Circulating tumor DNA (ctDNA) is a blood test that can be used to detect and monitor thoracic malignancies. It is being used to detect mutations, monitor for recurrence after surgery and other treatments, and can even be used in conjunction with screening to help identify malignancy. As the field continues to advance, it is crucial for thoracic surgeons, trainees, and healthcare providers to stay informed about the latest developments in ctDNA testing and its applications for thoracic patients.

Sponsored by AstraZeneca

 

Date
7 p.m. ET

Two papers recently published in The Annals of Thoracic Surgery aim to guide the management of thymoma1 and pleural drains following pulmonary lobectomy2 – thoracic conditions and treatments that lack widely accepted guidelines. Recognizing this need, the Society of Thoracic Surgeons (STS) Workforce on Evidenced-Based Surgery convened a task force to develop expert consensus documents to help alleviate this knowledge gap.

Thymoma, a rare epithelial tumor – but also the most common anterior mediastinal tumor in adult patients – is a condition thoracic surgeons will likely encounter as clinicians. However, there is a lack of evidence covering all aspects of treatment due to its relatively low incidence. Managing pleural drains following pulmonary lobectomy is standard practice, yet there are no established guidelines on this topic despite abundant published literature.

Management of thymoma

The STS Workforce on Evidence-Based Surgery, which includes general thoracic surgeons with expertise in thoracic surgical oncology, and medical and radiation oncologists with expertise in neoadjuvant and adjuvant therapies, evaluated existing literature about surgical considerations in managing thymomas, such as:

•    Imaging characteristics
•    Diagnostic tests 
•    Staging 
•    Surgical approach and technique
•    Neoadjuvant and adjuvant therapy 
•    Surgery for advanced or recurrent disease, and 
•    Postoperative surveillance

Consensus statements were drafted using the modified Delphi method. Votes for each proposed statement were tallied using a 5-point Likert scale, with the option to abstain on those not within the specific authors’ expertise. Statements with 75% of responding authors selecting “agree” or “strongly agree” were considered to have reached a consensus. 

Unlike broader guidelines encompassing various aspects of thymoma management, including medical oncology, radiology, and pathology, this paper addresses thymoma from a surgical perspective by guiding surgical interventions, especially in metastatic and recurrent diseases.

"Given the scarcity of randomized controlled trials due to the rarity of thymoma, this document is framed as an expert consensus rather than strict evidence-based clinical practice guidelines," said the study's lead author, Dr. Douglas Liou, clinical associate professor at Stanford Medicine. "Our findings rely more heavily on the combined experience and judgment of experts in the field rather than solely on data from large-scale studies." 

Read the Annals article

Management of pleural drains following pulmonary lobectomy

Similarly, the consensus document developed by the STS Workforce on Evidence-Based Surgery to manage pleural drains includes:

•    Choice of drain, including size, type, and number
•    Management, such as use of suction versus waterseal and criteria for removal
•    Imaging recommendations, including the use of daily and post-pull chest x-rays
•    Use of digital drainage systems, and
•    Management of prolonged air leak

Workforce members reviewed existing literature on the condition. A consensus using a modified Delphi method consisting of two rounds of voting until 75% agreement on the statements was reached, with a total of thirteen statements that encouraged standardization and stimulated additional research in this critical area. 

“Optimal management of these drains should reduce patient discomfort, length of stay, and complications.”  said study investigator Dr. Michael Kent, associate professor of surgery at Harvard Medical School. “However, despite how commonly chest tubes are used in practice, the literature must provide more clarity on this subject. Many important questions have yet to be addressed and may require well-designed, prospective randomized trials.”

Read the Annals article

1. Reference: Liou DZ, Berry MF, Brown LM, Demmy TL, Huang J, Khullar OV, Padda SK, Shah RD, Taylor MD, Toker SA, Weiss E, Wightman SC, Worrell SG, Hayanga JWA, The Society of Thoracic Surgeons Expert Consensus Document on the Surgical Management of Thymomas, The Annals of Thoracic Surgery (2024)

2. Reference: Kent MS, Mitzman B, Diaz-Gutierrez, I, Khullar OV, Fernando H, Backus L, Brunelli A, Cassivi SD, Cerfolio RJ, Crabtree TD, Kakuturu J, Martin LW, Worrell SG, Raymond DP, Schumacher L, Hayanaga JWA, The Society of Thoracic Surgeons Expert Consensus Document on the Management of Pleural Drains following Pulmonary Lobectomy, The Annals of Thoracic Surgery (2024)

Jul 25, 2024
3 min read

In this video in the 8 in 8 Series, Dr. Dwight Owen (Ohio State University) discussed advances in biomarker testing and neoadjuvant immunotherapy for resectable non-small cell lung cancer. The talk includes a look at the role of PD-L1 testing, peri-operative chemo-immunotherapy, and the importance of NGS testing for patients with actionable mutations.

Supported by AstraZeneca.

Duration
7 min.

In this 8 in 8 video, Dr. Jessica Donington provides an update on adjuvant and neoadjuvant clinical trials that have recently concluded or will be releasing data in the near future. She reviews patient populations, methodology, and implications of trial findings for the treatment of resectable lung cancer.

Presenter: 

Jessica S. Donington, MD, MSCR
University of Chicago Medicine & Biological Sciences
Chicago, IL

Supported by AstraZeneca

Duration
11 min

In part two of the Robotic Thoracic Surgery webinar series, experts will discuss how a collaborative thoracic and pulmonary robotic approach is expanding thoracic oncology. Through increased lung cancer screening and incidental pulmonary nodule programs, the management of 8-10 mm pulmonary nodules in high-risk patients has come to the forefront, especially with the growing adoption of robotic navigational bronchoscopy and its associated greater precision. This webinar will explore best practices and current technology in the pulmonary and thoracic fields, as well as emerging therapies.

Date
Duration
1 hr. 10 min.

In this panel discussion, STS members exchange viewpoints on a new study that found patients with postoperative PE had increased 30-day mortality, reintubation, and readmission rates, which was presented at the 2024 STS Annual Meeting.

Duration
10 min

As key members of the multidisciplinary care team, thoracic surgeons play a pivotal role in the patient journey for resectable Non-Small Cell Lung Cancer. This patient journey map, suitable for both surgeons and patients, outlines the stages of treatment of resectable NSCLC from diagnosis and staging, to resection, referral to a medical oncologist, and surveillance. This includes consideration of biomarker testing during the diagnostic biopsy and resection stages, and the potential benefit of perioperative and adjuvant therapies.

Click the image below to view or download the full document.

Image
Patient Journey Resectable NSCLC

 

 

 

 

Additional Resources

Webinars 

Video 

 

Mar 8, 2024
1 min read

In this video, Dr. Leah Backhus, thoracic surgeon and professor of cardiothoracic surgery at Stanford Medicine, discusses the surgeon’s role in managing patients with resectable non-small cell lung cancer.

Duration
12 min. 44 sec.
New research presented at STS 2024 found that patients with postoperative PE had increased 30-day mortality, reintubation, and readmission rates.
Feb 14, 2024

Two STS 2024 sessions featured late-breaking research covering new findings on a research study focused on resectable early stage non-small-cell lung cancer and a study that used data to define characteristics associated with long-term survival following esophagectomy for cancer.

Impact of Surgical Factors on Event-Free Survival in the Randomized, Placebo-Controlled, Phase 3 KEYNOTE-671 Trial of Perioperative Pembrolizumab For Early Stage Non-Small-Cell Lung Cancer

In a talk given by presenting author Jonathan David Spicer, MD, PhD, of McGill University, he discussed new findings from the KEYNOTE-671 research study, focused on resectable early stage non-small-cell lung cancer (NSCLC), which have unveiled a significant breakthrough in the treatment landscape. 

The study, titled "Impact of Surgical-Related Data on Event-Free Survival in KEYNOTE-671," demonstrated that neoadjuvant therapy with pembrolizumab plus chemotherapy did not delay surgery. "Results showed that neoadjuvant pembrolizumab plus chemotherapy with adjuvant pembrolizumab provided meaningful improvement in EFS," said Dr. Spicer. "This was shown when compared with neoadjuvant chemotherapy alone for resectable early stage NSCLC – regardless of clinical nodal status, baseline disease stage, or type of surgery."

Longitudinal Follow-up of Elderly Patients After Esophageal Cancer Resection in the Society of Thoracic Surgeons General Thoracic Surgery Database

In this study, Justin Blasberg, MD, of Yale School of Medicine, used the STS General Thoracic Surgery Database linked to the Centers for Medicare and Medicaid Services data to define characteristics associated with long-term survival following esophagectomy for cancer. The analysis included 4,798 patients from 207 STS sites who underwent esophagectomy between 2012-2019. "The researchers found that Medicare patients undergoing esophagectomy for cancer exhibit identifiable predictors for long-term survival and readmission," noted Dr. Blasberg. "The absence of pathologic T and N downstaging increases the risk for long-term mortality and readmission."

These findings suggest opportunities to enhance clinical practice and improve outcomes for Medicare patients undergoing esophagectomy for cancer. 

Jan 27, 2024
2 min read

The 2024 Lung Transplant Symposium: Surgical and Medical Insights for Transplant Assessment and Management, presented at the STS 2024 pre-conference convening on Friday, January 26. Approximately 100 surgeons, pulmonologists, anesthesiologists, and other transplant team members learned about best-practice approaches for surgical and medical care of lung transplant patients – from assessment as candidates though post-surgical care as recipients.

"2024 Lung Symposium"
Nearly 100 surgeons, pulmonologists, anesthesiologists, and other transplant team members attended the 2024 Lung Transplant Symposium. 

After a welcome and introduction by STS President Dr. Tom MacGillivray, Dr. Shaf Keshavjee of the Toronto Lung Transplant Program at the University Health Network, gave a brief overview of lung transplantation firsts and milestones before moving into present-day breakthroughs and areas of concern. 
  
"Current noteworthy topics we’re addressing in lung transplantation include primary graft dysfunction, donor management, and organ repair centers, refining the transplant ecosystem, as well as understanding the challenges of retrieval and transport of organs," said Dr. Keshavjeee.

Five 90-minute sessions covered the following subject areas: recipient selection, donor selection, intraoperative management, postoperative management, and challenging situations led by expert panels who answered questions from attendees.

Among the wide range of presentations, the Symposium featured included, "ECMO as Bridge to Transplant;" "Organ Procurement Techniques -- DBD, DCD, or NRP;" "Perioperative and Intraoperative Anesthesia Management;" and "Diagnosis, Monitoring and Therapeutic Challenges," which each cited current research and case study results.

Jan 26, 2024
1 min read