Comparative effectiveness of stereotactic body radiation therapy versus surgery for stage I lung cancer in otherwise healthy patients: An instrumental variable analysis.

Objectives: Stereotactic body radiation therapy (SBRT) is an established primary treatment modality in patients with lung cancer who have multiple comorbidities and/or advanced-stage disease. However, its role in otherwise healthy patients with stage I lung cancer is unclear. In this context, we compared the effectiveness of SBRT versus surgery on overall survival using a national database. Methods: We identified all patient with clinical stage I non-small cell lung cancer from the National Cancer Database from 2004 to 2016. We defined otherwise healthy patients as those with a Charlson-Deyo comorbidity index of 0 and whose treatment plan included options for either SBRT or surgery. We further excluded patients who received SBRT due to a contraindication to surgery. We first used propensity score matching and Cox proportional hazard models to identify associations. Next, we fit 2-stage residual inclusion models using an instrumental variables approach to estimate the effects of SBRT versus surgery on long-term survival. We used the hospital SBRT utilization rate as the instrument. Results: Of 25,963 patients meeting all inclusion/exclusion criteria, 5465 (21%) were treated with SBRT. On both Cox proportional hazards modeling and propensity-score matched Kaplan-Meier analysis, surgical resection was associated with improved survival relative to SBRT. In the instrumental-variable-adjusted model, SBRT remained associated with decreased survival (hazard ratio, 2.64; P < .001). Both lobectomy (hazard ratio, 0.17) and sublobar resections (hazard ratio, 0.28) were associated with improved overall survival compared with SBRT (P < .001). Conclusions: In otherwise healthy patients with stage I NSCLC, surgical resection is associated with a survival benefit compared with SBRT. This is true for both lobar and sublobar resections.

Low and moderate grade retroperitoneal liposarcoma: Is adjuvant radiotherapy associated with improved survival in patients undergoing R1 resection?

BACKGROUND: Few studies evaluate the efficacy of adjuvant radiotherapy (aXRT) in patients with retroperitoneal liposarcoma undergoing resection to histologically positive (R1) margins. METHODS: We queried the National Cancer Database to identify patients undergoing R1 resection for localized, large (>5 cm) low and moderate grade retroperitoneal liposarcoma between 2004 and 2016. Kaplan Meier method was used to compare overall survival (OS) for patients receiving aXRT to a 1:2 propensity-matched cohort of patients undergoing resection alone. RESULTS: A total of 322 (76.5%) patients underwent R1 resection alone, while 99 (23.5%) underwent resection followed by aXRT. The 99 receiving aXRT were successfully 1:2 propensity-score matched to 198 undergoing resection alone. There was no difference in 5-year OS between matched cohorts (69.7% vs 76.2%, p = 0.40). CONCLUSIONS: In patients undergoing R1 resection of moderate- and well-differentiated retroperitoneal liposarcoma, use of aXRT is not associated with an improvement in OS.

Octogenarians undergoing pancreaticoduodenectomy: Assessing outcomes, disposition, and timing of chemotherapy.

BACKGROUND: Inclusion of pancreaticoduodenectomy has demonstrated higher rates of curative treatment in pancreatic cancer, yet prior research has suggested increased postoperative complications in octogenarians (patients older than 80 years). This study aimed to understand the impact of age on patients undergoing a pancreaticoduodenectomy, focusing on postoperative outcomes and return to intended oncologic treatment. MATERIALS AND METHODS: We conducted a single-institution retrospective cohort study for patients undergoing pancreaticoduodenectomy from 2007 to 2018. Collected data included demographics, preoperative comorbidities, and postoperative data (length of stay, 30-day mortality, 1-year mortality, infection, discharge location). Data were separated into 2 cohorts: octogenarians (≥ 80 years) and nonoctogenarians (< 80). χ2 and independent-sample t tests were used for analysis. RESULTS: A total of 649 patients underwent pancreaticoduodenectomy from 2007 to 2018; 63 (9.7%) were octogenarians. No differences were found in infectious complications (P = .607), 30-day mortality (P = .363), or 1-year mortality (P = .895). Octogenarians had a longer length of stay (P = .003) and were more likely to be discharged to skilled nursing facilities (P < .001). There was no significant difference in neoadjuvant chemotherapy administration, although octogenarians were less likely to receive adjuvant chemotherapy (P = .048) and declined adjuvant therapy at a higher rate (P = .003). CONCLUSION: Performing a pancreaticoduodenectomy in octogenarians can be safe and effective in a properly selected cohort. Although postoperative morbidity and mortality are similar to younger patients, elderly patients are more likely to be discharged to nursing facilities and less likely to receive adjuvant chemotherapy. This study suggests that age alone should not be a discriminating factor when discussing surgical therapy for pancreatic cancer treatment in octogenarians.

Resectable intrahepatic and hilar cholangiocarcinoma: Is margin status associated with survival?

BACKGROUND: Prior studies evaluating the effect of margin status on clinical outcome in patients undergoing resection for intrahepatic and extrahepatic hilar cholangiocarcinoma include small numbers of patients with histologically positive margins. The value of margin negative resection in these cases remains unclear. METHODS: We queried the National Cancer Database to identify patients undergoing resection for clinical stage I to III intrahepatic and extrahepatic hilar between 2004 and 2015. Patients receiving neoadjuvant therapy and those having <3 lymph nodes examined were excluded. Patients undergoing positive resection were 1:1 propensity matched to those undergoing negative resection. Kaplan-Meier methods were used to compare overall survival for the matched cohorts. RESULTS: In the study, 3,618 patients met the inclusion criteria, and 3,018 (83.4%) underwent negative resection; 600 (16.6%) positive resection. Patients undergoing negative resection had smaller tumors (2.97 ± 0.07 cm vs 3.49 ± 0.15 cm), were less likely to have stage 3 disease (16.7% vs 25.7%) and to receive adjuvant radiation (27.1% vs 45.7%) and chemotherapy (49.4% vs 61.0%) than those undergoing positive resection (all P < .05). On comparison of matched cohorts, patients undergoing negative resection had longer median overall survival (24.5 ± 0.02 vs 19.1 ± 0.02 months) and higher rates of 5-year overall survival (24.5% vs 16.7%) than those undergoing positive resection (P < .01). CONCLUSION: In patients presenting with resectable intrahepatic and extrahepatic hilar, negative resection is associated with improved overall survival. Extended resections performed in an effort to clear surgical margins are warranted in patients fit for such procedures.

Is positive histologic surgical margin associated with overall survival in patients with resectable gallbladder cancer?

BACKGROUND: Achieving microscopically negative (R0) surgical margins in gallbladder cancer often requires a partial hepatectomy with associated risk of morbidity and potential to delay adjuvant therapy. Prior studies on the importance of margin status in resectable gall bladder cancer include small numbers of patients with positive (R1) resection margins and are underpowered. METHODS: We queried the National Cancer Database to identify patients undergoing resection of gallbladder adenocarcinoma between 2004 and 2015. Patients presenting with metastatic disease, those who received neoadjuvant therapy, and those with fewer than 3 lymph nodes assessed were excluded. 1:1 propensity score matching was used to develop cohorts undergoing either R0 or R1 resection, matched for demographic, pathologic, and facility characteristics. Kaplan-Meier analysis was used to assess the association between margin status and overall survival. RESULTS: A total of 1,439 patients met inclusion criteria; 1,285 underwent R0 and 154 underwent R1 resection. On Kaplan-Meier analysis of propensity-matched cohorts, patients undergoing R0 resection had a median overall survival that was 18 months longer than those undergoing R1 resection (34.6 ±â€¯2.0 months vs 16.3 ±â€¯1.7 months, P < .001). CONCLUSION: In patients presenting with resectable gallbladder adenocarcinoma, margin-negative resection is associated with significant improvement in overall survival.

The importance of the margin of resection and radiotherapy in retroperitoneal liposarcoma.

BACKGROUND: Prior studies evaluating the impact of adjuvant or neoadjuvant radiotherapy on clinical outcomes in retroperitoneal liposarcoma have been underpowered. METHODS: We queried the National Cancer Database for patients undergoing resection of retroperitoneal liposarcoma from 2004 to 2016. Cox proportional hazards modeling stratified by tumor size was used to identify factors associated with overall survival. RESULTS: 4018 patients met inclusion criteria. 251 had small (<5 cm), 574 intermediate (5-10 cm), and 3193 large (>10 cm) tumors. Positive surgical margins were correlated with risk of death across all tumor size categories (<5 cm HR 2.33, CI [1.20, 4.55]; 5-10 cm HR 1.49, CI [1.03, 2.14]; >10 cm HR 1.30, CI [1.12, 1.51]). Adjuvant radiotherapy was associated with improved survival for patients with large tumors only (HR 0.75, CI [0.64, 0.89]). CONCLUSIONS: In retroperitoneal liposarcoma, adjuvant radiation is associated with improved survival only for patients with tumors larger than 10 cm. Radiation should be used sparingly in patients with smaller tumors. SUMMARY: The use of radiotherapy in the management of retroperitoneal sarcoma remains controversial. We isolated retroperitoneal liposarcomas only and identified a survival benefit from radiotherapy treatment only in tumors larger than 10 cm and only in the adjuvant setting.

The importance of the margin of resection and external radiation in non-lipomatous retroperitoneal sarcoma.

BACKGROUND: Prior studies evaluating the impact of adjuvant or neoadjuvant radiation on clinical outcomes of patients with non-lipomatous retroperitoneal sarcoma have been underpowered. METHODS: We queried the National Cancer Database to identify patients undergoing surgical resection of retroperitoneal sarcoma with non-lipomatous histology from 2004 to 2016. Multivariable logistic regression and Cox proportional hazards modelling with patients stratified by tumor size were used to identify factors associated with overall survival. RESULTS: 3,394 patients met inclusion criteria. 592 had small (<5 cm), 1,186 had intermediate (5-10 cm), and 1,616 had large (>10 cm) tumors. Use of either neoadjuvant or adjuvant radiotherapy was associated with improved survival for patients with intermediate (neoadjuvant HR 0.67, CI [0.46, 0.98]; adjuvant HR 0.61, CI [0.50, 0.76]) and large (neoadjuvant HR 0.50, CI [0.37, 0.68]; adjuvant HR 0.56, CI [0.47, 0.69]) tumors, while adjuvant radiation therapy was associated with a survival benefit for small-sized tumors (HR 0.67, CI [0.46, 0.99]). CONCLUSIONS: Radiation therapy is associated with an overall survival benefit in patients presenting undergoing resection of non-lipomatous retroperitoneal sarcoma.