Irmina A. Elliott, MD

All Publications

• 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