Adjuvant chemotherapy for pulmonary sarcomatoid carcinoma: A retrospective analysis of the National Cancer Database.

OBJECTIVES: Pulmonary sarcomatoid carcinoma (PSC) is a rarely occurring variant of non-small cell lung cancer with sarcoma-like features. Compared with traditional non-small cell lung cancer, PSC patients typically present later and have poorer prognoses, irrespective of stage. The standard of care is resection, but guidelines for the use of adjuvant chemotherapy have not been established. To advance the development of evidence-based management algorithms for PSC after resection, a statistical analysis on a nationwide representative sample of patients was performed. METHODS: A retrospective cohort study was performed by querying the National Cancer Database for patients with a diagnosis of PSC between 2004 and 2015. Patients who received complete anatomical resection with or without adjuvant chemotherapy were included. Multivariable regression was used to detect factors associated with the receipt of adjuvant chemotherapy. Multivariable Cox regression of overall survival and Kaplan-Meier survival analysis on propensity-matched groups was conducted to study the association between adjuvant chemotherapy and prognosis. RESULTS: We included 1497 patients with PSC in the final analysis. Factors associated with receiving adjuvant chemotherapy were age, histology, and receipt of adjuvant radiation. The results of multivariable Cox analysis and Kaplan-Meier analysis on propensity matched groups yielded similar trends: adjuvant chemotherapy was associated with improved 5-year overall survival for stage II and III disease, but not for stage I disease. CONCLUSIONS: Multiple factors are associated with receipt of adjuvant chemotherapy for PSC, and this treatment appears to be associated with improved survival in stage II and stage III, but not stage I patients.

Incidence of adjacent-segment surgery following stand-alone lateral lumbar interbody fusion.

OBJECTIVE: Adjacent-segment disease (ASD) requiring operative intervention is a relatively common long-term consequence of lumbar fusion surgery. Although the incidence of ASD requiring reoperation is well described for traditional posterior lumbar approaches (2.5%-3.9% per year), it remains poorly characterized for stand-alone lateral lumbar interbody fusion (LLIF). In this study, the authors report their institutional experience with ASD requiring reoperation after LLIF over an extended follow-up period of 4 years. METHODS: Medical records were reviewed for 276 consecutive patients who underwent stand-alone LLIF by a single surgeon for degenerative spinal disorders. Inclusion criteria (single-stage, stand-alone LLIF without posterior supplementation, with no prior lumbar instrumentation, and a minimum of 4 years of follow-up) were met by 182 patients, who were analyzed for operative ASD incidence (per-year rate), demographics, and Oswestry Disability Index (ODI) score. Operative ASD was strictly defined as new-onset pathology following index surgery at directly adjacent levels to the prior construct. Operative, rather than symptomatic or radiographic, ASD was analyzed to provide a consistent and impactful endpoint while avoiding retrospective diagnosis. RESULTS: The study cohort of 182 patients had an operative ASD rate of 3.3% (n = 6 procedures) over 4 years of follow-up, for an incidence on Kaplan-Meier survival analysis of 0.88% (95% CI 0.67%-1.09%) per year. In comparing patients with operative ASD with those without, there were no significant differences in mean age (53.7 vs 56.2 years), male sex (33.3% vs 44.9%), smoking status (16.7% vs 25.0%), or number of levels fused (mean 1.33 vs 1.46). The operative ASD cohort had a greater mean BMI (37.3 vs 30.2, p < 0.01). Operative ASD patients had lower baseline ODI scores (33.8 vs 48.3, p = 0.02); however, no difference was observed in ODI at 6 weeks (34.0 vs 39.0) or 3 months (16.0 vs 32.8) postoperatively. CONCLUSIONS: The incidence of ASD in LLIF for degenerative lumbar etiologies in this cohort was 0.88% (95% CI 0.67%-1.09%) per year. Meanwhile, the reported reoperation rates for ASD in posterior spinal approaches was 2.5% to 3.9% per year, which implies that LLIF may be preferable for well-selected patients.

Lactate as a mediator of prehospital plasma mortality reduction in hemorrhagic shock.

BACKGROUND: Prehospital plasma transfusion in trauma reduces mortality. However, the underlying mechanism remains unclear. Reduction in shock severity may play a role. Lactate correlates with physiologic shock severity and mortality after injury. Our objective was to determine if prehospital plasma reduces lactate and if this contributes to the mortality benefit of plasma. METHODS: Patients in the Prehospital Air Medical Plasma trial in the upper quartile of injury severity (Injury Severity Score, >30) were included to capture severe shock. Trial patients were randomized to prehospital plasma or standard care resuscitation (crystalloid ± packed red blood cells). Regression determined the associations between admission lactate, 30-day mortality, and plasma while adjusting for demographics, prehospital crystalloid, time, mechanism, and injury characteristics. Causal mediation analysis determined what proportion of the effect of plasma on mortality is mediated by lactate reduction. RESULTS: A total of 125 patients were included. The plasma group had a lower adjusted admission lactate than standard of care group (coefficient, -1.64; 95% confidence interval [CI], -2.96 to -0.31; p = 0.02). Plasma was associated with lower odds of 30-day mortality (odds ratio [OR], 0.27; 95% CI, 0.08-0.90; p = 0.03). When adding lactate to this model, the effect of plasma on 30-day mortality was no longer significant (OR, 0.36; 95% CI, 0.07-1.88; p = 0.23), while lactate was associated with mortality (OR, 1.74 per 1 mmol/L increase; 95% CI, 1.10-2.73; p = 0.01). Causal mediation demonstrated 35.1% of the total effect of plasma on 30-day mortality was mediated by the reduction in lactate among plasma patients. CONCLUSION: Prehospital plasma is associated with reduced 30-day mortality and lactate in severely injured patients. More than one third of the effect of plasma on mortality is mediated by a reduction in lactate. Thus, reducing the severity of hemorrhagic shock appears to be one mechanism of prehospital plasma benefit. Further study should elucidate other mechanisms and if a dose response exists. LEVEL OF EVIDENCE: Therapeutic, level II.

Racial Disparity in Surgical Therapy for Thymic Malignancies.

BACKGROUND: The primary curative treatment for thymic malignancies is surgery. For lung and esophageal cancer, substantive disparities in outcomes by race exist. Many of these disparities are attributed to the decreased use of surgery in non-White patients. Although thymic malignancies are treated by the same specialists as lung and esophageal cancer, it is unknown if there are racial disparities in the treatment of thymic malignancies. RESEARCH QUESTION: Do racial disparities exist in the surgical treatment of thymic malignancies? STUDY DESIGN AND METHODS: A retrospective cohort analysis was performed using the National Cancer Data Base of patients diagnosed with thymoma and thymic carcinoma between 2004 and 2016. Univariate comparisons of demographics were compared using χ 2 and rank-sum tests. Multivariable analysis was performed to determine if race was an independent variable associated with receiving surgical resection. Preoperative and postoperative care was compared between races. RESULTS: Seven thousand four hundred eighty-nine patients met inclusion criteria. Four thousand nine hundred sixty-two (66%) were White, 1,311 (18%) were Black, 487 (7%) were Hispanic, 580 (8%) were Asian or Pacific Islander, and 143 (2%) were other races. Black patients with thymic malignancies were more likely to have a median income < $38,000 and not received surgery. Black and Hispanic patients had the lowest median age (54.3 and 53.6 years, respectively) and were most likely to be uninsured (8.2% and 12.5%, respectively). White patients received surgical therapy 1 week sooner and had a postoperative length of stay 1.5 days shorter than Black patients. Multivariable analysis controlling for age, sex, tumor size, insurance status, comorbidity score, histology, and facility type showed that race remained independently associated with the receipt of surgical resection. White patients had the greatest likelihood of receiving surgery with Black patients being least likely to receive surgery (OR, 0.60). INTERPRETATION: A racial disparity exists in surgical therapy for thymic malignancies.

Racial disparities in local therapy for early stage non-small-cell lung cancer.

OBJECTIVES: This study investigated disparities in the delivery of definitive therapy for early stage non-small-cell lung cancer (ESNSCLC) between Caucasian (CS) and African American (AA) populations. METHODS: The National Cancer Data Base was queried for AA and CS patients, diagnosed with c stage I Non small cell lung cancer between 2004 and 2015. Trends in surgery, stereotactic ablative radiotherapy (SABR), or external beam radiation therapy (EBRT) were compared. Kaplan-Meier and Cox hazards models were used to compare 5-year overall survival (5YOS). RESULTS: A total of 174,338 (90.6%) patients were CS and 18,077 (9.4%) patients were AA. AA patients were less likely to receive surgery (60.3% vs. 66.9%; p < .001) and more likely to receive EBRT (12.4% vs. 10.6%; p < .001); however, there was no significant difference in rates of SABR (8.8% vs. 9.2%; p = .066). From 2004 to 2015, the surgery rates increased for AA patients from 44.4% to 61.8% and for CS patients from 57.6% to 65.6%. AA patients had worse 5YOS on an unadjusted analysis (46.7% vs. 47.9%; p = .009). When adjusted for definitive treatment, AA patients had improved survival (hazard ratio = 0.97, 95% confidence interval = 0.94-0.99). CONCLUSION: Improvements in the delivery of surgery and equal utilization of definitive radiation therapy are at least partially responsible for closing the survival gap between AA and CS patients with ESNSCLC.

Adjuvant systemic therapy for small bowel gastrointestinal stromal tumor (GIST): Is there a survival benefit after R0 resection?

BACKGROUND: The utility of adjuvant systemic therapy in small bowel gastrointestinal stromal tumor remains unclear. METHODS: We queried the National Cancer Data Base for individuals having enterectomy to negative margins for small bowel gastrointestinal stromal tumor between 2010 and 2015. Subjects were categorized by tumor size (2.1-5 cm, 5.1-10 cm, >10 cm) and histologic grade (≤5 mitoses/50 high-power field and >5 mitoses/50 high-power field). Cox proportional hazard analysis was performed to evaluate the association between adjuvant therapy and overall survival. RESULTS: One thousand five hundred fifty-nine patients met the inclusion criteria. On univariate comparison to resection alone, adjuvant therapy was associated with improved overall survival for individuals with high-grade tumors of intermediate and large size (85% vs 48%, P = .010; 75% vs 47%, P = .003) but not for those with high-grade tumors of small size or low-grade tumors of any size. On multivariable analysis adjusted for age, comorbid disease state, and tumor size, adjuvant therapy was independently associated with reduced risk of mortality for high-grade (hazard ratio 0.37, 95% confidence interval: 0.21-0.64) but not low-grade tumors. CONCLUSION: Adjuvant therapy after R0 resection for small bowel gastrointestinal stromal tumor should be administered after careful consideration of the size and grade of a patient's tumor.

Impact of Enhanced Recovery Pathways and early urinary catheter removal on post-operative urinary retention.

BACKGROUND: Post-operative urinary retention (POUR) is a common complication after colorectal surgery. Enhanced recovery pathways (ERP) typically include early catheter removal but may place patients at risk for POUR. METHODS: This is a retrospective cohort analysis of patients undergoing colorectal surgery at a single institution between April 2014 and November 2017. Patients were stratified into non-ERP and ERP cohorts and post-operative outcomes were compared. RESULTS: Of 284 patients studied, ERP was applied to 161 (57%) while the remaining 123 (43%) recovered under standard care. Median duration of indwelling Foleys was 1 day for ERP and 2 days for non-ERP patients (p < 0.001). ERP patients experienced higher rates of straight catheterization (22% vs 12%,p = 0.036), Foley reinsertion (14% vs 7%,p = 0.07), and initiation of alpha antagonists (12% vs 5%,p = 0.04). Significant independent predictors of POUR were age (OR 1.03, p = 0.002), male gender (OR 2.79, p = 0.001), surgery duration (OR 1.27, p = 0.027), and ERP (OR 1.96, p = 0.025). CONCLUSION: ERP following colorectal surgery that include routine early Foley catheter removal on post-operative day one is associated with increased rates of POUR; however, this did not lead to increased rates of catheter-associated urinary tract infections during the index admission in the population studied.

Factors Associated With Survival in Complete Pathologic Response Non-Small Cell Lung Cancer.

OBJECTIVES: There is a strong association with improved survival for patients with non-small cell lung cancer (NSCLC) who have developed a pathological complete response (pCR) after neoadjuvant therapy. A national database was used to investigate factors associated with long-term survival in this cohort of patients. PATIENTS: Retrospective review was completed of the National Cancer Database of patients who obtained pCR and had neoadjuvant therapy for stage I to stage III NSCLC between 2004 and 2014. All patients had neoadjuvant chemotherapy with or without radiation therapy. METHODS: Univariate and multivariable analysis was performed on factors associated with overall survival (OS), including gender, clinical stage, and nodal count. Patients were divided into 2 groups based on the Commission on Cancer-recommended median number of lymph nodes (LNs) examined: 0 to 9 LNs and ≥10 LNs. Chi-square and Wilcoxon rank-sum tests were used to compare patient, hospital, and clinical variables between groups. RESULTS: Increased age (hazard ratio [HR] 1.02, 95% confidence interval [CI], 1.00-1.03), neoadjuvant radiation therapy (HR 1.48, 95% CI, 1.10-2.00), and pneumonectomy (HR 1.64, 95% CI, 1.22-2.22) were associated with worse survival in the 759-patient cohort. Multivariable regression demonstrated having ≥10 nodes harvested (HR 0.71, 95% CI, 0.56-0.89) was associated with improved survival as was every increase in LN harvest up to 17 LNs. No significant differences in 5-year OS were found between clinical stage I, II, and III, respectively (66.1% vs. 60.9% vs. 58.6%, P = .288). CONCLUSION: This study shows that younger age, increasing LN harvest, female sex, the absence of neoadjuvant radiation therapy and non-pneumonectomy resections are all associated with improved OS in patients with NSCLC who have developed pCR.

Higher lymph node harvest in patients with a pathologic complete response after neoadjuvant therapy for esophageal cancer is associated with improved survival.

BACKGROUND AND OBJECTIVES: Lymph node harvest during esophagectomy has been associated with improved survival for esophageal cancer but the value of enhanced lymph node harvest following complete pathologic response (pCR) is debated. This study investigated if increasing lymph node harvest in esophageal cancer patients with a pCR after neoadjuvant therapy and esophagectomy is associated with improved survival. METHODS: We queried the National Cancer Data Base for patients with esophageal cancer between 2004 and 2014 who underwent neoadjuvant chemotherapy or chemoradiation therapy followed by esophagectomy found to have pCR. Multivariable Cox modeling was utilized to evaluate the impact of increasing lymph node counts on overall survival (OS). RESULTS: A total of 1373 patients met inclusion criteria. A National Comprehensive Cancer Network compliant lymphadenectomy of ≥15 nodes was associated with improved survival (66.7% vs 51.1%; P < .001). Cox modeling showed that the first node cutoff to demonstrate a statistically significant improvement in OS was ≥7 nodes (hazard ratio [HR], 95% confidence interval [CI]: 0.81, 0.68-0.97; 5-year OS: 54.2%) with a trend of decreasing and statistically significant HRs until ≥25 nodes (HR, 95% CI: 0.52, 0.37-0.72; 5-year OS: 68.4%). CONCLUSIONS: High negative node counts after neoadjuvant therapy and esophagectomy are associated with improved survival in patients with pCR.

The association of robotic lobectomy volume and nodal upstaging in non-small cell lung cancer.

Robotic lung resection for lung cancer has gained popularity over the last 10 years. As with many surgical techniques, there are improvements in outcomes associated with increased operative volume. We sought to investigate lymph-node harvest and upstaging rates for robotic lobectomies performed at hospitals with varying robotic experience. The National Cancer Data Base was queried for patients with early stage non-small cell lung cancer who received lobectomy between 2010 and 2015. Hospitals were stratified into volume categories based on the number of robotic resections performed, as a proxy for robotic experience: low at ≤ 12, low-middle 13-26, middle-high 27-52, and high volume at greater than or equal to 53. Lymph-node counts and nodal upstaging were compared among these volume categories. 8360 robotic lobectomies were performed. Mean lymph-node counts were for low, low-middle, middle-high, and high-volume robotic lobectomies were 9.8, 11.4, 12.9, and 12.6, respectively (P < 0.001), while nodal-upstaging rates were 10.3%, 10.2%, 12.8%, and 13.4%, respectively (P < 0.001). Compared to low-volume hospitals, on multivariable analysis, high-volume robotic centers had increased nodal harvest (P < 0.001) and nodal-upstaging rates (P < 0.001). Robotic lobectomies performed at high-volume hospitals have greater lymph-node harvest and upstaging than low-volume hospitals.

Clinically resectable acinar cell carcinoma of the pancreas: Is there a benefit to adjuvant systemic therapy?

BACKGROUND: Prior studies of adjuvant systemic therapy in pancreatic acinar cell carcinoma have been underpowered. METHODS: We queried the National Cancer Data Base to identify patients presenting with resectable (clinical stage I and II) acinar cell carcinoma between 2004 and 2015. Multivariable Cox Regression was used to evaluate the association between overall survival and systemic therapy. RESULTS: 298 patients met inclusion criteria: 38 received no treatment; 60 received systemic therapy alone; 84 received surgical resection alone; 116 underwent resection followed by adjuvant systemic therapy. On univariate analysis, resection was associated with a survival benefit compared to no treatment and systemic therapy alone (3-year overall survival: 57% vs. 26%, p < 0.001). On Cox analysis, use of adjuvant therapy was associated with a survival benefit compared to resection alone (HR 0.54, 95% CI: 0.33-0.89). CONCLUSIONS: Adjuvant therapy is associated with a significant survival benefit in patients with resectable acinar cell carcinoma.

Adjuvant systemic therapy for intermediate and large gastric gastrointestinal stromal tumors (GISTs): Is there a survival benefit following margin negative surgical resection?

BACKGROUND: The value of adjuvant systemic therapy after margin-negative resection for gastric gastrointestinal stromal tumors (GISTs) remains unclear. METHODS: The National Cancer Data Base was queried to identify patients undergoing margin negative resections for gastric GISTs >2 cm between 2010 and 2015. Patients were stratified by tumor size (small: 2.1-5 cm, intermediate: 5.1-10 cm, large: >10 cm), histologic grade (low: ≤5 mitoses/50 HPF and high: >5 mitoses/50 HPF), and use of adjuvant therapy. Multivariable cox proportional hazard methods were used to compare overall survival (OS). RESULTS: 3520 patients met inclusion criteria. Adjuvant therapy was associated with a statistical improvement in OS (86% vs. 76%, p = 0.014) for those with large tumors but had no measurable effect in patients with small or intermediate sized tumors. On multivariable analysis, this association was independent of grade. CONCLUSIONS: Adjuvant therapy is associated with improved OS for patients with gastric GISTs >10 cm but provides no statistically significant benefit in OS for those with GISTs 2-10 cm.

Sublobar resection is associated with decreased survival for patients with early stage large-cell neuroendocrine carcinoma of the lung.

OBJECTIVES: Sublobar resection (SLR) for early non-small-cell lung carcinoma (NSCLC) has been shown to have a survival rate similar to that of lobectomy. Large-cell neuroendocrine carcinoma (LCNEC) of the lung, although treated like an NSCLC, has a poor prognosis compared to NSCLC. We sought to determine if outcomes are poor in patients with early stage LCNEC treated with SLR versus lobectomy. METHODS: We searched for patients with pathological stage I LCNEC ≤3 cm within the National Cancer Database between 2004 and 2014. Propensity score matching was used to compare the 5-year overall survival rate of patients having SLR (wedge or segmentectomy) to that of patients having a lobectomy. Patients were matched for age, node sampling, comorbidity score, tumour size, insurance status and other factors. Patients who received neoadjuvant therapy were excluded. Kaplan-Meier methods were used for analysis. RESULTS: A total of 1011 patients met the inclusion criteria: 263 were treated with SLR (223 wedges and 40 segmentectomies) and 748 patients, with lobectomy. Patients who received SLR were older, had more comorbidities and smaller tumours. On unadjusted Kaplan-Meier analysis, patients who had SLR had decreased 5-year overall survival compared to those who had a lobectomy (37.9% vs 56.6%, P < 0.001). Propensity score matching (1:1) across 12 demographic and tumour variables yielded 185 patients per group with 34 segmentectomies and 151 wedge resections in the SLR cohort. On Kaplan-Meier analysis of the matched cohort, patients who had SLR had a worse 5-year overall survival rate compared to those who had a lobectomy (41.5% vs 60.3%; P = 0.001). CONCLUSIONS: SLR for early stage LCNEC is associated with a lower 5-year overall survival rate compared to lobectomy on unadjusted and propensity matched analyses.

Node-Positive Segmentectomy for Non-Small-Cell Lung Cancer: Risk Factors and Outcomes.

BACKGROUND: Segmentectomy for well-selected early stage non-small-cell lung carcinoma (NSCLC) has been shown to have similar oncologic outcomes and survival to lobectomy. However, these data are based on the presumption that the disease is node negative. Few data exist regarding the risk factors for and the outcomes of patients with disease treated with segmentectomy that is found to be node positive. We sought to determine the risk factors for and outcomes of clinical stage I NSCLC patients who are treated with segmentectomy but are determined to be node positive. PATIENTS AND METHODS: We queried patients with clinical stage I NSCLC ≤ 3 cm within the National Cancer Data Base between 2004 and 2014 who were treated with segmentectomy or lobectomy and found to have positive nodes. Kaplan-Meier curves with log-rank tests were used to compare overall survival (OS) between segmentectomy and lobectomy. For comparison only, segmentectomy patients with pathologically node-negative disease were identified to determine predictors of node positivity after segmentectomy via multivariable logistic regression. RESULTS: A total of 4556 patients with node-positive disease were identified, comprising 115 segmentectomy patients and 4441 lobectomy patients. Multivariable analysis identified increasing tumor size, squamous-cell histology, and increasing number lymph nodes sampled as significant predictors of node positivity after segmentectomy. There was no difference in OS between segmentectomy and lobectomy, with 3-year OS rates of 66.3% and 68.1%, respectively (P = .723). CONCLUSION: There are discrete risk factors for discovering positive nodes after segmentectomy. Segmentectomy is associated with similar OS compared to lobectomy for clinical stage I NSCLC found to be node positive.

Health Disparities Impact Expected Treatment of Pancreatic Ductal Adenocarcinoma Nationally.

BACKGROUND AND PURPOSE: National adherence to treatment guidelines for pancreatic ductal adenocarcinoma (PDAC) is a concern. This study aims to evaluate national expected treatment (ET) adherence for all PDAC stages. We hypothesized that both patient and hospital demographics are associated with national ET disparities for PDAC. METHODS: Clinical stage I through IV PDAC patients were evaluated using the National Cancer Data Base from 2004 to 2013. ET was defined as surgery for stage I/II, chemotherapy or radiation for stage III, and chemotherapy for stage IV. Unexpected treatment (UT) was defined as no surgery for stage I/II, surgery for stage III, and radiation or surgery for stage IV. No treatment is denoted by NT. RESULTS: 171,351 patients were identified, of whom 56,589 (33.0%) were stage I/II, 23,459 (13.7%) were stage III, and 91,303 (53.3%) were stage IV. Of patients, 48.4% received ET, 14.7% received UT, and 36.9% received NT. ET rates were 41.1% for stage I/II, 65.4% for stage III, and 48.5% for stage IV patients. On multivariable analysis, older age, non-White race, lower socioeconomic status, being uninsured or Medicaid, increased comorbidities, nonacademic centers, and low-volume hospitals were independent negative predictors of receiving ET (P < 0.01). On subgroup analysis, high-volume academic centers had similar negative predictors of ET despite higher ET adherence overall (P < 0.01). CONCLUSIONS: Patient and hospital factors impact ET of PDAC on a national level. These treatment disparities for PDAC are concerning, even at high-volume academic centers. Future studies need to identify the causes of treatment disparities for PDAC with intervention measures aimed to relieve treatment disparities.

Neoadjuvant Chemoradiation Shows No Survival Advantage to Chemotherapy Alone in Stage IIIA Patients.

BACKGROUND: For operable patients with clinical stage IIIA non-small cell lung cancer, the optimum neoadjuvant treatment strategy remains unclear. Our aim was to compare perioperative and long-term outcomes for patients receiving neoadjuvant chemoradiotherapy (NCRT) versus neoadjuvant chemotherapy (NCT) alone. METHODS: We queried the National Cancer Database to identify all patients with N2 and either T1-T2 non-small cell lung cancer who received either NCRT or NCT followed by lobectomy between 2006 and 2012. Patients with T3 tumors were excluded. A propensity match analysis was performed incorporating preoperative variables, and the incidence of postoperative complications, pathologic downstaging, and long-term survival were compared. RESULTS: In all, 1,936 patients met criteria, 745 NCT and 1,191 NCRT. The NCRT patients were younger, less likely to be treated at an academic medical center, and more likely to have adenocarcinoma. After propensity matching, patients in the NCT group showed lower 30-day mortality (1.3% versus 2.9%) and 90-day mortality (2.9% versus 6.0%), and were more likely to undergo a minimally invasive resection (25.7% versus 14.1%). The NCRT patients were more likely to have a pathologic complete response (14.2% versus 4.0%) and to be N0 at the time of resection (45.2% versus 38.7%). In the multivariable analysis, NCRT patients were at a greater risk of mortality than NCT patients (hazard ratio 1.18, 95% confidence interval: 1.03 to 1.36). CONCLUSIONS: In our cohort, combined neoadjuvant chemotherapy and radiation therapy was associated with improved pathologic downstaging but showed increased perioperative mortality with no improvement in long-term overall survival. For stage IIIA patients with smaller tumors without local invasion, chemotherapy alone may be the preferred neoadjuvant treatment.

Thyroid lobectomy is not sufficient for T2 papillary thyroid cancers.

BACKGROUND: Histologic subtypes of papillary thyroid cancer affect prognosis. The objective of this study was to examine whether survival is affected by extent of surgery for conventional versus follicular-variant papillary thyroid cancer when stratified by tumor size. METHODS: Using the National Cancer Data Base, we evaluated 33,816 adults undergoing surgery for papillary thyroid cancer from 2004 to 2008 for 1.0-3.9 cm tumors and clinically negative lymph nodes. Conventional and follicular-variant papillary thyroid cancers were divided into separate groups. Cox regression models stratified by tumor size were used to determine if extent of surgery affected overall survival. RESULTS: A total of 30,981 patients had total thyroidectomy and 2,835 had thyroid lobectomy; 22,899 patients had conventional papillary thyroid cancer and 10,918 had follicular-variant papillary thyroid cancer. On unadjusted KM analysis, total thyroidectomy was associated with improved survival for conventional (P = 0.02) but not for follicular-variant papillary thyroid cancer patients (P = 0.42). For conventional papillary thyroid cancer, adjusted analysis showed total thyroidectomy was associated with improved survival for 2.0-3.9 cm tumors (P = 0.03) but not for 1.0-1.9 cm tumors (P = 0.16). For follicular-variant, lobectomy and total thyroidectomy had equivalent survival for 1.0-1.9 cm (P = 0.45) and 2.0-3.9 cm (P = 0.88) tumors. CONCLUSION: Tumor size, histologic subtype, and surgical therapy are important factors in papillary thyroid cancer survival. Total thyroidectomy was associated with improved survival in patients with 2.0-3.9 cm conventional papillary thyroid cancer, and should be considered for 2.0-3.9 cm papillary thyroid cancers when preoperative molecular analysis is not used to distinguish conventional from follicular-variant.

Robotic pancreatoduodenectomy at an experienced institution is not associated with an increased risk of post-pancreatic hemorrhage.

BACKGROUND: Postpancreatectomy hemorrhage (PPH) is a serious and life threatening complication following pancreaticoduodenectomy. The objective was to determine whether PPH incidence is elevated in a series of robotic pancreatoduodenectomy (RPD) from a high-volume institution and if video review can identify technical factors associated with PPH. METHODS: A retrospective review of RPDs from October 2008 to March 2016 was performed. PPH was classified by established international criteria. Technical factors from RPD resection were ascertained using video analysis. Clinical and technical variables were analyzed using multivariate analysis. RESULTS: Of 400 patients who underwent RPD PPH occurred in 19 (4.8%) and 168 (42%) had videos available to review. The technique of RPD was consistent but a falciform flap was performed routinely after RPD#181 and flaps were performed less (37.5% vs 75%) in the pseudoaneurysm group (p = 0.033). On univariate analysis of technical variables, gastroduodenal artery (GDA) mishandling and suture ligation were positive predictors of pseudoaneurysm formation while falciform flap placement was a negative predictor (all p < 0.05). GDA suture ligation remained significant on multivariate analysis (p = 0.006). A negative relationship was found between pseudoaneurysm occurrence and time (ρ = -0.533; p < 0.05). CONCLUSIONS: PPH in a large series of RPD is similar to reported rates in historical open control series; however, pseudoaneurysm is less common with increasing experience. Video review is a useful tool in identifying technical variables during in RPD.

Predictors of pathologic upstaging in early esophageal adenocarcinoma: Results from the national cancer database.

BACKGROUND: Upstaging in early esophageal adenocarcinoma (EAC) patients happens at a high rate and has implications for treatment. We sought to identify risk factors predicting upstaging. STUDY DESIGN: The National Cancer Database (2010-2013) was queried for all patients with clinical T1/T2 and N0 EAC who underwent esophagectomy without neoadjuvant therapy. Logistic regression models were developed to investigate risk factors for upstaging. RESULTS: A total of 1120 patients were included. Pathologic upstaging occurred in 21.3% (n = 239). After adjustment, risk of upstaging increased with tumor size (tumor size 1-3 cm, OR 4.57,95% CI 2.58-8.10, tumor size >3 cm, OR 10.57, 95% CI 5.77-19.35, as compared to tumors <1 cm) as well as with positive margins (OR 4.13, 95% CI 2.17-7.87) and > than 10 lymph nodes examined (OR 1.85, 95% CI 1.29-2.63), while facility volume was not significant. Odds of upstaging increased linearly with number of lymph nodes examined (OR 1.02 per node). CONCLUSION: Our data underscore the importance of tumor size as a predictor for upstaging and of completing a thorough lymph node dissection for staging purposes.