RESUMO
BACKGROUND: Prior studies suggest underutilization of invasive mediastinal staging for lung cancer. We hypothesized that The Society of Thoracic Surgeons General Thoracic Surgery Database (STS-GTSD) participants would have higher rates of invasive staging compared with previous reports. METHODS: We conducted a retrospective cohort study (2012 to 2016) of lung cancer patients staged by computed tomography and positron-emission tomography and first treated with an anatomic resection. We defined invasive staging by the use of mediastinoscopy, endosonography, or thoracoscopy. Standardized incidence ratios were used to compare participant-level rates of invasive staging, and Poisson regression was used to identify factors associated with invasive staging. RESULTS: Among 29,015 patients across 256 participating STS-GTSD sites, 34% (95% confidence interval: 33% to 34%) underwent invasive staging. The overall rate of invasive staging did not change between 2012 and 2016 (p trend = 0.16). Increasing clinical stage and features suggestive of a central tumor were associated with invasive staging (p < 0.001). Rates of invasive staging among patients with clinical stage IB or greater or features suggestive of a central tumor were 43% (95% confidence interval: 42% to 44%) and 52% (95% confidence interval: 50% to 54%), respectively. There was a more than 40-fold variation in rates of invasive staging across 251 centers contributing at least 10 cases (standardized incidence ratio: lowest = 0.08; highest = 3.26); 66 sites (26%) performed invasive mediastinal staging less often than average and 77 sites (31%) performed invasive staging more often than average. CONCLUSIONS: The STS-GTSD participants performed invasive mediastinal staging more frequently than prior reports, and yet only in a minority of patients. Rates of invasive mediastinal staging vary widely across STS-GTSD participants.
Assuntos
Carcinoma Pulmonar de Células não Pequenas/diagnóstico , Endossonografia/métodos , Neoplasias Pulmonares/diagnóstico , Mediastinoscopia/métodos , Estadiamento de Neoplasias/métodos , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada/métodos , Toracoscopia/métodos , Idoso , Carcinoma Pulmonar de Células não Pequenas/secundário , Carcinoma Pulmonar de Células não Pequenas/cirurgia , Bases de Dados Factuais , Feminino , Seguimentos , Humanos , Neoplasias Pulmonares/cirurgia , Metástase Linfática/diagnóstico por imagem , Masculino , Mediastino , Pneumonectomia/métodos , Estudos Retrospectivos , Sociedades Médicas , Cirurgia Torácica , Estados UnidosRESUMO
OBJECTIVES: Very few studies have examined the quality of wedge resection in patients with non-small cell lung cancer. Using the National Cancer Database, we evaluated whether the quality of wedge resection affects overall survival in patients with early disease and how these outcomes compare with those of patients who receive stereotactic radiation. METHODS: We identified 14,328 patients with cT1 to T2, N0, M0 disease treated with wedge resection (n = 10,032) or stereotactic radiation (n = 4296) from 2005 to 2013 and developed a subsample of propensity-matched wedge and radiation patients. Wedge quality was grouped as high (negative margins, >5 nodes), average (negative margins, ≤5 nodes), and poor (positive margins). Overall survival was compared between patients who received wedge resection of different quality and those who received radiation, adjusting for demographic and clinical variables. RESULTS: Among patients who underwent wedge resection, 94.6% had negative margins, 44.3% had 0 nodes examined, 17.1% had >5 examined, and 3.0% were nodally upstaged; 16.7% received a high-quality wedge, which was associated with a lower risk of death compared with average-quality resection (adjusted hazard ratio [aHR], 0.74; 95% confidence interval [CI], 0.67-0.82). Compared with stereotactic radiation, wedge patients with negative margins had significantly reduced hazard of death (>5 nodes: aHR, 0.50; 95% CI, 0.43-0.58; ≤5 nodes: aHR, 0.65; 95% CI, 0.60-0.70). There was no significant survival difference between margin-positive wedge and radiation. CONCLUSIONS: Lymph nodes examined and margins obtained are important quality metrics in wedge resection. A high-quality wedge appears to confer a significant survival advantage over lower-quality wedge and stereotactic radiation. A margin-positive wedge appears to offer no benefit compared with radiation.
Assuntos
Carcinoma Pulmonar de Células não Pequenas/cirurgia , Neoplasias Pulmonares/cirurgia , Pneumonectomia , Radiocirurgia , Idoso , Carcinoma Pulmonar de Células não Pequenas/mortalidade , Carcinoma Pulmonar de Células não Pequenas/patologia , Bases de Dados Factuais , Feminino , Humanos , Neoplasias Pulmonares/mortalidade , Neoplasias Pulmonares/patologia , Excisão de Linfonodo , Linfonodos/patologia , Linfonodos/cirurgia , Masculino , Margens de Excisão , Estadiamento de Neoplasias , Neoplasia Residual , Pneumonectomia/efeitos adversos , Pneumonectomia/mortalidade , Radiocirurgia/efeitos adversos , Radiocirurgia/mortalidade , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados UnidosRESUMO
BACKGROUND: For operable patients with clinical stage IIIA non-small cell lung cancer, the optimum neoadjuvant treatment strategy remains unclear. Our aim was to compare perioperative and long-term outcomes for patients receiving neoadjuvant chemoradiotherapy (NCRT) versus neoadjuvant chemotherapy (NCT) alone. METHODS: We queried the National Cancer Database to identify all patients with N2 and either T1-T2 non-small cell lung cancer who received either NCRT or NCT followed by lobectomy between 2006 and 2012. Patients with T3 tumors were excluded. A propensity match analysis was performed incorporating preoperative variables, and the incidence of postoperative complications, pathologic downstaging, and long-term survival were compared. RESULTS: In all, 1,936 patients met criteria, 745 NCT and 1,191 NCRT. The NCRT patients were younger, less likely to be treated at an academic medical center, and more likely to have adenocarcinoma. After propensity matching, patients in the NCT group showed lower 30-day mortality (1.3% versus 2.9%) and 90-day mortality (2.9% versus 6.0%), and were more likely to undergo a minimally invasive resection (25.7% versus 14.1%). The NCRT patients were more likely to have a pathologic complete response (14.2% versus 4.0%) and to be N0 at the time of resection (45.2% versus 38.7%). In the multivariable analysis, NCRT patients were at a greater risk of mortality than NCT patients (hazard ratio 1.18, 95% confidence interval: 1.03 to 1.36). CONCLUSIONS: In our cohort, combined neoadjuvant chemotherapy and radiation therapy was associated with improved pathologic downstaging but showed increased perioperative mortality with no improvement in long-term overall survival. For stage IIIA patients with smaller tumors without local invasion, chemotherapy alone may be the preferred neoadjuvant treatment.
Assuntos
Carcinoma Pulmonar de Células não Pequenas/mortalidade , Carcinoma Pulmonar de Células não Pequenas/terapia , Neoplasias Pulmonares/mortalidade , Neoplasias Pulmonares/terapia , Terapia Neoadjuvante , Idoso , Antineoplásicos/uso terapêutico , Carcinoma Pulmonar de Células não Pequenas/patologia , Quimiorradioterapia , Estudos de Coortes , Feminino , Humanos , Neoplasias Pulmonares/patologia , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Pneumonectomia , Taxa de SobrevidaRESUMO
BACKGROUND: Upstaging in early esophageal adenocarcinoma (EAC) patients happens at a high rate and has implications for treatment. We sought to identify risk factors predicting upstaging. STUDY DESIGN: The National Cancer Database (2010-2013) was queried for all patients with clinical T1/T2 and N0 EAC who underwent esophagectomy without neoadjuvant therapy. Logistic regression models were developed to investigate risk factors for upstaging. RESULTS: A total of 1120 patients were included. Pathologic upstaging occurred in 21.3% (n = 239). After adjustment, risk of upstaging increased with tumor size (tumor size 1-3 cm, OR 4.57,95% CI 2.58-8.10, tumor size >3 cm, OR 10.57, 95% CI 5.77-19.35, as compared to tumors <1 cm) as well as with positive margins (OR 4.13, 95% CI 2.17-7.87) and > than 10 lymph nodes examined (OR 1.85, 95% CI 1.29-2.63), while facility volume was not significant. Odds of upstaging increased linearly with number of lymph nodes examined (OR 1.02 per node). CONCLUSION: Our data underscore the importance of tumor size as a predictor for upstaging and of completing a thorough lymph node dissection for staging purposes.
Assuntos
Adenocarcinoma/diagnóstico , Detecção Precoce de Câncer , Neoplasias Esofágicas/diagnóstico , Excisão de Linfonodo/métodos , Estadiamento de Neoplasias/métodos , Sistema de Registros , Adenocarcinoma/secundário , Adenocarcinoma/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Progressão da Doença , Neoplasias Esofágicas/secundário , Neoplasias Esofágicas/cirurgia , Esofagectomia , Feminino , Humanos , Linfonodos/patologia , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de RiscoRESUMO
BACKGROUND: Lymph node assessment for non-small cell lung cancer (NSCLC) shows wide variation among centers. Our aim was to assess the quality of lymph node assessment in early-stage NSCLC and determine whether any factors are associated with improved lymph node harvest. METHODS: We queried the National Cancer Database to identify patients with clinical stage I NSCLC who underwent segmentectomy or lobectomy between 2004 and 2013. Patients were stratified into three groups (≤5, 6 to 15, and >15) based on the number of lymph nodes assessed. RESULTS: Patients (n = 51,358) met criteria, and mean lymph nodes assessed increased from 8.1 to 10.0 (p < 0.001) over the study period. There was a significant decrease in the percentage of patients with 0 to 5 nodes assessed (41.1% versus 31.1%, p < 0.001) and a significant increase in patients with more than 15 nodes assessed (10.1% versus 17.0%, p < 0.001). Patients at academic centers were less likely to have only 0 to 5 nodes assessed (27.2% versus 43.6% for community, p < 0.001). Variables associated with more than 15 nodes assessed were increasing year, age older than 65 years, male sex, non-African American race, academic centers, lobectomy, and clinical T2 disease. Patients with more than 14 nodes assessed demonstrated more nodal upstaging (17.9% versus 10.9% for 1 to 14 nodes, p < 0.001). Multivariable analysis suggests that at least 14 nodes should be assessed to maximize the probability that node-positive patients are correctly identified. CONCLUSIONS: Lymph node assessment has improved since 2004 but varies by facility type and other characteristics. In our analysis removing at least 14 nodes was associated with more accurate staging.
Assuntos
Carcinoma Pulmonar de Células não Pequenas/patologia , Neoplasias Pulmonares/patologia , Linfonodos/patologia , Idoso , Carcinoma Pulmonar de Células não Pequenas/mortalidade , Carcinoma Pulmonar de Células não Pequenas/terapia , Bases de Dados Factuais , Feminino , Humanos , Neoplasias Pulmonares/mortalidade , Neoplasias Pulmonares/terapia , Excisão de Linfonodo , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Pneumonectomia , Estudos Retrospectivos , Estados UnidosRESUMO
The use of minimally invasive esophagectomy (MIE) is increasing despite limited evidence to support its efficacy. We compared overall survival and perioperative mortality for MIE vs open esophagectomy (OE). We queried the National Cancer Database for all patients having esophagectomy as the primary procedure for primary squamous cell cancer and adenocarcinoma from 2010 through 2012. A propensity score analysis was performed. Postoperative pathology and quality, as well as overall patient survival outcomes, were compared between OE and MIE. The use of MIE increased from 26.9% in 2010 to 36.3% in 2012 (P < 0.001). Of 3032 patients (2050 OE and 982 MIE) who were identified, propensity score matching (1:1) yielded 977 patients in each group. Mean lymph nodes examined were higher in the MIE group (16.3 vs 14.5, P < 0.001). However, final pathologic nodal stage was not significantly different in the matched sample. There was also no difference in pathologic upstaging or margin status between the groups. All other postoperative variables were equivalent, including an average length of stay of 14 days, unplanned readmission rate of 6.5%, and 30-day and 90-day mortality rates of 3% and 7%, respectively. There was no survival difference, with a median survival of 48.7 months for OE and 46.6 months for MIE (Kaplan-Meier analysis, P = 0.376). During the 3-year period analyzed, there were no significant differences in postoperative outcomes and quality metrics between OE and MIE. Although short-term outcomes are limited in the National Cancer Database, MIE appears to have equivalent oncological outcomes and survival when compared with the open approach.
Assuntos
Neoplasias Esofágicas/cirurgia , Esofagectomia/métodos , Laparoscopia , Toracoscopia , Idoso , Distribuição de Qui-Quadrado , Bases de Dados Factuais , Neoplasias Esofágicas/mortalidade , Neoplasias Esofágicas/patologia , Esofagectomia/efeitos adversos , Esofagectomia/mortalidade , Feminino , Humanos , Estimativa de Kaplan-Meier , Laparoscopia/efeitos adversos , Laparoscopia/mortalidade , Tempo de Internação , Metástase Linfática , Masculino , Margens de Excisão , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Complicações Pós-Operatórias/etiologia , Pontuação de Propensão , Fatores de Risco , Toracoscopia/efeitos adversos , Toracoscopia/mortalidade , Fatores de Tempo , Resultado do Tratamento , Estados UnidosRESUMO
BACKGROUND: It is unknown whether acid/reflux control prevents progression in Barrett's esophagus. In this study, we investigate whether medical or surgical control of reflux is associated with a decreased risk of progression to dysplasia/esophageal adenocarcinoma. METHODS: We retrospectively collected and analyzed data from a cohort of Barrett's esophagus patients participating in this single-center study comprised of all patients diagnosed with Barrett's esophagus at NorthShore University Health System hospitals and clinics over a 10-year period. Patients were followed in order to identify those progressing from Barrett's esophagus to low-grade dysplasia, high-grade dysplasia, and esophageal adenocarcinoma. We collected information from the patient's electronic medical records regarding demographic, endoscopic findings, histological findings, smoking/alcohol history, medication use including proton-pump inhibitors, and history of bariatric and antireflux surgery. Risk-adjusted modeling was performed using multivariable logistic regression. RESULTS: This study included 1,830 total Barrett's esophagus patients, 102 of which had their Barrett's esophagus progress to low-grade dysplasia, high-grade dysplasia, or esophageal adenocarcinoma (confirmed by biopsy) with an annual incidence rate of 1.1%. Mean follow-up period was 5.51 years (10,083 patient-years). Compared to the group that did not progress, the group that progressed was older (69.3 ± 13.7 vs. 63.9 ± 13.4 years. p < 0.001) and likely to be male (75 vs. 61%, p < 0.01). In the multivariable analysis, patients who had a history of antireflux surgery (n = 44) or proton-pump inhibitor use without surgery (n = 1,641) were found to progress at significantly lower rates than patients who did not have antireflux surgery or were not taking PPI's (OR 0.18, 95% CI 0.09-0.36). CONCLUSIONS: Reflux control was associated with decreased risk of progression to low-grade dysplasia, high-grade dysplasia, or esophageal adenocarcinoma. These results support the use of reflux control strategies such as proton-pump inhibitor therapy or surgery in patients with non-dysplastic Barrett's esophagus for the prevention of progression to dysplasia/adenocarcinoma.
Assuntos
Esôfago de Barrett/terapia , Refluxo Gastroesofágico/prevenção & controle , Adenocarcinoma/etiologia , Idoso , Inibidores da Enzima Conversora de Angiotensina/efeitos adversos , Esôfago de Barrett/complicações , Transformação Celular Neoplásica , Progressão da Doença , Neoplasias Esofágicas/etiologia , Feminino , Refluxo Gastroesofágico/complicações , Humanos , Incidência , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Inibidores da Bomba de Prótons/uso terapêutico , Estudos Retrospectivos , Fatores de Risco , Vitamina D/administração & dosagemRESUMO
INTRODUCTION: Barrett's esophagus (BE) is the most predictive risk factor for development of esophageal adenocarcinoma (EAC), a malignancy with the fastest increasing incidence in the US. The aim of this study was to investigate differences in exposures, demographics, and comorbidities between regressing and non-regressing patients. METHODS AND PROCEDURES: We retrospectively collected and analyzed data from a cohort of BE patients participating in a single-center study comprised of all patients diagnosed with BE over a 10-year period. We collected information from the patient's electronic medical records regarding demographic data, endoscopic findings, histological findings, exposures, and history of antireflux surgery. RESULTS: This study included 1,342 BE patients, 505 (37.6%) of which experienced regression. The regressed group was 52.3% male, while the non-regressing group was 68.3% male (p < 0.001). Mean age was 65.2 ± 12.8 and 62.0 ± 13.1 years for non-regressing and regressing patients, respectively (p < 0.001). No difference was seen in BMI between regressing and non-regressing groups (27.5 ± 5.7 vs. 27.7 ± 5.4, p = 0.52). No difference was seen between groups with respect to PPI use (93.5% non-regressing vs. 94.1% regressed patients, p = 0.70), but regressed patients were more likely to take vitamin D than non-regressing patients (34.1 vs. 42.1%, p = 0.003). Regressed patients had an average segment length of 1.48 cm (±1.58 cm), in contrast to those not regressing (3.58 ± 3.09 cm (p < 0.001)). Interestingly, one patient in the regression group progressed to dysplasia, while 101 of the non-regressing patients progressed to dysplasia/EAC, a result found to be independent of segment length on multivariate analysis (p < 0.001). CONCLUSIONS: Currently, several studies have shown risk factors that can predict progression of non-dysplastic BE, but few investigate predictors for regression. Our study reports several factors that can be used to predict patients who will regress from BE and those who likely will not, tools that will be useful in tailoring therapeutic and surveillance strategies.
Assuntos
Esôfago de Barrett/patologia , Remissão Espontânea , Adenocarcinoma/patologia , Fatores Etários , Idoso , Conservadores da Densidade Óssea/administração & dosagem , Estudos de Coortes , Progressão da Doença , Neoplasias Esofágicas/patologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Regressão Neoplásica Espontânea , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Vitamina D/administração & dosagemRESUMO
BACKGROUND: The treatment of stage I and II non-small cell lung cancer (NSCLC) in patients with good or low surgical risk is primarily surgical resection. However, this area is undergoing many changes. With a greater prevalence of CT imaging, many lung cancers are being found that are small or constitute primarily ground-glass opacities. Treatment such as sublobar resection and nonsurgical approaches such as stereotactic body radiotherapy (SBRT) are being explored. With the advent of minimally invasive resections, the criteria to classify a patient as too ill to undergo an anatomic lung resection are being redefined. METHODS: The writing panel selected topics for review based on clinical relevance to treatment of early-stage lung cancer and the amount and quality of data available for analysis and relative controversy on best approaches in stage I and II NSCLC: general surgical care vs specialist care; sublobar vs lobar surgical approaches to stage I lung cancer; video-assisted thoracic surgery vs open resection; mediastinal lymph node sampling vs lymphadenectomy at the time of surgical resection; the use of radiation therapy, with a focus on SBRT, for primary treatment of early-stage NSCLC in high-risk or medically inoperable patients as well as adjuvant radiation therapy in the sublobar and lobar resection settings; adjuvant chemotherapy for early-stage NSCLC; and the impact of ethnicity, geography, and socioeconomic status on lung cancer survival. Recommendations by the writing committee were based on an evidence-based review of the literature and in accordance with the approach described by the Guidelines Oversight Committee of the American College of Chest Physicians. RESULTS: Surgical resection remains the primary and preferred approach to the treatment of stage I and II NSCLC. Lobectomy or greater resection remains the preferred approach to T1b and larger tumors. The use of sublobar resection for T1a tumors and the application of adjuvant radiation therapy in this group are being actively studied in large clinical trials. Every patient should have systematic mediastinal lymph node sampling at the time of curative intent surgical resection, and mediastinal lymphadenectomy can be performed without increased morbidity. Perioperative morbidity and mortality are reduced and long-term survival is improved when surgical resection is performed by a board-certified thoracic surgeon. The use of adjuvant chemotherapy for stage II NSCLC is recommended and has shown benefit. The use of adjuvant radiation or chemotherapy for stage I NSCLC is of unproven benefit. Primary radiation therapy remains the primary curative intent approach for patients who refuse surgical resection or are determined by a multidisciplinary team to be inoperable. There is growing evidence that SBRT provides greater local control than standard radiation therapy for high-risk and medically inoperable patients with NSCLC. The role of ablative therapies in the treatment of high-risk patients with stage I NSCLC is evolving. Radiofrequency ablation, the most studied of the ablative modalities, has been used effectively in medically inoperable patients with small (< 3 cm) peripheral NSCLC that are clinical stage I.
Assuntos
Carcinoma Pulmonar de Células não Pequenas/terapia , Neoplasias Pulmonares/terapia , Carcinoma Pulmonar de Células não Pequenas/patologia , Carcinoma Pulmonar de Células não Pequenas/cirurgia , Quimioterapia Adjuvante , Humanos , Neoplasias Pulmonares/patologia , Neoplasias Pulmonares/cirurgia , Excisão de Linfonodo , Estadiamento de Neoplasias , Seleção de Pacientes , Pneumonectomia , Radiocirurgia , Radioterapia Adjuvante , Cirurgia Torácica VídeoassistidaRESUMO
OBJECTIVE: The objective of this study was to compare the safety, use, and cost profiles of open thoracotomy vs video-assisted thoracoscopic surgery (VATS) for wedge resection in lung cancer performed by thoracic surgeons in the United States. METHODS: The Premier database, which contains complete patient billing, hospital cost, and coding histories from > 25 million inpatient discharges and > 175 million hospital outpatient visits, was used for this analysis. Eligible patients were those who underwent wedge resection by a thoracic surgeon for cancer diagnosis or treatment through open thoracotomy or VATS in 2007 or 2008. Multivariable logistic regression analyses were run for binary outcomes, and ordinary least squares regressions were used for continuous outcomes. All models were adjusted for patient demographics, comorbid conditions, and hospital characteristics. RESULTS: Of 8,228 eligible procedures, 2,051 patients underwent wedge resections by a thoracic surgeon using the open technique (n = 999) or VATS (n = 1,052). Hospital costs remained significantly higher for open wedge resections than for VATS ($17,377 vs $14,795, P = .000). Surgery time was significantly longer for open resections vs VATS (3.16 vs 2.82 h). Length of stay was 6.34 days for open vs 4.44 days for VATS. Adverse events were significant in the multivariable analysis, with an OR of 1.57 (95% CI, 1.29-1.91) in favor of VATS. CONCLUSIONS: Although this retrospective database analysis could not address the issue of oncologic outcome equivalence, a clear advantage of VATS over open wedge lung cancer resection was found for both acute clinical outcomes and hospital costs.
Assuntos
Neoplasias Pulmonares/cirurgia , Pneumonectomia/métodos , Cirurgia Torácica Vídeoassistida , Toracotomia/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Distribuição de Qui-Quadrado , Bases de Dados Factuais , Feminino , Humanos , Análise dos Mínimos Quadrados , Tempo de Internação/estatística & dados numéricos , Modelos Logísticos , Neoplasias Pulmonares/economia , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
BACKGROUND: The Premier Perspective Database (Premier Inc, Charlotte, NC) was used to compare hospital costs and perioperative outcomes for video-assisted thoracoscopic surgery (VATS) and open lobectomy procedures in the United States. METHODS: Eligible patients underwent a lobectomy for cancer by a thoracic surgeon, by VATS or open thoracotomy and were captured in the database between third quarter of 2007 and through 2008. Multivariable logistic regression analyses were performed for binary outcomes. Ordinary least-squares regressions were used to estimate continuous outcomes. All models were adjusted for patient and hospital characteristics. RESULTS: A total of 3,961 patients underwent a lobectomy by a thoracic surgeon by open (n = 2,907) or VATS (n = 1,054) approach. Hospital costs were higher for open versus VATS; $21,016 versus $20,316 (p = 0.027). Adjustment for surgeon experience with VATS over the 6 months prior to each operation showed a significant association between surgeon experience and cost. Average costs ranged from $22,050 for low volume surgeons to $18,133 for high volume surgeons. For open lobectomies, cost differences by surgeon experience were not significant and both levels were estimated at $21,000. Length of stay was 7.83 versus 6.15 days, for open versus VATS (p = 0.000). Surgery duration was shorter for open procedures at 3.75 versus 4.09 for VATS (p = 0.000). The risk of adverse events was significantly lower in the VATS group, odds ratio of 1.22 (p = 0.019). CONCLUSIONS: Lobectomy performed by the VATS approach as compared with an open technique results in shorter length of stay, fewer adverse events, and less cost to the hospital. Economic impact is magnified as the surgeon's experience increases.
Assuntos
Neoplasias Pulmonares/cirurgia , Pneumonectomia/economia , Pneumonectomia/estatística & dados numéricos , Cirurgia Torácica Vídeoassistida/economia , Cirurgia Torácica Vídeoassistida/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Morbidade , Estudos Retrospectivos , Estados UnidosRESUMO
OBJECTIVE: Low-dose chest computed tomography (CT) is being evaluated in several national trials as a screening modality for the early detection of lung cancer. The goal of the present study was to determine whether lung cancer screening could be done while minimizing the number of benign biopsy specimens taken in an area endemic for histoplasmosis. METHODS: The subjects were recruited by letters mailed to area physicians and local advertisement. The inclusion criteria were age older than 50 years and at least a 20 pack-year smoking history. The exclusion criteria were symptoms suggestive of lung cancer or a history of malignancy in the previous 5 years. The participants completed a questionnaire and underwent a chest CT scan at baseline and annually for 5 years. The management of positive screening results was determined using a defined algorithm: annual follow-up CT scan for nodules less than 5 mm; 6-month follow-up CT scan for nodules 5 to 7 mm; review by our multidisciplinary tumor board for nodules 8 to 12 mm; and biopsy for nodules greater than 12 mm. RESULTS: A total of 132 patients were recruited. Of the 132 patients, 61% had positive baseline CT findings and 22% had positive findings on the annual CT scans. Six cancers were detected. Of these 6 patients, 5 had stage I disease and underwent lobectomy, and 1 had stage IIIA disease and underwent induction chemotherapy and radiotherapy followed by lobectomy. All patients were alive and disease free at a mean follow-up of 41.7 ± 18.6 months. No biopsies were performed for benign lesions. Also, no cancers were missed when the protocol was followed. CONCLUSIONS: Screening with CT can be done effectively in an area endemic for histoplasmosis while minimizing benign biopsies.
Assuntos
Doenças Endêmicas , Histoplasmose/epidemiologia , Neoplasias Pulmonares/diagnóstico por imagem , Programas de Rastreamento/métodos , Nódulo Pulmonar Solitário/diagnóstico por imagem , Tomografia Computadorizada Espiral , Idoso , Algoritmos , Biópsia , Quimioterapia Adjuvante , Análise Custo-Benefício , Detecção Precoce de Câncer , Feminino , Seguimentos , Custos de Cuidados de Saúde , Humanos , Neoplasias Pulmonares/epidemiologia , Neoplasias Pulmonares/cirurgia , Masculino , Programas de Rastreamento/economia , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Ohio/epidemiologia , Pneumonectomia , Valor Preditivo dos Testes , Radioterapia Adjuvante , Nódulo Pulmonar Solitário/epidemiologia , Nódulo Pulmonar Solitário/cirurgia , Inquéritos e Questionários , Fatores de Tempo , Tomografia Computadorizada Espiral/economia , Resultado do Tratamento , Procedimentos DesnecessáriosRESUMO
PURPOSE: To assess the feasibility and effectiveness of intrapleural recombinant tissue-type plasminogen activator (r-tPA) in the treatment of loculated parapneumonic effusions (PPEs). MATERIALS AND METHODS: A single-arm prospective study of 25 consecutive patients with loculated PPEs was analyzed. All patients received 6-mg doses of intrapleural r-tPA on a defined schedule via a thoracostomy tube. The volume of output from the tubes was recorded and analysis of the fluid composition performed. Follow-up was both clinical and radiographic, with all patients undergoing pre- and postprocedural computed tomography. RESULTS: Eighteen of the 25 patients (72%) required no additional intervention and had a complete clinical and radiographic response with the fibrinolytic therapy. Seven patients (28%) were treated with video-assisted thoracoscopic surgery, but no patient required thoracotomy for total decortication. There were no hemorrhagic complications. CONCLUSIONS: Intrapleural r-tPA is effective in the treatment of loculated PPEs. It can be performed safely and in some patients may avoid the need for additional surgical intervention.
Assuntos
Derrame Pleural/tratamento farmacológico , Derrame Pleural/etiologia , Pneumonia/complicações , Pneumonia/tratamento farmacológico , Ativador de Plasminogênio Tecidual/uso terapêutico , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Fibrinolíticos/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Derrame Pleural/diagnóstico por imagem , Pneumonia/diagnóstico por imagem , Radiografia , Resultado do Tratamento , Adulto JovemRESUMO
Chronic obstructive pulmonary disease (COPD) is a lethal progressive lung disease culminating in permanent airway obstruction and alveolar enlargement. Previous studies suggest CTL involvement in COPD progression; however, their precise role remains unknown. Here, we investigated whether the CTL activation receptor NK cell group 2D (NKG2D) contributes to the development of COPD. Using primary murine lung epithelium isolated from mice chronically exposed to cigarette smoke and cultured epithelial cells exposed to cigarette smoke extract in vitro, we demonstrated induced expression of the NKG2D ligand retinoic acid early transcript 1 (RAET1) as well as NKG2D-mediated cytotoxicity. Furthermore, a genetic model of inducible RAET1 expression on mouse pulmonary epithelial cells yielded a severe emphysematous phenotype characterized by epithelial apoptosis and increased CTL activation, which was reversed by blocking NKG2D activation. We also assessed whether NKG2D ligand expression corresponded with pulmonary disease in human patients by staining airway and peripheral lung tissues from never smokers, smokers with normal lung function, and current and former smokers with COPD. NKG2D ligand expression was independent of NKG2D receptor expression in COPD patients, demonstrating that ligand expression is the limiting factor in CTL activation. These results demonstrate that aberrant, persistent NKG2D ligand expression in the pulmonary epithelium contributes to the development of COPD pathologies.
Assuntos
Pulmão/fisiopatologia , Doença Pulmonar Obstrutiva Crônica/imunologia , Mucosa Respiratória/fisiopatologia , Fumaça/efeitos adversos , Fumar/efeitos adversos , Animais , Linfócitos T CD8-Positivos/imunologia , Modelos Animais de Doenças , Enfisema/etiologia , Enfisema/imunologia , Regulação da Expressão Gênica , Células Matadoras Naturais/imunologia , Ativação Linfocitária , Proteínas de Membrana/genética , Camundongos , Subfamília K de Receptores Semelhantes a Lectina de Células NK/genética , Doença Pulmonar Obstrutiva Crônica/etiologia , Doença Pulmonar Obstrutiva Crônica/fisiopatologiaRESUMO
OBJECTIVE: Thoracoscopic lobectomy has been demonstrated to be safe and oncologically sound. However, few thoracic surgeons perform the operation. We hypothesized that use of a predetermined, stepwise plan for introduction of thoracoscopic lobectomy into a thoracic surgical training program would facilitate safe learning of the technique. METHODS: Databases from 2 affiliated institutions were queried to identify all lobectomies during a 4-year period. Our model for introduction of thoracoscopic lobectomy was established expertise in open lobectomy and video-assisted thoracoscopic surgery, participation in a formal thoracoscopic lobectomy course, stepwise introduction of specific techniques used in thoracoscopic lobectomy into the operative approach, proctoring of initial thoracoscopic lobectomies by partners, and teaching of the technique to other thoracic surgeons and residents. RESULTS: We performed 202 lobectomies: 97 open and 105 thoracoscopic. Mortality was 3.0%. The conversion rate from thoracoscopic to open thoracotomy was 13%. When divided into quartiles, the percentage of lobectomies performed thoracoscopically increased from 18% in the first quartile to 82% in the fourth quartile. With ongoing experience, the procedure was performed at higher frequency by new staff and trainees. Residents performed 0% of thoracoscopic lobectomies in the first quartile, increasing to 54% in the third quartile. In the fourth quartile residents and a new staff surgeon performed 76% of thoracoscopic lobectomies. A resident was the operating surgeon for 37 thoracoscopic lobectomies. CONCLUSIONS: Introduction of thoracoscopic lobectomy into an academic thoracic surgical practice can be achieved safely if a stepwise transition is invoked. Training of thoracic surgical residents and additional staff can thus be effectively accomplished.
Assuntos
Internato e Residência , Pneumonectomia/educação , Cirurgia Torácica Vídeoassistida/educação , Cirurgia Torácica/educação , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Neoplasias Pulmonares/patologia , Neoplasias Pulmonares/cirurgia , Masculino , Pessoa de Meia-Idade , Pneumonectomia/efeitos adversos , Pneumonectomia/métodos , Cirurgia Torácica Vídeoassistida/efeitos adversos , ToracotomiaRESUMO
Video-assisted thoracoscopic surgery is an effective and versatile tool for the diagnosis and staging of patients with lung cancer. Despite advances in imaging technology, including integrated positron emission tomography/computed tomography scans, the clinical staging of patients with lung cancer remains inaccurate. Tissue confirmation is critical for accurate staging and treatment of patients with lung cancer. Thoracoscopy is an excellent and often preferred approach to the biopsy of inferior mediastinal, anteroposterior window, and para-aortic lymph nodes, and has the added advantage of allowing simultaneous assessment of the pleural space, satellite lung nodules, and T status of the tumor. Thoracoscopic wedge resection is the preferred technique for diagnosing indeterminate solitary pulmonary nodules. In the era of computed tomography screening, most indeterminate lung nodules are less than 1 cm in size and pose unique challenges in determining malignant potential and obtaining a tissue diagnosis. Several techniques have been adopted to allow successful thoracoscopic biopsy of these subcentimeter lung nodules.
Assuntos
Carcinoma Pulmonar de Células não Pequenas/diagnóstico , Estadiamento de Neoplasias , Cirurgia Torácica Vídeoassistida/instrumentação , Carcinoma Pulmonar de Células não Pequenas/fisiopatologia , Humanos , Mediastino/patologia , Pleura/patologia , Cirurgia Torácica Vídeoassistida/métodosRESUMO
OBJECTIVE: To evaluate the feasibility and efficacy of sequential neoadjuvant chemotherapy, chemoradiation, and surgery in patients with locally advanced esophageal cancer. PATIENTS AND METHODS: There were 29 patients who received paclitaxel 150 mg/m2 and gemcitabine 3000 mg/m2 2 weeks apart. Two weeks later, patients received cisplatin 75 mg/m2 and 5-fluorouracil (5-FU) 1000 mg/m2/d continuous infusion for 4 days with concurrent radiotherapy in 15 fractions to a total dose of 4000 cGy. After 6 weeks, cisplatin and 5-FU were repeated at the above doses. After 4 to 6 weeks, patients were restaged and underwent surgical resection. RESULTS: All 29 patients completed the prescribed gemcitabine, paclitaxel, and radiation therapy. Febrile neutropenia occurred in 1 patient and 4 patients received growth factor support. After neoadjuvant treatment, 1 patient refused surgery, 23 underwent R0 resection (82%), while 5 developed progressive disease. Four patients developed anastomotic leaks (17%). Four patients had complete pathologic responses (14%) and 4 (14%) had only residual microscopic disease. Nine patients remain alive at a median follow-up of 48 months. Three-year survival for the entire cohort was 36%. CONCLUSION: This regimen was associated with a high rate of compliance and induction therapy had an acceptable toxicity profile. The R0 resection rate and 3-year survival data are similar to recently reported studies. While active, gemcitabine and paclitaxel induction therapy was associated with an increased rate of postoperative complications, but no increase in survival. Patterns of failure continue to demonstrate the need for regimens incorporating greater emphasis on systemic therapy for locally advanced esophageal cancer.
Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Carcinoma/tratamento farmacológico , Neoplasias Esofágicas/tratamento farmacológico , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma/radioterapia , Carcinoma/cirurgia , Cisplatino/administração & dosagem , Desoxicitidina/administração & dosagem , Desoxicitidina/análogos & derivados , Neoplasias Esofágicas/radioterapia , Neoplasias Esofágicas/cirurgia , Feminino , Fluoruracila/administração & dosagem , Humanos , Masculino , Pessoa de Meia-Idade , Terapia Neoadjuvante , Paclitaxel/administração & dosagem , Análise de Sobrevida , Resultado do Tratamento , GencitabinaRESUMO
BACKGROUND: Inactivation of retinoblastoma (RB) tumor suppressor function occurs frequently in lung cancer. Short-hairpin RNA can be constructed to target specific sequences and efficiently knock down protein expression. We developed a short-hairpin RNA approach to specifically target Rb in lung cancer cells to determine the influence of RB knockdown on proliferation. METHODS: NCI-H520 human lung cancer cells (wild-type Rb) were transfected with pMSCVpuro-Rb3C, a plasmid containing a short-hairpin sequence targeted to human Rb. Transfectants harboring the construct were selected with puromycin. Loss of RB expression in selected cell populations was determined by immunoblotting. Proliferating cells were counted to establish growth rates. Retinoblastoma-proficient and RB-deficient tumor growth was monitored in nude mice. RESULTS: Transfection with pMSCVpuro-Rb3C dramatically diminished RB expression and led to aberrant expression of RB-regulated genes. Cells harboring pMSCVpuro-Rb3C grew at an increased rate compared with control cells: 480.6 +/- 37.7 versus 159.4 +/- 36.2 (relative cell count at 12 days). Tumor growth in nude mice also increased with RB knockdown compared with control mice: 135.2 +/- 73.6 mm3 versus 40.0 +/- 17.0 mm3 (tumor volume at 10 days). CONCLUSIONS: Inhibition of RB expression is efficiently achieved in lung cancer cells with short-hairpin RNA. Genetic targets of RB are deregulated with RB knockdown. Retinoblastoma depletion increases growth in vitro and in murine xenografts. These studies indicate that even in the context of an established tumor cell line, RB limits tumorigenic proliferation. Additionally, this model will serve as an ideal system to evaluate the role of RB activity on therapeutic response.