Thymomas and thymic carcinomas are rare mediastinal tumors that originate in the thymus. Patients with thymoma may experience symptoms associated with autoimmune paraneoplastic diseases (such as myasthenia gravis), which typically do not occur in patients with thymic carcinoma. The NCCN Guidelines for Thymomas and Thymic Carcinomas provide guidance for the diagnosis, treatment, and surveillance of patients with thymoma and thymic carcinoma. Involvement of a multidisciplinary team with experience treating thymomas and thymic carcinomas is highly recommended.

Background:Stage I lung cancer is increasingly being treated with sublobar resection. However, it is unknown whether patients with airspace invasion derive similar benefits. We therefore analyzed the association between tumor spread through air spaces (STAS) and survival. Methods:A retrospective cohort analysis was conducted on 421 patients who underwent a lung cancer resection between 2018 and 2022 at an academic institution. Baseline characteristics were compared between patients who did and did not have STAS. Overall survival and disease recurrence were analyzed using Kaplan-Meier and Cox models. Results:Of 421 patients who underwent lung cancer resection, 97 (23%) had STAS. There was no difference in STAS based on comorbidities or pulmonary function, however, patients with STAS were more likely to have higher pack-year smoking histories (47 vs 40 years, P = .041). Patients with STAS were more likely to have adenocarcinoma (91% vs 78%, P = .049), larger tumor size (2.6 vs 2.2 cm, P = .016), and lymphovascular invasion (46% vs 32%, P = .012). In patients with stage I disease, those with STAS who underwent sublobar resection had decreased overall survival compared with those without STAS (P = .042) or those who underwent lobectomy, regardless of the presence or absence of STAS. Five-year overall survival was 73% for stage I patients with STAS who underwent sublobar resection compared with 87% in patients without STAS, and 90% in patients without STAS who underwent lobectomy. Conclusions:In patients with stage I disease, STAS is associated with decreased overall survival in patients who undergo sublobar resection; however, STAS does not affect overall survival after lobectomy.

BACKGROUND:Conflicts related to Operation Iraqi Freedom (OIF) led to nearly 32,000 wounded U.S. service members, with thoracic injuries seen in 8.6% of casualties. Our aim was to better understand the effects of deployed cardiothoracic surgeons. METHODS:A retrospective analysis of DoD Trauma Registry data was performed. Inclusion criteria included U.S. service members with thoracic trauma that sought care at the role 3 hospital at Balad and received a cardiothoracic procedure from 2004 to 2011 during OIF. Deployment timelines were established to determine when a U.S. Air Force cardiothoracic surgeon was present at Balad. Patients that met inclusion criteria were divided 2 two cohorts based on the presence of a cardiothoracic surgeon. Clinical outcomes were assessed and compared between the 2 cohorts. RESULTS:One hundred and nine patients met inclusion criteria; 93.6% (n = 102) of these patients were treated at Balad when a cardiothoracic surgeon was present and 6.4% (n = 7) when a cardiothoracic surgeon was not present. Ninety-eight percent of all patients from both cohorts were male and the most common mechanism of injury was penetrating (58.7%, n = 64). Average Injury Severity Score of patients when a cardiothoracic surgeon was present was 27.6 and when one was not was 29.4 (P-value .73). The most common injury observed between both cohorts was a pneumothorax and the most common thoracic procedure performed at Balad was bronchoscopy followed by chest tube placement. Mortality rate of 9.8% was observed in the cohort where a cardiothoracic surgeon was present and 14.3% in the cohort where a cardiothoracic surgeon was not present (P-value .70). CONCLUSIONS:A U.S. Air Force cardiothoracic surgeon was present at Balad for a large percentage of the time during OIF. The severity/distribution of patient injury and clinical outcomes appeared similar when a cardiothoracic surgeon was present/not present.

Objective:Preoperative patient education improves surgical outcomes but high variability of existing patient education materials (PEMs) exists. This study establishes thoracic surgeon consensus on essential content included in PEMs to help patients to prepare for lung cancer surgery. Methods:Board-certified thoracic surgeons were recruited to participate through email invitations. Statements about the inclusion of topics in preoperative PEMs were crafted and divided into 6 categories. During 3 rounds of Delphi voting, surgeons gave anonymized feedback, and statements were iteratively revised. Results and comments of each round were shared with all surgeons for the next round of voting. Statements were considered to reach consensus if they achieved more than 80% agreement. Thematic qualitative analysis was performed on the comments provided. Results:A total of 41 board certified thoracic surgeons averaging 17.1 years in practice and 133 lung resections per year were recruited. Response rates were 93% (38 out of 41) for round 1, 88% (34 out of 38) for round 2, and 91% (31 out of 34) for round 3. The initial 25 statements were revised into 19 statements, of which 13 (68%) reached consensus. Statements with details about the operation itself had the highest consensus, whereas details about the day of surgery and recovery had the lowest consensus rates. Thematic analysis showed that statements were likely to be accepted if they were supported by evidence to improve surgical outcomes, set patient expectations, or alleviated anxiety. Statements were likely to be rejected if they were perceived to be irrelevant, could vary depending on practice, or could overwhelm patients. Conclusions:This study provides consensus-based guidelines on content that should be included in preoperative lung cancer surgery PEMs from thoracic surgeons' perspective. Surgeon consensus gives valuable insight on topics that need expert opinion, whereas other topics require patient input. Patient preferences should be evaluated before finalizing guidelines.

BACKGROUND:Anastomotic leak after esophagectomy is a major cause of morbidity and mortality. We sought to identify the prevalence of anastomotic leak, stratified by operative approach and disease etiology, as well as risk factors for leak. METHODS:A retrospective cohort analysis using The Society of Thoracic Surgeons General Thoracic Surgery Database was conducted on patients who underwent esophagectomy with gastric reconstruction between 2009 and 2021. Baseline characteristics and postoperative outcomes were compared between patients who did and did not develop an anastomotic leak. Multivariable mixed effects logistic regression models identified risk factors for leak. RESULTS:Of 18,419 patients, 3416 (19%) developed an anastomotic leak. Patients who leaked had more comorbidities, including obesity and diabetes. There was no difference in leak based on disease etiology (P = .435.) Patients with anastomotic leak had increased 30-day mortality (7% vs 4%, P < .001), reoperation (58% vs 10%, P < .001), and longer lengths of stay (18 vs 10 days, P < .001). On multivariable analysis, obesity (odds ratio [OR], 1.27; 95% CI, 1.16-1.38; P < .001), diabetes (OR, 1.14; 95% CI, 1.04-1.25; P = .006), and smoking (OR, 1.26; 95% CI, 1.15-1.37; P < .001) were independently predictive of anastomotic leak. Compared with an open 2-field, a transhiatal (OR, 1.35; 95% CI, 1.17-1.55; P < .001) or 3-field esophagectomy (OR, 1.46; 95% CI, 1.25-1.70; P < .001) was more likely to leak. A robotic approach was associated with an increased risk of leak (OR, 1.28; 95% CI, 1.03-1.08; P < .001), however lost significance in a modern subgroup from 2018-2021. CONCLUSIONS:Obesity, diabetes, smoking, pulmonary hypertension, and a cervical anastomosis are risk factors for anastomotic leak regardless of disease etiology. These important clinical risk factors identify an opportunity for modifiable risk reduction with aggressive medical optimization perioperatively.

BACKGROUND:The Veterans Health Administration (VA) provides lung transplant care in collaboration with select academic centers, requiring travel and a shared-care model. This could potentially affect clinical care and survival of patients with end-stage lung disease. Hence, we compared survival after waitlisting and transplant for veterans vs non-veterans and for veterans treated through VA vs non-VA programs. METHODS:From January 2006 to March 2020, 31,302 adults were waitlisted and 25,790 received transplants in the Organ Procurement and Transplantation Network lung transplant database. Veterans represented 416 of those (1.3%) waitlisted and 363 (1.4%) of those receiving transplants, with 303 (73%) and 268 (74%) waitlisted and receiving transplants through the VA program, respectively. Survival was assessed after weighted matching. RESULTS:One-year waitlist survival of veterans vs non-veterans was 83% vs 80% (P = .27), with survival of veterans waitlisted at VA vs non-VA programs of 80% vs 85% at 0.75 year (P = .65). From transplant, 5-year survival of veterans vs non-veterans was 62% vs 58% (P = .065); 5-year survival of veterans receiving transplants at VA vs non-VA programs was 66% vs 61% (P = .39). CONCLUSIONS:Survival from both the time of listing and transplant for all veterans and veterans treated through the VA lung transplant program is at least comparable to outcomes through non-VA programs, suggesting that the VA program facilitates quality care for its patients.

PURPOSE:Tumor spread through air spaces (STAS) and visceral pleural invasion (VPI) are negative prognostic factors in lung cancer. However, it is unknown whether they have a compounding prognostic effect. Therefore, we analyzed the association between STAS and VPI with overall survival and recurrence. METHODS:A retrospective cohort analysis was conducted on 421 adult patients who underwent pulmonary resection for non-small cell lung cancer at an academic institution between 2018 and 2022. Baseline characteristics were compared between patients who had STAS only, VPI only, or both STAS and VPI. Overall survival and cumulative recurrence were compared using the Kaplan-Meier method. RESULTS:Of the 421 patients who underwent a pulmonary resection, 34 (8%) had both STAS and VPI. Their combined presence was associated with increased smoking pack-years, increased tumor size, and an increased presence of lymphovascular invasion. There was no overall survival difference (p = 0.190) between patients with both STAS and VPI and those with only one feature or neither. However, cumulative incidence of recurrence was increased (p = 0.001) for patients with both. CONCLUSION:The presence of STAS and VPI was not associated with decreased overall survival; however, their combined presence may have a compounding effect on recurrence risk.

Background and ObjectivesStandard treatment of patients with stage II/III esophageal or gastroesophageal junction (E/GEJ) cancer involves neoadjuvant chemoradiation (nCRT), resection, and immunotherapy. Our trial evaluated the addition of perioperative avelumab to standard treatments.MethodsPatients with resectable E/GEJ cancers received avelumab with nCRT and adjuvant avelumab after resection. Primary endpoints for phase I and II portions were safety and pathologic complete response (pCR) rate, respectively. Secondary endpoints included recurrence-free survival (RFS), surgical complication prevalence, and R0 resection rate.ResultsTwenty-two patients enrolled in the study. Median follow-up during data cutoff was 23.9 months. There were no dose-limiting toxicities during the run-in phase. Nineteen patients (86.4%) underwent resection with R0 resection rate of 78.9% and with pCR rate of 26%. Most common treatment-related adverse events (TRAE) were cytopenias from chemoradiation. Aside from one grade >= 3 avelumab-related hypersensitivity, no grade >= 3 avelumab TRAEs were seen. Median RFS was not reached, and 1-year RFS and overall survival were 71% and 81%, respectively. The study was terminated before full planned accrual due to standard practice change based on the CheckMate 577 trial.ConclusionsThe addition of perioperative avelumab to nCRT was tolerable and demonstrated promising outcomes.

e20086 Background: In 2018, consolidative durvalumab (D) was FDA-approved in patients with locally advanced non-small cell lung cancer(NSCLC) because it increased PFS and was later found to increase overall survival (OS). This analysis will check the real-world effects of this agent prior to and after its approval. Methods: The SEER-17 database was queried from 2015-2020 and assessed for differences in OS/lung cancer specific survival (LCSS) and rates of second cancers (2C). Patients included were those with NSCLC who received chemotherapy and radiation with at least 7 months of follow-up. The population was split into two different groups, those diagnosed before and after D’s approval (2015-2017(BA) and 2018-2020(AA). Multi-variate analyses (MVA) were used to find prognostic factors which were used to adjust OS/LCSS rates for the BA and AA at 12, 24, and 30 months. Variables analyzed included patient characteristics, histopathology, and previous cancers (separated into alcohol, diet, smoking, virus and hormone related). Inverse propensity scores were weighted for OS factors to determine rates of second cancers. Results: Of 12,022 patients, 501 patients developed 2Cs. The OS was significantly better for AA group than the BA group ( p < 0.001, HR = 0.79(0.74, 0.85) with rates at 12, 24, and 30 months of 0.86, 0.68, and 0.62%; and 0.83, 0.62, and 0.55%. Multivariate analyses for OS demonstrated similar prognostic factors in both year groups and were worse with advanced age, male sex, unmarried status, squamous histology, advanced stage and non-Hispanic white race. The LCSS was significantly better in AP than the BA group ( p < 0.001, HR = 0.84 (0.7, 0.89) with rates at 12, 24, and 30 months of groups of 0.82,0.61, and 0.55%; and 0.80,0.56,and 0.48%. The prognostic factors for LCSS were the same in both group and included age, male sex, squamous histology, and advanced stage. The adjusted rates of 2C in 2018-2020 group were trending less than in 2015-2017 (HR = 0.80(0.63-1.03), p =0.07), largely driven by a reduction in smoking-related cancers (HR = 0.74(0.53-1.02, p= 0.07). The 2C rates at 12, 24, and 30 months were 1.0, 2.7, and 3.5% in the 2015-2017 and 0.9, 1.6, and 1.9% in 2018-2020 groups. MVA significant risk factors for 2Cs were age, history of previous cancer, male sex, and squamous histology in the BA group, but no factors were significant for 102 second cancers in the AA group. Conclusions: In the years after durvalumab's approval, there was a significant benefit in terms of overall survival and lung cancer specific survival, but prognostic factors remained similar. In addition to the OS/LCSS benefit, durvalumab's approval was associated with a strong trend for reducing the incidence of second cancers, especially in those with previous smoking related cancers.

8595 Background: The role of consolidative thoracic and prophylactic brain radiation in extensive stage small cell lung cancer patients is controversial. We investigated the factors associated with the use of any radiation therapy (RT) and whether Radiation has a benefit to overall survival (OS) in the total patient group and whether this benefit is the same if Chemotherapy (CT) only is used, or chemo-immunotherapy (CT-IO) is used. Methods: The NCDB database was queried from years 2017-2019. Patients receiving systemic therapy- STX (CT or CT-IO) had to have at least 6 months of follow-up and have no brain metastases at diagnosis. All RT patients had to receive upfront systemic therapy, were treated 2 to 6 months from diagnosis, and if treated to the brain received 25Gy in 10 fractions only. Multi-variate analyses (MVA) were used to determine factors associated with OS and selection for any radiation. Propensity matching for factors affecting OS were used to generate Kaplan-Meier OS curves. Log-rank tests were used to determine differences in Kaplan Meier survival curves for the effects of RT on OS. Results: The total number of patients receiving RT or systemic therapy alone as well as their median follow-ups(months(mn) were (981, 33.02mn) and (8909, 30.59mn). The median time to the start of STX and RT were 22days and 135 days respectively. MVA noted that RT had a greater effect on OS (Thoracic, Brain, Both – HRs = 0.78, 0.75, and 0.68) than other interventions including IO (HR 0.87) and palliative care without RT (HR 1.07). Selection for radiation depended significantly upon factors affecting OS(HR) including liver metastases (0.59), females (1.21), age/10yr(0.78) and Charlson co-morbidity index of > 3(0.66), but did not depend upon insurance status, race, or county income/high school graduation rates. Propensity score matched OS curves noted the same effects of RT on OS whether CT or CT-IO was given. The lowest HRs were noted when both thoracic and brain RT were given (see table). Conclusions: The patient with extensive stage small cell lung cancer who reach candidacy and receive RT may have a significant improvement in OS compared to the patients treated only with CT or CT-IO. Combined thoracic and prophylactic brain RT seems to be better than either one alone. The impact of radiation whether given to one or two sites may be more beneficial than immunotherapy added to chemotherapy. [Table: see text]

The management of chylothorax remains challenging given the limited evidence and significant heterogeneity in practice. In addition, there are no practical guidelines on the optimal approach to manage this complex condition. We convened an international group of 27 experts from 20 institutions across five countries and four specialties (pulmonary, interventional radiology, thoracic surgery and nutrition) with experience and expertise in managing adult patients with chylothorax. We performed a literature and internet search for reports addressing seven clinically relevant PICO (Patient, Intervention, Comparison and Outcome) questions pertaining to the management of adult patients with chylothorax. This consensus statement, consisting of best practice statements based on expert consensus addressing these seven PICO questions, was formulated by a systematic and rigorous process involving the evaluation of published evidence, augmented with provider experience. Panel members participated in the development of the final best practice statements using the modified Delphi technique. Our consensus statement aims to offer guidance in clinical decision making when managing patients with chylothorax while also identifying gaps in knowledge and informing future research.

Mesothelioma is a rare cancer that originates from the mesothelial surfaces of the pleura and other sites, and is estimated to occur in approximately 3,500 people in the United States annually. Pleural mesothelioma is the most common type and represents approximately 85% of these cases. The NCCN Guidelines for Mesothelioma: Pleural provide recommendations for the diagnosis, evaluation, treatment, and follow-up for patients with pleural mesothelioma. These NCCN Guidelines Insights highlight signi ficant updates to the NCCN Guidelines for Mesothelioma: Pleural, including revised guidance on disease classi fication and systemic therapy options.

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Non-Small Cell Lung Cancer (NSCLC) provide recommendations for the treatment of patients with NSCLC, including diagnosis, primary disease management, surveillance for relapse, and subsequent treatment. The panel has updated the list of recommended targeted therapies based on recent FDA approvals and clinical data. This selection from the NCCN Guidelines for NSCLC focuses on treatment recommendations for advanced or metastatic NSCLC with actionable molecular biomarkers.

Immunotherapy has made recent improvements in disease-free survival (DFS) and/or overall survival (OS) in all stages of non-small-cell lung cancer (NSCLC). Here, we review the tumor microenvironment and its immunosuppressive effects and discuss how anti-angiogenic therapies may potentiate the anti-carcinogenic effects of immunotherapy. We also review all the past literature and discuss strategies of combining anti-angiogenic therapy and immunotherapy +/− chemotherapy and hypothesize how we can use this strategy for non-small-cell lung cancer in metastatic previously untreated/previously treated settings in previously treated EGFR-mutated NSCLC for the upfront treatment of brain metastases prior to radiation therapy and for the incorporation of this strategy into stage III unresectable disease. We assert the use of anti-angiogenic therapy and immunotherapy when combined appropriately with chemotherapy and radiotherapy has the potential to increase the long-term survivals in both the stage III and metastatic setting so that we can now consider more patients to experience curative treatment.

Bilateral lung transplantation (BLTx) offers diverse educational opportunities for all cardiothoracic trainees. The conduct of this operation involves principles of exposure, dissection, mechanical support, reconstruction, and procedural sequencing valuable for both cardiac and thoracic subspecialties. Unfortunately, the educational value of BLTx is threatened by an increasingly complex recipient population and the pressures of regulatory oversight with publicly reported outcomes. With proper forethought and attention to educational principles, a productive learning experience may be created even with a challenging transplant requiring multiple attending surgeons.

Mesothelioma is a rare cancer that originates from the mesothelial surfaces of the pleura and other sites, and is estimated to occur in approximately 3,500 people in the United States annually. Pleural mesothelioma is the most common type and represents approximately 85% of these cases. The NCCN Guidelines for Mesothelioma: Pleural provide recommendations for the diagnosis, evaluation, treatment, and follow-up for patients with pleural mesothelioma. These NCCN Guidelines Insights highlight significant updates to the NCCN Guidelines for Mesothelioma: Pleural, including revised guidance on disease classification and systemic therapy options.

Objective: The diagnostic criteria of lymphatic vascular invasion have not been standardized. Our investigation assesses the factors associated with lymphatic vascular invasion positive tumors and the impact of lymphatic vascular invasion on overall survival for patients with non-small cell lung cancer undergoing (bi)lobectomy with an adequate node dissection. Methods: The National Cancer Database was queried from the years 2010 to 2015 to fi nd surgical patients who underwent lobectomy with at least 10 lymph nodes examined (adequate node dissection) and with known lymphatic vascular invasion status. Paired t tests were used to distinguish differences between the patients with and without lymphatic vascular invasion in their specimen. Multivariable analysis was used to determine factors associated with overall survival. Propensity score matching adjusting for overall survival factors was used to determine the lymphatic vascular invasion's overall survival impact by grade, histology, p-T/N/overall stage, and tumor size. Results: Lymphatic vascular invasion status was reported in 91.6% and positive in 23.4% of 28,842 eligible patients. Academic medical centers, institutions with populations more than 1,000,000, and the mid-Atlantic region reported higher rates of lymphatic vascular invasion positive tumors as well as overall survival compared with other cancer centers. Lymphatic vascular invasion was independently associated with a significant decrement in overall survival as per multivariable analysis and propensity score matching. Propensity score matching demonstrated that lymphatic vascular invasion was associated with a significant decrement in overall survival for all histologies, tumor grades, tumor sizes, and stages, except for more advanced pathologic stages T3/III/N2 and larger tumors greater than 4 cm for which overall survival was trending worse with lymphatic vascular invasion positive. Conclusions: Lymphatic vascular invasion positive varies based on hospital location/type and population, but it was associated with a decrement in overall survival that was independent of pathologic T/N/overall stage, histology, and tumor grade. Lymphatic vascular invasion must be standardized and considered as a staging variable and should be considered as a sole determinant for prognosis, especially for those with earlier-stage and smaller tumors. (JTCVS Open 2024;21:313-40)

The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Non-Small Cell Lung Cancer (NSCLC) provide recommendations for the treatment of patients with NSCLC, including diagnosis, primary disease management, surveillance for relapse, and subsequent treatment. The panel has updated the list of recommended targeted therapies based on recent FDA approvals and clinical data. This selection from the NCCN Guidelines for NSCLC focuses on treatment recommendations for advanced or metastatic NSCLC with actionable molecular biomarkers.

The NCCN Guidelines for Non-Small Cell Lung Cancer (NSCLC) provide recommendations for management of disease in patients with NSCLC. These NCCN Guidelines Insights focus on neoadjuvant and adjuvant (also known as perioperative) systemic therapy options for eligible patients with resectable NSCLC.

ObjectiveWe investigated the impact of body mass index (BMI) on post-operative outcomes and survival of patients with interstitial pulmonary fibrosis (IPF) undergoing lung transplantation.MethodsWe retrospectively reviewed 222 patients with IPF that underwent lung transplant (LT) at our institution from 2005 to 2019. Recipients were divided in 4 groups: group-1 consisted of underweight patients (BMI ≤18.5 kg/m2), group-2 of normal weight patients (BMI 18.5–25 kg/m2), group-3 of over-weight patients (BMI 25–29.9 kg/m2) and group-4 of obese patients (BMI ≥30 kg/m2).ResultsGroup-1 consisted of 13 (6%) patients, group-2 of 67 (30%) patients, group-3 of 79 (36%) patients, group-4 consisted of 63 (28%) patients. Median BMI for group-1 was 17 [interquartile range (IQR): 17, 18], for group-2 was 23 (22, 24), for group-3 was 29 (28, 29.5) and group-4 was 32 (31, 33). Patients in group-1 were significantly younger (p < 0.01). Single LT comprised the majority of operation type in group-2 to group-4 and it was significantly higher than group 1 (p < 0.01). Median follow-up time was 39 months (13–76). A total of 79 (35.5%) patients died by the end of study. Overall, five deaths occurred in group-1, 17 in group-2, 33 in group-3, and 24 in group-4. Kaplan–Meier analysis showed that mortality was not statistically significant between the groups (p = 0.24). Cox-regression analysis was used to assess other possible risk factors that could influence the effect of BMI on mortality, including transplant type (single, double), lung allocation score, and age, diabetes and creatinine levels at surgery. None of these factors were shown to affect patient mortality (p > 0.05). Overall reasons for death included graft failure (24%), infection (23%), respiratory failure (14%), and malignancy (13%).ConclusionsBody mass index does not impact long-term survival of patients with IPF undergoing lung transplantation.