Background: Small cell lung cancer (SCLC) is an aggressive malignancy that has traditionally been treated as a systemic disease, with surgery largely excluded from standard management. A small subset of patients, however, present with clinical Stage I disease (T1–2N0M0). With improvements in imaging, staging, and systemic therapy, local therapy warrants consideration. Methods: We performed a narrative review of the literature focused on clinical Stage I SCLC, prioritizing studies addressing epidemiology, tumor biology, diagnostic workup, staging, treatment approaches, and surveillance. Emphasis was placed on current guideline recommendations and contemporary retrospective data relevant to surgical and non-surgical local therapies. Results: Clinical Stage I SCLC is rare and is frequently upstaged with complete diagnostic evaluation, highlighting the need for thorough staging and pathologic confirmation of node-negative disease when surgery is considered. Even in presumed local disease, distant metastases are many times evident with a proper staging workup. Retrospective analyses suggest potential for long-term control of disease in carefully selected Stage I patients treated with surgical resection, particularly lobectomy, as part of multimodality therapy that includes adjuvant systemic therapy. For patients who are not surgical candidates, stereotactic body radiation therapy combined with systemic therapy is a reasonable alternative. The role of prophylactic cranial irradiation and optimal surveillance strategies in Stage I disease remain areas of uncertainty. Conclusions: Clinical Stage I SCLC affects a small and unique group of patients where traditional treatment strategies may need to be reconsidered. Taken together, retrospective evidence suggests a survival benefit for surgery in carefully selected patients, although prospective validation is lacking. Surgery warrants consideration in appropriately staged, operable patients, while recognizing the limitations of existing data and the need for further study in this rare population.

Atrial esophageal fistula (AEF) is a rare complication of atrial ablation procedures. Because of the low incidence and associated morbidity and mortality, there is no consensus on optimal treatment. We present our experience with 4 patients, each with a different management strategy. Retrospective chart review of 4 patients treated for AEF at a single tertiary care center was performed. Patients were treated between March 2020 and April 2024. Three patients underwent surgical repair of the AEF and 1 underwent a combination of endoscopic and percutaneous approaches. Two of the surgical patients underwent right thoracotomy, while the third was approached via median sternotomy on cardiopulmonary bypass followed by a right thoracotomy. The 3 patients who underwent surgical repair are alive and tolerating oral intake. The patient who underwent endoscopic/percutaneous AEF repair had a considerably higher surgical risk at baseline. The patient recovered from the initial interventions and was discharged home but represented with AEF progression and subsequently expired secondary to neurologic sequalae. For AEF, open surgical management with or without the use of cardiopulmonary bypass has historically been the first-line treatment. Although successful management of AEF with endoscopic treatment has been documented in the literature, only surgical repair was successful in this case series. This series suggests that surgical management should be pursued for all patients except those with highly prohibitive surgical risk.

The increase in drug overdose deaths (DODs) has resulted in an increased pool of potential organ donors. We assessed the pattern of use of DOD donors and describe outcomes of lung transplant recipients who received allografts from DOD donors. The United Network for Organ Sharing registry was used to identify all adult (aged ≥18 years) isolated lung transplant recipients between January 2010 and June 2022. Recipient allografts from DOD donors were compared with allografts from donors who died of other causes. Long-term survival was assessed with unadjusted Kaplan-Meier curves, the log-rank test, and risk-adjusted multivariable Cox proportional hazards models. We identified 28,495 adult lung recipients who met inclusion criteria, and 12.1% (n = 3437) received allografts from DOD donors. The yearly volume of DOD recipients nationwide increased from 67 in 2010 to 531 in 2022 (Mann-Kendall trend test, P < .001). Survival did not significantly differ between DOD and non-DOD recipients at 30 days (hazard ratio, 0.96; 95% CI, 0.76-1.23), 1 year (hazard ratio, 1.04; 95% CI, 0.92-1.17), or 3 years (hazard ratio, 1.04; 95% CI, 0.96-1.12). DOD recipients had longer average length of stay (27.7 vs 27.4 days), were less likely to have no postoperative ventilatory support (1.6% vs 2.9%), and a greater proportion were intubated at 72 hours (25.4% vs 21.6%). Use of DOD lungs in lung transplantation has increased in the last decade. Long-term recipient outcomes were similar compared with all other donors. These results support the safety of using DOD lungs.