Radical Treatment of Stage II Non-small-cell Lung Cancer With Nonsurgical Approaches: A Multi-institution Report of Outcomes.

INTRODUCTION: Standard management of stage II non-small-cell lung cancer (NSCLC) is surgery, often followed by adjuvant chemotherapy. However, some patients do not undergo surgery for various reasons. We examined outcomes in this defined patient group. METHODS: We reviewed the records of patients with stage II NSCLC treated nonsurgically with curative intent from 2002 to 2012 across 3 academic cancer centers. Data collected included demographics, comorbidities, staging, treatments, and survival. The primary endpoint was overall survival (OS). We assessed factors associated with treatment choice and OS. RESULTS: A total of 158 patients were included: the median age was 74 years (range, 50-91 years), 44% were female, and 68% had a performance status of 0 to 1. The stage II groupings of the patients were T2b-T3 N0 in 55% and N1 in 45%. The most common reasons for inoperability were inadequate pulmonary reserve (27%) and medical comorbidities (24%). All patients received radical radiotherapy (RT) (median, 60 Gy [range, 48-75 Gy]). Seventy-three percent received RT alone; 24% received concurrent and 3% sequential chemoradiotherapy (CRT). In multivariate analyses, CRT was less likely in older patients (≥ 70 years) (odds ratio [OR], 0.28; 95% confidence interval [CI], 0.11-0.70; P = .006) and in patients with higher (> 5) Charlson comorbidity scores (OR, 0.34; 95% CI, 0.13-0.90; P = .03) or normal (< 10 × 109/L) white blood cell counts (OR, 0.26; 95% CI, 0.09-0.73; P = .01). At the time of our analysis, 74% have died. The median OS was 22.9 months (range, 17.1-26.6 months). Patients who had undergone CRT had a significantly longer median OS than those receiving RT alone (39.1 vs. 20.5 months; P = .0019), confirmed in multivariate analysis (hazard ratio, 0.38; 95% CI, 0.21-0.69; P = .001). CONCLUSION: Nonsurgical approaches to management of stage II NSCLC are varied. Treatment with CRT was associated with significantly longer survival compared with RT alone. A randomized trial may be warranted.

Radiographic patterns and survival of patients with early and late brain metastases in EGFR wild type and mutant non small cell lung cancer.

Brain metastasis (BM) in NSCLC is a negative prognostic indicator. In the era of EGFR mutations we evaluated the difference between early (≤6 months from diagnosis) versus late BM (>6 months), in EGFR wild type (WT) and mutant (MT) NSCLC patients with respect to radiographic patterns and overall survival (OS). A retrospective study was conducted of referred patients with non-squamous NSCLC with known EGFR mutation status treated for BM from Mar 2010-Dec 2012. Radiographic patterns, treatment and survival were collected. 430 patients were identified: 327 WT (207 early vs. 120 late) and 103 MT (65 early vs. 38 late). Early and late BM radiographic patterns were similar in EGFR WT patients. In EGFR MT there was a trend towards multiple lesions in the late compared to early BM group. OS from initial diagnosis early BM: WT 7.1 months versus MT 19.9 months (p < 0.001). OS from initial diagnosis late BM: WT 24.9 months versus MT 25.6 months (p = 0.51). In multivariate analysis chemotherapy, single lesion and late BM were associated with better survival in WT patients whereas age, and systemic treatment but not BM timing or single lesion were predictive of better outcomes in MT patients. In early BM, EGFR MT have an OS comparable to late BM. In contrast, early BM EGFR WT have a significantly reduced survival compared to late BM. The positive outcome in EGFR MT may be secondary to systemic control and EGFR TKI penetrance across the blood brain barrier.

Incidence, Magnitude, and Predictors of Shortening in Young Femoral Neck Fractures.

OBJECTIVES: To describe the incidence and magnitude of femoral neck fracture shortening in patients age younger than 60 years. Secondarily, to examine predictors of fracture shortening. DESIGN: Retrospective chart review. SETTING: Level I trauma centre. PATIENTS/PARTICIPANTS: Sixty-five patients with a median age of 51 years (interquartile range: 42-56 years) were included. Seventy-one percent were male, 75% were displaced fractures, and 78% were treated with cancellous screws. INTERVENTION: Internal fixation with multiple cancellous screws or sliding hip screw (SHS) + derotation screw. MAIN OUTCOME MEASUREMENTS: Radiographic femoral neck shortening at a minimum of 6 weeks after fixation. RESULTS: Fifty-four percent of patients had ≥5 mm of femoral neck shortening (22% had between ≥5 and <10 mm and 32% ≥10 mm). Initially, displaced fractures shortened more than undisplaced fractures (mean: 8.1 vs. 2.2 mm, P < 0.001), and fractures treated with SHS + derotation screw shortened more than fractures with cancellous screws alone (10.7 vs. 5.5 mm, P = 0.03). Even when adjusting for initial fracture displacement, fractures treated with SHS + derotation screw shortened an average of 2.2 mm more than fractures treated with screws alone (P = 0.03). CONCLUSIONS: The incidence of clinically significant shortening in our young femoral neck fracture population was higher than anticipated, and 32% of patients experienced severe shortening of >1 cm. Our findings highlight the need for further research to determine the impact of severe shortening on functional outcome and to determine if implant selection affects fracture shortening. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.