Adjuvant Therapy for Positive Nodes After Induction Therapy and Resection of Esophageal Cancer.

BACKGROUND: The value of adjuvant chemotherapy for patients with positive lymph nodes (+LNs) after induction therapy and resection of esophageal cancer is controversial. This study assesses survival benefit of adjuvant chemotherapy in this cohort. METHODS: We analyzed our single-institution database for patients with +LNs after induction therapy and resection of primary esophageal cancer between 2000 and 2013. Factors associated with survival were analyzed using a Cox proportional hazards model. RESULTS: A total of 101 of 764 esophagectomy patients received induction and had +LNs on final pathologic examination. Forty-five also received adjuvant therapy: 37 of 45 (82%) received chemotherapy alone, 1 of 45 (2%) received radiation alone, and 7 of 45 (16%) received both. Pathologic stage was IIB in 21 (47%), IIIA in 19 (42%), and IIIB in 5 (11%). In 56 node-positive patients with induction but not adjuvant therapy, pathologic stage was IIB in 28 (50%), IIIA in 18 (32%), IIIB in 7 (13%), and IIIC in 3 (5%). Neither age nor comorbidity score differed between cohorts. Adjuvant patients experienced a shorter hospital length of stay (mean, 10 days [range, 6 to 33 days] versus 11 days [range, 7 to 67 days]; p = 0.03]. Median survival favored the adjuvant group: 24.0 months (95% confidence interval, 16.6 to 32.2 months) versus 18.0 months (95% confidence interval, 11.1 to 25.0 months); p = 0.033). Multivariate Cox regression identified adjuvant therapy, length of stay, and number of +LNs as influential for survival. CONCLUSIONS: Optimal management of node-positive patients after induction therapy and esophagectomy remains unclear, but in this series, adjuvant therapy, length of stay, and number of +LNs impacted survival. A prospective trial may reduce potential bias and guide the evaluation of adjuvant therapy in this patient population.

Analysis of first recurrence and survival in patients with stage I non-small cell lung cancer treated with surgical resection or stereotactic radiation therapy.

OBJECTIVES: Comparative studies of survival between stereotactic body radiation therapy (SBRT) and surgery have been limited by lack of comparisons of recurrence patterns between matched cohorts in non-small cell lung cancer (NSCLC). METHODS: All patients undergoing treatment with surgery or SBRT for clinical stage I NSCLC between June 2004 and December 2010 were reviewed. Age, tumor characteristics, comorbidity score, pulmonary function, overall survival (OS), disease-free survival (DFS), and recurrence data were collected and propensity matching performed. RESULTS: The mean age for surgery (n = 458) was 65.8 ± 10.5 versus 74.4 ± 9.4 for SBRT (n = 151) (P < .0001). For the entire surgical cohort, 3-year OS was 78% and DFS was 72%. For the entire SBRT cohort, 3-year OS was 47% and DFS was 42%. The overall local recurrence rate for surgery was 2.6%. The overall local recurrence rate for SBRT was 10.7%. A propensity-matched comparison based on age, tumor size, Adult Comorbidity Evaluation comorbidity score, forced expiratory volume in the first second of expiration, and tumor location resulted in 56 matched pairs. The 3-year OS was 52% versus 68% for SBRT and surgery (P = .05); DFS was 47% versus 65% (P = .01). At 3 years, local recurrence-free survival was 90% versus 92% for SBRT and surgery (P = .07). CONCLUSIONS: Although surgical resection seems to result in better OS and DFS versus SBRT, matching these disparate cohorts of patients remains challenging. Participation in clinical trials is essential to define the indications and relative efficacy of surgery and radiation therapy in a high-risk population with stage I NSCLC.

A thoracic surgery clinic dedicated to indeterminate pulmonary nodules: too many scans and too little pathology?

OBJECTIVE: Widespread application of computed tomographic scans has increased detection of asymptomatic pulmonary nodules. A dedicated clinic was established to encourage referral and manage large numbers of patients with such nodules. METHODS: Patients were evaluated periodically by a nurse practitioner with surgeon oversight, and follow-up imaging was centralized. Patients were rescanned at intervals on the basis of radiologist recommendation. RESULTS: A total of 414 patients, 189 male and 225 female with a median age of 60.2 years (20.7-84.1 years), were evaluated since April 2000. Median follow-up was 1.51 years (0-6.65 years). Thirty-seven percent (153/414) were older than 60 years with at least 10 pack-years of tobacco use, whereas 30% (123/414) had never smoked. A total of 286 patients completed at least 2 years of follow-up computed tomographic evaluation. After 2 years, 24.2% (69/286) were deemed in stable condition and were discharged from further follow-up, whereas 22.4% (64/286) of patients were followed up longer than 2 years owing to the development of new nodules. Forty-five percent (127/286) of patients did not complete their recommended follow-up at our clinic. Overall, 3% (13/414) of our patients have been shown to have a malignant tumor. Only 5 patients underwent curative resection of a primary lung cancer. CONCLUSION: In a population of patients with indeterminate nodules in routine clinical practice, few patients required intervention and few cancers were detected. Although the benefits of a "nodule" clinic may include patient reassurance and convenience to referring physicians, a significant number of patients did not complete their follow-up in our clinic.