Immune-checkpoint inhibitors (ICIs) have an established role in the treatment of locally advanced and metastatic non-small cell lung cancer (NSCLC). ICIs have now entered the paradigm of early-stage NSCLC. The recent evidence shows that the addition of ICI to neoadjuvant chemotherapy improves the pathological complete response (pCR) rate and survival rate in early-stage resectable NSCLC and is now a standard of care option in this setting. In this regard, stage III NSCLC merits special consideration, as it is heterogenous and requires a multidisciplinary approach to management. As the neoadjuvant approach is being adopted widely, new challenges have emerged and the boundaries for resectability are being re-examined. Consequently, it is ever more important to carefully individualize the treatment strategy for each patient with resectable stage III NSCLC. In this review, we discuss the recent literature in this field with particular focus on evolving definitions of resectability, T4 disease, N2 disease (single and multi-station), and nodal downstaging. We also highlight the controversy around adjuvant treatment in this setting and discuss the selection of patients for adjuvant treatment, options of salvage, and next line treatment in cases of progression on/after neoadjuvant treatment or after R2 resection. We will conclude with a brief discussion of predictive biomarkers, predictive models, ongoing studies, and directions for future research in this space.

PurposeWe developed a model integrating multimodal quantitative imaging features from tumor and nontumor regions, qualitative features, and clinical data to improve the risk stratification of patients with resectable non-small cell lung cancer (NSCLC).ApproachWe retrospectively analyzed 135 patients [mean age, 69 years (43 to 87, range); 100 male patients and 35 female patients] with NSCLC who underwent upfront surgical resection between 2008 and 2012. The tumor and peritumoral regions on both preoperative CT and FDG PET-CT and the vertebral bodies L3 to L5 on FDG PET were segmented to assess the tumor and bone marrow uptake, respectively. Radiomic features were extracted and combined with clinical and CT qualitative features. A random survival forest model was developed using the top-performing features to predict the time to recurrence/progression in the training cohort (n = 101), validated in the testing cohort (n = 34) using the concordance, and compared with a stage-only model. Patients were stratified into high- and low-risks of recurrence/progression using Kaplan–Meier analysis.ResultsThe model, consisting of stage, three wavelet texture features, and three wavelet first-order features, achieved a concordance of 0.78 and 0.76 in the training and testing cohorts, respectively, significantly outperforming the baseline stage-only model results of 0.67 (p < 0.005) and 0.60 (p = 0.008), respectively. Patients at high- and low-risks of recurrence/progression were significantly stratified in both the training (p < 0.005) and the testing (p = 0.03) cohorts.ConclusionsOur radiomic model, consisting of stage and tumor, peritumoral, and bone marrow features from CT and FDG PET-CT significantly stratified patients into low- and high-risk of recurrence/progression.

Background and Objective: Descending necrotizing mediastinitis (DNM) is a severe and life-threatening infection that originates from oropharyngeal or cervical infections and spreads downward into the mediastinum. Despite advancements in medical and surgical treatments, DNM remains a condition with high morbidity and mortality. This narrative review aims to summarize the etiology, diagnostic strategies, and management approaches for DNM, emphasizing the importance of a multidisciplinary approach. Methods: A comprehensive literature search was conducted using PubMed/MEDLINE, Western University Libraries, and Google Scholar databases, without restriction on publication date. Articles were included if they discussed: (I) the etiology of mediastinitis, focusing on anatomy and pathogens; (II) the diagnosis of DNM; and (III) the treatment and surgical approach to mediastinitis. Key Content and Findings: DNM is commonly caused by oropharyngeal infections that spread downward through normal anatomical pathways. Diagnosis is challenging due to the subtle and varied presentation of symptoms. Diagnosis is primarily made with contrast-enhanced CT scans of the neck and thorax, but a convincing history should prompt appropriate suspicion and concern. Management requires a multidisciplinary approach, including sepsis management particularly with broad-spectrum antibiotics and early surgical intervention for source control. The choice of surgical technique, whether transcervical, thoracotomy, or video-assisted thoracoscopic surgery (VATS), is crucial for effective drainage and reducing mortality. Conclusions: DNM is a complex and critical condition that demands prompt recognition and aggressive treatment. The high mortality associated with DNM underscores the need for a multidisciplinary approach. Surgical drainage, tailored to the extent of the infection, and comprehensive post-operative care are essential for improving patient outcomes. Future research should focus on optimizing diagnostic criteria, refining surgical techniques, and exploring adjunct therapies to further reduce morbidity and mortality in DNM.

Background: Surgical recovery after hospital discharge often presents challenges for patients and caregivers. Postoperative complications and poorly managed pain at home can lead to unexpected visits to the emergency department (ED) and readmission to the hospital. Digital home monitoring (DHM) may improve postoperative care compared to standard methods. Objective: We conducted a feasibility study for a randomized controlled trial (RCT) to assess DHM's effectiveness following thoracic surgical procedures compared to standard care. Methods: We conducted a 2-arm parallel-group pilot RCT at a single tertiary care center. Adult patients undergoing thoracic surgical procedures were randomized 1:1 into 2 groups: the DHM group and the standard of care (control group). We adhered to the intention-to-treat analysis principle. The primary outcome was predetermined RCT feasibility criteria. The trial would be feasible if more than 75% of trial recruitment, protocol adherence, and data collection were achieved. Secondary outcomes included 30-day ED visit rates, 30-day readmission rates, postoperative complications, length of stay, postdischarge 30-day opioid consumption, 30-day quality of recovery, patient-program satisfaction, caregiver satisfaction, health care provider satisfaction, and cost per case. Results: All RCT feasibility criteria were met. The trial recruitment rate was 87.9% (95% CI 79.4%-93.8%). Protocol adherence and outcome data collection rates were 96.3% (95% CI 89.4%-99.2%) and 98.7% (95% CI 92.9%-99.9%), respectively. In total, 80 patients were randomized, with 40 (50%) in the DHM group and 40 (50%) in the control group. Baseline patient and clinical characteristics were comparable between the 2 groups. The DHM group had fewer unplanned ED visits (2.7% vs 20.5%; P=.02), fewer unplanned admission rates (0% vs 7.6%; P=.24), lower rates of postoperative complications (20% vs 47.5%, P=.01) shorter hospital stays (4.0 vs 6.9 days; P=.05), but more opioid consumption (111.6, SD 110.9) vs 74.3, SD 71.9 mg morphine equivalents; P=.08) compared to the control group. DHM also resulted in shorter ED visit times (130, SD 0 vs 1048, SD 1093 minutes; P=.48) and lower cost per case (CAD $12,145 [US $ 8436.34], SD CAD $8779 [US $ 6098.20] vs CAD $17,247 [US $11,980.37], SD CAD $15,313 [US $10,636.95]; P=.07). The quality of recovery scores was clinically significantly better than the controls (185.4, SD 2.6 vs 178.3, SD 3.3; P<.001). All 37 patients who completed the intervention answered the program satisfaction survey questionnaires (100%; 95% CI 90.5%-100%). Only 36 out of 80 caregivers responded to the caregiver satisfaction questionnaires at the end of the fourth week post hospital discharge (47.7%; 95% CI 35.7%-59.1%). Health care providers reported a 100% satisfaction rate. Conclusions: This pilot RCT demonstrates the feasibility of conducting a full-scale trial to assess DHM's efficacy in improving postoperative care following thoracic surgery. DHM shows promise for enhancing continuity of care and warrants further investigation. Trial Registration: ClinicalTrials.gov NCT04340960; https://clinicaltrials.gov/study/NCT04340960

Secondary spontaneous pneumothoraces continues to be a common problem faced by thoracic surgeons. There are multiple etiologies that result in the development of a secondary spontaneous pneumothoraces. Some of these are congenital in origin and others are acquired. However, emphysema from chronic obstructive pulmonary disease remains the leading cause and as such this paper will primarily focus on pneumothorax resulting from this entity. The past decade has seen several advances in thoracic surgery. These advances include the introduction of endobronchial interventions, new pleurodesis agents and surgical approaches. With the multitude of options available, it can be challenging to decide what the ideal management strategy should be. The purpose of this paper is to provide a summary of the various management strategies and when best to employ them. This paper will also provide a review of the literature around the newer technologies that are being employed and the success rates of each of them. Specifically, the paper will review endobronchial therapies, different chemical pleurodesis agents and the role of video assisted thoracic surgery. The latest guidelines regarding the management of secondary spontaneous pneumothoraces will also be reviewed. Lastly, key points and take-home messages will be provided. This paper hopes to provide a quick and informative read for cardiothoracic trainees and early career surgeons in the management of secondary spontaneous pneumothorax (SSP).