Central MessageQuality metrics are here to stay for health care professionals. Thoracic surgeons need to be involved in the design and measurement of these metrics to ensure the appropriateness of their use.See Article page 1219. Quality metrics are here to stay for health care professionals. Thoracic surgeons need to be involved in the design and measurement of these metrics to ensure the appropriateness of their use. See Article page 1219. In health care today, as we enter the era of optimizing value, measurement of the quality of care delivered by practitioners has moved rapidly to the forefront. To this end, the American College of Surgeons' Commission on Cancer (CoC) has begun to incorporate clinical quality metrics into their accreditation process for institutions that deliver cancer care. Performance in these quality metrics is intended to provide institutions with the feedback needed to guide future quality improvement processes. In this issue of The Journal of Thoracic and Cardiovascular Surgery, Odell and colleagues1Odell D.D. Feinglass J. Engelhardt K. Papastefan S. Meyerson S.L. Bharat A. et al.Evaluation of adherence to the commission on cancer lung cancer quality measures.J Thorac Cardiovasc Surg. 2019; 157: 1219-1235Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar present a retrospective, observational study of patients with non–small cell lung cancer to determine adherence to quality metrics that were first proposed by the CoC in 2014. To accomplish this, they queried the National Cancer Database for data from member institutions between 1998 and 2011. Odell and colleagues1Odell D.D. Feinglass J. Engelhardt K. Papastefan S. Meyerson S.L. Bharat A. et al.Evaluation of adherence to the commission on cancer lung cancer quality measures.J Thorac Cardiovasc Surg. 2019; 157: 1219-1235Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar found that adherence to the 4 CoC proposed metrics was extremely variable according to the metric being examined. Adequate surgical lymph node staging and the referral rate for adjuvant therapy after resection were poor, and the timing of surgery after neoadjuvant therapy and the lack of the use of up-front surgery for patients with clinical N2 disease were far higher adherence to adequate surgical lymph node staging and the referral rate for adjuvant therapy. In addition, survival was significantly improved in patients in whom the metric was achieved for 3 of 4 of these measures. Given the emphasis placed on value in the healthcare environment today, Odell and colleagues1Odell D.D. Feinglass J. Engelhardt K. Papastefan S. Meyerson S.L. Bharat A. et al.Evaluation of adherence to the commission on cancer lung cancer quality measures.J Thorac Cardiovasc Surg. 2019; 157: 1219-1235Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar are to be commended on addressing such a timely research topic in their study and correctly pointing out that there is room for quality improvement for patients with surgically managed non–small cell lung cancer. Although the study clearly demonstrates the adherence rates to the CoC-proposed metrics, drawing definitive conclusions about quality and survival from the data is more challenging. First, the definition of quality for each of the metrics proposed by the CoC is arbitrary at best. For example, the use of 10 resected lymph nodes as a definition of adequate staging does not take into account the location and number of nodal stations sampled and the fact that many nodes are removed in a fragmented state. In addition, lymph node count also depends as much on pathologic assessment as it does on completeness of surgical sampling. Second, measuring the adherence to guidelines during a period when the guidelines and modern standards of care did not yet exist is of limited utility going forward. Finally, conclusions regarding survival are difficult to draw from the presented analysis when a large number of variables will affect both physician conduct in any individual case as well as the survival of an individual patient. Quality measures, both at the institutional level (as described in the article of Odell and colleagues1Odell D.D. Feinglass J. Engelhardt K. Papastefan S. Meyerson S.L. Bharat A. et al.Evaluation of adherence to the commission on cancer lung cancer quality measures.J Thorac Cardiovasc Surg. 2019; 157: 1219-1235Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar) and at the individual practitioner level, are the way of the future as society tries to optimize the value obtained from health care delivery. Not only will quality metrics affect accreditation of entities, their measurement will most certainly permeate deeply into reimbursement practices. Evaluation of adherence to the Commission on Cancer lung cancer quality measuresThe Journal of Thoracic and Cardiovascular SurgeryVol. 157Issue 3PreviewIn this study we present historic data on adherence to and survival outcomes associated with recently introduced quality measures for the management of non–small-cell lung cancer. Full-Text PDF Open Archive

Background. The optimal approach to clinical T2N0 (cT2N0) esophageal cancer is unclear. Our objective is to perform a systematic review investigating whether neoadjuvant therapy results in better outcomes compared with upfront surgery in cT2N0 esophageal cancer. Methods. We performed a systematic review and meta-analysis of randomized and nonrandomized studies (1995 to 2017) comparing use of neoadjuvant therapy with upfront surgery in the treatment of cT2N0 esophageal cancer. Independent and duplicate assessment was used. All meta-analytical techniques were performed in Rev-Man 5.3. Results. Nine cohort studies, including 5433 patients, were included for meta-analysis. Use of neoadjuvant therapy was associated with significantly higher complete resection rates compared with upfront surgery (risk ratio, 0.67; 95% confidence interval, 0.55 to 0.81; P < .001). There was no difference in 5-year overall or recurrence-free survival. There were no significant differences in perioperative mortality as well as perioperative complications, although meta-analysis results are limited by inconsistent reporting of such complications. Lymphovascular invasion and larger tumor size were significant predictors of upstaging. Four of the studies were at high risk of bias. The remaining 5 studies were larger and more robust but were assessed as being of uncertain risk of bias. Conclusions. Use of neoadjuvant therapy was associated with significantly higher complete resection rates compared with upfront surgery although this did not translate to differences in survival outcomes. No differences in perioperative morbidity or mortality were identified. Based on qualitative systematic review, lymphovascular invasion and larger tumor size are potential factors for helping to select those patients who may benefit from neoadjuvant therapy. (C) 2019 by The Society of Thoracic Surgeons

INTRODUCTION:Mediastinal lesions are uncommon; studies on their distribution are, in general, small and from a single institution. Furthermore, these studies are usually based on pathology or surgical databases and, therefore, miss many lesions that did not undergo biopsy or resection. Our aim was to identify the distribution of lesions in the mediastinum in a large international, multi-institutional cohort. METHODS:At each participating institution, a standardized retrospective radiology database search was performed for interpretations of computed tomography, positron emission tomography-computed tomography, and magnetic resonance imaging scans including any of the following terms: "mediastinal nodule," "mediastinal lesion," "mediastinal mass," or "mediastinal abnormality" (2011-2014). Standardized data were collected. Statistical analysis was performed. RESULTS:Among 3308 cases, thymomas (27.8%), benign mediastinal cysts (20.0%), and lymphomas (16.1%) were most common. The distribution of lesions varied among mediastinal compartments; thymomas (38.3%), benign cysts (16.8%), and neurogenic tumors (53.9%) were the most common lesions in the prevascular, visceral, and paravertebral mediastinum, respectively (p < 0.001). Mediastinal compartment was associated with age; patients with paravertebral lesions were the youngest (p < 0.0001). Mediastinal lesions differed by continent or country, with benign cysts being the most common mediastinal lesions in the People's Republic of China, thymomas in Europe, and lymphomas in North America and Israel (p < 0.001). Benign cysts, thymic carcinomas, and metastases were more often seen in larger hospitals, whereas lymphomas and thymic hyperplasia occurred more often in smaller hospitals (p < 0.01). CONCLUSIONS:Our study confirmed that the spectrum and frequency of mediastinal lesions depend on mediastinal compartment and age. This information provides helpful demographic data and is important when considering the differential diagnosis of a mediastinal lesion.

Objective: To determine long-term survival of visceral pleural invasion (VPI) and parenchymal invasion (PAI) (angiolymphatic and/or vascular) on survival of NSCLCs less than 30 mm in maximum diameter. Methods: Kaplan-Meier survivals for NSCLCs, with and without VPI and/or PAI, were determined for a prospective cohort of screening participants stratified by pathologic tumor size (<= 10 mm, 11-20 mm, and 21-30 mm) and nodule consistency. Log-rank test statistics were calculated. Results: The frequency of PAI versus VPI was significantly lower in patients with subsolid nodules than in those with solid nodules (4.9% versus 27.7% [p < 0.0001]), and correspondingly, Kaplan-Meier lung cancer survival was significantly higher among patients with subsolid nodules (99.1% versus 91.3% [p = 0.0009]). Multivariable Cox regression found that only tumor diameter (adjusted hazard ratio [HR] = 1.07, 95% confidence interval [CI]: 1.01-1.14, p = 0.02) and PAI (adjusted HR = 3.15, 95% CI: 1.25-7.90, p = 0.01) remained significant, whereas VPI was not significant (p = 0.15). When clinical and computed tomography findings were included with the pathologic findings, Cox regression showed that the risk of dying of lung cancer increased 10-fold (HR = 10.06, 95% CI: 1.35-75.30) for NSCLCs in patients with solid nodules and more than twofold (by a factor of 2.27) in patients with moderate to severe emphysema (HR = 2.27, 95% CI: 1.01-5.11), as well as with increasing tumor diameter (HR = 1.06, 95% CI: 1.01-1.13), whereas PAI was no longer significant (p = 0.19). Conclusions: Nodule consistency on computed tomography was a more significant prognostic indicator than either PAI or VPI. We propose that patients with NSCLC with VPI and a maximum tumor diameter of 30 mm or less not be upstaged to T2 without further large, multicenter studies of NSCLCs, stratified by the new T status and that classification be considered separately for patients with subsolid or solid nodules. (C) 2019 International Association for the Study of Lung Cancer. Published by Elsevier Inc. All rights reserved.

The literature regarding laparoscopic hiatal hernia repair is difficult to interpret because of inconsistencies in describing hernia characteristics and outcome measures. This study was performed to evaluate risk factors for an unsatisfactory outcome after repair using objective definitions of hernia size and a clinically relevant outcome instrument. A retrospective review of a prospectively maintained database was conducted over a seven-year period. Data collected included patient demographics and hernia-related variables. Outcomes were defined using a validated quality of life (QOL) instrument. Postoperatively, the mean total QOL score decreased from 22.9 to 5.8 (P < 0.001). In all, 13.8 per cent of patients had unsatisfactory QOL scores postoperatively. Multivariate analysis showed that high gastroesophageal (GE) junction position (P = 0.03) and female gender (P = 0.02) were the only significant factors associated with an unsatisfactory postoperative QOL. Laparoscopic hiatal hernia repair significantly improves QOL. With respect to predicting clinically relevant outcomes, hernias are best characterized by the position of the GE junction. Females with high GE junction position are at the highest risk for an unsatisfactory outcome.

The goals of follow-up and surveillance of lung cancer patients who undergo treatment with curative intent involve the detection of recurrent disease, as well as second primary lung cancer. Protocols for the follow-up and surveillance of these patients are not supported by high-quality clinical evidence, yet most major organizations involved with lung cancer are advocates of this practice. Most of these guidelines recommend that healthcare providers perform periodic medical histories and physical examinations, as well as computed tomography of the chest. Other testing, including PET/CT and other imaging, and biochemical evaluations are not recommended. Published data suggest that patients may benefit when recurrent or new primary lung cancer is detected when it can be potentially treated with curative intent. A significant downside to this practice is the potential harm to patients that may result from false-positive testing, underlining the need for appropriate expertise when making patient care decisions. Patients should undergo surveillance as long as they are able to tolerate potentially curative treatment options.

Thymic epithelial tumors (TETs) are one of the rarest adult malignancies. Among TETs, thymoma is the most predominant, characterized by a unique association with autoimmune diseases, followed by thymic carcinoma, which is less common but more clinically aggressive. Using multi-platform omics analyses on 117 TETs, we define four subtypes of these tumors defined by genomic hallmarks and an association with survival and World Health Organization histological subtype. We further demonstrate a marked prevalence of a thymoma-specific mutated oncogene, GTF2I, and explore its biological effects on multi-platform analysis. We further observe enrichment of mutations in HRAS, NRAS, and TP53. Last, we identify a molecular link between thymoma and the autoimmune disease myasthenia gravis, characterized by tumoral overexpression of muscle autoantigens, and increased aneuploidy.

Purpose The efficacy of neoadjuvant chemoradiotherapy (NCRT) plus surgery for locally advanced esophageal squamous cell carcinoma (ESCC) remains controversial. In this trial, we compared the survival and safety of NCRT plus surgery with surgery alone in patients with locally advanced ESCC. Patients and Methods From June 2007 to December 2014, 451 patients with potentially resectable thoracic ESCC, clinically staged as T1-4N1M0/T4N0M0, were randomly allocated to NCRT plus surgery (group CRT; n = 224) and surgery alone (group S; n = 227). In group CRT, patients received vinorelbine 25 mg/m2 intravenously (IV) on days 1 and 8 and cisplatin 75 mg/m2 IV day 1, or 25 mg/m2 IV on days 1 to 4 every 3 weeks for two cycles, with a total concurrent radiation dose of 40.0 Gy administered in 20 fractions of 2.0 Gy on 5 days per week. In both groups, patients underwent McKeown or Ivor Lewis esophagectomy. The primary end point was overall survival. Results The pathologic complete response rate was 43.2% in group CRT. Compared with group S, group CRT had a higher R0 resection rate (98.4% v 91.2%; P = .002), a better median overall survival (100.1 months v 66.5 months; hazard ratio, 0.71; 95% CI, 0.53 to 0.96; P = .025), and a prolonged disease-free survival (100.1 months v 41.7 months; hazard ratio, 0.58; 95% CI, 0.43 to 0.78; P < .001). Leukopenia (48.9%) and neutropenia (45.7%) were the most common grade 3 or 4 adverse events during chemoradiotherapy. Incidences of postoperative complications were similar between groups, with the exception of arrhythmia (group CRT: 13% v group S: 4.0%; P = .001). Peritreatment mortality was 2.2% in group CRT versus 0.4% in group S ( P = .212). Conclusion This trial shows that NCRT plus surgery improves survival over surgery alone among patients with locally advanced ESCC, with acceptable and manageable adverse events.

Objective: To compare long-term survival rates of patients with first, primary, clinical stage IA nonsmall cell lung cancer from a large cohort undergoing computed tomography screening with and without mediastinal lymph node resection (MLNR) under an IRB-approved common protocol from 1992 to 2014.Background: Assessing survival differences of patients with and without MLNR manifesting as solid and subsolid nodules.Methods: Long-term Kaplan-Meier (K-M) survival rates for those with and without MLNR were compared and Cox regression analyses were used to adjust for demographic, computed tomography, and surgical covariates.Results: The long-term K-M rates for 462 with and 145 without MLNR was 92% versus 96% (P = 0.19), respectively. For 203 patients with a subsolid nodule, 151 with and 52 without MLNR, the rate was 100%. For the 404 patients with a solid nodule, 311 with and 93 without MLNR, the rate was 87% versus 94% (P = 0.24) and Cox regression showed no statistically significant difference (P = 0.28) when adjusted for all covariates. Risk of dying increased significantly with increasing decades of age (hazard ratio [HR] 2.3, 95% confidence interval [CI] 1.4-3.8), centrally located tumor (HR 2.5, 95% CI 1.2-5.2), tumor size 21 to 30mm (HR 2.7, 95% CI 1.2-6.0), and invasion beyond the lung stroma (HR 3.0, 95% CI 1.4-6.1). For the 346 patients with MLNR, tumor size was 20mm or less; K-M rates for the 269 patients with and 169 patients without MLNR were also not significantly different (HR 2.1, P = 0.24).Conclusions: It is not mandatory to perform MLNR when screen-diagnosed nonsmall cell lung cancer manifests as a subsolid nodule.

Background: Thymoma and thymic carcinoma are the most common malignancies of the anterior mediastinum. Additionally, thymoma has a unique association with autoimmune disorders, notably myasthenia gravis (MG). Histologic classification of thymic epithelial tumors (TETs) has been largely based on the gross description of the epithelial cell appearance and the relative abundance of associated lymphocytes. A comprehensive molecular analysis of TETs has not heretofore been conducted. Methods: The TCGA Research Network conducted multi-platform analyses of 117 TETs (thymoma =105; thymic carcinoma =10 and micronodular thymoma =2), which included whole-exome, transcriptome, methylome and targeted proteome analysis. Patient characteristics: median age =60 years (range, 17–84 years); M:F (%) =52:48; Masaoka stage {I [36], IIA [39], IIB [19]; III [15]; IVA [1]; IVB [5]}; MG was present in 32 patients. No patient had prior therapy for metastatic disease, but 14 had prior chemotherapy and 39 had prior radiation therapy in the adjuvant setting. WHO histologic classification (blinded review) revealed A =10; AB =48, B1 =12, B2 =25, B3 =10, micronodular thymoma =2 and TC =10. Results: Thymoma has the lowest tumor mutation burden among adult malignancies in the TCGA. A unique transcription factor, GTF2I, was the most commonly observed mutation in WHO Types A and A/B. All GTF2I mutations were exclusively at the amino acid 424 locus. This is the only tumor with this specific mutation within the entire TCGA database. Differential expression of the RNA and protein data revealed dysregulation of several oncogenic pathways in GTF2I mutants vs. wild-type. Oncogenic HRAS, NRAS and TP53 mutations were also observed, but at a lower frequency among all TETs. We further describe an MSI-unstable thymic carcinoma that was hyper-mutated. Using multi-platform analyses, four distinct molecular-driven subtypes of TETs were identified that strongly correlated with the current WHO histologic classification and were associated with survival. Genomic hallmarks of these subtypes were identified to aid pathologic diagnosis. Lastly, when comparing MG-positive vs. -negative thymomas, we observed increased aneuploidy and overexpression of muscle auto-antigens in MG-positive tumors, providing a pathophysiologic link between thymoma and MG. Conclusions: Based on molecular analysis, four clusters were identified that correlated strongly with the current WHO Histologic Classification. Also identified was a unique mutation in GTF2I, which was associated with WHO Type A and A/B thymoma. Lastly, a molecular link between MG and thymoma characterized by increased aneuploidy and tumoral over-expression of muscle auto-antigens was observed. This international effort represents the largest and most comprehensive molecular analysis of TETs conducted to date is expected to have important clinical and translational implications for this rare disease.

Introduction: Thymic epithelial tumors (TETs) are associated with paraneoplastic/autoimmune (PN/AI) syndromes. Myasthenia gravis is the most common PN/AI syndrome associated with TETs. Methods: The International Thymic Malignancy Interest Group retrospective database was examined to determine (1) baseline and treatment characteristics associated with PN/AI syndromes and (2) the prognostic role of PN/AI syndromes for patients with TETs. The competing risks model was used to estimate cumulative incidence of recurrence (CIR) and the Kaplan-Meier method was used to calculate overall survival (OS). A Cox proportional hazards model was used for multivariate analysis. Results: A total of 6670 patients with known PN/AI syndrome status from 1951 to 2012 were identified. PN/AI syndromes were associated with younger age, female sex, thymoma histologic type, earlier stage, and an increased rate of total thymectomy and complete resection status. There was a statistically significant lower CIR in the group with a PN/AI syndrome than in the group without a PN/AI syndrome (10-year CIR 17.3% versus 21.2%, respectively [p = 0.0003]). The OS was improved in the group with a PN/AI syndrome compared to the group without a PN/AI syndrome (median OS 21.6 years versus 17.0 years, respectively [hazard ratio = 0.63, 95% confidence interval: 0.54-0.74, p < 0.0001]). However, in the multivariate model for recurrence-free survival and OS, PN/AI syndrome was not an independent prognostic factor. Discussion: Previously, there have been mixed data regarding the prognostic role of PN/AI syndromes for patients with TETs. Here, using the largest data set in the world for TETs, PN/AI syndromes were associated with favorable features (i.e., earlier stage and complete resection status) but were not an independent prognostic factor for patients with TETs. (C) 2017 International Association for the Study of Lung Cancer. Published by Elsevier Inc. All rights reserved.

Central MessageThoracoscopic thymectomy for myasthenia gravis can technically be performed in spontaneously breathing patients, but further studies are needed to determine any benefits.See Article page 1882. Thoracoscopic thymectomy for myasthenia gravis can technically be performed in spontaneously breathing patients, but further studies are needed to determine any benefits. See Article page 1882. The anesthetic management of patients undergoing thymectomy for myasthenia gravis (MG) remains problematic due to the risk of precipitating myasthenic crisis (MC) postoperatively with prolonged need for mechanical ventilation. Patients with MG are often hypersensitive to the use of neuromuscular blocking agents that are administered to facilitate the delivery of general, endotracheal anesthesia, and their effects can be unpredictable. The risk of developing MC after thymectomy has been reported to be in the range of approximately 5% to 20%.1Li K.-K. Qian K. Feng Y.-G. Guo W. Tan Q.-Y. Deng B. Predictive factors of prolonged mechanical ventilation, overall survival, and quality of life in patients with post-thymectomy myasthenic crisis.World J Surg Oncol. 2017; 15: 150-156Crossref PubMed Scopus (10) Google Scholar, 2Xue L. Wang L. Dong J. Yuan Y. Fan H. Zhang Y. et al.Risk factors of myasthenic crisis after thymectomy for thymoma patients with myasthenia gravis.Eur J Cardiovasc Surg. 2017; 52: 692-697Crossref Scopus (28) Google Scholar, 3Leuzzi G. Meacci E. Cusumano G. Cesario A. Chiappetta M. Dall'armi V. et al.Thymectomy in myasthenia gravis: proposal for a predictive score of postoperative myasthenic crisis.Eur J Cardiothorac Surg. 2014; 45: e76-88Crossref PubMed Scopus (39) Google Scholar In this issue of the Journal, Jiang and colleagues4Jiang L. Depypere L. Rocco G. Chen J.S. Liu J. Shao W. et al.Spontaneous ventilation thoracoscopic thymectomy without muscle relaxant for myasthenia gravis: comparison with “standard” thoracoscopic thymectomy.J Thorac Cardiovasc Surg. 2018; 155: 1882-1889.e3Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar present a retrospective, comparative study of 2 cohorts of patients that underwent thoracoscopic thymectomy for MG: one cohort received standard, general endotracheal anesthesia during the surgical procedure, whereas the other was intubated with a laryngeal mask airway and allowed to spontaneously ventilate. The authors found a significantly lower rate of postoperative MC and a shorter hospital stay in the spontaneously breathing patients and should be commended on their continued work pioneering the performance of thoracic surgery in spontaneously breathing patients. Although the study clearly demonstrates the feasibility of the spontaneously breathing approach in thymectomy for MG, drawing definitive conclusions from the comparison of the 2 groups regarding the advantages of spontaneous ventilation over conventional general endotracheal anesthesia is more challenging. Although the authors used propensity matching to try to eliminate selection bias in some of the general baseline characteristics, this approach will not completely eliminate the effect of confounding factors in a retrospective series of patients. In addition, the 2 groups were managed differently in more ways other than the use of endotracheal intubation, especially regarding the uses of neuromuscular blocking agents and postoperative epidural pain control. Furthermore, it is difficult in a retrospective study to accurately analyze successful weaning from mechanical ventilation in the absence of a prospective protocol. Finally, the ability to draw conclusions regarding the length of hospital stay when factors other than medical necessity influence hospital discharge policies is extremely limited, which represents an issue in some countries outside of the United States. Despite these concerns, strategies aimed at determining the best anesthetic management of patients with MG undergoing thymectomy warrant further investigation. Although the authors have demonstrated technical feasibility of their approach to this problem, they will need to continue their work in the form of a prospective clinical trial, ultimately in a randomized fashion with established protocols to demonstrate any beneficial effect for these patients. Spontaneous ventilation thoracoscopic thymectomy without muscle relaxant for myasthenia gravis: Comparison with “standard” thoracoscopic thymectomyThe Journal of Thoracic and Cardiovascular SurgeryVol. 155Issue 4PreviewMyasthenia gravis (MG) benefits from thymectomy. However, its unpredictable response to muscle relaxants and volatile anesthetic agents may result in muscle weakness and subsequently in postoperative myasthenic crisis. The aim of this study was to determine the surgical outcomes after spontaneous ventilation compared with conventional intubated video-assisted thoracoscopic thymectomy (spontaneous-ventilation video-assisted thoracic thymectomy [SV-VATT] vs intubated video-assisted thoracic thymectomy) in patients with MG. Full-Text PDF Open Archive

Background. Positron emission tomography may have a role in the pretreatment workup of patients with thymic malignancies. This study was undertaken to determine the utility of the maximum standardized uptake value (SUVmax) in predicting histologic type and tumor stage in a large cohort of thymic epithelial tumors. Methods. The large, multiinstitutional, prospective database of The International Thymic Malignancy Interest Group (ITMIG) was queried for the use of positron emission tomography in the pretreatment workup of patients with thymic tumors. Data analyzed included demographics, SUVmax, histologic tumor type, and tumor stage. The distribution of SUVmax according to histologic type and Masaoka-Koga pathologic stage was determined, and the ability of SUVmax to predict these two variables was calculated using analysis of receiver operating characteristic curves. Results. Since 2012, data from 926 patients with thymic malignancies were entered into the ITMIG prospective database, of which 154 had a reported value for SUVmax. The area under the receiver operating characteristic curve for SUVmax in predicting histologic type and pathologic stage was 0.79 (95% confidence interval, 0.70 to 0.88; p < 0.001) and 0.81 (95% confidence interval, 0.73 to 0.88; p < 0.001), respectively. In addition, there was a significant relationship between SUVmax and histologic type (p < 0.001) as well as Masaoka-Koga pathologic stage (p < 0.001). Conclusions. Positron emission tomography has utility in predicting clinicopathologic features of thymic malignancies. These results may have clinical application in the pretreatment workup of patients with these rare tumors. (C) 2017 by The Society of Thoracic Surgeons

INTRODUCTION:Thymic carcinomas are rare epithelial malignancies with limited data to guide management. METHODS:To identify areas of agreement and variability in current clinical practice, a 16-question electronic survey was given to members of the International Thymic Malignancy Interest Group (ITMIG). Areas of controversy were discussed with the Thymic Carcinoma Working Group and consensus was achieved, as described. RESULTS:A total of 100 ITMIG members responded. There was general agreement regarding the role for multimodality therapy with definitive surgical resection in physically fit patients with advanced but resectable disease. Areas of controversy included the need for histologic confirmation before surgery, the role of adjuvant therapy, the optimal first-line chemotherapy regimen, and the recommended treatment course for marginally resectable disease with invasion into the great vessels, pericardium, and lungs. CONCLUSIONS:The results of the questionnaire provide a description of the management of thymic carcinoma by 100 ITMIG members with a specific interest or expertise in thymic malignancies. Although there was agreement in some areas, clinical practice appears to vary significantly. There is a great need for collaborative research to identify optimal evaluation and treatment strategies. Given the need for multimodality therapy in many cases, a multidisciplinary discussion of the management of patients with thymic carcinoma is critical.

Minimally invasive pulmonary resection for lung cancer benefits patients, regardless of the instrumentation used to conduct the operation.

Objectives: The aim of this study was to determine whether postoperative radiation therapy (PORT) is associated with an overall survival (OS) benefit in patients with completely resected Masaoka or Masaoka-Koga stage II and III thymoma.Methods: All patients with completely resected (R0) stage II or III thymoma were identified in a large database of the International Thymic Malignancy Interest Group. Clinical, pathologic, treatment, and follow-up information were extracted. OS was the primary end point. A univariate analysis using the log-rank test was performed, and a multivariate Cox model was created to identify factors associated with OS.Results: Of 1263 patients meeting the selection criteria, 870 (69%) had stage II thymoma. The WHO histologic subtype was A/AB in 360 patients (30%) and B1/B2/B3 in 827 (70%). PORT was given to 55% of patients (n = 689), 15% (n = 180) received chemotherapy, and 10% (n = 122) received both. The 5- and 10-year OS rates for patients having undergone an operation plus PORT were 95% and 86%, respectively, compared with 90% and 79% for patients receiving an operation alone (p = 0.002). This OS benefit remained significant when patients with stage II (p = 0.02) and stage III thymoma (p = 0.0005) were analyzed separately. On multivariate analysis, earlier stage, younger age, absence of paraneoplastic syndrome, and PORT were significantly associated with improved OS.Conclusions: We observed an OS benefit with the use of PORT in completely resected stage II and III thymoma. In the absence of a randomized trial, this represents the most comprehensive analysis of individual patient data and strong evidence in favor of PORT in this patient population. (C) 2016 International Association for the Study of Lung Cancer. Published by Elsevier Inc. All rights reserved.

We report the case of a 63-year-old woman who required emergent intubation after a choking episode at home. It resulted in a 5-cm tear in the membranous trachea. She was treated by placement of a temporary tracheal stent, which was successfully removed 3 months later.

Thymic epithelial tumors (TET) are uncommon tumors of the anterior mediastinum.Despite their rarity, they are actually the most common tumor type located in this mediastinal compartment.TET are comprised of three main types: thymoma (85-90%), thymic carcinoma (8-12%), and neuroendocrine tumors of the thymus (1-4%).Given the rare incidence of TET, it is not surprising that evidence-based practice patterns have not evolved to the extent that has been seen with other, more common malignancies.The published literature consists mainly of case reports and series, a few prospective, observational clinical trials, and no randomized controlled trials.Perhaps the most significant reason for the paucity of high quality published research is any given institution sees only a handful of cases per year, and the lack of the ability to perform coordinated research amongst centers.The only way to conduct high quality research regarding TET is to develop the infrastructure and commitment to coordinate studies between multiple institutions.To this end, a notable organization that has taken on this challenge in China is the Chinese Alliance for Research in Thymomas (ChART).Established in 2012, ChART organized retrospective data from over 2,300 patients from multiple institutions into a single database for research purposes.This dataset provides the basis for many of the studies presented in this Focused Issue of the Journal of Thoracic Disease.In addition to performing its own coordinated research, ChART has also contributed its data to the much larger, worldwide retrospective database of the International Thymic Malignancy Interest Group (ITMIG).ITMIG, founded in 2010, is an organization dedicated to research, education and support for patients with thymic malignancies with over 600 members worldwide.Building upon its success in developing its retrospective database comprising data from over 7,000 cases, ITMIG has also developed a prospective data collection mechanism that is utilized by member institutions on six continents, and is linked to a virtual tissue bank.These extremely large datasets allow ITMIG and its members to perform research studies that were never conceivable in the past due to the rarity of TET.On the educational front, ITMIG has established standard practice guidelines for clinicians who treat patients with TET, and has produced other educational tools and documents aimed at educating not only physicians, but also patients about these rare tumors.It is only through such collaborative mechanisms and organizations that knowledge regarding thymic tumors will be advanced in the future, which should also serve as model for performing research for other rare diseases.This Focused Issue of the Journal of Thoracic Disease is evidence of the progress allowed only through such collaboration.

OBJECTIVES:The latest World Health Organization (WHO) histological classification divides thymic epithelial tumours in thymomas and thymic carcinomas (TCs), the latter also including the neuroendocrine thymic tumours (NETTs). NETTs and other TC histotypes have been described to have a significantly lower survival than thymomas, but these two groups of tumours have rarely been compared directly. Using the European Society of Thoracic Surgeons and the International Thymic Malignancy Interest Group datasets, we wanted to study this issue. METHODS:This is a retrospective multicentre cohort study of patients operated for TC. Outcome measures were overall survival (OS) and recurrence-free survival (RFS). OS was analysed using the Kaplan-Meier method and RFS was assessed using competing risk analysis. The association with clinical and prognostic factors for OS and RFS was evaluated with log-rank test and Gray's test, respectively. RESULTS:A total of 1247 tumours (1042 TCs) were collected between 1984 and 2012. A R0 resection was performed in 363 TCs and in 52 NETTs. The median follow-up was 4.4 years for TCs and 4.1 years for NETTs. Owing to the missing values for survival information, a total of 728 TC patients and 132 NETTs were included in the OS analysis. Among them, 262 TC and 39 NETT patients died. The median OS was 6.6 years for TC and 7.5 years for NETTs. The overall 5-year survival rates were 60% for TC and 68% for NETTs; 10-year survival rates were 40% for TCs and 39% for NETTs (P = 0.19). Five-year RFS was 0.35 and 0.34 for TCs and NETTs (P = 0.36). On multivariate analysis, histology did not influence either OS (P = 0.79) or RFS (P = 0.59). CONCLUSIONS:This represents the largest clinical series of TCs and NETTs collected. Despite the biological aggressiveness of these rare neoplasms, the 5-year survival rate after resection is over 60% and TCs and NETT showed a similar rate of survival and recurrences after surgery.