Evaluation of gastroesophageal reflux disease and hiatal hernia as risk factors for lobectomy complications.

Objective: Up to 40% of lobectomies are complicated by adverse events. Gastroesophageal reflux disease (GERD) and hiatal hernia have been associated with morbidity across a range of clinical scenarios, yet their relation to recovery from pulmonary resection is understudied. We evaluated GERD and hiatal hernia as predictors of complications after lobectomy for lung cancer. Methods: Lobectomy patients at Yale-New Haven Hospital between January 2014 and April 2021 were evaluated for predictors of 30-day postoperative complications, pneumonia, atrial arrhythmia, readmission, and mortality. Multivariable regression models included sociodemographic characteristics, body mass index, surgical approach, cardiopulmonary comorbidities, hiatal hernia, GERD, and preoperative acid-suppressive therapy as predictors. Results: Overall, 824 patients underwent lobectomy, including 50.5% with a hiatal hernia and 38.7% with GERD. The median age was 68 [interquartile range, 61-74] years, and the majority were female (58.4%). At least 1 postoperative complication developed in 39.6% of patients, including atrial arrhythmia (11.7%) and pneumonia (4.1%). Male sex (odds ratio [OR], 1.51; 95% confidence interval [CI], 1.11-2.06, P = .01), age ≥70 years (OR, 1.55; 95% CI, 1.13-2.11, P = .01), hiatal hernia (OR, 1.40; 95% CI, 1.03-1.90, P = .03), and intraoperative packed red blood cells (OR, 4.80; 95% CI, 1.51-15.20, P = .01) were significant risk factors for developing at least 1 postoperative complication. Hiatal hernia was also a significant predictor of atrial arrhythmia (OR, 1.64; 95% CI, 1.02-2.62, P = .04) but was not associated with other adverse events. Conclusions: Our findings indicate that hiatal hernia may be a novel risk factor for complications, especially atrial arrhythmia, following lobectomy that should be considered in the preoperative evaluation of lung cancer patients.

Effectiveness of Thermal Ablation and Stereotactic Radiotherapy Based on Stage I Lung Cancer Histology.

PURPOSE: To assess whether the effectiveness of thermal ablation (TA) and stereotactic body radiotherapy (SBRT) as initial treatments for stage I lung cancer varies depending on the histological subtype. MATERIALS AND METHODS: The 2004-2016 National Cancer Database was queried for patients with American Joint Committee on Cancer stage I lung cancer treated with TA or SBRT. Patients <18 years, those treated with surgery or chemotherapy, or those with unknown survival and follow-up were excluded. TA and SBRT patients were 1:5 propensity score matched separately for each histological subtype to adjust for confounders. Overall survival (OS) was assessed using Cox models. RESULTS: A total of 28,425 patients were included (SBRT, n = 27,478; TA, n = 947). TA was more likely to be used in Caucasian patients, those with more comorbidities and smaller neuroendocrine tumors (NETs) of the lower lobe, and those whose treatment had taken place in the northeastern United States. After propensity score matching, a cohort with 4,085 SBRT and 817 TA patients with balanced confounders was obtained. In this cohort, OS for TA and SBRT was comparable (hazard ratio = 1.07; 95% confidence interval,0.98-1.18; P = .13), although it varied by histological subtypes: higher OS for TA was observed in patients with non-small cell NETs (vs SBRT hazard ratio = 0.48; 95% confidence interval, 0.24-0.95; P = .04). No significant OS differences between TA and SBRT were noted for adenocarcinomas, squamous cell carcinomas, small cell carcinomas, and non-neuroendocrine large cell carcinomas (each, P > .1). CONCLUSIONS: OS following TA and SBRT for stage I lung cancer is comparable for most histological subtypes, except that OS is longer after TA in non-small cell NETs.

Comparison of Survival Rates After a Combination of Local Treatment and Systemic Therapy vs Systemic Therapy Alone for Treatment of Stage IV Non-Small Cell Lung Cancer.

Importance: As many as 55% of patients with non-small cell lung cancer (NSCLC) present with stage IV disease at diagnosis. Although systemic therapy is the cornerstone for treatment of these patients, growing evidence suggests that local treatment of the primary tumor site may improve survival. Objective: To assess whether addition of local treatment for primary tumor site in stage IV NSCLC provides a survival benefit over systemic therapy alone. Design, Setting, and Participants: In this comparative effectiveness research study, the National Cancer Database (NCDB; 2018 version) was retrospectively queried from January 1, 2010, through December 31, 2015, for patients with a histopathologic diagnosis of stage IV NSCLC. Exclusion criteria were being younger than 18 years and missing information on tumor characteristics and follow-up data. Data were analyzed from November 1, 2018, through January 1, 2019. Exposures: Treatment groups were stratified as (1) surgical resection plus systemic therapy; (2) external beam radiotherapy (EBRT) or thermal ablation (TA; including cryosurgery and radiofrequency ablation) plus systemic therapy; and (3) systemic therapy alone. Main Outcomes and Measures: Overall survival was compared between treatment groups using multivariable Cox proportional hazards regression models and after propensity score matching. Subgroup analyses were planned a priori according to patient and tumor characteristics. Results: A total of 34 887 patients met inclusion criteria (19 002 male [54.5%]; median age, 68 years [interquartile range, 60-75 years]), among whom 835 underwent surgical resection plus systemic therapy; 9539, EBRT/TA plus systemic therapy; and 24 513, systemic therapy alone. Demographic and cancer-specific factors were associated with treatment allocation with a higher likelihood of surgical resection for oligometastatic NSCLC. After multivariable adjustment, surgical resection was associated with superior overall survival compared with EBRT/TA or systemic therapy alone (hazard ratio [HR] for EBRT/TA, 0.62; 95% CI, 0.57-0.67; P < .001; HR for systemic therapy alone, 0.59; 95% CI, 0.55-0.64; P < .001). Treatment with EBRT/TA demonstrated superior overall survival compared with systemic therapy alone (HR, 0.95; 95% CI, 0.93-0.98; P = .002). Interaction analyses identified heterogeneous associations with treatment; the EBRT/TA survival benefit was especially pronounced in stage IV squamous cell carcinoma with limited T and N category disease and oligometastases (HR, 0.68; 95% CI, 0.57-0.80; P < .001), with overall survival rates of 60.4% vs 45.4% at 1 year, 32.6% vs 19.2% at 2 years, and 20.2% vs 10.6% at 3 years for combination therapy vs systemic therapy alone. Conclusions and Relevance: In stage IV NSCLC, surgical resection or EBRT/TA of the primary tumor site may provide survival benefits in addition to systemic therapy alone in selected patients. Specifically, EBRT/TA may be considered as a treatment option in select patients who are ineligible for surgical resection.