OBJECTIVES:Compare oncologic outcomes between single-segment and multi-segment resections in patients with clinical stage IA1 and IA2 non-small-cell lung cancer. METHODS:A retrospective review (2011-2022) was conducted using a prospectively maintained database. Patients undergoing anatomical segmentectomy for clinical stage IA ≤2 cm non-small-cell lung cancers were included. Patients were grouped into single-segment and multi-segment resections. Patients were excluded if they had neuroendocrine tumours, small-cell lung cancer, underwent wedge resection or lobectomy. The primary outcome was locoregional recurrence. Secondary outcomes of disease-free survival, locoregional recurrence-free survival, overall survival, pathologic upstaging and perioperative complications were evaluated. RESULTS:One hundred ninety (63.8%) patients had single-segment resection and 108 (36.2%) had multi-segment resection. The single-segment resection group had smaller tumours (1.3 vs 1.45 cm, P = 0.02), but no significant difference in margin length (1.7 vs 2 cm, P = 0.15). Fewer lymph nodes were resected in single-segment resection (7 vs 10, P < 0.001), and a significantly lower rate of pathologic upstaging (4.2% vs 10.2%, P = 0.03) was observed compared with multi-segment resection. Nevertheless, locoregional recurrence developed in 6.3% of patients after single-segment resection and 7.4% patients following multi-segment resection (P = 0.72). With a median follow-up duration of 40 months, 5-year disease-free survival, locoregional recurrence-free survival and overall survival was 73, 89 and 87% following single-segment resection compared to 78, 95 and 84% after multi-segment resection. CONCLUSIONS:For patients with clinical stage IA non-small cell lung cancers ≤2 cm, locoregional recurrence and survival are not different based on whether patients receive a single-segment or multi-segment resection.

OBJECTIVE:Chat-based artificial intelligence programs like ChatGPT are reimagining how patients seek information. This study aims to evaluate the quality and accuracy of ChatGPT-generated answers to common patient questions about lung cancer surgery. METHODS:A 30-question survey of patient questions about lung cancer surgery was posed to ChatGPT in July 2023. The ChatGPT-generated responses were presented to 9 thoracic surgeons at 4 academic institutions who rated the quality of the answer on a 5-point Likert scale. They also evaluated if the response contained any inaccuracies and were prompted to submit free text comments. Responses were analyzed in aggregate. RESULTS:For ChatGPT-generated answers, the average quality ranged from 3.1 to 4.2 of 5.0, indicating they were generally "good" or "very good." No answer received a unanimous 1-star (poor quality) or 5-star (excellent quality) score. Minor inaccuracies were found by at least 1 surgeon in 100% of the answers, and major inaccuracies were found in 36.6%. Regarding ChatGPT, 66.7% of surgeons thought it was an accurate source of information for patients. However, only 55.6% thought they were comparable with answers given by experienced thoracic surgeons, and only 44.4% would recommend it to their patients. Common criticisms of ChatGPT-generated answers included lengthiness, lack of specificity regarding surgical care, and lack of references. CONCLUSIONS:Chat-based artificial intelligence programs have potential to become a useful information tool for patients with lung cancer surgery. However, the quality and accuracy of ChatGPT-generated answers need improvement before thoracic surgeons would consider this method as a primary education source for patients.

Background:Long-standing controversy has existed over whether sublobar resection is an adequate oncological procedure for clinical stage IA non-small cell lung cancer (NSCLC) ≤2 cm, despite the recent randomized trial reports of Japanese Clinical Oncology Group (JCOG) 0802 and Cancer and Leukemia Group B (CALGB) 140503 demonstrating non-inferior outcomes with sublobar resection compared to lobectomy. As practice patterns shift, we sought to compare oncologic outcomes in patients with these early-stage tumors after wedge resection, segmentectomy, or lobectomy in a contemporary, real-world, cohort. Methods:A retrospective review of a prospectively maintained database from a single institution was conducted from 2011 to 2020 to identify all patients with clinically staged IA1 or IA2 NSCLC (tumors ≤2 cm with no nodal involvement). The primary outcomes of interest were overall survival (OS) and disease-free survival (DFS), with secondary outcomes of lung cancer-specific survival (LCSS), recurrence patterns, and perioperative morbidity and mortality. Results:A total of 480 patients were identified; 93 (19.4%) patients underwent wedge resection, 90 (18.7%) received segmentectomy, and 297 (61.9%) underwent lobectomy. Patients who underwent wedge resection had worse Eastern Cooperative Oncology Group (ECOG) performance status (23.7% ECOG 1 or 2 vs. 5.6% among segmentectomy and 5.4% among lobectomy, P<0.05). Both wedge resection and segmentectomy patients had lower preoperative mean percentage of predicted forced expiratory volume in one second (%FEV1) compared to the lobectomy group (81.8% and 82.6% vs. 89.6%, P=0.002), a higher proportion of patients with chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD), and a higher Charlson Comorbidity Index. There were no statistically significant differences in 5-year OS, DFS, or LCSS between groups: 90%, 61%, 78% for wedge resections compared with 85%, 75%, 86% for segmentectomy, and 87%, 77%, 87% for lobectomy, respectively. Recurrence was observed in 17 patients who underwent wedge resection (18.3%, 8 local, 9 distant), 12 patients who received segmentectomy (13.4%, 6 local, 6 distant), and 38 patients who underwent lobectomy (12.8%, 11 local, 27 distant), which was not significantly different (P=0.36). Conclusions:Patients with inferior performance status or lower baseline pulmonary function are more likely to receive wedge resection for clinical stage IA NSCLC ≤2 cm in size. For these small tumors, lobectomy, segmentectomy, and wedge resection provide comparable oncologic outcomes.

Introduction Currently, there is no mandatory standard for reporting race and ethnicity in medical journals, presenting significant barriers to studying disparities in medical outcomes. We seek to investigate whether greater recent awareness of diversity and inclusion reflects in reporting of race and ethnicity by peer-reviewed cardiothoracic articles. Methods Pubmed was queried for clinical outcomes articles published from January 2017 to June 2023 in the Journal of Thoracic and Cardiovascular Surgery, Annals of Thoracic Surgery, Journal of Heart and Lung Transplantation, and CHEST Journal. Basic science, translational studies, and international studies were excluded. SAS Studio was used for statistical analysis. Results 817 papers were reviewed, 378 reported race/ethnicity with 354 (93%) reporting White, 267 (71%) reporting Black, 128 (34%) reporting Hispanic, and 119 (31%) reporting Asian. Over 8-y, there were no statistically significant changes in percent of articles that included White (odds ratio 0.808 95% confidence interval [0.624-1.047], P = 0.1068), Black (1.125 [0.984-1.288], P = 0.0857), or Asian (1.096 [0.960-1.250], P = 0.1751) groups. Hispanics were more likely to be reported in recent years (1.147 [1.006-1.307], P = 0.0397). Subset analysis was performed on cardiac (n = 157) and thoracic articles (n = 157) with no significant trends for race reporting in these subsets. Conclusions Minorities remain underrepresented in reported patient populations in peer-reviewed cardiothoracic journals. Future efforts should prioritize accurately representing these populations in the literature. Inaccurate data and exclusion of minority populations can contribute to disparities observed in overall outcomes.

Background:Robotic-assisted thoracoscopic surgery (RATS) is widely accepted for small-to-moderate-size thymomas. However, limited data exists comparing the feasibility of RATS for large tumors ≥5 cm. The aim of this study is to compare the oncological and perioperative outcomes of open thymectomy (OT) versus RATS for these larger tumors. Methods:The National Cancer Database (2010-2020) was queried for patients who underwent RATS and OT. Patients were excluded if they had thymic carcinoma, neoadjuvant therapy, tumors <5 cm, and underwent a video-assisted thoracoscopic approach. The primary outcome was overall survival (OS). Secondary outcomes included length of stay (LOS), 30-day readmission, and mortality rates. Survival outcomes were estimated using the Kaplan-Meier estimator and compared using log-rank test. Propensity score-matched analysis was performed (1:1, Caliper 0.2 without replacement), controlling for age, race, facility type, tumor size, comorbidity index, and year of diagnosis. Results:Of the 1,178 patients identified, 1,015 (86.2%) underwent OT, and 163 (13.8%) underwent RATS. RATS cases were more likely to be performed in academic centers and have a smaller median tumor size compared to OT cases. In the matched cohort, there was no difference between the groups' 30-day readmission, 30-day and 90-day mortality rates. RATS patients had a shorter median LOS compared to OT patients. The median follow-up time was 76 months; 5-year OS was 88% after OT and 90% after RATS (P=0.23). On multivariable Cox regression analysis, the surgical approach was not a predictor of worse survival. Conclusions:Patients who underwent RATS for tumors ≥5 cm had equivalent survival and perioperative outcomes compared to OT with a shorter LOS.

BACKGROUND:Recent randomized trials have shown equivalent survival after sublobar resection vs lobectomy in patients with clinical stage IA non-small cell lung cancer (NSCLC) ≤2 cm. High maximum standard uptake value (SUVmax) is a known risk factor in NSCLC, yet limited data exist on whether a high SUV should preclude a sublobar resection. This study aimed to determine whether there is an association between SUVmax and survival based on the extent of parenchymal resection. METHODS:A retrospective review of a prospectively maintained institutional database was conducted to identify patients with clinical stage IA NSCLC ≤2 cm (2011-2020) treated with sublobar resection or lobectomy. The primary outcome was cancer-specific survival (CSS). Secondary outcomes were overall survival and disease-free survival. RESULTS:There were 543 patients identified; 36.8% had sublobar resection and 63.2% had lobectomy. Baseline characteristics were similar. Patients who had sublobar resection had significantly worse Eastern Cooperative Oncology Group performance status and higher rates of comorbidities. The 5-year CSS, overall survival, and disease-free survival for the whole cohort were similar between sublobar resection and lobectomy. A receiver operating characteristic curve estimated the SUVmax cutoff point to be 4.15. For the whole cohort, patients with SUVmax >4.15 had worse CSS compared with SUVmax ≤4.15. However, there was no significant difference in 5-year CSS after sublobar resection vs lobectomy in patients with SUVmax ≤4.15 (98% in both groups; P = .77) or patients with SUVmax >4.15 (90% vs 94%, respectively; P = .12). CONCLUSIONS:SUVmax may not be a useful clinical determinant of the extent of parenchymal resection in patients with cT1 N0 NSCLC ≤2 cm. Patients treated by sublobar resection had comparable survival to lobectomy, irrespective of positron emission tomography avidity.

We previously reported the results of a randomized phase II trial (NCT02904954) in patients with early-stage non-small cell lung cancer (NSCLC) who were treated with either two preoperative cycles of the anti-PD-L1 antibody durvalumab alone or combined with immunomodulatory doses of stereotactic radiation (DRT). The trial met its primary endpoint of major pathological response, which was significantly higher following DRT with no new safety signals. Here, we report on the prespecified secondary endpoint of disease-free survival (DFS) regardless of treatment assignment and the prespecified exploratory analysis of DFS in each arm of the trial. DFS at 2 and 3 years across patients in both arms of the trial were 73% (95% CI: 62.1–84.5) and 65% (95% CI: 52.5–76.9) respectively. For the exploratory endpoint of DFS in each arm of the trial, three-year DFS was 63% (95% CI: 46.0–80.4) in the durvalumab monotherapy arm compared to 67% (95% CI: 49.6–83.4) in the dual therapy arm. In addition, we report post hoc exploratory analysis of progression-free survival as well as molecular correlates of response and recurrence through high-plex immunophenotyping of sequentially collected peripheral blood and gene expression profiles from resected tumors in both treatment arms. Together, our results contribute to the evolving landscape of neoadjuvant treatment regimens for NSCLC and identify easily measurable potential biomarkers of response and recurrence.

The Lung Cancer Study Group previously established lobectomy as the standard of care for treatment of clinical T1N0 NSCLC. Advances in imaging technology and refinements in staging have prompted a re-investigation to determine the non-inferiority of sub-lobar resections to lobectomies. Two recent randomized studies, JCOG 0802 and CALGB 140503, are reviewed here in the context of LCSG 0821. The studies confirm non-inferiority for sub-lobar resection (wedge or segmentectomy) compared to lobectomy for peripheral T1N0 NSCLC less than or equal to 2 cm. Sub-lobar resection should therefore be considered the new standard of care in this sub-set of patients with NSCLC.

Objectives:The aim of this study was to explore the potential value of extended nodal-dissection following neoadjuvant chemoradiation (CRT), by analyzing data from the National Cancer Database (NCDB). Background:A CROSS-trial post-hoc analysis showed that the number of dissected lymph nodes was associated with improved survival in patients undergoing upfront surgery but not in those treated with neoadjuvant CRT. Methods:The NCDB was queried (2004-2014) for patients who underwent esophagectomy following induction CRT. Predictors of overall survival (OS) were assessed. The optimal number of dissected LNs associated with highest survival benefit was determined by multiple regression analyses and receiveroperating characteristic curve analysis. The whole cohort was divided into 2 groups based on the predefined cutoff number. The two groups were propensity-matched (PMs). Results:Esophagectomy following induction-CRT was performed in 14,503 patients. The number of resected nodes was associated with improved OS in the multivariable analysis (hazard ratio for every 10 nodes: 0.95 (95% confidence interval: 0.93-0.98). The cutoff number of resected LNs that was associated with the highest survival benefit was 20 nodes. In the PM groups, patients in the ">= 20 LNs" group had a 14% relative-increase in OS (P= 0.002), despite having more advanced pathological stages (stage II-IV: 76% vs 72%, P <0.001), and higher number of positive nodes (0-2 vs 0-1, P < 0.001). Conclusions:The total number of resected nodes is a significant determinant of improved survival following induction CRT in patients with either node negative or node positive disease. In the matched groups, patients with higher number of resected lymph nodes had higher OS rate, despite having more advanced pathological disease and higher number of resected positive lymph nodes.

Objective: Several trials have recently reported the safety of pulmonary resection after neoadjuvant immunotherapy with encouraging major pathological response rates. We report the detailed adverse events profile from a recently conducted ran-domized phase II trial in patients with resectable non-small cell lung cancer treated with neoadjuvant durvalumab alone or with sub-ablative radiation.Methods: We conducted a randomized phase II trial in patients with non-small cell lung cancer clinical stages I to IIIA who were randomly assigned to receive neoad-juvant durvalumab alone or with sub-ablative radiation (8Gyx3). Secondary end points included the safety of 2 cycles of preoperative durvalumab with and without radiation followed by pulmonary resection. Postoperative adverse events within 30 days were recorded according to the National Cancer Institute Common Termi-nology Criteria for Adverse Events (version 4.0).Results: Sixty patients were enrolled and randomly assigned, with planned resection performed in 26 patients in each arm. Baseline demographics and clinical variables were balanced between groups. The median operative time was similar between arms: 128 minutes (97-201) versus 146 minutes (109-214) (P = .314). There was no 30-or 90-day mortality. Grade 3/4 adverse events occurred in 10 of 26 patients (38%) after monotherapy and in 10 of 26 patients (38%) after dual therapy. Anemia requiring transfusion and hypotension were the 2 most common adverse events. The median length of stay was similar between arms (5 days vs 4 days, P = .172).Conclusions: In this randomized trial, the addition of sub-ablative focal radiation to durvalumab in the neoadjuvant setting was not associated with increased mortality or morbidity compared with neoadjuvant durvalumab alone.

OBJECTIVE:The aim was to determine the prevalence of metastases to the cervical and recurrent laryngeal cervicothoracic (CT) nodes as well as survival and recurrence patterns after esophagectomy with three-field lymph node dissection (TFD) in patients with predominately adenocarcinoma (AC) of the esophagus.BACKGROUND:Although esophagectomy with TFD is commonly practiced in Japan and Southeast Asia for squamous cell cancer (SCC) of the esophagus, there are only a handful of reports about its' utilization and survival benefit in North American patients.METHODS:This is a retrospective case series of patients who had an esophagectomy with TFD. The primary outcomes of interest were the prevalence of nodal metastases to the CT nodes as well as overall survival (OS) and disease-free survival. Secondary outcomes included time to recurrence, recurrence patterns, operative morbidity as well as 30 and 90-day mortality.RESULTS:Two hundred forty-two patients with esophageal cancer (AC: 67%) underwent esophagectomy with TFD. Metastases to the CT nodes were present in 56 patients (23%: AC 20% and SCC 30%). Positive CT nodes were present in 14% of pT1/T2 tumors and 30% of pT3 tumors. For the 56 patients with CT positive nodes, 5-year OS was 25% (AC:16%; SCC:39%). Fifteen of 56 (26.7%) patients with metastases to the CT nodes were alive and disease-free at a minimum of 5 years postoperatively. Ten-year OS was 43% for all patients with SCC and 28% for patients with AC.CONCLUSIONS:Metastases to the CT nodes are common in both SCC and AC of the esophagus and may be present in at least 14% of early lesions. Five-year survival is encouraging particularly for patients with esophageal SCC cancer.

Background: Over the past several decades, there has been an apparent improvement in survival of patients with stage IIIA-N2 non-small cell lung cancer (NSCLC). Positron emission tomography (PET)-scanning for NSCLC staging/restaging was approved by the Centers of Medicare and Medicaid Services (CMS) in 2001. We sought to determine whether this survival improvement was due to more sensitive staging-modalities and/or an evolution in surgical practice. Methods: The Surveillance, Epidemiology, and End Results Program (SEER) database was queried [1988-2013] to identify patients with N2M0/1-NSCLC. Comparisons were made between two time periods defined by the time PET approval was granted by CMS: period-1 (P1) from 1988-2001 and period-2 (P2) from 2002-2013. Patients treated surgically (1988-2001 vs. 2002-2013) were propensity matched. Results: This study included 224,295 patients with N2-M0/M1 NSCLC. The 5-, 10-year overall survival (OS) was 4.8%, 2.2% in P1 (median OS 6 months, 95% CI: 5.9-6.1 months), and 6.7%, 3.2% in P2 (median OS 6 months, 95% CI: 6-6.1 months). There was a significant increase in the incidence of M1 disease in P2 compared to P1 (63% vs. 55%, P<0.001); 54,070 patients had T0-3N2M0 and their OS was significantly better in P2 (5-year OS rate: 16.3%, median OS: 15 months, 95% CI: 14.8-15.2 months), compared to P1 (5-year OS rate: 11.8%, median OS: 12 months, 95% CI: 11.7-12.3 months) (P<0.001). Survival was significantly better in P2 regardless of treatment modality. In patients undergoing surgical resection, there was a significant increased use of lobectomy (69% vs. 76.5%) and a decreased use of pneumonectomy (19% vs. 10%). Significantly more total lymph nodes were resected in P2 vs. P1 (9 vs. 7, P<0.001). In the matched cohorts, 5-year OS was significantly improved in P2 (5-year OS rate: 34%, median OS: 34 months, 95% CI: 31.7-36.3 months) compared to P1 (5-year OS rate: 24%, median OS: 23 months, 95% CI: 21.7-24.3 months) (P<0.001). Conclusions: The main driver of the significant improvement in survival of cT0-3N2M0-NSCLC patients over the last 25 years was improved clinical-staging with increased PET utilization. Survival-improvements might also be credited to surgical-practices evolution.

Objective: Sublobar resection is frequently offered to patients with small, peripheral lung cancers, despite the lack of outcome data from ongoing randomized clinical trials. Sublobar resection may be a particularly attractive surgical strategy for screen-detected lung cancers, which have been suggested to be less biologically aggressive than cancers detected by other means. Using prospective data collected from patients undergoing surgery in the National Lung Screening Trial, we sought to determine whether extent of resection affected survival for patients with screen-detected lung cancer. Methods: The National Lung Screening Trial database was queried for patients who underwent surgical resection for confirmed lung cancer. Propensity score matching analysis (lobectomy vs sublobar resection) was done (nearest neighbor, 1:1, matching with no replacement, caliper 0.2). Demographics, clinicopathologic and perioperative outcomes, and long-term survival were compared in the entire cohort and in the propensity-matched groups. Multivariable logistic regression analysis was done to identify factors associated with increased postoperative morbidity or mortality. Results: We identified 1029 patients who underwent resection for lung cancer in the National Lung Screening Trial, including 821 patients (80%) who had lobectomy and 166 patients (16%) who had sublobar resection, predominantly wedge resection (n = 114, 69% of sublobar resection). Patients who underwent sublobar resection were more likely to be female (53% vs 41%, P = .004) and had smaller tumors (1.5 cm vs 2 cm, P < .001). The sublobar resection group had fewer postoperative complications (22% vs 32%, P = .010) and fewer cardiac complications (4% vs 9%, P = .033). For stage I patients undergoing sublobar resection, there was no difference in 5-year overall survival (77% for both groups, P = .89) or cancer-specific survival (83% for both groups, P = .96) compared with patients undergoing lobectomy. On multivariable logistic regression analysis, sublobar resection was the only factor associated with lower postoperative morbidity/mortality (odds ratio, 0.63; 95% confidence interval, 0.40-0.98). To compare surgical strategies in balanced patient populations, we propensity matched 127 patients from each group undergoing sublobar resection and lobectomy. There were no differences in demographics or clinical and tumor characteristics among matched groups. There was again no difference in 5-year overall survival (71% vs 65%, P = .40) or cancer-specific survival (75% vs 73%, P = .89) for patients undergoing lobectomy and sublobar resection, respectively. Conclusions: For patients with screen-detected lung cancer, sublobar resection confers survival similar to lobectomy. By decreasing perioperative complications and potentially preserving lung function, sublobar resection may provide distinct advantages in a screened patient cohort.

BACKGROUND Minimal literature exists evaluating the impact of the extent of resection on survival in patients with small, early-stage non-small cell lung cancer (NSCLC) found to have occult nodal disease. We hypothesized that sublobar resection has comparable overall survival to patients undergoing lobectomy for clinical stage IA NSCLC that harbors occult nodal disease.METHODS The National Cancer Database was reviewed for identification of patients with clinical stage IA NSCLC who underwent wedge resection, segmentectomy, or lobectomy and were found to have occult nodal disease. Overall survival was compared between groups, and a multivariate Cox regression model identified factors associated with worse survival.RESULTS Occult nodal disease occurred in 6.1% of all patients with clinical stage IA disease undergoing resection. Patients undergoing wedge resection and segmentectomy found to have occult nodal disease were older (67.6 +/- 9.6 years of age vs 66.1 +/- 9.3 years of age vs 65.6 +/- 9.5 years of age; P = .004) and had more advanced pathologic stage (pStage III: 68.7% vs 50.5% vs 41.5%; P < .001) than those receiving lobectomy. There was no difference in the median overall survival between segmentectomy and lobectomy (68.5 months vs 57.6 months; P = .200). However, wedge resection was independently associated with worse overall survival when controlling for other preoperative variables (hazard ratio, 1.23; 95% confidence interval, 1.01-1.51; P = .042).CONCLUSIONS Review of the National Cancer Database suggests that there is no improvement in overall survival in patients undergoing lobectomy vs segmentectomy in carefully selected patients with clinical stage IA NSCLC harboring occult nodal disease. However, those undergoing wedge resection may have worse overall survival than those un-dergoing both lobectomy and segmentectomy.

Introduction: The COVID-19 pandemic reached New York City in early March 2020 resulting in an 11-week lockdown period to mitigate further spread. It has been well documented that cancer care was drastically affected as a result. Given New York City's early involvement, we attempted to identify any stage shift that may have occurred in the diagnoses of non-small cell lung cancer (NSCLC) at our institution as a result of these lockdowns. Patients and Methods: We conducted a retrospective review of a prospective database of lung cancer patients at our institution from July 1, 2019 until March 31, 2021. Patients were grouped by calendar year quarter in which they received care. Basic demographics and clinical staging were compared across quarters. Results: Five hundred and fifty four patients were identified that underwent treatment during the time period of interest. During the lockdown period, there was a 50% reduction in the mean number of patients seen (15 +/- 3 vs. 28 +/- 7, P = .004). In the quarter following easing of restrictions, there was a significant trend towards earlier stage (cStage I/II) disease. In comparison to quarters preceding the pandemic lockdown, there was a significant increase in the proportion of patients with Stage IV disease in the quarters following phased reopening (P = .026). Conclusion: After a transient but significant increase in Stage I/II disease with easing of restrictions there was a significant increase in patients with Stage IV disease. Extended longitudinal studies must be conducted to determine whether COVID-19 lockdowns will lead to further increases in the proportion of patients with advanced NSCLC. (C) 2021 Elsevier Inc. All rights reserved.