Minimally Invasive Surgery for Lung Cancer Following Neoadjuvant Therapy in the United States.

Introduction: Pulmonary resections following neoadjuvant therapy (NT) can be technically demanding. There is a paucity of data regarding the use of minimally invasive surgery (MIS) approaches in that setting on the National level. In this study, we explored the trends of using MIS approaches following NT and its associated outcomes. Methods: The study included all adult patients with non-small cell lung cancer who underwent pulmonary resection following NT between 2010 and 2016. Propensity score (PS) matching (MIS versus open) was performed and the perioperative outcomes were compared. Results: The study included 11,287 patients who underwent pulomonary resection after NT. The percentage of patients undergoing MIS lung resection and the number of hospitals performing one or more MIS increased from 19% and 166 (2010) to 41% and 305 (2016), respectively. When compared with thoracotomy, MIS lung resections were more frequently performed in academic centers in patients with higher income (P < .001). In PS matched groups, the use of MIS was associated with shorter hospital length of stay (5 days versus 6 days; P < .001), compared with open approach. However, there were no differences between the two groups in readmission rate (P = .513), or 30-/90-day mortality (P = .145/.685). In multivariable regression analysis, MIS approach was not associated with worse long-term, all-cause, survival (confidence interval: 0.91-1.09). Conclusion: The use of MIS approaches after NT increased significantly over the study period and was associated with perioperative outcomes and long-term survival comparable to those noted with the open approach.

Sublobar resection is comparable to lobectomy for screen-detected lung cancer.

OBJECTIVE: Sublobar resection is frequently offered to patients with small, peripheral lung cancers, despite the lack of outcome data from ongoing randomized clinical trials. Sublobar resection may be a particularly attractive surgical strategy for screen-detected lung cancers, which have been suggested to be less biologically aggressive than cancers detected by other means. Using prospective data collected from patients undergoing surgery in the National Lung Screening Trial, we sought to determine whether extent of resection affected survival for patients with screen-detected lung cancer. METHODS: The National Lung Screening Trial database was queried for patients who underwent surgical resection for confirmed lung cancer. Propensity score matching analysis (lobectomy vs sublobar resection) was done (nearest neighbor, 1:1, matching with no replacement, caliper 0.2). Demographics, clinicopathologic and perioperative outcomes, and long-term survival were compared in the entire cohort and in the propensity-matched groups. Multivariable logistic regression analysis was done to identify factors associated with increased postoperative morbidity or mortality. RESULTS: We identified 1029 patients who underwent resection for lung cancer in the National Lung Screening Trial, including 821 patients (80%) who had lobectomy and 166 patients (16%) who had sublobar resection, predominantly wedge resection (n = 114, 69% of sublobar resection). Patients who underwent sublobar resection were more likely to be female (53% vs 41%, P = .004) and had smaller tumors (1.5 cm vs 2 cm, P < .001). The sublobar resection group had fewer postoperative complications (22% vs 32%, P = .010) and fewer cardiac complications (4% vs 9%, P = .033). For stage I patients undergoing sublobar resection, there was no difference in 5-year overall survival (77% for both groups, P = .89) or cancer-specific survival (83% for both groups, P = .96) compared with patients undergoing lobectomy. On multivariable logistic regression analysis, sublobar resection was the only factor associated with lower postoperative morbidity/mortality (odds ratio, 0.63; 95% confidence interval, 0.40-0.98). To compare surgical strategies in balanced patient populations, we propensity matched 127 patients from each group undergoing sublobar resection and lobectomy. There were no differences in demographics or clinical and tumor characteristics among matched groups. There was again no difference in 5-year overall survival (71% vs 65%, P = .40) or cancer-specific survival (75% vs 73%, P = .89) for patients undergoing lobectomy and sublobar resection, respectively. CONCLUSIONS: For patients with screen-detected lung cancer, sublobar resection confers survival similar to lobectomy. By decreasing perioperative complications and potentially preserving lung function, sublobar resection may provide distinct advantages in a screened patient cohort.

National trends and perioperative outcomes of robotic oesophagectomy following induction chemoradiation therapy: a National Cancer Database propensity-matched analysis.

OBJECTIVES: Oesophagectomy following induction chemoradiation therapy (CRT) is technically challenging. To date, little data exist to describe the feasibility of a robotic approach in this setting. In this study, we assessed national trends and outcomes of robotic oesophagectomy following induction CRT compared to the traditional open approach. METHODS: The National Cancer Database was queried for patients who underwent oesophagectomy following induction CRT (2010-2014). Trends of robotic utilization were assessed by a Mantel-Haenszel test of trend. Propensity matching controlled for differences in age, gender, comorbidity, stage, histology and tumour location between the robotic and open groups. Overall survival was estimated by Kaplan-Meier analysis and compared by a log-rank test. RESULTS: Oesophagectomy following induction CRT was performed in 6958 patients. Of them, 555 patients (8%) underwent robotic surgery (5% converted to an open approach). Between 2010 and 2014, utilization of a robotic approach increased from 3% to 11% (Mantel-Haenszel, P < 0.001) and the number of hospitals performing at least 1 robotic oesophagectomy increased from 23 to 57. Compared to the traditional open approach, robotic oesophagectomy was used more frequently at academic hospitals (76% vs 60%, P < 0.001), and in patients living in metropolitan areas (85% vs 77%, P < 0.001) and those living in the Midwest (41% vs 33%, P < 0.001). In the matched groups, a robotic approach was associated with shorter median hospital stay (9 vs 10 days, P = 0.004) and dissection of more lymph nodes (median, 16 vs 12, P < 0.001). However, there were no differences in rates of positive margin resection (5% for both groups, P = 0.95), 30-day readmissions (5% vs 7%, P = 0.18), 30-day mortality (2.5% vs 4%, P = 0.79), 90-day mortality (9% vs 8.5%, P = 0.89) or 5-year overall survival (42% vs 39%, P = 0.19) between patients undergoing robotic and open surgery, respectively. CONCLUSIONS: Robotic oesophagectomy after induction CRT is feasible and associated with shorter hospitalization compared to an open approach, and does not compromise the adequacy of oncological resection, perioperative outcomes or long-term survival.

Blood utilization at a level I trauma center: is this as good as it gets?

Recognition of the adverse effects of allogeneic blood resulted in the decreased use of red blood cell (RBC) transfusion in surgical practice in the 1990s. Our objective was to evaluate patterns of RBC transfusion utilization among trauma patients during the current decade. Blunt trauma patients admitted to a regional trauma center between 2000 and 2007 were identified (n = 16,011). Annual trends in RBC utilization were estimated (negative binomial regression for continuous dependent variables and logistic regression for dichotomous variables). Models were stratified by Injury Severity Score to adjust for injury severity. Although the proportion of patients receiving a blood transfusion within 48 hours of hospitalization significantly increased (P < 0.0001), there was no significant change in the rate of units transfused (P = 0.5152) among transfused patients. After stratification by Injury Severity Score, a significantly decreasing trend in the proportion of severely injured patients transfused was observed (P = 0.0243). Annual variation in the relatively less injured groups was not significant. In the current decade, transfusion utilization at a Level I trauma center has demonstrated minimal variation on a year-to-year basis. Among the severely injured, the temporal decrease in relatively early utilization of RBC transfusion may reflect increasing inclination to accept a greater degree of anemia in higher acuity patients.

Segmentectomy Is Equivalent to Lobectomy in Hypermetabolic Clinical Stage IA Lung Adenocarcinomas.

BACKGROUND: Recent studies have suggested that lobectomy and segmentectomy hold equivalent oncologic outcomes, particularly for small, peripheral, subsolid nodules. However, for hypermetabolic nodules that are frequently associated with high rates of nodal disease, recurrence, or mortality, the optimum oncologic procedure was not assessed. We hypothesize that for hypermetabolic, cT1 N0 adenocarcinoma, lobectomy and segmentectomy are associated with comparable outcomes. METHODS: A prospectively collected database was queried for patients with clinical stage IA lung adenocarcinoma who underwent lobectomy or segmentectomy (2000 to 2016) for hypermetabolic tumors (maximum standard uptake value [SUVmax] ≥ 3g/dL). To obtain balanced groups of patients, a propensity matching analysis was done. RESULTS: A total of 414 patients had hypermetabolic tumors and underwent lobectomy or segmentectomy. Patients were propensity matched (4:1) (lobectomy: n = 156, segmentectomy: n = 46). Patients in the lobectomy group had a higher rate of pathologic nodal upstaging (17% versus 7%, p = 0.085) and a higher pathologic upstaging rate (38% versus 26%, p = 0.143) than the segmentectomy group. In addition, the lobectomy group had a higher number of resected lymph nodes than the segmentectomy group (median lymph nodes resected: 14 versus 7, p < 0.001). No differences were found in in 5-year recurrence-free survival (RFS; 72% versus 69%, p = 0.679) or in 5-year cancer-specific survival (CSS; 92% versus 83%, p = 0.557) between patients who underwent lobectomy or segmentectomy, respectively. CONCLUSIONS: Our data show that lobectomy and segmentectomy are comparable oncologic procedures for patients with carefully staged cT1 N0 lung adenocarcinoma with hypermetabolic tumors (SUVmax ≥ 3g/dL). Although lobectomy was associated with a more thorough lymph node dissection, this did not translate into a higher rate of RFS or CSS compared with segmentectomy.

Neoadjuvant Therapy for Locally Advanced Esophageal Cancer Should Be Targeted to Tumor Histology.

BACKGROUND: Controversy exists over the optimal neoadjuvant therapy in patients with locally advanced esophageal cancer (EC). Although most groups favor neoadjuvant chemoradiation (nCRT), some prefer preoperative chemotherapy (nCT) without radiation. The objective of this study was to compare outcomes in EC patients undergoing either regimen, followed by surgery. METHODS: We reviewed a prospectively collected database of EC patients undergoing esophagectomy after nCT or nCRT from 1989 to 2016. Choice of therapy was at the discretion of the multidisciplinary team. Disease-free survival (DFS) and cancer-specific survival (CSS) were compared by the Kaplan-Meier log-rank test. Independent predictors of CSS were estimated by Cox regression analysis. RESULTS: Among 700 EC patients 338 patients were treated with nCRT (n = 112) or nCT (n = 226) followed by surgery. Patients were well matched for age, gender, and clinical stage, although patients with squamous cell carcinoma were more likely to receive nCRT (49% vs 26%, p < 0.001). At surgery 90% and 91% of nCRT and nCT patients, respectively, underwent transthoracic esophagectomy. nCRT, in comparison with nCT, was associated with similar rates of Calvien-Dindo grade III/IV complications (34% vs 33%, p = 0.423) but with a trend toward higher perioperative mortality (5% vs 1%, p = 0.064). Among adenocarcinoma patients (n = 239) the use of nCRT was associated with higher rates of complete clinical response (18% vs 7.4%), pathologically negative lymph nodes (52% vs 30%, p = 0.001), and complete pathologic response (21% vs 5.1%, p < 0.001). However, there was no difference between nCRT and nCT for 5-year DFS (28% vs 31%, p = 0.636) or CSS (51% vs 52%, p = 0.824) among adenocarcinoma patients. For patients with squamous cell carcinoma (n = 98), nCRT and nCT had similar rates of complete clinical response (31% vs 26%, p = 0.205), but the rates of negative nodes (65% vs 46%, p = 0.064) and of complete pathologic response (42% vs 12%, p < 0.05) were higher with nCRT. For these patients nCRT was associated with no statistical difference in 5-year DFS (57% vs 40%, p = 0.595) but with improved 5-year CSS (87% vs 68%, p = 0.019) compared with nCT. On multivariable analysis for CSS, nCRT predicted improved survival for patients with squamous cell carcinoma (hazard ratio, 0.242; 95% confidence interval, 0.071-0.830) but not for those with adenocarcinoma (univariate hazard ratio, 0.940; 95% confidence interval, 0.544-1.623). CONCLUSIONS: For adenocarcinoma patients undergoing surgery for EC, nCRT leads to increased local tumor response compared with nCT alone but with no difference in survival. For squamous carcinoma patients nCRT appears to improve CSS compared with nCT. For patients with locally advanced EC targeted neoadjuvant regimens should be used depending on tumor histology.

Incidence and Prognostic Significance of Carcinoid Lymph Node Metastases.

BACKGROUND: Pulmonary carcinoid tumors are often considered indolent tumors. The prognostic significance of lymph node (LN) metastases and the need for mediastinal dissection is controversial. We sought to determine the incidence, risk factors, and prognosis of LN metastases in resected carcinoid patients. METHODS: Patients undergoing lung resection for carcinoid and removal of ≥10 LNs were identified in the National Cancer Database from 2004 to 2014. Typical (TCs) and atypical carcinoids (ACs) were included. Clinical and pathologic LN status was assessed. Overall survival (OS) was analyzed using log-rank test and Cox hazard regression analysis. RESULTS: A total of 3,335 patients (TC 2,893; AC 442), underwent resection (lobectomy/bilobectomy 84%, pneumonectomy 8%, sublobar resection 8%). LN involvement was present in 21% of patients (N1 15%, N2 6%) and increased with tumor size and AC histology. Tumor size was an independent predictor of LN disease. The rate of nodal upstaging was 13% (TC 11%, AC 24%). Independent predictors of OS were AC type (HR 3.25 [95% CI 2.19-4.78]) and LN metastases (HR 2.3 [1.49-3.58]). LN disease was associated with worse survival for TC > 2 cm (5-year OS 87% versus 94%, p = 0.005) and AC (58% versus 88%, p = 0.001), but not for small (≤ 2 cm) TC patients (5-year OS 93% versus 92%, p = 0.67). CONCLUSIONS: A substantial number of well-staged carcinoid patients had LN metastases. Large tumor size is a valuable predictor of carcinoid nodal disease. LN involvement was an independent predictor of worse survival. Nodal dissection in tumors > 2 cm and in atypical subtype can yield important prognostic information.