Strategies of Well-being Training and Resilience.

As cardiothoracic surgeons, we face frequent challenges to our well-being and our ability to function as our best selves. Building personal resilience is an important way to help us manage these challenges. Here, the authors outline the scope of the problem, the consequences of burnout, and offer 4 strategies to train ourselves to be more resilient: (1) Pursuit of fulfillment, (2) Cultivation of community and belonging, (3) Mitigation of microstresses and avoiding feelings of overwhelm, and (4) Building a "resilience bank account."

Assessment of the well-being of significant others of cardiothoracic surgeons.

OBJECTIVES: We aimed to evaluate how the current working climate of cardiothoracic surgery and burnout experienced by cardiothoracic surgeons influences their spouses and significant others (SOs). METHODS: A 33-question well-being survey was developed by the American Association for Thoracic Surgery Wellness Committee and distributed by e-mail to the SOs of cardiothoracic surgeons and to all surgeon registrants of the 2020 and 2021 American Association for Thoracic Surgery Annual Meetings with a request to share it with their SO. The 5-item Likert-scale survey questions were dichotomized, and associations were determined by χ2 or independent samples t tests, as appropriate. RESULTS: Responses from 238 SOs were analyzed. Sixty-six percent reported that the stress on their cardiothoracic surgeon partner had a moderate to severe influence on their family, and 63% reported that their partner's work demands didn't leave enough time for family. Fifty-one percent reported that their partner rarely had time for intimacy, 27% reported poor work-life balance, and 23% reported that interactions at home were usually or always not good-natured. SOs were most affected when their partner was <5 years out from training, worked in private vs academic practice, and worked longer hours. Having children, particularly younger than age 19 years, and a lack of workplace support resources further diminished well-being. CONCLUSIONS: The current work culture of cardiothoracic surgeons adversely affects their SOs, and the risk for families is concerning. These data present a major area for exploration as we strive to understand and mitigate the factors that lead to burnout among cardiothoracic surgeons.

The Resilience Bank Account: Skills for Optimal Performance.

The day-to-day life of a cardiothoracic surgeon and other high-stakes occupations is riddled with chronic stress punctuated by acute, sometimes life-threatening, crises. Additional stress from the realms of a surgeon's personal life can add to the silent burden surgeons often carry. The tolls paid for poor management of the cumulative stress load can impact surgeons and their patients, leading to errors of clinical judgment, burnout, early departures from practice, health issues, and substance abuse. This article reviews 6 individual skills or habits that can, when proactively integrated into a daily routine, make the difference. The idea of investing in a resilience bank account is suggested as a metaphor for the reserve building and cumulative positive impact of these habits over time.

Gemcitabine and metabolite pharmacokinetics in advanced NSCLC patients after bronchial artery infusion and intravenous infusion.

PURPOSE: We investigated the safety, pharmacokinetics, and efficacy of gemcitabine administered via bronchial artery infusion (BAI) and IV infusion in advanced NSCLC patients. METHODS: Patients were eligible if they had received at least two prior cytotoxic chemotherapy regimens. Gemcitabine was administered via BAI as 600 mg/m2 on day one of cycle one, followed by IV as 1000 mg/m2 on day eight of cycle one, and IV on days one and eight of all subsequent cycles. Pharmacokinetics for gemcitabine and dFdU metabolite in plasma, and dFdCTP active metabolite in peripheral blood mononuclear cells (PBMC) were evaluated. Intensive pharmacokinetic sampling was performed after BAI and IV infusions during cycle one. RESULTS: Three male patients (age range 59-68 years) were evaluated. All patients responded with stable disease or better. One PR was observed after cycle three, and the remaining had SD. Cmax (mean ± SD) following BAI for gemcitabine, dFdCTP, and dFdU were 7.71 ± 0.13, 66.5 ± 40.6, and 38 ± 6.27 µM and following IV infusion, 17 ± 2.36, 50.8 ± 3.61, and 83.2 ± 12.3 µM, respectively. The AUCinf (mean ± SD) following BAI for gemcitabine, dFdCTP, and dFdU were 6.89 ± 1.2, 791.1 ± 551.2, and 829.9 ± 217.8 µM h and following IV infusion, 12.5 ± 3.13, 584 ± 86.6, and 1394.64 ± 682.2 µM h, respectively. The AUC and Cmax of dFdCTP after BAI were higher than IV. The median OS was 6.27 months. No grade 3 or 4 toxicity was observed. The most common side effects were all grade ≤ 2 involving nausea, vomiting, rigor, thrombocytopenia, and anemia. CONCLUSIONS: Systemic exposure to dFdCTP was higher after BAI than IV in two out of three patients.

Detection of Occult Micrometastases in Patients With Clinical Stage I Non-Small-Cell Lung Cancer: A Prospective Analysis of Mature Results of CALGB 9761 (Alliance).

PURPOSE: Outcomes after resection of stage I non-small-cell lung cancer (NSCLC) are variable, potentially due to undetected occult micrometastases (OM). Cancer and Leukemia Group B 9761 was a prospectively designed study aimed at determining the prognostic significance of OM. MATERIALS AND METHODS: Between 1997 and 2002, 502 patients with suspected clinical stage I (T1-2N0M0) NSCLC were prospectively enrolled at 11 institutions. Primary tumor and lymph nodes (LNs) were collected and sent to a central site for molecular analysis. Both were assayed for OM using immunohistochemistry (IHC) for cytokeratin (AE1/AE3) and real-time reverse transcriptase polymerase chain reaction (RT-PCR) for carcinoembryonic antigen. RESULTS: Four hundred eighty-nine of the 502 enrolled patients underwent complete surgical staging. Three hundred four patients (61%) had pathologic stage I NSCLC (T1, 58%; T2, 42%) and were included in the final analysis. Fifty-six percent had adenocarcinomas, 34% had squamous cell carcinomas, and 10% had another histology. LNs from 298 patients were analyzed by IHC; 41 (14%) were IHC-positive (42% in N1 position, 58% in N2 position). Neither overall survival (OS) nor disease-free survival was associated with IHC positivity; however, patients who had IHC-positive N2 LNs had statistically significantly worse survival rates (hazard ratio, 2.04, P = .017). LNs from 256 patients were analyzed by RT-PCR; 176 (69%) were PCR-positive (52% in N1 position, 48% in N2 position). Neither OS nor disease-free survival was associated with PCR positivity. CONCLUSION: NSCLC tumor markers can be detected in histologically negative LNs by AE1/AE3 IHC and carcinoembryonic antigen RT-PCR. In this prospective, multi-institutional trial, the presence of OM by IHC staining in N2 LNs of patients with NSCLC correlated with decreased OS. The clinical significance of this warrants further investigation.

Minimally invasive esophagectomy: results of a prospective phase II multicenter trial-the eastern cooperative oncology group (E2202) study.

OBJECTIVE: The primary aim of this trial was to assess the feasibility of minimally invasive esophagectomy (MIE) in a multi-institutional setting. BACKGROUND: Esophagectomy is an important, potentially curative treatment for localized esophageal cancer, but is a complex operation. MIE may decrease the morbidity and mortality of resection, and single-institution studies have demonstrated successful outcomes with MIE. METHODS: We conducted a multicenter, phase II, prospective, cooperative group study (coordinated by the Eastern Cooperative Oncology Group) to evaluate the feasibility of MIE. Patients with biopsy-proven high-grade dysplasia or esophageal cancer were enrolled at 17 credentialed sites. Protocol surgery consisted of either 3-stage MIE or Ivor Lewis MIE. The primary end point was 30-day mortality. Secondary end points included adverse events, duration of hospital-stay, and 3-year outcomes. RESULTS: Protocol surgery was completed in 95 of the 104 patients eligible for the primary analysis (91.3%). The 30-day mortality in eligible patients who underwent MIE was 2.1%; perioperative mortality in all registered patients eligible for primary analysis was 2.9%. Median intensive care unit and hospital stay were 2 and 9 days, respectively. Grade 3 or higher adverse events included anastomotic leak (8.6%), acute respiratory distress syndrome (5.7%), pneumonitis (3.8%), and atrial fibrillation (2.9%). At a median follow-up of 35.8 months, the estimated 3-year overall survival was 58.4% (95% confidence interval: 47.7%-67.6%). Locoregional recurrence occurred in only 7 patients (6.7%). CONCLUSIONS: This prospective multicenter study demonstrated that MIE is feasible and safe with low perioperative morbidity and mortality and good oncological results. This approach can be adopted by other centers with appropriate expertise in open esophagectomy and minimally invasive surgery.

Descending necrotizing mediastinitis: a modified algorithmic approach to define a new standard of care.

BACKGROUND: Descending necrotizing mediastinitis (DNM) is a highly morbid infectious process. This uncommon disease process has carried historically a substantial burden of morbidity and mortality. In this study we hypothesized that application of a prospective modified management algorithm would decrease the morbidity and mortality from this highly destructive process. METHODS: We developed a systematic approach for managing DNM, focusing on serial debridement guided by imaging, in conjunction with the use of broad-spectrum antibiotics and modern principles of critical care. We reviewed all patients admitted with this disease process from 2007-2012. Data collected included demographic information, co-morbidities, laboratory data including culture results, operative details, imaging frequency and findings, complications, and survival. Continuous variables were reported as median values and ranges. RESULTS: From 2007-2010, we treated eight patients with DNM. The median age of the patients was 33 y (range 28-63 y), and 63% were male. In accordance with our algorithm, the patients underwent serial imaging at regular intervals following operative debridement. The median number of imaging studies was 11 (range 4-19). The patients required a median of five operative debridements (range 1-15). In five patients, drainage was necessary through a cervical exploration. A thoracic approach was required in six patients (two thoracoscopic, four via thoracotomy). Additional procedures included thymectomy (n=2), anterior mediastinotomy, carotid sheath exploration and resections of the clavicle, first rib, manubrium, pectoralis major muscle, and sternocleidomastoid muscle. The most common etiologic agents were Peptostreptococcus spp. and Streptococcus anginosus. Study patients received a median of six different antibiotics (range 2-10) for a total of 42 d (range 34-55 d). These patients were hospitalized for a median of 29 days (range 16-56 d), with 15 d (range 7-48 d) spent in the intensive care unit. Remarkably, the rate of survival was 100% (median follow-up of 33 mo). The patients developed no major complications, required no re-admissions, and had no re-infections. CONCLUSIONS: We applied an algorithmic approach to the treatment of DNM, consisting of aggressive operative debridement and enhanced by equally aggressive imaging. Our patients had excellent outcomes despite the widely known lethality of DNM. An aggressive approach may decrease complications and improve survival in this devastating disease process. Furthermore, our prospective experience with DNM suggests that this algorithm used in the present study should be the standard for managing patients with this challenging condition.

Thoracoscopic thymectomy: technical pearls to a 21st century approach.

PURPOSE: Thoracoscopic approaches to thymectomy have increased as imaging and instrumentation have advanced. Indications for the thoracoscopic approach are evolving. We reviewed our experience in the transition from sternotomy to thoracoscopy and have gleaned technical points to aid in performing thymectomy. METHODS: The experience during the transition of sternotomy to thoracoscopy was reviewed. RESULTS: THE FOLLOWING COMPONENTS HAVE BEEN OBSERVED TO BE ADVANTAGEOUS: (I) initial patient positioning is crucial; (II) thoracoscopy provides improved visualization (a separate camera setup can facilitate visualization of the left phrenic nerve); (III) CO2 aids in dissection; (IV) electrocautery and harmonic scalpel aid in dissection and hemostasis; (V) circumferential dissection identifies anatomic boundaries; (VI) endoscopic ligation of innominate vein branches is adequate; and (VII) minimal access techniques impart a shorter convalescence. In our transition, the length of stay has decreased from 4.3±2.9 to 2.3±1.2 days (P=0.0217). CONCLUSIONS: We are routinely able to employ this thoracoscopic approach for complete removal of thymic tissue in patients with myasthenia gravis and those with small (<3 cm) thymic masses. A standard approach to dissection in thoracoscopic thymectomy streamlines the procedure and enables safe resection.

Effect of insurance status on the surgical treatment of early-stage non-small cell lung cancer.

BACKGROUND: Social disparities permeate non-small cell lung cancer (NSCLC) treatment, yet little is known about the effect of insurance status on the delivery of guideline surgical treatment for early-stage (I or II) NSCLC. METHODS: We used the California Cancer Registry (1996 through 2008) to identify patients 50 to 94 years old with early-stage NSCLC. We used logistic regression models to assess whether or not insurance status (private insurance, Medicare, Medicaid, no insurance, and unknown) had an effect on whether or not a lobectomy (or bilobectomy) is performed. RESULTS: A total of 10,854 patients met our inclusion criteria. Compared with patients with private insurance, we found that patients with Medicare (adjusted odds ratio [aOR] 0.87; 95% confidence interval [CI]: 0.79 to 0.95), Medicaid (aOR 0.45; 95% CI: 0.36 to 0.57), or no insurance (aOR 0.45; 95% CI: 0.29 to 0.70) were significantly less likely to undergo lobectomy, even after adjusting for patient factors (age, race, and gender) and tumor characteristics (histology and tumor size). Increasing age, African American race, squamous cell carcinoma, and increasing tumor size were significant independent negative predictors of whether or not a lobectomy was performed. CONCLUSIONS: Patients without private insurance were significantly less likely than patients with private insurance to undergo a lobectomy for early-stage NSCLC. The variables(s) contributing to this disparity have yet to be elucidated.

Who's covering our loved ones: surprising barriers in the sign-out process.

BACKGROUND: The aims of this study were to characterize obstacles affecting current sign-out practices and to evaluate the potential impact of standardized sign-out guidelines. METHODS: In June 2011, detailed guidelines for transitions of care were implemented, and a 29-item multiple-choice survey was developed to assess sign-out practices, attitudes, and barriers to effective communication. Surveys were administered to residents and nurses at 3 time points. Comparisons between time points were assessed using t tests and χ(2) tests (α = .05). RESULTS: Guideline implementation achieved nonsignificant improvements in satisfaction with sign-outs, perceptions of patient safety, adequacy of information provided in sign-out, and patient knowledge by on-call residents. On follow-up, concerns surfaced regarding less complete sign-out processes due to new duty-hour restrictions. CONCLUSIONS: Guideline implementation mildly improved perceptions of safety and adequacy of sign-out; however, persistent barriers to continuity of care remain. Sign-out standardization may not adequately ensure patient safety, and further efforts to improve handoff processes are in need.

True negative predictive value of endobronchial ultrasound in lung cancer: are we being conservative enough?

BACKGROUND: Mediastinal staging in patients with non-small cell lung cancer (NSCLC) with endobronchial ultrasound-guided fine-needle aspiration (EBUS-FNA) requires a high negative predictive value (NPV) (ie, low false negative rate). We provide a conservative calculation of NPV that calls for caution in the interpretation of EBUS results. METHODS: We retrospectively analyzed our prospectively gathered database (January 2007 to November 2011) to include NSCLC patients who underwent EBUS-FNA for mediastinal staging. We excluded patients with metastatic NSCLC and other malignancies. We assessed FNAs with rapid on-site evaluation (ROSE). The calculation of NPV is NPV = true negatives/true negatives + false negatives. However, this definition ignores nondiagnostic samples. Nondiagnostic samples should be added to the NPV denominator because decisions based on nondiagnostic samples could be flawed. We conservatively calculated NPV for EBUS-FNA as NPV = true negatives/true negatives + false negatives + nondiagnostic. We defined false negatives as negative FNAs but NSCLC-positive surgical biopsy of the same site. Nondiagnostic FNAs were nonrepresentative of lymphoid tissue. We compared diagnostic performance with the inclusion and exclusion of nondiagnostic procedures. RESULTS: We studied 120 patients with NSCLC who underwent EBUS-FNA; 5 patients had false negative findings and 10 additional patients had nondiagnostic results. The NPV with and without inclusion of nondiagnostic samples was 65.9% and 85.3%, respectively. CONCLUSIONS: The inclusion of nondiagnostic specimens into the conservative, worst-case-scenario calculation of NPV for EBUS-FNA in NSCLC lowers the NPV from 85.3% to 65.9%. The true NPV is likely higher than 65.9% as few nondiagnostic specimens are false negatives. Caution is imperative for the safe application of EBUS-FNA in NSCLC staging.

Surgeons' volume-outcome relationship for lobectomies and wedge resections for cancer using video-assisted thoracoscopic techniques.

This study examined the effect of surgeons' volume on outcomes in lung surgery: lobectomies and wedge resections. Additionally, the effect of video-assisted thoracoscopic surgery (VATS) on cost, utilization, and adverse events was analyzed. The Premier Hospital Database was the data source for this analysis. Eligible patients were those of any age undergoing lobectomy or wedge resection using VATS for cancer treatment. Volume was represented by the aggregate experience level of the surgeon in a six-month window before each surgery. A positive volume-outcome relationship was found with some notable features. The relationship is stronger for cost and utilization outcomes than for adverse events; for thoracic surgeons as opposed to other surgeons; for VATS lobectomies rather than VATS wedge resections. While there was a reduction in cost and resource utilization with greater experience in VATS, these outcomes were not associated with greater experience in open procedures.

Giant paraesophageal hernia repair: technical pearls.

The optimal operative management of giant paraesophageal hiatal hernias continues to evolve, with recent series reporting promising results with minimally invasive approaches. The laparoscopic repair of a giant paraesophageal hernia is one of the more challenging cases a minimally invasive surgeon may perform. Our technical approach to this procedure involves a consistent emphasis on several key operative points: circumferential sac dissection with maintenance of crural integrity; extensive mediastinal esophageal dissection; crural closure with pledgeted sutures; wedge Collis gastroplasty for shortened esophagus; 3-stitch fundoplication incorporating esophageal tissue with each bite; additional sutures securing the top of the fundoplication to the crura; and biologic mesh buttressing. We believe that diligence paid toward these key steps permits laparoscopic giant paraesophageal hiatal hernia repair to be performed with similar outcomes as the open approach while avoiding the morbidity of thoracotomy or laparotomy.

T1/T2 non-small-cell lung cancer treated by lobectomy: does tumor anatomic location matter?

BACKGROUND: The effect of tumor location on long-term survival after lobectomy for stage I non-small-cell lung cancer is unclear. Current data are limited to a retrospective single-institution series. We sought to determine if tumor anatomic location (i.e., the particular lobe that was involved) confers a survival advantage based on population-based data. METHODS: Using the Surveillance, Epidemiology and End Results database (1988-2007), we identified patients who underwent lobectomy for pathologic T1/T2 adenocarcinoma or squamous cell carcinomas. Wedge resections, segmentectomies, and pneumonectomies were excluded. We evaluated the association between the particular lobe that was involved, lymph node (LN) yield, and survival using the Kaplan-Meier method. To adjust for potential confounders, we used a Cox proportional hazards regression model. RESULTS: We identified 13,650 patients who met our inclusion criteria. There were significant differences in unadjusted overall (P=0.03) and cancer-specific survivals (P=0.03) based on tumor location. However, after adjusting for patient factors, geographic location of treatment, and tumor characteristics, we found that tumor location was not associated with significant differences in survival. We found that male gender, black race, squamous cell histology, increasing grade, and age were independent negative predictors of survival. Higher LN yields were independently associated with improved survival. Although adjusted survival rates were not significantly different, there were significant differences (P<0.0001) in LN yield based on tumor location; right middle lobe had the lowest yield (5.1 nodes), and left upper lobe had the highest yield (eight nodes). CONCLUSIONS: LN counts are independent predictors of survival. Although it is associated with significant difference in LN yield, tumor location is not an independent predictor of survival. Age, race, gender, tumor size, histology, and grade appear to be more important prognostic factors. These data suggest that treatment of T1/T2 non-small-cell lung cancer should be dictated by the same oncologic principles, regardless of tumor location.

Esophageal stenting and radiotherapy: a multimodal approach for the palliation of symptomatic malignant dysphagia.

BACKGROUND: Esophageal stents provide immediate palliation of malignant dysphagia; however, radiotherapy (RT) is a superior long-term option. We review the outcomes of combined esophageal stenting and RT for patients with malignant dysphagia. METHODS: We retrospectively reviewed patients with esophageal stents placed for palliation of malignant dysphagia from esophageal stricture, esophageal extrinsic compression, or malignant tracheoesophageal fistula (TEF). We excluded patients with radiation-induced TEF in the absence of tumor. We analyzed and compared outcomes between patients with no RT, RT before stent placement, and RT after stent placement. RESULTS: We placed stents in 45 patients for esophageal stricture from esophageal cancer (n = 30; 66.7 %), malignant TEF (n = 8; 17.7 %), and esophageal compression from airway, mediastinal, or metastatic malignancies (n = 7; 15.6 %). Twenty patients (44.4 %) had no RT; 25 patients had RT before stent placement (n = 16; 35.6 %), RT after stent placement (n = 8; 17.8 %), or both (n = 1; 2.2 %). Median follow-up was 30 days. Complications requiring stent revision were similar with or without RT. Subjective symptom relief was achieved in 68.9 % of all patients, with no differences noted between groups (p = 0.99). The 30-day mortality was 15.6 %. Patients with RT after stent placement had a longer median survival compared to those without RT (98 vs. 38 days). CONCLUSIONS: Esophageal stent placement with RT is a safe approach for malignant dysphagia.

The significant impact of a competency-based preparatory course for senior medical students entering surgical residency.

PURPOSE: Previous data suggest that formal, structured preparation might improve knowledge and skills of senior medical students (SMSs) as they transition to surgical residency. However, subsequent impact on clinical performance has not been demonstrated. METHOD: The authors developed a comprehensive course for SMSs entering surgical residencies and studied the impact of the course on the subsequent performance of 2010 graduates (n = 22) compared with matched peers (16 nonparticipant controls at authors' home institution and 24 nonparticipant peer controls at outside institutions; total n = 62). Through pre- and postcourse surveys, knowledge tests, and technical examinations, they measured confidence and skill acquisition in 32 specific, job-related tasks. They followed participants and matched peers into internship and collected performance evaluations from supervising senior residents to determine whether course graduates would display performance advantages in these same tasks. The authors used t tests for all comparisons, α = 0.05. RESULTS: Participants demonstrated marked improvement in task-specific confidence in all 32 tasks from course beginning to end, with improved scores on written and technical skill examinations. Further, course participants outperformed peers in all 32 tasks in July, with their performance advantage predictably dissipating into the third month of residency. There was a marked correlation between confidence and competence in all tasks. CONCLUSIONS: Competency-based preparation for surgical internship resulted in objective gains in task-specific confidence and test performance at course conclusion, translating to improved performance and better patient care upon residency matriculation. These data emphasize the significant impact of formally preparing SMSs before graduation.

Surgical treatment of lung cancer: predicting postoperative morbidity in the elderly population.

OBJECTIVES: Surgical resection is standard treatment for early-stage non-small cell lung cancer; however, perception of postoperative risk may influence the decision to proceed for elderly patients. With population data, we analyzed postoperative complications and morbidity predictors for older patients undergoing lobectomy for stage I non-small cell lung cancer. METHODS: The Surveillance Epidemiology and End-Results-Medicare linked database (2000-2005) identified patients (ages 66-80 years) undergoing lobectomy for stage I non-small cell lung cancer. We comprehensively evaluated in-hospital postoperative complications (pulmonary, cardiac, infectious, noncardiopulmonary) with International Classification of Diseases, Ninth Revision, diagnosis codes. Logistic regression models were constructed to identify patient, tumor, and treatment characteristics associated with complications. RESULTS: In all, 4171 patients were included, 2329 of whom had 4097 in-hospital postoperative complications (55.8%). Pulmonary complications were most common (n = 1598; 38.3%) followed by cardiac (n = 1020; 24.5%). Complications were significantly associated with age at least 75 years, male sex, higher comorbidity index, larger tumors, and treatment at nonteaching hospitals (P < .05). Patients with complications had a longer median stay (8 days) than patients without (6 days; P < .001). The 30-day mortality was 4.2%. CONCLUSIONS: Population-based analysis demonstrated that perioperative complications after lobectomy for stage I non-small cell lung cancer in older patients exceeded 50% and were associated with specific patient, tumor, and treatment characteristics. Better understanding of the impact of these risk factors may facilitate surgical decision making and encourage implementation of more effective perioperative care guidelines for older surgical patients.

Invasive adenocarcinoma with bronchoalveolar features: a population-based evaluation of the extent of resection in bronchoalveolar cell carcinoma.

OBJECTIVE: We used a population-based data set to assess the association between the extent of pulmonary resection for bronchoalveolar carcinoma and survival. The reports thus far have been limited to small, institutional series. METHODS: Using the Surveillance, Epidemiology, and End Results database (1988-2007), we identified patients with bronchoalveolar carcinoma who had undergone wedge resection, segmentectomy, or lobectomy. The bronchoalveolar carcinoma histologic findings were mucinous, nonmucinous, mixed, not otherwise specified, and alveolar carcinoma. To adjust for potential confounders, we used a Cox proportional hazards regression model. RESULTS: A total of 6810 patients met the inclusion criteria. Compared with the sublobar resections (wedge resections and segmentectomies), lobectomy conferred superior 5-year overall (59.5% vs 43.9%) and cancer-specific (67.1% vs 53.1%) survival (P < .0001). After adjusting for potential confounding patient and tumor characteristics, we found that patients who underwent an anatomic resection had significantly better overall (segmentectomy: hazard ratio, 0.59; 95% confidence interval, 0.43-0.81; lobectomy: hazard ratio, 0.50; 95% confidence interval, 0.44-0.57) and cancer-specific (segmentectomy: hazard ratio, 0.51; 95% confidence interval, 0.34-0.75; lobectomy: hazard ratio, 0.46; 95% confidence interval, 0.40-0.53) survival compared with patients who underwent wedge resection. Additionally, gender, race, tumor size, and degree of tumor de-differentiation were negative prognostic factors. Our results were unchanged when we limited our analysis to early-stage disease. CONCLUSIONS: Using a population-based data set, we found that anatomic resections for bronchoalveolar carcinoma conferred superior overall and cancer-specific survival rates compared with wedge resection. Bronchoalveolar carcinoma's propensity for intraparenchymal spread might be the underlying biologic basis of our observation of improved survival after anatomic resection.