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Advances in the multidisciplinary care of early stage resectable NSCLC (rNSCLC) are emerging at an unprecedented pace. Numerous phase 3 trials produced results that have transformed patient outcomes for the better, yet these findings also require important modifications to the patient treatment journey trajectory and reorganization of care pathways. Perhaps, most notably, the need for multispecialty collaboration for this patient population has never been greater. These rapid advances have inevitably left us with important gaps in knowledge for which definitive answers will only become available in several years. To this end, the International Association for the Study of Lung Cancer commissioned a diverse multidisciplinary international expert panel to evaluate the current landscape and provide diagnostic, staging, and therapeutic recommendations for patients with rNSCLC, with particular emphasis on patients with American Joint Committee on Cancer-Union for International Cancer Control TNM eighth edition stages II and III disease. Using a team-based approach, we generated 19 recommendations, of which all but one achieved greater than 85% consensus among panel members. A public voting process was initiated, which successfully validated and provided qualitative nuance to our recommendations. Highlights include the following: (1) the critical importance of a multidisciplinary approach to the evaluation of patients with rNSCLC driven by shared clinical decision-making of a multispecialty team of expert providers; (2) biomarker testing for rNSCLC; (3) a preference for neoadjuvant chemoimmunotherapy for stage III rNSCLC; (4) equipoise regarding the optimal management of patients with stage II between upfront surgery followed by adjuvant therapy and neoadjuvant or perioperative strategies; and (5) the robust preference for adjuvant targeted therapy for patients with rNSCLC and sensitizing EGFR and ALK tumor alterations. Our primary goals were to provide practical recommendations sensitive to the global differences in biology and resources for patients with rNSCLC and to provide expert consensus guidance tailored to the individualized patient needs, goals, and preferences in their cancer care journey as these are areas where physicians must make daily clinical decisions in the absence of definitive data. These recommendations will continue to evolve as the treatment landscape for rNSCLC expands and more knowledge is acquired on the best therapeutic approach in specific patient and disease subgroups.
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BACKGROUND: Despite surgical resection, long-term survival of patients with resectable non-small cell lung cancer (NSCLC) remains poor. Adjuvant chemotherapy, the standard of care for locally advanced NSCLC, provides a marginal 5.4% benefit in survival. Immune checkpoint inhibitors (ICIs) have shown a significant survival benefit in some patients with advanced NSCLC and are being evaluated for perioperative use in resectable NSCLC. METHODS: We conducted a literature search using the PubMed online database to identify clinical trials of immunotherapy in resectable NSCLC and studies analyzing biomarkers and immune priming strategies. RESULTS: Building on previous phase I and II trials, randomized phase III trials have shown efficacy of neoadjuvant nivolumab, perioperative pembrolizumab, adjuvant atezolizumab, and adjuvant pembrolizumab in the treatment of NSCLC with improvement of event-free/disease-free survival of 24% to 42%, leading to United States Food and Drug Administration approval of these drugs in the treatment of resectable NSCLC. Three additional phase III trials have also recently reported the use of immunotherapy both before and after surgery, with pathologic complete response rates of 17% to 25%, significantly better than chemotherapy alone. Perioperative ICI therapy has comparable perioperative morbidity to chemotherapy alone and does not impair surgical outcomes. CONCLUSIONS: Perioperative immunotherapy, in combination with chemotherapy, is safe and improves outcomes in patients with resectable NSCLC. Questions regarding patient selection, the need for adjuvant ICI therapy after neoadjuvant chemoimmunotherapy, and the duration of perioperative immunotherapy remain to be answered by future trials.
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Carcinoma Pulmonar de Células não Pequenas , Imunoterapia , Neoplasias Pulmonares , Carcinoma Pulmonar de Células não Pequenas/terapia , Carcinoma Pulmonar de Células não Pequenas/imunologia , Carcinoma Pulmonar de Células não Pequenas/tratamento farmacológico , Humanos , Neoplasias Pulmonares/terapia , Neoplasias Pulmonares/tratamento farmacológico , Neoplasias Pulmonares/imunologia , Imunoterapia/métodos , Pneumonectomia , Terapia NeoadjuvanteRESUMO
Outcomes for patients with esophageal cancer have improved over the last decade with the implementation of multimodality therapy. There are currently no comprehensive guidelines addressing multidisciplinary management of esophageal cancer that have incorporated the input of surgeons, radiation oncologists, and medical oncologists. To address the need for multidisciplinary input in the management of esophageal cancer and to meet current best practices for clinical practice guidelines, the current guidelines were created as a collaboration between The Society of Thoracic Surgeons (STS), American Society for Radiation Oncology (ASTRO), and the American Society of Clinical Oncology (ASCO). Physician representatives chose 8 key clinical questions pertinent to the care of patients with locally advanced, resectable thoracic esophageal cancer (excluding cervical location). A comprehensive literature review was performed identifying 227 articles that met the inclusion criteria covering the use of induction chemotherapy, chemotherapy vs chemoradiotherapy before surgery, optimal radiation dose, the value of esophagectomy, timing of esophagectomy, the approach and extent of lymphadenectomy, the use of minimally invasive esophagectomy, and the value of adjuvant therapy after resection. The relevant data were reviewed and voted on by the panel with 80% of the authors, with 75% agreement on class and level of evidence. These data were then complied into the guidelines document.
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Neoplasias Esofágicas , Radioterapia (Especialidade) , Cirurgiões , Humanos , Estados Unidos , Terapia Combinada , Neoplasias Esofágicas/radioterapia , Junção EsofagogástricaRESUMO
Outcomes for patients with esophageal cancer have improved over the last decade with the implementation of multimodality therapy. There are currently no comprehensive guidelines addressing multidisciplinary management of esophageal cancer that have incorporated the input of surgeons, radiation oncologists, and medical oncologists. To address the need for multidisciplinary input in the management of esophageal cancer and to meet current best practices for clinical practice guidelines, the current guidelines were created as a collaboration between The Society of Thoracic Surgeons (STS), American Society for Radiation Oncology (ASTRO), and the American Society of Clinical Oncology (ASCO). Physician representatives chose 8 key clinical questions pertinent to the care of patients with locally advanced, resectable thoracic esophageal cancer (excluding cervical location). A comprehensive literature review was performed identifying 227 articles that met the inclusion criteria covering the use of induction chemotherapy, chemotherapy vs chemoradiotherapy before surgery, optimal radiation dose, the value of esophagectomy, timing of esophagectomy, the approach and extent of lymphadenectomy, the use of minimally invasive esophagectomy, and the value of adjuvant therapy after resection. The relevant data were reviewed and voted on by the panel with 80% of the authors, with 75% agreement on class and level of evidence. These data were then complied into the guidelines document.
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Neoplasias Esofágicas , Radioterapia (Especialidade) , Cirurgiões , Humanos , Estados Unidos , Terapia Combinada , Neoplasias Esofágicas/cirurgia , Junção Esofagogástrica/cirurgiaRESUMO
OBJECTIVES: To characterize and quantify accumulating immunologic alterations, pre and postoperatively in patients undergoing elective surgical procedures. BACKGROUND: Elective surgery is an anticipatable, controlled human injury. Although the human response to injury is generally stereotyped, individual variability exists. This makes surgical outcomes less predictable, even after standardized procedures, and may provoke complications in patients unable to compensate for their injury. One potential source of variation is found in immune cell maturation, with phenotypic changes dependent on an individual's unique, lifelong response to environmental antigens. METHODS: We enrolled 248 patients in a prospective trial facilitating comprehensive biospecimen and clinical data collection in patients scheduled to undergo elective surgery. Peripheral blood was collected preoperatively, and immediately on return to the postanesthesia care unit. Postoperative complications that occurred within 30 days after surgery were captured. RESULTS: As this was an elective surgical cohort, outcomes were generally favorable. With a median follow-up of 6 months, the overall survival at 30 days was 100%. However, 20.5% of the cohort experienced a postoperative complication (infection, readmission, or system dysfunction). We identified substantial heterogeneity of immune senescence and terminal differentiation phenotypes in surgical patients. More importantly, phenotypes indicating increased T-cell maturation and senescence were associated with postoperative complications and were evident preoperatively. CONCLUSIONS: The baseline immune repertoire may define an immune signature of resilience to surgical injury and help predict risk for surgical complications.
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Procedimentos Cirúrgicos Eletivos , Complicações Pós-Operatórias , Humanos , Estudos Prospectivos , Procedimentos Cirúrgicos Eletivos/métodos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Readmissão do Paciente , Coleta de DadosRESUMO
OBJECTIVE: To determine the threshold annualized esophagectomy volume that is associated with improved survival, oncologic resection, and postoperative outcomes. BACKGROUND: Esophagectomy at high-volume centers is associated with improved outcomes; however, the definition of high-volume remains debated. METHODS: The 2004 to 2016 National Cancer Database was queried for patients with clinical stage I to III esophageal cancer undergoing esophagectomy. Center esophagectomy volume was modeled as a continuous variable using restricted cubic splines. Maximally selected ranks were used to identify an inflection point of center volume and survival. Survival was compared using multivariable Cox proportional hazards methods. Multivariable logistic regression was used to examine secondary outcomes. RESULTS: Overall, 13,493 patients met study criteria. Median center esophagectomy volume was 8.2 (interquartile range: 3.2-17.2) cases per year. On restricted cubic splines, inflection points were identified at 9 and 30 cases per year. A multivariable Cox model was constructed modeling annualized center surgical volume as a continuous variable using 3 linear splines and inflection points at 9 and 30 cases per year. On multivariable analysis, increasing center volume up to 9 cases per year was associated with a substantial survival benefit (hazard ratio: 0.97, 95% confidence interval, 0.95-0.98, P ≤0.001). On multivariable logistic regression, factors associated with undergoing surgery at a high-volume center (>9 cases per year) included private insurance, care at an academic center, completion of high school education, and greater travel distance. CONCLUSIONS: This National Cancer Database study utilizing multivariable analysis and restricted cubic splines suggests the threshold definition of a high-volume esophagectomy center as one that performs at least 10 operations a year.
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Neoplasias Esofágicas , Esofagectomia , Humanos , Esofagectomia/métodos , Modelos de Riscos Proporcionais , Neoplasias Esofágicas/cirurgia , Modelos Logísticos , Bases de Dados Factuais , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: The outcomes associated with receipt of adjuvant radiation in patients after surgery for MPM are poorly understood. OBJECTIVE: The objective of this study was to use 2 registries to compare the outcomes of patients receiving adjuvant radiation or no radiation after definitive surgery for pathologic stage I-III MPM. METHODS: Patients with resected pathologic stage I-III MPM were identified from the Duke University registry (1996-2016) and National Cancer Database (NCDB) (2004-2015). The primary outcome was overall survival. Propensity score-matched and landmark subgroup analyses were performed. RESULTS: A total of 212 institutional and 1615 NCDB patients met criteria. In both cohorts, patients who underwent radiation were more likely to have margin-negative resection and more advanced pathologic stage. At a landmark time of 4.4 and 4.7 months from surgery, Duke [hazard ratio (HR) 1.14; 95% confidence interval (CI) 0.62-2.11] and NCDB patients (HR 0.97; 95% CI 0.81-1.17) who received adjuvant radiation did not experience improved survival compared to those who did not receive radiation in multivariable analysis. Duke patients who received radiation had similar incidence of recurrence and time to both overall recurrence and ipsilateral recurrence (HR 0.87; 95% CI 0.43-1.77) compared to those who did not. Duke patients experienced 100 grade 1/2, 21 grade 3/4, and one grade 5 toxicity events during radiation. CONCLUSIONS: In this dual registry analysis of patients with resected stage I-III MPM, the receipt of adjuvant hemithoracic radiation was not associated with improved survival compared to no radiation.
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Neoplasias Pulmonares , Mesotelioma Maligno , Mesotelioma , Neoplasias Pleurais , Humanos , Mesotelioma/radioterapia , Mesotelioma/cirurgia , Neoplasias Pulmonares/radioterapia , Neoplasias Pulmonares/cirurgia , Neoplasias Pleurais/radioterapia , Neoplasias Pleurais/cirurgia , Sistema de RegistrosRESUMO
OBJECTIVE: To design and establish a prospective biospecimen repository that integrates multi-omics assays with clinical data to study mechanisms of controlled injury and healing. BACKGROUND: Elective surgery is an opportunity to understand both the systemic and focal responses accompanying controlled and well-characterized injury to the human body. The overarching goal of this ongoing project is to define stereotypical responses to surgical injury, with the translational purpose of identifying targetable pathways involved in healing and resilience, and variations indicative of aberrant peri-operative outcomes. METHODS: Clinical data from the electronic medical record combined with large-scale biological data sets derived from blood, urine, fecal matter, and tissue samples are collected prospectively through the peri-operative period on patients undergoing 14 surgeries chosen to represent a range of injury locations and intensities. Specimens are subjected to genomic, transcriptomic, proteomic, and metabolomic assays to describe their genetic, metabolic, immunologic, and microbiome profiles, providing a multidimensional landscape of the human response to injury. RESULTS: The highly multiplexed data generated includes changes in over 28,000 mRNA transcripts, 100 plasma metabolites, 200 urine metabolites, and 400 proteins over the longitudinal course of surgery and recovery. In our initial pilot dataset, we demonstrate the feasibility of collecting high quality multi-omic data at pre- and postoperative time points and are already seeing evidence of physiologic perturbation between timepoints. CONCLUSIONS: This repository allows for longitudinal, state-of-the-art geno-mic, transcriptomic, proteomic, metabolomic, immunologic, and clinical data collection and provides a rich and stable infrastructure on which to fuel further biomedical discovery.
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Biologia Computacional , Proteômica , Genômica , Humanos , Metabolômica , Estudos Prospectivos , Proteômica/métodosRESUMO
OBJECTIVE: Determine whether adjuvant chemotherapy is associated with a survival benefit in high risk T2-4a, pathologically node-negative distal esophageal adenocarcinoma. SUMMARY OF BACKGROUND DATA: There is minimal literature to substantiate the NCCN guidelines recommending adjuvant therapy for patients with distal esophageal adenocarcinoma and no pathologic evidence of nodal disease. METHODS: The National Cancer Database was used to identify adult patients with pT2-4aN0M0 esophageal adenocarcinoma who underwent definitive surgery (2004-2015) and had characteristics considered high risk by the NCCN. Patients were stratified by receipt of adjuvant chemotherapy with or without radiation. The primary outcome was overall survival, which was evaluated using Kaplan-Meier and multivariable Cox Proportional Hazards models. A 1:1 propensity score-matched analysis was also performed to compare survival between the groups. RESULTS: Four hundred three patients met study criteria: 313 (78%) without adjuvant therapy and 90 who received adjuvant chemotherapy with or without radiation (22%). In both unadjusted and multivariable analysis, adjuvant chemotherapy with or without radiation was not associated with a significant survival benefit compared to no adjuvant therapy. In a subgroup analysis of 335 patients without high risk features by NCCN criteria, adjuvant chemotherapy was not independently associated with a survival benefit. CONCLUSION: In this analysis, adjuvant chemotherapy with or without radiation was not associated with a significant survival benefit in completely resected, pathologically node-negative distal esophageal adenocarcinoma, independent of presence of high risk characteristics. The risks and benefits of adjuvant therapy should be weighed before offering it to patients with completely resected pT2-4aN0M0 esophageal adenocarcinoma.
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Adenocarcinoma/tratamento farmacológico , Adenocarcinoma/mortalidade , Quimioterapia Adjuvante , Neoplasias Esofágicas/tratamento farmacológico , Neoplasias Esofágicas/mortalidade , Esofagectomia , Adenocarcinoma/patologia , Adenocarcinoma/cirurgia , Idoso , Neoplasias Esofágicas/patologia , Neoplasias Esofágicas/cirurgia , Feminino , Humanos , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Estudos Retrospectivos , Taxa de SobrevidaRESUMO
BACKGROUND: Endoscopic resection (ER) is the preferred treatment for superficial esophageal cancer; however, a safe time frame for performing ER has not been established. This study evaluated the period in which ER can be performed for patients with stage I esophageal adenocarcinoma without compromising outcomes. METHODS: The 2004-2015 National Cancer Database was used to identify patients with cT1 N0 M0 esophageal adenocarcinoma who underwent upfront ER. The primary outcome was overall survival, which was evaluated using Kaplan-Meier and multivariable Cox proportional hazards methods. The secondary outcome was rate of margin-positive resection, which was evaluated using a multivariable logistic regression. RESULTS: A total of 983 patients met study criteria. The median time from diagnosis to ER was 34 days (interquartile range, 5-70 days). Patients in the highest quartile of time to ER were more likely to be treated at a high-volume center and at a center different from that of diagnosis compared with those in the lowest quartile. Increasing time to ER was not independently associated with survival (adjusted hazard ratio per 10 days, 1.02; 95% confidence interval, 0.98-1.05; P = .32) or margin-positive resection (odds ratio per 10 days 1.01; 95% confidence interval, 0.96-1.06; P = .60). CONCLUSIONS: In this National Cancer Database analysis, increasing time to endoscopic resection, up to 180 days from diagnosis, was not associated with worsened survival or increased odds of margin-positive resection in patients with cT1 N0 M0 esophageal adenocarcinoma. Given these findings, patients may be afforded time to be seen in specialty centers without risk of tumor progression.
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Adenocarcinoma , Neoplasias Esofágicas , Adenocarcinoma/patologia , Esofagectomia/métodos , Humanos , Estadiamento de Neoplasias , Estudos Retrospectivos , Resultado do TratamentoRESUMO
OBJECTIVES: Pembrolizumab is a programmed death receptor-1 masking antibody approved for metastatic non-small cell lung cancer. This Phase 2 study (NCT02818920) of neoadjuvant pembrolizumab in non-small cell lung cancer had a primary end point of safety and secondary end points of efficacy and correlative science. METHODS: Patients with untreated clinical stage IB to IIIA non-small cell lung cancer were enrolled. Two cycles of pembrolizumab (200 mg) were administered before surgery. Standard adjuvant chemotherapy and radiation were encouraged but not required. Four cycles of adjuvant pembrolizumab were provided. RESULTS: Of 35 patients enrolled, 30 received neoadjuvant pembrolizumab and 25 underwent lung resection. Only 1 patient had a delay before surgery attributed to pembrolizumab; this was due to thyroiditis. All patients underwent anatomic resection and mediastinal lymph node dissection; the majority (18/25%, 72%) of patients underwent lobectomy. Of the 25 patients, 23 had an initial minimally invasive approach (92%); 5 of these were converted to thoracotomy (21.7%). R0 resection was achieved in 22 patients (88%), and major pathologic response was observed in 7 of 25 patients (28%). The most common postoperative adverse event was atrial fibrillation, affecting 6 of 25 patients (24%). Median chest tube duration and length of stay were 3 and 4 days, respectively. One patient required readmission to the hospital within 30 days. There was no mortality within 90 days of surgery. CONCLUSIONS: In this study, pembrolizumab was safe and well tolerated in the neoadjuvant setting, and its use was not associated with excess surgical morbidity or mortality. Minimally invasive approaches are feasible in this patient population, but may be more challenging than in cases without neoadjuvant immunotherapy. Pathologic response was higher than typically observed with standard neoadjuvant chemotherapy.
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Anticorpos Monoclonais Humanizados/administração & dosagem , Carcinoma Pulmonar de Células não Pequenas/terapia , Inibidores de Checkpoint Imunológico/administração & dosagem , Neoplasias Pulmonares/terapia , Terapia Neoadjuvante , Pneumonectomia , Cirurgia Torácica Vídeoassistida , Toracotomia , Idoso , Idoso de 80 Anos ou mais , Anticorpos Monoclonais Humanizados/efeitos adversos , Carcinoma Pulmonar de Células não Pequenas/patologia , Quimioterapia Adjuvante , Intervalo Livre de Doença , Feminino , Humanos , Inibidores de Checkpoint Imunológico/efeitos adversos , Neoplasias Pulmonares/patologia , Masculino , Pessoa de Meia-Idade , Terapia Neoadjuvante/efeitos adversos , Estadiamento de Neoplasias , Pneumonectomia/efeitos adversos , Complicações Pós-Operatórias/terapia , Cirurgia Torácica Vídeoassistida/efeitos adversos , Toracotomia/efeitos adversos , Fatores de Tempo , Estados UnidosRESUMO
BACKGROUND: We hypothesized that the ratio of positive lymph nodes to total assessed lymph nodes (LNR) is an indicator of cancer burden in esophageal adenocarcinoma and may identify patients who may most benefit from AC. OBJECTIVE: The aim of this study was to discern whether there is a threshold LNR above which AC is associated with a survival benefit in this population. METHODS: The 2004-2015 National Cancer Database was queried for patients who underwent upfront, complete resection of pT1-4N1-3M0 esophageal adenocarcinoma. The primary outcome, overall survival, was examined using multivariable Cox proportional hazards models employing an interaction term between LNR and AC. RESULTS: A total of 1733 patients were included: 811 (47%) did not receive AC whereas 922 (53%) did. The median LNR was 20% (interquartile range 9-40). In a multivariable Cox model, the interaction term between LNR and receipt of AC was significant (P = 0.01). A plot of the interaction demonstrated that AC was associated with improved survival beyond a LNR of about 10%-12%. In a sensitivity analysis, the receipt of AC was not associated with improved survival in patients with LNR <12% (hazard ratio 1.02; 95% confidence interval 0.72-1.44) but was associated with improved survival in those with LNR ≥12% (hazard ratio 0.65; 95% confidence interval 0.50-0.79). CONCLUSIONS: In this study of patients with upfront, complete resection of node-positive esophageal adenocarcinoma, AC was associated with improved survival for LNR ≥12%. LNR may be used as an adjunct in multidisciplinary decision-making about adjuvant therapies in this patient population.
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Adenocarcinoma/tratamento farmacológico , Adenocarcinoma/mortalidade , Quimioterapia Adjuvante , Neoplasias Esofágicas/tratamento farmacológico , Neoplasias Esofágicas/mortalidade , Razão entre Linfonodos , Adenocarcinoma/patologia , Idoso , Estudos de Coortes , Neoplasias Esofágicas/patologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Taxa de SobrevidaRESUMO
BACKGROUND: Although SABR is increasingly emerging as an alternative to surgery for node-negative non-small cell lung cancer, there is poor understanding of patients who may most benefit SABR compared to surgery. OBJECTIVE: This study examined the relationship between tumor size and the comparative outcomes of SABR and sublobar resection in patients with node-negative non-small cell lung cancer. RESULTS: A total of 59,949 patients met study criteria: 19,888 (33%) underwent SABR, 33,052 (55%) wedge resection, and 7009 (12%) segmental resection. In multivariable regression, a significant 3-way interaction was found between histology, tumor size, and type of treatment. After stratification by histology, a significant interaction between tumor size and treatment was preserved for patients with adenocarcinoma and squamous cell carcinoma. Sublobar resection was associated with greater survival compared to SABR for tumor sizes greater than 6 and 8 mm for patients with adenocarcinoma and squamous cell carcinoma, respectively. SABR was associated with similar survival compared to sublobar resection for patients with papillary and large cell histology. CONCLUSIONS: In this National Cancer Database analysis, sublobar resection was associated with greater survival compared to SABR for lesions >6or 8 mm in patients with adenocarcinoma or squamous cell carcinoma; however, SABR was associated with similar survival compared to sublobar resection in patients with aggressive tumors including papillary and large cell histology. Histologic diagnosis in patients with even small tumors may enable better treatment selection in those who cannot tolerate lobectomy.
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Adenocarcinoma , Carcinoma Pulmonar de Células não Pequenas , Carcinoma de Células Escamosas , Neoplasias Pulmonares , Humanos , Pneumonectomia/efeitos adversos , Estadiamento de Neoplasias , Resultado do Tratamento , Adenocarcinoma/patologia , Carcinoma de Células Escamosas/cirurgia , Carcinoma de Células Escamosas/patologiaRESUMO
BACKGROUND: There are conflicting reports in the literature comparing outcomes after open Ravitch and minimally invasive Nuss procedures for pectus excavatum repair, and there is relatively little data available comparing the outcomes of these procedures performed by thoracic surgeons. METHODS: The 2010 to 2018 Society of Thoracic Surgeons General Thoracic Surgery Database was queried for patients age 12 or greater undergoing open or minimally invasive repair of pectus excavatum. Patients were stratified by operative approach. Multivariable logistic regression was performed with a composite outcome of 30-day complications. RESULTS: A total of 1,767 patients met inclusion criteria, including 1,017 and 750 patients who underwent minimally invasive pectus repair and open repair, respectively. Open repair patients were more likely to be American Society of Anesthesiologists (ASA) class III or greater (24% vs 14%; P < .001), have a history of prior cardiothoracic surgery (26% vs 14%; P < .001), and require longer operations (median 268 vs 185 minutes; P < .001). Open repair patients were more likely to require greater than 6 days of hospitalization (18% vs 7%; P < .001), undergo transfusion (7% vs 2%; P < .001), and be readmitted (8% vs 5%; P = .004). After adjustment, open repair was not associated with an increased risk of a composite of postoperative complications (odds ratio 0.99, 95% confidence interval 0.67-1.46). This finding persisted after propensity score matching (odds ratio 1.11, 95% confidence interval 0.74-1.67). CONCLUSION: Pectus excavatum repair procedure type was not associated with the risk of postoperative complications after adjustment. Further investigation is necessary to determine the impact of pectus excavatum repair type on recurrence and patient reported outcomes, including satisfaction, quality of life, and pain control.
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Tórax em Funil/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Procedimentos Cirúrgicos Torácicos/efeitos adversos , Adulto , Feminino , Humanos , Masculino , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Satisfação do Paciente , Pontuação de Propensão , Qualidade de Vida , Estudos Retrospectivos , Fatores de Risco , Esterno/cirurgia , Procedimentos Cirúrgicos Torácicos/métodos , Adulto JovemRESUMO
BACKGROUND: The interaction between tumor size and the comparative prognosis of lobar and sublobar resection has been defined poorly. RESEARCH QUESTION: The purpose of this study was to characterize the relationship between tumor size and the receipt of segmentectomy or lobectomy in association with overall survival in patients with clinically node-negative non-small cell lung cancer (NSCLC). STUDY DESIGN AND METHODS: The 2004-2015 National Cancer Database (NCDB) was queried for patients with cT1-3N0M0 NSCLC who underwent segmentectomy or lobectomy without neoadjuvant therapy or missing survival data. The primary outcome was overall survival, which was evaluated using multivariate Cox proportional hazards including an interaction term between tumor size and type of surgery. RESULTS: A total of 143,040 patients were included: 135,446 (95%) underwent lobectomy and 7594 (5%) underwent segmentectomy. In multivariate Cox regression, a significant three-way interaction was found among tumor size, histologic results, and type of surgery (P < .001). When patients were stratified by histologic results, lobectomy was associated with significantly improved survival compared with segmentectomy beyond a tumor size of approximately 10 mm for adenocarcinoma and 15 mm for squamous cell carcinoma that was recapitulated in subgroup analyses. No interaction between tumor size and type of surgery was found for patients with neuroendocrine tumors. INTERPRETATION: In this NCDB study of patients with node-negative NSCLC, we found different tumor size thresholds, based on histologic results, that identified populations of patients who least and most benefitted from lobectomy compared with segmentectomy.
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Carcinoma Pulmonar de Células não Pequenas/patologia , Carcinoma Pulmonar de Células não Pequenas/cirurgia , Neoplasias Pulmonares/patologia , Neoplasias Pulmonares/cirurgia , Pneumonectomia , Carga Tumoral , Idoso , Carcinoma Pulmonar de Células não Pequenas/mortalidade , Bases de Dados Factuais , Feminino , Humanos , Neoplasias Pulmonares/mortalidade , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Taxa de Sobrevida , Resultado do TratamentoRESUMO
BACKGROUND: Older patients are often considered high-risk surgical candidates for locally advanced esophageal cancer, and the benefit of surgery in this population is unclear. This national analysis examines the effect of age on esophagectomy outcomes and compares surgery versus chemoradiation in older patients. METHODS: The National Cancer Database was used to identify patients with clinical stage II to III esophageal adenocarcinoma undergoing surgery or definitive chemoradiation between 2004 and 2015. Restricted cubic splines were used to examine the relationship between age and survival after esophagectomy, and maximally selected rank statistics were used to identify an age at which survival worsened. We used Cox proportional hazard models including an interaction term between age and treatment to compare overall survival, as well as survival of patients receiving esophagectomy versus definitive chemoradiation. RESULTS: Of 17,495 patients, 11,680 underwent esophagectomy and 5815 received chemoradiation. Survival after esophagectomy worsened with increasing age and decreased considerably after age 73 (hazard ratio = 1.05, 95% confidence interval, 1.04-1.06, per increasing year after 73 versus hazard ratio = 1.01, 95% confidence interval, 1.00-1.01, per increasing year to 73; both P < .001). Chemoradiation was increasingly used over surgery as age increased. The interaction between age and treatment was significant, and a graph of this interaction demonstrated a survival benefit for surgery over chemoradiation at most ages, including octogenarians. CONCLUSIONS: Survival worsens with age after esophagectomy for locally advanced esophageal cancer. However, esophagectomy is associated with improved survival compared with definitive chemoradiation at most ages, including octogenarians. Esophagectomy may be considered over chemoradiation for patients who can tolerate surgery regardless of age.
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Adenocarcinoma/cirurgia , Neoplasias Esofágicas/cirurgia , Esofagectomia/métodos , Estadiamento de Neoplasias , Adenocarcinoma/diagnóstico , Adenocarcinoma/mortalidade , Fatores Etários , Idoso , California/epidemiologia , Neoplasias Esofágicas/diagnóstico , Neoplasias Esofágicas/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Taxa de Sobrevida/tendências , Resultado do TratamentoRESUMO
The objective of this study was to evaluate the impact of a video-assisted thoracoscopic (VATS) approach on outcomes in patients who underwent sleeve lobectomy for non-small-cell lung cancer (NSCLC). Outcomes of patients with cT1-T3, N0-N2, M0 NSCLC who underwent sleeve lobectomy in the National Cancer Data Base (NCDB) from 2010-2015 were assessed using Kaplan-Meier, propensity score-matching, and Cox proportional hazards analyses. An "intent-to-treat" analysis was performed. In the NCDB, 210 sleeve lobectomy patients met inclusion criteria (VATS 44 [21%], thoracotomy 166 [79%]). Nine (20%) of the VATS cases were converted to open. Compared to an open approach, VATS was associated with no significant differences in lymph nodes examined (median 9.5 vs 9.0; pâ¯=â¯0.72), length of stay (median 6 days vs 6 days; pâ¯=â¯0.36), 30-day mortality (4.5% vs 1.8%; pâ¯=â¯0.28), and 90-day mortality (6.8% vs 4.8%; pâ¯=â¯0.70). There were no significant differences in 5-year survival between the VATS and open groups in both the entire cohort (VATS [85%] vs open [79%]; log-rank pâ¯=â¯0.91) and in a propensity score-matched analysis of 86 patients (log-rank pâ¯=â¯0.75). Furthermore, a VATS approach was also not associated with worse survival in multivariable analysis (HRâ¯=â¯0.64; 95% CI [0.23-1.78]; pâ¯=â¯0.39). In this national analysis, a VATS approach for sleeve lobectomy for NSCLC was not associated with worse short-term or long-term outcomes when compared to an open approach.
Assuntos
Carcinoma Pulmonar de Células não Pequenas , Neoplasias Pulmonares , Carcinoma Pulmonar de Células não Pequenas/diagnóstico por imagem , Carcinoma Pulmonar de Células não Pequenas/patologia , Carcinoma Pulmonar de Células não Pequenas/cirurgia , Humanos , Neoplasias Pulmonares/diagnóstico por imagem , Neoplasias Pulmonares/patologia , Neoplasias Pulmonares/cirurgia , Estadiamento de Neoplasias , Pneumonectomia/efeitos adversos , Estudos Retrospectivos , Cirurgia Torácica Vídeoassistida/efeitos adversos , Toracotomia/efeitos adversos , Resultado do TratamentoRESUMO
BACKGROUND: Induction therapy for patients with cT2N0M0 esophageal cancer is controversial. We performed a retrospective cohort analysis of the National Cancer Database to examine the patterns of use of induction therapy for this population. METHODS: The National Cancer Database was queried for patients with cT2N0M0 esophageal cancer who underwent esophagectomy (2004-2015). Patients were stratified by upfront surgery or induction therapy. Overall survival was analyzed and a multivariable logistic regression performed to identify factors associated with receipt of induction therapy. RESULTS: Overall 2540 patients met study criteria: 1177 (46%) received upfront esophagectomy and 1363 (53%) received induction therapy. Patients receiving induction therapy were more likely to be younger, male, without comorbidities, privately insured, and treated at a nonacademic center. These patients were also less likely to be treated in highest volume surgery centers. In multivariable regression, factors independently associated with receipt of induction therapy included later year of diagnosis, increasing tumor size, and increasing tumor grade. Factors associated with upfront esophagectomy included advancing age, comorbidities, lack of insurance, geographic location, and highest volume centers. The receipt of induction chemotherapy was not associated with a survival benefit compared with no induction therapy. CONCLUSIONS: Several patient-, treatment center-, and tumor-related factors are associated with receipt of induction therapy for cT2N0M0 esophageal cancer, although induction therapy is not associated with a survival benefit. Further inquiry into these differences and the potential benefit or lack thereof of induction therapy should be conducted to provide more equitable and appropriate care for patients with esophageal cancer.
Assuntos
Antineoplásicos/uso terapêutico , Neoplasias Esofágicas/tratamento farmacológico , Estadiamento de Neoplasias , Idoso , Neoplasias Esofágicas/diagnóstico , Neoplasias Esofágicas/cirurgia , Esofagectomia , Feminino , Seguimentos , Humanos , Quimioterapia de Indução , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: There is poor understanding of the comparative effectiveness of lobar and sublobar resections for limited-stage small cell lung cancer (SCLC). We analyzed the National Cancer Database to examine the outcomes of patients undergoing wedge resection (WR), segmentectomy (SR), and lobectomy (LB) for limited-stage SCLC. METHODS: Patients with cT1-2N0M0 SCLC (2004-2015) who underwent definitive surgery were identified and stratified by extent of resection: WR, SR, or LB. The primary outcome was overall survival (OS) and secondary outcomes were margin-positive resection (>R0) and pathologic nodal upstaging. RESULTS: A total 1948 patients met study criteria: 619 (32%) underwent WR, 96 (5%) SR, and 1233 (63%) LB. Patients receiving LB were more likely to be younger, have fewer comorbidities, and be privately insured. The unadjusted 5-year OS of WR, SR, and LB patients was 31% (95% confidence interval [CI], 27-35), 35% (95% CI, 25-49), and 45% (95% CI, 42-49), respectively. In a multivariable Cox model, WR was associated with worse OS (hazard ratio, 1.53; 95% CI, 1.31-1.79) and SR similar OS (hazard ratio, 1.20; 95% CI, 0.87-1.67) compared with LB. SR was associated with similar survival compared with LB in a propensity score-matched multivariable analysis as well. WR was also associated with greater odds of >R0 resection compared with LB. CONCLUSIONS: In this study, patients with limited-stage SCLC undergoing WR experienced worse survival compared with those undergoing LB; survival was similar between segmentectomy and LB.