As a powerful, objective marker of frailty, 4-m gait speed (4MGS) can predict morbidity and mortality in various populations including cardiac surgery and oncology patients. Its role in thoracic surgery is understudied. This study aimed to evaluate associations between preoperative 4MGS and outcomes after pulmonary resection. A cohort study analyzed patients undergoing pulmonary resections at a high-volume surgical center from January 2021 to October 2023. Preoperative 4MGS was prospectively collected by medical assistants as part of routine vital sign assessments in clinic. Uni- and multivariable analyses were performed to evaluate the associations of preoperative 4MGS with postoperative length of stay, adverse events, and discharge disposition, controlling for lung function (FEV1), extent of resection, comorbidity, and other covariates. Overall, 401 patients were included (median age, 69 years; interquartile range, 61–75 years): 123 (31

Background Unsuspected (defined here as occult) N2-positive lung cancer impacts overall survival (OS), and treatment patterns likely influence outcomes. We aimed to evaluate factors that could improve the long-term outcomes of patients with occult N2 disease compared to biopsy-proven, pre-resectional N2 disease. Methods Our institutional prospective database was queried for N2 non–small cell lung cancer (NSCLC) at presentation (biopsy-proven) prior to surgical resection or postoperatively diagnosed N2 (occult N2), excluding stage IV disease or patients with insufficient follow-up. In occult N2 group, postoperative therapy was stratified into complete (≥3 cycles), incomplete (1-2 cycles), or no adjuvant treatment. Propensity score weighting adjusted for age, comorbidities, tumor size, and N2 involvement. Kaplan-Meier analysis assessed 5-year overalls survival (OS). Results Between 2006-2023, 483 patients met inclusion criteria, stratified into 325 patients (67.2%) with biopsy-proven N2 and 158 (32.8%) with occult N2. The biopsy-proven N2 group primarily received neoadjuvant therapy (chemo/chemoimmunotherapy ± radiation). In the occult N2 group, 86 patients (54.4%) received full-dose adjuvant therapy, 31 (19.6%) received incomplete adjuvant therapy, and 41 (26%) received no adjuvant therapy. After propensity score weighting, the occult N2 group had significantly lower OS (P = .03); however, when the cohort was stratified by completeness of adjuvant treatment, those who received full adjuvant therapy had OS comparable to that of the biopsy-proven group (hazard ratio [HR], 0.98; 95% confidence interval [CI], 0.65-1.48; P = .9). Incomplete therapy provided some survival benefits but was associated with worse OS compared to complete therapy (HR, 1.54; 95% CI, 0.9-2.6; P = .1). The no-therapy group had the lowest OS. Conclusions Patients with occult N2 treated with adjuvant treatment may achieve improved survival rates compared to those not fully treated. Neoadjuvant treatment is optimal to ensure delivery of therapy as prescribed, and thus every effort should be made to identify N2 disease prior to resection.

Central Picture Legend: Incision in the 5th right intercostal space used to perform uniportal VATS lobectomy.Central Message: Lobectomy via uniportal video-assisted thoracoscopic surgery (U-VATS) allows a fast recovery with fewer complications.Standardized approaches to U-VATS facilitate learning and promote better outcomes.

Objective: To evaluate the impact of empiric tissue flaps on bronchopleural fistula (BPF) rates after pneumonectomy. Methods: Patients who underwent pneumonectomy between January 2001 and December 2019 were included. Primary end point was development of BPF. Secondary end points were impact of flap type on BPF rates, time to BPF development, and perioperative mortality. Results: During the study period, 383 pneumonectomies were performed; 93 were extrapleural pneumonectomy. Most pneumonectomy cases had empiric flap coverage, with greater use in right -sided operations (right: 97%, 154/159; left: 80%, 179/224, P < .001). Empiric flaps harvested included intercostal, latissimus dorsi, serratus anterior, omentum, pectoralis major, pericardial fat/thymus, pericardium, and pleura. BPF occurred in 10.4% of the entire cohort but decreased to 6.6% when extrapleural pneumonectomy cases were excluded; 90% (36/40) of BPFs occurred on the right side (P < .001). Median time to develop BPF was 63 days, and 90 -day mortality was greater in patients with BPF (12.5% BPF vs 7.4% non-BPF, P < .0001). Intercostal muscle had the lowest rate of BPF (4.5%), even in right -sided operations (8.7%). In contrast, larger muscle flaps such as latissimus dorsi (21%) and serratus anterior (33%) had greater rates of BPF, but the sample size was small in these cohorts. Conclusions: Empiric bronchial stump coverage should be performed in all right pneumonectomy cases due to greater risk of BPF. In our series, intercostal muscle flaps had low BPF rates, even in right -sided operations. Coverage of the left pneumonectomy stump is unnecessary due to low incidence of BPF in these cases. (J Thorac Cardiovasc Surg 2024;167:849-58)

BACKGROUND Invasive mediastinal staging is a crucial component of the preoperative evaluation for potential surgical candidates with pleural mesothelioma (PM). Endobronchial ultrasound (EBUS) is less invasive than mediastinoscopy for staging, however, its accuracy in PM patients remains undefined. We present our institutional experience with EBUS staging in mesothelioma patients. METHODS Patients with PM who underwent EBUS for mediastinal staging between January 2017 and February 2021 followed by surgical resection were retrospectively reviewed. EBUS cytology was compared to final pathology for corresponding lymph node removed at time of pleurectomy to assess EBUS accuracy. RESULTS During the study period, 91 patients with PM met inclusion criteria. EBUS diagnostic yield was highest at station 7 (84%) and lowest at station 4L (40%). There were 74 patients taken for surgical resection and 41 patients had matching lymph nodes for analysis. In our series, EBUS had a sensitivity of 81%, specificity of 93%, positive predictive value of 90% and negative predictive value of 84%. CONCLUSIONS EBUS is a reasonable alternative to mediastinoscopy for mediastinal staging in mesothelioma patients.

Central MessageSublobar resection is a sound option to treat peripheral GGOs with a low risk of recurrence. Intraoperative pathologic analysis should drive decisions to perform sublobar resection.See Article page 1222. Sublobar resection is a sound option to treat peripheral GGOs with a low risk of recurrence. Intraoperative pathologic analysis should drive decisions to perform sublobar resection. See Article page 1222. Ground-glass opacities (GGOs) are often discovered on computed tomography performed during the workup for other medical issues or through lung cancer screening programs.1Kobayashi Y. Mitsudomi T. Management of ground-glass opacities: should all pulmonary lesions with ground-glass opacity be surgically resected?.Transl Lung Cancer Res. 2013; 2: 354-363PubMed Google Scholar,2Wood D.E. Kazerooni E.A. Baum S.L. Eapen G.A. Ettinger D.S. Hou L. et al.Lung cancer screening, version 3.2018, NCCN clinical practice guidelines in oncology.J Natl Compr Canc Netw. 2018; 16: 412-441Crossref PubMed Scopus (368) Google Scholar GGOs that persist on interval imaging are concerning for early-stage lung cancer.1Kobayashi Y. Mitsudomi T. Management of ground-glass opacities: should all pulmonary lesions with ground-glass opacity be surgically resected?.Transl Lung Cancer Res. 2013; 2: 354-363PubMed Google Scholar, 2Wood D.E. Kazerooni E.A. Baum S.L. Eapen G.A. Ettinger D.S. Hou L. et al.Lung cancer screening, version 3.2018, NCCN clinical practice guidelines in oncology.J Natl Compr Canc Netw. 2018; 16: 412-441Crossref PubMed Scopus (368) Google Scholar, 3Nakata M. Saeki H. Takata I. Segawa Y. Mogami H. Mandai K. et al.Focal ground-glass opacity detected by low-dose helical CT.Chest. 2002; 121: 1464-1467Abstract Full Text Full Text PDF PubMed Scopus (265) Google Scholar In patients who can tolerate surgery, resection of the GGO can provide both a definitive diagnosis and treatment with an extremely high rate of cure. Currently, there is no consensus on the extent of surgical resection needed to treat this type of lung lesion. Last year, midterm survival outcomes were published from the Japanese Clinical Oncology Group 0804 trial of patients with peripheral GGOs treated with sublobar resection. The GGOs in the study participants were 2 cm or less in size and had a consolidation tumor ratio of 0.25 or less.4Suzuki K. Watanabe S. Wakabayashi M. Saji H. Aokage K. Moriya Y. et al.A single-arm study of sublobar resection for ground-glass opacity dominant peripheral lung cancer.J Thorac Cardiovasc Surg. 2022; 163: 289-301Abstract Full Text Full Text PDF PubMed Scopus (112) Google Scholar In this prospective, multicenter trial, 314 patients underwent sublobar resection (258 wedge resections [82%] and 56 segmentectomy [18%]). Recurrence-free survival was 99.7% at 5 years, and overall survival was 99.4%. In the current article by Yoshino and colleagues,5Yoshino I. Moriya Y. Suzuki K. Wakabayashi M. Saji H. Aokage K. et al.Long-term outcome of patients with peripheral ground-glass opacity-dominant lung cancer after sublobar resections.J Thorac Cardiovasc Surg. 2023; 166: 1222-1231.e1Abstract Full Text Full Text PDF Scopus (1) Google Scholar updated survival data, extending to 10 years after surgical resection, are reported from this series. With longer follow-up, the recurrence-free survival was 98.6% and overall survival was 98.5% at 10 years. One patient developed a recurrence at the staple line (0.3%) that was detected 8.3 years after his index segmentectomy. The authors also comment on the prevalence of second lung cancers within the cohort—18 patients (5.8%) were diagnosed with a second lung cancer within 10 years of their initial operation, which was similar to the incidence seen in the Japanese population. Within the surgical community, there is increasing interest in parenchymal-sparing operations, such as segmentectomy or wedge resection, for the treatment of early-stage lung cancer. Although a randomized controlled trial more than 30 years ago found that patients who underwent wedge resection had more loco-regional recurrence than patients who underwent lobectomy, more recent studies suggest that wedge resection yields acceptable outcomes in a clinical climate with detection of smaller tumors, better staging, and an increasingly older patient population with comorbidities.6Kent M. Landreneau R. Mandrekar S. Hillman S. Nichols F. Jones D. et al.Segmentectomy versus wedge resection for non-small cell lung cancer in high-risk operable patients.Ann Thorac Surg. 2013; 96: 1747-1754Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar,7Altorki N.K. Wang X. Wigle D. Gu L. Darling G. Ashrafi A.S. et al.Perioperative mortality and morbidity after sublobar versus lobar resection for early-stage non-small cell lung cancer: post-hoc analysis of an international, randomized, phase 3 trial (CALGB/Alliance 140503).Lancet Respir Med. 2018; 6: 915-924Abstract Full Text Full Text PDF PubMed Scopus (231) Google Scholar This debate on the optimal approach for treatment of early-stage lung cancer is ongoing with the main criticisms of parenchymal-sparing resections being the potential for inadequate oncologic margins and accompanying risk of cancer recurrence.8Altorki N. Wang X. Kozono D. Watt C. Landreneau R. Wigle D. et al.Lobar or Sublobar Resection for Peripheral Stage IA Non-Small-Cell Lung Cancer.N Engl J Med. 2023; 388: 489-498Crossref PubMed Scopus (88) Google Scholar In the Japanese Clinical Oncology Group 0804 multi-institution trial of sublobar resection with wedge resections, in 82% of the participants, there was only 1 documented recurrence in 10 years, suggesting that nonanatomic sublobar resection is a reasonable treatment option for peripheral GGOs less than 2 cm.5Yoshino I. Moriya Y. Suzuki K. Wakabayashi M. Saji H. Aokage K. et al.Long-term outcome of patients with peripheral ground-glass opacity-dominant lung cancer after sublobar resections.J Thorac Cardiovasc Surg. 2023; 166: 1222-1231.e1Abstract Full Text Full Text PDF Scopus (1) Google Scholar One rationale for sublobar resection is preservation of lung parenchyma in the event that future operations become necessary. Patients with lung cancer are at higher risk of developing a second malignancy in their lifetime, although this was not reflected in the incidence of a second lung cancer in this study. Although the type of sublobar resection used was not randomized in this trial, the study reflects real-life decisions that surgeons must make regarding the adequacy of the surgical margins and the need for completion segmentectomy or lobectomy based on intraoperative pathologic assessments. The majority of GGOs treated with sublobar resection in this study were adenocarcinoma in situ, minimally invasive adenocarcinoma, or invasive adenocarcinoma with lepidic growth. Because adenocarcinoma in situ and minimally invasive adenocarcinoma have a low potential for nodal or distant metastasis,9Zha J. Xie D. Xie H. Zhang L. Zhou F. Ying P. et al.Recognition of “aggressive” behavior in “indolent” ground glass opacity and mixed density lesions.J Thorac Dis. 2016; 8: 1460-1468Crossref PubMed Google Scholar,10Cheng Z. Zheng D. Li Y. Li H. Sun Y. Xiang J. et al.Tumor histology predicts mediastinal nodal status and may be used to guide limited lymphadenectomy in patients with clinical stage I non-small cell lung cancer.J Thorac Cardiovasc Surg. 2018; 155: 2648-2656Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar treating these “well-behaved” lesions with wedge resection may be appropriate but not generalizable to solid lesions that may harbor cells with a more aggressive tumor biology. Although prospective trials provide a glimpse of anticipated outcomes after sublobar resection, tumor biology ultimately drives survival and is hard to predict preoperatively. As surgeons, we must continue to provide individualized surgical plans based on intraoperative pathologic analysis to provide the best care for our patients. Long-term outcome of patients with peripheral ground-glass opacity–dominant lung cancer after sublobar resectionsThe Journal of Thoracic and Cardiovascular SurgeryVol. 166Issue 4PreviewThis study aimed to evaluate the long-term prognosis of patients with peripheral small ground-glass opacity–dominant lung cancer after sublobar resection. We have already reported the 5-year safety and efficacy of sublobar resection and report the long-term outcomes after a 10-year follow-up period. Full-Text PDF Open Access

The increased utilization of computed tomography for diagnostic imaging has led to an influx of incidentally discovered pulmonary nodules.Both thoracic surgeons and radiologists are burdened with risk stratifying these lesions for observation versus biopsy or resection.The diagnostic accuracy of percutaneous biopsy is dependent on the lesion's size, density, and anatomic location.Nodules that are not amenable to percutaneous biopsy are often referred to surgeons for excisional biopsy.Certain characteristics make some lesions more difficult to resect than others.Small (<1 cm), partially solid, pure ground glass, and central lesions can be difficult to palpate intraoperatively.These lesions can be challenging to resect with thoracoscopic and robotic assisted approaches due to diminished tactile feedback and smaller incisions.Over the past 30 years, techniques have been developed to assist surgeons in locating these lesions with the use of hook wires, fiducials, dyes, and radiolabeled isotopes.These markers are placed preoperatively but are prone to migration or diffusion.In this chapter a new localization and resection technique, image-guided video assisted thoracoscopic surgery (iVATS) is reviewed.iVATS is an attractive option for both patients and surgeons since the localization procedure and parenchymal resection are performed under a single anesthetic.A detailed description of the iVATS technique, success rate, and common complications are reviewed.For pulmonary nodules that are centered within a defined bronchovascular segment, upfront segmentectomy is a reasonable option for obtaining pathologic diagnosis.Since segmentectomy relies on surgeon knowledge and experience with segmental anatomy, non-palpable lesions can be easily treated with this technique.Pearls and pitfalls of the most common segmental resections are addressed.Despite the refinement of localization techniques, small pulmonary nodules continue to present a diagnostic challenge.Ongoing innovation of new clinical tools has generated promising options for the future.In this chapter, we will review some of the tools undergoing development including computer generated algorithms for nodule risk assessment, liquid biopsy, three-dimensional printing, and superselective segmentectomy.Some technologies are focused on creating non-invasive methods to determine if a nodule is benign or malignant, while others seek to improve localization techniques.All of the described tools will need further validation but will potentially streamline the diagnosis and treatment of pulmonary nodules for future clinical practice.

In appropriately selected patients diaphragm plication improves quality of life by alleviating dyspnea and allowing patients to return to their routine activities. Many plication techniques exist, but the optimal surgical approach remains unclear. We report our experience with a minimally invasive radial diaphragm plication technique. It offers 2 distinct advantages: (1) suture placement avoids the phrenic nerve fibers, allowing for potential nerve recovery, and (2) the interrupted radial sutures improve the distribution of tension along the flaccid muscle and may achieve a more durable repair.

Resections of chest wall malignancies – primary or metastatic – require extensive experience in reconstruction techniques and often the use of prosthetic materials. Significant osseomuscular defects of the hemithorax may require reconstruction with a combination of prostheses. Targets are: a) clear resection margins and b) restoration of normal thoracic shape and functioning. The variety of prostheses is not excessive in hospitals, so novel materials may be utilized to achieve acceptable results. In order to reconstruct a large defect, we used the vertical expandable prosthetic titanium rib system (trade name: VEPTR II by Depuy Synthes Companies J&J). It has never been used before in adult patients as it is designed for correction of chest deformities in children and adolescents [1]. Hereinafter we describe our experience with VEPTR.

Background While the optimal treatment for primary spontaneous pneumothorax remains unclear, mechanical pleurodesis is a well-established treatment. The Pleurabrade is a spiral brush designed for mechanical pleurodesis during thoracoscopy. We present two patients who underwent mechanical pleurodesis with the Pleurabrade. Case Description Two patients with spontaneous pneumothorax underwent operative intervention including mechanical pleurodesis with the Pleurabrade. Chest tubes were removed within 48 hours postoperatively and they were discharged home. Both patients remain recurrence free at 11 and 22 months, respectively. Conclusion While further testing is needed, these case reports and operative video highlight the Pleurabrade as an efficient device for thoracoscopic mechanical pleurodesis.

Central MessageAs long-term survival from mesothelioma improves with aggressive multimodality treatment, we anticipate a shift in the recurrence pattern from local to distant sites of failure.See Commentaries on pages 361, 363, and 365. As long-term survival from mesothelioma improves with aggressive multimodality treatment, we anticipate a shift in the recurrence pattern from local to distant sites of failure. See Commentaries on pages 361, 363, and 365. Mesothelioma is a rare but aggressive malignancy, previously thought to only spread through local invasion.1Falconieri G. Grandi G. DiBonito L. Bonifacio-Gori D. Giarelli L. Intracranial metastases from malignant pleural mesothelioma. Report of three autopsy cases and review of the literature.Arch Pathol Lab Med. 1991; 115: 591-595PubMed Google Scholar,2Miller A.C. Miettinen M. Schrump D.S. Hassan R. Malignant mesothelioma and central nervous system metastases. Report of two cases, pooled analysis, and systematic review.Ann Am Thorac Soc. 2014; 11: 1075-1081Crossref PubMed Scopus (8) Google Scholar However, autopsy studies identified distant metastases in 54% of cases, with intracranial lesions representing only 3% of patients.1Falconieri G. Grandi G. DiBonito L. Bonifacio-Gori D. Giarelli L. Intracranial metastases from malignant pleural mesothelioma. Report of three autopsy cases and review of the literature.Arch Pathol Lab Med. 1991; 115: 591-595PubMed Google Scholar Due to the low incidence of intracranial metastasis, there is no consensus on management for these patients.1Falconieri G. Grandi G. DiBonito L. Bonifacio-Gori D. Giarelli L. Intracranial metastases from malignant pleural mesothelioma. Report of three autopsy cases and review of the literature.Arch Pathol Lab Med. 1991; 115: 591-595PubMed Google Scholar, 2Miller A.C. Miettinen M. Schrump D.S. Hassan R. Malignant mesothelioma and central nervous system metastases. Report of two cases, pooled analysis, and systematic review.Ann Am Thorac Soc. 2014; 11: 1075-1081Crossref PubMed Scopus (8) Google Scholar, 3Kitai R. Kabuto M. Kawano H. Uno H. Kobayashi H. Kubota T. Brain metastasis from malignant mesothelioma—case report.Neurol Med Chir (Tokyo). 1995; 35: 172-174Crossref PubMed Scopus (10) Google Scholar We report a case of pleural mesothelioma treated with pleurectomy and adjuvant chemotherapy that developed isolated recurrence to the brain 2 years after resection. A 48-year-old man with history of asbestos exposure was hospitalized for appendicitis, and an incidental right pleural effusion was noted during workup. Dedicated chest imaging demonstrated right pleural thickening; pleural biopsy was performed and diagnosed epithelioid type mesothelioma. Staging workup included positron emission tomography–computed tomography (PET-CT) and magnetic resonance imaging (MRI) of the chest, which revealed localized disease within the right hemithorax and no distant metastasis. There was no evidence of nodal involvement by mediastinoscopy. The patient underwent radical pleurectomy, decortication, and intraoperative heated chemotherapy with cisplatin and gemcitabine. Final pathologic staging was pT3N0, and he completed 4 cycles of adjuvant chemotherapy (cisplatin and pemetrexed). Routine surveillance was performed every 4 months with CT chest; he had no evidence of disease recurrence. Two years after pleurectomy, he presented to the emergency department with word-finding difficulty and slurred speech. Examination noted new right facial droop and mild dysarthria. CT imaging showed a single lesion in the left frontal lobe measuring 2.4 × 2.2 cm. MRI of the brain demonstrated vasogenic edema and 6 mm of midline shift (Figure 1). Restaging imaging was performed and negative for other sites of disease. He underwent a left craniotomy and resection of the mass. Pathology confirmed epithelioid mesothelioma; there was no evidence of de-differentiation to biphasic or sarcomatoid subtype (Figure 2). He had an uneventful postoperative course with no residual neurologic symptoms. Due to close margins, he completed stereotactic radiation (25 Gy) to the surgical bed one month after resection. Current surveillance plan includes MRI of the brain and CT of the chest every 6 months. He is 5.5 years postpleurectomy and 3.5 years since treatment of oligometastatic disease; he has no evidence of disease recurrence at time of reporting. Consent was obtained from the patient to publish this work. Our case highlights the successful treatment of an intracranial recurrence from pleural mesothelioma. Although mesothelioma recurrence is common, the typical pattern favors ipsilateral hemithorax and mediastinum (54%) over distant sites (5%).4Baldini E.H. Richards W.G. Gill R.R. Goodman B.M. Winfrey O.K. Eisen H.M. et al.Updated patterns of failure after multimodality therapy for malignant pleural mesothelioma.J Thorac Cardiovasc Surg. 2015; 149: 1374-1381Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar Isolated recurrence of the chest wall treated with surgical resection has been shown to extend the overall survival in these patients.5Burt B.M. Ali S.O. DaSilva M.C. Yeap B.Y. Richards W.G. Baldini E.H. et al.Clinical indications and results after chest wall resection for recurrent mesothelioma.J Thorac Cardiovasc Surg. 2013; 146: 1373-1380Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar The survival benefit was more apparent in patients with long disease-free intervals before development of recurrence; this was true for epithelioid and biphasic subtypes.5Burt B.M. Ali S.O. DaSilva M.C. Yeap B.Y. Richards W.G. Baldini E.H. et al.Clinical indications and results after chest wall resection for recurrent mesothelioma.J Thorac Cardiovasc Surg. 2013; 146: 1373-1380Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar We suspect contributing factors to the survival of our patient were the 2-year duration before recurrence development and control of the primary and secondary sites of disease. Intracranial metastasis from mesothelioma is rare and usually diagnosed at autopsy.1Falconieri G. Grandi G. DiBonito L. Bonifacio-Gori D. Giarelli L. Intracranial metastases from malignant pleural mesothelioma. Report of three autopsy cases and review of the literature.Arch Pathol Lab Med. 1991; 115: 591-595PubMed Google Scholar, 2Miller A.C. Miettinen M. Schrump D.S. Hassan R. Malignant mesothelioma and central nervous system metastases. Report of two cases, pooled analysis, and systematic review.Ann Am Thorac Soc. 2014; 11: 1075-1081Crossref PubMed Scopus (8) Google Scholar, 3Kitai R. Kabuto M. Kawano H. Uno H. Kobayashi H. Kubota T. Brain metastasis from malignant mesothelioma—case report.Neurol Med Chir (Tokyo). 1995; 35: 172-174Crossref PubMed Scopus (10) Google Scholar Most patients do not exhibit neurologic symptoms, leading to the low detection rate.1Falconieri G. Grandi G. DiBonito L. Bonifacio-Gori D. Giarelli L. Intracranial metastases from malignant pleural mesothelioma. Report of three autopsy cases and review of the literature.Arch Pathol Lab Med. 1991; 115: 591-595PubMed Google Scholar,2Miller A.C. Miettinen M. Schrump D.S. Hassan R. Malignant mesothelioma and central nervous system metastases. Report of two cases, pooled analysis, and systematic review.Ann Am Thorac Soc. 2014; 11: 1075-1081Crossref PubMed Scopus (8) Google Scholar Autopsy studies suggest that few patients have isolated brain lesions and more frequently have diffuse metastatic disease, contributing to their poor survival.1Falconieri G. Grandi G. DiBonito L. Bonifacio-Gori D. Giarelli L. Intracranial metastases from malignant pleural mesothelioma. Report of three autopsy cases and review of the literature.Arch Pathol Lab Med. 1991; 115: 591-595PubMed Google Scholar,3Kitai R. Kabuto M. Kawano H. Uno H. Kobayashi H. Kubota T. Brain metastasis from malignant mesothelioma—case report.Neurol Med Chir (Tokyo). 1995; 35: 172-174Crossref PubMed Scopus (10) Google Scholar Analysis of 59 patients with mesothelioma brain metastases compiled from case reports revealed 53% of these patients had sarcomatoid subtype as their primary tumor.2Miller A.C. Miettinen M. Schrump D.S. Hassan R. Malignant mesothelioma and central nervous system metastases. Report of two cases, pooled analysis, and systematic review.Ann Am Thorac Soc. 2014; 11: 1075-1081Crossref PubMed Scopus (8) Google Scholar Brain imaging is not routinely obtained as part of the initial staging workup or postresection surveillance for patients with mesothelioma at our institution. Due to the low prevalence of intracranial recurrences, we do not advise routine brain imaging for postoperative surveillance. This patient is 1 of more than 150 long-term (>5 years) survivors at our program and is the first to develop an intracranial metastasis. We recommend having a low threshold for CT or MRI brain in any mesothelioma patient with new neurologic complaints. Given the 2-fold increase of brain metastases in patients with sarcomatoid mesothelioma,2Miller A.C. Miettinen M. Schrump D.S. Hassan R. Malignant mesothelioma and central nervous system metastases. Report of two cases, pooled analysis, and systematic review.Ann Am Thorac Soc. 2014; 11: 1075-1081Crossref PubMed Scopus (8) Google Scholar brain imaging at time of initial staging or as part of their surveillance may be warranted. There is no consensus on treatment of oligometastatic disease for mesothelioma, especially for intracranial lesions, given their low incidence.1Falconieri G. Grandi G. DiBonito L. Bonifacio-Gori D. Giarelli L. Intracranial metastases from malignant pleural mesothelioma. Report of three autopsy cases and review of the literature.Arch Pathol Lab Med. 1991; 115: 591-595PubMed Google Scholar, 2Miller A.C. Miettinen M. Schrump D.S. Hassan R. Malignant mesothelioma and central nervous system metastases. Report of two cases, pooled analysis, and systematic review.Ann Am Thorac Soc. 2014; 11: 1075-1081Crossref PubMed Scopus (8) Google Scholar, 3Kitai R. Kabuto M. Kawano H. Uno H. Kobayashi H. Kubota T. Brain metastasis from malignant mesothelioma—case report.Neurol Med Chir (Tokyo). 1995; 35: 172-174Crossref PubMed Scopus (10) Google Scholar We have observed improved survival with salvage chest wall resections for recurrent disease5Burt B.M. Ali S.O. DaSilva M.C. Yeap B.Y. Richards W.G. Baldini E.H. et al.Clinical indications and results after chest wall resection for recurrent mesothelioma.J Thorac Cardiovasc Surg. 2013; 146: 1373-1380Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar and strongly believe that resectable recurrences should be treated aggressively. With future advancements in treatment and better local control of disease, we anticipate a shift in the recurrence pattern and predict more distant failures occurring as presented in this case. We propose that isolated recurrences (brain, adrenal, liver) be discussed in multidisciplinary conference and patients at least 1 year post-pleurectomy and without other sites of disease should be offered resection and/or radiation.

Abstract Venovenous extracorporeal membrane oxygenation (ECMO) has emerged as an important tool in the treatment of acute respiratory distress syndrome (ARDS). The creation of portable ECMO circuits and pumps has supported the development of interfacility ECMO programs. Prior studies have demonstrated that ECMO transport is safe; however, long-term outcomes for these patients remain unknown. Retrospective analysis of our 5-year experience identified 58 patients transported on ECMO and 82 patients cannulated at our institution. When short-term (30 days) and long-term (1 year) outcomes were compared between these cohorts, there was no statistically significant difference in survival (P = 0.44 and 0.49). There were no deaths related to transport, and the rate of ECMO-related complications was similar between the groups. With established patient safety and similar long-term survival, ECMO transport is a feasible solution to provide access to ECMO for all communities.

Shah, Rohan M.; Hirji, Sameer A. MD; Osho, Asishana A. MD; Swanson, Scott J. MD; Steimer, Desiree A. MD; Jaklitsch, Michael T. MD; Mody, Gita N. MD, MPH Author Information

In the past decade, extracorporeal membrane oxygenation (ECMO) has emerged as an innovative therapy for influenza-associated acute respiratory distress syndrome (ARDS). Despite its promising results, the ideal timing of ECMO initiation for these patients remains unclear. Retrospective analysis of a single institution experience with venovenous ECMO for influenza-induced ARDS was performed. Twenty-one patients were identified and categorized into early (0-2 days), standard (3-6 days), or late (more than 7 days) cannulation cohorts. Patients cannulated within 48 hours of admission had 80% survival rate at 90 days. Comparatively, the standard and late cannulation cohorts had an observed 90-day survival rate of 60 and 16.7%, respectively.

A 71-year-old male with a past medical history of coronary artery bypass surgery developed multiple, infected pseudoaneurysms of the ascending aorta and aortic root 1 year after cardiac catheterization. He underwent aortic root replacement with a 24-mm homograft. Tissue culture from operative specimens revealed invasive Aspergillus fumigatus infection. He was treated with voriconazole for 3 months. After 1 year, he had no recurrence of symptoms, pseudoaneurysm, or fungal infection.