Irmina A. Elliott, MD

All Publications

• ACR Appropriateness Criteria® Management of Chylothorax. Journal of the American College of Radiology : JACR Monroe, E. J., Kim, C. Y., Ahmed, O., Cline, B., Elliott, I. A., Hirasaki, K., Liles, A., Makary, M. S., Molena, D., Tomihama, R. T., Uppot, R. N., Fidelman, N. 2026

  Abstract

  Chylothorax, the accumulation of lymphatic fluid within the pleural cavity, results from disruption or obstruction of the thoracic duct or its tributaries, or from transdiaphragmatic chylous ascites. When severe, this condition may impair respiratory function and induce metabolic complications because of chronic loss of protein and lipids. Management strategies ranging from dietary modifications, medical therapy, surgical ligation, pleurodesis, and lymphatic embolization, generally follow a tiered approach. Special considerations apply to chylothorax associated with central venous obstruction or concurrent chylous ascites, sometimes requiring unique management strategies. The various approaches to the management of chylothorax and their appropriateness in a variety of clinical circumstances are discussed. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

  View details for DOI 10.1016/j.jacr.2026.01.029

  View details for PubMedID 41790078

• Endoscopic findings predictive of pathologic upstaging in T2N0 esophageal cancer JTCVS OPEN Tsai, L. L., Bommakanti, S., Kapula, N., Satoyoshi, M., Aboujudom, C., Elliott, I. A., Guenthart, B. A., Liou, D. Z., Lui, N. S., Backhus, L. M., Shrager, J. B., Berry, M. F. 2026; 29

  View details for DOI 10.1016/j.xjon.2025.101561

  View details for Web of Science ID 001703993700009

• A novel robotic-assisted lung lobectomy simulation model. JTCVS open Chang, C. C., Kapula, N., Kim, J. J., Choi, A., Elliott, I. A., Liou, D. Z., Backhus, L. M., Berry, M. F., Shrager, J. B., Guenthart, B. A., Lui, N. S. 2025; 28: 593-602

  Abstract

  Although most thoracic surgery programs seek robotic-competent partners, more than one half of graduating residents report needing more training. We aimed to develop a reproducible, high-fidelity model that serves as an effective training tool for surgeons at all levels.Porcine heart-lung blocks were prepped for a left upper lobectomy and cannulated to distend the vasculature using an artificial blood substitute capable of simulating bleeding. A linear actuator was positioned beneath a platform to simulate a heartbeat, and a da Vinci Xi robotic system (Intuitive Surgical) was docked above it. Participants performed 3 key steps of a left upper lobectomy, then evaluated fidelity of model features and training value using the Likert scale. Pre- and postsimulation confidence were reported (institutional review board approval no. 76506).Among 20 participants, 15 were trainees (75%) and 5 were faculty (25%). Trainees reported a median of 26 bedside (interquartile range, 15-48) and 5 console cases (interquartile range, 3-30). Faculty experience ranged from <5 to >20 years. The model was rated highly for fidelity, with 100% (n = 9) of features receiving a Likert score ≥4 from faculty, with stapling rated highest (5.0 ± 0.0). Trainees rated 89% of features ≥4, with stapling (4.7 ± 0.4) and lung tissue handling (4.7 ± 0.5) rated highest. Both groups rated the simulation as highly valuable, with trainee confidence significantly improving postsimulation (2.5-3.9, P = .0014).The model was rated highly for fidelity and value by both trainees and faculty, and significantly improved trainee confidence. This model offers an effective and reproducible training tool for individual program implementation.

  View details for DOI 10.1016/j.xjon.2025.10.006

  View details for PubMedID 41473062

  View details for PubMedCentralID PMC12745124

• A novel robotic-assisted lung lobectomy simulation model JTCVS OPEN Chang, C. C., Kapula, N., Kim, J. J., Choi, A., Elliott, I. A., Liou, D. Z., Backhus, L. M., Berry, M. F., Shrager, J. B., Guenthart, B. A., Lui, N. S. 2025; 28: 593-602

  View details for DOI 10.1016/j.xjon.2025.10.006

  View details for Web of Science ID 001639240900001

• The Association of Short-Term Outcomes and Long-Term Survival After Lung Cancer Resection. The Journal of thoracic and cardiovascular surgery Woodson, D. R., Kapula, N., Liou, D. Z., Elliott, I. A., Shrager, J. B., Berry, M. F. 2025

  Abstract

  Quality metrics that compare care across institutions are typically based on short-term outcomes. This study evaluated whether short-term quality metrics for non-small cell lung cancer (NSCLC) resections predict long-term survival.Centers in the National Cancer Database that performed ≥ 30 NSCLC resections between 2010-2019 were ranked based on major postoperative morbidity, defined as a weighted composite of 30-day mortality, unplanned readmissions, and hospital stays longer than 14 days. Centers were stratified by morbidity rates into quintiles, with the top quintile designated high-quality. The impact of care at high-quality institutions on survival was assessed with Kaplan-Meier analysis and Cox proportional hazards modeling.The study included 198,115 patients from 928 centers. High-quality centers had lower 30-day mortality (0.8% [362/47,321] vs 2.4% [3,614/150,794], p<0.001) and morbidity rates (median 5% [Interquartile Range {IQR} 4.0%-5.9%] vs 10.8% [IQR 8.7%-14.0%], p<0.001) than non-high-quality centers. Patients treated at high-quality centers had improved long-term survival compared to other patients in both univariable (5-year survival 71.5% [95% Confidence Interval {CI} 71.0-71.9%] vs 62.6% [95% CI 62.3-62.8%], p<0.0001) and multivariable analysis (hazard ratio [HR] 0.75 [95% CI 0.73-0.77], p<0.001). Sensitivity analysis of stage IA patients treated with lobectomy and no induction therapy showed similar survival benefits to care at high-quality centers in both univariable (5-year survival 79% [95% CI 78.3-79.7%] vs 73.2% [95% CI 72.8-73.6%], p<0.001) and multivariable (HR 0.76 [95% CI 0.73-0.78], p<0.001) analyses.Patients who underwent lung cancer resection at institutions deemed high-quality based on short-term outcomes also had better long-term survival.

  View details for DOI 10.1016/j.jtcvs.2025.11.007

  View details for PubMedID 41260411

• Assessment of Postoperative Chylothorax Volume Threshold Associated with Failed Conservative Management. The Annals of thoracic surgery Lin, N., Kapula, N., Wallen, B., Kim, J., Manapat, P., Kamtam, D., Guenthart, B., Elliott, I., Lui, N., Backhus, L., Shrager, J., Berry, M., Liou, D. Z. 2025

  Abstract

  BACKGROUND: Management of postoperative chylothorax typically involves a stepwise strategy of initial conservative management followed by lymphangiography and re-operation when conservative management fails. This study tested the hypothesis that high-volume chylothorax drainage over the first 48 hours is associated with failure of conservative management.METHODS: Our institutional database was queried for patients who developed chylothorax following lung, foregut, or mediastinal surgery and underwent initial conservative management between 2009 and 2024. Patients were stratified according to whether the chylothorax resolved with conservative management versus intervention with lymphangiography and/or re-operation. Daily thoracostomy tube drainage was evaluated, and a 48-hour chylothorax volume cut-off point associated with failure of conservative management was calculated by using Youden's index from the receiver operating characteristic (ROC) curve. Predictors of failed conservative management were estimated using multivariable logistic regression.RESULTS: Seventy-seven patients experienced postoperative chylothorax, including 43 (56%) after lung resection, 22 (29%) after esophageal surgery, and 12 (16%) after mediastinal surgery. Forty-eight (62%) patients were successfully managed conservatively while 29 (38%) patients required intervention. Daily chylothorax drainage was significantly lower in patients who required conservative management. The area under the ROC curve was 0.75, and the 48-hour chylothorax volume cut-off point was 1,110 mL based on Youden's index. This cut-off was associated with a nearly 4-fold increased risk of failed conservative management (AOR 3.84, p=0.023).CONCLUSIONS: Patients who develop postoperative chylothorax with drainage >1,100 mL over the first 48 hours should be considered for early intervention with lymphangiography or re-operation given the likelihood of failing conservative management.

  View details for DOI 10.1016/j.athoracsur.2025.10.015

  View details for PubMedID 41203002

• Accuracy of DOTATATE-positron emission tomography for preoperative nodal staging of carcinoid tumors of the lung. JTCVS open Tsai, L. L., Bommakanti, S., Sridharan, S., Myall, N. J., Guenthart, B. A., Liou, D. Z., Lui, N. S., Backhus, L. M., Berry, M. F., Shrager, J. B., Elliott, I. A. 2025; 27: 157-163

  Abstract

  DOTATATE-positron emission tomography (PET) scans use a radiotracer that binds somatostatin receptor 2 on neuroendocrine cells to identify carcinoid tumors. Use of DOTATATE-PET during preoperative evaluation of lung carcinoids is increasing, but the accuracy of DOTATATE-PET in nodal staging of pulmonary carcinoids is unknown.We reviewed patients with lung carcinoids undergoing DOTATATE-PET before surgical resection between November 2013 and 2023. Exclusions included non-avid primary tumors on DOTATATE-PET or absent pathologic lymph node assessment. Using surgical pathology as the gold standard, we assessed concordance between DOTATATE-PET-based clinical stage and postoperative pathologic stage. Sensitivity, specificity, negative predictive value, and positive predictive value were calculated, with χ2 and Mann-Whitney U test used for comparisons.Among 58 patients undergoing resection of lung carcinoid tumors (48 typical, 10 atypical carcinoids), 15 (25.8%) had pathologic nodal involvement, but DOTATATE-PET detected only 3. For the 43 patients who were pathologic node-negative, DOTATATE-PET was negative in 42. This yielded 42 true negatives, 3 true positives, 12 false negatives, and 1 false positive, with sensitivity of 20%, specificity 97.7%, negative predictive value 77.8%, positive predictive value 75%, and overall accuracy of 77.6%. Larger tumor size was significantly associated with inaccurate DOTATATE-PET (P = .03). No other clinical characteristics significantly correlated with DOTATATE-PET accuracy.DOTATATE-PET has poor sensitivity for nodal disease in patients with pulmonary carcinoid tumors. Thorough pathologic lymph node evaluation is necessary regardless of DOTATATE-PET results when resecting carcinoid tumors. Given that primary surgery is indicated even if it were known there were positive lymph nodes, the utility of a DOTATATE-PET is likely limited.

  View details for DOI 10.1016/j.xjon.2025.07.018

  View details for PubMedID 41169312

  View details for PubMedCentralID PMC12570576

• Modern Preoperative Evaluation for Lung Cancer Treatment. Surgical oncology clinics of North America Tsai, L. L., Elliott, I. A. 2025; 34 (4): 501-512

  Abstract

  Preoperative evaluation is crucial for ensuring optimal patient selection and minimizing surgical risk. Advances in surgical techniques, including minimally invasive procedures and sublobar resection, have broadened the pool of patients eligible for resection. Incorporating modern technologies and thorough risk assessment is essential for enhancing preoperative optimization and improving patient outcomes. Staying current with these evolving approaches allows for better management of comorbidities, physical status, and surgical readiness, ultimately contributing to more successful surgery and recovery. By integrating the latest tools and strategies, health care providers can improve both short-term and long-term outcomes for patients with lung cancer.

  View details for DOI 10.1016/j.soc.2025.03.007

  View details for PubMedID 41110869

• Factors and outcomes associated with successful minimally invasive pneumonectomy. JTCVS open Trope, W. L., Kapula, N., Elliott, I. A., Guenthart, B. A., Lui, N. S., Backhus, L. M., Berry, M. F., Shrager, J. B., Liou, D. Z. 2025; 24: 423-437

  Abstract

  To test the hypothesis that patients undergoing minimally invasive pneumonectomy at high-volume minimally invasive lung surgery centers have improved survival compared with patients who undergo open pneumonectomy.Patients from the National Cancer Database who underwent pneumonectomy for lung cancer between 2010 and 2020 were stratified into 3 groups according to surgical technique (open, minimally invasive, converted from minimally invasive to open). Institutions were categorized as low-, mid-, or high-volume minimally invasive lung surgery centers according to percentage of total anatomic lung resections performed by video-assisted or robotic-assisted thoracoscopic surgery. Outcomes were compared using Cox regression, Kaplan-Meier survival analysis, and propensity score matching.In total, 5750 patients from 850 facilities were included, with 4597 (79.9%) undergoing upfront open pneumonectomy. Among the 1153 attempted minimally invasive pneumonectomies, 364 (31.6%) required conversion to open pneumonectomy. Surgery at a non-high-volume center was associated with greater conversion risk (adjusted odds ratio, 4.16; P < .001), whereas neoadjuvant therapy was associated with lower risk (adjusted odds ratio, 0.60; P = .015). Similar 5-year overall survival was seen among the 3 groups (open 45.2%, minimally invasive 48.3%, converted 43.3%); however, conversion from minimally invasive to open pneumonectomy demonstrated a trend towards increased risk of death (hazard ratio, 1.16; P = .058).Minimally invasive pneumonectomy for lung cancer had similar 5-year survival compared with open pneumonectomy. However, conversion from minimally invasive to open pneumonectomy showed a trend toward increased risk of death, and conversion rates were high irrespective of institutional minimally invasive lung surgery volume. Careful patient selection is necessary when considering minimally invasive pneumonectomy so that long-term outcomes are not compromised.

  View details for DOI 10.1016/j.xjon.2025.02.006

  View details for PubMedID 40309687

  View details for PubMedCentralID PMC12039441

• Novel Robotic Esophagogastric Anastomosis Simulation Model for Skill Development and Training. Annals of thoracic surgery short reports Wong, L., Kamtam, D., Kim, J., Wallen, B., Elliott, I. A., Guenthart, B. A., Liou, D. Z., Backhus, L. M., Berry, M. F., Shrager, J. B., Lui, N. S. 2025; 3 (1): 206-211

  Abstract

  Background: Esophagogastric anastomosis is a critical step of esophagectomy. We aimed to develop a novel robotic esophagectomy simulator with high rates of fidelity and educational value for trainee surgeons to advance these skills in a low-risk setting.Methods: A porcine esophagus-stomach block was secured on a platform resembling the anatomy during an esophagectomy, and a da Vinci Xi (Intuitive Surgical) robotic system was docked above it. Participants completed 5 key steps (creating the gastric conduit, transecting the esophagus, making the gastrotomy and esophagotomy, creating the anastomosis, and sewing the common enterotomy). The model was assessed through surveys under domains of fidelity (surgical field, reality of materials, anatomy, and experience) and value as a training tool on a scale of 1 to 5 (strongly disagree to strongly agree).Results: Of 14 participants, 8 (57.1%) were women, 9 (64.3%) were integrated cardiothoracic surgery residents, 1 (7.1%) was a thoracic-track resident, and 10 (71.4%) were in postgraduate year 4 or higher. Participants thought most aspects of the model had high fidelity, including the anatomy of conduit (4.8 ± 0.4) and proximal esophagus (4.9 ± 0.4), realism of the stomach (4.9 ± 0.4) and esophagus (4.9 ± 0.4), stapling (4.7 ± 0.6), suturing (4.8 ± 0.4), and tissue handling (4.4 ± 0.6). Participants rated the model highly overall (4.7 ± 0.5) and as a training tool (4.9 ± 0.4), with strong interrater reliability (0.69).Conclusions: The robotic esophagogastric simulation model demonstrated high fidelity and value as a training tool, suggesting its potential effectiveness for surgeons with limited experience. However, it warrants further refinement to address limitations and to optimize its value as a training tool.

  View details for DOI 10.1016/j.atssr.2024.07.030

  View details for PubMedID 40098829

• Community Awareness of Lung Cancer Screening: A Cross-Sectional Survey. Annals of thoracic surgery short reports Ryan, L. C., Choudhary, S., Kapula, N., Kang, A., Shula, L. G., Elliott, I. A., Guenthart, B. A., Liou, D. Z., Backhus, L. M., Berry, M. F., Shrager, J. B., Lui, N. S. 2025; 3 (1): 113-117

  Abstract

  Background: Lung cancer remains the leading cause of cancer mortality in the United States, but only 4.5% of eligible people undergo recommended screening. We hypothesize that low community awareness remains a barrier to lung cancer screening.Methods: A cross-sectional survey was conducted in a convenience sample of attendees at our institution's community health fair. Survey topics included demographics, smoking history, cancer history, lung cancer screening knowledge, and perceptions of screening risks and benefits.Results: Of 214 survey participants, 139 (65%) were women, and there were 98 (46%) Asian and 86 (40%) White participants. Almost a third of the sample had worked in health care, and just more than a half had completed some graduate school. There were only 6 (2.8%) current smokers and 28 (13%) former smokers. Most participants (71%) did not know there was a way to screen for lung cancer. Most participants (66%) knew that cigarette smoking was the risk factor considered for lung cancer screening, but very few knew the screening criteria. More than 75% of participants chose "strongly agree" or "agree" that several benefits of lung cancer screening are important to consider, but only 50.0% to 66.3% for several risks. Most participants (71%) responded that they are "very likely" or "likely" to undergo screening if eligible.Conclusions: In a survey study at a community health fair, community awareness of lung cancer screening was very low, but most participants said they would be willing to be screened if eligible. Community education is critical in increasing our lung cancer screening rates.

  View details for DOI 10.1016/j.atssr.2024.08.010

  View details for PubMedID 40098881

• Utility of PET for Nodal Staging in Subsolid Clinical Stage IA (T1 N0) Lung Adenocarcinoma. Annals of thoracic surgery short reports Kamtam, D. N., Shrager, J. B., Elliott, I. A., Guo, H. H., Guenthart, B. A., Liou, D. Z., Lui, N. S., Backhus, L. M., Berry, M. F. 2025; 3 (1): 118-122

  Abstract

  Background: Positron emission tomography (PET) is the standard of care for non-small cell lung cancer (NSCLC) clinical staging, but it may have limited utility in evaluating subsolid lung adenocarcinomas that can have relatively indolent behavior without hypermetabolic activity.Methods: The sensitivity and specificity of PET for determining pathologic lymph node status and disease-free survival were assessed in patients operated on for cT1 N0 subsolid lung adenocarcinoma from January 2006 to June 2022 (at Stanford University School of Medicine, Stanford, CA). Patients with clinical or pathologic tumor size >30 mm, hilar or mediastinal lymph node size >1cm, and purely solid tumors were excluded.Results: PET was available in 498 of 534 (93.2%) patients and more often was used in older patients with larger and more solid tumors. The overall pathologic lymph node-positive rate was 8.4% (45 of 534). PET specificity was 95.1%, but sensitivity was only 20.0%. A tumor diameter of 18.5 mm and a solid component percentage of 62.5% had the maximum predictive accuracy for pathologic lymph node positivity, with a 0% and 1.5% rate of pathologic and PET lymph node positivity, respectively, for tumors with values lower than those thresholds. There was no significant difference in 5-year disease-free survival between individuals who did and did not undergo PET scanning (76.6% vs 96.8%; P= .07). Conversely, 134 (26.9%) patients who underwent PET scanning had 171 incidentally detected hypermetabolic lesions unrelated to lung cancer, with only 13 of 134 (9.7%) patients identified as having non-NSCLC premalignant or malignant conditions requiring further therapy.Conclusions: PET scan use for subsolid lung adenocarcinoma has high specificity but limited sensitivity for predicting pathologic lymph node positivity. PET also has no association with disease-free survival and often detects clinically unimportant findings rather than changing lung cancer management, particularly for patients with smaller and less solid tumors.

  View details for DOI 10.1016/j.atssr.2024.07.007

  View details for PubMedID 40098873

• The impact of extent of nodal involvement on stage IIIA (N2) non-small cell lung cancer outcomes JTCVS OPEN Wong, L., Tsai, L. L., He, H., Elliott, I. A., Berry, M. F. 2025; 23: 256-265

  View details for DOI 10.1016/j.xjon.2024.11.018

  View details for Web of Science ID 001431381600001

• The impact of extent of nodal involvement on stage IIIA (N2) non-small cell lung cancer outcomes. JTCVS open Wong, L. Y., Tsai, L. L., He, H., Elliott, I. A., Berry, M. F. 2025; 23: 256-265

  Abstract

  Stage IIIA (N2) non-small cell lung cancer (NSCLC) treatment can depend on the extent of nodal involvement, with surgery considered for limited disease and definitive chemoradiation preferred for bulky or multi-station disease. Evidence to support management is limited. This study evaluated the impact of the extent of stage IIIA (N2) nodal involvement on outcomes after surgery.Patients who underwent surgical resection of T1-2N2M0 NSCLC in the Surveillance, Epidemiology, and End Results database from 2004 to 2019 were stratified as having limited (1 positive node) versus more extensive (>1 positive node) nodal disease, and survival was evaluated with Kaplan-Meier and Cox analyses.Of the 6933 patients identified surgical patients, 2129 (30.7%) had limited nodal disease whereas 4804 (69.3%) had more extensive nodal involvement. The limited nodal group had greater 5-year overall survival than the more extensive node group (39.3% vs 30.3%, P < .001), and more extensive nodal involvement (hazard ratio, 1.26; P < .001) was independently associated with worse survival in Cox analysis. Surgical patients had a greater 5-year overall survival than 1644 comparable N2 patients with extensive nodal involvement who received definitive chemoradiation (30.9% vs 18.9%, P < .001).Increasing nodal involvement is associated with worse survival for patients with stage IIIA (N2) NSCLC but select patients with more extensive nodal disease may still benefit from surgery compared to chemoradiation.

  View details for DOI 10.1016/j.xjon.2024.11.018

  View details for PubMedID 40061550

  View details for PubMedCentralID PMC11883707

• The association of chylothorax with aggressiveness of lymph node management during pulmonary resection. The Annals of thoracic surgery Kamtam, D. N., Berry, M. F., Lin, N., Kapula, N., Kim, J. J., Wallen, B., Satoyoshi, M., Elliott, I. A., Guenthart, B. A., Liou, D. Z., Lui, N. S., Backhus, L. M., Shrager, J. B. 2025

  Abstract

  Chylothorax is a morbid and costly complication that can originate in lymph node resection beds. We hypothesized a close association between the occurrence of chylothorax and the extent/aggressiveness of lymph node dissection.We conducted a nested case-control study of 1728 non-small cell lung cancer patients who underwent resection at our institution January 2005-July 2023. Cases were defined as patients who developed chylothorax. Each case was matched with 3 control subjects who did not develop chylothorax, based on year of diagnosis, clinical N-descriptor, presence of granulomatous lymph nodes, extent of resection, and tumor laterality. Using conditional logistic regression, we estimated risk ratios with 95% confidence intervals to examine the association between the occurrence of chylothorax and several measures of the extent of lymph node resection.The incidence of chylothorax was 33/1728 (1.9%). In the matched groups, patients with chylothorax had higher rates of complete lymphadenectomy (82% vs. 65%, p=0.059) and systematic lymph node dissection as defined by IASLC/ESMO/ESTS (85% vs. 52%, p=0.002). Station 2 was resected significantly more often in the chylothorax group (48.5% vs. 29%, p=0.04). The chylothorax group had a longer median in-hospital stay (7 vs. 4 days, p=0.003), and higher reoperation (18% vs. 1.0%, p=0.006) and readmission (18% vs. 5%, p=0.03) rates.In matched groups, chylothorax is associated with several measures of more aggressive lymph node management and results in substantial postoperative morbidity. This finding provides additional support for more selective lymph node management approaches when resecting smaller, less-solid, less 18-fluorodeoxyglucose-avid tumors.

  View details for DOI 10.1016/j.athoracsur.2025.01.019

  View details for PubMedID 39894428

• JAK inhibition with tofacitinib rapidly increases contractile force in human skeletal muscle. Life science alliance Shrager, J. B., Randle, R., Lee, M., Ahmed, S. S., Trope, W., Lui, N., Poultsides, G., Liou, D., Visser, B., Norton, J. A., Nesbit, S. M., He, H., Kapula, N., Wallen, B., Fatodu, E., Sadeghi, C. A., Konsker, H. B., Elliott, I., Guenthart, B., Backhus, L., Cooke, R., Berry, M., Tang, H. 2024; 7 (11)

  Abstract

  Reduction in muscle contractile force associated with many clinical conditions incurs serious morbidity and increased mortality. Here, we report the first evidence that JAK inhibition impacts contractile force in normal human muscle. Muscle biopsies were taken from patients who were randomized to receive tofacitinib (n = 16) or placebo (n = 17) for 48 h. Single-fiber contractile force and molecular studies were carried out. The contractile force of individual diaphragm myofibers pooled from the tofacitinib group (n = 248 fibers) was significantly higher than those from the placebo group (n = 238 fibers), with a 15.7% greater mean maximum specific force (P = 0.0016). Tofacitinib treatment similarly increased fiber force in the serratus anterior muscle. The increased force was associated with reduced muscle protein oxidation and FoxO-ubiquitination-proteasome signaling, and increased levels of smooth muscle MYLK. Inhibition of MYLK attenuated the tofacitinib-dependent increase in fiber force. These data demonstrate that tofacitinib increases the contractile force of skeletal muscle and offers several underlying mechanisms. Inhibition of the JAK-STAT pathway is thus a potential new therapy for the muscle dysfunction that occurs in many clinical conditions.

  View details for DOI 10.26508/lsa.202402885

  View details for PubMedID 39122555

  View details for PubMedCentralID PMC11316201

• The Role of Primary Care Providers in Lung Cancer Screening: A Cross-Sectional Survey. Clinical lung cancer Wong, L. Y., Kapula, N., Kang, A., Phadke, A. J., Schechtman, A. D., Elliott, I. A., Guenthart, B. A., Liou, D. Z., Backhus, L. M., Berry, M. F., Shrager, J. B., Lui, N. S. 2024

  Abstract

  Multidisciplinary lung cancer screening (LCS) programs that perform shared decision-making visits (SDMV) and follow up annual low dose computed tomography (LDCT) have been emerging. We hypothesize that primary care providers (PCPs) prefer to refer patients to LCS programs instead of facilitating the screening process themselves.This is a mixed-methods, cross-sectional study in which an online survey was administered to PCPs between April 2023 and June 2023.58 PCPs in the same hospital network participated in the study with a median age of 43 (34-51), predominance of women (77.6%), and clinicians of white and Asian race (44.8% and 48.3%). Respondents estimated that 26.1% (SD 32.4%) of their eligible patients participate in LCS screening. PCPs thought that an LCS program was equally convenient to performing screening themselves for identifying eligible patients and ordering LDCT. However, 63.8% of participants preferred an LCS program for performing SDMVs, 62.1% for ensuring annual follow-up on negative LDCTs, 70.7% for deciding next steps on positive LDCTs, and 60.4% for performing smoking cessation counseling. PCPs agreed that an LCS program saves time (69%), allows patients to receive specialty care (65.6%), addresses patient concerns (70.7%), ensures annual follow-up (77.6%), and manages abnormal findings (79.3%). However, they also expressed concerns about an additional visit for the patient (48.2%) and patient cost (46.5%).Most PCPs believe that formal LCS programs have many benefits including providing specialized care and follow up, although there were concerns about patient time and cost.

  View details for DOI 10.1016/j.cllc.2024.10.002

  View details for PubMedID 39472235

• Segmentectomy vs Lobectomy for Non-Small Cell Lung Cancer: The Impact of Tumor Location. Annals of thoracic surgery short reports Wong, L. Y., Kapula, N., Elliott, I. A., Liou, D. Z., Backhus, L. M., Lui, N. S., Shrager, J. B., Berry, M. F. 2024; 2 (3): 458-463

  Abstract

  The technical complexity of segmentectomy and preservation of lung parenchyma compared with lobectomy vary by lobe. This study evaluated the impact of non-small cell lung cancer tumor location on segmentectomy use and outcomes.Outcomes after lobectomy or segmentectomy for cT1N0M0 (≤2 cm) non-small cell lung cancer patients stratified by tumor location in smaller (right upper/middle) vs larger (bilateral lower/left upper) lobes were evaluated with logistic regression, Kaplan-Meier curves, and Cox proportional hazards methods.A minority of patients in the cohort (N = 31,243) underwent segmentectomy (n = 2783, 9%). Segmentectomy was more common for tumors in larger compared with smaller lobes (11.8% vs 5.1%, P < .001). Major morbidity after segmentectomy was significantly lower than lobectomy for both smaller (2.6% vs 5.7%, odds ratio, 0.41, P < .001) and larger (2.5% vs 5.2%, odds ratio, 0.46, P < .001) lobes. Segmentectomy was associated with smaller lymph node harvest for both types of lobes (small lobes 7.0 vs 10.5, P < .001; large lobes 7.5 vs 10.4, P < .001) but did not compromise survival in multivariate analysis for both small (hazard ratio, 0.99, P = .9) and large (hazard ratio, 1.05, P = .34) lobes.Segmentectomy that does not compromise oncologic principles should be considered if complete resection is feasible regardless of tumor location.

  View details for DOI 10.1016/j.atssr.2024.01.014

  View details for PubMedID 39790437

  View details for PubMedCentralID PMC11708542

• Impacts of Positive Margins and Surgical Extent on Outcomes after Early-Stage Lung Cancer Resection. The Annals of thoracic surgery Wong, L. Y., Dale, R., Kapula, N., Elliott, I. A., Liou, D. Z., Backhus, L. M., Lui, N. S., Shrager, J. B., Berry, M. F. 2024

  Abstract

  Sublobar resection of early-stage non-small cell lung cancer (NSCLC) is increasingly considered appropriate but may compromise margins compared to lobectomy. This study evaluated resection extent, margin status, and survival for clinical stage I NSCLC patients.Clinical T1-2N0M0 NSCLC patients in the National Cancer Database (2006-2020) treated with primary surgery were compared stratified by margin status. The potential benefit of radiation was explored in subgroup analysis of sublobar resection patients with positive margins.Positive margins occurred in 5,089 (2.8%) of 181,824 patients and were more common in sublobar resections compared to lobectomy (4.3% vs 2.4%,p<0.001). Sublobar resection had the strongest association with positive margins in multivariable analysis (OR 2.06 [95% CI 1.91-2.23],p<0.001). Patients with positive margins were more likely to undergo both adjuvant chemotherapy (16% vs 13%,p<0.001) and radiation (17% vs 1%,p<0.001) but had worse survival in univariate (44.0% 5-year OS vs 69.2%,p<0.001) and multivariable Cox analysis (HR 1.71 [95% CI 1.63-1.78, p<0.001) in the entire cohort, as well as in univariate subset analysis of lobectomy (46.9% vs 70.4%, p<0.001) and sublobar (37.5% vs 64.1%,p<0.001). Postoperative radiation for sublobar patients with positive margins did not improve 5-year OS (36.3% for irradiated patients vs 38.3% for non-irradiated patients,p=0.57), and positive margin sublobar patients treated with radiation had inferior survival to negative margin lobectomy patients.Positive margins occur more frequently after sublobar resection of clinical stage I NSCLC compared to lobectomy. Patients with positive margins have worse survival than complete resection patients and are not rescued by post-operative radiation.

  View details for DOI 10.1016/j.athoracsur.2024.05.032

  View details for PubMedID 38866199

• What is an Adequate Margin During Sublobar Resection of ≤3cm N0 Subsolid Lung Adenocarcinomas? The Annals of thoracic surgery Kamtam, D. N., Berry, M. F., Lui, N. S., Satoyoshi, M., Elliott, I. A., Liou, D. Z., Guenthart, B., Backhus, L. M., Shrager, J. B. 2024

  Abstract

  Sublobar resection offers non-inferior survival vs. lobectomy for ≤2cm NSCLC and is commonly employed for subsolid tumors. While data exists for solid tumors, the minimum adequate margin of resection for subsolid adenocarcinomas remains unclear.Retrospective review of 1101 adenocarcinoma resections at our institution, 2006-2022.tumors≤3cm with ≥10% radiographic ground glass, excised by sublobar resection.positive nodes, positive or unreported margin. The primary outcome was rate of local recurrence(LR) at multiple thresholds of margin distance. Relationship between margin distance and solid-component size was also explored.194 patients met inclusion criteria. Median(IQR) tumor diameter and margin distance were 12(9-17)mm and 10(5-17)mm, respectively. Median follow-up was 42.5 months. There was a progressive increase in LR with diminishing margin (0.1cm decrements) from 1.5cm to 0.5cm. The difference in the rate of LR between "over"(n=143) and "under"(n=51) was most significant at 0.5cm [8/51(15.7%) vs. 6/143(4.2%),p=0.01] but did not reach α adjusted for multiple comparisons. On Cox regression for LR-free survival (LRFS), margin ≤0.5cm(p=0.19) and %solid component (p=0.14) trended to significance. Combining these using margin-distance-to-solid-component-size ratio, a ratio≤1 did show a significantly higher rate of local recurrence [7(14.3%) vs. 2(2.0%),p=0.009]. Treatment of local recurrences provided at least intermediate-term survival in 87% of recurrences (median post-recurrence follow-up 44 months).During sublobar resection of subsolid lung adenocarcinomas, margin-to-solid-component-size ratio>1.0 appears to be a more reliable factor than margin distance alone to minimize local recurrence. Local recurrence, however, may not impact survival in patients with subsolid adenocarcinomas if timely treatment is administered.

  View details for DOI 10.1016/j.athoracsur.2024.04.018

  View details for PubMedID 38734402

• Barriers to Completing Low Dose Computed Tomography Scan for Lung Cancer Screening. Clinical lung cancer Wong, L. Y., Choudhary, S., Kapula, N., Lin, M., Elliott, I. A., Guenthart, B. A., Liou, D. Z., Backhus, L. M., Berry, M. F., Shrager, J. B., Lui, N. S. 2024

  Abstract

  Annual low-dose computed tomography (LDCT) screening has been shown to reduce lung cancer mortality in high-risk individuals by detecting the disease at an earlier stage. This study aims to assess the barriers to completing LDCT in a cohort of patients who were determined eligible for lung cancer screening (LCS).We performed a single institution, mixed methods, cross-sectional study of patients who had a LDCT ordered from July to December 2022. We then completed phone surveys with patients who did not complete LDCT to assess knowledge, attitude, and perceptions toward LCS.We identified 380 patients who met inclusion criteria, including 331 (87%) who completed LDCT and 49 (13%) who did not. Patients who completed a LDCT and those who did not were similar regarding age, sex, race, primary language, household income, body mass index, median pack years, and quit time. Positive predictors of LDCT completion were: meeting USPSTF guidelines (97.9% vs 81.6%), being married (58.3% vs 44.9%), former versus current smokers (55% vs 41.7%), personal history of emphysema (60.4% vs 42.9%), and family history of lung cancer (13.9% vs 4.1%) (all P < .05). Of the patients who participated in the phone survey, only 7% of respondents thought they were high risk for developing lung cancer despite attending a shared decision-making visit and only 10% wanted to re-schedule their LDCT.There exist barriers to completing LDCT even after patients are identified as eligible and complete a shared decision-making visit secondary to knowledge barriers, misperceptions, and patient disinterest.

  View details for DOI 10.1016/j.cllc.2024.04.014

  View details for PubMedID 38749902

• Randomized controlled trials in lung cancer surgery: How are we doing? JTCVS open Wong, L. Y., Li, Y., Elliott, I. A., Backhus, L. M., Berry, M. F., Shrager, J. B., Oh, D. S. 2024; 18: 234-252

  Abstract

  Randomized control trials are considered the highest level of evidence, yet the scalability and practicality of implementing randomized control trials in the thoracic surgical oncology space are not well described. The aim of this study is to understand what types of randomized control trials have been conducted in thoracic surgical oncology and ascertain their success rate in completing them as originally planned.The ClinicalTrials.gov database was queried in April 2023 to identify registered randomized control trials performed in patients with lung cancer who underwent surgery (by any technique) as part of their treatment.There were 68 eligible randomized control trials; 33 (48.5%) were intended to examine different perioperative patient management strategies (eg, analgesia, ventilation, drainage) or to examine different intraoperative technical aspects (eg, stapling, number of ports, port placement, ligation). The number of randomized control trials was relatively stable over time until a large increase in randomized control trials starting in 2016. Forty-four of the randomized control trials (64.7%) were open-label studies, 43 (63.2%) were conducted in a single facility, 66 (97.1%) had 2 arms, and the mean number of patients enrolled per randomized control trial was 236 (SD, 187). Of 21 completed randomized control trials (31%), the average time to complete accrual was 1605 days (4.4 years) and average time to complete primary/secondary outcomes and adverse events collection was 2125 days (5.82 years).Given the immense investment of resources that randomized control trials require, these findings suggest the need to scrutinize future randomized control trial proposals to assess the likelihood of successful completion. Future study is needed to understand the various contributing factors to randomized control trial success or failure.

  View details for DOI 10.1016/j.xjon.2024.01.008

  View details for PubMedID 38690441

  View details for PubMedCentralID PMC11056451

• Lepidic-Type Lung Adenocarcinomas: Is It Safe to Observe for Growth Prior to Treating? The Annals of thoracic surgery Wong, L. Y., Elliott, I. A., Liou, D. Z., Backhus, L. M., Lui, N. S., Shrager, J. B., Berry, M. F. 2024

  Abstract

  Lepidic-type adenocarcinomas (LPA) can be multi-focal, and treatment is often deferred until there is observed growth. This study investigated the potential downside of that strategy by evaluating the relationship of nodal involvement with tumor size and survival.The impact of tumor size on lymph node involvement and survival was evaluated for National Cancer Database patients who received surgery without induction therapy as primary treatment for cT1-3N0M0 histologically confirmed LPA from 2006-2019 using logistic regression, Kaplan-Meier, and Cox analyses.Positive nodes occurred in 442 (5.3%) of 8,286 patients. The incidence of having positive nodes approximately doubled with each 1cm increment increase in size. Patients with positive nodes were more likely to have larger tumors (27mm vs 20mm,p<0.001) and clinical T2+ disease (40.7% vs 26.8%,p<0.001) compared to node-negative patients, but tumor size was the only significant independent predictor of having positive nodal disease in logistic regression analysis; this association grew stronger with each incremental centimeter increase in size. Patients with positive nodes were more likely to undergo adjuvant radiation (23.5% vs 1.1%,p<0.001) and chemotherapy (72.9% vs 7.9%,p<0.001), and expectedly had worse survival compared to the node negative group in univariate (5-year overall survival 50.9% vs 81.1%,p<0.001) and multivariable (Hazard ratio 2.56 [95% CI 2.14-3.05],p<0.001) analyses.Nodal involvement is relatively uncommon in early-stage LPAs but steadily increases with tumor size and is associated with dramatically worse survival. This data can be used to inform treatment decisions when evaluating LPA patients.

  View details for DOI 10.1016/j.athoracsur.2024.03.003

  View details for PubMedID 38490310

• Outcomes of surgery for catastrophic hiatal hernia presentations. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract Wong, L., Leipzig, M., Elliott, I. A., Liou, D. Z., Backhus, L. M., Shrager, J. B., Berry, M. F. 2024; 28 (3): 285-286

  View details for DOI 10.1016/j.gassur.2023.12.024

  View details for PubMedID 38445922

• The Impact of Immunotherapy Use in Stage IIIA (T1-2N2) NSCLC: A Nationwide Analysis. JTO clinical and research reports Wong, L. Y., Liou, D. Z., Roy, M., Elliott, I. A., Backhus, L. M., Lui, N. S., Shrager, J. B., Berry, M. F. 2024; 5 (3): 100654

  Abstract

  Multiple clinical trials have revealed the benefit of immunotherapy (IO) for NSCLC, including unresectable stage III disease. Our aim was to investigate the impact of IO use on treatment and outcomes of potentially resectable stage IIIA NSCLC in a broader nationwide patient cohort.We queried the National Cancer Database (2004-2019) for patients with stage IIIA (T1-2N2) NSCLC. Treatment and survival were evaluated with descriptive statistics, logistic regression, Kaplan-Meier analysis, and Cox proportional hazards modeling.Overall, 5.5% (3777 of 68,335) of patients received IO. IO use was uncommon until 2017, but by 2019, it was given to 40.1% (1544 of 2308) of stage IIIA patients. The increased use of IO after 2017 was associated with increased definitive chemoradiation treatment (54.2% [6800 of 12,535] from years 2017 to 2019 versus 46.9% [26,251 of 55,914] from 2004 to 2016, p < 0.001) and less use of surgery (18.1% [2266 of 12,535] from years 2017 to 2019 versus 22.0% [12,300 of 55,914] from 2004 to 2016, p < 0.001). IO treatment was associated with significantly better 5-year survival in the entire cohort (36.9% versus 23.4%, p < 0.001) and the subsets of patients treated with chemoradiation (37.2% versus 22.7%, p < 0.001) and surgery (48.6% versus 44.3%, p < 0.001). Pneumonectomy use decreased with increased IO treatment (5.1% of surgical patients [116 of 2266] from years 2017 to 2019 versus 9.2% [1127 of 12,300] from 2004 to 2016, p < 0.001).Increased use of IO was associated with a change in treatment patterns and improved survival for patients with stage IIIA(N2) NSCLC.

  View details for DOI 10.1016/j.jtocrr.2024.100654

  View details for PubMedID 38496376

  View details for PubMedCentralID PMC10941003

• Risk of developing subsequent primary lung cancer after receiving radiation for breast cancer. JTCVS open Wong, L., Kapula, N., He, H., Guenthart, B. A., Vitzthum, L. K., Horst, K., Liou, D. Z., Backhus, L. M., Lui, N. S., Berry, M. F., Shrager, J. B., Elliott, I. A. 2023; 16: 919-928

  Abstract

  Background: Radiotherapy (RT) is integral to breast cancer treatment, especially in the current era that emphasizes breast conservation. The aim of our study was to determine the incidence of subsequent primary lung cancer after RT exposure for breast cancer over a time span of 3decades to quantify this risk over time as modern oncologic treatment continues to evolve.Methods: The SEER (Surveillance, Epidemiology, and End Results) database was queried from 1988 to 2014 for patients diagnosed with nonmetastatic breast cancer. Patients who subsequently developed primary lung cancer were identified. Multivariable regression modeling was performed to identify independent factors associated with the development of lung cancer stratified by follow up intervals of 5 to 9years, 10 to 15years, and >15years after breast cancer diagnosis.Results: Of the 612,746 patients who met our inclusion criteria, 319,014 (52%) were irradiated. primary lung cancer developed in 5556 patients (1.74%) in the RT group versus 4935 patients (1.68%) in the non-RT group. In a multivariable model stratified by follow-up duration, the overall HR of developing subsequent ipsilateral lung cancer in the RT group was 1.14 (P=.036) after 5 to 9years of follow-up, 1.28 (P=.002) after 10 to 15years of follow-up, and 1.30 (P=.014) after >15years of follow-up. The HR of contralateral lung cancer was not increased at any time interval.Conclusions: The increased risk of developing a primary lung cancer secondary to RT exposure for breast cancer is much lower than previously published. Modern RT techniques may have contributed to the improved risk profile, and this updated study is important for counseling and surveillance of breast cancer patients.

  View details for DOI 10.1016/j.xjon.2023.10.031

  View details for PubMedID 38204675

• The Impact of Tumor Size on Node Involvement in Typical Lung Carcinoids. Annals of thoracic surgery short reports Elliott, I. A., Liou, D. Z., Lui, N. S., Backhus, L. M., Shrager, J. B., Myall, N., Berry, M. F. 2023; 1 (4): 543-547

  Abstract

  Observation has been suggested as an alternative to surgical resection for small typical lung carcinoids. We sought to evaluate the potential impact of tumor growth and lymphatic spread during observation by examining predictors of node positivity and the impact of tumor size and node status on survival.National Cancer Database cases of typical lung carcinoid resections from 2006 to 2016 were analyzed. Predictors of lymph node involvement and survival were determined.Overall, 1019 of 8257 patients who underwent typical carcinoid resection had at least 1 positive node (12.3%). The incidence of node positivity among the 921 patients with subcentimeter tumors was 5.4% (n = 50). Increasing tumor size was independently associated with nodal involvement. Patients with nodal involvement had significantly worse 5-year survival (89.5% vs 94.0%; P < .001). Increasing tumor size was not associated with worse survival in multivariable analysis, but node positivity did independently predict worse survival.More than 5% of patients with subcentimeter typical carcinoids of the lung have nodal metastases, and node involvement is an independent predictor of worse survival, whereas tumor size is not. These data suggest that even patients with small tumors should generally undergo resection when diagnosed.

  View details for DOI 10.1016/j.atssr.2023.07.016

  View details for PubMedID 39790680

  View details for PubMedCentralID PMC11708276

• Comparison of failure to rescue in younger versus elderly patients following lung cancer resection. JTCVS open Wang, Y., Kapula, N., Yang, C. J., Manapat, P., Elliott, I. A., Guenthart, B. A., Lui, N. S., Backhus, L. M., Berry, M. F., Shrager, J. B., Liou, D. Z. 2023; 16: 855-872

  Abstract

  Objective: Failure to rescue (FTR), defined as in-hospital death following a major complication, has been increasingly studied in patients who undergo cardiothoracic surgery. This study tested the hypothesis that elderly patients undergoing lung cancer resection have greater rates of FTR compared with younger patients.Methods: Patients who underwent surgery for primary lung cancer between 2011 and 2020 and had at least 1 major postoperative complication were identified using the National Surgical Quality Improvement Program database. Patients who died following complications (FTR) were compared with those who survived in an elderly (80+ years) and younger (<80years) cohort.Results: Of the 2823 study patients, the younger cohort comprised 2497 patients (FTR: n=139 [5.6%]), whereas the elderly cohort comprised 326 patients (FTR: n=39 [12.0%]). Pneumonia was the most common complication in younger (877/2497, 35.1%) and elderly patients (118/326, 36.2%) but was not associated with FTR on adjusted analysis. Increasing age was associated with FTR (adjusted odds ratio [AOR], 1.55 per decade, P<.001), whereas unplanned reoperation was associated with reduced risk (AOR, 0.55, P=.01). Within the elderly cohort, surgery conducted by a thoracic surgeon was associated with lower FTR risk (AOR, 0.29, P=.028).Conclusions: FTR following lung cancer resection was more frequent with increasing age. Pneumonia was the most common complication but not a predictor of FTR. Unplanned reoperation was associated with reduced FTR, as was treatment by a thoracic surgeon for elderly patients. Surgical therapy for complications after lung cancer resection and elderly patients managed by a thoracic specialist may mitigate the risk of death following an adverse postoperative event.

  View details for DOI 10.1016/j.xjon.2023.08.002

  View details for PubMedID 38204720

• The impact of refusing esophagectomy for treatment of locally advanced esophageal adenocarcinoma. JTCVS open Wong, L., Elliott, I. A., Liou, D. Z., Backhus, L. M., Lui, N. S., Shrager, J. B., Berry, M. F. 2023; 16: 987-995

  Abstract

  Objective: Patients with esophageal cancer may be reluctant to proceed with surgery due to high complication rates. This study aims to compare outcomes between eligible surgical candidates who proceeded with surgery versus those who refused surgery.Methods: Characteristics and survival of patients with locally advanced (cT3N0M0, cT1-3N+M0) mid-/distal esophageal adenocarcinoma in the National Cancer Database (2006-2019) who either proceeded with or refused surgery after chemoradiotherapy were evaluated with logistic regression, Kaplan-Meier curves, and Cox proportional hazards methods.Results: Of the 13,594 patients included in the analysis, 595 (4.4%) patients refused esophagectomy. Patients who refused surgery were older, had less distance to travel to their treatment facility, were more likely to have cN0 disease, and were more likely to be treated at a community rather than academic or integrated network program, but did not have significantly different comorbid disease distributions. On multivariable analysis, refusing surgery was independently associated with older age, uninsured, lower income, less distance to a hospital, and treatment in a community program versus an academic/research or integrated network program. Esophagectomy was associated with better survival (5-year survival 40.1% [39.2-41] vs 23.6% [19.9-27.9], P<.001) and was also independently associated with better survival in the Cox model (hazard rate, 0.78 [95% confidence interval, 0.7-0.87], P<.001).Conclusions: The results of this study can inform selected patients with resectable esophageal adenocarcinoma that their survival will be significantly diminished if surgery is not pursued. Many factors associated with refusing surgery are non-clinical and suggest that access to or support for care could influence patient decisions.

  View details for DOI 10.1016/j.xjon.2023.09.006

  View details for PubMedID 38204633

• Impact of hyperthermic intrathoracic chemotherapy (HITHOC) during resection of pleural mesothelioma on patient survival. Journal of thoracic disease Elliott, I. A., He, H., Lui, N. S., Liou, D. Z., Guenthart, B. A., Shrager, J. B., Berry, M. F., Backhus, L. M. 2023; 15 (11): 6140-6150

  Abstract

  Pleural mesothelioma (PM) is rare but portends a poor prognosis. Multimodal treatment, including aggressive surgical resection, may offer the best chance of treatment response and improved survival. Single-center studies suggest that hyperthermic intrathoracic chemotherapy (HITHOC) during surgical resection improves outcomes, but the impact of HITHOC on postoperative morbidity and survival has not been examined on a larger scale.The National Cancer Database was queried for patients undergoing resection for PM from 2006-2017. Patients were excluded if staging or survival data was incomplete. After propensity-score matching, patients who underwent HITHOC were compared to patients who did not (case-control study). Perioperative outcomes and survival were analyzed.The final cohort consisted of 3,232 patients; of these, 365 patients underwent HITHOC. After propensity-score matching, receipt of HITHOC was associated with increased length of stay (12 vs. 7 days, P<0.001) and increased 30-day readmissions (9.9% vs. 4.9%, P=0.007), but decreased 30-day mortality (3.2% vs. 6.0%, P=0.017) and 90-day mortality (7.5% vs. 10.9%). Kaplan-Meier modeling demonstrated that HITHOC was associated with improved survival in the overall cohort (median 20.5 vs. 16.8 months, P=0.001). In multivariable analysis, HITHOC remained associated with improved overall survival [hazard ratio (HR) =0.80; 95% confidence interval (CI): 0.69-0.92; P=0.002], and this persisted in the propensity-matched analysis (HR =0.73; 95% CI: 0.61-0.88; P=0.001).Using a large national database, we describe the impact of HITHOC on survival in patients with PM. Despite observed increased short-term morbidity, in multivariable analysis HITHOC was associated with an overall survival advantage for patients undergoing surgical resection of PM.

  View details for DOI 10.21037/jtd-23-466

  View details for PubMedID 38090290

  View details for PubMedCentralID PMC10713319

• Impact of hyperthermic intrathoracic chemotherapy (HITHOC) during resection of pleural mesothelioma on patient survival JOURNAL OF THORACIC DISEASE Elliott, I. A., He, H., Lui, N. S., Liou, D. Z., Guenthart, B. A., Shrager, J. B., Berry, M. F., Backhus, L. M. 2023

  View details for DOI 10.21037/jtd-23-466

  View details for Web of Science ID 001101361100001

• Outcomes of a Failed Observation Approach for Paraesophageal Hernia Wong, L., Leipzig, M., Elliott, I. A., Lui, N., Liou, D., Backhus, L. M., Shrager, J. B., Berry, M. LIPPINCOTT WILLIAMS & WILKINS. 2023: S483

  View details for Web of Science ID 001094086301454

• Outcomes of a Failed Observation Approach for Paraesophageal Hernia Wong, L., Leipzig, M., Elliott, I. A., Lui, N., Liou, D., Backhus, L. M., Shrager, J. B., Berry, M. LIPPINCOTT WILLIAMS & WILKINS. 2023: S483

  View details for Web of Science ID 001100379000036

• Half of Anastomotic Leaks after Esophagectomy are Undetected on Initial Postoperative Esophagram. The Annals of thoracic surgery Elliott, I. A., Berry, M. F., Trope, W., Lui, N. S., Guenthart, B. A., Liou, D. Z., Whyte, R. I., Backhus, L. M., Shrager, J. B. 2022

  Abstract

  The sensitivity of fluoroscopic esophagrams with oral contrast to exclude anastomotic leak after esophagectomy is not well-documented, and the consequences of missing a leak in this setting have not been previously described.We performed a retrospective cohort study of a prospectively maintained institutional database of patients undergoing esophagectomy with esophagogastric anastomosis 2008-2020. Relevant details regarding leaks, management, and outcomes were obtained from the database and formal chart review. Statistical analysis was performed to compare patients with and without leaks, and those with false negative versus positive esophagrams.There were 384 patients who underwent esophagectomy with gastric reconstruction: the majority were Ivor-Lewis (82%), and 51% were wholly or partially minimally-invasive. Using a broad definition of leak, 55 patients (16.7%) developed an anastomotic leak. Twenty-seven of the 55 patients (49%) who ultimately were found to have a leak initially had a negative esophagram (performed on average on postoperative day 6). Those with a negative initial esophagram were more likely to have an uncontained leak (81% vs. 29%, p<0.01), require unplanned readmission (70% vs. 39%, p=0.02), and undergo reoperation (44% vs. 11%, p<0.01).Early postoperative esophagrams intended to evaluate anastomotic integrity have a low sensitivity of 51%, and leaks missed on initial esophagram have greater clinical consequences than those identified on initial esophagram. These findings suggest a high index of suspicion must be maintained even after a normal esophagram and calls into question the common practice of using this test to triage patients for diet advancement.

  View details for DOI 10.1016/j.athoracsur.2022.04.053

  View details for PubMedID 35618049

• Social Disparities in Lung Cancer. Thoracic surgery clinics Elliott, I., Gonzalez, C., Backhus, L., Lui, N. 2022; 32 (1): 33-42

  Abstract

  Social disparities in lung cancer diagnosis, treatment, and survival have been studied using national databases, statewide registries, and institution-level data. Some disparities emerge consistently, such as lower adherence to treatment guidelines and worse survival by race and socioeconomic status, whereas other disparities are less well studied. A critical appraisal of current data is essential to increasing equity in lung cancer care.

  View details for DOI 10.1016/j.thorsurg.2021.09.009

  View details for PubMedID 34801193

• Resection of a Giant Epithelioid Hemangioendothelioma Arising from the Superior Vena Cava. The Annals of thoracic surgery Elliott, I. A., Kasinpila, P., Guenthart, B. A., MacArthur, J. W., Berry, M. F. 2021

  Abstract

  Epithelioid hemangioendothelioma is a rare malignant vascular sarcoma. Here we present a patient with a very large tumor arising from the superior vena cava (SVC), in whom a resection with negative margins was accomplished using veno-venous bypass and bovine pericardial patch reconstruction of the SVC.

  View details for DOI 10.1016/j.athoracsur.2021.01.034

  View details for PubMedID 33529605

• Smooth Muscle Operator: Robotic-Assisted Enucleation of an Esophageal Leiomyoma. Digestive diseases and sciences Elliott, I. A., Forgó, E. n., Lui, N. S. 2021

  View details for DOI 10.1007/s10620-020-06703-7

  View details for PubMedID 33479860

• First lung and kidney multi-organ transplant following COVID-19 Infection. The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation Guenthart, B. A., Krishnan, A., Alassar, A., Madhok, J., Kakol, M., Miller, S., Cole, S. P., Rao, V. K., Acero, N. M., Hill, C. C., Cheung, C., Jackson, E. C., Feinstein, I., Tsai, A. H., Mooney, J. J., Pham, T., Elliott, I. A., Liou, D. Z., La Francesca, S., Shudo, Y., Hiesinger, W., MacArthur, J. W., Brar, N., Berry, G. J., McCarra, M. B., Desai, T. J., Dhillon, G. S., Woo, Y. J. 2021

  Abstract

  As the world responds to the global crisis of the COVID-19 pandemic an increasing number of patients are experiencing increased morbidity as a result of multi-organ involvement. Of these, a small proportion will progress to end-stage lung disease, become dialysis dependent, or both. Herein, we describe the first reported case of a successful combined lung and kidney transplantation in a patient with COVID-19. Lung transplantation, isolated or combined with other organs, is feasible and should be considered for select patients impacted by this deadly disease.

  View details for DOI 10.1016/j.healun.2021.02.015

  View details for PubMedID 34059432

• Commentary: An innovative, minimally-invasive approach to post-pneumonectomy bronchopleural fistula. JTCVS techniques Elliott, I. A., Bedi, H. S., Lui, N. S. 2020; 4: 351-352

  View details for DOI 10.1016/j.xjtc.2020.08.032

  View details for PubMedID 34318072

  View details for PubMedCentralID PMC8304844

• Commentary: An innovative, minimally-invasive approach to post-pneumonectomy bronchopleural fistula Comment JTCVS TECHNIQUES Elliott, I. A., Bedi, H. S., Lui, N. S. 2020; 4: 351-352

  View details for DOI 10.1016/j.xjtc.2020.08.032

  View details for Web of Science ID 000655724800132

• Chemotherapy-Induced Inflammatory Gene Signature and Protumorigenic Phenotype in Pancreatic CAFs via Stress-Associated MAPK MOLECULAR CANCER RESEARCH Toste, P. A., Nguyen, A. H., Kadera, B. E., Duong, M., Wu, N., Gawlas, I., Tran, L. M., Bikhchandani, M., Li, L., Patel, S. G., Dawson, D. W., Donahue, T. R. 2016; 14 (5): 437–47

  Abstract

  Pancreatic ductal adenocarcinoma (PDAC) has a characteristically dense stroma comprised predominantly of cancer-associated fibroblasts (CAF). CAFs promote tumor growth, metastasis, and treatment resistance. This study aimed to investigate the molecular changes and functional consequences associated with chemotherapy treatment of PDAC CAFs. Chemoresistant immortalized CAFs (R-CAF) were generated by continuous incubation in gemcitabine. Gene expression differences between treatment-naïve CAFs (N-CAF) and R-CAFs were compared by array analysis. Functionally, tumor cells (TC) were exposed to N-CAF- or R-CAF-conditioned media and assayed for migration, invasion, and viability in vitro Furthermore, a coinjection (TC and CAF) model was used to compare tumor growth in vivo R-CAFs increased TC viability, migration, and invasion compared with N-CAFs. In vivo, TCs coinjected with R-CAFs grew larger than those accompanied by N-CAFs. Genomic analysis demonstrated that R-CAFs had increased expression of various inflammatory mediators, similar to the previously described senescence-associated secretory phenotype (SASP). In addition, SASP mediators were found to be upregulated in response to short duration treatment with gemcitabine in both immortalized and primary CAFs. Inhibition of stress-associated MAPK signaling (P38 MAPK or JNK) attenuated SASP induction as well as the tumor-supportive functions of chemotherapy-treated CAFs in vitro and in vivo These results identify a negative consequence of chemotherapy on the PDAC microenvironment that could be targeted to improve the efficacy of current therapeutic regimens.Chemotherapy treatment of pancreatic cancer-associated fibroblasts results in a proinflammatory response driven by stress-associated MAPK signaling that enhances tumor cell growth and invasiveness. Mol Cancer Res; 14(5); 437-47. ©2016 AACR.

  View details for DOI 10.1158/1541-7786.MCR-15-0348

  View details for Web of Science ID 000375852900003

  View details for PubMedID 26979711

  View details for PubMedCentralID PMC4867256