]:2117-27.). “This study suggests that a patient may improve their chance of survival substantially, even at high-volume institutions, by selecting surgeons who perform operations more frequently,” Dr. Finley and his colleagues said.

They said that despite their study’s limitations, the findings on how surgeon experience can influence the choice of lung resection for cancer warrant further study.

McMaster University, Division of Thoracic Surgery, provided funding for the study. The study authors had no disclosures.

A surgeon’s comfort level with a favored operation for non–small cell lung cancer can strongly influence whether the patient will have that operation, which, in turn, can affect the patient’s outcome and long-term survival, according to an analysis of a population-linked database. For patients whose surgeons have lower levels of experience, that could mean a greater chance they will have more invasive total lung removal rather than more difficult operations that spare part of the affected lung, according to investigators at McMaster University in Hamilton, Ontario.

“If a surgeon with high surgical volumes is less likely to perform higher-risk pneumonectomy procedures than one with lower volumes, this may translate to a significant reduction in adverse events,” said lead author Dr. Christian Finley and coauthors online in the Journal of Thoracic and Cardiovascular Surgery (2015 Jun 30 [doi: 10.1016/j.jtcvs.2015.04.060]). “Surgeon volume should be considered an important component in how care is delivered in this population.”

The McMaster investigators evaluated 8,070 patients in an Ontario population-based linked database who underwent surgical resection for non–small cell lung cancer during 2004-2011, including pneumonectomy, or total lung removal (842 patients), lobectomy (6,212 patients), and wedge resection (1,002 patients). Over the years of the study, the proportion of patients who underwent pneumonectomy fell by more than half, from 14.8% in 2004 to 7.6% in 2011.

Of the three procedures, pneumonectomy carries a threefold greater mortality and while the procedure is often avoidable, there may be cases where it’s necessary because of the location of the tumor, Dr. Finley and his colleagues said. Lobectomy is desirable because it spares the parenchyma and has lower recurrence rates than laser resections.

The study investigators aimed to explore the hypothesis that surgeons with less expertise are more inclined to perform the higher-risk pneumonectomy or sublobar resections such as a segmentectomy or a wedge resection than a lobectomy, the rationale being that these procedures can be less challenging than a standard or sleeve lobectomy. The study analyzed results from 124 different physicians at 45 institutions in Ontario.

Data analysis showed that physician volume, age, year of procedure, sex, and comorbidities were predictive of the surgeon performing a pneumonectomy. “Adjusting for these variables, the results indicated that for each 10-unit increase in physician volume, the relative risk of performing a pneumonectomy decreased by 9.1%,” Dr. Finley and his colleagues wrote. They also found no significant difference in stage distribution among low-, medium-, and high-volume surgeons.

“This is meaningful as pneumonectomy is known to have the highest mortality rate of lung cancer resection, found in this study to be 12.6%, demonstrating a potentially large impact on patient survival,” Dr. Finley and his colleagues said.

This analysis cites an earlier study that surgeon volume for many procedures was a key determinant in the link between hospital volume and operative mortality (N Engl J Med. 2003 Nov 27;349[2]:2117-27.). “This study suggests that a patient may improve their chance of survival substantially, even at high-volume institutions, by selecting surgeons who perform operations more frequently,” Dr. Finley and his colleagues said.

They said that despite their study’s limitations, the findings on how surgeon experience can influence the choice of lung resection for cancer warrant further study.

McMaster University, Division of Thoracic Surgery, provided funding for the study. The study authors had no disclosures.

As Medicare and commercial payers rely increasingly on quality outcomes to determine reimbursement levels, clinicians focused on traditional clinical outcomes like length of hospital stay and readmission may be missing the point if they don’t take into consideration more patient-centric outcome. A team of investigators at MD Anderson Cancer Center in Houston recently evaluated that institution’s tool for measuring patient-reported outcomes in tracking results after thoracic surgery for lung cancer.

Christopher P. Fagundes, Ph.D., led the research team that reported their findings in the September issue of the Journal of Thoracic and Cardiovascular Surgery (2015 [doi:10.1016/j.jtcvs.2015.05.057]).

“We used the MD Anderson Symptom Inventory (MDASI) to elicit patient reports of the worst symptoms experienced after thoracic surgery,” Dr. Fagundes and his colleagues said in what may be the first study to use patient-reported outcomes to chart a recovery course after surgery. “This study demonstrates that the MDASI is a sensitive tool for detecting symptomatic recovery with an expected relationship among surgery type, preoperative performance status, and comorbid conditions,” the authors stated.

The MDASI measures the severity of 13 common cancer-related symptoms over the previous 24 hours and rates each on a scale from 0-10, with 10 as most severe. Patients in the study completed a written MDASI questionnaire, 60 upon enrollment, and 77 patients 3 and 5 days after surgery in the hospital. After discharge and for 3 months after surgery, patients received weekly calls from a computer/telephone interactive voice-response system that asked them to rate their symptoms.

All patients were newly diagnosed and treatment naive with early-stage non–small cell lung cancer (NSCLC) who had either standard open thoracotomy or video-assisted thoracoscopic surgery (VATS) lobectomy.

The investigators used a two-pronged approach to define recovery after surgery: symptoms returning to their baseline levels or to a mild level of severity. In the first week after surgery, pain, fatigue, and shortness of breath were “highly prevalent,” perhaps a combined effect from surgical insult and care during and after surgery. After a month, ratings for most symptoms returned to baseline, but fatigue remained the most-persistent symptom during the 3-month study.

NSCLC patients typically have a host of symptoms after major surgery, including inflammation, organ stress, and reaction to medications. In addition, up to a quarter have postsurgical complications that can amplify their symptoms and even delay their course of cancer treatment. The five most-severe postoperative symptoms patients in the study reported were fatigue, pain, shortness of breath, disturbed sleep, and drowsiness.

Courtesy of JTCVS/American Association for Thoracic Surgery

The median time to return to mild symptom severity for these five symptoms was shorter than return to baseline severity, with fatigue taking longer. Pain recovered significantly faster for patients who underwent VATS lobectomy vs. standard open thoracotomy (8 vs. 18 days, respectively; P = .022), according to the researchers. In addition, the researchers found that patients who had poor preoperative performance status or comorbidities reported significantly higher postoperative pain (P less than .05).

Having the ability to measure patient-reported outcomes allows physicians to identify patients at greatest risk for symptoms after surgery and to help caregivers develop pathways to speed up recovery and get patients to chemotherapy or other cancer treatments on schedule, Dr. Fagundes and his coauthors said.

“Using a straightforward, concise tool like the MDASI to obtain the patient’s perspective on how well he or she is recovering is a clinically relevant and user-friendly method for optimizing perioperative care,” the authors added.

Minimally invasive surgical techniques along with opioid-sparing analgesia have been incorporated into enhanced recovery programs to aim for better objective postoperative outcomes like fewer complications and shorter hospital stays. “Missing from these metrics is the voice of the patient, who is arguably the best source of information about what ‘recovery’ from surgery means,” Dr. Fagundes and colleagues said. “Lack of research on how to define and measure symptomatic and functional recovery after major cancer surgery from the patent’s perspective is an important gap in comprehensive postoperative care; it also compromises any comparison of ERP [enhanced recovery program] innovations against standard care.”

Study coauthors received funding from the National Cancer Institute of the National Institutes of Health, the MD Anderson Cancer Center Support Grant program and the American Cancer Society Research Scholar Grant program. The coauthors reported no conflicts of interest in this work.

As Medicare and commercial payers rely increasingly on quality outcomes to determine reimbursement levels, clinicians focused on traditional clinical outcomes like length of hospital stay and readmission may be missing the point if they don’t take into consideration more patient-centric outcome. A team of investigators at MD Anderson Cancer Center in Houston recently evaluated that institution’s tool for measuring patient-reported outcomes in tracking results after thoracic surgery for lung cancer.

Christopher P. Fagundes, Ph.D., led the research team that reported their findings in the September issue of the Journal of Thoracic and Cardiovascular Surgery (2015 [doi:10.1016/j.jtcvs.2015.05.057]).

“We used the MD Anderson Symptom Inventory (MDASI) to elicit patient reports of the worst symptoms experienced after thoracic surgery,” Dr. Fagundes and his colleagues said in what may be the first study to use patient-reported outcomes to chart a recovery course after surgery. “This study demonstrates that the MDASI is a sensitive tool for detecting symptomatic recovery with an expected relationship among surgery type, preoperative performance status, and comorbid conditions,” the authors stated.

The MDASI measures the severity of 13 common cancer-related symptoms over the previous 24 hours and rates each on a scale from 0-10, with 10 as most severe. Patients in the study completed a written MDASI questionnaire, 60 upon enrollment, and 77 patients 3 and 5 days after surgery in the hospital. After discharge and for 3 months after surgery, patients received weekly calls from a computer/telephone interactive voice-response system that asked them to rate their symptoms.

All patients were newly diagnosed and treatment naive with early-stage non–small cell lung cancer (NSCLC) who had either standard open thoracotomy or video-assisted thoracoscopic surgery (VATS) lobectomy.

The investigators used a two-pronged approach to define recovery after surgery: symptoms returning to their baseline levels or to a mild level of severity. In the first week after surgery, pain, fatigue, and shortness of breath were “highly prevalent,” perhaps a combined effect from surgical insult and care during and after surgery. After a month, ratings for most symptoms returned to baseline, but fatigue remained the most-persistent symptom during the 3-month study.

NSCLC patients typically have a host of symptoms after major surgery, including inflammation, organ stress, and reaction to medications. In addition, up to a quarter have postsurgical complications that can amplify their symptoms and even delay their course of cancer treatment. The five most-severe postoperative symptoms patients in the study reported were fatigue, pain, shortness of breath, disturbed sleep, and drowsiness.

Courtesy of JTCVS/American Association for Thoracic Surgery

The median time to return to mild symptom severity for these five symptoms was shorter than return to baseline severity, with fatigue taking longer. Pain recovered significantly faster for patients who underwent VATS lobectomy vs. standard open thoracotomy (8 vs. 18 days, respectively; P = .022), according to the researchers. In addition, the researchers found that patients who had poor preoperative performance status or comorbidities reported significantly higher postoperative pain (P less than .05).

Having the ability to measure patient-reported outcomes allows physicians to identify patients at greatest risk for symptoms after surgery and to help caregivers develop pathways to speed up recovery and get patients to chemotherapy or other cancer treatments on schedule, Dr. Fagundes and his coauthors said.

“Using a straightforward, concise tool like the MDASI to obtain the patient’s perspective on how well he or she is recovering is a clinically relevant and user-friendly method for optimizing perioperative care,” the authors added.

Minimally invasive surgical techniques along with opioid-sparing analgesia have been incorporated into enhanced recovery programs to aim for better objective postoperative outcomes like fewer complications and shorter hospital stays. “Missing from these metrics is the voice of the patient, who is arguably the best source of information about what ‘recovery’ from surgery means,” Dr. Fagundes and colleagues said. “Lack of research on how to define and measure symptomatic and functional recovery after major cancer surgery from the patent’s perspective is an important gap in comprehensive postoperative care; it also compromises any comparison of ERP [enhanced recovery program] innovations against standard care.”

Study coauthors received funding from the National Cancer Institute of the National Institutes of Health, the MD Anderson Cancer Center Support Grant program and the American Cancer Society Research Scholar Grant program. The coauthors reported no conflicts of interest in this work.

As Medicare and commercial payers rely increasingly on quality outcomes to determine reimbursement levels, clinicians focused on traditional clinical outcomes like length of hospital stay and readmission may be missing the point if they don’t take into consideration more patient-centric outcome. A team of investigators at MD Anderson Cancer Center in Houston recently evaluated that institution’s tool for measuring patient-reported outcomes in tracking results after thoracic surgery for lung cancer.

Christopher P. Fagundes, Ph.D., led the research team that reported their findings in the September issue of the Journal of Thoracic and Cardiovascular Surgery (2015 [doi:10.1016/j.jtcvs.2015.05.057]).

“We used the MD Anderson Symptom Inventory (MDASI) to elicit patient reports of the worst symptoms experienced after thoracic surgery,” Dr. Fagundes and his colleagues said in what may be the first study to use patient-reported outcomes to chart a recovery course after surgery. “This study demonstrates that the MDASI is a sensitive tool for detecting symptomatic recovery with an expected relationship among surgery type, preoperative performance status, and comorbid conditions,” the authors stated.

The MDASI measures the severity of 13 common cancer-related symptoms over the previous 24 hours and rates each on a scale from 0-10, with 10 as most severe. Patients in the study completed a written MDASI questionnaire, 60 upon enrollment, and 77 patients 3 and 5 days after surgery in the hospital. After discharge and for 3 months after surgery, patients received weekly calls from a computer/telephone interactive voice-response system that asked them to rate their symptoms.

All patients were newly diagnosed and treatment naive with early-stage non–small cell lung cancer (NSCLC) who had either standard open thoracotomy or video-assisted thoracoscopic surgery (VATS) lobectomy.

The investigators used a two-pronged approach to define recovery after surgery: symptoms returning to their baseline levels or to a mild level of severity. In the first week after surgery, pain, fatigue, and shortness of breath were “highly prevalent,” perhaps a combined effect from surgical insult and care during and after surgery. After a month, ratings for most symptoms returned to baseline, but fatigue remained the most-persistent symptom during the 3-month study.

NSCLC patients typically have a host of symptoms after major surgery, including inflammation, organ stress, and reaction to medications. In addition, up to a quarter have postsurgical complications that can amplify their symptoms and even delay their course of cancer treatment. The five most-severe postoperative symptoms patients in the study reported were fatigue, pain, shortness of breath, disturbed sleep, and drowsiness.

Courtesy of JTCVS/American Association for Thoracic Surgery

The median time to return to mild symptom severity for these five symptoms was shorter than return to baseline severity, with fatigue taking longer. Pain recovered significantly faster for patients who underwent VATS lobectomy vs. standard open thoracotomy (8 vs. 18 days, respectively; P = .022), according to the researchers. In addition, the researchers found that patients who had poor preoperative performance status or comorbidities reported significantly higher postoperative pain (P less than .05).

Having the ability to measure patient-reported outcomes allows physicians to identify patients at greatest risk for symptoms after surgery and to help caregivers develop pathways to speed up recovery and get patients to chemotherapy or other cancer treatments on schedule, Dr. Fagundes and his coauthors said.

“Using a straightforward, concise tool like the MDASI to obtain the patient’s perspective on how well he or she is recovering is a clinically relevant and user-friendly method for optimizing perioperative care,” the authors added.

Minimally invasive surgical techniques along with opioid-sparing analgesia have been incorporated into enhanced recovery programs to aim for better objective postoperative outcomes like fewer complications and shorter hospital stays. “Missing from these metrics is the voice of the patient, who is arguably the best source of information about what ‘recovery’ from surgery means,” Dr. Fagundes and colleagues said. “Lack of research on how to define and measure symptomatic and functional recovery after major cancer surgery from the patent’s perspective is an important gap in comprehensive postoperative care; it also compromises any comparison of ERP [enhanced recovery program] innovations against standard care.”

Study coauthors received funding from the National Cancer Institute of the National Institutes of Health, the MD Anderson Cancer Center Support Grant program and the American Cancer Society Research Scholar Grant program. The coauthors reported no conflicts of interest in this work.

Many techniques for repair of aortic dissection have evolved, but no trials have compared those techniques to determine which is the best. However, a study team has attempted to evaluate a surgical approach (the “David technique”) that includes three specific steps – no aortic cross clamp, the use of deep hypothermic circulatory arrest (DHCA), and the antegrade resumption of cardiopulmonary bypass. They found that this approach yielded significantly better long-term outcomes than did other approaches tried.

The study investigators, led by Dr. Jennifer S. Lawton of Washington University in St. Louis, reported their findings in the Journal of Thoracic and Cardiovascular Surgery (J. Thorac. Cardiovasc. Surg. 2015 [doi:10.1016/j.jtcvs.2015.03.023]). “We hypothesized that a surgical strategy to prevent cross-clamp injury or false lumen pressurization would be associated with reduced morbidity, mortality, persistent false lumen patency, and improved survival,” Dr. Lawton and her coauthors wrote. “This study was designed to determine the differences in outcomes between operative techniques.”

The study evaluated 196 patients who had surgery for acute type A aortic dissection over 17 years. Group 1, which comprised 49 patients, had the operation according to the protocol that involved the three specific steps, as Dr. Tirone David of the University of Toronto first reported in 1999 (Ann. Thorac. Surg. 1999;67:1999-2001) — the “David technique,” as the study authors called it. Group 2 consisted of patients whose repair involved a variety of techniques, including one or two steps of the David technique but not all three.

Study endpoints were 30-day mortality rate, postoperative adverse events, presence of a false aortic lumen, and overall survival, the latter defined as the time from the date of surgery to the date or death or last follow-up. The evaluation included examination of patients’ latest CT scan or MRI that was at least 6 months after the operation for false lumen, but only 78 patients had imaging at that interval.

Patients in Group 1 had a higher rate of persistent false lumen – 74% vs. 68% in Group 2. Thirty-day mortality was 6.1% in Group 1 and 15.7% in Group 2, but Dr. Lawton and her coauthors said this difference was not statistically significant.

Survival rates at 1, 5 and 10 years among both groups were “consistent with published ranges,” the authors said. At 5 years, the predicted survival was 86% for Group 1 and 56% for Group 2; and at 10 years, 72% and 37% respectively.

The study authors acknowledged the controversy that surrounds the use of retrograde resumption of cardiopulmonary bypass after replacement of the ascending aorta and that there’s no consensus on which method is best for resuming cardiopulmonary bypass after repair of a type A aortic dissection.

The study also found no difference in the incidence of false lumen between the two groups, but again, this is a source of controversy. “Persistence of a false lumen following repair for type A aortic dissection has been reported to be associated with poor prognosis and reduced long-term survival,” Dr. Lawton and her colleagues said.

“Others have reported a patent false lumen was not an independent predictor of late reoperation, but was a predictor of aortic growth following repair of type A aortic dissection.”

The study authors said one limit of their findings is its retrospective nature, but they also said that a prospective, randomized trial would be difficult to conduct.

None of the study coauthors had any relationships to disclose. They presented their original data at the American Association for Thoracic Surgery Aortic Symposium, April 24-25, 2014, in New York.

Many techniques for repair of aortic dissection have evolved, but no trials have compared those techniques to determine which is the best. However, a study team has attempted to evaluate a surgical approach (the “David technique”) that includes three specific steps – no aortic cross clamp, the use of deep hypothermic circulatory arrest (DHCA), and the antegrade resumption of cardiopulmonary bypass. They found that this approach yielded significantly better long-term outcomes than did other approaches tried.

The study investigators, led by Dr. Jennifer S. Lawton of Washington University in St. Louis, reported their findings in the Journal of Thoracic and Cardiovascular Surgery (J. Thorac. Cardiovasc. Surg. 2015 [doi:10.1016/j.jtcvs.2015.03.023]). “We hypothesized that a surgical strategy to prevent cross-clamp injury or false lumen pressurization would be associated with reduced morbidity, mortality, persistent false lumen patency, and improved survival,” Dr. Lawton and her coauthors wrote. “This study was designed to determine the differences in outcomes between operative techniques.”

The study evaluated 196 patients who had surgery for acute type A aortic dissection over 17 years. Group 1, which comprised 49 patients, had the operation according to the protocol that involved the three specific steps, as Dr. Tirone David of the University of Toronto first reported in 1999 (Ann. Thorac. Surg. 1999;67:1999-2001) — the “David technique,” as the study authors called it. Group 2 consisted of patients whose repair involved a variety of techniques, including one or two steps of the David technique but not all three.

Study endpoints were 30-day mortality rate, postoperative adverse events, presence of a false aortic lumen, and overall survival, the latter defined as the time from the date of surgery to the date or death or last follow-up. The evaluation included examination of patients’ latest CT scan or MRI that was at least 6 months after the operation for false lumen, but only 78 patients had imaging at that interval.

Patients in Group 1 had a higher rate of persistent false lumen – 74% vs. 68% in Group 2. Thirty-day mortality was 6.1% in Group 1 and 15.7% in Group 2, but Dr. Lawton and her coauthors said this difference was not statistically significant.

Survival rates at 1, 5 and 10 years among both groups were “consistent with published ranges,” the authors said. At 5 years, the predicted survival was 86% for Group 1 and 56% for Group 2; and at 10 years, 72% and 37% respectively.

The study authors acknowledged the controversy that surrounds the use of retrograde resumption of cardiopulmonary bypass after replacement of the ascending aorta and that there’s no consensus on which method is best for resuming cardiopulmonary bypass after repair of a type A aortic dissection.

The study also found no difference in the incidence of false lumen between the two groups, but again, this is a source of controversy. “Persistence of a false lumen following repair for type A aortic dissection has been reported to be associated with poor prognosis and reduced long-term survival,” Dr. Lawton and her colleagues said.

“Others have reported a patent false lumen was not an independent predictor of late reoperation, but was a predictor of aortic growth following repair of type A aortic dissection.”

The study authors said one limit of their findings is its retrospective nature, but they also said that a prospective, randomized trial would be difficult to conduct.

None of the study coauthors had any relationships to disclose. They presented their original data at the American Association for Thoracic Surgery Aortic Symposium, April 24-25, 2014, in New York.

Many techniques for repair of aortic dissection have evolved, but no trials have compared those techniques to determine which is the best. However, a study team has attempted to evaluate a surgical approach (the “David technique”) that includes three specific steps – no aortic cross clamp, the use of deep hypothermic circulatory arrest (DHCA), and the antegrade resumption of cardiopulmonary bypass. They found that this approach yielded significantly better long-term outcomes than did other approaches tried.

The study investigators, led by Dr. Jennifer S. Lawton of Washington University in St. Louis, reported their findings in the Journal of Thoracic and Cardiovascular Surgery (J. Thorac. Cardiovasc. Surg. 2015 [doi:10.1016/j.jtcvs.2015.03.023]). “We hypothesized that a surgical strategy to prevent cross-clamp injury or false lumen pressurization would be associated with reduced morbidity, mortality, persistent false lumen patency, and improved survival,” Dr. Lawton and her coauthors wrote. “This study was designed to determine the differences in outcomes between operative techniques.”

The study evaluated 196 patients who had surgery for acute type A aortic dissection over 17 years. Group 1, which comprised 49 patients, had the operation according to the protocol that involved the three specific steps, as Dr. Tirone David of the University of Toronto first reported in 1999 (Ann. Thorac. Surg. 1999;67:1999-2001) — the “David technique,” as the study authors called it. Group 2 consisted of patients whose repair involved a variety of techniques, including one or two steps of the David technique but not all three.

Study endpoints were 30-day mortality rate, postoperative adverse events, presence of a false aortic lumen, and overall survival, the latter defined as the time from the date of surgery to the date or death or last follow-up. The evaluation included examination of patients’ latest CT scan or MRI that was at least 6 months after the operation for false lumen, but only 78 patients had imaging at that interval.

Patients in Group 1 had a higher rate of persistent false lumen – 74% vs. 68% in Group 2. Thirty-day mortality was 6.1% in Group 1 and 15.7% in Group 2, but Dr. Lawton and her coauthors said this difference was not statistically significant.

Survival rates at 1, 5 and 10 years among both groups were “consistent with published ranges,” the authors said. At 5 years, the predicted survival was 86% for Group 1 and 56% for Group 2; and at 10 years, 72% and 37% respectively.

The study authors acknowledged the controversy that surrounds the use of retrograde resumption of cardiopulmonary bypass after replacement of the ascending aorta and that there’s no consensus on which method is best for resuming cardiopulmonary bypass after repair of a type A aortic dissection.

The study also found no difference in the incidence of false lumen between the two groups, but again, this is a source of controversy. “Persistence of a false lumen following repair for type A aortic dissection has been reported to be associated with poor prognosis and reduced long-term survival,” Dr. Lawton and her colleagues said.

“Others have reported a patent false lumen was not an independent predictor of late reoperation, but was a predictor of aortic growth following repair of type A aortic dissection.”

The study authors said one limit of their findings is its retrospective nature, but they also said that a prospective, randomized trial would be difficult to conduct.

None of the study coauthors had any relationships to disclose. They presented their original data at the American Association for Thoracic Surgery Aortic Symposium, April 24-25, 2014, in New York.

Injecting patients with a molecular contrast agent before lung cancer surgery and then using fluorescent imaging during the operation proved safe and somewhat effective at finding lung adenocarcinomas and discovering tumor metastases in a pilot clinical trial of 50 patients.

Investigators from the University of Pennsylvania, Philadelphia, and Emory (Atlanta) and Purdue (West Lafayette, Ind.) universities reported their findings online in the Journal of Thoracic and Cardiovascular Surgery (2015 [doi:10.1016/j.jtcvs.2015.05.014]).

“We believe the most important finding in this study was the ability to systemically inject our contrast agent into patients prior to surgery and have 92% of the lung adenocarcinomas fluoresce in the operating room,” Dr. Olugbenga Okusanya of the University of Pennsylvania, Philadelphia, and his colleagues said. Their approach overcomes some of the limitations of other contrast agents for imaging of lung cancer.

The approach involves intravenous administration of 0.1 mg/kg of a fluorescent folate receptor-alpha (FR-alpha)–targeted molecule contrast agent 4 hours before surgery. The specific agent they used is a synthetic conjugate between folate and fluorescein isothiocyanate that binds to serum proteins.

They set out to determine if an optical-targeted molecular contrast agent to FR-alpha could bind lung adenocarcinoma and then if real-time optical imaging, either in situ or ex vivo during surgery, would show the lesions. The 50 study subjects all had biopsy-confirmed lung adenocarcinoma. In the OR, the researchers used a gantry-mounted fluorescent imaging system to capture images of the tumors.

With the operating room lights switched off, imaging of the cancer was captured by fluorescence and white light in situ. The lung was deflated during imaging to expose as much of the lung surface to the imaging as possible. The in situ optical imaging required on average eight minutes to perform. Only seven tumors (14%) appeared fluorescent in situ before they were excised. Computed tomography (CT) before surgery showed that all seven of these tumors were below the pleural surface and within 1.2 cm of the lung surface.

Among the other 43 tumors, 39 exhibited uniform fluorescence once the surgical team exposed their surfaces while 4 – all invasive adenocarcinomas – did not. Final pathology confirmed that all 50 tumors were cancerous.

“With further refinements, this tool may prove useful in locating adenocarcinomas deeper in the lung parenchyma, lymph nodes and at pleural and resection margins,” Dr. Okusanya and his coauthors said.

The investigators noted that one advantage of this imaging strategy is that it can locate tumors of varying sizes, subtypes and metabolic activity with tumor-to-background ratios “not markedly different” among them. “This finding demonstrates that intraoperative molecular imaging may be potentially broadly applicable to all FR-alpha lung tumors,” they said.

Other advantages is that wavelength fluorophore poses no radiation exposure and that surgeons readily understand optical imaging “with no need for special training to interpret or process the data.” They did acknowledge that a significant drawback of the molecular contrast agent was its lack of penetration into the lung parenchyma.

“New molecular tools are emerging to identify lung adenocarcinomas during pulmonary resection,” Dr. Okusanya and colleagues said. “This technology will permit precise visualization of tumor margins, localization of small malignant ground-glass opacities, and accurate selection of lymph nodes with metastatic cancer cells. With miniaturization of imaging devices, this method will be particularly useful in minimally invasive surgery.”

The pilot clinical trial was partially supported by grant from the Biomedical Laboratory Research & Development Service of the Veterans Affairs Office of Research and Development and by the CHEST Foundation One Breath Clinical Research Award (SS).

Dr. Shuming Nie is a coauthor and a consultant for Spectropath, a start-up company that is developing advanced instrumentation and nanoparticle contrast agents. Dr. Philip S. Low is a coauthor and a consultant and stakeholder in OnTarget Laboratories. None of the other coauthors had any relationships to disclose.

Injecting patients with a molecular contrast agent before lung cancer surgery and then using fluorescent imaging during the operation proved safe and somewhat effective at finding lung adenocarcinomas and discovering tumor metastases in a pilot clinical trial of 50 patients.

Investigators from the University of Pennsylvania, Philadelphia, and Emory (Atlanta) and Purdue (West Lafayette, Ind.) universities reported their findings online in the Journal of Thoracic and Cardiovascular Surgery (2015 [doi:10.1016/j.jtcvs.2015.05.014]).

“We believe the most important finding in this study was the ability to systemically inject our contrast agent into patients prior to surgery and have 92% of the lung adenocarcinomas fluoresce in the operating room,” Dr. Olugbenga Okusanya of the University of Pennsylvania, Philadelphia, and his colleagues said. Their approach overcomes some of the limitations of other contrast agents for imaging of lung cancer.

The approach involves intravenous administration of 0.1 mg/kg of a fluorescent folate receptor-alpha (FR-alpha)–targeted molecule contrast agent 4 hours before surgery. The specific agent they used is a synthetic conjugate between folate and fluorescein isothiocyanate that binds to serum proteins.

They set out to determine if an optical-targeted molecular contrast agent to FR-alpha could bind lung adenocarcinoma and then if real-time optical imaging, either in situ or ex vivo during surgery, would show the lesions. The 50 study subjects all had biopsy-confirmed lung adenocarcinoma. In the OR, the researchers used a gantry-mounted fluorescent imaging system to capture images of the tumors.

With the operating room lights switched off, imaging of the cancer was captured by fluorescence and white light in situ. The lung was deflated during imaging to expose as much of the lung surface to the imaging as possible. The in situ optical imaging required on average eight minutes to perform. Only seven tumors (14%) appeared fluorescent in situ before they were excised. Computed tomography (CT) before surgery showed that all seven of these tumors were below the pleural surface and within 1.2 cm of the lung surface.

Among the other 43 tumors, 39 exhibited uniform fluorescence once the surgical team exposed their surfaces while 4 – all invasive adenocarcinomas – did not. Final pathology confirmed that all 50 tumors were cancerous.

“With further refinements, this tool may prove useful in locating adenocarcinomas deeper in the lung parenchyma, lymph nodes and at pleural and resection margins,” Dr. Okusanya and his coauthors said.

The investigators noted that one advantage of this imaging strategy is that it can locate tumors of varying sizes, subtypes and metabolic activity with tumor-to-background ratios “not markedly different” among them. “This finding demonstrates that intraoperative molecular imaging may be potentially broadly applicable to all FR-alpha lung tumors,” they said.

Other advantages is that wavelength fluorophore poses no radiation exposure and that surgeons readily understand optical imaging “with no need for special training to interpret or process the data.” They did acknowledge that a significant drawback of the molecular contrast agent was its lack of penetration into the lung parenchyma.

“New molecular tools are emerging to identify lung adenocarcinomas during pulmonary resection,” Dr. Okusanya and colleagues said. “This technology will permit precise visualization of tumor margins, localization of small malignant ground-glass opacities, and accurate selection of lymph nodes with metastatic cancer cells. With miniaturization of imaging devices, this method will be particularly useful in minimally invasive surgery.”

The pilot clinical trial was partially supported by grant from the Biomedical Laboratory Research & Development Service of the Veterans Affairs Office of Research and Development and by the CHEST Foundation One Breath Clinical Research Award (SS).

Dr. Shuming Nie is a coauthor and a consultant for Spectropath, a start-up company that is developing advanced instrumentation and nanoparticle contrast agents. Dr. Philip S. Low is a coauthor and a consultant and stakeholder in OnTarget Laboratories. None of the other coauthors had any relationships to disclose.

Injecting patients with a molecular contrast agent before lung cancer surgery and then using fluorescent imaging during the operation proved safe and somewhat effective at finding lung adenocarcinomas and discovering tumor metastases in a pilot clinical trial of 50 patients.

Investigators from the University of Pennsylvania, Philadelphia, and Emory (Atlanta) and Purdue (West Lafayette, Ind.) universities reported their findings online in the Journal of Thoracic and Cardiovascular Surgery (2015 [doi:10.1016/j.jtcvs.2015.05.014]).

“We believe the most important finding in this study was the ability to systemically inject our contrast agent into patients prior to surgery and have 92% of the lung adenocarcinomas fluoresce in the operating room,” Dr. Olugbenga Okusanya of the University of Pennsylvania, Philadelphia, and his colleagues said. Their approach overcomes some of the limitations of other contrast agents for imaging of lung cancer.

The approach involves intravenous administration of 0.1 mg/kg of a fluorescent folate receptor-alpha (FR-alpha)–targeted molecule contrast agent 4 hours before surgery. The specific agent they used is a synthetic conjugate between folate and fluorescein isothiocyanate that binds to serum proteins.

They set out to determine if an optical-targeted molecular contrast agent to FR-alpha could bind lung adenocarcinoma and then if real-time optical imaging, either in situ or ex vivo during surgery, would show the lesions. The 50 study subjects all had biopsy-confirmed lung adenocarcinoma. In the OR, the researchers used a gantry-mounted fluorescent imaging system to capture images of the tumors.

With the operating room lights switched off, imaging of the cancer was captured by fluorescence and white light in situ. The lung was deflated during imaging to expose as much of the lung surface to the imaging as possible. The in situ optical imaging required on average eight minutes to perform. Only seven tumors (14%) appeared fluorescent in situ before they were excised. Computed tomography (CT) before surgery showed that all seven of these tumors were below the pleural surface and within 1.2 cm of the lung surface.

Among the other 43 tumors, 39 exhibited uniform fluorescence once the surgical team exposed their surfaces while 4 – all invasive adenocarcinomas – did not. Final pathology confirmed that all 50 tumors were cancerous.

“With further refinements, this tool may prove useful in locating adenocarcinomas deeper in the lung parenchyma, lymph nodes and at pleural and resection margins,” Dr. Okusanya and his coauthors said.

The investigators noted that one advantage of this imaging strategy is that it can locate tumors of varying sizes, subtypes and metabolic activity with tumor-to-background ratios “not markedly different” among them. “This finding demonstrates that intraoperative molecular imaging may be potentially broadly applicable to all FR-alpha lung tumors,” they said.

Other advantages is that wavelength fluorophore poses no radiation exposure and that surgeons readily understand optical imaging “with no need for special training to interpret or process the data.” They did acknowledge that a significant drawback of the molecular contrast agent was its lack of penetration into the lung parenchyma.

“New molecular tools are emerging to identify lung adenocarcinomas during pulmonary resection,” Dr. Okusanya and colleagues said. “This technology will permit precise visualization of tumor margins, localization of small malignant ground-glass opacities, and accurate selection of lymph nodes with metastatic cancer cells. With miniaturization of imaging devices, this method will be particularly useful in minimally invasive surgery.”

The pilot clinical trial was partially supported by grant from the Biomedical Laboratory Research & Development Service of the Veterans Affairs Office of Research and Development and by the CHEST Foundation One Breath Clinical Research Award (SS).

Dr. Shuming Nie is a coauthor and a consultant for Spectropath, a start-up company that is developing advanced instrumentation and nanoparticle contrast agents. Dr. Philip S. Low is a coauthor and a consultant and stakeholder in OnTarget Laboratories. None of the other coauthors had any relationships to disclose.

When performing on-pump coronary artery bypass grafting (CABG), cardiac surgeons can control very few factors to reduce the risk of stroke – with the exception of which method of aortic manipulation they use. Debate and controversy, however, have surrounded which aortic manipulation technique is best: single- or double-clamp occlusion.

A large retrospective study of almost 8,500 patients who had CABG at the Mayo Clinic in Rochester, Minn., over a 17-year period showed that, while use of the single-aortic cross-clamp (SC) technique steadily increased, the risk of stroke is virtually the same as it is with the partial aortic cross-clamp (PC), or double cross-clamp, technique. The study authors, led by Dr. Juan C. Araque, published their results online in the Journal of Thoracic and Cardiovascular Surgery (J. Thorac. Cardiovasc. Surg. 2015 [doi:10.1016/j.jtcvs.2015.04.010]).

“It is intuitive that less aortic manipulation would result in less risk of stroke,” Dr. Araque and colleagues said, but even off-pump CABG, which requires no aortic manipulation, is not without stroke risk.

“It is conceivable that there is some inherent risk of stroke associated with any cardiac operation, and that risk may increase with manipulation of the ascending aortic with the aortic cross clamp,” they wrote. “Our data would suggest, however, that the risk does not increase further with the additional aortic manipulation of the partial occlusion clamp.”

The study comes on the heels of a 2008 meta-analysis that found no benefit of SC in comparison to PC (Interact. Cardiovasc. Thorac. Surg. 2008;7:500-3), while another study in 2011 suggested that less aortic manipulation carried a significantly lower stroke risk (Heart Lung Circ. 2011;20:318-24).

The Mayo study evaluated the SC technique in 2,051 patients and PC in 6,446 patients who had isolated on-pump CABG between 1993 and 2010. The rate of stroke was 1.2% in the SC group and 1.5% among those who had PC. In two propensity-matched cohorts of 1,333 patients each, the stroke rate was 1.2% in each group. The investigators used the Society of Thoracic Surgeons’ risk calculator variables to create the propensity-matched cohorts.

The study group excluded high-risk patients, including those who had off-pump operations or previous cardiac surgeries or required replacement of a cross clamp during an unplanned operation.

The goal of the study was not to compare outcomes with the off-pump technique. “It is only to bring attention to the associated non-zero stroke rate with both techniques,” Dr. Araque and colleagues said.

Their findings are significant because on-pump CABG is the preferred operation of cardiac surgeons, accounting for more than 80% of the CABG operations in the SYNTAX study (N. Engl. J. Med. 2009;360:961-72). “The ‘anaortic’ off-pump technique may be a more specialized technique, representing less than 15% of operations in one large series,” Dr. Araque and coauthors said.

They acknowledged a few limitations resulting from the observational nature of the study, including that surgeons may have missed some strokes because they did not use a routine, standardized procedure for evaluating stroke signs along with the lack of documented assessment of the descending aorta. But they also stated that the large number of patients in the study, along with the use of propensity matching, addresses some of the bias inherent in an observational study.

The study authors disclosed no relationships.

When performing on-pump coronary artery bypass grafting (CABG), cardiac surgeons can control very few factors to reduce the risk of stroke – with the exception of which method of aortic manipulation they use. Debate and controversy, however, have surrounded which aortic manipulation technique is best: single- or double-clamp occlusion.

A large retrospective study of almost 8,500 patients who had CABG at the Mayo Clinic in Rochester, Minn., over a 17-year period showed that, while use of the single-aortic cross-clamp (SC) technique steadily increased, the risk of stroke is virtually the same as it is with the partial aortic cross-clamp (PC), or double cross-clamp, technique. The study authors, led by Dr. Juan C. Araque, published their results online in the Journal of Thoracic and Cardiovascular Surgery (J. Thorac. Cardiovasc. Surg. 2015 [doi:10.1016/j.jtcvs.2015.04.010]).

“It is intuitive that less aortic manipulation would result in less risk of stroke,” Dr. Araque and colleagues said, but even off-pump CABG, which requires no aortic manipulation, is not without stroke risk.

“It is conceivable that there is some inherent risk of stroke associated with any cardiac operation, and that risk may increase with manipulation of the ascending aortic with the aortic cross clamp,” they wrote. “Our data would suggest, however, that the risk does not increase further with the additional aortic manipulation of the partial occlusion clamp.”

The study comes on the heels of a 2008 meta-analysis that found no benefit of SC in comparison to PC (Interact. Cardiovasc. Thorac. Surg. 2008;7:500-3), while another study in 2011 suggested that less aortic manipulation carried a significantly lower stroke risk (Heart Lung Circ. 2011;20:318-24).

The Mayo study evaluated the SC technique in 2,051 patients and PC in 6,446 patients who had isolated on-pump CABG between 1993 and 2010. The rate of stroke was 1.2% in the SC group and 1.5% among those who had PC. In two propensity-matched cohorts of 1,333 patients each, the stroke rate was 1.2% in each group. The investigators used the Society of Thoracic Surgeons’ risk calculator variables to create the propensity-matched cohorts.

The study group excluded high-risk patients, including those who had off-pump operations or previous cardiac surgeries or required replacement of a cross clamp during an unplanned operation.

The goal of the study was not to compare outcomes with the off-pump technique. “It is only to bring attention to the associated non-zero stroke rate with both techniques,” Dr. Araque and colleagues said.

Their findings are significant because on-pump CABG is the preferred operation of cardiac surgeons, accounting for more than 80% of the CABG operations in the SYNTAX study (N. Engl. J. Med. 2009;360:961-72). “The ‘anaortic’ off-pump technique may be a more specialized technique, representing less than 15% of operations in one large series,” Dr. Araque and coauthors said.

They acknowledged a few limitations resulting from the observational nature of the study, including that surgeons may have missed some strokes because they did not use a routine, standardized procedure for evaluating stroke signs along with the lack of documented assessment of the descending aorta. But they also stated that the large number of patients in the study, along with the use of propensity matching, addresses some of the bias inherent in an observational study.

The study authors disclosed no relationships.

When performing on-pump coronary artery bypass grafting (CABG), cardiac surgeons can control very few factors to reduce the risk of stroke – with the exception of which method of aortic manipulation they use. Debate and controversy, however, have surrounded which aortic manipulation technique is best: single- or double-clamp occlusion.

A large retrospective study of almost 8,500 patients who had CABG at the Mayo Clinic in Rochester, Minn., over a 17-year period showed that, while use of the single-aortic cross-clamp (SC) technique steadily increased, the risk of stroke is virtually the same as it is with the partial aortic cross-clamp (PC), or double cross-clamp, technique. The study authors, led by Dr. Juan C. Araque, published their results online in the Journal of Thoracic and Cardiovascular Surgery (J. Thorac. Cardiovasc. Surg. 2015 [doi:10.1016/j.jtcvs.2015.04.010]).

“It is intuitive that less aortic manipulation would result in less risk of stroke,” Dr. Araque and colleagues said, but even off-pump CABG, which requires no aortic manipulation, is not without stroke risk.

“It is conceivable that there is some inherent risk of stroke associated with any cardiac operation, and that risk may increase with manipulation of the ascending aortic with the aortic cross clamp,” they wrote. “Our data would suggest, however, that the risk does not increase further with the additional aortic manipulation of the partial occlusion clamp.”

The study comes on the heels of a 2008 meta-analysis that found no benefit of SC in comparison to PC (Interact. Cardiovasc. Thorac. Surg. 2008;7:500-3), while another study in 2011 suggested that less aortic manipulation carried a significantly lower stroke risk (Heart Lung Circ. 2011;20:318-24).

The Mayo study evaluated the SC technique in 2,051 patients and PC in 6,446 patients who had isolated on-pump CABG between 1993 and 2010. The rate of stroke was 1.2% in the SC group and 1.5% among those who had PC. In two propensity-matched cohorts of 1,333 patients each, the stroke rate was 1.2% in each group. The investigators used the Society of Thoracic Surgeons’ risk calculator variables to create the propensity-matched cohorts.

The study group excluded high-risk patients, including those who had off-pump operations or previous cardiac surgeries or required replacement of a cross clamp during an unplanned operation.

The goal of the study was not to compare outcomes with the off-pump technique. “It is only to bring attention to the associated non-zero stroke rate with both techniques,” Dr. Araque and colleagues said.

Their findings are significant because on-pump CABG is the preferred operation of cardiac surgeons, accounting for more than 80% of the CABG operations in the SYNTAX study (N. Engl. J. Med. 2009;360:961-72). “The ‘anaortic’ off-pump technique may be a more specialized technique, representing less than 15% of operations in one large series,” Dr. Araque and coauthors said.

They acknowledged a few limitations resulting from the observational nature of the study, including that surgeons may have missed some strokes because they did not use a routine, standardized procedure for evaluating stroke signs along with the lack of documented assessment of the descending aorta. But they also stated that the large number of patients in the study, along with the use of propensity matching, addresses some of the bias inherent in an observational study.

The study authors disclosed no relationships.