Outcomes of single-lung retransplantation after double-lung transplantation.

OBJECTIVE: To compare outcomes of single-lung retransplantation (SLRTx) and double-lung retransplantation (DLRTx) after an initial double-lung transplantation. METHODS: The Organ Procurement and Transplantation Network/United Network for Organ Sharing database between May 2005 and December 2022 was retrospectively analyzed. Multiorgan transplantations, repeated retransplantations, and lung retransplantations when the status of the initial transplantation was unknown were excluded. RESULTS: A total of 891 patients were included in the analysis, included 698 (78.3%) with DLRTx and 193 (21.7%) with SLRTx. The mean lung allocation score was higher in the DLRTx group (59.6 ± 20.7 vs 55.1 ± 19.3; P = .007). The use of extracorporeal membrane oxygenation (ECMO) bridge to lung transplantation was similar in the 2 groups (P = .125), as was waitlist time (P = .610). The need for mechanical ventilation (54.6% vs 35.8%; P = .005) and ECMO (17.9% vs 9.0%; P = .069) at 72 hours post-transplantation was greater in the DLRTx group. However, median post-transplantation hospital stay (21.5 [interquartile range (IQR), 12-35] days versus 20 [IQR, 12-35] days; P = .119) and in-hospital mortality (10.9% [n = 76/698] vs 12.4% [n = 24/193]; P = .547) were comparable in the 2 groups. Long-term survival was significantly better in the DLRTx group (P < .001, log-rank test). In the propensity score-weighted multivariable model, the DLRTx group had 28% lower risk of mortality at any point during follow-up compared to the SLRTx group (hazard ratio, 0.72; 95% confidence interval, 0.57-0.91; P = .006). CONCLUSIONS: The less invasiveness of single-lung transplantation in the retransplantation setting has minimal short-term benefit and is associated with significantly worse long-term survival. Double-lung retransplantation should remain the standard for lung retransplantation after initial double-lung transplantation.

Thrombolysis and Surgical Decompression for Venous Thoracic Outlet Syndrome.

INTRODUCTION: Treatment for venous thoracic outlet syndrome (vTOS) includes thrombolysis followed by decompressive rib resection. Given the rarity of the disease, the goal of this study was to describe current practices in treatment of vTOS. METHODS: All patients with diagnoses of subclavian vTOS who underwent rib resection in the 2018-2020 Nationwide Readmissions Database were included in this study. Patients were grouped based on number of days between thrombolysis and by number of hospitalizations: thrombolysis followed by surgery in the same hospitalization was considered "simultaneous" and in separate hospitalizations was "staged." RESULTS: Five hundred ninety patients met the inclusion criteria. The average age was 34.1 ± 13.3 y, and 42.9% (253 of 590) were female. Among the patients receiving thrombolysis and decompressive rib resection, 46.8% (164 of 350) patients had <14 d between interventions, 19.1% (67 of 350) patients had 14-30 d between interventions, and 34.0% (119 of 350) had >30 d between interventions. There were no significant differences in postoperative bleeding between patients with <14 d, 14-30 d, and >30 d between thrombolysis and surgery. In terms of number of hospital visits, 19.0% (112 of 590) had "simultaneous" thrombolysis and surgery and 40.5% (239 of 590) had thrombolysis and surgery in a "staged" approach. Forty point five percent (239 of 590) of patients received only surgical decompression without thrombolysis. CONCLUSIONS: Thrombolysis followed by first rib resection for vTOS can be performed during the same hospital admission without an associated risk of bleeding complications.

Initial management and outcomes of nonmalignant esophageal perforations: A Nationwide Inpatient Sample analysis.

BACKGROUND: Management of esophageal perforation includes open surgery, minimally invasive surgery, and endoscopic stent placement. This study analyzed initial treatment and the associated short-term outcomes. METHODS: A retrospective study using the National Inpatient Sample between October 2015 and December 2019 identified adults >18 years with esophageal perforation undergoing an initial nonelective esophageal procedure categorized into either open surgery, minimally invasive surgery, or endoscopic stent placement. Patients with esophageal cancer were excluded. Baseline characteristics and the van Walraven-weighted Elixhauser Comorbidity Index were identified. Outcomes included in-hospital mortality and postintervention complications. Univariable and multivariable Cox regression was used to compare in-hospital survival. RESULTS: In total, 3,345 patients met inclusion criteria: the median age was 62 years (interquartile range 50-72 years), and 1,310 (39%) were female. Open procedure was pursued in 2,650 (79%), minimally invasive surgery in 310 (9%), and endoscopic stent placement in 385 (12%) with no differences in van Walraven-weighted Elixhauser Comorbidity Index or mortality. Patients who underwent minimally invasive surgery had a greater proportion of gastrointestinal complications (P = .006); otherwise, there were no differences in postintervention complications. In total, 380 (11%) patients died and were significantly older, with greater van Walraven-weighted Elixhauser Comorbidity Index, and had more postintervention complications. Univariable Cox regression identified age (hazard ratio 1.95, P < .001), van Walraven-weighted Elixhauser Comorbidity Index (hazard ratio 1.06, P < .001), stent placement (hazard ratio 1.93, P = .045), and transfer from a health facility (HR 2.40, P = .049) as associated with decreased in-hospital survival. Multivariable Cox regression revealed age (hazard ratio 1.041, P < .001) and van Walraven-weighted Elixhauser comorbidity index (hazard ratio 1.055, P < .001) were associated with decreased in-hospital survival. CONCLUSION: Patients with esophageal perforation had an 11% in-hospital mortality rate and significant associated complications regardless of intervention. Increasing age and comorbidities are associated with poorer in-hospital survival.

Association between underweight status and chylothorax after esophagectomy for esophageal cancer: A propensity score-matched analysis.

Objective: To use a nationwide database of hospitalizations to investigate underweight status as a risk factor for postesophagectomy complications. Methods: We identified all patients who underwent esophagectomy with a diagnosis of esophageal cancer and known body mass index in the 2018-2020 Nationwide Readmissions Database. All hospital visits for esophagectomy and within 30 days of initial discharge were analyzed for postoperative complications, including chylothorax. Patients who were underweight were propensity score matched with patients who were not. Multivariable logistic regression was performed to identify complications that were significantly associated with underweight status. Results: There were 1877 patients with esophageal cancer meeting inclusion criteria. Following propensity score matching, 433 patients who were underweight were matched to 433 patients who were not. In the multivariable model of the matched sample, which adjusted for age, sex, Charlson Comorbidity Index, history of chemotherapy or radiation therapy, and preoperative surgical feeding access, patients who were underweight were estimated to have 2.06 times the odds for chylothorax (95% confidence interval [CI], 1.07-4.25, P = .035). Underweight status was also significantly associated with acute bleed (odds ratio [OR], 1.52; 95% CI, 1.12-2.05, P = .007), pneumothorax (OR, 2.33; 95% CI, 1.19-4.85; P = .017), pneumonia (OR, 2.30; 95% CI, 1.53-3.50, P < .001), and in-hospital mortality (OR, 2.42; 95% CI, 1.31-4.69, P = .006). Conclusions: Underweight status was found to be a risk factor for chylothorax after esophagectomy, which may have implications for perioperative care of esophageal cancer patients. Future studies should assess whether using feeding tubes or total parenteral nutrition preoperatively or thoracic duct ligation intraoperatively decreases risk of chylothorax among patients who were underweight.

Delayed esophagectomy for adenocarcinoma is associated with a negative impact on long-term survival and an increased risk of perioperative morbidity.

OBJECTIVE: Delayed esophagectomy (DE) following chemoradiation therapy (CXRT) for esophageal carcinoma is undertaken in selected patients. This study aimed to assess both short-term outcomes and long-term survival for patients with adenocarcinoma undergoing DE. METHODS: The National Cancer Database was queried for patients with American Joint Committee on Cancer clinical stage II-III esophageal adenocarcinoma undergoing esophagectomy after CXRT. Patients were categorized as (1) DE, ≥90 days between completion of CXRT and surgery or (2) nondelayed esophagectomy (NDE), <90 days. Cox regression was performed to identify factors associated with mortality. RESULTS: A total of 8157 patients met criteria. Age >69, nonwhite race, Medicare/Medicaid insured patients preferentially underwent DE. Five-year overall survival (OS) favored NDE (36% vs. 31%, p = 0.008). Cox regression identified DE, clinical stage >T2, or >N0 as factors associated with mortality. Within the DE group, OS favored early cT-status. DE fared worse than NDE in 30- and 90-day mortality (4.5%/11.1% vs. 2.9%/6.5%, p < 0.01/p < 0.001) and margin positive resection (7.1% vs. 4.2%, p < 0.001). CONCLUSIONS: For esophageal adenocarcinoma, DE is associated with decreased OS compared to NDE. For DE, cT-status is prognostic for OS, while cN-status was not. Increased 30-/90-day mortality and margin positive resection rates for DE question whether patients with locally advanced (cT3/T4) primary esophageal adenocarcinoma should undergo intentional DE.

Longer hospitalizations, more complications, and greater readmissions for patients with comorbid psychiatric disorders undergoing pulmonary lobectomy.

OBJECTIVE: To examine the influence of comorbid psychiatric disorders (PSYD) on postoperative outcomes in patients undergoing pulmonary lobectomy. METHODS: A retrospective analysis of the Healthcare Cost and Utilization Project Nationwide Readmissions Database from 2016 to 2018 was performed. Patients with lung cancer with and without psychiatric comorbidities who underwent pulmonary lobectomy were collated and analyzed (International Classification of Diseases, 10th Revision, Clinical Modification Mental, Behavioral and Neurodevelopmental disorders [F01-99]). The association of PSYD with complications, length of stay, and readmissions was assessed using a multivariable regression analysis. Additional subgroup analyses were performed. RESULTS: A total of 41,691 patients met inclusion criteria. Of these, 27.84% (11,605) of the patients had at least 1 PSYD. PSYD was associated with a significantly increased risk of postoperative complications (relative risk, 1.041; 95% CI, 1.015-1.068; P = .0018), pulmonary complications (relative risk, 1.125; 95% CI, 1.08-1.171; P < .0001), longer length of stay (PSYD mean, 6.79 days and non-PSYD mean, 5.68 days; P < .0001), higher 30-day readmission rate (9.2% vs 7.9%; P < .0001), and 90-day readmission rate (15.4% vs 12.9%; P < .007). Among patients with PSYD, those with cognitive disorders and psychotic disorders (eg, schizophrenia) appear to have the highest rates and risks of postoperative morbidity and in-hospital mortality. CONCLUSIONS: Patients with lung cancer with comorbid psychiatric disorders undergoing lobectomy experience worse postoperative outcomes with longer hospitalization, increased rates of overall and pulmonary complications, and greater readmissions suggesting potential opportunities for improved psychiatric care during the perioperative period.

Delays to surgery and worse outcomes: The compounding effects of social determinants of health in non-small cell lung cancer.

Objective: To quantify the compounding effects of social determinants of health on time to surgery (T2S) and clinical outcomes. Methods: The National Cancer Database was queried for treatment-naïve patients with cT1-4N0-1M0 non-small cell lung cancer undergoing (bi)lobectomy or pneumonectomy between 2006 and 2016 with 1 to 180 days T2S, the number of days between diagnosis and surgery; surgical delays were defined as statistically significant increased T2S compared with a reference cohort. Social determinants of health factors prognostic for surgical delays were identified using multivariable regression. The 30-/90-day mortality and 5-year survival estimates were calculated using logistic and Cox regressions, respectively. Results: In total, 110,005 patients met inclusionary criteria. Multivariable analysis identified race, insurance, and facility type as factors with significant 3-way interaction: T2S of one depended on the others. Income and education also contributed to delays. Privately insured (private) non-Hispanic White patients at academic medical centers (AMCs) were the reference with T2S of 44.1 days. At AMCs, private Black patients had significant delays to surgery (54.7 days; P < .0001), as did Medicaid and uninsured Black patients (58.5 days; P < .0001, 59.4 days; P < .0001, respectively). The 15-day surgical delays were associated with statistically significant 5% increased 30-day mortality odds (confidence interval [CI], 1.03-1.08), 6% increased 90-day mortality odds (CI, 1.04-1.08), and 4% decrease in hazard of death at 5 years (CI, 1.04-1.05). Conclusions: In treatment-naïve patients with cT1-4N0-1M0 non-small cell lung cancer, Black race, Medicaid, uninsured status, and AMCs generate compounding surgical delays with increased 30-/90-day mortality and decreased 5-year survival. Thoracic surgeons can leverage these facility and demographic-specific insights to standardize time to surgery and begin mitigating underlying disparities.

Early outcomes of lung transplantation with lung allografts from coronavirus disease 2019 (COVID-19)-positive donors.

OBJECTIVE: Coronavirus disease 2019 (COVID-19) can be detected for extended periods of time with nucleic acid amplification test even after transmissibility becomes negligible. Lung allografts from COVID-19-positive donors have been used for transplantation in highly selected cases. This study aimed to clarify the early outcomes of lung transplantation with COVID-19-positive donors. METHODS: The Organ Procurement and Transplantation Network/United Network for Organ Sharing database between April 2020 and June 2022 was retrospectively analyzed. RESULTS: In the study period, 1297 COVID-19-positive donors were identified and the lungs were transplanted from 47 donors (3.6%). Of 47 donors, 44 donors were positive for COVID-19 NAT with nasopharyngeal swabs and the other 3 were positive with bronchoalveolar lavage. The COVID-19-positive lung donors were younger than the COVID-19-negative donors (28.4 ± 11.6 years vs 35.4 ± 13.6 years, P < .001). Recipients of the COVID-19-positive lungs (n = 47) were more likely have a greater lung allocation score (57.1 ± 22.9 vs 50.5 ± 19.7, P = .057) than recipients of COVID-19-negative lungs (n = 5501). The posttransplant length of hospital stay (39.8 ± 43.6 days vs 30.6 ± 34.5 days, P = .181), need for extracorporeal membrane oxygenation support at 72 hours after transplantation (2.6% [1/38] vs 10.4% [541/5184], P = .18), and 1-year overall survival rate (85.6% vs 87.1%, P = .63) were comparable between the 2 groups. CONCLUSIONS: Carefully selected lung allografts from COVID-19-positive donors had comparable early posttransplant outcomes to lung allografts from COVID-19-negative donors.

Centers for Disease Control (CDC) Wound Classification is Prognostic of 30-Day Readmission Following Surgery.

BACKGROUND: The goal of this study was to investigate factors associated with 30-day readmission in a multivariate model, including the CDC wound classes "clean," "clean/contaminated," "contaminated," and "dirty/infected." METHODS: The 2017-2020 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for all patients undergoing total hip replacement, coronary artery bypass grafting, Ivor Lewis esophagectomy, pancreaticoduodenectomy, distal pancreatectomy, pneumonectomy, and colectomies. ACS-defined wound classes were concordant with CDC definitions. Multivariate linear mixed regression was used to determine risk factors for readmission while adjusting for type of surgery as a random intercept. RESULTS: 477,964 cases were identified, with 38,734 (8.1%) patients having experienced readmission within 30 days of surgery. There were 181,243 (37.9%) cases classified as wound class "clean", 215,729 (45.1%) cases classified as "clean/contaminated", 40,684 cases (8.5%) classified as "contaminated", and 40,308 (8.4%) cases classified as "dirty/infected". In the multivariate generalized mixed linear model adjusting for type of surgery, sex, body mass index, race, American Society of Anesthesiologists class, presence of comorbidity, length of stay, urgency of surgery, and discharge destination, "clean/contaminated" (p < .001), "contaminated" (p < .001), and "dirty/infected" (p < .001) wound classes (when compared to "clean") were significantly associated with 30-day readmission. Organ/space surgical site infection and sepsis were among the most common reasons for readmission in all wound classes. CONCLUSIONS: Wound classification was strongly prognostic for readmission in multivariable models, suggesting that it may serve as a marker of readmissions. Surgical procedures that are "non-clean" are at significantly greater risk for 30-day readmission. Readmissions may be due to infectious complications; optimizing antibiotic use or source control to prevent readmission are areas of future study.

Adjuvant chemotherapy, not radiotherapy, prolongs survival for node-negative non-small cell lung cancer with positive surgical margins.

Objective: The study objective was to determine differences in survival depending on adjuvant therapy type, timing, and sequence in node-negative disease with positive margins after non-small cell lung cancer resection. Methods: The National Cancer Database was queried for patients with positive margins after surgical resection of treatment-naïve cT1-4N0M0 pN0 non-small cell lung cancer who underwent adjuvant radiotherapy or chemotherapy from 2010 to 2016. Adjuvant treatment groups were defined as surgery alone, chemotherapy alone, radiotherapy alone, concurrent chemoradiotherapy, sequential chemotherapy then radiotherapy, and sequential radiotherapy then chemotherapy. The impact of adjuvant radiotherapy initiation timing on survival was evaluated using multivariable Cox regression. Kaplan-Meier curves were generated to compare 5-year survival. Results: A total of 1713 patients met inclusion criteria. Five-year survival estimates differed significantly between cohorts: surgery alone, 40.7%; chemotherapy alone, 47.0%; radiotherapy alone, 35.1%; concurrent chemoradiotherapy, 45.7%; sequential chemotherapy then radiotherapy, 36.6%; and sequential radiotherapy then chemotherapy, 32.2% (P = .033). Compared with surgery alone, adjuvant radiotherapy alone had a lower estimated survival at 5 years, although overall survival did not differ significantly (P = .8). Chemotherapy alone improved 5-year survival compared with surgery alone (P = .0016) and provided a statistically significant survival advantage over adjuvant radiotherapy (P = .002). Compared with radiotherapy-inclusive multimodal therapies, chemotherapy alone yielded similar 5-year survival (P = .066). Multivariable Cox regression showed an inverse linear association between time to adjuvant radiotherapy initiation and survival, but with an insignificant trend (10-day hazard ratio, 1.004; P = .90). Conclusions: In treatment-naïve cT1-4N0M0 pN0 non-small cell lung cancer with positive surgical margins, only adjuvant chemotherapy was associated with a survival improvement compared with surgery alone, with no radiotherapy-inclusive treatment providing additional survival benefit. Delayed timing of radiotherapy initiation was not associated with a survival reduction.

Estimating revenue, costs, and operating margin of any hospital-based thoracic surgery practice using a novel financial model.

OBJECTIVE: The study objective was to develop a generalizable financial model that estimates payor-specific reimbursements associated with anatomic lung resections for any hospital-based thoracic surgery practice. METHODS: Medical records of patients who presented to the thoracic surgery clinic and eventually underwent an anatomic lung resection from January 2019 to December 2020 were reviewed. The volume of preoperative and postoperative studies, clinic visits, and outpatient referrals was measured. Neither subsequent studies nor procedures from outpatient referrals were captured. Diagnosis-related group, cost-to-charge ratios, Current Procedural Terminology Medicare payment data, and Private:Medicare and Medicaid:Medicare payment ratios were used to estimate payor-specific reimbursements and operating margin. RESULTS: A total of 111 patients met inclusion criteria and underwent 113 operations: 102 (90%) lobectomies, 7 (6%) segmentectomies, and 4 (4%) pneumonectomies. These patients underwent 554 total studies, received 60 referrals to other specialties, and had 626 total clinic visits. The total charges and Medicare reimbursement were $12.5 M and $2.7 M, respectively. After adjusting for a 41% Medicare, 2% Medicaid, and 57% Private payor mix, the total reimbursement was $4.7 M. With a 0.252 cost-to-charge ratio, total costs and operating income were $3.2 M and $1.5 M, respectively (ie, 33% operating margin). Average reimbursement per surgery by payor was $51k for Private, $29k for Medicare, and $23k for Medicaid. CONCLUSIONS: For any hospital-based thoracic surgery practice, this novel financial model can calculate both overall and payor-specific reimbursements, costs, and operating margin across the full perioperative spectrum. By manipulating hospital name, hospital state, volume, and payor mix, any program can gain insights into their financial contributions and use the outputs to guide investment decisions.

Heart transplantation for pediatric foreign nationals in the United States.

BACKGROUND: This study aimed to clarify survival outcomes, waitlist mortality, and waitlist days of heart transplantation of pediatric foreign nationals compared to pediatric United States (US) citizens. METHODS: We retrieved data from March 2012 to June 2021 in the United Network Organ Sharing (UNOS) registry. RESULTS: Of 5857 pediatric patients newly waitlisted, 133 (2.27%) patients were non-US citizen/non-US residents (non-citizen non-resident [NCNR]). Patients with congenital heart disease were higher in the US citizen group than in the NCNR group (51.9% vs. 22.6%, p < .001); 76.7% of patients in the NCNR group (102/133) had cardiomyopathy. Of the 133 NCNRs, 111 patients (83.5%) underwent heart transplantation, which was significantly higher than that in the US citizen group (68.6%, p < .001). The median waitlist time was 71 days (IQR, 22-172 days) in the NCNR group and 74 days (29-184 days) in the US citizen group (p = .48). Survival after heart transplant was significantly better in the NCNR group than in the US citizen group (n = 3982; logrank test p = .015). CONCLUSIONS: Heart transplantation for pediatric foreign nationals was mostly indicated for cardiomyopathy, and their transplant rate was significantly higher than that in the US citizen group, with better survival outcomes. The better survival outcomes in the NCNR group compared to the US citizen group can likely be attributed to the differing diagnoses for which transplantation was performed.

The role of surveillance and salvage esophagectomy in previously treated esophageal cancer.

Esophageal cancer remains a significant cause of cancer-related mortality among men and women in the United States. The utility of surgery, as either an immediate or delayed resection in the form of esophagectomy following neoadjuvant therapy in local-regionally advanced esophageal cancer, remains controversial. While neoadjuvant therapy followed by immediate surgery is a guideline-concordant treatment, emerging data suggests that active surveillance with delayed resection at the time of local-regional recurrence may be considered.

Benefit of adjuvant chemotherapy for resected pathologic N1 non-small cell lung cancer is unrecognized: A subgroup analysis of the JBR10 trial.

Adjuvant chemotherapy is underutilized in clinical practice, in part, because its anticipated survival benefit is limited. We evaluated the impact of AC on overall and recurrence-free survival among completely resected pN1 NSCLC patients enrolled in the North American Intergroup phase III (JBR10) trial. A post-hoc subgroup analysis of pN1 NSCLC patients was performed. Participants were randomized to cisplatin+vinorelbine (AC) (n = 118) or observation (n = 116) following complete resection. The primary endpoint was overall survival (OS). The secondary endpoint was recurrence free survival (RFS). Kaplan-Meier methods were used to compare OS and RFS between the two treatment groups. Cox regression was used to identify factors associated with OS and RFS endpoints. Both groups had similar baseline characteristics. AC patients had improved 5-year OS (AC 61.4% vs observation 41.0%, log-rank p = .008) and 5-year RFS (AC 56.2% vs observation 39.9%, log-rank p = .011) rates compared to observation. Cox regression analyses confirmed the OS (HR 0.583, 95% CI 0.402-0.846, p = .005) and RFS (HR 0.573, 95% CI 0.395-0.830, p = .003) benefit associated with AC. AC was associated with a lower risk (HR 0.648, 95% CI 0.435-0.965, p = .0326) and a lower cumulative incidence (Subdistribution Hazard Ratio [SHR], 0.67, 95% CI 0.449-0.999, p = .0498) of lung cancer deaths. In the JBR10 trial, treatment with AC conferred a significant OS and RFS advantage over observation for pN1 NSCLC patients. These data suggest that pN1 NSCLC patients may experience a disproportionately greater clinical benefit from AC than the 6% survival advantage estimated by the LACE meta-analysis.

Surgical decision-making in advanced-stage non-small cell lung cancer is influenced by more than just guidelines.

Objective: This qualitative study sought to uncover factors that influence decisions to offer curative-intent surgery for patients with advanced-stage (stage IIIB/IV) non-small cell lung cancer. Methods: A trained interviewer conducted open-ended, semistructured telephone interviews with cardiothoracic surgeons in the United States. Participants were recruited from the Thoracic Surgery Outcomes Research Network, with subsequent diversification through snowball sampling. Four hypothetical clinical scenarios were presented, each demonstrating varying levels of ambiguity with respect to international guideline recommendations. Interviews continued until thematic saturation was reached. Interview transcripts were coded using inductive reasoning and conventional content analysis. Results: Of the 27 participants, most had been in practice for ≤20 years (n = 23) and were in academic practice (n = 18). When considering nonguideline-concordant surgeries, participants were aware of relevant guidelines but acknowledged their limitations for unique scenarios. Surgeons perceived that a common barrier to offering surgery is incomplete nonsurgeon physician understanding of surgical capabilities or expected morbidity; and that improved education is necessary to correct these misperceptions. Surgeons expressed concern that undertaking a controversial resection for an individual patient could fracture trust built in long-term professional relationships. Surgeons may face pressure from patients to operate despite a low expectation of clinical benefit, leading to emotional turmoil for the patient and surgeon. Conclusions: This qualitative study generates the hypothesis that the scope of current guidelines, availability of clinical trial protocols, perceived surgical knowledge among nonsurgeon colleagues, interprofessional relationships, and emotional pressure all influence a surgeon's willingness to offer curative-intent surgery for patients with advanced-stage non-small cell lung cancer.

Lobectomy offers improved survival outcomes relative to segmentectomy for >2 but ≤4 cm non-small cell lung cancer tumors.

Objective: The objective was to compare overall survival (OS) between lobectomy and segmentectomy for patients with non-small cell lung cancers (NSCLCs) > 2 but ≤4 cm. Methods: The National Cancer Database was queried to identify treatment-naïve patients with NSCLC tumors >2 but ≤4 cm. Eligible patients were diagnosed with pT1 or T2 N0 M0 disease, underwent lobectomy or segmentectomy, and received no adjuvant therapy. OS was compared using the Kaplan-Meier method, and the Cox proportional-hazards model was used to identify prognostic factors for death. Propensity score matching was performed to minimize the effects of potential confounders. Results: Included were 32,792 patients: lobectomy (n = 31,353) and segmentectomy (n = 1439). Five-year OS was improved following lobectomy over segmentectomy for patients with >2 but ≤4 cm NSCLCs (62.3% vs 52.6%; P < .0001). Further stratification demonstrated improved 5-year OS following lobectomy over segmentectomy: >2 but ≤3 cm (64.9% vs 54.3%; P < .0001) and >3 but ≤4 cm (56.9% vs 47.6%; P = .0003). In patients with a Charlson-Deyo comorbidity index of 0, 5-year OS was greater following lobectomy for >2 but ≤4 cm tumors (67.1% vs 62.1%; P = .03). Further stratification demonstrated improved 5-year OS following lobectomy for patients with Charlson-Deyo comorbidity index of 0 and > 3 but ≤4 cm tumors (61.8% vs 54.6%; P = .02). Segmentectomy was prognostic for increased risk of death in the year 1 through 5 postoperative period (hazard ratio, 1.35; P < .0001). Five-year OS remained greater following lobectomy after propensity score matching (59.6% vs 52.7%; P = .02). Conclusions: Lobectomy is associated with superior 5-year OS compared with segmentectomy and may be preferred for NSCLC tumors >2 but ≤4 cm when feasible.

Adhering to guideline concordant care improves survival among the different subtypes of T3 N2 non-small cell lung cancer.

Objectives: T3 disease comprises heterogeneous morphologic characteristics, a variation only further complicated when in the context of N2-confirmed involvement. This study aims to examine whether or not specific features of T3 N2 non-small cell lung cancer are associated with improved 5-year overall survival when using a multimodal therapeutic approach consistent with guideline recommendations compared with definitive surgery alone. Methods: Patients with pathologic T3 N2 non-small cell lung cancer were identified in the National Cancer Database. Therapy modality, as defined by surgery alone versus surgery with adjuvant therapy, and T3 disease descriptors were compared for differences in 5-year overall survival using Kaplan-Meier analysis and log-rank tests. Multivariable Cox regression was used to determine prognostic factors for survival. Results: A total of 1924 patients met the inclusion criteria. Of these, 80.0% (n = 1539) received adjuvant chemotherapy with or without radiation therapy following surgery and 20.0% (n = 385) underwent definitive surgery alone. Patients in the 2 cohorts differed significantly in age, race, insurance status, and Charlson-Deyo score (P < .05). The overall survival for patients who underwent surgery followed by chemotherapy with or without radiation therapy compared with those who underwent surgery alone was 31.7% and 11.1%, respectively (P < .0001). Multivariable analysis demonstrated a lower risk of death with multimodal therapeutic intervention compared with surgery alone for patients with disease marked by chest wall invasion, additional ipsilateral pulmonary nodules, tumor size, and the presence of multiple T3 features. Conclusions: The utilization of a multimodal approach to treating pathologic T3 N2 NSCLC, compared with surgery alone, is associated with superior overall survival and lower risk of death for many subtypes of T3 disease.

Adjuvant chemotherapy for visceral pleural invasion in 3-4-cm non-small-cell lung cancer improves survival.

OBJECTIVES: Visceral pleural invasion (VPI) guidelines, for tumours ≤4 cm are ambiguous. Non-small-cell lung cancers (NSCLCs) 3 to ≤4 cm are assigned the T2a designation. Similarly, any tumours with VPI, smaller than 3 cm, are upstaged and also assigned the same T2a designation. We hypothesized that adjuvant chemotherapy would significantly improve 5-year survival for NSCLC ≤4 cm with VPI. METHODS: The National Cancer Database was queried from 2010 to 2016 for cases of NSCLC with clinical stage I disease, ≤4 cm, who subsequently underwent surgical resection. These stage I NSCLCs were stratified according to clinical tumour sizes (0 to ≤1, 1 to ≤2, 2 to ≤3 and 3 to ≤4 cm). This cohort was then divided into groups with and without VPI and further split based on the administration of adjuvant chemotherapy. Kaplan-Meier analysis was used to calculate 5-year overall survival (OS) for patients categorized by tumour size, VPI status, and receipt of adjuvant chemotherapy. Multivariable Cox regression adjusting for tumour size and VPI status was used to determine associations between use of adjuvant chemotherapy and OS. RESULTS: A total of 61 454 patients with NSCLC and clinical tumour sizes <4 cm were identified and grouped based on size along with VPI and adjuvant chemotherapy. The 5-year OS for combined tumour sizes without VPI was higher than for patients with VPI (66.2% vs 59.5%, P < 0.001). The OS for tumour size (0 to ≤1, 1 to ≤2, 2 to ≤3 and 3 to ≤4 cm) was lower for patients with VPI regardless of size (all P ≤ 0.010). When all tumour sizes were combined, patients with VPI who received adjuvant chemotherapy had an improved 5-year OS compared to patients without adjuvant chemotherapy (65.5% vs 58.8%, P < 0.001). When cohorts were created by tumour size, only VPI tumours 3 to ≤4 cm had a statistically significant increase in 5-year OS for patients receiving adjuvant chemotherapy (68.8% vs 49.9%, P < 0.001). On multivariable Cox regression for OS, adjuvant chemotherapy was associated with significantly longer 5-year OS in tumour size 3 to ≤4 (hazard ratio = 0.62, 95% confidence interval 0.46-0.83, P = 0.001). CONCLUSIONS: VPI remains a poor prognostic factor in clinically node-negative, T2a or less, NSCLC patients. Guidelines recommend considering chemotherapy for high-risk T2aN0, margin-negative patients-including those patients with VPI. Based on the analysis, adjuvant chemotherapy should be considered specifically for 3 to ≤4 cm with VPI due to an observed 5-year OS advantage.