Publications by authors named "Onkar Khullar"

35 Publications

Patient reported outcomes: integration into clinical practices.

J Thorac Dis 2020 Nov;12(11):6940-6946

Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA.

Patient-centered care is a growing focus of research and modern surgical practice. To this end, there has been an ever-increasing utilization of patient reported outcomes (PRO) and health-related quality of life metrics (HR-QOL) in thoracic surgery research. Here we describe reasons and methods for integration of PRO measurement into routine thoracic surgical practice, commonly utilized PRO measurement instruments, and several examples of successful integration.
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http://dx.doi.org/10.21037/jtd.2020.03.91DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7711395PMC
November 2020

Safety and Feasibility of Thoracoscopic Lung Resection for Non-Small-Cell Lung Cancer in Octogenarians.

Innovations (Phila) 2021 Jan-Feb;16(1):68-74. Epub 2020 Nov 27.

1371 Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA.

Objective: Octogenarians comprise an increasing proportion of patients presenting with non-small-cell lung cancer (NSCLC). This study examines postoperative morbidity and mortality, and long-term survival in octogenarians undergoing thoracoscopic anatomic lung resection for NSCLC, compared with younger cohorts.

Methods: We conducted a retrospective review of our institutional Society of Thoracic Surgeons General Thoracic Surgery Database of all patients ≥60 years old undergoing elective lobectomy or segmentectomy for pathologic stage I, II, and IIIA NSCLC between 2009 and 2018. Results were compared between octogenarians ( = 71) to 2 younger cohorts of 60- to 69-year-olds ( = 359) and 70- to 79-year-olds ( = 308). Long-term survival among octogenarians was graphically summarized using the Kaplan-Meier method. Cox regression analysis was used to identify preoperative risk factors for mortality.

Results: A greater proportion of octogenarians required intensive care unit admission and discharge to extended-care facilities; however, postoperative length of stay was similar between groups. Among postoperative complications, arrhythmia and renal failure were more likely in the older cohort. Compared to the youngest cohort, in-hospital and 30-day mortality were highest among octogenarians. Overall survival among octogenarians at 1, 3, and 5 years was 87.3%, 61.8%, and 50.5%, respectively. On multivariable Cox regression analysis of baseline demographic variables, presence of stroke (hazard ratio [HR] = 28.5, 95% confidence interval [CI]: 6.1 to 132.7, < 0.001) and coronary artery disease (HR = 2.5, 95% CI: 1.2 to 5.3, = 0.02) were significant predictors of overall mortality among octogenarians.

Conclusions: Thoracoscopic resection can be performed with favorable early postoperative outcomes among octogenarians. Long-term survival, although comparable to their healthy peers, is worse than those of younger cohorts. Further study into preoperative risk stratification and alternative therapies among octogenarians is needed.
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http://dx.doi.org/10.1177/1556984520971620DOI Listing
November 2020

Community Size and Lung Cancer Resection Outcomes: Studying the Society of Thoracic Surgery Database.

Ann Thorac Surg 2020 Nov 12. Epub 2020 Nov 12.

Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia.

Background: Socioeconomic factors play key roles in surgical outcomes. Socioeconomic data within the Society of Thoracic Surgery General Thoracic Surgery Database (STS GTSD) is limited. Therefore, we utilized community size as a surrogate to understand socioeconomic differences in lung cancer resection outcomes.

Methods: We retrospectively reviewed all lung cancer resections from January 2012 to January 2017 in the STS GTSD. This captured 68,722 patients from 286 centers nationwide. We then linked patient zip codes with 2013 Rural Urban Continuum Codes (RUCC) to understand the association between community size and postoperative outcomes. Demographic and clinical variables were evaluated for relationships with 30-day mortality, major morbidity, and readmission.

Results: Zip codes were included in 47.2% of patients. Zip coded patients were older, more comorbid, with less advanced disease, and more commonly treated with minimally invasive approaches than those without zip code classification. For geocoded patients, multivariable analyses demonstrated that sex, insurance payor, and hospital region were associated with all three major endpoints. Community size, based on RUCC coding, was not associated with any primary endpoint. Invasive mediastinal staging was related to morbidity, greater pathological stage predicted mortality, and worsened clinical stage was associated with readmission. More invasive surgery and greater extent of lung resection were associated with all primary endpoints.

Conclusions: Incomplete data capture can promote selection bias within the STS GTSD and skew outcomes reporting. Moreover, community size is an insufficient surrogate, compared to sex, insurance payor, hospital region, for understanding socioeconomic differences in lung cancer resection outcomes.
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http://dx.doi.org/10.1016/j.athoracsur.2020.08.076DOI Listing
November 2020

Association Between Patient Physical Function and Length of Stay After Thoracoscopic Lung Cancer Surgery.

Semin Thorac Cardiovasc Surg 2020 Nov 11. Epub 2020 Nov 11.

Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia. Electronic address:

Patient-reported outcomes (PRO) are an ideal method for measuring patient functional status. We sought to evaluate whether preoperative PRO were associated with resource utilization. We hypothesize that higher preoperative physical function PRO scores, measured via the NIH-sponsored Patient Reported Outcome Measurement Information System (PROMIS), are associated with shorter length of stay (LOS). Preoperative physical function scores were obtained using NIH PROMIS in a prospective observational study of patients undergoing minimally invasive surgery for lung cancer. Poisson regression models were constructed to estimate the association between the length of stay and PROMIS physical function T-score, adjusting for extent of resection, age, gender, and race. Due to the significant interaction between postoperative complications and physical function T-score, the relationship between physical function and LOS was described separately for each complication status. A total of 123 patients were included; 88 lobectomy, 35 sublobar resections. Mean age was 67 years, 35% were male, 65% were Caucasian. Among patients who had a postoperative complication, a lower preoperative physical function T-score was associated with progressively increasing LOS (P  value = 0.006). In particular, LOS decreased by 18% for every 10-point increase in physical function T-score. Among patients without complications, T-score was not associated with LOS (P = 0.86). Preoperative physical function measured via PRO identifies patients who are at risk for longer LOS following thoracoscopic lung cancer surgery. In addition to its utility for preoperative counseling and planning, these data may be useful in identifying patients who may benefit from risk-reduction measures.
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http://dx.doi.org/10.1053/j.semtcvs.2020.10.003DOI Listing
November 2020

Preoperative Lung Function is Associated with Patient Reported Outcomes After Lung Cancer Surgery.

Ann Thorac Surg 2020 Oct 29. Epub 2020 Oct 29.

Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, GA.

Background: Patient quality of life (QOL) is a critical outcomes measure in lung cancer surgery. Patient reported outcomes (PRO) provide valuable insight into the patient experience and allow measurement of pre- and post-operative QOL. Our objective was to determine which clinical factors predict differences in QOL, as measured by patient-reported physical function and pain intensity among patients undergoing minimally-invasive lung cancer surgery.

Methods: PRO surveys assessing physical function and pain intensity were conducted using instruments from the NIH Patient Reported Outcome Measurement Information System (PROMIS). PRO surveys were administered to patients undergoing minimally-invasive lung cancer resections at preoperative, one and six month postoperative time points, in an academic institution. Linear mixed-effects regression models were constructed to assess the association between clinical variables on PRO scores over time.

Results: A total of 123 patients underwent a thoracoscopic lung resection for cancer. Mean age of the cohort was 67±9.6, 43% were male, and 80% were Caucasian. When comparing clinical variables with PRO scores after surgery, lower DLCO was associated with significantly worse physical function (p<0.01) and greater pain intensity scores (p<0.01) at 6 months, with no differences identified at 1 month. No other studied clinical factor was associated with significant differences in PRO scores.

Conclusions: Low preoperative DLCO was associated with significant decreases in PRO following minimally-invasive lung cancer surgery. DLCO may be of utility in identifying patients who experience greater decline in QOL after surgery and for guiding surgical decision-making.
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http://dx.doi.org/10.1016/j.athoracsur.2020.09.016DOI Listing
October 2020

Percutaneous Tracheostomy With Apnea During Coronavirus Disease 2019 Era: A Protocol and Brief Report of Cases.

Crit Care Explor 2020 May 22;2(5):e0134. Epub 2020 May 22.

Section of Interventional Pulmonology, Division of Pulmonary Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA.

Objective: To assess feasibility of modified protocol during percutaneous tracheostomy in coronavirus disease 2019 pandemic era.

Design: A retrospective review of cohort who underwent percutaneous tracheostomy with modified protocol.

Settings: Medical, surgical, and neurologic ICUs.

Subjects: Patients admitted in medical, surgical, and neurologic units with prolonged need of mechanical ventilation or inability to liberate from the ventilator.

Interventions: A detailed protocol was written. Steps were defined to be performed before apnea and during apnea. A feasibility study of 28 patients was conducted. The key aerosol-generating portions of the procedure were performed with the ventilator switched to standby mode with the patient apneic.

Measurements And Main Results: Data including patient demographics, primary diagnosis, age, body mass index, and duration of apnea time during the tracheostomy were collected. Average ventilator standby time (apnea) during the procedure was 238 seconds (3.96 min) with range 149 seconds (2.48 min) to 340 seconds (5.66 min). Single-use (disposable) bronchoscopes (Ambu A/S [Ballerup, Denmark] or Glidescope [Verathon, Inc., Bothell, WA]) were used during all procedures except in nine. No desaturation events occurred during any procedure.

Conclusions: Percutaneous tracheostomy performed with apnea protocol may help minimize aerosolization, reducing risk of exposure of coronavirus disease 2019 to staff. It can be safely performed with portable bronchoscopes to limit staff and minimize the surfaces requiring disinfection post procedure.
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http://dx.doi.org/10.1097/CCE.0000000000000134DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7259562PMC
May 2020

ERAS and patient reported outcomes in thoracic surgery: a review of current data.

J Thorac Dis 2019 Apr;11(Suppl 7):S976-S986

Section of General Thoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA.

Quality-focused, cost-effective, patient-centered care is at the forefront of current healthcare reform. Recent data show that enhanced recovery after surgery (ERAS) results in improved surgical outcomes and decreased hospital costs. As a result, ERAS has been widely accepted among multiple surgical subspecialties as a modality for increasing the value of healthcare delivered to our patients. While this objective data is convincing for practitioners and administrators alike, how ERAS directly impacts the patient experience is unclear. Patient reported outcomes (PRO) are starting to drive patterns of healthcare delivery and influence surgical decision-making. In order to improve surgical outcomes and deliver patient-centered care, it is imperative that clinicians start reviewing objective metrics contained within morbidity and mortality data alongside subjective data regarding patients' experience. This article reviews the current data surrounding both ERAS and PROs within thoracic surgery and investigates how the two concepts are ultimately related.
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http://dx.doi.org/10.21037/jtd.2019.04.08DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6535471PMC
April 2019

Patient-Reported Outcomes: Time to Integrate Into Outcomes Reporting?

Semin Thorac Cardiovasc Surg 2019 Winter;31(4):856-860. Epub 2019 Jun 6.

Section of General Thoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia. Electronic address:

Historically, surgical outcomes research has focused on objective endpoints that are straightforward to measure and interpret using patient medical records, institutional databases, and national registries. In recent years, such data have been used to drive quality improvement, influence healthcare reform, and impact reimbursement of healthcare spending. In order to continue improving outcomes and deliver high-quality patient-centered care, it is imperative that clinicians review not only objective morbidity and mortality data, but also subjective data regarding patients' experience. Patient-reported outcomes (PRO) are starting to drive patterns of healthcare delivery and influence surgical decision-making. The current article reviews the historical background of PRO, tools for integrating it into surgical outcomes research, current data reported within the literature, and future implications within thoracic surgery.
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http://dx.doi.org/10.1053/j.semtcvs.2019.05.030DOI Listing
January 2020

Patient-Reported Outcomes in Cardiothoracic Surgery.

Ann Thorac Surg 2019 01;107(1):294-301

Section of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia. Electronic address:

Background: Current studies in cardiothoracic clinical research frequently fail to use end points that are most meaningful to patients, including measures associated with quality of life. Patient-reported outcomes (PROs) represent an underused but important component of high-quality patient-centered care. Our objective was to highlight important principles of PRO measurement, describe current use in cardiothoracic operations, and discuss the potential for and challenges associated with integration of PROs into large clinical databases.

Methods: We performed a literature review by using the PubMed/EMBASE databases. Clinical articles that focused on the use of PROs in cardiothoracic surgical outcomes measurement or clinical research were included in this review.

Results: PROs measure the outcomes that matter most to patients and facilitate the delivery of patient-centered care. When effectively used, PRO measures have provided detailed and nuanced quality-of-life data for comparative effectiveness research. However, further steps are needed to better integrate PROs into routine clinical care.

Conclusions: Incorporation of PROs into routine clinical practice is essential for delivering high-quality patient-centered care. Future integration of PROs into prospectively collected registries and databases, including that The Society of Thoracic Surgeons National Database, has the potential to enrich comparative effectiveness research in cardiothoracic surgery.
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http://dx.doi.org/10.1016/j.athoracsur.2018.06.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7025869PMC
January 2019

Excess Cost and Predictive Factors of Esophagectomy Complications in the SEER-Medicare Database.

Ann Thorac Surg 2018 11 23;106(5):1484-1491. Epub 2018 Jun 23.

Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia. Electronic address:

Background: Postoperative complications result in significantly increased health care expenditures. The objective of this study was to examine 90-day excess costs associated with inpatient complications after esophagectomy and their predictive factors, by using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database.

Methods: The study examined patients older than 65 years of age with a diagnosis from 2002 to 2009 and who were undergoing esophagectomy for cancer in the SEER-Medicare database. Quantile regression models were fit at 5% intervals for excess 90-day cost associated with perioperative complications while controlling for baseline characteristics. Excess cost was defined as the difference in total cost for patients with versus without the complication. Analyses were stratified by patients' characteristics to identify factors predictive of excess cost.

Results: A total of 1,462 patients were identified in the cohort; 51% had at least one complication. Significant excess cost was associated with pulmonary and mechanical wound complications across all quantiles (p < 0.05). Infectious (0.35 to 0.75 quantiles), intraoperative (0.05 to 0.85 quantiles), and systemic (0.30 to 0.85 quantiles) complications were associated with higher costs. Further, excess costs were significantly elevated in the higher quantiles. At the 0.50 quantile (median) of total cost distribution, excess cost in patients with any complication were significantly higher in patients with the following characteristics: transthoracic esophagectomy, emergency esophagectomy, Charlson Comorbidity Index >0, living in a nonmetropolitan area or poorer community, or treated in larger hospitals; no such difference was identified in patients without complications.

Conclusions: Complications after esophagectomy result in significant excess 90-day cost. Efforts at cost reduction and quality improvement will need to focus on reducing complications, in particular pulmonary and infectious, as well as risk factors for higher complication costs.
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http://dx.doi.org/10.1016/j.athoracsur.2018.05.062DOI Listing
November 2018

Long-term outcomes after near-infrared sentinel lymph node mapping in non-small cell lung cancer.

J Thorac Cardiovasc Surg 2018 03 14;155(3):1280-1291. Epub 2017 Dec 14.

Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Mass. Electronic address:

Objective: To report the first analysis of long-term outcomes using near-infrared (NIR) image-guided sentinel lymph node (SLN) mapping in non-small cell lung cancer (NSCLC).

Methods: Retrospective analysis of patients with NSCLC enrolled in 2 prospective phase 1 NIR-guided SLN mapping trials, including an indocyanine green (ICG) dose-escalation trial, was performed. All patients underwent NIR imaging for SLN identification followed by multistation mediastinal lymph node sampling (MLNS) and pathologic assessment. Disease-free (DFS) and overall survival (OS) were compared between patients with NIR SLN (SLN group) and those without (non-SLN group).

Results: SLN detection, recurrence, DFS, and OS were assessed in 42 patients with NSCLC who underwent intraoperative peritumoral ICG injection, NIR imaging, and MLNS. NIR SLNs were identified in 23 patients (SLN group), whereas SLNs were not identified in 19 patients enrolled before ICG dose and camera optimization (non-SLN group). Median follow-up was 44.5 months. Pathology from NIR SLNs was concordant with overall nodal status in all 23 patients. Sixteen patients with SLN were deemed pN0 and no recurrences were, whereas 4 of 15 pN0 non-SLN patients developed nodal or distant recurrent disease. Comparing SLN versus non-SLN pN0 patients, the probability of 5-year OS is 100% versus 70.0% (P = .062) and 5-year DFS is statistically significantly improved at 100% versus 66.1% (P = .036), respectively. Among the 11 pN+ patients, 7 were in the SLN group, with >40% showing metastases in the SLN alone.

Conclusions: Patients with pN0 SLNs showed favorable disease-free and overall survival. This preliminary review of NIR SLN mapping in NSCLC suggests that pN0 SLNs may better represent true N0 status. A larger clinical trial is planned to validate these findings.
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http://dx.doi.org/10.1016/j.jtcvs.2017.09.150DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5816699PMC
March 2018

Hospitalization Costs After Surgery in High-Risk Patients With Early Stage Lung Cancer.

Ann Thorac Surg 2018 Jan 24;105(1):263-270. Epub 2017 Nov 24.

Department of Surgery, Emory University School of Medicine, Atlanta, Georgia; Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia.

Background: We previously reported that early stage lung cancer patients who are considered high risk for surgery can undergo resection with favorable perioperative results and long-term mortality. To further elucidate the role of surgical resection in this patient cohort, this study evaluated the length of stay and total hospitalization cost among patients classified as standard or high risk with early stage lung cancer who underwent pulmonary resection.

Methods: A total of 490 patients from our institutional Society of Thoracic Surgeons data from 2009 to 2013 underwent resection for clinical stage I lung cancer. High-risk patients were identified by American College of Surgeons Oncology Group z4032-z4099 criteria. Demographics, length of stay, and hospitalization cost between high-risk and standard-risk patients undergoing lobectomy and sublobar resection were compared. Univariate analysis was performed using the chi-square test or Fisher's exact test. Multivariate analysis was performed using a linear regressions model.

Results: A total of 180 (37%) of patients were classified as high risk. These patients were older (70 years of age vs. 65 years of age; p < 0.0001), had worse forced expiratory volume in 1 second (57% vs. 85%; p < 0.0001), and had worse diffusion capacity of carbon dioxide (47% vs. 77%; p < 0.0001). The baseline cost and length of stay was represented by a thoracoscopic wedge resection in a standard-risk patient. A larger extent of resection, thoracotomy, or high-risk classification increased the cost and length of stay.

Conclusions: Our previous study showed that good clinical outcomes after surgery for early stage lung cancer can be achieved in patients classified as high risk. In this study, although surgery in high-risk patients led to slightly increased costs, these costs seemed negligible when viewed along with the patients' excellent short-term and long-term results. This study suggests that surgical resection on high-risk patients with early stage lung cancer is associated with acceptable hospital lengths of stay and overall cost when compared with standard-risk patients.
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http://dx.doi.org/10.1016/j.athoracsur.2017.08.038DOI Listing
January 2018

Patient-Reported Outcomes in Thoracic Surgery.

Thorac Surg Clin 2017 Aug 22;27(3):279-290. Epub 2017 May 22.

Section of General Thoracic Surgery, Emory University School of Medicine, 201 Dowman Drive, Atlanta, GA 30322, USA. Electronic address:

The existing thoracic surgical literature contains several retrospective and observational studies that include patient-reported outcomes. To deliver true patient-centered care, it will be necessary to universally gather patient-reported outcomes prospectively, including them in routine patient care, clinical registries, and clinical trials.
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http://dx.doi.org/10.1016/j.thorsurg.2017.03.007DOI Listing
August 2017

Pilot Study to Integrate Patient Reported Outcomes After Lung Cancer Operations Into The Society of Thoracic Surgeons Database.

Ann Thorac Surg 2017 Jul 5;104(1):245-253. Epub 2017 May 5.

Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia. Electronic address:

Background: A critical gap in The Society of Thoracic Surgeons (STS) Database is the absence of patient-reported outcomes (PRO), which are of increasing importance in outcomes and performance measurement. Our aim was to demonstrate the feasibility of integrating PRO into the STS Database for patients undergoing lung cancer operations.

Methods: The National Institutes of Health Patient Reported Outcome Measurement Information System (PROMIS) includes reliable, precise measures of PRO. We used validated item banks within PROMIS to develop a survey for patients undergoing lung cancer resection. PRO data were prospectively collected electronically on tablet devices and merged with our institutional STS data. Patients were enrolled over 18 months (November 2014 to May 2016). The survey was administered preoperatively and at 1 and 6 months after lung cancer resection.

Results: The study included 127 patients. All patients completed the initial postoperative survey, and 108 reached the 6-month follow-up. The most common procedure was video-assisted thoracic lobectomy (55%). At the first postoperative visit, there was a significant increase in pain, fatigue, and sleep impairment and a decrease in physical function. By 6 months, these PRO measures had generally improved toward baseline.

Conclusions: Collecting PRO data from lung cancer surgical patients and integrating the results into an institutional database is feasible. This pilot serves as a model for widespread incorporation of PRO data into the STS Database. Future integration of such data will continue to position the STS National Database as the gold standard for clinical registries. This will be necessary for assessing overall patient responses to different surgical therapies.
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http://dx.doi.org/10.1016/j.athoracsur.2017.01.110DOI Listing
July 2017

Prosthetic Reconstruction of the Chest Wall.

Thorac Surg Clin 2017 May 1;27(2):201-208. Epub 2017 Mar 1.

Section of General Thoracic Surgery, Emory University School of Medicine, 1365 Clifton Road, NE, Suite A2214, Atlanta, GA 30322, USA. Electronic address:

Large chest wall resections can result in skeletal instability, altered respiratory mechanics, and significant cosmetic defects. Here the authors review a variety of prostheses that can be used to reconstruct these defects, the indications for their use, the technique for implantation, and the available data regarding their clinical outcomes.
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http://dx.doi.org/10.1016/j.thorsurg.2017.01.014DOI Listing
May 2017

A novel technique for tumor localization and targeted lymphatic mapping in early-stage lung cancer.

J Thorac Cardiovasc Surg 2017 09 10;154(3):1110-1118. Epub 2017 Feb 10.

Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Mass. Electronic address:

Objective: To investigate safety and feasibility of navigational bronchoscopy (NB)-guided near-infrared (NIR) localization of small, ill-defined lung lesions and sentinel lymph nodes (SLN) for accurate staging in patients with non-small cell lung cancer (NSCLC).

Methods: Patients with known or suspected stage I NSCLC were enrolled in a prospective pilot trial for lesion localization and SLN mapping via NB-guided NIR marking. Successful localization, SLN detection rates, histopathologic status of SLN versus overall nodes, and concordance to initial clinical stage were measured. Ex vivo confirmation of NIR SLNs and adverse events were recorded.

Results: Twelve patients underwent NB-guided marking with indocyanine green of lung lesions ranging in size from 0.4 to 2.2 cm and located 0.1 to 3 cm from the pleural surface. An NIR "tattoo" was identified in all cases. Ten patients were diagnosed with NSCLC and 9 SLNs were identified in 8 of the 10 patients, resulting in an 80% SLN detection rate. SLN pathologic status was 100% sensitive and specific for overall nodal status with no false-negative results. Despite previous nodal sampling, one patient was found to have metastatic disease in the SLN alone, a 12.5% rate of disease upstaging with NIR SLN mapping. SLN were detectable for up to 3 hours, allowing time for obtaining a tissue diagnosis and surgical resection. There were no adverse events associated with NB-labeling or indocyanine green dye itself.

Conclusions: NB-guided NIR lesion localization and SLN identification was safe and feasible. This minimally invasive image-guided technique may permit the accurate localization and nodal staging of early stage lung cancers.
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http://dx.doi.org/10.1016/j.jtcvs.2016.12.058DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5552457PMC
September 2017

Midesophageal Pulsion Diverticulum Resulting From Hypercontractile (Jackhammer) Esophagus.

Ann Thorac Surg 2017 Feb;103(2):e127-e129

Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.

We report a patient with significant dysphagia from hypercontractile "jackhammer" esophagus and a midesophageal pulsion diverticulum. This was treated with a thoracoscopic diverticulectomy and a long esophageal myotomy sparing the lower esophageal sphincter (LES). We describe the clinical diagnosis and surgical treatment of this uncommon esophageal motility disorder. To our knowledge, this is the first report in the literature of a midesophageal diverticulum caused by jackhammer esophagus. We propose that in the setting of normal LES function, successful treatment should include diverticulectomy with an LES-sparing myotomy.
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http://dx.doi.org/10.1016/j.athoracsur.2016.07.030DOI Listing
February 2017

Time is Money: Hospital Costs Associated With Video-Assisted Thoracoscopic Surgery Lobectomies.

Ann Thorac Surg 2016 Sep 19;102(3):940-947. Epub 2016 May 19.

Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia. Electronic address:

Background: Proposed changes in health care will place an increasing burden on surgeons to care for patients more efficiently to minimize cost. We reviewed costs surrounding video-assisted thoracoscopic surgery (VATS) lobectomies to see where changes could be made to ensure maximum value.

Methods: We queried The Society of Thoracic Surgeons database for all VATS lobectomies performed for lung cancer from January 2011 to December 2013. Clinical data were linked with hospital financial data to determine hospital expenditures for each patient.

Results: In all, 263 VATS lobectomies were included. Mean operating room time was 236 minutes, and median length of stay was 4 days. Mean hospital cost was $19,769. The majority of cost (58%) was attributed to operating room and floor costs (length of stay), and the majority of operating room costs were secondary to room rate and staplers. A total of 77 complications, as defined by STS, occurred in the cohort; 41 patients had only one complication, 11 patients had two complications, and 6 patients had three or more complications. The occurrence of one complication was associated with a net loss of $496 whereas two complications in a patient led to a $3,882 net loss. Overall, complications were independently correlated with significant cost increases.

Conclusions: Our study shows that the most significant costs associated with VATS lobectomies relate to operating room time, stapler use, floor charges, and cost associated with complications. Cost-reducing strategies will need to concentrate on optimizing operating room times and reducing length of stay while simultaneously minimizing complications.
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http://dx.doi.org/10.1016/j.athoracsur.2016.03.024DOI Listing
September 2016

Transthoracic versus transhiatal resection for esophageal adenocarcinoma of the lower esophagus: A value-based comparison.

J Surg Oncol 2015 Oct 16;112(5):517-23. Epub 2015 Sep 16.

Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.

Background And Objective: Our objective was to compare clinical outcomes, costs, and resource use based on operative approach, transthoracic (TT) or transhiatal (TH), for resection of esophageal cancer.

Methods: This cohort analysis utilized the Surveillance, Epidemiology, and End Results--Medicare linked data from 2002 to 2009. Only adenocarcinomas of the lower esophagus were examined to minimize confounding. Medicare data was used to determine episode of care costs and resource use. Propensity score matching was used to control for identified confounders. Kaplan-Meier method and Cox-proportional hazard modeling were used to compare long-term survival.

Results: 537 TT and 405 TH resections were identified. TT and TH esophagectomy had similar complication rates (46.7% vs. 50.8%), operative mortality (7.9% vs 7.1%), and 90 days readmission rates (30.5% vs. 32.5%). However, TH was associated with shorter length of stay (11.5 vs. 13.0 days, P = 0.006) and nearly $1,000 lower cost of initial hospitalization (P = 0.03). No difference in 5-year survival was identified (33.5% vs. 36%, P = 0.75).

Conclusions: TH esophagectomy was associated with lower costs and shorter length of stay in an elderly Medicare population, with similar clinical outcomes to TT. The TH approach to esophagectomy for distal esophageal adenocarcinoma may, therefore, provide greater value (quality/cost).
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http://dx.doi.org/10.1002/jso.24024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4664447PMC
October 2015

Survival After Sublobar Resection versus Lobectomy for Clinical Stage IA Lung Cancer: An Analysis from the National Cancer Data Base.

J Thorac Oncol 2015 Nov;10(11):1625-33

*Division of Cardiothoracic Surgery, †Biostatistics and Bioinformatics Shared Resource at Winship Cancer Institute, ‡Rollins School of Public Health, §Department of Hematology and Medical Oncology, ‖Department of Surgery, ¶Department of Radiation Oncology, and #Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia.

Background: Recent data have suggested possible oncologic equivalence of sublobar resection with lobectomy for early-stage non-small-cell lung cancer (NSCLC). Our aim was to evaluate and compare short-term and long-term survival for these surgical approaches.

Methods: This retrospective cohort study utilized the National Cancer Data Base. Patients undergoing lobectomy, segmentectomy, or wedge resection for preoperative clinical T1A N0 NSCLC from 2003 to 2011 were identified. Overall survival (OS) and 30-day mortality were analyzed using multivariable Cox proportional hazards models, logistic regression models, and propensity score matching. Further analysis of survival stratified by tumor size, facility type, number of lymph nodes (LNs) examined, and surgical margins was performed.

Results: A total of 13,606 patients were identified. After propensity score matching, 987 patients remained in each group. Both segmentectomy and wedge resection were associated with significantly worse OS when compared with lobectomy (hazard ratio: 1.70 and 1.45, respectively, both p < 0.001), with no difference in 30-day mortality. Median OS for lobectomy, segmentectomy, and wedge resection were 100, 74, and 68 months, respectively (p < 0.001). Finally, sublobar resection was associated with increased likelihood of positive surgical margins, lower likelihood of having more than three LNs examined, and significantly lower rates of nodal upstaging.

Conclusion: In this large national-level, clinically diverse sample of clinical T1A NSCLC patients, wedge and segmental resections were shown to have significantly worse OS compared with lobectomy. Further patients undergoing sublobar resection were more likely to have inadequate lymphadenectomy and positive margins. Ongoing prospective study taking into account LN upstaging and margin status is still needed.
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http://dx.doi.org/10.1097/JTO.0000000000000664DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5798611PMC
November 2015

Epstein-Barr Virus-Associated Pulmonary Smooth Muscle Tumor After Lung Transplantation.

Ann Thorac Surg 2015 Jun;99(6):e145-6

Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia. Electronic address:

We report an Epstein-Barr virus (EBV)-associated pulmonary posttransplant smooth muscle tumor arising in the left lung of a 71-year-old bilateral lung transplant recipient nearly 3 years after transplantation, treated with thoracoscopic wedge resection. Four previous smooth muscle tumors have been reported following lung transplantation. To our knowledge, this is the first reported case of an EBV-positive posttransplant smooth muscle tumor within the transplanted lung. We describe the clinical, pathologic, and histologic diagnosis of this uncommon tumor.
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http://dx.doi.org/10.1016/j.athoracsur.2015.02.097DOI Listing
June 2015

Socioeconomic risk factors for long-term mortality after pulmonary resection for lung cancer: an analysis of more than 90,000 patients from the National Cancer Data Base.

J Am Coll Surg 2015 Feb 27;220(2):156-168.e4. Epub 2014 Oct 27.

Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA. Electronic address:

Background: Several clinical variables, such as tumor stage and age, are well established factors associated with long-term survival after surgical resection of lung cancer. Our aim was to examine the impact of other clinical and demographic variables, controlling for known predictors of long-term survival, in order to investigate how outcomes varied according to important nonclinical factors.

Study Design: The National Cancer Data Base, jointly supported by the Commission on Cancer of the American College of Surgeons and the American Cancer Society, was used to identify patients undergoing pulmonary resection for lung cancer and perform a retrospective cohort study. The cohort consisted of patients diagnosed with nonsmall cell lung cancer from 2003 to 2006, who underwent resection; overall survival data are available only for patients diagnosed through 2006. A Cox proportional hazards survival model was used to examine factors associated with risk of mortality.

Results: A total of 92,929 patients were identified as diagnosed during the study period and undergoing surgical resection for lung cancer. On multivariable analysis, several socioeconomic factors such as lack of insurance, lower income, less education, and treatment at community centers vs academic or research programs predicted worse overall survival after controlling for disease characteristics known to be predictors of worse survival, such as tumor stage, histology, age, and extent of resection.

Conclusions: Diminished long-term survival after pulmonary resection was associated with a number of socioeconomic factors. To date, this represents the largest database analysis of long-term mortality in patients undergoing surgical resection for lung cancer. The disparities in survival outcomes reported here require further detailed investigation.
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http://dx.doi.org/10.1016/j.jamcollsurg.2014.10.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4297595PMC
February 2015

Hospital readmission is associated with poor survival after esophagectomy for esophageal cancer.

Ann Thorac Surg 2015 Jan 11;99(1):292-7. Epub 2014 Nov 11.

Department of Surgery, Emory University School of Medicine, Atlanta, Georgia.

Background: Hospital readmissions are costly and associated with inferior patient outcomes. There is limited knowledge related to readmissions after esophagectomy for malignancy. Our aim was to determine the impact on survival of readmission after esophagectomy.

Methods: This cohort study utilizes Surveillance, Epidemiology, and End Results-Medicare data (2002 to 2009). Survival, length of stay, 30-day readmissions, and discharge disposition were determined. Multivariate logistic regression models were created to examine risk factors associated with readmission.

Results: In all, 1,744 patients with esophageal cancer underwent esophagectomy: 80% of patients (1,390) were male, and mean age was 73 years; 71.8% of tumors (1,251) were adenocarcinomas, and 72.5% (1,265) were distal esophageal tumors; 38% of patients (667) received induction therapy. Operative approach was transthoracic in 52.6% of patients (918) and transhiatal in 37.4% (653), and required complex reconstruction (intestinal interposition) in 9.9% (173). Stage distribution was as follows: stage I, 35.3% (616); stage II, 32.5% (566); stage III, 27.9% (487); and stage IV, 2.3% (40). Median length of stay was 13 days, hospital mortality was 9.3% (158 patients), and 30-day readmission rate was 18.6% (212 of 1,139 home discharges); 25.4% of patients (443) were discharged to institutional care facilities. Overall survival was significantly worse for patients who were readmitted (p < 0.0001, log rank test). Risk factors for readmission were comorbidity score of 3+, urgent admission, and urban residence.

Conclusions: Hospital readmissions after esophagectomy for cancer occur frequently and are associated with worse survival. Improved identification of patients at risk for readmission after esophagectomy can inform patient selection, discharge planning, and outpatient monitoring. Optimization of such practices may lead to improved outcomes at reduced cost.
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http://dx.doi.org/10.1016/j.athoracsur.2014.07.052DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4282960PMC
January 2015

Identification of metastatic nodal disease in a phase 1 dose-escalation trial of intraoperative sentinel lymph node mapping in non-small cell lung cancer using near-infrared imaging.

J Thorac Cardiovasc Surg 2013 Sep 19;146(3):562-70; discussion 569-70. Epub 2013 Jun 19.

Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Mass 02115, USA.

Objectives: Early-stage non-small cell lung cancer (NSCLC) has a high recurrence rate and poor 5-year survival, particularly if lymph nodes are involved. Our objective was to perform a dose-escalation study to assess safety and feasibility of intraoperative near-infrared (NIR) fluorescence imaging to identify the first tumor-draining lymph nodes (ie, sentinel lymph nodes [SLNs] in patients with NSCLC).

Methods: A-dose escalation phase 1 clinical trial assessing real-time NIR imaging after peritumoral injection of 3.8 to 2500 μg indocyanine green (ICG) was initiated in patients with suspected stage I/II NSCLC. Visualization of lymphatic migration, SLN identification, and adverse events were recorded.

Results: Thirty-eight patients underwent ICG injection and NIR imaging via thoracotomy (n = 18) or thoracoscopic imaging (n = 20). SLN identification increased with ICG dose, with fewer than 25% SLNs detected in dose cohorts of 600 μg or less versus 89% success at 1000 μg or greater. Twenty-six NIR(+) SLNs were identified in 15 patients, with 7 NIR(+) SLNs (6 patients) harboring metastatic disease on histologic analysis. Metastatic nodal disease was never identified in patients with a histologically negative NIR(+) SLN. No adverse reactions were noted.

Conclusions: NIR-guided SLN identification with ICG was safe and feasible in this initial dose-escalation trial. ICG doses greater than 1000 μg yielded nearly 90% intrathoracic SLN visualization, with the presence or absence of metastatic disease in the SLN directly correlating with final nodal status of the lymphadenectomy specimen. Further studies are needed to optimize imaging parameters and confirm sensitivity and specificity of SLN mapping in NSCLC using this promising imaging technique.
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http://dx.doi.org/10.1016/j.jtcvs.2013.04.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3748170PMC
September 2013

Effective low-dose escalation of indocyanine green for near-infrared fluorescent sentinel lymph node mapping in melanoma.

Ann Surg Oncol 2013 Jul 26;20(7):2357-63. Epub 2013 Feb 26.

Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.

Background: Regional lymph node metastasis is the strongest prognostic factor in patients with melanoma. Published reports that used lymphoscintigraphy with radioactive colloids and blue dye demonstrated accurate sentinel lymph node (SLN) identification in inguinal nodes and axillary nodes, but decreased accuracy in cervical, popliteal, epitrochlear, and parascapular nodes. Near-infrared imaging (NIR) may utilize indocyanine green (ICG) to improve SLN identification. The safety, feasibility and optimal dose of albumin-bound ICG (ICG:HSA) was assessed by NIR to improve SLN mapping in patients with melanoma.

Methods: Twenty-five consecutive patients with biopsy-proven melanoma underwent standard SLN mapping with preoperatively administered technetium-99 m nanocolloid (Tc-99 m). Intraoperative NIR fluorescence imaging was performed after injection of 1.0 ml of 100, 250 or 500 μM of ICG:HSA in four quadrants around the primary lesion.

Results: NIR fluorescent imaging demonstrated accuracy of 98 % when compared with radioactive colloid. A total of 65 lymph nodes were identified (65 with Tc-99 m, 64 with ICG:HSA). Overall, successful mapping that used either technique was 96 % as one patient failed to map with either modality. As the dose of ICG was increased, the signal-to-background ratio increased from a median of 3.1 to 8.4 to 10.9 over the range of 100, 250, and 500 μM, respectively.

Conclusions: SLN mapping with ICG:HSA is feasible and accurate in melanoma. ICG has the added advantage of a low cost and an intraoperative technique that does not alter the surgical field, thus allowing for easy identification of SLNs.
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http://dx.doi.org/10.1245/s10434-013-2905-xDOI Listing
July 2013

Preclinical study of near-infrared-guided sentinel lymph node mapping of the porcine lung.

Ann Thorac Surg 2013 Jan 25;95(1):312-8. Epub 2012 Oct 25.

Division of Thoracic Surgery, Brigham & Women's Hospital, Boston, Massachusetts, USA.

Background: The presence of lymph node metastasis is the most important prognostic factor in early non-small cell lung cancer. Our objective was to develop a rapid, simple, and reliable method for thoracic sentinel lymph node (SLN) identification using near-infrared fluorescence imaging and clinically available contrast agents.

Methods: Indocyanine green (ICG) reconstituted in saline, human serum albumin, human fresh frozen plasma, and autologous porcine plasma was evaluated for optimal formulation and dosing for SLN within porcine lungs. Animals were imaged using the fluorescence-assisted resection and exploration for surgery imaging system. The SLN identification rate, time to identification and fluorescence intensity of the SLN, bronchus, and background were measured.

Results: The SLN identification rates varied widely, ranging from 33% to 100% as a function of the carrier used for ICG reconstitution. No significant difference was noted in SLN fluorescence intensity; however, bronchial intensity was significantly higher with ICG: albumin, which resulted in the lowest rate of SLN identification. Subsequent evaluation with 125 μM and 250 μM ICG:porcine plasma resulted in identification of strongly fluorescent SLNs, with identification rates of 93% and 100% and median signal-to-background ratios of 8.5 and 12.15, respectively, in less than 2 minutes in situ.

Conclusions: Near-infrared fluorescence imaging with ICG is a reliable method for SLN mapping in the lung with high sensitivity. Mixing of ICG with plasma resulted in strong SLN fluorescence signal with reliable identification rates.
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http://dx.doi.org/10.1016/j.athoracsur.2012.08.101DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3600556PMC
January 2013

Developing intrathoracic sentinel lymph node mapping with near-infrared fluorescent imaging in non-small cell lung cancer.

J Thorac Cardiovasc Surg 2012 Sep 20;144(3):S80-4. Epub 2012 Jun 20.

Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA, USA.

With poor survival and high recurrence rates, early-stage lung cancer currently appears to be understaged or undertreated, or both. Although sentinel lymph node biopsy is standard for patients with breast cancer and melanoma, its success has been unreliable in non-small cell lung cancer. Sentinel lymph node biopsy might aid in the identification of lymph nodes at the greatest risk of metastasis and allow for more detailed analysis to select for patients who might benefit from adjuvant therapy. The early results in our recent clinical trial of patients with early-stage lung cancer have suggested that near-infrared imaging might offer a platform for reliable sentinel lymph node identification in these patients.
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http://dx.doi.org/10.1016/j.jtcvs.2012.05.072DOI Listing
September 2012

Video-assisted thoracoscopic mediastinal lymph node dissection.

J Thorac Cardiovasc Surg 2012 Sep 5;144(3):S32-4. Epub 2012 Jun 5.

Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.

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http://dx.doi.org/10.1016/j.jtcvs.2012.05.026DOI Listing
September 2012

Nanoparticle migration and delivery of Paclitaxel to regional lymph nodes in a large animal model.

J Am Coll Surg 2012 Mar 5;214(3):328-37. Epub 2012 Jan 5.

Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, MA 02115, USA.

Background: The aim of this study was to demonstrate feasibility of migration and in situ chemotherapy delivery to regional lymph nodes (LN) in a large animal model using an expansile polymer nanoparticle (eNP) delivery system.

Study Design: Dual-labeled 50-nm and 100-nm eNP were prepared by encapsulating an IR-813 near-infrared (NIR) fluorescent dye within coumarin-conjugated expansile polymer nanoparticles (NIR-C-eNP). NIR imaging and fluorescent microscopy were used to identify intralymphatic migration of NIR-nanoparticles to draining inguinal or mesenteric LN after injection in swine hind legs or intestine. Nanoparticle-mediated intranodal delivery of chemotherapy was subsequently assessed with Oregon Green paclitaxel-loaded NIR-eNP (NIR-OGpax-eNP).

Results: NIR imaging demonstrated direct lymphatic migration of 50-nm, but not 100-nm, NIR-C-eNP and NIR-OGpax-eNP to the draining regional LNs after intradermal injection in the hind leg or subserosal injection in intestine. Fluorescent microscopy demonstrated that IR-813 used for NIR real-time trafficking colocalized with both the coumarin-labeled polymer and paclitaxel chemotherapy and was identified within the subcapsular spaces of the draining LNs. These studies verify nodal migration of both nanoparticle and encapsulated payload, and confirm the feasibility of focusing chemotherapy delivery directly to regional nodes.

Conclusions: Regionally-targeted intranodal chemotherapy can be delivered to draining LNs for both skin and solid organs using 50-nm paclitaxel-loaded eNP.
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http://dx.doi.org/10.1016/j.jamcollsurg.2011.11.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3288886PMC
March 2012

Paclitaxel-loaded expansile nanoparticles delay local recurrence in a heterotopic murine non-small cell lung cancer model.

Ann Thorac Surg 2011 Apr;91(4):1077-83; discussion 1083-4

Division of Thoracic Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.

Background: Surgical resection remains the most effective treatment option for patients with early stage non-small cell lung cancer; however, comorbidities and poor pulmonary reserve often limit the extent of resection. Limited resections are associated with a twofold to threefold increase in locoregional recurrence, suggesting that microscopic disease remains near the resection margin. We hypothesized that local delivery of paclitaxel through 100-nm expansile polymer nanoparticles (pax-eNP) immediately after tumor resection could prevent local recurrence.

Methods: Primary tumors, initiated on the dorsum of C57BL/6J mice through subcutaneous injection of 750,000 Lewis lung carcinoma cells, were excised when tumor volume reached 300 mm(3). After resection, animals were randomized to receive 300 μg paclitaxel intravenously or as pax-eNP locally at the tumor resection site versus unloaded eNP or saline controls.

Results: In all mice receiving saline, unloaded eNP, or paclitaxel intravenously, visible local tumor recurrence developed at a median of 6 days. In contrast, tumor recurrence after pax-eNP was delayed to 10 days (pax-eNP versus all other groups, Kaplan-Meier, p < 0.05). Delay in local recurrence was associated with increased survival in the pax-eNP group (16 days) versus all other groups (11 and 12 days, p < 0.05).

Conclusions: The pax-eNP placed at the time of surgical resection delayed local tumor recurrence and modestly prolonged survival in a murine Lewis lung carcinoma recurrence model.
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http://dx.doi.org/10.1016/j.athoracsur.2010.12.040DOI Listing
April 2011