Leah Backhus trained in general surgery at the University of Southern California and cardiothoracic surgery at the University of California Los Angeles. She practices at Stanford Hospital and is Chief of Thoracic Surgery at the VA Palo Alto. Her surgical practice consists of general thoracic surgery with special emphasis on thoracic oncology and minimally invasive surgical techniques. She is also Co-Director of the Thoracic Surgery Clinical Research Program, and has grant funding through the Veterans Affairs Administration and NIH. Her current research interests are in imaging surveillance following treatment for lung cancer and cancer survivorship. She is a member of the National Lung Cancer Roundtable of the American Cancer Society and the Task Group on Health Equity. She also serves on the Board of Directors of the Society of Thoracic Surgeons. As an educator, Dr. Backhus is the Associate Program Director for the Thoracic Track Residency and is former Chair of the ACGME Residency Review Committee for Thoracic Surgery.

Clinical Focus

  • Lung Cancer
  • Mesothelioma
  • Pectus Excavatum
  • Minimally Invasive Surgery
  • Esophageal Cancer
  • Lung Volume Reduction Surgery
  • Mediastinal Masses
  • Thoracic and Cardiac Surgery

Academic Appointments

Administrative Appointments

  • Co- Director, Thoracic Surgery Clinical Research Program (2015 - Present)
  • Associate Program Director, Thoracic Track, CT Surgery Residency Training Program (2015 - Present)

Honors & Awards

  • Extraordinary Women in Cardiothoracic Surgery Award, Society of Thoracic Surgeons (2023)
  • McGoon Award for Teaching in Thoracic Surgery, Thoracic Surgery Residents Association (2019)
  • Levi Watkins Innovation and Leadership Scholarship, Thoracic Surgery Foundation (2019)
  • Faculty Member, Alpha Omega Alpha Honor Society (2018-present)

Boards, Advisory Committees, Professional Organizations

  • Deputy Editor, JAMA Surgery (2022 - Present)
  • Member, Society of University Surgeons (2020 - Present)
  • Director-At-Large, Society of Thoracic Surgeons (2019 - Present)
  • Member, American Association for Thoracic Surgery (2019 - Present)
  • Chair, ACGME Thoracic Surgery Resident Review Committee (2019 - 2022)
  • Member, International Association for the Study of Lung Cancer, Membership Committee (2017 - Present)
  • Chair, Task Group, Lung Cancer in Women; National Lung Cancer Roundtable (American Cancer Society) (2017 - 2022)
  • Member, American Medical Association (2016 - Present)
  • Member, American Society of Clinical Oncology (2016 - Present)
  • Fellow, American College of Surgeons (2013 - Present)
  • Member, Western Thoracic Surgical Association (2011 - Present)
  • Member, Society of Thoracic Surgeons (2010 - Present)
  • Member, Women in Thoracic Surgery (2010 - Present)
  • Member, Harkins Surgical Society (2010 - 2015)

Professional Education

  • Medical Education: University of Southern California Keck School of Medicine (2000) CA
  • Board Certification: American Board of Thoracic Surgery, Thoracic and Cardiac Surgery (2010)
  • Residency: LACplusUSC Dept of Surgery (2007) CA
  • Board Certification: American Board of Surgery, General Surgery (2008)
  • Residency: UCLA Thoracic Surgery Residency (2009) CA
  • MPH, University of Washington, Health Services (2014)
  • AB, Stanford University, Human Biology

Stanford Advisees

All Publications

  • 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


    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

  • Combined Breast and Lung Cancer Screening Among Dual-Eligible Women: A Descriptive Study. The Journal of surgical research Yue, T., Wong, L. Y., Jani, C., Agarwal, L., Al Omari, O., Aghagoli, G., Ahmed, A., Bhatt, P., Lee, A., Lotz, M., Marmor, H., Paliotti, G., Pories, S., Richmond, J., Shula, L., Sandler, K. L., Conley Thomson, C., Backhus, L. M. 2024


    Lung cancer is consistently the leading cause of cancer death among women in the United States, yet lung cancer screening (LCS) rates remain low. By contrast, screening mammography rates are reliably high, suggesting that screening mammography can be a "teachable moment" to increase LCS uptake among dual-eligible women.This is a prospective survey study conducted at two academic institutions. Patients undergoing screening mammography were evaluated for LCS eligibility and offered enrollment in a pilot dual-cancer screening program. A series of surveys was administered to characterize participants' knowledge, perceptions, and attitudes about LCS before and after undergoing dual screening. Data were descriptively summarized.Between August 2022 and July 2023, 54 LCS-eligible patients were enrolled. The study cohort was 100% female and predominantly White (81%), with a median age of 57 y and median of 36 pack-y of smoking. Survey results showed that 98% felt they were at risk for lung cancer, with most (80%) motivated by early detection of potential cancer. Regarding screening barriers, 58% of patients lacked knowledge about LCS eligibility and 47% reported concerns about screening cost. Prior to undergoing LCS, 87% of patients expressed interest in combined breast and lung screening. Encouragingly, after LCS, 84% were likely or very likely to undergo dual screening again and 93% found the shared decision-making visit helpful or very helpful.Pairing breast and LCS is a feasible, acceptable intervention that, along with increasing patient and provider education about LCS, can increase LCS uptake and reduce lung cancer mortality.

    View details for DOI 10.1016/j.jss.2024.05.024

    View details for PubMedID 38862305

  • Harnessing Opportunity: Pilot Intervention to Improve Lung Cancer Screening for Women Undergoing Breast Screening Mammography. JTO clinical and research reports Wong, L., Yue, T., Aghagoli, G., Baiu, I., Shula, L., Lee, A., Lui, N. S., Backhus, L. M. 2024; 5 (6): 100671


    Introduction: The screening mammogram could be a "teachable moment" to improve lung cancer screening (LCS) uptake. The aim of our project was to combine patient self-referral with eligibility identification by providers as a two-pronged approach to increase rates of LCS among eligible women.Methods: LCS education materials were created to stimulate patient education and encourage self-referral. Chart review of patients scheduled for screening mammography was performed to identify patients who met LCS criteria. The primary outcome was rate of acceptance of targeted interventions as measured by qualitative survey material and rate of LCS uptake.Results: Between August 2022 and August 2023, 116 patients were identified by providers for potential eligibility for LCS and 34 patients (29.3%) deemed eligible based on the U.S. Preventative Services Task Force 2021 guidelines. There were 19 patients (56%) who completed LCS with three patients (16%) with screen-detected nodules that led to further workup. Post-implementation qualitative survey results reveal that 100% of the participants rated their shared decision-making visit experience as "very helpful" and 67% responded "very likely" to seek simultaneous breast and LCS in the future. Informational materials were rated as 80% favorable among all respondents; however, the rate of self-referral alone was 0%. The combined rates of eligible patients lost to follow-up or refusal was 24%.Conclusion: The self-referral aspect of the intervention revealed that patients are unlikely to self-refer for LCS. Nevertheless, patients undergoing screening mammograms individually identified for LCS were very responsive to learning more about dual screening.

    View details for DOI 10.1016/j.jtocrr.2024.100671

    View details for PubMedID 38799132

  • ASO Visual Abstract: Complications of Outpatient Chest Tube Management for Prolonged Air Leaks After Pulmonary Surgery. Annals of surgical oncology Randle, R. J., Bhandari, P., He, H., Berry, M. F., Backhus, L. M., Lui, N. S., Liou, D. Z., Shrager, J. B. 2024

    View details for DOI 10.1245/s10434-024-15405-7

    View details for PubMedID 38743281

  • 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


    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

  • The Society of Thoracic Surgeons Expert Consensus Document on the Management of Pleural Drains following Pulmonary Lobectomy. The Annals of thoracic surgery Kent, M. S., Mitzman, B., Diaz-Gutierrez, I., Khullar, O. V., Fernando, H., Backhus, L., Brunelli, A., Cassivi, S. D., Cerfolio, R. J., Crabtree, T. D., Kakuturu, J., Martin, L. W., Raymond, D. P., Schumacher, L., Hayanga, J. W. 2024


    The Society of Thoracic Surgeons Workforce on Evidence Based Surgery provides this document on management of pleural drains following pulmonary lobectomy. The goal of this consensus document is to provide guidance regarding pleural drains in five specific areas: 1) choice of drain including size, type, and number, 2) management including use of suction versus water seal and criteria for removal, 3) imaging recommendations including the use of daily and post-pull chest x-rays, 4) use of digital drainage systems and 5) management of prolonged air leak. To formulate the consensus statements a task force of 15 general thoracic surgeons were invited to review the existing literature on this topic. Consensus was obtained using a modified Delphi method consisting of two rounds of voting until 75% agreement on the statements was reached. A total of thirteen consensus statements are provided to encourage standardization and stimulate additional research in this important area.

    View details for DOI 10.1016/j.athoracsur.2024.04.016

    View details for PubMedID 38723882

  • 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


    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


    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 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

  • Complications of Outpatient Chest Tube Management for Prolonged Air Leaks After Pulmonary Surgery. Annals of surgical oncology Randle, R. J., Bhandari, P., He, H., Berry, M. F., Backhus, L. M., Lui, N. S., Liou, D. Z., Shrager, J. B. 2024


    Air leaks are common after pulmonary surgery. Prolonged air leaks (PALs) may persist through discharge and often are managed with one-way valve devices (OWD). We sought to determine the course and complications of patients discharged with OWDs, risk factors for complications, and to evaluate the utility of clamp trials before chest tube (CT) removal.Single-institution, retrospective review of patients discharged with a OWD after pulmonary surgery between 2008 and 2022. Charts were examined for the presence of complications and CT duration. Differences in CT duration were compared by using the Wilcoxon rank-sum test.Sixty-four of 1917 (3.3%) pulmonary surgeries resulted in OWD use. Twelve of 64 (19%) patients discharged with a OWD suffered a complication. Nine of 64 (14%) had a CT-related readmission, and seven of 64 (11%) required PAL intervention. Patients sustaining a complication demonstrated longer CT durations before complication compared with duration in patients without complications, with median days of 13 [IQR 6-21] vs. 7 [IQR 6-12], p = 0.04). Five (7.8%) OWD patients developed an empyema; only one (20%) occurred before a CT duration of 14 days. Sixteen of 64 (25%) patients underwent a clamp trial before CT removal. One of ten (10%) failed even with no air leak present, whereas one of six (17%) failed with a present/questionable air leak.One-way valve device use has a substantial complication rate, and chest tube duration is a risk factor. In-hospital interventions might benefit patients with larger leaks that likely require prolonged OWD use. Because clamp trials occasionally fail, we contend that a clamp trial is the safest course before CT removal.

    View details for DOI 10.1245/s10434-024-15219-7

    View details for PubMedID 38536584

    View details for PubMedCentralID 6026238

  • 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


    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

  • 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


    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

  • 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

  • Impact of guideline therapy on survival of patients with stage I-III epithelioid mesothelioma. Journal of thoracic disease Liou, D. Z., Wang, Y., Bhandari, P., Shrager, J. B., Lui, N. S., Backhus, L. M., Berry, M. F. 2023; 15 (12): 6661-6673


    Modern treatment guidelines recommend multimodal therapy with at least chemotherapy and surgery for patients with potentially resectable epithelioid mesothelioma. This study evaluated guideline compliance for patients with stage I-III epithelioid mesothelioma and tested the hypothesis that guideline-concordant therapy improved survival.The National Cancer Database was queried for patients with stage I-III epithelioid malignant pleural mesothelioma between 2004 and 2016. The impact of therapy was evaluated using logistic regression, Kaplan-Meier analysis, Cox-proportional hazards analysis, and propensity-scoring methods.During the study period, guideline-concordant therapy was used in 677 patients (19.1%), and 2,857 patients (80.8%) did not have guideline-concordant therapy. Younger age, being insured, living in a census tract with a higher income, clinical stage, and being treated at an academic or research program were all predictors of receiving guideline-concordant therapy in multivariable analysis. Guideline-concordant therapy yielded improved median survival [24.7 (22.4-26.1) vs. 13.7 (13.2-14.4) months] and 5-year survival [17.7% (14.7-21.3%) vs. 8.0% (7.0-9.3%)] (P<0.001), and continued to be associated with better survival in both multivariable analysis and propensity-matched analysis. In the patients who received guideline therapy, median survival [24.9 (21.9-27.2) vs. 24.5 (21.7-28.1) months] and 5-year survival [14.9% (10.9-20.2%) vs. 20.1% (16.0-25.4%)] was not significantly different between patients who underwent induction (n=304) versus adjuvant (n=373) chemotherapy (P=0.444).Guideline-concordant therapy for potentially resectable epithelioid mesothelioma is associated with significantly improved survival but used in a minority of patients. The timing of chemotherapy with surgery in this study did not have a significant impact on overall survival.

    View details for DOI 10.21037/jtd-23-1334

    View details for PubMedID 38249900

    View details for PubMedCentralID PMC10797401

  • 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


    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

  • 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


    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


    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


    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
  • 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
  • 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
  • Second Primary Lung Cancer Among Lung Cancer Survivors Who Never Smoked. JAMA network open Choi, E., Su, C. C., Wu, J. T., Aredo, J. V., Neal, J. W., Leung, A. N., Backhus, L. M., Lui, N. S., Le Marchand, L., Stram, D. O., Liang, S. Y., Cheng, I., Wakelee, H. A., Han, S. S. 2023; 6 (11): e2343278


    Lung cancer among never-smokers accounts for 25% of all lung cancers in the US; recent therapeutic advances have improved survival among patients with initial primary lung cancer (IPLC), who are now at high risk of developing second primary lung cancer (SPLC). As smoking rates continue to decline in the US, it is critical to examine more closely the epidemiology of lung cancer among patients who never smoked, including their risk for SPLC.To estimate and compare the cumulative SPLC incidence among lung cancer survivors who have never smoked vs those who have ever smoked.This population-based prospective cohort study used data from the Multiethnic Cohort Study (MEC), which enrolled participants between April 18, 1993, and December 31, 1996, with follow-up through July 1, 2017. Eligible individuals for this study were aged 45 to 75 years and had complete smoking data at baseline. These participants were followed up for IPLC and further SPLC development through the Surveillance, Epidemiology, and End Results registry. The data were analyzed from July 1, 2022, to January 31, 2023.Never-smoking vs ever-smoking exposure at MEC enrollment.The study had 2 primary outcomes: (1) 10-year cumulative incidence of IPLC in the entire study cohort and 10-year cumulative incidence of SPLC among patients with IPLC and (2) standardized incidence ratio (SIR) (calculated as the SPLC incidence divided by the IPLC incidence) by smoking history.Among 211 414 MEC participants, 7161 (3.96%) developed IPLC over 4 038 007 person-years, and 163 (2.28%) developed SPLC over 16 470 person-years. Of the participants with IPLC, the mean (SD) age at cohort enrollment was 63.6 (7.7) years, 4031 (56.3%) were male, and 3131 (43.7%) were female. The 10-year cumulative IPLC incidence was 2.40% (95% CI, 2.31%-2.49%) among ever-smokers, which was 7 times higher than never-smokers (0.34%; 95% CI, 0.30%-0.37%). However, the 10-year cumulative SPLC incidence following IPLC was as high among never-smokers (2.84%; 95% CI, 1.50%-4.18%) as ever-smokers (2.72%; 95% CI, 2.24%-3.20%), which led to a substantially higher SIR for never-smokers (14.50; 95% CI, 8.73-22.65) vs ever-smokers (3.50; 95% CI, 2.95-4.12).The findings indicate that SPLC risk among lung cancer survivors who never smoked is as high as among those with IPLC who ever-smoked, highlighting the need to identify risk factors for SPLC among patients who never smoked and to develop a targeted surveillance strategy.

    View details for DOI 10.1001/jamanetworkopen.2023.43278

    View details for PubMedID 37966839

  • Risk Model-Based Lung Cancer Screening and Racial and Ethnic Disparities in the US. JAMA oncology Choi, E., Ding, V. Y., Luo, S. J., Ten Haaf, K., Wu, J. T., Aredo, J. V., Wilkens, L. R., Freedman, N. D., Backhus, L. M., Leung, A. N., Meza, R., Lui, N. S., Haiman, C. A., Park, S. L., Le Marchand, L., Neal, J. W., Cheng, I., Wakelee, H. A., Tammemägi, M. C., Han, S. S. 2023


    The revised 2021 US Preventive Services Task Force (USPSTF) guidelines for lung cancer screening have been shown to reduce disparities in screening eligibility and performance between African American and White individuals vs the 2013 guidelines. However, potential disparities across other racial and ethnic groups in the US remain unknown. Risk model-based screening may reduce racial and ethnic disparities and improve screening performance, but neither validation of key risk prediction models nor their screening performance has been examined by race and ethnicity.To validate and recalibrate the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial 2012 (PLCOm2012) model-a well-established risk prediction model based on a predominantly White population-across races and ethnicities in the US and evaluate racial and ethnic disparities and screening performance through risk-based screening using PLCOm2012 vs the USPSTF 2021 criteria.In a population-based cohort design, the Multiethnic Cohort Study enrolled participants in 1993-1996, followed up through December 31, 2018. Data analysis was conducted from April 1, 2022, to May 19. 2023. A total of 105 261 adults with a smoking history were included.The 6-year lung cancer risk was calculated through recalibrated PLCOm2012 (ie, PLCOm2012-Update) and screening eligibility based on a 6-year risk threshold greater than or equal to 1.3%, yielding similar eligibility as the USPSTF 2021 guidelines.Predictive accuracy, screening eligibility-incidence (E-I) ratio (ie, ratio of the number of eligible to incident cases), and screening performance (sensitivity, specificity, and number needed to screen to detect 1 lung cancer).Of 105 261 participants (60 011 [57.0%] men; mean [SD] age, 59.8 [8.7] years), consisting of 19 258 (18.3%) African American, 27 227 (25.9%) Japanese American, 21 383 (20.3%) Latino, 8368 (7.9%) Native Hawaiian/Other Pacific Islander, and 29 025 (27.6%) White individuals, 1464 (1.4%) developed lung cancer within 6 years from enrollment. The PLCOm2012-Update showed good predictive accuracy across races and ethnicities (area under the curve, 0.72-0.82). The USPSTF 2021 criteria yielded a large disparity among African American individuals, whose E-I ratio was 53% lower vs White individuals (E-I ratio: 9.5 vs 20.3; P < .001). Under the risk-based screening (PLCOm2012-Update 6-year risk ≥1.3%), the disparity between African American and White individuals was substantially reduced (E-I ratio: 15.9 vs 18.4; P < .001), with minimal disparities observed in persons of other minoritized groups, including Japanese American, Latino, and Native Hawaiian/Other Pacific Islander. Risk-based screening yielded superior overall and race and ethnicity-specific performance to the USPSTF 2021 criteria, with higher overall sensitivity (67.2% vs 57.7%) and lower number needed to screen (26 vs 30) at similar specificity (76.6%).The findings of this cohort study suggest that risk-based lung cancer screening can reduce racial and ethnic disparities and improve screening performance across races and ethnicities vs the USPSTF 2021 criteria.

    View details for DOI 10.1001/jamaoncol.2023.4447

    View details for PubMedID 37883107

  • Risk model-based management for second primary lung cancer among lung cancer survivors through a validated risk prediction model. Cancer Choi, E., Luo, S. J., Ding, V. Y., Wu, J. T., Kumar, A. V., Wampfler, J., Tammemägi, M. C., Wilkens, L. R., Aredo, J. V., Backhus, L. M., Neal, J. W., Leung, A. N., Freedman, N. D., Hung, R. J., Amos, C. I., Le Marchand, L., Cheng, I., Wakelee, H. A., Yang, P., Han, S. S. 2023


    Recent therapeutic advances and screening technologies have improved survival among patients with lung cancer, who are now at high risk of developing second primary lung cancer (SPLC). Recently, an SPLC risk-prediction model (called SPLC-RAT) was developed and validated using data from population-based epidemiological cohorts and clinical trials, but real-world validation has been lacking. The predictive performance of SPLC-RAT was evaluated in a hospital-based cohort of lung cancer survivors.The authors analyzed data from 8448 ever-smoking patients diagnosed with initial primary lung cancer (IPLC) in 1997-2006 at Mayo Clinic, with each patient followed for SPLC through 2018. The predictive performance of SPLC-RAT and further explored the potential of improving SPLC detection through risk model-based surveillance using SPLC-RAT versus existing clinical surveillance guidelines.Of 8448 IPLC patients, 483 (5.7%) developed SPLC over 26,470 person-years. The application of SPLC-RAT showed high discrimination area under the receiver operating characteristics curve: 0.81). When the cohort was stratified by a 10-year risk threshold of ≥5.6% (i.e., 80th percentile from the SPLC-RAT development cohort), the observed SPLC incidence was significantly elevated in the high-risk versus low-risk subgroup (13.1% vs. 1.1%, p < 1 × 10-6 ). The risk-based surveillance through SPLC-RAT (≥5.6% threshold) outperformed the National Comprehensive Cancer Network guidelines with higher sensitivity (86.4% vs. 79.4%) and specificity (38.9% vs. 30.4%) and required 20% fewer computed tomography follow-ups needed to detect one SPLC (162 vs. 202).In a large, hospital-based cohort, the authors validated the predictive performance of SPLC-RAT in identifying high-risk survivors of SPLC and showed its potential to improve SPLC detection through risk-based surveillance.Lung cancer survivors have a high risk of developing second primary lung cancer (SPLC). However, no evidence-based guidelines for SPLC surveillance are available for lung cancer survivors. Recently, an SPLC risk-prediction model was developed and validated using data from population-based epidemiological cohorts and clinical trials, but real-world validation has been lacking. Using a large, real-world cohort of lung cancer survivors, we showed the high predictive accuracy and risk-stratification ability of the SPLC risk-prediction model. Furthermore, we demonstrated the potential to enhance efficiency in detecting SPLC using risk model-based surveillance strategies compared to the existing consensus-based clinical guidelines, including the National Comprehensive Cancer Network.

    View details for DOI 10.1002/cncr.35069

    View details for PubMedID 37877788

  • A Tale of Two Presidential Addresses. JAMA surgery Varghese, T. K., Backhus, L. M., Dimick, J. B. 2023

    View details for DOI 10.1001/jamasurg.2023.4655

    View details for PubMedID 37792346

  • Overall Survival Among Patients With De Novo Stage IV Metastatic and Distant Metastatic Recurrent Non-Small Cell Lung Cancer. JAMA network open Su, C. C., Wu, J. T., Choi, E., Myall, N. J., Neal, J. W., Kurian, A. W., Stehr, H., Wood, D., Henry, S. M., Backhus, L. M., Leung, A. N., Wakelee, H. A., Han, S. S. 2023; 6 (9): e2335813


    Despite recent breakthroughs in therapy, advanced lung cancer still poses a therapeutic challenge. The survival profile of patients with metastatic lung cancer remains poorly understood by metastatic disease type (ie, de novo stage IV vs distant recurrence).To evaluate the association of metastatic disease type on overall survival (OS) among patients with non-small cell lung cancer (NSCLC) and to identify potential mechanisms underlying any survival difference.Cohort study of a national US population based at a tertiary referral center in the San Francisco Bay Area using participant data from the National Lung Screening Trial (NLST) who were enrolled between 2002 and 2004 and followed up for up to 7 years as the primary cohort and patient data from Stanford Healthcare (SHC) for diagnoses between 2009 and 2019 and followed up for up to 13 years as the validation cohort. Participants from NLST with de novo metastatic or distant recurrent NSCLC diagnoses were included. Data were analyzed from January 2021 to March 2023.De novo stage IV vs distant recurrent metastatic disease.OS after diagnosis of metastatic disease.The NLST and SHC cohort consisted of 660 and 180 participants, respectively (411 men [62.3%] vs 109 men [60.6%], 602 White participants [91.2%] vs 111 White participants [61.7%], and mean [SD] age of 66.8 [5.5] vs 71.4 [7.9] years at metastasis, respectively). Patients with distant recurrence showed significantly better OS than patients with de novo metastasis (adjusted hazard ratio [aHR], 0.72; 95% CI, 0.60-0.87; P < .001) in NLST, which was replicated in SHC (aHR, 0.64; 95% CI, 0.43-0.96; P = .03). In SHC, patients with de novo metastasis more frequently progressed to the bone (63 patients with de novo metastasis [52.5%] vs 19 patients with distant recurrence [31.7%]) or pleura (40 patients with de novo metastasis [33.3%] vs 8 patients with distant recurrence [13.3%]) than patients with distant recurrence and were primarily detected through symptoms (102 patients [85.0%]) as compared with posttreatment surveillance (47 patients [78.3%]) in the latter. The main finding remained consistent after further adjusting for metastasis sites and detection methods.In this cohort study, patients with distant recurrent NSCLC had significantly better OS than those with de novo disease, and the latter group was associated with characteristics that may affect overall survival. This finding can help inform future clinical trial designs to ensure a balance for baseline patient characteristics.

    View details for DOI 10.1001/jamanetworkopen.2023.35813

    View details for PubMedID 37751203

  • JAMA Surgery Reaffirmation to Diversity, Equity, and Inclusion. JAMA surgery Newman, L. A., Backhus, L. M., Kibbe, M. R. 2023

    View details for DOI 10.1001/jamasurg.2023.4033

    View details for PubMedID 37477928

  • The American Association for Thoracic Surgery (AATS) 2023 Expert Consensus Document: Staging and multidisciplinary management of patients with early-stage non-small cell lung cancer. The Journal of thoracic and cardiovascular surgery Kidane, B., Bott, M., Spicer, J., Backhus, L., Chaft, J., Chudgar, N., Colson, Y., D'Amico, T. A., David, E., Lee, J., Najmeh, S., Sepesi, B., Shu, C., Yang, J., Swanson, S., Stiles, B. 2023


    Novel targeted therapy and immunotherapy drugs have recently been approved for use in patients with surgically resectable lung cancer. Accurate staging, early molecular testing, and knowledge of recent trials are critical to optimize oncologic outcomes in these patients.

    View details for DOI 10.1016/j.jtcvs.2023.04.039

    View details for PubMedID 37306641

  • The impact of neoadjuvant immunotherapy on perioperative outcomes and survival after esophagectomy for esophageal cancer. JTCVS open Wong, L., Liou, D. Z., Backhus, L. M., Lui, N. S., Shrager, J. B., Berry, M. F. 2023; 14: 547-560


    Objective: Immunotherapy for esophageal cancer is relatively novel but increasingly used. This study evaluated the early use of immunotherapy as an adjunct to neoadjuvant chemoradiotherapy before esophagectomy for locally advanced disease.Methods: Perioperative morbidity (composite of mortality, hospitalization ≥21days, or readmission) and survival of patients with locally advanced (cT3N0M0, cT1-3N + M0) distal esophageal cancer in the National Cancer Database from 2013 to 2020 who underwent neoadjuvant immunotherapy plus chemoradiotherapy or chemoradiotherapy alone followed by esophagectomy were evaluated using logistic regression, Kaplan-Meier curves, Cox proportional hazards methods, and propensity-matched analysis.Results: Immunotherapy was used in 165 (1.6%) of 10,348 patients. Younger age (odds ratio, 0.66; 95% confidence interval, 0.53-0.81; P<.001) predicted immunotherapy use, which slightly delayed time from diagnosis to surgery versus chemoradiation alone (immunotherapy 148 [interquartile range, 128-177] days vs chemoradiation 138 [interquartile range, 120-162] days, P<.001). There were no statistically significant differences between the immunotherapy and chemoradiation groups for the composite major morbidity index (14.5% [24/165] vs 15.6% [1584/10,183], P=.8). Immunotherapy was associated with a significant improvement in median overall survival (69.1months vs 56.3months, P=.005) and 3-year overall survival in univariate analysis (65.6% [95% confidence interval, 57.7-74.5] vs 55.0% [53.9-56.1], P=.005), and independently predicted improved survival in multivariable analysis (hazard ratio 0.68 [95% confidence interval, 0.52-0.89], P=.006). Propensity-matched analysis also showed that immunotherapy use was not associated with increased surgical morbidity (P=.5) but was associated with improved survival (P=.047).Conclusions: Neoadjuvant immunotherapy use before esophagectomy for locally advanced esophageal cancer did not lead to worse perioperative outcomes and shows promising results on midterm survival.

    View details for DOI 10.1016/j.xjon.2023.03.015

    View details for PubMedID 37425457

  • Characterization of Epidural Analgesia Interruption and Associated Outcomes After Esophagectomy. The Journal of surgical research Byrd, C. T., Kim, R. K., Manapat, P., He, H., Tsui, B. C., Shrager, J. B., Berry, M. F., Backhus, L. M., Lui, N. S., Liou, D. Z. 2023; 290: 92-100


    Interruption of thoracic epidural analgesia may impact the postoperative course following esophagectomy. This study investigates the incidence and causes of epidural interruption in esophagectomy patients along with associated postoperative outcomes.This single-institution retrospective analysis examined patients undergoing esophagectomy who received a thoracic epidural catheter from 2016 to 2020. Patients were stratified according to whether epidural catheter infusion was interrupted or not postoperatively. Outcomes were compared between the two groups, and predictors of epidural interruption and postoperative complications were estimated using multivariable logistic regression.Of the 168 patients who received a thoracic epidural before esophagectomy, 60 (35.7%) required epidural interruption and 108 (64.3%) did not. Interruption commonly occurred on postoperative day 1 and was due to hypotension 80% of the time. Heart failure (10.0% versus 0.9%, P = 0.009), atrial fibrillation (20.0% versus 3.7%, P = 0.002), preoperative opioid use (30.0% versus 16.7%, P = 0.043), and higher American Society of Anesthesiology classification (88.4% versus 70.4%, P = 0.008) were more prevalent in the epidural interruption cohort. The female gender was associated with epidural interruption on multivariable logistic regression (adjusted odds ratio [AOR] 2.45, P = 0.039). Patients in the epidural interruption cohort had a higher incidence of delirium (30.5% versus 13.9%, P = 0.010), sepsis (13.6% versus 3.7%, P = 0.028), and severe anastomotic leak (18.3% versus 7.4%, P = 0.032). On adjusted analysis, heart disease (AOR 4.26, P = 0.027), BMI <18.5 (AOR 9.83, P = 0.031), and epidural interruption due to hypotension (AOR 3.51, P = 0.037) were associated with severe anastomotic leak.Early epidural interruption secondary to hypotension in esophagectomy patients may be a harbinger of postoperative complications such as sepsis and severe anastomotic leak. Patients requiring epidural interruption due to hypotension should have a low threshold for additional workup and early intervention.

    View details for DOI 10.1016/j.jss.2023.04.009

    View details for PubMedID 37224609

  • Surgical Management of Esophageal Perforation: Examining Trends in a Multi-Institutional Cohort. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract Wong, L. Y., Leipzig, M., Liou, D. Z., Backhus, L. M., Lui, N. S., Shrager, J. B., Berry, M. F. 2023


    Esophageal perforations historically are associated with significant morbidity and mortality and generally require emergent intervention. The influence of improved diagnostic and therapeutic modalities available in recent years on management has not been examined. This study examined the surgical treatments and outcomes of a modern cohort.Patients with esophageal perforation management in the 2005-2020 American College of Surgeons National Surgical Quality Improvement Program database were stratified into three eras (2005-2009, 2010-2014, and 2015-2020). Surgical management was classified as primary repair, resection, diversion, or drainage alone based on procedure codes. The distribution of procedure use, morbidity, and mortality across eras was examined.Surgical management of 378 identified patients was primary repair (n=193,51%), drainage (n=89,24%), resection (n=70,18%), and diversion (n=26,7%). Thirty-day mortality in the cohort was 9.5% (n=36/378) and 268 patients (71%) had at least one complication. The median length of stay was 15 days. Both morbidity (Era 1 65% [n=42/60] versus Era 2 69% [n=92/131] versus Era 3 72% [n=135/187], p=0.3) and mortality (Era 1 11% [n=7/65] versus Era 2 9% [n=12/131] versus Era 3 10% [n=19/187], p=0.9) did not change significantly over the three defined eras. Treatment over time evolved such that primary repair was more frequently utilized (43% in Era 1 to 51% in Era 3) while diversion was less often performed (13% in Era 1 to 7% in Era 3) (p=0.009).Esophageal perforation management in recent years uses diversion less often but remains associated with significant morbidity and mortality.

    View details for DOI 10.1007/s11605-023-05700-1

    View details for PubMedID 37165161

    View details for PubMedCentralID 7330325

  • ASO Visual Abstract: Impact of Delaying Surgery After Chemoradiation on Outcomes for Locally Advanced Esophageal Squamous Cell Carcinoma. Annals of surgical oncology Wong, L. Y., Liou, D. Z., Vitzthum, L. K., Backhus, L. M., Lui, N. S., Chang, D., Shrager, J. B., Berry, M. F. 2023

    View details for DOI 10.1245/s10434-023-13156-5

    View details for PubMedID 36759429

  • A hybrid modelling approach for abstracting CT imaging indications by integrating natural language processing from radiology reports with structured data from electronic health records. Khan, A., Wu, J., Choi, E., Graber-Naidich, A., Henry, S., Wakelee, H. A., Kurian, A. W., Liang, S., Leung, A., Langlotz, C., Backhus, L. M., Han, S. S. AMER ASSOC CANCER RESEARCH. 2023
  • Does delaying surgery following induction chemotherapy compromise survival in patients with mesothelioma? JOURNAL OF CANCER METASTASIS AND TREATMENT Wong, L., Baiu, I., Leipzig, M., Titan, A., Liou, D. Z., Lui, N., Berry, M., Shrager, J. B., Backhus, L. 2023; 9
  • Impact of Delaying Surgery After Chemoradiation on Outcomes for Locally Advanced Esophageal Squamous Cell Carcinoma. Annals of surgical oncology Wong, L., Liou, D. Z., Vitzthum, L. K., Backhus, L. M., Lui, N. S., Chang, D., Shrager, J. B., Berry, M. F. 2022


    BACKGROUND: Performing selective esophagectomy for locally advanced squamous cell carcinoma may spare patients morbidity, but delayed surgery may infer higher risks. This study evaluated the impact of length of time between chemoradiation and esophagectomy on perioperative outcomes and long-term survival.METHODS: The impact of surgical timing, stratified by surgery performed < 180 and ≥ 180 days from starting radiation, on perioperative outcomes and survival in patients treated with chemoradiation and esophagectomy for cT1N + M0 and cT2-4, any N, M0 squamous cell carcinoma of the mid-distal esophagus in the National Cancer Database (2006-2016) was evaluated with logistic regression, Kaplan-Meier curves, Cox proportional-hazards methods, and propensity-matched analysis.RESULTS: Median time between starting radiation and esophagectomy in 1641 patients was 93 (IQR 81-114) days. Most patients (96.8%, n = 1589) had surgery within 180 days of starting radiation, while 52 patients (3.2%) had delayed surgery. Black race and clinical T stage were associated with delayed surgery. Rates of pathologic upstaging, downstaging, complete response, and positive margins were not significantly different between the groups. Patients with delayed surgery had increased major morbidity as measured by a composite of length of hospital stay, readmission, and 30-day mortality [42.3% (22/52) vs 22.3% (355/1589), p = 0.001]. However, delayed surgery was not associated with a significant difference in survival in both univariate [5-year survival 32.8% (95% CI 21.1-50.7) vs 47.3% (44.7-50.1), p = 0.19] and multivariable analysis [hazard ratio (HR) 1.23 (0.85-1.78), p = 0.26].CONCLUSIONS: Delaying surgery longer than 180 days after starting chemoradiation for esophageal squamous cell carcinoma is associated with worse perioperative outcomes but not long-term survival.

    View details for DOI 10.1245/s10434-022-12980-5

    View details for PubMedID 36572807

  • Diversity, Equity, and Inclusion: Visiting The Society of Thoracic Surgeons Priority ANNALS OF THORACIC SURGERY Hayanga, J., Chatterjee, S., Balsara, K., Backhus, L., Wolf, S., Preventza, O., Horvath, K. A., Lahey, S., Soc Thoracic urgeons Workforce 2023; 115 (1): 25-33
  • Generating Rare Surgical Events Using CycleGAN: Addressing Lack of Data for Artificial Intelligence Event Recognition. The Journal of surgical research Mohamadipanah, H., Kearse, L., Wise, B., Backhus, L., Pugh, C. 2022; 283: 594-605


    Artificial Intelligence (AI) has shown promise in facilitating surgical video review through automatic recognition of surgical activities/events. There are few public video data sources that demonstrate critical yet rare events which are insufficient to train AI for reliable video event recognition. We suggest that a generative AI algorithm can create artificial massive bleeding images for minimally invasive lobectomy that can be used to augment the current lack of data in this field.A generative adversarial network (GAN) algorithm was used (CycleGAN) to generate artificial massive bleeding event images. To train CycleGAN, six videos of minimally invasive lobectomies were utilized from which 1819 frames of nonbleeding instances and 3178 frames of massive bleeding instances were used.The performance of the CycleGAN algorithm was tested on a new video that was not used during the training process. The trained CycleGAN was able to alter the laparoscopic lobectomy images according to their corresponding massive bleeding images, where the contents of the original images were preserved (e.g., location of tools in the scene) and the style of each image is changed to massive bleeding (i.e., blood automatically added to appropriate locations on the images).The result could suggest a promising approach to supplement the lack of data for the rare massive bleeding event that can occur during minimally invasive lobectomy. Future work could be dedicated to developing AI algorithms to identify surgical strategies and actions that potentially lead to massive bleeding and warn surgeons prior to this event occurrence.

    View details for DOI 10.1016/j.jss.2022.11.008

    View details for PubMedID 36442259

  • Risk of adenocarcinoma in patients with a suspicious ground-glass opacity: a retrospective review. Journal of thoracic disease Roy, E., Shrager, J., Benson, J., Trope, W. L., Bhandari, P., Lui, N., Liou, D., Backhus, L., Berry, M. F. 2022; 14 (11): 4236-4245


    Both primary lung adenocarcinoma and benign processes can have a ground-glass opacity (GGO) appearance on imaging. This study evaluated the incidence of and risk factors for malignancy in a diverse cohort of patients who underwent resection of a GGO suspicious for lung cancer.All patients who underwent resection of a pulmonary nodule with a GGO component and suspected to be primary lung cancer at a single institution from 2001-2017 were retrospectively reviewed. Risk factors for malignancy were evaluated using multivariable logistic regression analysis that included nodule size, age, sex, and race as potential predictors.The incidence of pulmonary adenocarcinoma in the 243 patients who met inclusion criteria was 86% (n=208). The most common pathologic findings in 35 patients with a benign pathology was granulomatous inflammation (n=14, 40%). Risk factors for adenocarcinoma in multivariable logistic regression were age [odds ratio (OR) 1.06, P=0.003], GGO size (OR 2.76, P<0.001), female sex (OR 4.47, P=0.002), and Asian race (OR 8.35, P=0.002). In this cohort, adenocarcinoma was found in 100% (44/44) of Asian females, 86% (25/29) of Asian males, 84% (98/117) of non-Asian females, and 77% (41/53) of non-Asian males.The likelihood of adenocarcinoma in lung nodules with a ground-glass component is influenced by sex and race. Asian females with a GGO have a much higher likelihood of having adenocarcinoma than men and non-Asians. This data can be used when deciding whether to pursue nodule resection or surveillance in a patient with a GGO.

    View details for DOI 10.21037/jtd-22-583

    View details for PubMedID 36524073

    View details for PubMedCentralID PMC9745528

  • Lobar versus sublobar resection in clinical stage IA primary lung cancer with occult N2 disease. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery Liou, D. Z., Chan, M., Bhandari, P., Lui, N. S., Backhus, L. M., Shrager, J. B., Berry, M. F. 2022


    Sublobar resection is increasingly being utilized for early-stage lung cancers, but optimal management when final pathology shows unsuspected mediastinal nodal disease is unclear. This study tested the hypothesis that lobectomy has improved survival compared to sublobar resection for clinical stage IA tumors with occult N2 disease.The use of sublobar resection and lobectomy for patients in the National Cancer Database who underwent primary surgical resection for clinical stage IA non-small cell lung cancer with pathologic N2 disease between 2010 and 2017 was evaluated using logistic regression. Survival was assessed with Kaplan-Meier analysis, log-rank test, and Cox proportional hazards model.A total of 2,419 patients comprised the study cohort, including 320 sublobar resections (13.2%) and 2,099 lobectomies (86.8%). Older age, female sex, smaller tumour size, and treatment at an academic facility predicted the use of sublobar resection. Patients undergoing lobectomy had larger tumors (2.40 vs 2.05 cm, p < 0.001) and more lymph nodes examined (11 vs 5, p < 0.001). Adjuvant chemotherapy use was similar between the two groups (sublobar 79.4% vs lobectomy 77.4%, p = 0.434). Sublobar resection was not associated with worse survival compared to lobectomy in both univariate (5-year survival 46.6% vs 45.2%, p = 0.319) and multivariable Cox proportional hazards analysis (HR 0.97, p = 0.789).Clinical stage IA non-small cell lung cancer patients with N2 disease on final pathology have similar long-term survival with either sublobar resection or lobectomy. Patients with occult N2 disease after sublobar resection may not require reoperation for completion lobectomy but should instead proceed to adjuvant chemotherapy.

    View details for DOI 10.1093/ejcts/ezac440

    View details for PubMedID 36063054

  • Risk of adenocarcinoma in patients with a suspicious ground-glass opacity: a retrospective review JOURNAL OF THORACIC DISEASE Roy, E., Shrager, J., Benson, J., Trope, W., Bhandari, P., Lui, N., Liou, D., Backhus, L., Berry, M. F. 2022
  • Eligibility for Lung Cancer Screening Among Women Receiving Screening for Breast Cancer. JAMA network open Titan, A. L., Baiu, I., Liou, D., Lui, N. S., Berry, M., Shrager, J., Backhus, L. 2022; 5 (9): e2233840

    View details for DOI 10.1001/jamanetworkopen.2022.33840

    View details for PubMedID 36178692

  • Demographics of Current and Aspiring Integrated Six-Year Cardiothoracic Surgery Trainees. The Annals of thoracic surgery Olive, J. K., Yost, C. C., Robinson, J. A., Brescia, A. A., Han, J. J., Haney, J. C., Forbess, J. M., Varghese, T. K., Backhus, L. M., Cooke, D. T., Cornwell, L. D., Preventza, O. A. 2022


    BACKGROUND: The integrated thoracic surgery (I-6) residency model was developed, in part, to promote early interest in cardiothoracic (CT) surgery in diverse trainees. To determine gaps in and opportunities for recruitment of women and minority groups in the pipeline for I-6 residency, we quantified rates of progression at each training level, as well as trends over time.METHODS: We obtained 2015-2019 medical student, I-6 applicant, and I-6 resident gender and race/ethnicity demographic data from the American Association of Medical Colleges and Electronic Residency Application Service public databases and Accreditation Council for Graduate Medical Education Data Resource Books. We performed Chi-square, Fisher exact, and Cochran-Armitage tests for trend to compare 2015 and 2019.RESULTS: Our cross-sectional analysis found increased representation of women and all non-White races/ethnicities, except American Indian, at each training level from 2015 to 2019 (p<0.001 for all). The greatest trend in increases were seen in the proportions of women (28% vs 22%, p=0.46) and Asian/Pacific Islander (25% vs 15%, p=0.08) applicants. There was also an increase in the proportions of women (28% vs 24%, p=0.024) and White (61% vs 58%, p=0.007) I-6 residents, with a trend for Asian/Pacific Islanders (20% vs 17%, p=0.08). The proportions of Hispanic (5%) and Black/African American (2%) I-6 residents in 2019 remained low.CONCLUSIONS: I-6 residency matriculation is not representative of medical student demographics and spotlights a need to foster early interest in CT surgery among all groups underrepresented in medicine, while ensuring that we mitigate bias in residency recruitment.

    View details for DOI 10.1016/j.athoracsur.2022.06.051

    View details for PubMedID 35934069

  • Genomic Profiling of Bronchoalveolar Lavage Fluid in Lung Cancer. Cancer research Nair, V. S., Hui, A. B., Chabon, J. J., Shahrokh Esfahani, M., Stehr, H., Nabet, B. Y., Zhou, L., Chaudhuri, A. A., Benson, J. A., Ayers, K., Bedi, H., Ramsey, M. C., Van Wert, R., Antic, S., Lui, N. S., Backhus, L. M., Berry, M. F., Sung, A. W., Massion, P. P., Shrager, J. B., Alizadeh, A. A., Diehn, M. 2022


    Genomic profiling of Bronchoalveolar Lavage (BAL) samples may be useful for tumor profiling and diagnosis in the clinic. Here, we compared tumor-derived mutations detected in BAL samples from subjects with non-small cell lung cancer (NSCLC) to those detected in matched plasma samples. CAncer Personalized Profiling by deep Sequencing (CAPP-Seq) was used to genotype DNA purified from BAL, plasma and tumor samples from patients with NSCLC. The characteristics of cell-free DNA (cfDNA) isolated from BAL fluid were first characterized to optimize the technical approach. Somatic mutations identified in tumor were then compared to those identified in BAL and plasma, and the potential of BAL cfDNA analysis to distinguish lung cancer patients from risk-matched controls was explored. In total, 200 biofluid and tumor samples from 38 cases and 21 controls undergoing BAL for lung cancer evaluation were profiled. More tumor variants were identified in BAL cfDNA than plasma cfDNA in all stages (p<0.001) and in stage I-II disease only. Four of 21 controls harbored low levels of cancer-associated driver mutations in BAL cfDNA (mean VAF=0.5%), suggesting the presence of somatic mutations in non-malignant airway cells. Finally, using a Random Forest model with leave-one-out cross validation, an exploratory BAL genomic classifier identified lung cancer with 69% sensitivity and 100% specificity in this cohort and detected more cancers than BAL cytology. Detecting tumor-derived mutations by targeted sequencing of BAL cfDNA is technically feasible and appears to be more sensitive than plasma profiling. Further studies are required to define optimal diagnostic applications and clinical utility.

    View details for DOI 10.1158/0008-5472.CAN-22-0554

    View details for PubMedID 35748739

  • Long term effect of radiotherapy on risk of second primary lung cancer and overall mortality among lung cancer patients Choi, E., Lam, V. T., Aredo, J. A., Kumar, A. V., Wampfler, J., Wu, J. T., Christiani, D. C., Cheng, I., Amos, C. I., Hung, R. J., Backhus, L. M., Neal, J. W., Wakelee, H. A., Yang, P., Han, S. S. AMER ASSOC CANCER RESEARCH. 2022
  • Performance of a rule-based semi-automated method to optimize chart abstraction for surveillance imaging among patients treated for non-small cell lung cancer. BMC medical informatics and decision making Byrd, C., Ajawara, U., Laundry, R., Radin, J., Bhandari, P., Leung, A., Han, S., Asch, S. M., Zeliadt, S., Harris, A. H., Backhus, L. 2022; 22 (1): 148


    BACKGROUND: We aim to develop and test performance of a semi-automated method (computerized query combined with manual review) for chart abstraction in the identification and characterization of surveillance radiology imaging for post-treatment non-small cell lung cancer patients.METHODS: A gold standard dataset consisting of 3011 radiology reports from 361 lung cancer patients treated at the Veterans Health Administration from 2008 to 2016 was manually created by an abstractor coding image type, image indication, and image findings. Computerized queries using a text search tool were performed to code reports. The primary endpoint of query performance was evaluated by sensitivity, positive predictive value (PPV), and F1 score. The secondary endpoint of efficiency compared semi-automated abstraction time to manual abstraction time using a separate dataset and the Wilcoxon rank-sum test.RESULTS: Query for image type demonstrated the highest sensitivity of 85%, PPV 95%, and F1 score 0.90. Query for image indication demonstrated sensitivity 72%, PPV 70%, and F1 score 0.71. The image findings queries ranged from sensitivity 75-85%, PPV 23-25%, and F1 score 0.36-0.37. Semi-automated abstraction with our best performing query (image type) improved abstraction times by 68% per patient compared to manual abstraction alone (from median 21.5min (interquartile range 16.0) to 6.9min (interquartile range 9.5), p<0.005).CONCLUSIONS: Semi-automated abstraction using the best performing query of image type improved abstraction efficiency while preserving data accuracy. The computerized query acts as a pre-processing tool for manual abstraction by restricting effort to relevant images. Determining image indication and findings requires the addition of manual review for a semi-automatic abstraction approach in order to ensure data accuracy.

    View details for DOI 10.1186/s12911-022-01863-0

    View details for PubMedID 35659230

  • Career Progression and Research Productivity of Women in Academic Cardiothoracic Surgery. The Annals of thoracic surgery Williams, K. M., Wang, H., Bajaj, S. S., Hironaka, C. E., Kasinpila, P., O'Donnell, C. T., Sanchez, M., Watkins, A. C., Lui, N. S., Backhus, L. M., Boyd, J. 2022


    The objective of this work was to delineate career progression and research productivity of women practicing cardiothoracic surgery in the academic setting.Cardiothoracic surgeons at the 79 accredited U.S. cardiothoracic surgery training programs in 2020 were included in this cross-sectional analysis. Data regarding sub-specialization, training, practice history, and publications were gathered from public sources including department websites, CTSNet, and Scopus.A total of 1065 surgeons (51.3% cardiac, 32.1% thoracic, 16.6% congenital) were identified. Women accounted for 10.6% (113) of the population (7.9% of cardiac, 15.5% of thoracic, 9.6% of congenital surgeons). The median number of cardiothoracic surgeons per institution was 12 [IQR 10-17], with a median of one woman [IQR 0-2]. Fifteen of 79 (19%) programs had zero women. Among women faculty, 5.3% were clinical instructors, 51.3% were assistant professors, 23.0% were associate professors, 16.8% were full professors, and 3.5% had unspecified titles (vs. 2.0%, 32.9%, 23.0%, 37.5%, and 4.6% among men, respectively, p<0.001). Women and men authored a comparable number of first-author (0.4 [0.0-1.3] vs. 0.5 [0.0-1.1], p=0.56) publications per year, but fewer last-author (0.1 [0.0-0.7] vs. 0.4 [0.0-1.3], p<0.0001) and total publications per year (2.7 [1.0-6.2] vs. 3.7 [1.3-7.8], p=0.05) than men. H-index was lower for women than for men overall (8.0 [3.0-15.0] vs. 15.0 [7.0-28.0], p<0.001), but was similar between men and women who had been practicing for 10-20 years.Gender disparities persist in academic cardiothoracic surgery. Efforts should be made to support women in achieving senior roles and academic productivity.

    View details for DOI 10.1016/j.athoracsur.2022.04.057

    View details for PubMedID 35643331

  • 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


    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

  • Moving the Needle ... Evidence of Durability of Impact REPLY ANNALS OF THORACIC SURGERY Williams, K. M., Backhus, L. M. 2022; 113 (5): 1758-1759
  • Moving the Needle. . .Evidence of Durability of Impact ANNALS OF THORACIC SURGERY Williams, K. M., Backhus, L. M. 2022; 113 (5): 1758-1759
  • Positron emission tomography/computed tomography differentiates resectable thymoma from anterior mediastinal lymphoma. The Journal of thoracic and cardiovascular surgery Byrd, C. T., Trope, W. L., Bhandari, P., Konsker, H. B., Moradi, F., Lui, N. S., Liou, D. Z., Backhus, L. M., Berry, M. F., Shrager, J. B. 2022


    OBJECTIVE: Discrete anterior mediastinal masses most often represent thymoma or lymphoma. Lymphoma treatment is nonsurgical and requires biopsy. Noninvasive thymoma is ideally resected without biopsy, which may potentiate pleural metastases. This study sought to determine if clinical criteria or positron emission tomography/computed tomography could accurately differentiate the 2, guiding a direct surgery versus biopsy decision.METHODS: A total of 48 subjects with resectable thymoma and 29 subjects with anterior mediastinal lymphoma treated from 2006 to 2019 were retrospectively examined. All had pretreatment positron emission tomography/computed tomography and appeared resectable (solitary, without clear invasion or metastasis). Reliability of clinical criteria (age and B symptoms) and positron emission tomography/computed tomography maximum standardized uptake value were assessed in differentiating thymoma and lymphoma using Wilcoxon rank-sum test, chi-square test, and logistic regression. Receiver operating characteristic analysis identified the maximum standardized uptake value threshold most associated with thymoma.RESULTS: There was no association between tumor type and age group (P=.183) between those with thymoma versus anterior mediastinal lymphoma. Patients with thymoma were less likely to report B symptoms (P<.001). The median maximum standardized uptake value of thymoma and lymphoma differed dramatically: 4.35 versus 18.00 (P<.001). Maximum standardized uptake value was independently associated with tumor type on multivariable regression. On receiver operating characteristic analysis, lower maximum standardized uptake value was associated with thymoma. Maximum standardized uptake value less than 12.85 was associated with thymoma with 100.00% sensitivity and 88.89% positive predictive value. Maximum standardized uptake value less than 7.50 demonstrated 100.00% positive predictive value for thymoma.CONCLUSIONS: Positron emission tomography/computed tomography maximum standardized uptake value of resectable anterior mediastinal masses may help guide a direct surgery versus biopsy decision. Tumors with maximum standardized uptake value less than 7.50 are likely thymoma and thus perhaps appropriately resected without biopsy. Tumors with maximum standardized uptake value greater than 7.50 should be biopsied to rule out lymphoma. Lymphoma is likely with maximum standardized uptake value greater than 12.85.

    View details for DOI 10.1016/j.jtcvs.2022.02.055

    View details for PubMedID 35568521

  • Examination of Intersectionality and the Pipeline for Black Academic Surgeons. JAMA surgery Keshinro, A., Butler, P., Fayanju, O., Khabele, D., Newman, E., Greene, W., Ude Welcome, A., Joseph, K., Stallion, A., Backhus, L., Frangos, S., DiMaggio, C., Berman, R., Hasson, R., Rodriguez, L. M., Stain, S., Bukur, M., Klein, M. J., Henry-Tillman, R., Barry, L., Oseni, T., Martin, C., Johnson-Mann, C., Smith, R., Karpeh, M., White, C., Turner, P., Pugh, C., Hayes-Jordan, A., Berry, C. 2022


    Importance: The lack of underrepresented in medicine physicians within US academic surgery continues, with Black surgeons representing a disproportionately low number.Objective: To evaluate the trend of general surgery residency application, matriculation, and graduation rates for Black trainees compared with their racial and ethnic counterparts over time.Design, Setting, and Participants: In this nationwide multicenter study, data from the Electronic Residency Application Service (ERAS) for the general surgery residency match and Graduate Medical Education (GME) surveys of graduating general surgery residents were retrospectively reviewed and stratified by race, ethnicity, and sex. Analyses consisted of descriptive statistics, time series plots, and simple linear regression for the rate of change over time. Medical students and general surgery residency trainees of Asian, Black, Hispanic or Latino of Spanish origin, White, and other races were included. Data for non-US citizens or nonpermanent residents were excluded. Data were collected from 2005 to 2018, and data were analyzed in March 2021.Main Outcomes and Measures: Primary outcomes included the rates of application, matriculation, and graduation from general surgery residency programs.Results: Over the study period, there were 71 687 applicants, 26 237 first-year matriculants, and 24 893 graduates. Of 71 687 applicants, 24 618 (34.3%) were women, 16 602 (23.2%) were Asian, 5968 (8.3%) were Black, 2455 (3.4%) were Latino, and 31 197 (43.5%) were White. Women applicants and graduates increased from 29.4% (1178 of 4003) to 37.1% (2293 of 6181) and 23.5% (463 of 1967) to 33.5% (719 of 2147), respectively. When stratified by race and ethnicity, applications from Black women increased from 2.2% (87 of 4003) to 3.5% (215 of 6181) (P<.001) while applications from Black men remained unchanged (3.7% [150 of 4003] to 4.6% [284 of 6181]). While the matriculation rate for Black women remained unchanged (2.4% [46 of 1919] to 2.3% [52 of 2264]), the matriculation rate for Black men significantly decreased (3.0% [57 of 1919] to 2.4% [54 of 2264]; P=.04). Among Black graduates, there was a significant decline in graduation for men (4.3% [85 of 1967] to 2.7% [57 of 2147]; P=.03) with the rate among women remaining unchanged (1.7% [33 of 1967] to 2.2% [47 of 2147]).Conclusions and Relevance: Findings of this study show that the underrepresentation of Black physicians at every stage in surgical training pipeline persists. Black men are especially affected. Identifying factors that address intersectionality and contribute to the successful recruitment and retention of Black trainees in general surgery residency is critical for achieving racial and ethnic as well as gender equity.

    View details for DOI 10.1001/jamasurg.2021.7430

    View details for PubMedID 35138327

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


    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

  • The impact of gender bias in cardiothoracic surgery in Europe: a European Society of Thoracic Surgeons and European Association for Cardio-Thoracic Surgery survey. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery Pompili, C., Opitz, I., Backhus, L., Leschber, G., Veronesi, G., Lauk, O., Novoa, N., Daddi, N., Deglurkar, I., Cleuziou, J., Emrich, A. L., D'Auria, F., Kluin, J. 1800


    OBJECTIVES: The European Society of Thoracic Surgeons and the European Association for Cardio-Thoracic Surgery designed a questionnaire to assess the impact of gender bias on a cardiothoracic surgery career.METHODS: A 46-item survey investigating gender bias was designed using online survey software from December 2020 to January 2021. All European Society of Thoracic Surgeons and European Association for Cardio-Thoracic Surgery members and non-members included in the mailing lists were invited to complete an electronic survey. Descriptive statistics and a comparison between gender groups were performed.RESULTS: Our overall response rate was 11.5% (1118/9764), of which 36.14% were women and 63.69% were men. Women were more likely to be younger than men (P < 0.0001). A total of 66% of the women reported having no children compared to only 19% of the men (P < 0.0001). Only 6% of women vs 22% of men were professors. More women (72%) also reported never having been a formal mentor themselves compared to men (38%, P < 0.0001). A total of 35% of female respondents considered leaving surgery because of episodes of discrimination compared to 13% of men; 67% of women said that they experienced being unfairly treated due to gender discrimination. Of the male surgeons, 31% reported that they were very satisfied with their career compared to only 17% of women (P < 0.0001).CONCLUSIONS: Women in cardiothoracic surgery reported significantly high rates of experiences with bias that may prevent qualified women from advancing to positions of leadership. Efforts to mitigate bias and support the professional development of women are at the centre of newly formed European committees.

    View details for DOI 10.1093/ejcts/ezac034

    View details for PubMedID 35092281

  • A brief overview of thoracic surgery in the United States. Journal of thoracic disease Byrd, C. T., Williams, K. M., Backhus, L. M. 2022; 14 (1): 218-226


    The 331 million people of the United States are served by a complex and expensive healthcare system that accounts for nearly 18% of the country's gross domestic product. Over 90% of patients are insured by private or government-funded plans, but despite high coverage and unusually high healthcare spending, vast disparities exist within the United States population based on demographics in terms of diagnosis, treatment, and outcomes of disease. Thoracic surgeons in the United States are trained to treat patients with diseases of the chest in the operative and perioperative settings, and can accomplish this training through multiple highly competitive pathways. Thoracic surgeons perform an average of 135 operations each per year which address diseases of the lungs, trachea, esophagus, chest wall, mediastinum, and diaphragm. Video assisted thoracoscopic surgeries are the most commonly performed procedures, which are primarily completed to treat lung cancer. Lung cancer is the deadliest and second most prevalent malignancy in the United States, with over 200,000 new cases expected this year. In addition to encouragement of smoking cessation and more attention to air pollutants, increased access to lung cancer screening has significantly expedited diagnosis and reduced mortality from lung cancer in the last several years. Thoracic surgeons in the United States are tasked with treating common yet highly morbid diseases of the chest in a patient population that is diverse in terms of race, socioeconomic status, and healthcare insurance coverage. As the population ages and a shortage of thoracic surgeons looms, the importance of early diagnosis, skillful surgical management, and attention to the disparities that exist in our system cannot be overstated.

    View details for DOI 10.21037/jtd-21-1504

    View details for PubMedID 35242386

    View details for PubMedCentralID PMC8828520

  • A brief overview of thoracic surgery in the United States JOURNAL OF THORACIC DISEASE Byrd, C. T., Williams, K. M., Backhus, L. M. 2021
  • Consensus for Thoracoscopic Lower Lobectomy: Essential Components and Targets for Simulation. The Annals of thoracic surgery Erwin, P. A., Lee, A. C., Ahmad, U., Antonoff, M., Arndt, A., Backhus, L., Berry, M., Birdas, T., Cassivi, S. D., Chang, A. C., Cooke, D. T., Crabtree, T., DeCamp, M., Donington, J., Fernandez, F., Force, S., Gaissert, H., Hofstetter, W., Huang, J., Kent, M., Kim, A. W., Lin, J., Martin, L. W., Meyerson, S., Mitchell, J. D., Molena, D., Odell, D., Onaitis, M., Puri, V., Putnam, J., Reddy, R., Schipper, P., Seder, C. W., Shrager, J., Tong, B., Veeramachaneni, N., Watson, T., Whyte, R., Ferguson, M. K. 2021


    BACKGROUND: Despite demonstration of its clear benefits relative to open approaches, a video-assisted thoracic surgery (VATS) technique for pulmonary lobectomy has not been universally adopted. This study aims to overcome potential barriers by establishing the essential components of the operation as well as determining which steps would be most useful for simulation training.METHODS: After randomly selecting experienced thoracic surgeons to participate, an initial list of components to a lower lobectomy was distributed. Feedback was provided by the participants and modifications were made based on anonymous responses in a Delphi process. Components were declared essential once at least 80% of participants came to an agreement. The steps were then rated based upon cognitive and technical difficulty, followed by listing the components most appropriate for simulation.RESULTS: After three rounds of voting, 18 components were identified as essential to performance of a VATS lower lobectomy. The components deemed the most difficult included isolation and division of the basilar and superior segmental branches of the pulmonary artery, isolation and division of the lower lobe bronchus, and the dissection of lymphovascular tissue to expose the target bronchus. The steps determined to be most amenable for simulation included isolation and division of the branches of the pulmonary artery, the lower lobe bronchus, and the inferior pulmonary vein.CONCLUSIONS: Using a Delphi process, a list of essential components for a VATS lower lobectomy was established. Furthermore, three components were identified as most appropriate for simulation-based training, providing insights for future simulation development.

    View details for DOI 10.1016/j.athoracsur.2021.09.033

    View details for PubMedID 34688617

  • The Academic Impact of Advanced Clinical Fellowship Training among General Thoracic Surgeons. Journal of surgical education Patel, D. C., Wang, H., Bajaj, S. S., Williams, K. M., Pickering, J. M., Heiler, J. C., Manjunatha, K., O'Donnell, C. T., Sanchez, M., Boyd, J. H., Backhus, L. M. 2021


    OBJECTIVE: Advanced clinical fellowship training has become a popular option for surgical trainees seeking to bolster their clinical training and expertise. However, the long-term academic impact of this additional training following a traditional thoracic surgery fellowship is unknown. This study aimed to delineate the impact of an advanced clinical fellowship on subsequent research productivity and advancement in academic career among general thoracic surgeons.METHODS: Using an internally constructed database of active, academic general thoracic surgeons who are current faculty at accredited cardiothoracic surgery training programs within the United States, surgeons were dichotomized according to whether an advanced clinical fellowship was completed or not. Academic career metrics measured by research productivity, scholarly impact (H-index), funding by the National Institutes of Health, and academic rank were compared.RESULTS: Among 285 general thoracic surgeons, 89 (31.2%) underwent an advanced fellowship, whereas 196 (68.8%) did not complete an advanced fellowship. The most commonly pursued advanced fellowship was minimally invasive thoracic surgery (32.0%). There were no differences between the two groups in terms of gender, international medical training, or postgraduate education. Those who completed an advanced clinical fellowship were less likely to have completed a dedicated research fellowship compared to those who had not completed any additional clinical training (58.4% vs. 74.0%, p = 0.0124). Surgeons completing an advanced clinical fellowship demonstrated similar cumulative first-author publications (p = 0.4572), last-author publications (p = 0.7855), H-index (p = 0.9651), National Institutes of Health funding (p = 0.7540), and years needed to advance to associate professor (p = 0.3410) or full rank professor (p = 0.1545) compared to surgeons who did not complete an advanced fellowship. These findings persisted in sub-analyses controlling for surgeons completing a dedicated research fellowship.CONCLUSIONS: Academic general thoracic surgeons completing an advanced clinical fellowship demonstrate similar research output and ascend the academic ladder at a similar pace as those not pursuing additional training.

    View details for DOI 10.1016/j.jsurg.2021.09.003

    View details for PubMedID 34674980

  • Rationale and design of a mechanistic clinical trial of JAK inhibition to prevent ventilator-induced diaphragm dysfunction. Respiratory medicine Shrager, J. B., Wang, Y., Lee, M., Nesbit, S., Trope, W., Konsker, H., Fatodu, E., Berry, M. S., Poulstides, G., Norton, J., Burdon, T., Backhus, L., Cooke, R., Tang, H. 2021; 189: 106620


    INTRODUCTION: Ventilator-induced diaphragm dysfunction (VIDD) is an important phenomenon that has been repeatedly demonstrated in experimental and clinical models of mechanical ventilation. Even a few hours of MV initiates signaling cascades that result in, first, reduced specific force, and later, atrophy of diaphragm muscle fibers. This severe, progressive weakness of the critical ventilatory muscle results in increased duration of MV and thus increased MV-associated complications/deaths. A drug that could prevent VIDD would likely have a major positive impact on intensive care unit outcomes. We identified the JAK/STAT pathway as important in VIDD and then demonstrated that JAK inhibition prevents VIDD in rats. We subsequently developed a clinical model of VIDD demonstrating reduced contractile force of isolated diaphragm fibers harvested after 7 vs 1h of MV during a thoracic surgical procedure.MATERIALS AND METHODS: The NIH-funded clinical trial that has been initiated is a prospective, placebo controlled trial: subjects undergoing esophagectomy are randomized to receive 6 preoperative doses of the FDA-approved JAK inhibitor Tofacitinib (commonly used for rheumatoid arthritis) vs. placebo. The primary outcome variable will be the difference in the reduction that occurs in force generation of diaphragm single muscle fibers (normalized to their cross-sectional area), in the Tofacitinib vs. placebo subjects, over 6h of MV.DISCUSSION: This trial represents a first-in-human, mechanistic clinical trial of a drug to prevent VIDD. It will provide proof-of-concept in human subjects whether JAK inhibition prevents clinical VIDD, and if successful, will support an ICU-based clinical trial that would determine whether JAK inhibition impacts clinical outcome variables such as duration of MV and mortality.

    View details for DOI 10.1016/j.rmed.2021.106620

    View details for PubMedID 34655959

  • Induction therapy is not associated with improved survival in large cT4N0 non-small cell lung cancers. The Annals of thoracic surgery Sun, B. J., Bhandari, P., Jeffrey Yang, C., Berry, M. F., Shrager, J. B., Backhus, L. M., Lui, N. S., Liou, D. Z. 2021


    BACKGROUND: The 8th edition staging for non-small cell lung cancer reclassified tumors >7 cm as stage IIIA (T4N0); previously, such tumors without nodal disease were considered stage IIB (T3N0). This study tested the hypothesis that induction chemotherapy for these stage IIIA patients does not improve survival compared to primary surgery.METHODS: The National Cancer Database was queried for non-small cell lung cancer patients with tumor size >7 cm who underwent surgical resection from 2010 - 2015. Patients with clinically node-positive disease or tumor invasion of major structures were excluded. Patients undergoing induction chemotherapy followed by surgery (IC) were compared to patients undergoing primary surgery (PS). Propensity-score matching was performed.RESULTS: In total, 1,610 patients with cT4N0 disease based on tumor size >7 cm and no tumor invasion underwent surgical resection: 1,346 (83.6%) comprised the PS group and 264 (16.4%) the IC group. After propensity-score matching, IC had a higher rate of pN0 (78.4% vs 66.0%, p<0.001) and less lymphovascular invasion (13.9% vs 26.3%, p<0.001), but longer postoperative stay (6 vs 5 days, p<0.001) and higher 30-day mortality (3.5% vs 0%, p=0.002). Median 5-year survival was similar between IC and PS (53.5% vs 62.2%, p=0.075), and IC was not independently associated with survival (HR 1.45, p=0.146).CONCLUSIONS: Patients with cT4N0 non-small cell lung cancer based on tumor size >7 cm and no tumor invasion of major structures have similar overall survival with either IC or PS. IC should not be routinely given for this subset of stage IIIA patients.

    View details for DOI 10.1016/j.athoracsur.2021.07.058

    View details for PubMedID 34425099

  • Surgical resection for patients with pulmonary aspergillosis in the national inpatient sample. Journal of thoracic disease Patel, D. C., Bhandari, P., Epstein, D. J., Liou, D. Z., Backhus, L. M., Berry, M. F., Shrager, J. B., Lui, N. S. 2021; 13 (8): 4977-4987


    The role of lung resection in patients with pulmonary aspergillosis is generally reserved for those with localized disease who fail medical management. We used a national database to investigate the influence of preoperative patient comorbidities on inpatient mortality and need for surgery.Patients admitted with pulmonary aspergillosis between 2007 to 2015 were identified in the National Inpatient Sample dataset. Inpatient mortality rates were compared between patients treated medically and surgically. Predictors of mortality, surgical intervention, and non-elective admission were evaluated using multivariable logistic regression.Among a population estimate of 112,998 patients with pulmonary aspergillosis, 107,606 (95.2%) underwent medical management alone and 5,392 (4.8%) underwent surgical resection. Positive predictors for surgery included hemoptysis, and history of lung cancer or chronic pulmonary diseases. Surgically treated patients had a lower inpatient mortality when compared to those treated medically (11.5% vs. 15.1%, P<0.001) in univariate analysis, but this finding did not persist in multivariable analysis (AOR 0.97, P=0.509). The odds of mortality were lower in patients undergoing video assisted thoracoscopic surgery compared to an open approach (AOR 0.77, P=0.001). Among patients treated surgically, mortality was higher in those with a history of lung cancer, solid organ transplantation, liver disease, human immunodeficiency virus infection, hematologic diseases, chronic pulmonary diseases, and those admitted non-electively requiring surgery.In this generalizable study, medical and surgical management of pulmonary aspergillosis were comparable in terms of inpatient mortality. However, non-elective admission and patients with select comorbidities have significantly worse outcomes after surgical intervention.

    View details for DOI 10.21037/jtd-21-151

    View details for PubMedID 34527336

    View details for PubMedCentralID PMC8411153

  • Short-term and intermediate-term readmission after esophagectomy. Journal of thoracic disease Wang, Y., Yang, C. J., He, H., Buchan, J. M., Patel, D. C., Liou, D. Z., Lui, N. S., Berry, M. F., Shrager, J. B., Backhus, L. M. 2021; 13 (8): 4678-4689


    The objective of this study was to characterize short- and intermediate-term readmissions following esophagectomy and to identify predictors of readmission in these two groups.Patients who underwent esophagectomy in the National Readmissions Database (2013-2014) were grouped according to whether first readmission was "short-term" (readmitted <30 days) or "intermediate-term" (readmitted 31-90 days) following index admission for esophagectomy. Predictors of readmission were evaluated using multivariable logistic regression modeling.Of the 3,005 patients who underwent esophagectomy, 544 (18.1%) had a short-term readmission and 305 (10.1%) had an intermediate-term readmission. The most frequent reasons for short-term readmission were post-operative infection (7.5%), dysphagia (6.3%) and pneumonia (5.1%). The most common intermediate-term complications were pneumonia (7.2%), gastrointestinal stricture/stenosis (6.9%) and dysphagia (5.9%). In multivariable analysis, being located in a micropolitan area, increasing number of comorbidities and higher severity of illness score were associated with an increased likelihood of having a short-term readmission while being discharged to a facility (as opposed to directly home) was associated with increased likelihood of both short- and intermediate-term readmission (all P<0.05).In this analysis, postoperative infection was the most common reason for short-term readmission. Dysphagia and pneumonia were common reasons for both short- and intermediate-term readmission of patients following esophagectomy. Interventions focused on reducing the risk of postoperative infection and pneumonia may reduce hospital readmissions. Gastrointestinal stricture and dysphagia were associated with increased risk of intermediate readmission and should be examined in the context of morbidity associated with pyloric procedures (e.g., pyloromyotomy) at the time of esophagectomy.

    View details for DOI 10.21037/jtd-21-637

    View details for PubMedID 34527309

    View details for PubMedCentralID PMC8411130

  • Surgical resection for patients with pulmonary aspergillosis in the national inpatient sample JOURNAL OF THORACIC DISEASE Patel, D. C., Bhandari, P., Epstein, D. J., Liou, D. Z., Backhus, L. M., Berry, M. F., Shrager, J. B., Lui, N. S. 2021
  • Short-term and intermediate-term readmission after esophagectomy JOURNAL OF THORACIC DISEASE Wang, Y., Yang, C., He, H., Buchan, J. M., Patel, D. C., Liou, D. Z., Lui, N. S., Berry, M. F., Shrager, J. B., Backhus, L. M. 2021
  • Early Discharge after Lobectomy for Lung Cancer does not Equate to Early Readmission. The Annals of thoracic surgery Patel, D. C., Leipzig, M., Jeffrey Yang, C., Wang, Y., Shrager, J. B., Backhus, L. M., Lui, N. S., Liou, D. Z., Berry, M. F. 2021


    BACKGROUND: Enhanced recovery after surgery (ERAS) pathways in several specialties reduce length of stay, but accelerated discharge after thoracic surgery is not well characterized. This study tested the hypothesis that patients discharged on post-operative day 1 (POD1) after lobectomy for lung cancer have an increased risk of readmission.METHODS: Patients who underwent a lobectomy for lung cancer between 2011-2019 in the American College of Surgeons National Surgical Quality Improvement Program database were identified. Readmission rates were compared between patients discharged on postoperative day 1 (POD1) and patients discharged POD 2-6. Early discharge and readmission predictors were evaluated using multivariable logistic regression analysis.RESULTS: Only 854 (3.8%) of 22,585 patients that met inclusion criteria were discharged on POD1, though POD1 discharge rates increased from 2.3% to 8.1% (p< 0.001) from 2011 to 2019. Median hospitalization for POD2-6 patients was 4 days (IQR: 3-5). Patient characteristics associated with a lower likelihood of POD1 discharge were increasing age, smokers, or history of dyspnea, while a minimally invasive approach was the strongest predictor of early discharge (AOR 5.42, p<0.001). Readmission rates were not significantly different for POD1 and POD2-6 groups in univariate analysis (6.0% vs 7.0%, p=0.269). Further, POD1 discharge was not a risk factor for readmission in multivariable analysis (AOR 1.10, p=0.537).CONCLUSIONS: Select patients can be discharged on POD1 after lobectomy for lung cancer without an increased readmission risk, supporting this accelerated discharge target inclusion in lobectomy ERAS protocols.

    View details for DOI 10.1016/j.athoracsur.2021.05.053

    View details for PubMedID 34126077

  • Influence of facility volume on long-term survival of patients undergoing esophagectomy for esophageal cancer. The Journal of thoracic and cardiovascular surgery Patel, D. C., Jeffrey Yang, C., He, H., Liou, D. Z., Backhus, L. M., Lui, N. S., Shrager, J. B., Berry, M. F. 2021


    OBJECTIVE: This study investigated the influence of facility volume on long-term survival in patients with esophageal cancer treated with esophagectomy.METHODS: Patients treated with esophagectomy for cT1 3N0 3M0 adenocarcinoma or squamous cell carcinoma of the mid-distal esophagus in the National Cancer Database between 2006 and 2013 were stratified by annual facility esophagectomy volume dichotomized as more/less than both 6 and 20. Patient characteristics associated with facility volume were evaluated using logistic regression, and the influence of facility volume on survival was evaluated with Kaplan-Meier curves, Cox proportional hazards methods, and propensity matched analysis.RESULTS: Of 11,739 patients who had esophagectomy at 1018 facilities where annual volume ranged from 1 to 47.6 cases, 4262 (36.3%) were treated at 44 facilities with annual esophagectomy volume>6 and 1515 (12.9%) were treated at 7 facilities with annual volume>20. Higher volume was associated with significantly better 5-year survival for both annual volume > 6 (47.6% vs 40.2%; P<.001) and annual volume>20 (47.2% vs 42.3%; P<.001), which persisted in propensity matched analyses as well as Cox multivariable analysis (hazard ratio, 0.81; 95% confidence interval, 0.74-0.89; P<.001 for facility volume>6 and hazard ratio, 0.78; 95% confidence interval, 0.65-0.95; P=.01 for facility volume>20). In Cox multivariable analysis that considered facility volume as a continuous variable, higher volume continued to be associated with better survival (hazard ratio, 0.93 per 5 cases; 95% CI, 0.91-0.96; P<.001).CONCLUSIONS: Esophageal cancer patients treated with esophagectomy at higher volume facilities have significantly better long-term survival than patients treated at lower volume facilities.

    View details for DOI 10.1016/j.jtcvs.2021.05.048

    View details for PubMedID 34247867

  • The role of gender in non-small cell lung cancer: a narrative review JOURNAL OF THORACIC DISEASE Baiu, I., Titan, A. L., Martin, L. W., Wolf, A., Backhus, L. 2021; 13 (6): 3816-3826
  • The role of gender in non-small cell lung cancer: a narrative review. Journal of thoracic disease Baiu, I., Titan, A. L., Martin, L. W., Wolf, A., Backhus, L. 2021; 13 (6): 3816-3826


    The role of gender in the development, treatment and prognosis of thoracic malignancies has been underappreciated and understudied. While most research has been grounded in tobacco-related malignancies, the incidence of non-smoking related lung cancer is on the rise and disproportionately affecting women. Recent research studies have unveiled critical differences between men and women with regard to risk factors, timeliness of diagnosis, incongruent screening practices, molecular and genetic mechanisms, as well as response to treatment and survival. These studies also highlight the increasingly recognized need for targeted therapies that account for variations in the response and complications as a function of gender. Similarly, screening recommendations continue to evolve as the role of gender is starting to be ellucidated. As women have been underrepresented in clinical trials until recently, the data regarding optimal care and outcomes is still lagging behind. Understanding the underlying similarities and differences between men and women is paramount to providing adequate care and prognostication to patients of either gender. This review provides an overview of the critical role that gender plays in the care of patients with non-small cell lung cancer and other thoracic malignancies, with an emphasis on the need for increased awareness and further research to continue elucidating these disparities.

    View details for DOI 10.21037/jtd-20-3128

    View details for PubMedID 34277072

    View details for PubMedCentralID PMC8264700

  • The Survival Impact of Second Primary Lung Cancer in Patients with Lung Cancer Choi, E., Luo, S., Aredo, J., Wilkens, L., Leung, A., Le Marchand, L., Cheng, I., Wakelee, H., Han, S. AMER THORACIC SOC. 2021
  • Investigating gene expression profiles associated with clinical radiation resistance in KEAP1/NFE2L2 wildtype lung cancer. Binkley, M. S., Jeon, Y., Nesselbush, M., Moding, E. J., Nabet, B., Almanza, D., Yoo, C., Kurtz, D. M., Owen, S., Backhus, L. M., Berry, M. F., Shrager, J. B., Ramchandran, K. J., Padda, S. K., Das, M., Neal, J. W., Wakelee, H. A., Alizadeh, A. A., Loo, B. W., Diehn, M. AMER ASSOC CANCER RESEARCH. 2021
  • Cancer diagnoses and survival rise as 65-year-olds become Medicare-eligible. Cancer Patel, D. C., He, H., Berry, M. F., Yang, C. J., Trope, W. L., Wang, Y., Lui, N. S., Liou, D. Z., Backhus, L. M., Shrager, J. B. 2021


    BACKGROUND: A Medicare effect has been described to account for increased health care utilization occurring at the age of 65 years. The existence of such an effect in cancer care, where it would be most likely to reduce mortality, has been unclear.METHODS: Patients aged 61 to 69 years who were diagnosed with lung, breast, colon, or prostate cancer from 2004 to 2016 were identified with the Surveillance, Epidemiology, and End Results database and were dichotomized on the basis of eligibility for Medicare (61-64 vs 65-69 years). With age-over-age (AoA) percent change calculations, trends in cancer diagnoses and staging were characterized. After matching, uninsured patients who were 61 to 64 years old (pre-Medicare group) were compared with insured patients who were 65 to 69 years old (post-Medicare group) with respect to cancer-specific mortality.RESULTS: In all, 134,991 patients were identified with lung cancer, 175,558 were identified with breast cancer, 62,721 were identified with colon cancer, and 238,823 were identified with prostate cancer. The AoA growth in the number of cancer diagnoses was highest at the age of 65 years in comparison with all other ages within the decade for all 4 cancers (P < .01, P < .001, P < .01, and P < .001, respectively). In a comparison of diagnoses at the age of 65 years with those in the 61- to 64-year-old cohort, the greatest difference for all 4 cancers was seen in stage I. In matched analyses, the 5-year cancer-specific mortality was worse for lung (86.3% vs 78.5%; P < .001), breast (32.7% vs 11.0%; P < .001), colon (57.1% vs 35.6%; P < .001), and prostate cancer (16.9% vs 4.8%; P < .001) in the uninsured pre-Medicare group than the insured post-Medicare group.CONCLUSIONS: The age threshold of 65 years for Medicare eligibility is associated with more cancer diagnoses (particularly stage I), and this results in lower long-term cancer-specific mortality for all cancers studied.LAY SUMMARY: Contributing to the current debate regarding Medicare for all, this study shows that the expansion of Medicare would improve cancer outcomes for the near elderly.

    View details for DOI 10.1002/cncr.33498

    View details for PubMedID 33778953

  • Strong for Surgery: Association Between Bundled Risk Factors and Outcomes After Major Elective Surgery in the VA Population. World journal of surgery Liou, D. Z., Patel, D. C., Bhandari, P., Wren, S. M., Marshall, N. J., Harris, A. H., Shrager, J. B., Berry, M. F., Lui, N. S., Backhus, L. M. 2021


    BACKGROUND: Strong for Surgery (S4S) is a public health campaign focused on optimizing patient health prior to surgery by identifying evidence-based modifiable risk factors. The potential impact of S4S bundled risk factors on outcomes after major surgery has not been previously studied. This study tested the hypothesis that a higher number of S4S risk factors is associated with an escalating risk of complications and mortality after major elective surgery in the VA population.METHODS: The Veterans Affairs Surgical Quality Improvement Program (VASQIP) database was queried for patients who underwent major non-emergent general, thoracic, vascular, urologic, and orthopedic surgeries between the years 2008 and 2015. Patients with complete data pertaining to S4S risk factors, specifically preoperative smoking status, HbA1c level, and serum albumin level, were stratified by number of positive risk factors, and perioperative outcomes were compared.RESULTS: A total of 31,285 patients comprised the study group, with 16,630 (53.2%) patients having no S4S risk factors (S4S0), 12,323 (39.4%) having one (S4S1), 2,186 (7.0%) having two (S4S2), and 146 (0.5%) having three (S4S3). In the S4S1 group, 60.3% were actively smoking, 35.2% had HbA1c>7, and 4.4% had serum albumin<3. In the S4S2 group, 87.8% were smokers, 84.8% had HbA1c>7, and 27.4% had albumin<3. Major complications, reoperations, length of stay, and 30-day mortality increased progressively from S4S0 to S4S3 groups. S4S3 had the greatest adjusted mortality risk (adjusted odds radio [AOR] 2.56, p=0.04) followed by S4S2 (AOR 1.58, p=0.02) and S4S1 (AOR 1.34, p=0.02).CONCLUSION: In the VA population, patients who had all three S4S risk factors, namely active smoking, suboptimal nutritional status, and poor glycemic control, had the greatest risk of postoperative mortality compared to patients with fewer S4S risk factors.

    View details for DOI 10.1007/s00268-021-05979-8

    View details for PubMedID 33598723

  • Seeing is Believing. The Annals of thoracic surgery Williams, K. M., Backhus, L. M. 2021

    View details for DOI 10.1016/j.athoracsur.2020.12.065

    View details for PubMedID 33581155

  • Global analysis of shared T cell specificities in human non-small cell lung cancer enables HLA inference and antigen discovery. Immunity Chiou, S. H., Tseng, D. n., Reuben, A. n., Mallajosyula, V. n., Molina, I. S., Conley, S. n., Wilhelmy, J. n., McSween, A. M., Yang, X. n., Nishimiya, D. n., Sinha, R. n., Nabet, B. Y., Wang, C. n., Shrager, J. B., Berry, M. F., Backhus, L. n., Lui, N. S., Wakelee, H. A., Neal, J. W., Padda, S. K., Berry, G. J., Delaidelli, A. n., Sorensen, P. H., Sotillo, E. n., Tran, P. n., Benson, J. A., Richards, R. n., Labanieh, L. n., Klysz, D. D., Louis, D. M., Feldman, S. A., Diehn, M. n., Weissman, I. L., Zhang, J. n., Wistuba, I. I., Futreal, P. A., Heymach, J. V., Garcia, K. C., Mackall, C. L., Davis, M. M. 2021; 54 (3): 586–602.e8


    To identify disease-relevant T cell receptors (TCRs) with shared antigen specificity, we analyzed 778,938 TCRβ chain sequences from 178 non-small cell lung cancer patients using the GLIPH2 (grouping of lymphocyte interactions with paratope hotspots 2) algorithm. We identified over 66,000 shared specificity groups, of which 435 were clonally expanded and enriched in tumors compared to adjacent lung. The antigenic epitopes of one such tumor-enriched specificity group were identified using a yeast peptide-HLA A∗02:01 display library. These included a peptide from the epithelial protein TMEM161A, which is overexpressed in tumors and cross-reactive epitopes from Epstein-Barr virus and E. coli. Our findings suggest that this cross-reactivity may underlie the presence of virus-specific T cells in tumor infiltrates and that pathogen cross-reactivity may be a feature of multiple cancers. The approach and analytical pipelines generated in this work, as well as the specificity groups defined here, present a resource for understanding the T cell response in cancer.

    View details for DOI 10.1016/j.immuni.2021.02.014

    View details for PubMedID 33691136

  • Moving the Needle…Evidence of Durability of Impact. The Annals of thoracic surgery Williams, K. M., Backhus, L. M. 2021

    View details for DOI 10.1016/j.athoracsur.2021.01.086

    View details for PubMedID 33766520

  • Women in thoracic surgery: lesson learned from medical industry partners. Journal of thoracic disease Pompili, C., Bruls, A., Elswick, E., Masschelein, K., Backhus, L. 2021; 13 (1): 485–91


    Medical technology has led to important achievements in surgery as minimally invasive techniques have expanded over the past several years. These innovations have changed the dynamic between industry and surgeons towards a more collaboration relationship forming partnerships important to surgical advancement and technical training opportunities. On this backdrop of transformation is growing awareness of the gender disparity that exists within the thoracic surgery workforce where we have experienced strikingly little change. At the same time, medicine is not unique with its gender disparity. As we have benefited from important partnerships to create excellence in technical innovation, so too may we benefit from drawing upon some of the successes within the medical industry towards achieving gender equity. This paper highlights examples of female leaders in the medical industry surrounding thoracic surgery, who have demonstrated excellence in the advancement and promotion of female thoracic surgeons through fellowships, mentorships or networking.

    View details for DOI 10.21037/jtd-2020-wts-02

    View details for PubMedID 33569236

  • US women in thoracic surgery: reflections on the past and opportunities for the future. Journal of thoracic disease Preventza, O., Backhus, L. 2021; 13 (1): 473–79


    Herein, we examine the state of women in thoracic surgery from the United States (US) perspective in terms of our past, present, and opportunities for the future. We explore the achievements of the first three women certified in thoracic surgery in 1961 and describe the progress made resulting in the current state. Women constitute slightly more than 50% of all medical students in the US, yet women remain underrepresented in thoracic surgery. The disparity is most notable for female representation in senior academic leadership positions, reflecting stagnation in progress. The lack of gender equity has important implications for projected workforce shortages and patient safety in cardiothoracic surgery. Recent organized efforts in scholarships and leadership training, as well as increasing awareness and mentorship, may herald progress on the horizon. Ultimately, however, engagement of leadership and top-down change are needed to achieve equity and, thereby, to improve patient health and satisfaction.

    View details for DOI 10.21037/jtd.2020.04.13

    View details for PubMedID 33569234

  • Time for change: women leading in cardiothoracic surgery, a global perspective. Journal of thoracic disease Pompili, C., Backhus, L. 2021; 13 (1): 430–31

    View details for DOI 10.21037/jtd-2020-wts-01

    View details for PubMedID 33569227

  • Perioperative Outcomes After Combined Esophagectomy and Lung Resection. The Journal of surgical research Patel, D. C., Bhandari, P., Shrager, J. B., Berry, M. F., Backhus, L. M., Lui, N. S., Liou, D. Z. 2021; 270: 413-420


    The impact of concomitant lung resection during esophagectomy on short-term outcomes is not well characterized. This study tests the hypothesis that lung resection at the time of esophagectomy is not associated with increased perioperative morbidity or mortality.Perioperative outcomes for esophageal cancer patients who underwent esophagectomy alone (EA) were compared to patients who had concurrent esophagectomy and lung resection (EL) using the NSQIP database between 2006-2017. Predictors of morbidity and mortality, including combined surgery, were evaluated using multivariable logistic regression.Among the 6,225 study patients, 6,068 (97.5%) underwent EA and 157 (2.5%) underwent EL. There were no differences in baseline characteristics between the two groups. Operating time for EL was longer than EA (median 416 versus 371 minutes, P < 0.01). Median length of stay was 10 d for both groups. Perioperative mortality was not significantly different between EL and EA patients (5.1% versus 2.8%, P = 0.08). EL patients had higher rates of postoperative pneumonia (22.3% versus 16.2%, P = 0.04) and sepsis (11.5% versus 7.1%, P = 0.03), however major complication rates overall were similar (40.8% versus 35.3%, P = 0.16). Combining lung resection with esophagectomy was not independently associated with increased postoperative morbidity (AOR 1.21 [95% CI 0.87-1.69]) or mortality (AOR 1.63 [95% CI 0.74-3.58]).Concurrent lung resection during esophagectomy is not associated with increased mortality or overall morbidity, but is associated with higher rates of pneumonia beyond esophagectomy alone. Surgeons considering combined lung resection with esophagectomy should carefully evaluate the patient's risk for pulmonary complications and pursue interventions preoperatively to optimize respiratory function.

    View details for DOI 10.1016/j.jss.2021.09.037

    View details for PubMedID 34775148

  • Impact of Low-Dose CT Screening for Primary Lung Cancer on Subsequent Risk of Brain Metastasis. Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer Su, C. C., Wu, J. T., Neal, J. W., Popat, R. A., Kurian, A. W., Backhus, L. M., Nagpal, S., Leung, A. N., Wakelee, H. A., Han, S. S. 2021


    Brain metastasis (BM) is one of the most common metastases from primary lung cancer (PLC). Recently, the National Lung Screening Trial (NLST) demonstrated the efficacy of low-dose computed tomography (LDCT) screening on LC mortality reduction. However, it remains unknown if early detection of PLC through LDCT may be potentially beneficial in reducing the risk of subsequent metastases. Our study aimed to investigate the impact of LDCT screening for PLC on the risk of developing BM after PLC diagnosis.We used NLST data to identify 1,502 participants who were diagnosed with PLC in 2002-2009 and have follow-up data for BM. Cause-specific competing risk regression was applied to evaluate an association between BM risk and the mode of PLC detection-i.e., LDCT screen-detected versus non-LDCT screen-detected. Subgroup analyses were conducted in early-stage PLC patients and those who underwent surgery for PLC.Of 1502 participants, 41.4% had PLC detected through LDCT-screening versus 58.6% detected through other methods, e.g., chest X-Ray or incidental detection. Patients whose PLC was detected with LDCT-screening had a significantly lower 3-year incidence of BM (6.5%) versus those without (11.9%), with a cause-specific hazard ratio (HR) of 0.53 (p=0.001), adjusting for PLC stage, histology, diagnosis age and smoking status. This significant reduction in BM risk among PLCs detected through LDCT-screening persisted in subgroups of early-stage PLC participants (HR 0.47, p=0.002) and those who underwent surgery (HR 0.37, p=0.001).Early detection of PLC using LDCT-screening is associated with lower risk of BM after PLC diagnosis based on a large population-based study.

    View details for DOI 10.1016/j.jtho.2021.05.010

    View details for PubMedID 34091050

  • The Survival Impact of Second Primary Lung Cancer in Patients with Lung Cancer. Journal of the National Cancer Institute Choi, E., Luo, S. J., Aredo, J. V., Backhus, L. M., Wilkens, L. R., Su, C. C., Neal, J. W., Le Marchand, L., Cheng, I., Wakelee, H. A., Han, S. S. 2021


    Lung cancer survivors have a high risk of developing second primary lung cancer (SPLC), but little is known about the survival impact of SPLC diagnosis.We analyzed data from 138,969 patients in the Surveillance, Epidemiology, and End Results (SEER), who were surgically treated for initial primary lung cancer (IPLC) in 1988-2013. Each patient was followed from the date of IPLC diagnosis to SPLC diagnosis (for those with SPLC) and last vital status through 2016. We performed multivariable Cox regression to evaluate the association between overall survival and SPLC diagnosis as a time-varying predictor. To investigate potential effect modification, we tested interaction between SPLC and IPLC stage. Using data from the Multiethnic Cohort Study (MEC) (N = 1,540 IPLC patients with surgery), we evaluated the survival impact of SPLC by smoking status. All statistical tests were 2-sided.A total of 12,115 (8.7%) patients developed SPLC in SEER over 700,421 person-years of follow up. Compared to patients with single primary lung cancer, those with SPLC had statistically significantly reduced overall survival (hazard ratio [HR]=2.12, 95% confidence interval [CI] = 2.06-2.17; P < .001). The effect of SPLC on reduced survival was more pronounced among patients with early-stage IPLC vs. advanced-stage IPLC (HR = 2.14 [95% CI = 2.08-2.20] vs. 1.43 [95% CI = 1.21-1.70], respectively; Pinteraction <0.001). Analysis using MEC data showed that the effect of SPLC on reduced survival was statistically significantly larger among persons who actively smoked at initial diagnosis vs. those who formerly or never smoked (HR = 2.31 [95% CI = 1.48-3.61] vs. 1.41 [95% CI = 0.98-2.03], respectively; Pinteraction=0.04).SPLC diagnosis is statistically significantly associated with decreased survival in SEER and MEC. Intensive surveillance targeting patients with early-stage IPLC and active smoking at IPLC diagnosis may lead to a larger survival benefit.

    View details for DOI 10.1093/jnci/djab224

    View details for PubMedID 34893871

  • Use of a Personalized Multimedia Education Platform Improves Preoperative Teaching for Lung Cancer Patients. Seminars in thoracic and cardiovascular surgery Benson, J. n., Bhandari, P. n., Lui, N. n., Berry, M. n., Liou, D. Z., Shrager, J. n., Ayers, K. n., Backhus, L. M. 2021


    We sought to develop and evaluate a personalized multimedia education (ME) tool for pre-operative patient education to improve patient health knowledge, quality of life and satisfaction with care in thoracic surgery. The ME tool was developed and deployed in outpatient clinic during preoperative teaching for patients undergoing surgical resection for lung cancer for quality improvement. Patients were given an electronic survey prior to preoperative teaching and at initial post-operative visit to assess teaching effectiveness and care satisfaction. Sequential patients received either standard preoperative teaching or teaching using the ME tool. Pre- and postoperative survey responses were compared using independent sample paired t-test and multivariable linear regression modeling for adjustment. The final ME tool was an iPad application that incorporated real-time annotations of 3-dimensional, interactive anatomic diagrams. The tool featured video tours of operations, and radiology image import for annotation by the surgeon. Forty-eight patients were included in this pilot study (standard education (SE) n=26; ME, n=22). ME patients had significantly higher satisfaction scores compared to SE patients with respect to length of education materials, clarity of content, supportiveness of content and willingness to recommend materials to others. There was no difference in length of clinic visit between groups. Both patient and provider input can be used to create an innovative electronic preoperative educational tool that prepares and empowers patients in shared decision-making before surgery. Improvements in health literacy and self-efficacy may be more difficult to achieve but remain important as multimedia teaching tools are further developed.

    View details for DOI 10.1053/j.semtcvs.2021.03.003

    View details for PubMedID 33711462

  • Society of Thoracic Surgeons (STS) Virtual Conference Taskforce: Recommendations for Hosting a Virtual Surgical Meeting. The Annals of thoracic surgery Antonoff, M. B., Mitzman, B., Backhus, L., Bradbury, S. T., Chatterjee, S., Cooke, D. T., Crestanello, J., Goldstone, A. B., Kim, K. M., Nguyen, T. C., Romano, J. C., Vaporciyan, A. A., Varghese, T. K. 2020

    View details for DOI 10.1016/j.athoracsur.2020.10.008

    View details for PubMedID 33137298

  • Esophageal Cancer Surgery. JAMA Baiu, I., Backhus, L. 2020; 324 (15): 1580

    View details for DOI 10.1001/jama.2020.2101

    View details for PubMedID 33079155

  • Early Discharge Does Not Equate to Early Return for Patients Undergoing Lobectomy for Lung Cancer: A National Analysis Patel, D. C., Leipzig, M., Yang, C., Wang, Y., Shrager, J. B., Backhus, L. M., Lui, N. S., Liou, D. Z., Berry, M. F. ELSEVIER SCIENCE INC. 2020: S288
  • Greater Ipsilateral Rectus Muscle Atrophy after Robotic Thoracic Surgery Compared to Open and VATS Approaches Wang, Y., Bhandari, P., Trope, W., Guenthart, B. A., Guo, H., Liou, D., Backhus, L. M., Berry, M., Ben Shrager, J., Lui, N. ELSEVIER SCIENCE INC. 2020: S289
  • Institutional factors associated with adherence to quality measures for stage I and II non-small cell lung cancer. The Journal of thoracic and cardiovascular surgery Khorfan, R., Cooke, D. T., Meguid, R. A., Backhus, L., Varghese, T. K., Farjah, F., Bilimoria, K. Y., Odell, D. D., ThORN Collaborative, Khorfan, R., Cooke, D. T., Meguid, R. A., Backhus, L., Varghese, T. K., Farjah, F., Bilimoria, K. Y., Odell, D. D., Phillips, J. D., Broderick, S., Kidane, B., Coughlin, J. M. 2020


    OBJECTIVE: Although previous studies have identified variation in quality lung cancer care, existing quality metrics may not fully capture the complexity of cancer care. The Thoracic Surgery Outcomes Research Network recently developed quality measures to address this. We evaluated baseline adherence to these measures and identified factors associated with adherence.METHODS: Patients with pathologic stage I and II non-small cell lung cancer from 2010 to 2015 were identified in the National Cancer Database. Patient-level and hospital-level adherence to 7 quality measures was calculated. Goal hospital adherence threshold was 85%. Factors influencing adherence were identified using multilevel logistic regression.RESULTS: We identified 253,182 patients from 1324 hospitals. Lymph node sampling was performed in 91% of patients nationally, but only 76% of hospitals met the 85% adherence mark. Similarly, 89% of T1b (seventh edition staging) tumors had anatomic resection, with 69% hospital-level adherence. Sixty-nine percent of pathologic stage II patients were recommended chemotherapy, with only 23% hospitals adherent. Eighty-three percent of patients had biopsy before primary radiation, with 64% hospitals adherent. Higher volume and academic institutions were associated with nonadherence to adjuvant chemotherapy and radiation therapy measures. Conversely, lower volume and nonacademic institutions were associated with inadequate nodal sampling and nonanatomic resection.CONCLUSIONS: Significant gaps continue to exist in the delivery of quality care to patients with early-stage lung cancer. High-volume academic hospitals had higher adherence for surgical care measures, but lower rates for coordination of care measures. This requires further investigation, but suggests targets for quality improvement may vary by institution type.

    View details for DOI 10.1016/j.jtcvs.2020.05.123

    View details for PubMedID 34144822

  • Transitioning from VATS to robotic lobectomy VIDEO-ASSISTED THORACIC SURGERY Backhus, L. M. 2020; 5
  • KEAP1/NFE2L2 mutations to predict local recurrence after radiotherapy but not surgery in localized non-small cell lung cancer. Binkley, M. S., Jeon, Y., Nesselbush, M., Moding, E. J., Nabet, B., Almanza, D. S., Yoo, C., Kurtz, D., Owen, S., Backhus, L., Berry, M. F., Shrager, J. B., Ramchandran, K., Padda, S., Das, M., Neal, J. W., Wakelee, H. A., Alizadeh, A. A., Loo, B. W., Diehn, M. AMER SOC CLINICAL ONCOLOGY. 2020
  • Cancer diagnoses and survival rise as 65-year-olds become Medicare eligible. Patel, D. C., He, H., Berry, M. F., Yang, C., Trope, W., Lui, N., Liou, D. Z., Backhus, L., Shrager, J. B. AMER SOC CLINICAL ONCOLOGY. 2020
  • Discovery of a novel shared tumor antigen in human lung cancer. Tseng, D., Chiou, S., Yang, X., Reuben, A., Wilhelmy, J., McSween, A., Conley, S., Sinha, R., Nabet, B., Wang, C., Shrager, J. B., Berry, M. F., Backhus, L., Lui, n., Wakelee, H. A., Neal, J. W., Zhang, J., Garcia, K., Mackall, C., Davis, M. AMER SOC CLINICAL ONCOLOGY. 2020
  • Sub-solid lung adenocarcinoma in Asian versus Caucasian patients: different biology but similar outcomes. Journal of thoracic disease Lui, N. S., Benson, J., He, H., Imielski, B. R., Kunder, C. A., Liou, D. Z., Backhus, L. M., Berry, M. F., Shrager, J. B. 2020; 12 (5): 2161-2171


    Asian and Caucasian patients with lung cancer have been compared in several database studies, with conflicting findings regarding survival. However, these studies did not include proportion of ground-glass opacity or mutational status in their analyses. Asian patients commonly develop sub-solid lung adenocarcinomas that harbor EGFR mutations, which have a better prognosis. We hypothesized that among patients undergoing surgery for sub-solid lung adenocarcinomas, Asian patients have better survival compared to Caucasian patients.We identified Asian and Caucasian patients who underwent surgical resection for a sub-solid lung adenocarcinoma from 2002 to 2015 at our institution. Sub-solid was defined as ≥10% ground-glass opacity on preoperative CT scan or ≥10% lepidic component on surgical pathology. Time-to-event multivariable analysis was performed to determine which characteristics were associated with recurrence and survival.Two hundred twenty-four patients were included with median follow up 48 months. Asian patients were more likely to be never smokers (76.3% vs. 29.0%, P<0.01) and have an EGFR mutation (69.4% vs. 25.6% of those tested, P<0.01), while Caucasian patients were more likely to have a KRAS mutation (23.5% vs. 4.9% of those tested, P<0.01). There was a trend towards Asian patients having a higher proportion of ground-glass opacity (38.8% vs. 30.5%, P=0.11). Time-to-event multivariable analysis showed that higher proportion of ground-glass opacity was significantly associated with better recurrence-free survival (HR 0.76 per 20% increase, P=0.02). However, mutational status and race did not have a significant impact on recurrence-free or overall survival.Asian and Caucasian patients with sub-solid lung adenocarcinoma have different tumor biology, but recurrence-free and overall survival after surgical resection is similar.

    View details for DOI 10.21037/jtd.2020.04.37

    View details for PubMedID 32642121

    View details for PubMedCentralID PMC7330405

  • Sub-solid lung adenocarcinoma in Asian versus Caucasian patients: different biology but similar outcomes JOURNAL OF THORACIC DISEASE Lui, N. S., Benson, J., He, H., Imielski, B. R., Kunder, C. A., Liou, D. Z., Backhus, L. M., Berry, M. F., Shrager, J. B. 2020; 12 (5): 2161–71
  • A Call to Action: Black/African American Women Surgeon Scientists, Where are They? Annals of surgery Berry, C., Khabele, D., Johnson-Mann, C., Henry-Tillman, R., Joseph, K., Turner, P., Pugh, C., Fayanju, O. M., Backhus, L., Sweeting, R., Newman, E. A., Oseni, T., Hasson, R. M., White, C., Cobb, A., Johnston, F. M., Stallion, A., Karpeh, M., Nwariaku, F., Rodriguez, L. M., Jordan, A. H. 2020


    OBJECTIVE: To determine the representation of Black/AA women surgeons in academic medicine among U.S. medical school faculty and to assess the number of NIH grants awarded to Black/AA women surgeon-scientists over the past 2 decades.SUMMARY OF BACKGROUND DATA: Despite increasing ethnic/racial and sex diversity in U.S. medical schools and residencies, Black/AA women have historically been underrepresented in academic surgery.METHODS: A retrospective review of the Association of American Medical Colleges 2017 Faculty Roster was performed and the number of grants awarded to surgeons from the NIH (1998-2017) was obtained. Data from the Association of American Medical Colleges included the total number of medical school surgery faculty, academic rank, tenure status, and department Chair roles. Descriptive statistics were performed.RESULTS: Of the 15,671 U.S. medical school surgical faculty, 123 (0.79%) were Black/AA women surgeons with only 11 (0.54%) being tenured faculty. When stratified by academic rank, 15 (12%) Black/AA women surgeons were instructors, 73 (59%) were assistant professors, 19 (15%) were associate professors, and 10 (8%) were full professors of surgery. Of the 372 U.S. department Chairs of surgery, none were Black/AA women. Of the 9139 NIH grants awarded to academic surgeons from 1998 and 2017, 31 (0.34%) grants were awarded to fewer than 12 Black/AA women surgeons.CONCLUSION: A significant disparity in the number of Black/AA women in academic surgery exists with few attaining promotion to the rank of professor with tenure and none ascending to the role of department Chair of surgery. Identifying and removing structural barriers to promotion, NIH grant funding, and academic advancement of Black/AA women as leaders and surgeon-scientists is needed.

    View details for DOI 10.1097/SLA.0000000000003786

    View details for PubMedID 32209893

  • Consensus for Thoracoscopic Left Upper Lobectomy-Essential Components and Targets for Simulation. The Annals of thoracic surgery Bryan, D. S., Ferguson, M. K., Antonoff, M. B., Backhus, L. M., Birdas, T. J., Blackmon, S. H., Boffa, D. J., Chang, A. C., Chmielewski, G. W., Cooke, D. T., Donington, J. S., Gaissert, H. A., Hagen, J. A., Hofstetter, W. L., Kent, M. S., Kim, K. W., Krantz, S. B., Lin, J. n., Martin, L. W., Meyerson, S. L., Mitchell, J. D., Molena, D. n., Odell, D. D., Onaitis, M. W., Puri, V. n., Putnam, J. B., Seder, C. W., Shrager, J. B., Soukiasian, H. J., Stiles, B. M., Tong, B. C., Veeramachaneni, N. K. 2020


    Simulation-based training is a valuable component of cardiothoracic surgical education. Effective curriculum development requires consensus on procedural components and focused attention on specific learning objectives. Through use of a Delphi process, we established consensus on the steps of video-assisted thoracoscopic surgery (VATS) left upper lobectomy and identified targets for simulation.Experienced thoracic surgeons were randomly selected for participation. Surgeons voted and commented on the necessity of individual steps comprising VATS left upper lobectomy. Steps with greater than 80% of participants in agreement of their necessity were determined to have established "consensus." Participants voted on the physical or cognitive complexity of each, or both, and chose steps most amenable to focused simulation.Thirty thoracic surgeons responded and joined in the voting process. Twenty operative steps were identified, with surgeons reaching consensus on the necessity of 19. Components deemed most difficult and amenable to simulation included those related to dissection and division of the bronchus, artery, and vein.Through a Delphi process, surgeons with a variety of practice patterns can achieve consensus on the operative steps of left upper lobectomy and agreement on those most appropriate for simulation. This information can be implemented in the development of targeted simulation for VATS lobectomy.

    View details for DOI 10.1016/j.athoracsur.2020.06.152

    View details for PubMedID 33127408

  • The Role of Race and Gender in the Career Experiences of Black/African-American Academic Surgeons: A Survey of the Society of Black Academic Surgeons and a Call to Action. Annals of surgery Crown, A. n., Berry, C. n., Khabele, D. n., Fayanju, O. M., Cobb, A. n., Backhus, L. n., Smith, R. n., Sweeting, R. n., Hasson, R. n., Johnson-Mann, C. n., Oseni, T. n., Newman, E. A., Turner, P. n., Karpeh, M. n., Pugh, C. n., Jordan, A. H., Henry-Tillman, R. n., Joseph, K. A. 2020


    To determine the role of race and gender in the career experience of Black/AA academic surgeons and to quantify the prevalence of experience with racial and gender bias stratified by gender.Compared to their male counterparts, Black/African American (AA) women remain significantly underrepresented among senior surgical faculty and department leadership. The impact of racial and gender bias on the academic and professional trajectory of Black/AA women surgeons has not been well-studied.A cross-sectional survey regarding demographics, employment, and perceived barriers to career advancement was distributed via email to faculty surgeon members of the Society of Black American Surgeons (SBAS) in September 2019.Of 181 faculty members, 53 responded (29%), including 31 women (58%) and 22 men (42%). Academic positions as a first job were common (men 95% vs women 77%, p = 0.06). Men were more likely to attain the rank of full professor (men 45% vs women 7%, p = 0.01). Reports of racial bias in the workplace were similar (women 84% vs men 86%, NS); however, reports of gender bias (women 97% vs men 27%, p < 0.001) and perception of salary inequities (women 89% vs 63%, p = 0.02) were more common among women.Despite efforts to increase diversity, high rates of racial bias persist in the workplace. Black/AA women also report experiencing a high rate of gender bias and challenges in academic promotion.

    View details for DOI 10.1097/SLA.0000000000004502

    View details for PubMedID 32941287

  • Transcervical Thymectomy is the Most Cost-Effective Surgical Approach in Myasthenia Gravis. The Annals of thoracic surgery Sholtis, C. n., Teymourtash, M. n., Berry, M. n., Backhus, L. n., Bhandari, P. n., He, H. n., Benson, J. n., Wang, Y. Y., Yevudza, E. n., Lui, N. n., Shrager, J. n. 2020


    Extended thymectomy is now proven to improve the course of myasthenia gravis. Retrospective studies demonstrate that several techniques for thymectomy achieve overlapping remission rates. We therefore compared perioperative outcomes and costs among 3 approaches to thymectomy: sternotomy; video/robot assisted; transcervical.To ensure similar study groups, we excluded patients with >4cm or invasive tumors and those who underwent less than an extended thymectomy or concurrent procedures. Hospital costs were collected and analyzed by blinded finance personnel.The final study group consisted of 25 transcervical, 23 video/robotic, and 14 sternotomy subjects. There was a higher incidence of myasthenia gravis in the transcervical and sternotomy groups (p<0.01) and of thymoma in the video/robotic and sternotomy groups (p<0.01). Mean modified Charlson co-morbidity score was higher for sternotomy (2.7±2.1) than transcervical (1.00±.58; p<0.001) and video/robotic (1.13±.97; p=0.001). There was no difference in complication rates between approaches (p=0.83). The cost of transcervical thymectomy was 45% of the cost of sternotomy (p<0.001) and 58% of the cost of video/robotic (p=0.018) approaches; these differences remained highly significant on multivariate analysis. Transcervical thymectomy had shorter mean length of stay (1.2±.5 days) than median sternotomy (4.4±3.5; p<0.001) and video/robot assisted thymectomy (2.6±.96; p=0.045), and "bed cost" was the major contributor to cost difference between the groups.Transcervical thymectomy, which provides overlapping myasthenia gravis remission rates vs. more invasive approaches, is equally safe and far less costly than sternotomy and video/robotic approaches.

    View details for DOI 10.1016/j.athoracsur.2020.01.047

    View details for PubMedID 32135150

  • Does size matter? A national analysis of the utility of induction therapy for large thymomas. Journal of thoracic disease Liou, D. Z., Ramakrishnan, D. n., Lui, N. S., Shrager, J. B., Backhus, L. M., Berry, M. F. 2020; 12 (4): 1329–41


    Tumor size of 8 cm or greater is a risk factor for recurrence after thymoma resection, but the role of induction therapy for large thymomas is not well defined. This study tested the hypothesis that induction therapy for thymomas 8 cm and larger improves survival.The use of induction therapy for patients treated with surgical resection for Masaoka stage I-III thymomas in the National Cancer Database between 2006-2013 was evaluated using logistic regression, Kaplan-Meier analysis, and Cox-proportional hazards methods.Of the 1,849 patients who met inclusion criteria, 582 (31.5%) had tumors ≥8 cm. Five-year survival was worse in patients with tumors ≥8 cm compared to smaller tumors [84.6% (95% CI: 81.2-88.1%) vs. 89.4% (95% CI: 87.2-91.7%), P=0.003]. Induction therapy was used in 166 (9.0%) patients overall and was more likely in patients with tumors ≥8 cm [adjusted odds ratio (AOR) 3.257, P<0.001]. Induction therapy was not associated with improved survival in the subset of patients with tumors ≥8 cm in either univariate [80.9% (95% CI: 72.6-90.1%) vs. 85.4% (95% CI: 81.8-89.3%), P=0.27] or multivariable analysis [hazard ratio (HR) 1.54, P=0.10]. Increasing age (HR 1.56/decade, P<0.001) and Masaoka stage III (HR 1.76, P=0.04) were associated with worse survival in patients with tumors ≥8 cm.Survival after thymoma resection is worse for tumors 8 cm or larger compared to smaller tumors and is not improved by induction therapy. Size alone should not be a criterion for using induction therapy prior to thymoma resection.

    View details for DOI 10.21037/jtd.2020.02.63

    View details for PubMedID 32395270

    View details for PubMedCentralID PMC7212162

  • Women in Thoracic Surgery Scholarship: Impact on Career Path and Interest in Cardiothoracic Surgery. The Annals of thoracic surgery Williams, K. M., Hironaka, C. E., Wang, H. n., Bajaj, S. S., O'Donnell, C. T., Sanchez, M. n., Boyd, J. n., Kane, L. n., Backhus, L. n. 2020


    Women remain underrepresented in Cardiothoracic Surgery (CTS). In 2005, Women in Thoracic Surgery (WTS) began offering scholarships to promote engagement of women in CTS careers. This study explores the effect of WTS scholarships on CTS career milestones.We assessed career development using the number of awardees matching into CTS residency/fellowship, American Board of Thoracic Surgery (ABTS) certification, and academic CTS appointment. Scholarship awardee data were obtained from our WTS database. Comparison data were gathered from the National Residency Match Program and ABTS. Details of the current roles of ABTS certified women were determined from public resources. Qualitative results were gathered from post-scholarship surveys.106 WTS scholarships have been awarded to 38 medical students (MS, 36%), 41 General Surgery residents (GR, 39%), and 27 CTS residents/fellows (CR, 25%). Among MS, 26% of awardees entered integrated CTS residency (vs. <0.1% for medical students, p<0.0001), while 37% entered general surgery residency (vs. 4.8% for medical students, p<0.0001). Of GR awardees, 59% entered CTS fellowships (vs. 7.7% for general surgery residents, p<0.0001), and of CR awardees, 100% earned ABTS certification (vs. 73% ABTS pass rate, p=.01). Of ABTS certified awardees, 44% are practicing CT surgeons at U.S. academic training institutions (vs. 33% of non-awardee ABTS certified women, p=0.419). All awardees reported that their scholarship was valuable in their development.Receipt of a WTS scholarship is associated with successful pursuit of CTS career milestones at significantly higher rates than contemporaries. These scholarships foster a supportive community for women trainees in CTS.

    View details for DOI 10.1016/j.athoracsur.2020.07.020

    View details for PubMedID 32961134

  • KEAP1/NFE2L2 mutations predict lung cancer radiation resistance that can be targeted by glutaminase inhibition. Cancer discovery Binkley, M. S., Jeon, Y. J., Nesselbush, M. n., Moding, E. J., Nabet, B. Y., Almanza, D. n., Kunder, C. n., Stehr, H. n., Yoo, C. H., Rhee, S. n., Xiang, M. n., Chabon, J. J., Hamilton, E. n., Kurtz, D. M., Gojenola, L. n., Owen, S. G., Ko, R. B., Shin, J. H., Maxim, P. G., Lui, N. S., Backhus, L. M., Berry, M. F., Shrager, J. B., Ramchandran, K. J., Padda, S. K., Das, M. n., Neal, J. W., Wakelee, H. A., Alizadeh, A. A., Loo, B. W., Diehn, M. n. 2020


    Tumor genotyping is not routinely performed in localized non-small cell lung cancer (NSCLC) due to lack of associations of mutations with outcome. Here, we analyze 232 consecutive patients with localized NSCLC and demonstrate that KEAP1 and NFE2L2 mutations are predictive of high rates of local recurrence (LR) after radiotherapy but not surgery. Half of LRs occurred in KEAP1/NFE2L2 mutation tumors, indicating they are major molecular drivers of clinical radioresistance. Next, we functionally evaluate KEAP1/NFE2L2 mutations in our radiotherapy cohort and demonstrate that only pathogenic mutations are associated with radioresistance. Furthermore, expression of NFE2L2 target genes does not predict LR, underscoring the utility of tumor genotyping. Finally, we show that glutaminase inhibition preferentially radiosensitizes KEAP1 mutant cells via depletion of glutathione and increased radiation-induced DNA damage. Our findings suggest that genotyping for KEAP1/NFE2L2 mutations could facilitate treatment personalization and provide a potential strategy for overcoming radioresistance conferred by these mutations.

    View details for DOI 10.1158/2159-8290.CD-20-0282

    View details for PubMedID 33071215

  • Paradoxical Motion on Sniff Test Predicts Greater Improvement Following Diaphragm Plication. The Annals of thoracic surgery Patel, D. C., Berry, M. F., Bhandari, P. n., Backhus, L. M., Raees, S. n., Trope, W. n., Nash, A. n., Lui, N. S., Liou, D. Z., Shrager, J. B. 2020


    Diaphragm plication (DP) improves pulmonary function and quality of life for those with diaphragm paralysis/dysfunction. It is unknown whether differing degrees of diaphragm dysfunction as measured by sniff testing impact results after plication.Patients who underwent minimally invasive DP from 2008-2019 were dichotomized based on sniff test results: paradoxical motion (PM) vs. no paradoxical motion (NPM) - the latter including normal/decreased/no motion. Preoperative and postoperative pulmonary function testing (PFT) after DP was compared between the two groups. The impact of diaphragm height index (DHI), a measure of diaphragm elevation, was also assessed.Twenty-six patients underwent preoperative sniff testing, DP, and postoperative PFTs. Including all patients, DP resulted in a 17.8 ± 5.5% (p<0.001) improvement in forced expiratory volume at 1 second (FEV1), a 14.4 ± 5.3% (p<0.001) improvement in forced vital capacity (FVC), and a 4.7 ± 4.6% (p=0.539) improvement in diffusing capacity (DLCO). There were greater improvements in the PM group (n=16) vs. NPM group (n=10) for FEV1 (27.2 ± 6.0% vs. 3.9 ± 6.2%, p=0.017) and FVC (28.1 ± 5.3% vs. -0.5 ± 3.3%, p=0.001). There was no difference in ΔDLCO between groups. There were no differences between patients with PM and NPM in postoperative course/complications. No value for DHI predicted improvement in PFTs following DP.Patients with PM on sniff test have dramatically greater objective improvements in pulmonary function following plication than those without PM. Most patients without PM do not demonstrate improvement in standard PFTs. Improvements in dyspnea require additional study.

    View details for DOI 10.1016/j.athoracsur.2020.07.049

    View details for PubMedID 33031777

  • Commentary: Lung cancer outcomes reporting within the VA system: room for improvement. Seminars in thoracic and cardiovascular surgery Guenthart, B. A., Backhus, L. M., Lui, N. S. 2020

    View details for DOI 10.1053/j.semtcvs.2020.06.008

    View details for PubMedID 32569647

  • A National Analysis of Treatment Patterns and Outcomes for Patients 80 Years or Older with Esophageal Cancer. Seminars in thoracic and cardiovascular surgery Yang, C. J., Wang, Y. n., Raman, V. n., Patel, D. n., Lui, N. n., Backhus, L. n., Shrager, J. n., Berry, M. F., Liou, D. n. 2020


    The purpose of this study was to evaluate practice patterns and outcomes for patients 80 years or older with esophageal cancer using a nationwide cancer database. Practice patterns for patients 80 years or older with stage I-IV esophageal cancer in the National Cancer Database from 2004-2014 were analyzed. Overall survival associated with different treatment strategies were evaluated using the Kaplan-Meier method and multivariable Cox proportional hazard models. In the study period, 40.5% and 46.2% of patients with stage I adenocarcinoma and squamous cell carcinoma, respectively, did not receive any treatment at all. Less than 11% (196/1,865) of patients with stage I-II disease underwent esophagectomy, even though surgery was associated with a better 5-year survival compared to no treatment (stage I: 47.3% [95% CI 36.2%-57.6%] vs 14.9% [95% CI: 11.2%-19.1%]; stage II: 29.3% [95% CI 20.1%-39.1%] vs 1.2% [95% CI: 0.1%-5.5%]). Of the 1,596 (37.7%) patients with stage III disease who received curative-intent treatment (surgery or chemoradiation), the 5-year survival was significantly better than that of patients who received no treatment (11.9% [95% CI: 9.7%-14.4% vs 4.3% [95% CI: 1.9%-8.3%]). In this national analysis of patients 80 years and older with esophageal cancer, over 40% of patients with stage I disease did not receive treatment. Patients with stage I-III disease had better survival and risks and benefits of treatment for elderly patients should be discussed in a multidisciplinary setting.

    View details for DOI 10.1053/j.semtcvs.2020.09.004

    View details for PubMedID 32977014

  • What Is a Tracheostomy? JAMA Baiu, I., Backhus, L. 2019; 322 (19): 1932

    View details for DOI 10.1001/jama.2019.14994

    View details for PubMedID 31742632

  • The Oldest Old: A National Analysis of Outcomes for Patients 90 Years or Older With Lung Cancer. The Annals of thoracic surgery Yang, C. J., Brown, A. B., Deng, J. Z., Lui, N. S., Backhus, L. M., Shrager, J. B., D'Amico, T. A., Berry, M. F. 2019


    BACKGROUND: Most clinicians will encounter patients 90 years or older with non-small cell lung cancer (NSCLC), but evidence that informs treatment decisions for this extremely elderly population is lacking. This study evaluated outcomes associated with treatment strategies for this nonagenarian population.METHODS: Treatment and overall survival for patients 90 years and older with NSCLC in the National Cancer Data Base (2004-2014) were evaluated using logistic regression, the Kaplan-Meier method, and multivariable Cox proportional hazard models.RESULTS: The majority (n = 4152, 57.6%) of the 7205 patients 90 years or older with stage I-IV NSCLC did not receive any therapy. For the entire cohort, receiving treatment was associated with significantly better survival when compared with no therapy (5-year survival, 9.3% [95% confidence interval [CI], 8.0%-10.7%] vs 1.7% [95% CI, 1.2%-2.2%]; multivariable adjusted hazard ratio, 0.53; P < .001). Stage I patients had the most pronounced survival benefit with treatment (median survival, 27.4 months vs 10.0 months with no treatment; P < .001). Among this subset of patients with stage I disease (n= 1430), only 12.7% (n= 182) had surgery and 33% (n= 471) had no therapy. In these stage I patients surgery was associated with significantly better 5-year survival (33.7% [95% CI, 25.4%-42.1%]) than nonoperative therapy (17.1% [95% CI, 13.7%-20.8%]) and no therapy (6.2% [95% CI, 3.8%-9.4%]).CONCLUSIONS: Therapy for nonagenarians with NSCLC is associated with a significant survival benefit but is not used in most patients. Treatment should not be withheld for these "oldest old" patients based on their age alone but should be considered based on stage and patient preferences in a multidisciplinary setting.

    View details for DOI 10.1016/j.athoracsur.2019.09.027

    View details for PubMedID 31757356

  • Report from the Workforce on Diversity & Inclusion - Society of Thoracic Surgeons Members' Bias Experiences. The Annals of thoracic surgery Erhunmwunsee, L., Backhus, L. M., Godoy, L., Edwards, M. A., Cooke, D. T. 2019


    Diversity and inclusion within the Society of Thoracic Surgeons is paramount to the growth and excellence of our specialty. As such, discussions about challenges that prevent our society from achieving this goal are necessary. The Workforce on Diversity & Inclusion has been tasked with understanding our membership's comprehension and experience with bias, which is known to have a negative impact on those of female gender, minority race, sexual orientation status, and religious status. Bias contributes to the fact that we are far from gender parity within our society's leadership and that we must make significant changes in order to achieve a diverse membership. Within this report, we discuss the literature regarding experience with gender and racial/ethnic directed implicit and explicit bias during surgical training and within the cardiothoracic surgical workforce. We also share survey results on members' experience with racial/ethnic, gender and other minority demographic directed bias.

    View details for DOI 10.1016/j.athoracsur.2019.08.015

    View details for PubMedID 31520637

  • Unconscious Bias: Addressing the Hidden Impact on Surgical Education. Thoracic surgery clinics Backhus, L. M., Lui, N. S., Cooke, D. T., Bush, E. L., Enumah, Z., Higgins, R. 2019; 29 (3): 259–67


    Unconscious (or implicit) biases are learned stereotypes that are automatic, unintentional, deeply engrained, universal, and able to influence behavior. Several studies have documented the effects of provider biases on patient care and outcomes. This article provides a framework for exploring the implications for unconscious bias in surgical education and highlights best practices toward minimizing its impact. Presented is the background related to some of the more common unconscious biases and effects on medical students, resident trainees, and academic faculty. Finally, targeted strategies are highlighted for individuals and institutions for identification of biases and the means to address them.

    View details for DOI 10.1016/j.thorsurg.2019.03.004

    View details for PubMedID 31235294

  • STS, ESTS and JACS survey on surveillance practices after surgical resection of lung cancer. Interactive cardiovascular and thoracic surgery Pompili, C., Edwards, M., Bhandari, P., Novoa, N., Hasegawa, S., Yoshino, I., Chida, M., Brunelli, A., Naunheim, K., Backhus, L. 2019


    OBJECTIVES: A 1995 survey of Society of Thoracic Surgeons (STS) members revealed wide variation in postresection lung cancer surveillance practices and pessimism regarding any survival benefit. We sought to compare contemporary practice patterns and attitudes among members of STS, European Society of Thoracic Surgeons (ESTS) and the Japanese Association for Chest Surgery (JACS).METHODS: A survey identical to the one conducted in 1995 was administered via mail or electronically. chi2 tests for associations were used to compare profiles of respondents and attitudes towards testing between groups. All the statistical tests were two-sided and P-values of 0.05 or less were considered statistically significant.RESULTS: A total of 2978 STS members (response rate 7.8%, n=234), 1450 ESTS members (response rate 8.4%, n=122) and 272 JACS (response rate 40.8%, n=111) members were surveyed. Rate of guideline-recommended surveillance computed tomography was reported highest among ESTS respondents for stage I patients (22% ESTS, 3% STS and 6% JACS members, P<0.001). However, both JACS and ESTS respondents reported higher rates of use of non-guidelines-recommended tests compared to STS respondents, which persisted on adjusted analyses. Regarding attitudes towards surveillance, more JACS and ESTS members either 'agree' or 'strongly agree' that routine testing for non-small-cell lung cancer recurrence results in potentially curative treatment (ESTS: 86%, STS: 70%, JACS: 90%, P<0.001). Similarly, JACS and ESTS respondents believe that the current literature documents definitive survival benefits from routine follow-up testing (ESTS: 57%, STS: 30%, JACS: 62%, P<0.001).CONCLUSIONS: The Japanese attitude towards surveillance is similar to that of ESTS members potentially highlighting significant differences between European and Asian surgeons compared to STS members. These differences clearly highlight the need for better prospective studies and joint recommendations to globally standardize practice.

    View details for DOI 10.1093/icvts/ivz149

    View details for PubMedID 31289810

  • Optimizing health before elective thoracic surgery: systematic review of modifiable risk factors and opportunities for health services research JOURNAL OF THORACIC DISEASE Stokes, S. M., Wakeam, E., Antonoff, M. B., Backhus, L. M., Meguid, R. A., Odell, D., Varghese, T. K. 2019; 11: S537–S554
  • Optimizing health before elective thoracic surgery: systematic review of modifiable risk factors and opportunities for health services research. Journal of thoracic disease Stokes, S. M., Wakeam, E., Antonoff, M. B., Backhus, L. M., Meguid, R. A., Odell, D., Varghese, T. K. 2019; 11 (Suppl 4): S537-S554


    Despite progress in many different domains of surgical care, we are still striving toward practices which will consistently lead to the best care for an increasingly complex surgical population. Thoracic surgical patients, as a group, have multiple medical co-morbidities and are at increased risk for developing complications after surgical intervention. Our healthcare systems have been focused on treating complications as they occur in the hopes of minimizing their impact, as well as aiding in recovery. In recent years there has emerged a body of evidence outlining opportunities to optimize patients and likely prevent or decrease the impact of many complications. The purpose of this review article is to summarize four major domains-optimal pain control, nutritional status, functional fitness, and smoking cessation-all of which can have a substantial impact on the thoracic surgical patient's course in the hospital-as well as to describe opportunities for improvement, and areas for future research efforts.

    View details for DOI 10.21037/jtd.2019.01.06

    View details for PubMedID 31032072

    View details for PubMedCentralID PMC6465421

  • The influence of hormone replacement therapy on lung cancer incidence and mortality. The Journal of thoracic and cardiovascular surgery Titan, A. L., He, H. n., Lui, N. n., Liou, D. n., Berry, M. n., Shrager, J. B., Backhus, L. M. 2019


    Data regarding the effects of hormone replacement therapy (HRT) on non-small cell lung cancer (NSCLC) are mixed. We hypothesized HRT would have a protective benefit with reduced NSCLC incidence among women in a large, prospective cohort.We used data from the multicenter randomized Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (1993-2001). Participants were women aged 50 to 74 years followed prospectively for up to 13 years for cancer screening. The influence of HRT on the primary outcome of NSCLC incidence and secondary outcomes of all-cause and disease-specific mortality were assessed with Kaplan-Meier analysis and Cox proportional hazard models adjusting for covariates.In the overall cohort of 75,587 women, 1147 women developed NSCLC after a median follow-up of 11.5 years. HRT use was characterized as 49.4% current users, 17.0% former users, and 33.6% never users. Increased age, smoking, comorbidities, and family history were associated with increased risk of NSCLC. On multivariable analysis, current HRT use was associated with reduced risk of NSCLC compared with never users (hazard ratio, 0.80; 95% confidence interval, 0.70-0.93; P = .009). HRT or oral contraception use was not associated with significant differences in all-cause mortality or disease-specific mortality.These data represent among the largest prospective cohorts suggesting HRT use may have a protective effect on the development of NSCLC among women; the physiological basis of this effect merits further study; however, the results may influence discussion surrounding HRT use in women.

    View details for DOI 10.1016/j.jtcvs.2019.10.070

    View details for PubMedID 31866083

  • An Exploration of Myths, Barriers and Strategies for Improving Diversity Among STS Members. The Annals of thoracic surgery Backhus, L. M., Kpodonu, J. n., Romano, J. C., Pelletier, G. n., Preventza, O. n., Cooke, D. T. 2019


    Diversity within health care organizations has many proven benefits, yet women and other groups remain under-represented in cardiothoracic surgery. We sought to explore responses from a Society of Thoracic Surgeons (STS) survey to identify myths and barriers for informing organizational strategies in the STS and cardiothoracic surgery. We performed a qualitative review of narrative survey responses within three domains surrounding diversity in cardiothoracic surgery: Myths, Barriers, and Strategies for improvement. Common diversity myths included: diversity as a pipeline problem (24%), diversity equated to exclusivity (21%), and diversity not supporting meritocracy (18%). The most frequent barrier code was perceived prejudice (22%). Suggested strategies towards improvement were: culture change prioritizing diversity (22%) and training the leaders (14%). Notably, 15% of response codes reflected the belief that disparities do not exist thus the issue should not be prioritized by the organization. The results do not necessarily reflect the beliefs of the majority of STS membership, nonetheless they provide important insight critical to guide any efforts towards eliminating disparities within cardiothoracic surgery and improving the care of our patients.

    View details for DOI 10.1016/j.athoracsur.2019.09.007

    View details for PubMedID 31593654

  • A national analysis of open versus minimally invasive thymectomy for stage I to III thymoma. The Journal of thoracic and cardiovascular surgery Yang, C. J., Hurd, J. n., Shah, S. A., Liou, D. n., Wang, H. n., Backhus, L. M., Lui, N. S., D'Amico, T. A., Shrager, J. B., Berry, M. F. 2019


    The oncologic efficacy of minimally invasive thymectomy for thymoma is not well characterized. We compared short-term outcomes and overall survival between open and minimally invasive (video-assisted thoracoscopic and robotic) approaches using the National Cancer Data Base.Perioperative outcomes and survival of patients who underwent open versus minimally invasive thymectomy for clinical stage I to III thymoma from 2010 to 2014 in the National Cancer Data Base were evaluated using multivariable Cox proportional hazards modeling and propensity score-matched analysis. Predictors of minimally invasive use were evaluated using multivariable logistic regression. Outcomes of surgical approach were evaluated using an intent-to-treat analysis.Of the 1223 thymectomies that were evaluated, 317 (26%) were performed minimally invasively (141 video-assisted thoracoscopic and 176 robotic). The minimally invasive group had a shorter median length of stay when compared with the open group (3 [2-4] days vs 4 [3-6] days, P < .001). In a propensity score-matched analysis of 185 open and 185 minimally invasive (video-assisted thoracoscopic + robotic) thymectomy, the minimally invasive group continued to have a shorter median length of stay (3 vs 4 days, P < .01) but did not have significant differences in margin positivity (P = .84), 30-day readmission (P = .28), 30-day mortality (P = .60), and 5-year survival (89.4% vs 81.6%, P = .20) when compared with the open group.In this national analysis, minimally invasive thymectomy was associated with shorter length of stay and was not associated with increased margin positivity, perioperative mortality, 30-day readmission rate, or reduced overall survival when compared with open thymectomy.

    View details for DOI 10.1016/j.jtcvs.2019.11.114

    View details for PubMedID 32245668

  • Culture of Safety and Gender Inclusion in Cardiothoracic Surgery ANNALS OF THORACIC SURGERY Backhus, L. M., Fann, B. E., Hui, D. S., Cooke, D. T., Berfield, K. S., Moffatt-Bruce, S. D. 2018; 106 (4): 951–58
  • Thirty-day unplanned postoperative inpatient and emergency department visits following thoracotomy JOURNAL OF SURGICAL RESEARCH Shaffer, R., Backhus, L., Finnegan, M. A., Remington, A. C., Kwong, J. Z., Curtin, C., Hernandez-Boussard, T. 2018; 230: 117–24
  • Thirty-day unplanned postoperative inpatient and emergency department visits following thoracotomy. The Journal of surgical research Shaffer, R., Backhus, L., Finnegan, M. A., Remington, A. C., Kwong, J. Z., Curtin, C., Hernandez-Boussard, T. 2018; 230: 117–24


    BACKGROUND: Unplanned visits to the emergency department (ED) and inpatient setting are expensive and associated with poor outcomes in thoracic surgery. We assessed 30-d postoperative ED visits and inpatient readmissions following thoracotomy, a high morbidity procedure.MATERIALS AND METHODS: We retrospectively analyzed inpatient and ED administrative data from California, Florida, and New York, 2010-2011. "Return to care" was defined as readmission to inpatient facility or ED within 30 d of discharge. Factors associated with return to care were analyzed via multivariable logistic regressions with a fixed effect for hospital variability.RESULTS: Of 30,154 thoracotomies, 6.3% were admitted to the ED and 10.2% to the inpatient setting within 30 d of discharge. Increased risk of inpatient readmission was associated with Medicare (odds ratio [OR] 1.30; P<0.001) and Medicaid (OR 1.31; P<0.0001) insurance status compared to private insurance and black race (OR 1.18; P=0.02) compared to white race. Lung cancer diagnosis (OR 0.83; P<0.001) and higher median income (OR 0.89; P=0.04) were associated with decreased risk of inpatient readmission. Postoperative ED visits were associated with Medicare (OR 1.24; P<0.001) and Medicaid insurance status (OR 1.59; P<0.001) compared to private insurance and Hispanic race (OR 1.19; P=0.04) compared to white race.CONCLUSIONS: Following thoracotomy, postoperative ED visits and inpatient readmissions are common. Patients with public insurance were at high risk for readmission, while patients with underlying lung cancer diagnosis had a lower readmission risk. Emphasizing postoperative management in at-risk populations could improve health outcomes and reduce unplanned returns to care.

    View details for PubMedID 30100026

  • Culture of Safety and Gender Inclusion in Cardiothoracic Surgery. The Annals of thoracic surgery Backhus, L. M., Fann, B. E., Hui, D. S., Cooke, D. T., Berfield, K. S., Moffatt-Bruce, S. D. 2018

    View details for PubMedID 30120943

  • Induction therapy for locally advanced distal esophageal adenocarcinoma: Is radiation Always necessary? Liou, D. Z., Backhus, L. M., Lui, N. S., Shrager, J. B., Berry, M. F. MOSBY-ELSEVIER. 2018: 2697–2705
  • Intraoperative costs of video-assisted thoracoscopic lobectomy can be dramatically reduced without compromising outcomes JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Richardson, M. T., Backhus, L. M., Berry, M. F., Vail, D. G., Ayers, K. C., Benson, J. A., Bhandari, P., Teymourtash, M., Shrager, J. B. 2018; 155 (3): 1267-+


    To determine whether surgeon selection of instrumentation and other supplies during video-assisted thoracoscopic lobectomy (VATSL) can safely reduce intraoperative costs.In this retrospective, cost-focused review of all video-assisted thoracoscopic surgery anatomic lung resections performed by 2 surgeons at a single institution between 2010 and 2014, we compared VATSL hospital costs and perioperative outcomes between the surgeons, as well as costs of VATSL compared with thoracotomy lobectomy (THORL).A total of 100 VATSLs were performed by surgeon A, and 70 were performed by surgeon B. The preoperative risk factors did not differ significantly between the 2 groups of surgeries. Mean VATSL total hospital costs per case were 24% percent greater for surgeon A compared with surgeon B (P = .0026). Intraoperative supply costs accounted for most of this cost difference and were 85% greater for surgeon A compared with surgeon B (P < .0001). The use of nonstapler supplies, including energy devices, sealants, and disposables, drove intraoperative costs, accounting for 55% of the difference in intraoperative supply costs between the surgeons. Operative time was 25% longer for surgeon A compared with surgeon B (P < .0001), but this accounted for only 11% of the difference in total cost. Surgeon A's overall VATSL costs per case were similar to those of THORLs (n = 100) performed over the same time period, whereas surgeon B's VATSL costs per case were 24% less than those of THORLs. On adjusted analysis, there was no difference in VATSL perioperative outcomes between the 2 surgeons.The costs of VATSL differ substantially among surgeons and are heavily influenced by the use of disposable equipment/devices. Surgeons can substantially reduce the costs of VATSL to far lower than those of THORL without compromising surgical outcomes through prudent use of costly instruments and technologies.

    View details for PubMedID 29224839

  • Induction therapy for locally advanced distal esophageal adenocarcinoma: Is radiation Always necessary? The Journal of thoracic and cardiovascular surgery Liou, D. Z., Backhus, L. M., Lui, N. S., Shrager, J. B., Berry, M. F. 2018


    OBJECTIVE: To compare outcomes between induction chemotherapy alone (ICA) and induction chemoradiation (ICR) in patients with locally advanced distal esophageal adenocarcinoma.METHODS: Patients in the National Cancer Database treated with ICA or ICR followed by esophagectomy between 2006 and 2012 for cT1-3N1M0 or T3N0M0 adenocarcinoma of the distal esophagus were compared using logistic regression, Kaplan-Meier analysis, and Cox proportional hazards methods.RESULTS: The study group included 4763 patients, of whom 4323 patients (90.8%) received ICR and 440 patients (9.2%) received ICA. There were no differences in age, sex, race, Charlson Comorbidity Index, treatment facility type, clinical T or N status between the 2 groups. Tumor size ≥5cm (odds ratio, 1.46; P=.006) was the only factor that predicted ICR use. Higher rates of T downstaging (39.7% vs 33.4%; P=.012), N downstaging (32.0% vs 23.4%; P<.001), and complete pathologic response (13.1% vs 5.9%; P<.001) occurred in ICR patients. Positive margins were seen more often in ICA patients (9.6% vs 5.5%; P=.001), but there was no difference in 5-year survival (ICR 35.9% vs ICA 37.2%; P=.33), and ICR was not associated with survival in multivariable analysis (hazard ratio=1.04; P=.61).CONCLUSIONS: ICR for locally advanced distal esophageal adenocarcinoma is associated with a better local treatment effect, but not improved survival compared with ICA, which suggests that radiation can be used selectively in this clinical situation.

    View details for PubMedID 29530567

  • Patients reported outcomes in thoracic surgery JOURNAL OF THORACIC DISEASE Pompili, C., Absolom, K., Velikova, G., Backhus, L. 2018; 10 (2): 703–6

    View details for PubMedID 29607138

    View details for PubMedCentralID PMC5864594

  • Presence of Even a Small Ground-Glass Component in Lung Adenocarcinoma Predicts Better Survival CLINICAL LUNG CANCER Berry, M. F., Gao, R., Kunder, C. A., Backhus, L., Khuong, A., Kadoch, M., Leung, A., Shrager, J. 2018; 19 (1): E47–E51


    While lepidic-predominant lung adenocarcinomas are known to have better outcomes than similarly sized solid tumors, the impact of smaller noninvasive foci within predominantly solid tumors is less clearly characterized. We tested the hypothesis that lung adenocarcinomas with even a small ground-glass opacity (GGO) component have a better prognosis than otherwise similar pure solid (PS) adenocarcinomas.The maximum total and solid-component diameters were determined by preoperative computed tomography in patients who underwent lobar or sublobar resection of clinical N0 adenocarcinomas without induction therapy between May 2003 and August 2013. Survival between patients with PS tumors (0% GGO) or tumors with a minor ground-glass (MGG) component (1%-25% GGO) was compared by Kaplan-Meier and Cox analyses.A total of 123 patients met the inclusion criteria, comprising 54 PS (44%) and 69 MGG (56%) whose mean ground-glass component was 18 ± 7%. The solid component tumor diameter was not significantly different between the groups (2.3 ± 1.2 cm vs. 2.5 ± 1.3 cm, P = .2). Upstaging to pN1-2 was more common for the PS group (13% [7/54] vs. 3% [2/69], P = .04), but the distribution of pathologic stage was not significantly different between the groups (PS 76% stage I [41/54] vs. MGG 80% stage I [55/69], P = .1). Having a MGG component was associated with markedly better survival in both univariate analysis (MGG 5-year overall survival 86.7% vs. PS 64.5%, P = .001) and multivariable survival analysis (hazard ratio, 0.30, P = .01).Patients with resected cN0 lung adenocarcinoma who have even a small GGO component have markedly better survival than patients with PS tumors, which may have implications for both treatment and surveillance strategies.

    View details for PubMedID 28743420

  • Unhealthy alcohol use is associated with postoperative complications in veterans undergoing lung resection. Journal of thoracic disease Graf, S. A., Zeliadt, S. B., Rise, P. J., Backhus, L. M., Zhou, X. H., Williams, E. C. 2018; 10 (3): 1648–56


    Lung resections carry a significant risk of complications necessitating the characterization of peri-operative risk factors. Unhealthy alcohol use represents one potentially modifiable factor. In this retrospective cohort study, the largest to date of lung resections in the Veterans Health Administration (VHA), we examined the association between unhealthy alcohol use and postoperative complications and mortality.Veterans Affairs Surgical Quality Improvement Program data recorded at 86 medical centers between 2007 and 2011 were used to identify 4,715 patients that underwent lung resection. Logistic regression models, adjusted for demographics and comorbidities, were fit to assess the association between unhealthy alcohol use (report of >2 drinks per day in the 2 weeks preceding surgery) and 30-day outcomes.Among 4,715 patients that underwent pulmonary resection, 630 (13.4%) reported unhealthy alcohol use (>2 drinks/day). Overall, postoperative complications occurred in 896 (19.0%) patients, including pneumonia in 524 (11.1%). The rate of mortality was 2.6%. In adjusted analyses, complications were significantly more common among patients with unhealthy alcohol use [odds ratio (OR), 1.42; 95% confidence interval (CI), 1.15-1.74] including, specifically, pneumonia (OR, 1.69; 95% CI, 1.32-2.15). No statistically significant association was identified between unhealthy alcohol use and mortality (OR, 1.27; 95% CI, 0.75-2.02). In secondary analyses that stratified by smoking status at the time of surgery, drinking more than 2 drinks per day was associated with post-operative complications in patients reporting current smoking (OR, 1.51; 95% CI, 1.18-1.91) and was not identified in those reporting no current smoking at the time of surgery (OR, 1.23; 95% CI, 0.79-1.85).In this large VHA study, 13% of patients undergoing lung resection reported drinking more than 2 drinks per day in the preoperative period, which was associated with increased risk of post-operative complications. Unhealthy alcohol use may be an important target for perioperative risk-mitigation interventions, particularly in patients who report current smoking.

    View details for PubMedID 29707317

    View details for PubMedCentralID PMC5906255

  • Progress in the Management of Early-Stage Non-Small Cell Lung Cancer in 2017. Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer Donington, J. S., Kim, Y. T., Tong, B. n., Moreira, A. L., Bessich, J. n., Weiss, K. D., Colson, Y. L., Wigle, D. n., Osarogiagbon, R. U., Zweig, J. n., Wakelee, H. n., Blasberg, J. n., Daly, M. n., Backhus, L. n., Van Schil, P. n. 2018; 13 (6): 767–78


    The landscape of care for early-stage non-small cell lung cancer continues to evolve. While some of the developments do not seem as dramatic as what has occurred in advanced disease in recent years, there is a continuous improvement in our ability to diagnose disease earlier and more accurately. We have an increased understanding of the diversity of early-stage disease and how to better tailor treatments to make them more tolerable without impacting efficacy. The International Association for the Study of Lung Cancer and the Journal of Thoracic Oncology publish this annual update to help readers keep pace with these important developments. Experts in the care of early-stage lung cancer patients have provided focused updates across multiple areas including screening, pathology, staging, surgical techniques and novel technologies, adjuvant therapy, radiotherapy, surveillance, disparities, and quality of life. The source for information includes large academic meetings, the published literature, or novel unpublished data from other international oncology assemblies.

    View details for PubMedID 29654928

  • Protocol and pilot testing: The feasibility and acceptability of a nurse-led telephone-based palliative care intervention for patients newly diagnosed with lung cancer CONTEMPORARY CLINICAL TRIALS Reinke, L. F., Vig, E. K., Tartaglione, E. V., Backhus, L. M., Gunnink, E., Au, D. H. 2018; 64: 30–34

    View details for PubMedID 29175560

  • Survival and risk factors for progression after resection of the dominant tumor in multifocal, lepidic-type pulmonary adenocarcinoma Gao, R. W., Berry, M. F., Kunder, C. A., Khuong, A. A., Wakelee, H., Neal, J. W., Backhus, L. M., Shrager, J. B. MOSBY-ELSEVIER. 2017: 2092-+


    It remains unclear whether a dominant lung adenocarcinoma that presents with multifocal ground glass opacities (GGOs) should be treated by local therapy. We sought to address survival in this setting and to identify risk factors for progression of unresected GGOs.Retrospective review of 70 patients who underwent resection of a pN0, lepidic adenocarcinoma, who harbored at least 1 additional GGO. Features associated with GGO progression were determined using logistic regression and survival was evaluated using the Kaplan-Meier method.Subjects harbored 1 to 7 GGOs beyond their dominant tumor (DT). Mean follow-up was 4.1 ± 2.8 years. At least 1 GGO progressed after DT resection in 21 patients (30%). In 11 patients (15.7%), this progression prompted resection (n = 5) or stereotactic radiotherapy (n = 6) at mean 2.8 ± 2.3 years. Several measures of the overall tumor burden were associated with GGO progression (all P values < .03) and with progression prompting intervention (all P values < .01). In logistic regression, greater DT size (odds ratio, 1.07; 95% confidence interval, 1.01-1.14) and an initial GGO > 1 cm (odds ratio, 4.98; 95% confidence interval, 1.15-21.28) were the only factors independently associated with GGO progression. Survival was not negatively influenced by GGO progression (100% with vs 80.7% without; P = .1) or by progression-prompting intervention (P = .4).At 4.1-year mean follow-up, 15.7% of patients with unresected GGOs after resection of a pN0 DT underwent subsequent intervention for a progressing GGO. Some features correlated with GGO growth, but neither growth, nor need for an intervention, negatively influenced survival. Thus, even those at highest risk for GGO progression should not be denied resection of a DT.

    View details for PubMedID 28863952

  • Occam's Razor versus Hickam's Dictum ANNALS OF THE AMERICAN THORACIC SOCIETY Newman, T. A., Takasugi, J. E., Matute-Bello, G., Virgin, J. B., Backhus, L. M., Adamson, R. 2017; 14 (11): 1709–10

    View details for PubMedID 29090995

  • Disparities in kidney transplantation across the United States: Does residential segregation play a role? American journal of surgery Olufajo, O. A., Adler, J. T., Yeh, H., Zeliadt, S. B., Hernandez, R. A., Tullius, S. G., Backhus, L., Salim, A. 2017


    Although residential segregation has been implicated in various negative health outcomes, its association with kidney transplantation has not been examined.Age- and sex-standardized kidney transplantation rates were calculated from the Scientific Registry of Transplant Recipients, 2000-2013. Population characteristics including segregation indices were derived from the 2010 U.S. Census data and the U.S. Renal Data System. Separate multivariable Poisson regression models were constructed to identify factors independently associated with kidney transplantation among Blacks and Whites.Median age- and sex-standardized kidney transplantation rates were 114 per 100,000 for Blacks and 38 per 100,000 for Whites. 16.1% of the U.S. population lived in counties with high segregation. There was no difference in the kidney transplantation rates across the levels of segregation among Blacks and Whites.Factors other than residential segregation may play roles in kidney transplantation disparities. Continued efforts to identify these factors may be beneficial in reducing transplantation disparities across the U.S.Using the Scientific Registry of Transplant Recipients and U.S. census data, we aimed to determine whether residential segregation was associated with kidney transplantation rates. We found that there was no association between residential segregation and kidney transplantation rates.

    View details for DOI 10.1016/j.amjsurg.2016.10.034

    View details for PubMedID 28228248

  • Effect of EGFR Mutations on Survival in Patients following Surgical Resection of Lung Adenocarcinoma Laidlaw, G., Gao, R., Ayers, K., Backhus, L., Berry, M., Shrager, J. ELSEVIER SCIENCE INC. 2017: S751
  • The Importance of Patient Recall within Cancer Survivorship Care for Improved Post-Treatment Surveillance in Lung Cancer Survivors Backhus, L., Reinke, L., Au, D., Zeliadt, S., Edwards, T., Roy, U., Mantel, S., Jacobson, M., Ferris, A. ELSEVIER SCIENCE INC. 2017: S1111–S1112
  • Video-assisted thoracoscopic diaphragm plication using a running suture technique is durable and effective. journal of thoracic and cardiovascular surgery Demos, D. S., Berry, M. F., Backhus, L. M., Shrager, J. B. 2016


    Surgeons have hesitated to adopt minimally invasive diaphragm plication techniques because of technical limitations rendering the procedure cumbersome or leading to early failure or reduced efficacy. We sought to demonstrate efficacy and durability of our thoracoscopic plication technique using a single running suture.We retrospectively reviewed patients who underwent our technique for diaphragm plication since 2008. We used a single, buttressed, double-layered, to-and-fro running suture with additional plicating horizontal mattress sutures as needed.Eighteen patients underwent thoracoscopic plication from 2008 to 2015. There were no operative mortalities and 2 unrelated late deaths. Median hospital stay was 3 days (range, 1-12). Atrial fibrillation occurred in 1 patient (5.5%), pneumonia occurred in 2 patients (11%), reintubation occurred in 1 patient (5.5%), and ileus occurred in 1 patient (5.5%). Of 14 patients with complete follow-up, median follow-up was 29.4 months (range, 3.4-84.7). Significant increases between preoperative and postoperative pulmonary function tests (% predicted values) were found for mean forced expiratory volume in 1 second (73.5% ± 3.5% to 88.8% ± 4.5%, P = .002) and mean forced vital capacity (70.6% ± 3.5% to 82.3% ± 3.5%, P = .002). Preoperative mean Baseline Dyspnea Index was 8.1 ± 0.7. Mean Transitional Dyspnea Index 6 months postoperatively was 7.1 ± 0.6 (moderate to major improvement). Transitional Dyspnea Index at last contact (median 29.4 months postoperatively) was 7.2 ± 0.6 (P = .38). Compared with previously published results, this is at least equivalent.Thoracoscopic diaphragm plication with a running suture is safe and achieves excellent early and long-term improvements. This addresses technical challenges of tying multiple interrupted sutures by video-assisted thoracoscopic surgery without any apparent compromise to efficacy or durability.

    View details for DOI 10.1016/j.jtcvs.2016.11.062

    View details for PubMedID 28087113

  • Imaging in Lung Transplantation: Surgical Considerations of Donor and Recipient. Radiologic clinics of North America Backhus, L. M., Mulligan, M. S., Ha, R., Shriki, J. E., Mohammed, T. H. 2016; 54 (2): 339-353


    Modifications in recipient and donor criteria and innovations in donor management hold promise for increasing rates of lung transplantation, yet availability of donors remains a limiting resource. Imaging is critical in the work-up of donor and recipient including identification of conditions that may portend to poor posttransplant outcomes or necessitate modifications in surgical technique. This article describes the radiologic principles that guide selection of patients and surgical procedures in lung transplantation.

    View details for DOI 10.1016/j.rcl.2015.09.013

    View details for PubMedID 26896228

  • Assessment and Management of Symptoms for Outpatients Newly Diagnosed With Lung Cancer AMERICAN JOURNAL OF HOSPICE & PALLIATIVE MEDICINE Reinke, L. F., Feemster, L. C., Backhus, L. M., Gylys-Colwell, I., Au, D. H. 2016; 33 (2): 178-183


    Little is known about symptom assessment around the time of lung cancer diagnosis. The purpose of this pilot study was to assess symptoms within 2 months of diagnosis and the frequency with which clinicians addressed symptoms among a cohort of veterans (n = 20) newly diagnosed with lung cancer. We administered questionnaires and then reviewed medical records to identify symptom assessment and management provided by subspecialty clinics for 6 months following diagnosis.Half (50%) of the patients were diagnosed with early-stage non-small-cell lung cancer (NSCLC), stage I or II. At baseline, 45% patients rated their overall symptoms as severe. There were no significant differences in symptoms among patients with early- or late-stage NSCLC or small-cell lung cancer. Of the 212 clinic visits over 6 months, 70.2% occurred in oncology. Clinicians most frequently addressed pain although assessment differed by clinic.Veterans with newly diagnosed lung cancer report significant symptom burden. Despite ample opportunities to address patients' symptoms, variations in assessment exist among subspecialty services. Coordinated approaches to symptom assessment are likely needed among patients newly diagnosed with lung cancer.

    View details for DOI 10.1177/1049909114557635

    View details for Web of Science ID 000370200800011

    View details for PubMedID 25376224

  • Imaging in Lung Transplantation Surgical Considerations of Donor and Recipient RADIOLOGIC CLINICS OF NORTH AMERICA Backhus, L. M., Mulligan, M. S., Ha, R., Shriki, J. E., Mohammed, T. H. 2016; 54 (2): 339-?


    Modifications in recipient and donor criteria and innovations in donor management hold promise for increasing rates of lung transplantation, yet availability of donors remains a limiting resource. Imaging is critical in the work-up of donor and recipient including identification of conditions that may portend to poor posttransplant outcomes or necessitate modifications in surgical technique. This article describes the radiologic principles that guide selection of patients and surgical procedures in lung transplantation.

    View details for DOI 10.1016/j.rcl.2015.09.013

    View details for Web of Science ID 000372770600011

  • Imaging surveillance and survival for surgically resected non-small-cell lung cancer JOURNAL OF SURGICAL RESEARCH Backhus, L. M., Farjah, F., Liang, C. J., He, H., Varghese, T. K., Au, D. H., Flum, D. R., Zeliadt, S. B. 2016; 200 (1): 171-176


    The importance of imaging surveillance after treatment for lung cancer is not well characterized. We examined the association between initial guideline recommended imaging surveillance and survival among early-stage resected non-small-cell lung cancer (NSCLC) patients.A retrospective study was conducted using Surveillance, Epidemiology, and End Results-Medicare data (1995-2010). Surgically resected patients, with stage I and II NSCLC, were categorized by imaging received during the initial surveillance period (4-8 mo) after surgery. Primary outcome was overall survival. Secondary treatment interventions were examined as intermediary outcomes.Most (88%) patients had at least one outpatient clinic visit, and 24% received an initial computerized tomography (CT) during the first surveillance period. Five-year survival by initial surveillance imaging was 61% for CT, 58% for chest radiography, and 60% for no imaging. After adjustment, initial CT was not associated with improved overall survival (hazard ratio [HR], 1.04; 95% confidence interval [CI] 0.96-1.14). On subgroup analysis, restricted to patients with demonstrated initial postoperative follow-up, CT was associated with a lower overall risk of death for stage I patients (HR, 0.85; 95% CI, 0.74-0.98), but not for stage II (HR, 1.01; 95% CI, 0.71-1.42). There was no significant difference in rates of secondary interventions predicted by type of initial imaging surveillance.Initial surveillance CT is not associated with improved overall or lung cancer-specific survival among early-stage NSCLC patients undergoing surgical resection. Stage I patients with early follow-up may represent a subpopulation that benefits from initial surveillance although this may be influenced by healthy patient selection bias.

    View details for DOI 10.1016/j.jss.2015.06.048

    View details for Web of Science ID 000366840700025

    View details for PubMedID 26231974

    View details for PubMedCentralID PMC5575864

  • Gaps in Guideline-Concordant Use of Diagnostic Tests Among Lung Cancer Patients ANNALS OF THORACIC SURGERY Flanagan, M. R., Varghese, T. K., Backhus, L. M., Wood, D. E., Mulligan, M. S., Cheng, A. M., Flum, D. R., Farjah, F. 2015; 100 (6): 2006-2012


    Practice guidelines recommend routine use of pulmonary function tests (PFTs), computed tomography (CT), and positron emission tomography (PET) for the workup of resectable lung cancer patients. Little is known about the frequency of guideline concordance in routine practice.A cohort study (2007 to 2013) of 15,951 lung cancer patients undergoing lobectomy or pneumonectomy was conducted with MarketScan, a claims database of individuals with employer-provided health insurance. Guideline concordance was defined by claims for PFT within 180 days of resection and for CT and PET within 90 days of resection. Generalized linear models were used to evaluate temporal trends, patient characteristics, and costs associated with guideline-concordant care.Overall, 61% of patients received guideline-concordant care, increasing from 57% in 2007 to 66% in 2013 (p < 0.001). Compared with patients who received guideline-discordant care, patients with guideline-concordant care more frequently underwent repeat testing (PFT: 21% versus 12%, p < 0.001; CT: 46% versus 22%, p < 0.001; PET: 2.3% versus 1.1%, p < 0.001). Health plan-adjusted mean total test-related costs were higher among guideline-concordant patients who underwent repeat testing than patients who did not ($4,304 versus $3,454, p < 0.001).Forty percent of lung cancer patients treated with surgical procedures did not receive recommended noninvasive cancer staging and physiologic assessment before resection. Guideline concordance was associated with repeat testing, and repeat testing was associated with higher costs. These findings support the need for quality improvement interventions that can increase guideline concordance while curbing potential excess use of diagnostic tests.

    View details for DOI 10.1016/j.athoracsur.2015.08.010

    View details for Web of Science ID 000365824700015

    View details for PubMedID 26507425

  • Failure to rescue and pulmonary resection for lung cancer JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Farjah, F., Backhus, L., Cheng, A., Englum, B., Kim, S., Saha-Chaudhuri, P., Wood, D. E., Mulligan, M. S., Varghese, T. K. 2015; 149 (5): 1365-1371


    Failure to rescue is defined as death after an acute inpatient event and has been observed among hospitals that perform general, vascular, and cardiac surgery. This study aims to evaluate variation in complication and failure to rescue rates among hospitals that perform pulmonary resection for lung cancer.By using the Society of Thoracic Surgeons General Thoracic Surgery Database, a retrospective, multicenter cohort study was performed of adult patients with lung cancer who underwent pulmonary resection. Hospitals participating in the Society of Thoracic Surgeons General Thoracic Surgery Database were ranked by their risk-adjusted, standardized mortality ratio (using random effects logistic regression) and grouped into quintiles. Complication and failure to rescue rates were evaluated across 5 groups (very low, low, medium, high, and very high mortality hospitals).Between 2009 and 2012, there were 30,000 patients cared for at 208 institutions participating in the Society of Thoracic Surgeons General Thoracic Surgery Database (median age, 68 years; 53% were women, 87% were white, 71% underwent lobectomy, 65% had stage I). Mortality rates varied over 4-fold across hospitals (3.2% vs 0.7%). Complication rates occurred more frequently at hospitals with higher mortality (42% vs 34%, P < .001). However, the magnitude of variation (22%) in complication rates dwarfed the 4-fold magnitude of variation in failure to rescue rates (6.8% vs 1.7%, P < .001) across hospitals.Variation in hospital mortality seems to be more strongly related to rescuing patients from complications than to the occurrence of complications. This observation is significant because it redirects quality improvement and health policy initiatives to more closely examine and support system-level changes in care delivery that facilitate early detection and treatment of complications.

    View details for DOI 10.1016/j.jtcvs.2015.01.063

    View details for Web of Science ID 000354567100034

    View details for PubMedID 25791948

  • External validation of a prediction model for pathologic N2 among patients with a negative mediastinum by positron emission tomography JOURNAL OF THORACIC DISEASE Farjah, F., Backhus, L. M., Varghese, T. K., Manning, J. P., Cheng, A. M., Mulligan, M. S., Wood, D. E. 2015; 7 (4): 576-?


    A prediction model for pathologic N2 (pN2) among lung cancer patients with a negative mediastinum by positron emission tomography (PET) was recently internally validated. Our study sought to determine the external validity of that model.A cohort study [2005-2013] was performed of lung cancer patients with a negative mediastinum by PET. Previously published model coefficients were used to estimate the probability of pN2 based on tumor location and size, nodal enlargement by computed tomography (CT), maximum standardized uptake value (SUVmax) of the primary tumor, N1 disease by PET, and pretreatment histology.Among 239 patients, 18 had pN2 [7.5%, 95% confidence interval (CI): 4.5-12%]. Model discrimination was excellent (c-statistic 0.80, 95% CI: 0.75-0.85) and the model fit the data well (P=0.191). The accuracy of the model was as follows: sensitivity 100%, 95% CI: 81-100%; specificity 49%, 95% CI: 42-56%; positive predictive value (PPV) 14%, 95% CI: 8-21%, and negative predictive value (NPV) 100%, 95% CI: 97-100%. CI inspection revealed a significantly higher c-statistic in this external validation cohort compared to the internal validation cohort. The model's apparently poor specificity for patient selection is in fact significantly better than usual care (i.e., aggressive but allowable guideline concordant staging) and minimum guideline mandated selection criteria for invasive staging.A prediction model for pN2 is externally valid. The high NPV of this model may allow pulmonologists and thoracic surgeons to more comfortably minimize the number of invasive procedures performed among patients with a negative mediastinum by PET.

    View details for DOI 10.3978/j.issn.2072-1439.2015.02.09

    View details for Web of Science ID 000355276400019

    View details for PubMedID 25973222

  • Impact of primary caregivers on long-term outcomes after lung transplantation JOURNAL OF HEART AND LUNG TRANSPLANTATION Mollberg, N. M., Farjah, F., Howell, E., Ortiz, J., Backhus, L., Mulligan, M. S. 2015; 34 (1): 59-64


    Current guidelines consider the absence of a dependable social support system as an absolute contraindication to lung transplantation, yet there are varying degrees of social support among those selected for transplantation. We sought to characterize the relationship between a patient's self-reported primary caregiver and long-term outcomes after lung transplantation.We conducted a retrospective cohort study of all lung transplant recipients ≥18 years of age who had undergone an initial transplant (2000 to 2010). Cox regression was used to explore the relationship between type of caregiver and the long-term risk of death and chronic graft failure while adjusting for potential confounders.There were 452 patients undergoing lung transplantation over the study period who met the inclusion criteria. Five types of primary caregivers were identified, with spouse 60% (270 of 452) being the most common. Compared with spousal caregiver, overall survival was significantly worse for patients who identified an adult child (hazard ratio [HR] 2.04, 95% confidence interval [CI] 1.15 to 3.60) or sibling (HR 3.79, 95% CI 2.48 to 5.78) as their primary caregiver. In addition, risk for long-term graft failure was increased significantly (HR 3.34, 95% CI 1.58 to 7.06) among patients with sibling caregivers.Type of primary caregiver selected before transplantation was associated with long-term outcomes. These results may be a reflection of the long-term support requirements and/or competing responsibilities of other caregiver types. Interventions to increase support for at-risk patients may include identifying additional caregivers during the pre-transplant assessment. As lung allocation is designed to maximize graft potential, risk stratification for listing patients should include type of caregiver and be considered as critically as major organ dysfunction.

    View details for DOI 10.1016/j.healun.2014.09.022

    View details for Web of Science ID 000348273400007

    View details for PubMedID 25447578

  • Predictors of Imaging Surveillance for Surgically Treated Early-Stage Lung Cancer ANNALS OF THORACIC SURGERY Backhus, L. M., Farjah, F., Zeliadt, S. B., Varghese, T. K., Cheng, A., Kessler, L., Au, D. H., Flum, D. R. 2014; 98 (6): 1944-1952


    Current guidelines recommend routine imaging surveillance for patients with non-small cell lung cancer (NSCLC) after treatment. Little is known about surveillance patterns for patients with surgically resected early-stage lung cancer in the community at large. We sought to characterize surveillance patterns in a national cohort.We conducted a retrospective study using the Surveillance, Epidemiology, and End-Results (SEER)-Medicare database (1995-2010). Patients with stage I/II NSCLC treated with surgical resection were included. Our primary outcome was receipt of imaging between 4 and 8 months after the surgical procedure. Covariates included demographics and comorbidities.Chest radiography (CXR) was the most frequent initial modality (60%), followed by chest computed tomography (CT) (25%). Positron emission tomography (PET) was least frequent as an initial imaging modality (3%). A total of 13% of patients received no imaging within the initial surveillance period. Adherence to National Comprehensive Cancer Network (NCCN) guidelines for imaging by overall prevalence was 47% for receipt of CT; however, rates of CT increased over time from 28% to 61% (p < 0.01). Reduced rates of CT were associated with stage I disease and surgical resection as the sole treatment modality.Imaging after definitive surgical treatment for NSCLC predominantly used CXR rather than CT. Most of this imaging is likely for surveillance, and in that context CXR has inferior detection rates for recurrence and new cancers. Adherence to guideline-recommended CT surveillance after surgical treatment is poor, but the reasons are multifactorial. Efforts to improve adherence to imaging surveillance must be coupled with greater evidence demonstrating improved long-term outcomes.

    View details for DOI 10.1016/j.athoracsur.2014.06.067

    View details for Web of Science ID 000345743200017

    View details for PubMedID 25282167

  • Appropriateness of Imaging for Lung Cancer Staging in a National Cohort JOURNAL OF CLINICAL ONCOLOGY Backhus, L. M., Farjah, F., Varghese, T. K., Cheng, A. M., Zhou, X., Wood, D. E., Kessler, L., Zeliadt, S. B. 2014; 32 (30): 3428-U266


    Optimizing evidence-based care to improve quality is a critical priority in the United States. We sought to examine adherence to imaging guideline recommendations for staging in patients with locally advanced lung cancer in a national cohort.We identified 3,808 patients with stage IIB, IIIA, or IIIB lung cancer by using the national Department of Veterans Affairs (VA) Central Cancer Registry (2004-2007) and linked these patients to VA and Medicare databases to examine receipt of guideline-recommended imaging based on National Comprehensive Cancer Network and American College of Radiology Appropriateness Criteria. Our primary outcomes were receipt of guideline-recommended brain imaging and positron emission tomography (PET) imaging. We also examined rates of overuse defined as combined use of bone scintigraphy (BS) and PET, which current guidelines recommend against. All imaging was assessed during the period 180 days before and 180 days after diagnosis.Nearly 75% of patients received recommended brain imaging, and 60% received recommended PET imaging. Overuse of BS and PET occurred in 25% of patients. More advanced clinical stage and later year of diagnosis were the only clinical or demographic factors associated with higher rates of guideline-recommended imaging after adjusting for covariates. We observed considerable regional variation in recommended PET imaging and overuse of combined BS and PET.Receipt of guideline-recommended imaging is not universal. PET appears to be underused overall, whereas BS demonstrates continued overuse. Wide regional variation suggests that these findings could be the result of local practice patterns, which may be amenable to provider education efforts such as Choosing Wisely.

    View details for DOI 10.1200/JCO.2014.55.6589

    View details for Web of Science ID 000343880800014

    View details for PubMedID 25245440

  • Ninety-Day Costs of Video-Assisted Thoracic Surgery Versus Open Lobectomy for Lung Cancer ANNALS OF THORACIC SURGERY Farjah, F., Backhus, L. M., Varghese, T. K., Mulligan, M. S., Cheng, A. M., Alfonso-Cristancho, R., Flum, D. R., Wood, D. E. 2014; 98 (1): 191-196


    Complications after pulmonary resection lead to higher costs of care. Video-assisted thoracoscopic surgery (VATS) for lobectomy is associated with fewer complications, but lower inpatient costs for VATS have not been uniformly demonstrated. Because some complications occur after discharge, we compared 90-day costs of VATS lobectomy versus open lobectomy and explored whether differential health care use after discharge might account for any observed differences in costs.A cohort study (2007-2011) of patients with lung cancer who had undergone resection was conducted using MarketScan-a nationally representative sample of persons with employer-provided health insurance. Total costs reflect payments made for inpatient, outpatient, and pharmacy claims up to 90 days after discharge.Among 9,962 patients, 31% underwent VATS lobectomy. Compared with thoracotomy, VATS was associated with lower rates of prolonged length of stay (PLOS) (3.0% versus 7.2%; p<0.001), 90-day emergency department (ED) use (22% versus 24%; p=0.005), and 90-day readmission (10% versus 12%; p=0.026). Risk-adjusted 90-day costs were $3,476 lower for VATS lobectomy (p=0.001). Differential rates of PLOS appeared to explain this cost difference. After adjustment for PLOS, costs were $1,276 lower for VATS, but this difference was not significant (p=0.125). In the fully adjusted model, PLOS was associated with the highest cost differential (+$50,820; p<0.001).VATS lobectomy is associated with lower 90-day costs--a relationship that appears to be mediated by lower rates of PLOS. Although VATS may lead to lower rates of PLOS among patients undergoing lobectomy, observational studies cannot verify this assertion. Strategies that reduce PLOS will likely result in cost-savings that can increase the value of thoracic surgical care.

    View details for DOI 10.1016/j.athoracsur.2014.03.024

    View details for Web of Science ID 000338432600051

    View details for PubMedID 24820393

  • Lung Resection Outcomes and Costs in Washington State: A Case for Regional Quality Improvement ANNALS OF THORACIC SURGERY Farjah, F., Varghese, T. K., Costas, K., Krishnadasan, B., Farivar, A. S., Hubka, M., Louie, B. E., Backhus, L. M., Chong, N., Gorden, J., Cheng, A. M., He, H., Flum, D. R., Low, D., Aye, R., Vallieres, E., Mulligan, M. S., Wood, D. E. 2014; 98 (1): 175-181


    A regional quality improvement effort does not exist for thoracic surgery in the United States. To initiate the development of one, we sought to describe temporal trends and hospital-level variability in associated outcomes and costs of pulmonary resection in Washington (WA) State.A cohort study (2000-2011) was conducted of operated-on lung cancer patients. The WA State discharge database was used to describe outcomes and costs for operations performed at all nonfederal hospitals within the state.Over 12 years, 8,457 lung cancer patients underwent pulmonary resection across 49 hospitals. Inpatient deaths decreased over time (adjusted p-trend=0.023) but prolonged length of stay did not (adjusted p-trend=0.880). Inflation-adjusted hospital costs increased over time (adjusted p-trend<0.001). Among 24 hospitals performing at least 1 resection per year, 5 hospitals were statistical outliers in rates of death (4 lower and 1 higher than the state average), and 13 were outliers with respect to prolonged length of stay (7 higher and 6 lower than the state average) and costs (5 higher and 8 lower than the state average). When evaluated for rates of death and costs, there were hospitals with fewer deaths/lower costs, fewer deaths/higher costs, more deaths/lower costs, and more deaths/higher costs.Variability in outcomes and costs over time and across hospitals suggest opportunities to improve the quality and value of thoracic surgery in WA State. Examples from cardiac surgery suggest that a regional quality improvement collaborative is an effective way to meaningfully and rapidly act upon these opportunities.

    View details for DOI 10.1016/j.athoracsur.2014.03.014

    View details for Web of Science ID 000338432600047

    View details for PubMedID 24793691

  • Outcomes in lung transplantation after previous lung volume reduction surgery in a contemporary cohort JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Backhus, L., Sargent, J., Cheng, A., Zeliadt, S., Wood, D., Mulligan, M. 2014; 147 (5): 1678-?


    Lung volume reduction surgery (LVRS) provides palliation and improved quality of life in select patients with end-stage chronic obstructive pulmonary disease (COPD). The effect of previous LVRS on lung transplant outcomes has been inadequately studied. We report our experience in the largest single institution series of these combined procedures.The records of 472 patients with COPD undergoing lung transplantation or LVRS between 1995 and 2010 were reviewed. Outcomes of patients undergoing transplant after LVRS were compared with outcomes of patients undergoing transplant or LVRS alone. Survival was compared using log-rank tests and the Kaplan-Meier method.Demographics, comorbidities, and spirometry were similar at the time of transplantation. Patients who had undergone lung transplant after LVRS had longer transplant operative times (mean 4.4 vs 5.6 hours; P = .020) and greater hospital length of stay (mean 17.6 vs 29.1 days; P = .005). Thirty-day mortality and major morbidity were similar. Posttransplant survival was reduced for transplant after LVRS (median, 49 months; 95% confidence interval [CI], 16, 85 months) compared with transplant alone (median, 96 months; 95% CI, 82, 106 months; P = .008). The composite benefit of combined procedures, defined as bridge from LVRS to transplant of 55 months and posttransplant survival of 49 months (total 104 months), was comparable with survival of patients undergoing either procedure alone.Lung transplant after LVRS leads to minimal additional perioperative risk. The reduced posttransplant survival in patients undergoing combined procedures is in contradistinction to reports from other smaller series. When determining the best surgical treatment for patients with more severe disease, the benefit of LVRS before transplant should be weighed against the consequence of reduced posttransplant survival.

    View details for DOI 10.1016/j.jtcvs.2014.01.045

    View details for Web of Science ID 000335443300040

    View details for PubMedID 24589202

  • Preoperative PET and the Reduction of Unnecessary Surgery Among Newly Diagnosed Lung Cancer Patients in a Community Setting JOURNAL OF NUCLEAR MEDICINE Zeliadt, S. B., Loggers, E. T., Slatore, C. G., Au, D. H., Hebert, P. L., Klein, G. J., Kessler, L. G., Backhus, L. M. 2014; 55 (3): 379-385


    The goals of this study were to examine the real-world effectiveness of PET in avoiding unnecessary surgery for newly diagnosed patients with non-small cell lung cancer.A cohort of 2,977 veterans with non-small cell lung cancer between 1997 and 2009 were assessed for use of PET during staging and treatment planning. The subgroup of 976 patients who underwent resection was assessed for several outcomes, including pathologic evidence of mediastinal lymph node involvement, distant metastasis, and 12-mo mortality. We anticipated that PET may have been performed selectively on the basis of unobserved characteristics (e.g., providers ordered PET when they suspected disseminated disease). Therefore, we conducted an instrumental variable analysis, in addition to conventional multivariate logistic regression, to reduce the influence of this potential bias. This type of analysis attempts to identify an additional variable that is related to receipt of treatment but not causally associated with the outcome of interest, similar to randomized assignment. The instrument here was calendar time. This analysis can be informative when patients do not receive the treatment that the instrument suggests they "should" have received.Overall, 30.3% of patients who went to surgery were found to have evidence of metastasis uncovered during the procedure or within 12 mo, indicating that nearly one third of patients underwent surgery unnecessarily. The use of preoperative PET increased substantially over the study period, from 9% to 91%. In conventional multivariate analyses, PET use was not associated with a decrease in unnecessary surgery (odds ratio, 0.87; 95% confidence interval, 0.66-1.16; P = 0.351). However, a reduction in unnecessary surgery (odds ratio, 0.53; 95% confidence interval, 0.34-0.82; P = 0.004) was identified in the instrumental variable analyses, which attempted to account for potentially unobserved confounding.PET has now become routine in preoperative staging and treatment planning in the community and appears to be beneficial in avoiding unnecessary surgery. Evaluating the effectiveness of PET appears to be influenced by potentially unmeasured adverse selection of patients, especially when PET first began to be disseminated in the community.

    View details for DOI 10.2967/jnumed.113.124230

    View details for Web of Science ID 000332352100017

    View details for PubMedID 24449594

  • Management of Centrally Located Non-Small-Cell Carcinoma ONCOLOGY-NEW YORK Backhus, L. M., Wood, D. E. 2014; 28 (3): 215-221


    Treatment optimization for centrally located lung cancers requires special considerations for determining resectability and patient selection. Evaluation involves an experienced multidisciplinary team performing careful clinical and invasive-disease staging to identify the best management approach and ascertain the need for multimodality therapy. Preoperative imaging alone is often inaccurate in its ability to determine whether the patient is at an advanced clinical T stage that might preclude curative surgical resection. Therefore, other modalities are often necessary to complete the clinical staging. In the absence of irrefutable evidence of unresectability, however, surgical exploration should be undertaken with curative intent. Long-term outcomes can be favorable in select patients, and most of the procedures, including complex reconstructions, can be performed with acceptable morbidity and mortality.

    View details for Web of Science ID 000333550900009

    View details for PubMedID 24855729

  • Lymphovascular Invasion as a Prognostic Indicator in Stage I Non-Small Cell Lung Cancer: A Systematic Review and Meta-Analysis ANNALS OF THORACIC SURGERY Mollberg, N. M., Bennette, C., Howell, E., Backhus, L., Devine, B., Ferguson, M. K. 2014; 97 (3): 965-972


    Lymphovascular invasion (LVI) is considered a high-risk pathologic feature in resected non-small cell carcinoma (NSCLC). The ability to stratify stage I patients into risk groups may permit refinement of adjuvant treatment recommendations. We performed a systematic review and meta-analysis to evaluate whether the presence of LVI is associated with disease outcome in stage I NSCLC patients.A systematic search of the literature was performed (1990 to December 2012 in MEDLINE/EMBASE). Two reviewers independently assessed the quality of the articles and extracted data. Pooled hazard ratios (HRs) and 95% confidence intervals (CI) were estimated with a random effects model. Two end points were independently analyzed: recurrence-free survival (RFS) and overall survival (OS). We analyzed unadjusted and adjusted effect estimates, resulting in four separate meta-analyses.We identified 20 published studies that reported the comparative survival of stage I patients with and without LVI. The unadjusted pooled effect of LVI was significantly associated with worse RFS (HR, 3.63; 95% CI, 1.62 to 8.14) and OS (HR, 2.38; 95% CI, 1.72 to 3.30). Adjusting for potential confounders yielded similar results, with RFS (HR, 2.52; 95% CI, 1.73 to 3.65) and OS (HR, 1.81; 95% CI, 1.53 to 2.14) both significantly worse for patients exhibiting LVI.The present study indicates that LVI is a strong prognostic indicator for poor outcome for patients with surgically managed stage I lung cancer. Future prospective lung cancer trials with well-defined methods for evaluating LVI are necessary to validate these results.

    View details for DOI 10.1016/j.athoracsur.2013.11.002

    View details for Web of Science ID 000332408500044

    View details for PubMedID 24424014

  • The Effect of Provider Density on Lung Cancer Survival Among Blacks and Whites in the United States JOURNAL OF THORACIC ONCOLOGY Backhus, L. M., Hayanga, A. J., Au, D., Zeliadt, S. B. 2013; 8 (5): 549-553


    Lung cancer mortality rates may vary with access to specialty providers and local resources. We sought to examine the effect of access to care, using density of lung cancer care providers, on lung cancer mortality among blacks and whites in the United States.We examined U.S. county-level data for age-adjusted lung cancer mortality rates from 2003 to 2007. Our primary independent variable was per capita number of thoracic oncologic providers, adjusting for county-level smoking rates, socioeconomic status, and other geographic factors. Data were obtained from 2009 Area Resource File, National Center for Health Statistics, and the County Health Rankings Project.Providers of lung cancer care were unevenly distributed among the U.S. counties. For example, 41.4% of the U.S. population reside in counties with less than four thoracic surgeons per 100,000 people, 23.4% in counties with 4 to 15 surgeons per 100,000 people, and 35.3% in counties with more than 15 surgeons per 100,000 people. Geographically, 4.3% of whites compared with 11.2% of blacks lived in high lung cancer mortality zones. Lung cancer mortality did not vary by density of thoracic surgeons or oncology services; however, higher primary care provider density was associated with lung cancer mortality reduction of 4.1 per 100,000 for whites.Variation in provider density for thoracic oncology in the United States was not associated with a difference in lung cancer mortality. Lower mortality associated with higher primary care provider density suggests that equitable access to primary care may lead to reduced cancer disparities.

    View details for DOI 10.1097/JTO.0b013e318287c24c

    View details for Web of Science ID 000317582000017

    View details for PubMedID 23446202

  • Radiographic evaluation of the patient with lung cancer: surgical implications of imaging. Current problems in diagnostic radiology Backhus, L., Puneet, B., Bastawrous, S., Mariam, M., Michael, M., Varghese, T. 2013; 42 (3): 84-98


    Lung cancer is the leading cause of cancer deaths in the United States. Despite many advances in treatment, surgery remains the preferred treatment modality for patients presenting with early stage disease. Imaging is critical in the preoperative evaluation of these patients being considered for a curative resection. Advanced imaging techniques provide valuable information, including primary diagnostics, staging, and intraoperative localization for suspected lung cancer. Knowledge of surgical implications of imaging findings can aid both radiologists and surgeons in delivering safe and effective care.

    View details for DOI 10.1067/j.cpradiol.2012.08.001

    View details for PubMedID 23683850

  • Residential Segregation and Lung Cancer Mortality in the United States JAMA SURGERY Hayanga, A. J., Zeliadt, S. B., Backhus, L. M. 2013; 148 (1): 37-42


    To examine the relationship between race and lung cancer mortality and the effect of residential segregation in the United States.A retrospective, population-based study using data obtained from the 2009 Area Resource File and Surveillance, Epidemiology and End Results program.Each county in the United States.Black and white populations per US county.A generalized linear model with a Poisson distribution and log link was used to examine the association between residential segregation and lung cancer mortality from 2003 to 2007 for black and white populations. Our primary independent variable was the racial index of dissimilarity. The index is a demographic measure that assesses the evenness with which whites and blacks are distributed across census tracts within each county. The score ranges from 0 to 100 in increasing degrees of residential segregation. RESULTS The overall lung cancer mortality rate was higher for blacks than whites (58.9% vs 52.4% per 100 000 population). Each additional level of segregation was associated with a 0.5% increase in lung cancer mortality for blacks (P < .001) and an associated decrease in mortality for whites (P = .002). Adjusted lung cancer mortality rates among blacks were 52.4% and 62.9% per 100 000 population in counties with the least (<40% segregation) and the highest levels of segregation (≥60% segregation), respectively. In contrast, the adjusted lung cancer mortality rates for whites decreased with increasing levels of segregation.Lung cancer mortality is higher in blacks and highest in blacks living in the most segregated counties, regardless of socioeconomic status.

    View details for Web of Science ID 000316675300009

    View details for PubMedID 23324839

  • Comparison of Demographic Characteristics, Surgical Resection Patterns, and Survival Outcomes for Veterans and Nonveterans with Non-small Cell Lung Cancer in the Pacific Northwest JOURNAL OF THORACIC ONCOLOGY Zeliadt, S. B., Sekaran, N. K., Hu, E. Y., Slatore, C. C., Au, D. H., Backhus, L., Wu, D. Y., Crawford, J., Lyman, G. H., Dale, D. C. 2011; 6 (10): 1726-1732


    Lung cancer is a leading cause of death in the United States and among veterans. This study compares patterns of diagnosis, treatment, and survival for veterans diagnosed with non-small cell lung cancer (NSCLC) using a recently established cancer registry for the Veterans Affairs Pacific Northwest Network with the Puget Sound Surveillance, Epidemiology, and End Results cancer registry.A cohort of 1715 veterans with NSCLC were diagnosed between 2000 and 2006, and 7864 men were diagnosed in Washington State during the same period. Demographics, tumor characteristics, initial surgical patterns, and survival across the two registries were evaluated.Veterans were more likely to be diagnosed with stage I or II disease (32.8%) compared with the surrounding community (21.5%, p = 0.001). Surgical resection rates were similar for veterans (70.2%) and nonveterans (71.2%) older than 65 years with early-stage disease (p = 0.298). However, veterans younger than 65 years with early-stage disease were less likely to undergo surgical resection (83.3% versus 91.5%, p = 0.003). Because there were fewer late-stage patients among veterans, overall survival was better, although within each stage group veterans experienced worse survival compared with community patients. The largest differences were among early-stage patients with 44.6% 5-year survival for veterans compared with 57.4% for nonveterans (p = 0.004).The use of surgical resection among younger veterans with NSCLC may be lower compared with the surrounding community and may be contributing to poorer survival. Cancer quality of care studies have primarily focused on patients older than 65 years using Medicare claims; however, efforts to examine care for younger patients within and outside the Department of Veterans Affairs are needed.

    View details for DOI 10.1097/JTO.0b013e31822ada77

    View details for PubMedID 21857253

  • Intrathoracic splenosis after remote trauma NEW ENGLAND JOURNAL OF MEDICINE Backhus, L. M., Bremner, R. M. 2006; 355 (17): 1811

    View details for DOI 10.1056/NEJMicm050481

    View details for Web of Science ID 000241512500011

    View details for PubMedID 17065643

  • Perioperative cyclooxygenase 2 inhibition to reduce tumor cell adhesion and metastatic potential of circulating tumor cells in non-small cell lung cancer JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Backhus, L. M., Sievers, E., Lin, G. Y., Castanos, R., Bart, R. D., Starnes, V. A., Bremner, R. M. 2006; 132 (2): 297-303


    Surgical manipulation of lung cancers may increase circulating tumor cells and contribute to metastatic recurrence after resection. Cyclooxygenase 2 is overexpressed in most non-small cell lung cancer and upregulates the cell adhesion receptor CD44. Our goal was to examine the effects of perioperative cyclooxygenase blockade on the metastatic potential of circulating tumor cells, CD44 expression, and adhesion of cancer cells to extracellular matrix.Human non-small cell lung cancer cells (A549) were injected through the lateral tail vein in an in vivo murine model of tumor metastasis with three random treatment groups: no treatment, perioperative selective cyclooxygenase 2 inhibition (celecoxib) only, and continuous celecoxib. Lung metastases were assessed at 6 weeks by a blinded observer. For in vitro experiments, cells were treated with celecoxib, and expression of CD44 was determined by Western blotting. Extracellular matrix adhesion was assessed by Matrigel (BD Labware, Bedford, Mass) assay.In vivo lung metastases were significantly decreased relative to control by both perioperative and continuous celecoxib (P = .0135). There was no significant difference in number of metastases between continuous and perioperative treatment groups. In vitro adhesion to the extracellular matrix was significantly inhibited by celecoxib in a dose-dependent manner (P < .01). A549 cells expressed high levels of CD44, upregulated by interleukin 1beta and downregulated by celecoxib.Celecoxib significantly reduced establishment of metastases by circulating tumor cells in a murine model. It also inhibited CD44 expression and extracellular matrix adhesion in vitro. Perioperative modulation of cyclooxygenase 2 may be a novel strategy to minimize metastases from circulating tumor cells during this high-risk period.

    View details for DOI 10.1016/j.jtcvs.2005.10.060

    View details for Web of Science ID 000239549700018

    View details for PubMedID 16872953

  • Pleural space problems after living lobar transplantation JOURNAL OF HEART AND LUNG TRANSPLANTATION Backhus, L. M., Sievers, E. M., Schenkel, F. A., Barr, M. L., Cohen, R. G., Smith, M. A., Starnes, V. A., Bremner, R. M. 2005; 24 (12): 2086-2090


    We reviewed our experience with adult living lobar lung transplant (LL) recipients to assess whether size and shape mismatch of the donor organ to the recipient pre-disposes to the development of pleural space problems (PSP).Eighty-seven LL were performed on 84 adult recipients from 1993 through 2003. Seventy-six patients had cystic fibrosis. Patient records were examined for PSP, defined as air leak or bronchopleural fistula for more than 7 days; pneumothorax, loculated pleural effusions, or empyema in 68 patients for which complete data were available.There were 24 PSP identified for an overall incidence of 35%. The most common PSP was air leak/bronchopleural fistula, accounting for 38% of PSP. The second most common PSP was loculated pleural effusion (21% of PSP). Empyema was uncommon (2 patients, 3% of total patients) in our series of patients despite the large population of cystic fibrosis patients. In 4 of these patients, computed tomography-guided drainage was used for loculated effusions after chest tube removal. Three LL patients underwent surgery for persistent air leak and required muscle flap repair. One of these required subsequent omental transfer. Two LL patients required decortication for empyema. Many patients with PSP could be managed without further surgical intervention (14/24 patients). Donor-recipient height mismatch was not significantly different between PSP and non-PSP patients (p = 0.53).The incidence of PSP in LL recipients is similar to that reported in the literature on cadaveric transplant recipients. The relatively small lobe in the potentially contaminated chest cavity of cystic fibrosis recipients does not significantly pre-dispose to development of empyema despite immunosuppression. Many PSP can be managed non-operatively, although early aggressive intervention for large air leaks and judicious chest tube management are essential for a good outcome.

    View details for DOI 10.1016/j.healun.2005.06.013

    View details for Web of Science ID 000234308700013

    View details for PubMedID 16364854

  • Dimethyl celecoxib as a novel non-cyclooxygenase 2 therapy in the treatment of non-small cell lung cancer JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Backhus, L. M., Petasis, N. A., Uddin, J., Schonthal, A. H., Bart, R. D., Lin, Y., Starnes, V. A., Bremner, R. M. 2005; 130 (5): 1406-1412


    The cyclooxygenase 2 enzyme has become a therapeutic target in cancer treatment. Cyclooxygenase 2 blockade with selective inhibitors increases apoptosis and decreases the metastatic potential of lung cancer cells. Some of the antitumor effects of these inhibitors may occur through both cyclooxygenase 2-dependent and independent pathways. Our goal was to investigate these pathways using celecoxib (selective cyclooxygenase 2 inhibitor) and 2,5-dimethyl celecoxib, a structural analog modified to eliminate cyclooxygenase 2 inhibitory activity, while potentially maintaining antineoplastic properties.2,5-dimethyl celecoxib was synthesized in the Department of Chemistry at the University of Southern California. With the use of non-small cell lung cancer cells (A549), prostaglandin E2 production was quantified by enzyme-linked immunosorbent assay to assess cyclooxygenase 2 activity. Cell proliferation was assessed by 3-(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium, inner salt assay. Cell migration was performed using transwell inserts that were matrigel coated for invasion experiments. Gelatin zymography was used to assess matrix-metalloproteinase activity.2,5-dimethyl celecoxib did not inhibit interleukin-1beta-stimulated prostaglandin E2 production, whereas celecoxib did even at low doses. Both celecoxib and 2,5-dimethyl celecoxib decreased tumor cell viability and proliferation with IC50 for celecoxib and 2,5-dimethyl celecoxib of 73 and 53 micromol/L, respectively. Both drugs were also potent inducers of apoptosis, and both inhibited tumor cell migration and invasion. This was associated with down-regulation of matrix metalloproteinase activity.2,5-dimethyl celecoxib is a structural analog of celecoxib that lacks cyclooxygenase 2 inhibitory activity but exhibits significant antineoplastic properties comparable to celecoxib. This suggests that the antineoplastic activities of celecoxib are, at least in part, cyclooxygenase independent and that therapeutic strategies can be developed without the side effects of global cyclooxygenase 2 blockade.

    View details for DOI 10.1016/j.jtcvs.2005.07.018

    View details for Web of Science ID 000233120100024

    View details for PubMedID 16256796

  • Evaluation of cyclooxygenase-2 inhibition in an orthotopic murine model of lung cancer for dose-dependent effect JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Sievers, E. M., Bart, R. D., Backhus, L. M., Lin, Y. G., Starnes, M., Castanos, R., Starnes, V. A., Bremner, R. M. 2005; 129 (6): 1242-1249


    Cyclooxygenase-2 plays a role in growth, apoptosis, angiogenesis, and metastasis in lung cancer. Inhibition of cyclooxygenase-2 with celecoxib has been shown to inhibit tumor growth. We evaluated the effect of increasing doses of celecoxib in a murine model of human lung cancer.Human lung adenocarcinoma cells (A549) were implanted in the left lung upper lobe of mice with severe combined immunodeficiency syndrome. Mice were randomly assigned to 4 groups at implantation (n = 10 per group): control, 125 mg/kg chow, 500 mg/kg chow, 1000 mg/kg chow. After 3 weeks, mice were killed, and a blinded observer measured total tumor volume. The dose effect of celecoxib was examined in vitro by studying cell proliferation, expression of cyclooxygenase-2 (mRNA and protein), and production of prostaglandin E 2 in unstimulated and interleukin 1beta-stimulated cells.All 40 mice survived for 3 weeks with no observed toxicities. Total tumor volume was inhibited in each celecoxib group ( P = .0038, Welch analysis of variance): 206.7 +/- 119.5 mm 3 (control group), 41.4 +/- 54.0 mm 3 (low-dose group), 34.5 +/- 39.3 mm 3 (medium-dose group), and 27.3 +/- 53.6 mm 3 (high-dose group). In vitro celecoxib was effective at inhibiting production of prostaglandin E 2 , even in stimulated cells, although little effect was seen on cyclooxygenase-2 protein levels. Inhibition of proliferation was evident only at doses that exceeded those used in the animal model.Inhibition of cyclooxygenase-2 with low-dose celecoxib restricted the growth of lung cancer in this model. This might be mediated by prostaglandin E 2 . Higher doses of celecoxib afforded no additional benefit. Chronic therapy with low-dose cyclooxygenase-2 inhibition has the potential to influence tumor progression in non-small cell lung cancer.

    View details for DOI 10.1016/j.jtcvs.2004.12.048

    View details for Web of Science ID 000229789400004

    View details for PubMedID 15942563

  • Pleural space problems following living lobar transplantation Backhus, L. M., Sievers, E. M., Bart, R. D., Schenkel, F. A., Cohen, R. G., Barr, M. L., Nigro, J. J., Starnes, V. A., Bremner, R. M. AMER COLL CHEST PHYSICIANS. 2004: 844S
  • Selective COX-2 blockade inhibits lung adenocarcinoma cell migration in vitro Backhus, L. M., Sievers, E. M., Bart, R. D., Starnes, V. A., Bremner, R. M., Starnes, M. J., Lin, Y. G. AMER COLL CHEST PHYSICIANS. 2004: 731S
  • Functional and marker MicroPET imaging in a murine model of orthotopic lung cancer Bading, Bremner, R. M., Sievers, E. M., Chen, X. Y., Bart, R. D., Park, R., Backhus, L. M. AMER COLL CHEST PHYSICIANS. 2004: 748S-749S
  • Abnormal esophageal body function: Radiographic-manometric correlation AMERICAN SURGEON Fuller, L., Huprich, J. E., Theisen, J., Hagen, J. A., Crookes, P. F., DeMeester, S. R., Bremner, C. G., DeMeester, T. R., Peters, J. H. 1999; 65 (10): 911-914


    Stationary manometry is the gold standard for the evaluation of patients with suspected esophageal motility disorders. Comparison of videoesophagram in the evaluation of esophageal motility disorders with stationary motility has not been objectively studied. Two hundred two patients with foregut symptoms underwent stationary motility and videoesophagram. Radiographic assessment of esophageal motility was done by video recording of five 10-cc swallows of barium. Abnormal esophageal body function was defined by stasis of barium in the middle third of the esophagus on at least four swallows or stasis on at least three swallows in the distal third. Stationary manometry was performed using a five-channel water perfused system. Contraction amplitudes <25 mm Hg in any of the last two channels or the presence of simultaneous or interrupted waves in 10 per cent or more were considered to be abnormal. Sixty-two patients had abnormal manometry. Thirty-four patients also demonstrated abnormal videoesophagrams for an overall sensitivity of 55 per cent. The positive predictive value was 53 per cent; specificity was 79 per cent; and negative predictive value was 80 per cent. Sensitivity was greatest in patients with achalasia (94%) and scleroderma (100%) and in patients presenting with dysphagia (89%). Sensitivity was poor for nonspecific esophageal motility disorders. A videoesophagram is relatively insensitive in detecting motility disorders. It seems most useful in the detection of patients with esophageal dysfunction, for which surgical treatment is beneficial, and in those patients presenting with dysphagia.

    View details for Web of Science ID 000082913800003

    View details for PubMedID 10515533

  • Thoracic Endometriosis Syndrome: A Review of Diagnosis and Management. JSLS : Journal of the Society of Laparoendoscopic Surgeons Nezhat, C. n., Lindheim, S. R., Backhus, L. n., Vu, M. n., Vang, N. n., Nezhat, A. n., Nezhat, C. n. ; 23 (3)


    Endometriosis is characterized by the presence of endometrial-like glands and stroma outside the uterine cavity and is believed to affect 6%-10% of reproductive-age women. Endometriosis within the lung parenchyma or on the diaphragm and pleural surfaces produces a range of clinical and radiological manifestations. This includes catamenial pneumothorax, hemothorax, hemoptysis, and pulmonary nodules, resulting in an entity known as thoracic endometriosis syndrome (TES).Computerized searches of MEDLINE and PubMed were conducted using the key words "thoracic endometriosis," "catamenial pneumothorax," "catamenial hemothorax," and "catamenial hemoptysis." References from identified sources were manually searched to allow for a thorough review.TES can produce incapacitating symptoms for some patients. Symptoms of TES are nonspecific, so a high degree of clinical suspicion is warranted. Medical management represents the first-line treatment approach. When this fails or is contraindicated, definitive surgical treatment for cases of suspected TES uses a combined video laparoscopy performed by a gynecologic surgeon and video-assisted thoracoscopic surgery performed by a thoracic surgeon. Postoperative hormonal suppression may further reduce disease recurrence.

    View details for DOI 10.4293/JSLS.2019.00029

    View details for PubMedID 31427853

    View details for PubMedCentralID PMC6684338