Sublobar resections for lung cancer: Finally, some answers and some more questions?

The Lung Cancer Study Group Trial, published in 1995, set the tone for lobectomy as the standard of care for early-stage nonsmall cell lung cancer. Twenty-seven years and two randomized trials later, does the thoracic oncology community have clarity regarding the choice type of resection, or more questions?

Hyperthermic intraoperative chemotherapy (HIOC) for Stage IVa thymic malignancy may improve 5-year disease-free survival.

BACKGROUND AND OBJECTIVES: Stage IVa thymic malignancy has limited treatments. This study evaluated whether hyperthermic intraoperative chemotherapy (HIOC) after radical resection of Stage IVa thymic malignancy improves survival. METHODS: All patients who underwent resection, with or without HIOC, for Stage IVa thymic malignancy at a single center from 1990 to 2021 were reviewed. RESULTS: Thirty-four patients were identified; 22 surgery-only versus 12 surgery and HIOC (60 min cisplatin regimen 175 mg/m2 ). Demographics and comorbidities were similar between groups. Three patients in each group were carcinomas; remainder were thymomas. Thirty-two patients underwent attempted macroscopic complete resection; 22 operations succeeded, 68.8%. Significant complications were similar between groups, 18.2% surgery-only versus 25.0% HIOC, p = 0.68. Median time to recurrence trended longer for HIOC patients (42.9 vs. 32.9 months in surgery-only, p = 0.77). Overall survival, 5-year, was similar (75.8% HIOC vs. 76.2% surgery-only, p = 0.91). On stratified analysis, thymoma patients with macroscopic complete resection and HIOC experienced similar 5-year Overall (80.0% vs. 100.0% surgery-only, p = 0.157) but longer trending 5-year disease-free (85.7% vs. 40.0%, p = 0.18) and 5-year locoregional recurrence-free survival (85.7% vs. 68.6%, p = 0.75). CONCLUSIONS: This retrospective cohort study treating Stage IVa thymic malignancy with radical pleurectomy, with or without HIOC, found addition of HIOC-signaled delayed recurrence and improved disease-free survival.

Salvage surgery for local recurrence after sublobar surgery in Stages I and II non-small cell lung cancer.

BACKGROUND AND OBJECTIVES: To examine if patients undergoing salvage surgery for local recurrence following sublobar resection (SLR) have similar perioperative complications and overall survival (OS) compared to lobectomy patients for early stage non-small cell lung cancer (NSCLC). METHODS: Patients undergoing lobectomy and SLR (segmentectomy or wedge resection) for Stages I and II NSCLC from 2010 to 2016 were reviewed. Lobectomy patients and those who underwent salvage surgery for local recurrence after SLR were compared. Salvage surgeries were curative-intent resections for recurrence. RESULTS: Cases included 634 lobectomies and 986 SLR. Fifty-nine SLR patients (6.0%) recurred at a local site compared to 11 lobectomy patients (1.7%; p < 0.001). Twenty-three locally recurrent SLR patients (39.0%) went on to salvage surgery. Peri-operative complications after salvage surgeries were similar to lobectomies (34.8% 8/23 vs. 34.7% 220/634, p = 1.00). OS at 5 years for salvage surgery patients was similar to lobectomy patients (79.6% 13/23 vs. 70.6% 227/634, p = 0.23). OS for patients who underwent salvage surgery was significantly better than those who did not have salvage surgery for recurrence (79.6% vs. 53.0%, p = 0.02). CONCLUSIONS: Patients who undergo salvage surgery for local recurrence after SLR had similar perioperative complications and OS compared to lobectomy patients but less than half underwent salvage surgery.

Adjuvant therapy following induction therapy and surgery improves survival in N2-positive non-small cell lung cancer.

BACKGROUND: The purpose of this study was to evaluate treatment strategies and factors influencing overall survival (OS) and disease-free survival (DFS) in resectable, non-small cell lung cancer (NSCLC) with mediastinal (N2) lymph node metastasis. METHODS: All patients undergoing surgery for NSCLC with N2 disease between 2006 and 2016 were included. Treatment approaches included surgery only, neoadjuvant therapy followed by surgery, surgery followed by adjuvant therapy, and neoadjuvant therapy followed by surgery and adjuvant therapy (triple therapy). Patient clinical and pathologic data were retrospectively collected. RESULTS: A total of 281 patients were included in the study. In total, 209 patients had neoadjuvant therapy, 47.4% of which went on to received additional adjuvant therapy. The pathologic complete response rate was 12.9%. The treatment strategy which included triple therapy was isolated as a significant contributor to improved OS and DFS. Nodal downstaging (N0) after induction therapy conferred an OS benefit (38.3% vs. 15.6%, p = .03). Patients with single-station N2 disease experienced higher DFS. Video-assisted thoracic surgery (VATS) lobectomy completion rates were higher at the end of the study period compared to the beginning (p < .001). CONCLUSIONS: Patients who undergo neoadjuvant therapy for N2-positive NSCLC may benefit from additional adjuvant therapy. Single-station N2 disease confers higher DFS. VATS completion rates for lobectomy increase as experience increases.

Outcomes of superior segmentectomy versus lower lobectomy for superior segment Stage I non-small-cell lung cancer are equivalent: An analysis of 196 patients at a single, high volume institution.

OBJECTIVES: To determine if superior segmentectomy has equivalent overall (OS), disease-free (DFS), and locoregional-recurrence-free survival (LRFS) to lower lobectomy for early-stage non-small-cell lung cancer (NSCLC) in the superior segment. METHODS: We retrospectively reviewed all Stage 1 lower lobectomies for superior segment lesions and superior segmentectomies at our hospital from 2000 to 2018. Comparison statistics and Cox hazard modeling were performed to determine differences between groups and attempt to identify risk factors for OS, DFS, and LRFS. RESULTS: Superior segmentectomy patients, compared with lower lobectomy patients, had more current smokers, worse forced expiratory volume in 1 s percentage, radiologic emphysema scores, clinically and pathologically smaller tumors, and more occurrences of 0 lymph nodes examined. Outcomes for superior segmentectomy compared with lower lobectomy were equivalent for 5-year OS (67.0% vs. 75.1%, p = 0.70), DFS (56.9% vs. 60.4%, p = 0.59), and LRFS (87.9% vs. 91.3%, p = 0.46). Multivariable Cox modeling lacked utility due to no outcome differences. CONCLUSIONS: In well-selected patients, superior segmentectomies can have equivalent OS, DFS, and LRFS compared with lower lobectomies of superior segment tumors for early stage lung cancer. Further data are needed to provide better risk estimates.

Neoadjuvant atezolizumab and chemotherapy in patients with resectable non-small-cell lung cancer: an open-label, multicentre, single-arm, phase 2 trial.

BACKGROUND: Approximately 25% of all patients with non-small-cell lung cancer present with resectable stage IB-IIIA disease, and although perioperative chemotherapy is the standard of care, this treatment strategy provides only modest survival benefits. On the basis of the activity of immune checkpoint inhibitors in metastatic non-small-cell lung cancer, we designed a trial to test the activity of the PD-L1 inhibitor, atezolizumab, with carboplatin and nab-paclitaxel given as neoadjuvant treatment before surgical resection. METHODS: This open-label, multicentre, single-arm, phase 2 trial was done at three hospitals in the USA. Eligible patients were aged 18 years or older and had resectable American Joint Committee on Cancer-defined stage IB-IIIA non-small-cell lung cancer, an Eastern Cooperative Oncology Group performance status of 0-1, and a history of smoking exposure. Patients received neoadjuvant treatment with intravenous atezolizumab (1200 mg) on day 1, nab-paclitaxel (100 mg/m2) on days 1, 8, and 15, and carboplatin (area under the curve 5; 5 mg/mL per min) on day 1, of each 21-day cycle. Patients without disease progression after two cycles proceeded to receive two further cycles, which were then followed by surgical resection. The primary endpoint was major pathological response, defined as the presence of 10% or less residual viable tumour at the time of surgery. All analyses were intention to treat. This study is registered with ClinicalTrials.gov, NCT02716038, and is ongoing but no longer recruiting participants. FINDINGS: Between May 26, 2016, and March 1, 2019, we assessed 39 patients for eligibility, of whom 30 patients were enrolled. 23 (77%) of these patients had stage IIIA disease. 29 (97%) patients were taken into the operating theatre, and 26 (87%) underwent successful R0 resection. At the data cutoff (Aug 7, 2019), the median follow-up period was 12·9 months (IQR 6·2-22·9). 17 (57%; 95% CI 37-75) of 30 patients had a major pathological response. The most common treatment-related grade 3-4 adverse events were neutropenia (15 [50%] of 30 patients), increased alanine aminotransferase concentrations (two [7%] patients), increased aspartate aminotransferase concentration (two [7%] patients), and thrombocytopenia (two [7%] patients). Serious treatment-related adverse events included one (3%) patient with grade 3 febrile neutropenia, one (3%) patient with grade 4 hyperglycaemia, and one (3%) patient with grade 2 bronchopulmonary haemorrhage. There were no treatment-related deaths. INTERPRETATION: Atezolizumab plus carboplatin and nab-paclitaxel could be a potential neoadjuvant regimen for resectable non-small-cell lung cancer, with a high proportion of patients achieving a major pathological response, and manageable treatment-related toxic effects, which did not compromise surgical resection. FUNDING: Genentech and Celgene.

The Impact of Hospital Size on National Trends and Outcomes Following Open Esophagectomy.

Background and Objectives: Previous studies have demonstrated superior patient outcomes for thoracic oncology patients treated at high-volume surgery centers compared to low-volume centers. However, the specific role of overall hospital size in open esophagectomy morbidity and mortality remains unclear. Materials and Methods: Patients aged >18 years who underwent open esophagectomy for primary malignant neoplasia of the esophagus between 2002 and 2014 were identified using the National Inpatient Sample. Minimally invasive procedures were excluded. Discharges were stratified by hospital size (large, medium, and small) and analyzed using trend and multivariable regression analyses. Results: Over a 13-year period, a total of 69,840 open esophagectomy procedures were performed nationally. While the proportion of total esophagectomies performed did not vary by hospital size, in-hospital mortality trends decreased for all hospitals (large (7.2% to 3.7%), medium (12.8% vs. 4.9%), and small (12.8% vs. 4.9%)), although this was only significant for large hospitals (P < 0.01). After controlling for patient demographics, comorbidities, admission, and hospital-level factors, hospital length of stay (LOS), total inflation-adjusted costs, in-hospital mortality, and complications (cardiac, respiratory, vascular, and bleeding) did not vary by hospital size (all P > 0.05). Conclusions: After risk adjustment, patient morbidity and in-hospital mortality appear to be comparable across all institutions, including small hospitals. While there appears to be an increased push for referring patients to large hospitals, our findings suggest that there may be other factors (such as surgeon type, hospital volume, or board status) that are more likely to impact the results; these need to be further explored in the current era of episode-based care.

Minimally Invasive Surgery for Early-Stage Lung Cancer: From Innovation to Standard of Care.

The era of minimally invasive surgery for lung cancer follows decades of research; the collection and interpretation of countless qualitative and quantitative data points; and tireless efforts by a few pioneering thoracic surgeons who believed they could deliver a safe and oncologically sound operation with less tissue trauma, an improved physiologic profile, and fewer complications than traditional open surgery. This review highlights those efforts and the role of minimally invasive surgery for early-stage lung cancer in light of evolving technology, the emerging understanding of the biology of early-stage lung cancer, and lung cancer screening.

Achieving optimal cancer outcomes in East Africa through multidisciplinary partnership: a case study of the Kenyan National Retinoblastoma Strategy group.

BACKGROUND: Strategic, interdisciplinary partnerships are essential to addressing the complex drivers of health inequities that result in survival disparities worldwide. Take for example the aggressive early childhood eye cancer retinoblastoma, where survival reaches 97 % in resource-rich countries, but is as low 30 % in some resource-limited nations, where 92 % of the burden lies. This suggests a need for a multifaceted approach to achieve a tangible and sustainable increase in survival. METHODS: We assembled the history the Kenyan National Retinoblastoma Strategy (KNRbS), using information documented in NGO reports, grant applications, news articles, meeting agendas and summaries. We evaluated the KNRbS using the principles found in the guide for transboundary research partnerships developed by the Swiss Commission for Research Partnerships with Developing Countries. RESULTS: A nationally co-ordinated approach drawing input and expertise from multiple disciplines and sectors presented opportunities to optimise cure of children with retinoblastoma. Annual meetings were key to achieving the over 40 major outputs of the group's efforts, related to Awareness, Medical Care, Family Support and Resource Mobilization. Three features were found to be critical to the KNRbS success: multidisciplinarity, consistency and flexibility. CONCLUSION: The KNRbS has achieved a number of key outputs with limited financial investment. As a partnership, the KNRbS meets most of the criteria identified for success. Challenges remain in securing the long-term sustainability of its achievements. Elements of the Kenyan National Retinoblastoma Strategy may be useful to other developing countries struggling with limited survival of retinoblastoma and other cancers or rare diseases.

Retinoblastoma.

Retinoblastoma is an aggressive eye cancer of infancy and childhood. Survival and the chance of saving vision depend on severity of disease at presentation. Retinoblastoma was the first tumour to draw attention to the genetic aetiology of cancer. Despite good understanding of its aetiology, mortality from retinoblastoma is about 70% in countries of low and middle income, where most affected children live. Poor public and medical awareness, and an absence of rigorous clinical trials to assess innovative treatments impede progress. Worldwide, most of the estimated 9000 newly diagnosed patients every year will die. However, global digital communications present opportunities to optimise standards of care for children and families affected by this rare and often devastating cancer. Parents are now leading the effort for widespread awareness of the danger of leucocoria. Genome-level technologies could make genetic testing a reality for every family affected by retinoblastoma. Best-practice guidelines, online sharing of pathological images, point-of-care data entry, multidisciplinary research, and clinical trials can reduce mortality. Most importantly, active participation of survivors and families will ensure that the whole wellbeing of the child is prioritised in any treatment plan.

Anatomy of mediastinal veins and nerves.

The mediastinum is the central compartment in the thoracic cavity that lies between the lungs. It extends from the thoracic inlet superiorly to the diaphragm inferiorly and sternum anteriorly to the vertebral column posteriorly. It is commonly divided into four compartments-superior, anterior, middle and posterior mediastinum. However, some have started to classify it into the more recent three compartments-anterior (prevascular), middle (visceral) and posterior (paravertebral). The mediastinum is of clinical significance because many vital structures, such as the heart, great vessels, esophagus, lymphatics, and trachea, lie within these compartments. Disease presentation can greatly vary depending on the structures involved, and the differential diagnosis can range widely. Therefore, knowledge of the anatomy and subdivisions of the mediastinum is vital for thoracic surgeons. Herein, we have provided a brief review of the mediastinal anatomy. Utilizing the four-compartment model, we detail the contents of each compartment of the mediastinum with special attention to its veins and nerves. There are also several venous junctions that are important for mediastinal surgery, such as the internal jugular-subclavian venous junction and the left-right brachiocephalic venous junction. We describe useful superficial landmarks, such as the sternocleidomastoid and manubrium, and how they relate to some of the key venous junctions.

Analysis of recurrence in lung adenocarcinoma with spread through air spaces.

OBJECTIVES: Spread through air spaces is defined as tumor cells in air spaces away from the edge of tumor in lung carcinoma. It is associated with higher locoregional recurrence and lower survival in lung adenocarcinoma. The features of spread through air spaces portending worse outcomes are still under investigation. We reviewed our lung cancer experience to define potential factors related to spread through air spaces that influence recurrence and survival. METHODS: Between January 2010 and December 2017, we identified 968 patients who underwent resection for T1-3N0M0 lung adenocarcinoma. Of these, histologic examination was possible in 787 patients. We examined the presence of spread through air spaces, spread through air spaces characteristics (micropapillary, solid nest, or single cell), average density (number per slide), and farthest distance from tumor at which spread through air spaces was detected, or maximal spread distance. Overall survival and recurrence-free survival were estimated using Kaplan-Meier curves, and differences between spread through air spaces positive versus spread through air spaces negative groups were assessed using the log-rank test. RESULTS: Spread through air spaces was present in 389 of 787 of the reviewed cases (49.4%). Overall survival and recurrence-free survival were significantly lower in the spread through air spaces positive group over 10 years (P < .0001). The incidences of locoregional and distant recurrence were nearly doubled over 10 years in the spread through air spaces positive group compared with the spread through air spaces negative group (P = .002 and <.0001, respectively). In a multivariable Cox regression model adjusted for spread through air spaces characteristics, distance, and tumor size, lobar resection did not confer survival advantage in patients with spread through air spaces (hazard ratio of sublobar resection with respect to lobar resection, 1.44; 95% confidence interval, 0.98-2.11; P = .067). In the spread through air spaces positive group, spread through air spaces density was 2.7 ± 1.4 clusters per slide and the maximal spread distance was 2.2 ± 1.7 mm from the tumor edge. There was no observed correlation between spread through air spaces density or maximal spread distance and overall survival or recurrence. CONCLUSIONS: We show increased distant recurrence in spread through air spaces positive lung adenocarcinoma. Quantifiable measures of spread through air spaces do not appear to correlate with recurrence or survival metrics.

Perioperative Esophagectomy Outcomes in Older Esophageal Cancer Patients in Two Different Time Eras.

To investigate perioperative outcomes of esophagectomies by age groups. Retrospective analysis of esophageal cancer patients undergoing esophagectomy from 2005 to 2020 at a single academic institution. Baseline characteristics and outcomes were analyzed by 3 age groups: <70, 70-79, and ≥80 years-old. Sub-analysis was done for 2 time periods: 2005-2012 and 2013-2020. Of 1135 patients, 789 patients were <70, 294 were 70-79, and 52 were ≥80 years-old. Tumor characteristics, and operative technique were similar, except positive longitudinal margins rates (all <3%) (P = 0.008). Older adults experienced increased complications (53.6% vs 69.7% vs 65.4% respectively; P < 0.001) attributable to grade II complications (41.4% vs 62.2% vs 63.5% respectively; P < 0.001). Hospital length of stay (LOS) and rehabilitation requirements were higher in older adults (both P < 0.05). 30-day readmissions, reoperation, and 30-day mortality rates (all <2%) showed no association with age group. Overall complications, LOS, discharge disposition and re-operative rates improved from 2005 to 2012 to 2013-2020 for all (P < 0.05). Increasing age was an independent risk factor for cardiovascular complications (OR 1.7, 95% CI 1.23-2.46 for ages 70-79 and OR 2.7, 95% CI 1.37-5.10 for ages ≥80 ), inpatient rehabilitation (OR 3.3, 95% CI 2.26-5.05 for ages 70-79 and OR 12.1 95% CI 5.83-25.04 for ages ≥80), and prolonged LOS (OR 1.64 95% CI 1.16-2.31 for ages 70-79 and OR 3.6 95% CI 1.71-7.67 for ≥80. After adjusting for time period, older age remained associated with complications (P < 0.05). Highly selected older adults at a large volume esophagectomy center can undergoesophagectomy with increased minor complication and rehabilitation needs.

Evidence-based thermoregulation for adult trauma patients.

The purpose of this project was to develop a staff nurse-led initiative to implement and evaluate evidence-based thermoregulation care for adult trauma patients. An evidence-based practice protocol was developed and implemented, addressing varying patient needs across the spectrum of hypothermia seen in practice, serving as a guide for improving thermoregulation care in trauma patients. There were 2 key pieces to the evidence-based practice protocol. The first piece consisted of an interdisciplinary thermoregulation flowchart to provide focused care based on patient temperatures. The flowchart outlined progressive interventions for increasing hypothermia. The second piece outlined the nursing assistant role, preparing the care area before patient arrival and assisting nursing staff during trauma care. Data from staff questionnaires and patient documentation were used in a pre- and postevaluation of the practice change. Improvements were demonstrated in staff feeling better prepared to identify patients with hypothermia, treat hypothermia, and document thermal care of trauma patients. Clinically important improvement in temperature control during emergency treatment in both moderate and severe hypothermic patients were observed. Ongoing monitoring is underway to promote integration of the practice change.

Manubrium Reconstruction.

To date, there is no standard approach for manubrial reconstruction. We had previously utilized mesh; however, this resulted in breakage, infection, and poor cosmesis. In this case series, we describe our transition to iliac wing autograft reconstruction. We examined 7 patients who underwent manubrial resection and reconstruction: 2 with mesh and methyl methacrylate and 5 with an iliac wing autograft. The outcomes of the autograft patients were overall favorable with no short-term complications or instances of breakage. We conclude that an iliac wing autograft for manubrial reconstruction is feasible and effective alternative to methyl methacrylate mesh.

Survival and Recurrence Following Wedge Resection Versus Lobectomy for Early-Stage Non-Small Cell Lung Cancer.

To determine if wedge resection is equivalent to lobectomy for Stage I Non-Small Cell Lung Cancer (NSCLC) and to evaluate the impact of radiologic and pathologic variables not available in large national databases. Records were reviewed from 2010-2016 for patients with pathologic Stage I NSCLC who underwent wedge resection or lobectomy. Propensity score matching was performed on pre-operative variables and patients with ≥1 lymph node removed. Clinical variables were compared. Kaplan-Meier curves and multivariable Cox proportional hazard models for 5-year overall survival (OS), disease-free (DFS), and locoregional-recurrence-free survival (LRFS) were created. A total of 1086 patients met inclusion criteria; 391 lobectomies and 695 wedge resections. Propensity score matching yielded 167 pairs of lobectomy and wedge resection patients. Complications were fewer for wedge resections than lobectomies, 19.2% for wedge resection patients vs 34.1% for lobectomy patients, p < 0.01. OS was equivalent between groups, 86.2% for lobectomy patients vs 83.4% for wedge resection patients p = 0.47. DFS was similar, 79.0% for lobectomy patients vs 72.5% for wedge resection patients p = 0.10. Overall LRFS was worse in wedge resection patients vs lobectomy patients, 82.0% vs 93.4% p < 0.01. However, in the matched wedge resection patients with a margin >10 mm the LRFS was equal to that of lobectomy patients, 86.4% for wedge resection patients vs 91.8% for lobectomy patients p = 0.140. Patients with Stage I NSCLC can experience similar OS, DFS, and LRFS with wedge resection as compared to lobectomy, when wedge resection margins are >10 mm and appropriate lymph node dissection is performed.

Short and Long-term Outcomes Among High-Volume vs Low-Volume Esophagectomy Surgeons at a High-Volume Center.

To determine associations between surgeon volume and esophagectomy outcomes at a high-volume institution. All esophagectomies for esophageal cancer at our institution from August 2005 to August 2019 were reviewed. Cases were divided by surgeon into low, <7 cases/year, vs high volume, ≥7 cases/year, based on Leapfrog Group recommendations. Surgeons remained 'high-volume' after one year of ≥7 cases. Demographics, comorbidities, course of care, and long-term outcomes were compared. In total, 1029 cases were evaluated; 120 performed by low-volume surgeons vs 909 by high-volume surgeons. Never-smokers, atrial fibrillation, and clinical Stage IVa patients were associated with high-volume surgeons. Other demographics were similar. Low-volume surgeons did more open cases, 45.8% vs 14.5%, P < 0.01. Low-volume surgeons had more complications than high-volume surgeons (71.7% vs 57.6%, P < 0.01), specifically Grade II and III (59.2% vs 46.8%, P = 0.01, and 44.2% vs 27.0%, P <0.01). No differences were seen in anastomotic leak rate, 90-day mortality, recurrences, 5-year overall survival (46.7% low-volume vs 49.3% high-volume, P = 0.64), or 5-year disease-free survival (35.7% low-volume vs 42.2% high-volume, P = 0.27). In multivariable logistic regression for Grade III or higher complications, high-volume surgeons had an odds ratio of 0.56 (95% confidence interval 0.36-0.87) for complications. Our study found higher rates of open esophagectomies and complications in low-volume esophagectomy surgeons compared to high-volume surgeons at the same, high-volume institution. However, low-volume surgeons were not associated with worse survival outcomes compared to high-volume surgeons. Low-volume esophagectomy surgeons may benefit from mentoring and support to improve perioperative outcomes; these efforts are underway at our institution.

Esophagectomy for Esophageal Cancer Performed During the Early Phase of the COVID-19 Pandemic.

Delay in time to esophagectomy for esophageal cancer has been shown to have worse peri-operative and long-term outcomes. We hypothesized that COVID-19 would cause a delay to surgery, with worse perioperative outcomes, compared to standard operations. All esophagectomies for esophageal cancer at a single institution from March-June 2020, COVID-19 group, and from 2019 were reviewed and peri-operative details were compared between groups. Ninety-six esophagectomies were performed in 2019 vs 37 during March-June 2020 (COVID-19 group). No differences between groups were found for preoperative comorbidities. Wait-time to surgery from final neoadjuvant treatment was similar, median 50 days in 2019 vs 53 days during COVID-19 p = 0.601. There was no increased upstaging, from clinical stage to pathologic stage, 9.4% in 2019 vs 7.5% in COVID-19 p = 0.841. Fewer overall complications occurred during COVID-19 vs 2019, 43.2% vs 64.6% p = 0.031, but complications were similar by specific grades. Readmission rates were not statistically different during COVID-19 than 2019, 16.2% vs 10.4% p = 0.38. No peri-operative mortalities or COVID-19 infections were seen in the COVID-19 group. Esophagectomy for esophageal cancer was not associated with worse outcomes during the COVID-19 pandemic with minimal risk of infection when careful COVID-19 guidelines are followed. Prioritization is recommended to ensure no delays to surgery.

Report on lung cancer surgery during COVID-19 pandemic at a high volume US institution.

Background: The impact of COVID-19 has been felt in every field of medicine. We sought to understand how lung cancer surgery was affected at a high volume institution. We hypothesized that patients would wait longer for surgery, have more advanced tumors, and experience more complications during the COVID-19 crisis. Methods: A retrospective review was conducted, comparing pathologically confirmed non-small cell lung cancer (NSCLC) surgical cases performed in 2019 to cases performed from March to May 2020, during the height of the COVID-19 crisis. Clinical and pathologic stage, tumor size, time to surgery, follow up time, and complications were evaluated. Results: A total of 375 cases were performed in 2019 vs. 58 cases in March to May 2020. Overall, there were no differences in the distribution of clinical stages or in the distribution of median wait times to surgery between groups (COVID-19 16.5 days vs. pre-COVID-19 17 days, P=0.54), nor were there differences when subdivided into Stage I-II and Stage III-IV. Case volume was lowest in April 2020 with 6 cases vs. 37 in April 2019, P<0.01. Tumor size was clinically larger in the COVID-19 group (median 2.1 vs. 1.9 cm, P=0.05) but not at final pathology. No differences in complications were observed between groups (COVID-19 31.0% vs. pre-COVID-19 30.9%, P=1.00). No patients from the COVID-19 group tested positive for the disease during their hospital stay or by the median 15 days to first follow-up. Conclusions: Surgical wait time, pathologic tumor size, and complications were not different among patients undergoing surgery before vs. during the pandemic. Importantly, no patients became infected as a result of their hospital stay. The significant decrease in surgical cases is concerning for untreated cancers that may progress without proper treatment.

Long-term Outcomes Following Esophagectomy in Older and Younger Adults with Esophageal Cancer.

BACKGROUND: Patterns of overall and disease-free survival after esophagectomy for esophageal cancer in older adults have not been carefully studied. METHODS: Retrospective analysis of all patients with esophageal cancer undergoing esophagectomy from 2005 to 2020 at our institution was performed. Differences in outcomes were stratified by age groups, < 75 and ≥ 75 years old, and two time periods, 2005-2012 and 2013-2020. RESULTS: A total of 1135 patients were included: 979 (86.3%) patients were < 75 (86.3%), and 156 (13.7%) were ≥ 75 years old. Younger patients had fewer comorbidities, better nutritional status, and were more likely to receive neoadjuvant and adjuvant therapy (all p < 0.05). However, tumor stage and operative approach were similar, except for increased performance of the McKeown technique in younger patients (p = 0.02). Perioperatively, younger patients experienced fewer overall and grade II complications (both p < 0.05). They had better overall survival (log-rank p-value < 0.001) and median survival, 62.2 vs. 21.5 months (p < 0.05). When stratified by pathologic stage, survival was similar for yp0 and pathologic stage II disease (both log-rank p-value > 0.05). Multivariable Cox models showed older age (≥ 75 years old) had increased hazard for reduced overall survival (HR 2.04 95% CI 1.5-2.8; p < 0.001) but not disease-free survival (HR 1.1 95% CI 0.78-1.6; p = 0.54). Over time, baseline characteristics remained largely similar, while stage became more advanced with a rise in neoadjuvant use and increased performance of minimally invasive esophagectomy (all p < 0.05). While overall complication rates improved (p < 0.05), overall and recurrence-free survival did not. Overall survival was better in younger patients during both time periods (both log-rank p < 0.05). CONCLUSIONS: Despite similar disease-free survival rates, long-term survival was decreased in older adults as compared to younger patients. This may be related to unmeasured factors including frailty, long-term complications after surgery, and competing causes of death. However, our results suggest that survival is similar in those with complete pathologic responses.