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1.
Ann Surg ; 278(1): 79-86, 2023 Jul 01.
Artículo en Inglés | MEDLINE | ID: mdl-36040026

RESUMEN

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.


Asunto(s)
Neoplasias Esofágicas , Esofagectomía , Humanos , Esofagectomía/métodos , Modelos de Riesgos Proporcionales , Neoplasias Esofágicas/cirugía , Modelos Logísticos , Bases de Datos Factuales , Estudios Retrospectivos , Resultado del Tratamiento
2.
Ann Surg ; 277(3): e648-e656, 2023 03 01.
Artículo en Inglés | MEDLINE | ID: mdl-34091506

RESUMEN

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.


Asunto(s)
Neoplasias Pulmonares , Mesotelioma Maligno , Mesotelioma , Neoplasias Pleurales , Humanos , Mesotelioma/radioterapia , Mesotelioma/cirugía , Neoplasias Pulmonares/radioterapia , Neoplasias Pulmonares/cirugía , Neoplasias Pleurales/radioterapia , Neoplasias Pleurales/cirugía , Sistema de Registros
3.
Ann Surg ; 275(2): 348-355, 2022 02 01.
Artículo en Inglés | MEDLINE | ID: mdl-32209899

RESUMEN

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.


Asunto(s)
Adenocarcinoma/tratamiento farmacológico , Adenocarcinoma/mortalidad , Quimioterapia Adyuvante , Neoplasias Esofágicas/tratamiento farmacológico , Neoplasias Esofágicas/mortalidad , Esofagectomía , Adenocarcinoma/patología , Adenocarcinoma/cirugía , Anciano , Neoplasias Esofágicas/patología , Neoplasias Esofágicas/cirugía , Femenino , Humanos , Metástasis Linfática , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Estudios Retrospectivos , Tasa de Supervivencia
4.
Ann Surg ; 275(3): e562-e567, 2022 03 01.
Artículo en Inglés | MEDLINE | ID: mdl-32649467

RESUMEN

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.


Asunto(s)
Adenocarcinoma/tratamiento farmacológico , Adenocarcinoma/mortalidad , Quimioterapia Adyuvante , Neoplasias Esofágicas/tratamiento farmacológico , Neoplasias Esofágicas/mortalidad , Índice Ganglionar , Adenocarcinoma/patología , Anciano , Estudios de Cohortes , Neoplasias Esofágicas/patología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Tasa de Supervivencia
5.
Ann Surg ; 276(6): e1000-e1007, 2022 12 01.
Artículo en Inglés | MEDLINE | ID: mdl-33417330

RESUMEN

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.


Asunto(s)
Adenocarcinoma , Carcinoma de Pulmón de Células no Pequeñas , Carcinoma de Células Escamosas , Neoplasias Pulmonares , Humanos , Neumonectomía/efectos adversos , Estadificación de Neoplasias , Resultado del Tratamiento , Adenocarcinoma/patología , Carcinoma de Células Escamosas/cirugía , Carcinoma de Células Escamosas/patología
6.
J Natl Compr Canc Netw ; 20(7): 754-764, 2022 07.
Artículo en Inglés | MEDLINE | ID: mdl-35830884

RESUMEN

The NCCN Guidelines for Lung Cancer Screening recommend criteria for selecting individuals for screening and provide recommendations for evaluation and follow-up of lung nodules found during initial and subsequent screening. These NCCN Guidelines Insights focus on recent updates to the NCCN Guidelines for Lung Cancer Screening.


Asunto(s)
Detección Precoz del Cáncer , Neoplasias Pulmonares , Humanos , Neoplasias Pulmonares/diagnóstico , Tamizaje Masivo
7.
Respiration ; 101(4): 394-400, 2022.
Artículo en Inglés | MEDLINE | ID: mdl-34784603

RESUMEN

RATIONALE: Transbronchial lung cryobiopsy (TBLC) has emerged as a less invasive method to obtain a tissue diagnosis in patients with interstitial lung disease (ILD). The diagnostic yield of TBLC compared to surgical lung biopsy (SLB) remains uncertain. OBJECTIVES: The aim of this study was to determine the diagnostic accuracy of forceps transbronchial lung biopsy (TBLB) and TBLC compared to SLB when making the final diagnosis based on multidisciplinary discussion (MDD). METHODS: Patients enrolled in the study underwent sequential TBLB and TBLC followed immediately by SLB. De-identified cases, with blinding of the biopsy method, were reviewed by a blinded pathologist and then discussed at a multidisciplinary conference. MAIN RESULTS: Between August 2013 and October 2017, we enrolled 16 patients. The raw agreement between TBLC and SLB for the MDD final diagnosis was 68.75% with a Cohen's kappa of 0.6 (95% CI 0.39, 0.81). Raw agreement and Cohen's kappa of TBLB versus TBLC and TBLB versus SLB for the MDD final diagnosis were much lower (50%, 0.21 [95% CI 0, 0.42] and 18.75%, 0.08 [95% CI -0.03, 0.19], respectively). TBLC was associated with mild bleeding (grade 1 bleeding requiring suction to clear) in 56.2% of patients. CONCLUSIONS: In patients with ILD who have an uncertain type based on clinical and radiographic data and require tissue sampling to obtain a specific diagnosis, TBLC showed moderate correlation with SLB when making the diagnosis with MDD guidance. TBLB showed poor concordance with both TBLC and SLB MDD diagnoses.


Asunto(s)
Broncoscopía , Enfermedades Pulmonares Intersticiales , Biopsia/métodos , Broncoscopía/métodos , Humanos , Pulmón/patología , Enfermedades Pulmonares Intersticiales/diagnóstico , Enfermedades Pulmonares Intersticiales/patología , Instrumentos Quirúrgicos
8.
J Magn Reson Imaging ; 53(2): 374-380, 2021 02.
Artículo en Inglés | MEDLINE | ID: mdl-32048438

RESUMEN

Magnetic resonance lymphangiography (MRL) is a noninvasive imaging technique that can be used in the management of lymphatic disorders to delineate the central lymphatic system for treatment planning. This article reviews the MRL technique, its advantages, limitations, indications, and impact on patient management. Level of Evidence 5 Technical Efficacy Stage 3 J. MAGN. RESON. IMAGING 2021;53:374-380.


Asunto(s)
Medios de Contraste , Linfografía , Humanos , Sistema Linfático/diagnóstico por imagen , Imagen por Resonancia Magnética , Espectroscopía de Resonancia Magnética
9.
J Hand Surg Am ; 46(3): 242.e1-242.e11, 2021 03.
Artículo en Inglés | MEDLINE | ID: mdl-33127208

RESUMEN

PURPOSE: Attending surgeons must participate in critical and key portions of procedures and otherwise be immediately available. However, surgeon-defined standards of the critical and key portions of surgery have been questioned, potentially affecting trainee graduated responsibility. This study compares the opinions of surgeons and the general public regarding what constitutes the critical portions of carpal tunnel release (CTR). METHODS: A survey was devised inquiring about the appropriateness of surgical trainee execution of each step of CTR. Surgeons who perform CTR were queried (n = 112) and 32 (29%) responded. The survey was modified to compare responses from a sample of 184 nonmedical respondents (NMRs). The NMRs were excluded if they indicated having a career in health care. RESULTS: Of the surgeon respondents, 94% (n = 30) had completed hand fellowship training, 53% (n = 17) declared themselves academic or affiliated with academia, and 53% (n = 17) utilized concurrent operating rooms. The NMR average age was 35.3 ± 10.3 years, 40% were female (n = 73), and they represented various regions of the United States including an assortment of socioeconomic and ethnic groups. Surgeons demonstrated significantly more hesitation with trainees performing surgical steps. Academic surgeons were significantly more comfortable having trainees performing surgical steps than nonacademic surgeons. Critical portions of CTR as agreed upon by surgeons and NMRs included incision, dissection, transverse carpal ligament division, and inspection of the median nerve for injury/complete release. CONCLUSIONS: Surgeons are significantly less comfortable with trainee performance of CTR steps than the general public. Surgeons who regularly work with trainees are more accepting of trainee involvement than those who do not. CLINICAL RELEVANCE: Understanding the opinions of surgeons as well as NMRs with respect to surgical trainee participation in the operating room is important to optimize the informed consent process as well as influence hospital policies that affect graduated surgical trainee autonomy.


Asunto(s)
Síndrome del Túnel Carpiano , Cirugía General , Cirujanos , Adulto , Síndrome del Túnel Carpiano/cirugía , Femenino , Humanos , Ligamentos , Nervio Mediano , Persona de Mediana Edad , Quirófanos , Estados Unidos
10.
N C Med J ; 82(5): 321-326, 2021.
Artículo en Inglés | MEDLINE | ID: mdl-34544766

RESUMEN

BACKGROUND Low-dose chest CT (LDCT) is the only effective screening test for lung cancer. Annual lung cancer screening (LCS) is recommended by the US Preventive Services Task Force (USPSTF) for individuals at high risk for primary lung neoplasm.METHODS We retrospectively identified patients receiving LCS from January 2016 through March 2018 whose residential addresses were within our health center's county. We estimated driving distance from the patient's address to our health center and obtained sociodemographic characteristics from the electronic health record (EHR). The census-tract-level LCS-eligible population size was estimated, and their population characteristics determined via US Census Bureau, Centers for Disease Control and Prevention (CDC), and Behavioral Risk Factor Surveillance System (BRFSS) data. The Cochran-Mantel-Haenszel test was used to determine differences amongst the LCS-eligible and LCS-enrolled populations. Multivariable regression was used to determine the effects of sociodemographic characteristics on LCS eligibility.RESULTS There was modest correlation between census-tract-level LCS-eligible population size and LCS enrollment (r = 0.68, P < .001). 5.9% (364/6185) of the estimated LCS-eligible population in our county received LCS, with census-tract LCS rates ranging from 1.5% to 12.5%. Nonwhite race status (Hispanic and African American) was associated with decreased likelihood of LCS enrollment compared to White race (OR = 95% CI, 0.765 [0.61, 0.95] and 0.031 [0.008, 0.124], respectively). Older age, Medicaid, and uninsured statuses were positively correlated with LCS eligibility (P ≤ .01).LIMITATIONS This analysis comprises a single county. Other LCS facilities within our health system in neighboring counties, as well as individuals receiving LCS outside of our health system, are not captured.CONCLUSIONS The uptake of LCS remains low, with disproportionately lower screening rates amongst Hispanic and African American populations. Medicaid and uninsured patients in our community are also more likely to be LCS-eligible. These populations may be targets for interventions aimed at increasing LCS awareness and uptake.


Asunto(s)
Neoplasias Pulmonares , Salud Poblacional , Anciano , Detección Precoz del Cáncer , Humanos , Neoplasias Pulmonares/diagnóstico , Estudios Retrospectivos , Tomografía Computarizada por Rayos X , Estados Unidos
11.
J Surg Res ; 253: 214-223, 2020 09.
Artículo en Inglés | MEDLINE | ID: mdl-32380347

RESUMEN

BACKGROUND: Underinsured and uninsured surgical-oncology patients are at higher risk of perioperative morbidity and mortality. Curricular innovation is needed to train medical students to work with this vulnerable population. We describe the implementation of and early educational outcomes from a student-initiated pilot program aimed at improving medical student insight into health disparities in surgery. MATERIALS/METHODS: First-year medical students participated in a dual didactic and perioperative-liaison experience over a 10-month period. Didactic sessions included surgical-skills training and faculty-led lectures on financial toxicity and management of surgical-oncology patients. Students were partnered with uninsured and Medicaid patients receiving surgical-oncology care and worked with these patients by providing appointment reminders, clarifying perioperative instructions, and accompanying patients to surgery and clinic appointments. Students' interest in surgery and self-reported comfort in 15 Association of American Medical Colleges core competencies were assessed with preparticipation and postparticipation surveys using a 5-point Likert scale. RESULTS: Twenty-four first-year students were paired with 14 surgical-oncology patients during the 2017-2018 academic year. Sixteen students (66.7%) completed both preprogram and postprogram surveys. Five students (31.3%) became "More Interested" in surgery, whereas 11 (68.8%) reported "Similar Interest or No Change." Half of the students (n = 8) felt more prepared for their surgery clerkship after participating. Median self-reported comfort improved in 7/15 competencies including Oral Communication and Ethical Responsibility. All students reported being "Somewhat" or "Extremely Satisfied" with the program. CONCLUSIONS: We demonstrate that an innovative program to expose preclinical medical students to challenges faced by financially and socially vulnerable surgical-oncology patients is feasible and may increase students' clinical preparedness and interest in surgery.


Asunto(s)
Curriculum , Educación de Pregrado en Medicina/organización & administración , Disparidades en Atención de Salud/economía , Neoplasias/cirugía , Oncología Quirúrgica/educación , Educación de Pregrado en Medicina/métodos , Femenino , Humanos , Masculino , Neoplasias/economía , Proyectos Piloto , Desarrollo de Programa , Evaluación de Programas y Proyectos de Salud , Factores Socioeconómicos , Estudiantes de Medicina/estadística & datos numéricos , Encuestas y Cuestionarios/estadística & datos numéricos , Poblaciones Vulnerables
12.
Curr Hypertens Rep ; 22(12): 100, 2020 10 23.
Artículo en Inglés | MEDLINE | ID: mdl-33097982

RESUMEN

PURPOSE OF REVIEW: To highlight the indications, procedural considerations, and data supporting the use of stellate ganglion blockade (SGB) for management of refractory ventricular arrhythmias. RECENT FINDINGS: In patients with refractory ventricular arrhythmias, unilateral or bilateral SGB can reduce arrhythmia burden and defibrillation events for 24-72 h, allowing time for use of other therapies like catheter ablation, surgical sympathectomy, or heart transplantation. The efficacy of SGB appears to be consistent despite the type (monomorphic vs polymorphic) or etiology (ischemic vs non-ischemic cardiomyopathy) of the ventricular arrhythmia. Ultrasound-guided SGB is safe with low risk for complications, even when performed on anticoagulation. SGB is effective and safe and could be considered for patients with refractory ventricular arrhythmias.


Asunto(s)
Bloqueo Nervioso Autónomo , Hipertensión , Taquicardia Ventricular , Arritmias Cardíacas , Humanos , Ganglio Estrellado , Taquicardia Ventricular/terapia
13.
Semin Respir Crit Care Med ; 41(3): 335-345, 2020 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-32450587

RESUMEN

Lung carcinoma widely affects men and women in the sixth and seventh decades of life. Thorough workup with radiographic imaging, pathologic diagnosis, and cardiopulmonary functional assessment is key to successful treatment. Accurate staging is essential for both assessing prognosis and directing therapy. Early-stage lung cancer is most often treated with anatomic lobectomy; locally advanced cancers may require induction or adjuvant therapies. Any nonnodal metastases will require definitive systemic therapy. Traditionally, surgery was performed with a posterolateral thoracotomy incision, division of the hilar vessels, removal of affected lung parenchyma, and a complete mediastinal and hilar lymph node dissection for accurate pathologic staging. In recent years, however, video-assisted thoracoscopic (VATS) or other minimally invasive approaches have emerged as the standard of care for early-stage disease. Compared with standard thoracotomy, VATS lobectomy offers improved postoperative outcomes as well as potential survival benefit. Thoracoscopic lobectomy is also cost-effective. This article focuses on the technique, outcomes, adaptation, and evolution of thoracoscopic lobectomy and other minimally invasive techniques in the treatment of lung cancer.


Asunto(s)
Carcinoma de Pulmón de Células no Pequeñas/cirugía , Neoplasias Pulmonares/cirugía , Procedimientos Quirúrgicos Mínimamente Invasivos , Neumonectomía/métodos , Cirugía Torácica Asistida por Video/métodos , Carcinoma de Pulmón de Células no Pequeñas/patología , Análisis Costo-Beneficio , Humanos , Neoplasias Pulmonares/patología , Escisión del Ganglio Linfático , Estadificación de Neoplasias , Neumonectomía/efectos adversos , Cirugía Torácica Asistida por Video/efectos adversos , Toracotomía/efectos adversos , Toracotomía/métodos
14.
Ann Surg ; 269(1): 163-171, 2019 01.
Artículo en Inglés | MEDLINE | ID: mdl-28799982

RESUMEN

OBJECTIVE: The objective of this study was to compare the long-term survival of open versus thoracoscopic (VATS) lobectomy for early stage non-small-cell lung cancer (NSCLC). BACKGROUND: Data from national studies on long-term survival for VATS versus open lobectomy are limited. METHODS: Outcomes of patients who underwent open versus VATS lobectomy for clinical T1-2, N0, M0 NSCLC in the National Cancer Data Base were evaluated using propensity score matching. RESULTS: The median follow-up of 7114 lobectomies (5566 open and 1548 VATS) was 52.0 months. The VATS approach was associated with a better 5-year survival when compared to the open approach (66.0% vs. 62.5%, P = 0.026). Propensity score matching resulted in 1464 open and 1464 VATS patients who were well matched by 14 common prognostic covariates including tumor size and comorbidities. After propensity score matching, the VATS approach was associated with a shorter median length of stay (5 vs. 6 days, P < 0.001). The VATS approach was not significantly different compared with the open approach with regard to nodal upstaging (11.6% vs 12.3%, P = 0.53), 30-day mortality (1.7% vs 2.3%, P = 0.50) and 5-year survival (66.3% vs 65.8%, P = 0.92). CONCLUSIONS: In this national analysis, VATS lobectomy was used in the minority of patients with stage I NSCLC. VATS lobectomy was associated with shorter length of stay and noninferior long-term survival when compared with open lobectomy. These results support previous findings from smaller single- and multi-institutional studies that suggest that VATS does not compromise oncologic outcomes when used for early-stage lung cancer and suggest the need for broader implementation of VATS techniques.


Asunto(s)
Carcinoma de Pulmón de Células no Pequeñas/mortalidad , Neoplasias Pulmonares/mortalidad , Estadificación de Neoplasias , Neumonectomía/métodos , Puntaje de Propensión , Cirugía Torácica Asistida por Video/métodos , Anciano , Biopsia , Carcinoma de Pulmón de Células no Pequeñas/diagnóstico , Carcinoma de Pulmón de Células no Pequeñas/cirugía , Bases de Datos Factuales , Femenino , Estudios de Seguimiento , Humanos , Neoplasias Pulmonares/diagnóstico , Neoplasias Pulmonares/cirugía , Masculino , Persona de Mediana Edad , Periodo Posoperatorio , Puerto Rico/epidemiología , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Factores de Tiempo , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Estados Unidos/epidemiología
15.
J Natl Compr Canc Netw ; 17(2): 127-139, 2019 02.
Artículo en Inglés | MEDLINE | ID: mdl-30787126

RESUMEN

Background: Accurate staging for small cell lung cancer (SCLC) is critical for determining appropriate therapy. The clinical impact of increasing PET adoption and stage migration is well described in non-small cell lung cancer but not in SCLC. The objective of this study was to evaluate temporal trends in PET staging and survival in the Veterans Affairs Central Cancer Registry and the impact of PET on outcomes. Patients and Methods: Patients diagnosed with SCLC from 2001 to 2010 were identified. PET staging, overall survival (OS), and lung cancer-specific survival (LCSS) were assessed over time. The impact of PET staging on OS and LCSS was assessed for limited-stage (LS) and extensive-stage (ES) SCLC. Results: From 2001 to 2010, PET use in a total of 10,135 patients with SCLC increased from 1.1% to 39.2%. Median OS improved for all patients (from 6.2 to 7.9 months), those with LS-SCLC (from 10.9 to 13.2 months), and those with ES-SCLC (from 5.0 to 7.0 months). Among staged patients, the proportion of ES-SCLC increased from 63.9% to 65.7%. Among 1,536 patients with LS-SCLC treated with concurrent chemoradiotherapy, 397 were staged by PET. In these patients, PET was associated with longer OS (median, 19.8 vs 14.3 months; hazard ratio [HR], 0.78; 95% CI, 0.68-0.90; P<.0001) and LCSS (median, 22.9 vs 16.7 months; HR, 0.74; 95% CI, 0.63-0.87; P<.0001) with multivariate adjustment and propensity-matching. In the 6,143 patients with ES-SCLC, PET was also associated with improved OS and LCSS. Conclusions: From 2001 to 2010, PET staging increased in this large cohort, with a corresponding relative increase in ES-SCLC. PET was associated with greater OS and LCSS for LS-SCLC and ES-SCLC, likely reflecting stage migration and stage-appropriate therapy. These findings emphasize the importance of PET in SCLC and support its routine use.


Asunto(s)
Hospitales de Veteranos , Neoplasias Pulmonares/diagnóstico por imagen , Neoplasias Pulmonares/epidemiología , Tomografía de Emisión de Positrones , Carcinoma Pulmonar de Células Pequeñas/diagnóstico por imagen , Carcinoma Pulmonar de Células Pequeñas/epidemiología , Servicios de Salud para Veteranos , Anciano , Anciano de 80 o más Años , Comorbilidad , Femenino , Humanos , Neoplasias Pulmonares/patología , Masculino , Persona de Mediana Edad , Imagen Multimodal/métodos , Estadificación de Neoplasias , Oportunidad Relativa , Modelos de Riesgos Proporcionales , Carcinoma Pulmonar de Células Pequeñas/patología
16.
Dysphagia ; 34(6): 904-915, 2019 12.
Artículo en Inglés | MEDLINE | ID: mdl-30798360

RESUMEN

(1) To examine the association between vocal fold paresis/paralysis (VFP) and poor swallowing outcomes in a thoracic surgery cohort at the population level, and (2) to assess utilization of ENT/speech-language pathology intervention in these cases. The National Inpatient Sample (NIS) represents a 20% stratified sample of discharges from US hospitals. Using ICD-9 codes, discharges undergoing general thoracic surgical procedures between 2008 and 2013 were identified in the NIS. Sub-cohorts of discharges with VFP and those who utilized ENT/SLP services were also identified. Weighted logistic regression models were used to compare binary outcomes such as dysphagia, aspiration pneumonia, and other complications; generalized linear models with generalized estimating equations (GEE) were used to compare total hospital costs and length of stay (LOS). We identified a weighted estimate of 673,940 discharges following general thoracic surgery procedures. The weighted frequency of VFP was 3738 (0.55%). Compared to those without VFP, patients who discharged with VFP had increased odds of dysphagia (6.56, 95% CI 5.07-8.47), aspiration pneumonia (2.54, 95% CI 1.74-3.70), post-operative tracheotomy (3.10, 95% CI 2.16-4.45), and gastrostomy tube requirement (2.46, 95% CI 1.66-3.64). Discharges with VFP also had a longer length of stay and total hospital costs. Of the discharges with VFP, 15.7% received ENT/SLP intervention. VFP after general thoracic procedures is associated with negative swallowing-related health outcomes and higher costs. Despite these negative impacts, most patients with VFP do not receive ENT/SLP intervention, identifying a potential opportunity for improving adverse swallowing-related outcomes.


Asunto(s)
Trastornos de Deglución/diagnóstico , Procedimientos Quirúrgicos Torácicos/efectos adversos , Parálisis de los Pliegues Vocales/diagnóstico , Anciano , Anciano de 80 o más Años , Trastornos de Deglución/etiología , Biomarcadores Ambientales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Medición de Riesgo/métodos , Factores de Riesgo , Parálisis de los Pliegues Vocales/etiología
17.
Cancer ; 124(4): 667-678, 2018 02 15.
Artículo en Inglés | MEDLINE | ID: mdl-29266226

RESUMEN

Non-small cell lung cancer (NSCLC) is the leading cause of cancer-related death in the United States. With the implementation of lung cancer screening, the number and proportion of patients diagnosed with early-stage disease are anticipated to increase. Surgery is currently the standard of care for patients with operable stage I NSCLC. However, promising outcomes with stereotactic body radiation therapy (SBRT) in patients with inoperable disease has led to interest in directly comparing SBRT and surgery in operable patients. Unfortunately, early randomized trials comparing surgery and SBRT closed early because of poor accrual. In this article, the nuances of surgery and SBRT for early-stage NSCLC are reviewed. Furthermore, retrospective and prospective analyses of SBRT in early-stage NSCLC are discussed, and active randomized trials comparing these 2 approaches are described. Cancer 2018;124:667-78. © 2017 American Cancer Society.


Asunto(s)
Carcinoma de Pulmón de Células no Pequeñas/radioterapia , Neoplasias Pulmonares/radioterapia , Neumonectomía/métodos , Radiocirugia/métodos , Carcinoma de Pulmón de Células no Pequeñas/patología , Carcinoma de Pulmón de Células no Pequeñas/cirugía , Supervivencia sin Enfermedad , Humanos , Neoplasias Pulmonares/patología , Neoplasias Pulmonares/cirugía , Recurrencia Local de Neoplasia , Estadificación de Neoplasias , Ensayos Clínicos Controlados Aleatorios como Asunto
18.
J Natl Compr Canc Netw ; 16(4): 412-441, 2018 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-29632061

RESUMEN

Lung cancer is the leading cause of cancer-related mortality in the United States and worldwide. Early detection of lung cancer is an important opportunity for decreasing mortality. Data support using low-dose computed tomography (LDCT) of the chest to screen select patients who are at high risk for lung cancer. Lung screening is covered under the Affordable Care Act for individuals with high-risk factors. The Centers for Medicare & Medicaid Services (CMS) covers annual screening LDCT for appropriate Medicare beneficiaries at high risk for lung cancer if they also receive counseling and participate in shared decision-making before screening. The complete version of the NCCN Guidelines for Lung Cancer Screening provides recommendations for initial and subsequent LDCT screening and provides more detail about LDCT screening. This manuscript focuses on identifying patients at high risk for lung cancer who are candidates for LDCT of the chest and on evaluating initial screening findings.


Asunto(s)
Neoplasias Pulmonares/diagnóstico , Tamizaje Masivo , Tomografía Computarizada por Rayos X , Toma de Decisiones Clínicas , Análisis Costo-Beneficio , Detección Precoz del Cáncer/métodos , Humanos , Neoplasias Pulmonares/epidemiología , Tamizaje Masivo/métodos , Imagen Multimodal/métodos , Ensayos Clínicos Controlados Aleatorios como Asunto , Reproducibilidad de los Resultados , Medición de Riesgo , Factores de Riesgo , Tomografía Computarizada por Rayos X/métodos , Carga Tumoral , Estados Unidos
19.
BMC Infect Dis ; 18(1): 336, 2018 07 18.
Artículo en Inglés | MEDLINE | ID: mdl-30021526

RESUMEN

BACKGROUND: Blastomycosis is an endemic mycosis in North America that is caused by the dimorphic fungus Blastomyces dermatitidis. The illness is a systemic disease with a wide variety of pulmonary and extra-pulmonary manifestations. The initial presentation of blastomycosis may easily be mistaken for other infectious or non-infectious etiologies. CASE PRESENTATION: We present the case of a 52-year-old African-American male and former smoker that presented to his primary care provider with a 2-week history of non-productive cough, night sweats and weight loss. Initially diagnosed with primary lung malignancy, the patient was subsequently found to have pulmonary blastomycosis mimicking lung cancer. The patient underwent a successful course of treatment with posaconazole. CONCLUSIONS: Chronic blastomycosis can present with clinical and radiographic features indistinguishable from thoracic malignancies. There is no clinical syndrome specific for blastomycosis, thus a high degree of suspicion is required for early diagnosis. In this case report, we review recent evidence in radiographic features, diagnostic considerations and treatment of the disease.


Asunto(s)
Blastomyces/genética , Blastomicosis/diagnóstico , Antifúngicos/uso terapéutico , Blastomyces/aislamiento & purificación , Blastomicosis/tratamiento farmacológico , Blastomicosis/microbiología , ADN de Hongos/genética , ADN de Hongos/metabolismo , Diagnóstico Diferencial , Humanos , Pulmón/patología , Neoplasias Pulmonares/diagnóstico , Masculino , Persona de Mediana Edad , Tomografía Computarizada por Tomografía de Emisión de Positrones , Tomografía Computarizada por Rayos X , Triazoles/uso terapéutico
20.
J Hand Surg Am ; 43(7): 678.e1-678.e9, 2018 07.
Artículo en Inglés | MEDLINE | ID: mdl-29456053

RESUMEN

PURPOSE: We used conjoint analysis to assess the relative importance of factors that influence a patient's decision between surgical or nonsurgical management of a nondisplaced scaphoid fracture. Our hypothesis was that out-of-pocket costs will have a greater influence on decision making than the time spent in a cast or brace, degree of soreness, or the risk of treatment failure. METHODS: Two-hundred and fifty participants were recruited using Amazon Mechanical Turk and asked to assume that they had experienced a nondisplaced scaphoid waist fracture. They then indicated their relative preferences among 13 pairs of alternatives with variations in the following attributes: time in a cast, time in a brace, duration of ongoing soreness, risk of treatment failure (by which we meant scaphoid nonunion), out-of-pocket costs based on estimates of direct costs ($500-2,500), and apprehension about surgery. A conjoint analysis was used to determine the relative importance of these factors when choosing between surgical or nonsurgical management. RESULTS: The factor with the greatest influence on treatment choice was the cost of the procedure. After assessing the respondent's apprehension to undergo surgery, a sensitivity analysis showed the proportion of respondents who would choose surgery given different outcomes. To make the predicted share of those who are "not worried" about surgery equal to those who are "somewhat worried" or "a little worried" would require that the cost of surgery increase by $2,700. In addition, 2 weeks in a cast, 3 weeks in a brace, 2 months of soreness, or a 2% increase in the risk of fracture nonunion generates the same surgical choice probability as a $2,000 increase in the out-of-pocket cost of surgery. CONCLUSIONS: As conceptualized in this conjoint analysis, out-of-pocket costs and apprehension about surgery seem to have a greater impact on a decision for surgery than the time spent in a brace or cast and the risk of treatment failure. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and decision analysis III.


Asunto(s)
Toma de Decisiones , Fracturas Óseas/terapia , Prioridad del Paciente/estadística & datos numéricos , Hueso Escafoides/lesiones , Adolescente , Adulto , Anciano , Tirantes , Moldes Quirúrgicos , Femenino , Gastos en Salud , Humanos , Masculino , Persona de Mediana Edad , Dolor/psicología , Recuperación de la Función , Hueso Escafoides/cirugía , Encuestas y Cuestionarios , Factores de Tiempo , Insuficiencia del Tratamiento , Adulto Joven
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