Background Studies evaluating risk factors for complications after lobectomy in elderly patients have not adequately analyzed the effect of using minimally invasive approaches. Methods A model for ...morbidity including published preoperative risk factors and surgical approach was developed by multivariable logistic regression. All patients aged 70 years or older who underwent lobectomy for primary lung cancer without chest wall resection or airway procedure between December 1999 and October 2007 at a single institution were reviewed. Preoperative, histopathologic, perioperative, and outcome variables were assessed using standard descriptive statistics. Morbidity was measured as a patient having any perioperative complication. The impact of bias in the selection of surgical approach was assessed using propensity scoring. Results During the study period, 338 patients older than 70 years (mean age, 75.7 ± 0.2) underwent lobectomy (219 thoracoscopy, 119 thoracotomy). Operative mortality was 3.8% (13 patients) and morbidity was 47% (159 patients). Patients with at least one complication had increased length of stay (8.3 ± 0.6 versus 3.8 ± 0.1 days; p < 0.0001) and mortality (6.9% 11 of 159 versus 1.1% 2 of 179; p = 0.008). Significant predictors of morbidity by multivariable analysis included age (odds ratio, 1.09 per year; p = 0.01) and thoracotomy as surgical approach (odds ratio, 2.21; p = 0.004). Thoracotomy remained a significant predictor of morbidity when the propensity to undergo thoracoscopy was considered (odds ratio, 4.9; p = 0.002). Conclusions Patients older than 70 years of age can undergo lobectomy for lung cancer with low morbidity and mortality. Advanced age and the use of a thoracotomy increased the risk of complications in this patient population.
Background This study was undertaken to review a large series of resections of colorectal pulmonary metastases in the era of modern chemotherapy. Methods A retrospective chart review of prospectively ...maintained thoracic surgery databases identified 378 patients who underwent pulmonary resection for colorectal cancer metastases with curative intent from 1998 to 2007. Results The primary site of disease was rectum (52%), left colon (26%), right colon (16%), and unknown (6%). Before thoracic recurrence, 166 patients (44%) had previously undergone resection of extrathoracic metastases. Median disease-free interval (DFI) was 24 months from the time of the primary operation. The number of metastatic deposits resected was one in 60%, two in 20%, three in 10%, and four or more in 10%. Chemotherapy was administered to 87 patients (23%) before resection and to 169 patients (45%) after resection. Three-year recurrence-free survival was 28%, and 3-year overall survival was 78%. Multivariable analysis revealed age younger than 65 years, female sex, DFI less than 1 year, and number of metastases greater than three as independent predictors of recurrence. Of 44 patients with three or more lesions and less than 1 year DFI, none was cured by operation. By contrast, recurrence-free survival was 49% at 3 years for those with one lesion and DFI greater than 1 year. Conclusions Age younger than 65 years, female sex, DFI less than 1 year, and number of metastases greater than three predict recurrence. Medical management alone should be considered standard for patients who have both three or more pulmonary metastases and less than 1 year DFI.
Keep Moving Forward D'Amico, Thomas A., MD
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
06/2017, Letnik:
153, Številka:
6
Journal Article
Abstract Objective Lobectomy is considered optimal therapy for early-stage non–small cell lung cancer, but sublobar wedge resection and stereotactic body radiation therapy are alternative treatments. ...This study compared outcomes between wedge resection and stereotactic body radiotherapy. Methods Overall survival of patients with cT1N0 and tumors ≤2 cm who underwent stereotactic body radiotherapy or wedge resection in the National Cancer Data Base from 2008 to 2011 was assessed via a Kaplan-Meier and propensity score–matched analysis. A center-level sensitivity analysis that used observed/expected mortality ratios was conducted to identify an association between center use of stereotactic body radiotherapy and mortality. Results Of the 6295 patients included, 1778 (28.2%) underwent stereotactic body radiotherapy, and 4517 (71.8%) underwent wedge resection. Stereotactic body radiotherapy was associated with significantly reduced 5-year survival compared with wedge resection in both unmatched analysis (30.9% vs 55.2%, P < .001) and after adjustment for covariates (31.0% vs 49.9%, P < .001). Stereotactic body radiotherapy also was associated with worse overall survival than wedge resection after 2 subgroup analyses of propensity-matched patients ( P < .05 for both). Centers that used stereotactic body radiotherapy more often as opposed to surgery for patients with cT1N0 patients with tumors <2 cm were more likely to have an observed/expected mortality ratio > 1 for 3-year mortality ( P = .034). Conclusions In this national analysis, wedge resection was associated with better survival for stage IA non–small cell lung cancer than stereotactic body radiotherapy.
Lymphovascular space invasion (LVI) is an established negative prognostic factor and an indication for postoperative radiation therapy in many malignancies. The purpose of this study was to evaluate ...LVI in patients with early-stage non–small-cell lung cancer, undergoing surgical resection.
All patients who underwent initial surgery for pT1-3N0-2 non–small-cell lung cancer at Duke University Medical Center from 1995 to 2008 were identified. A multivariate ordinal regression was used to assess the relationship between LVI and pathologic hilar and/or mediastinal lymph node (LN) involvement. A multivariate Cox regression analysis was used to evaluate the relationship of LVI and other clinical and pathologic factors on local failure (LF), freedom from distant metastasis (FFDM), and overall survival (OS). Kaplan-Meier methods were used to generate estimates of LF, FFDM, and OS in patients with and without LVI.
One thousand five hundred and fifty-nine patients were identified. LVI was independently associated with the presence of regional LN involvement (p < 0.001) along with lobar (versus sublobar) resections (p < 0.001), and an open thoracotomy (versus video-assisted thoracoscopic surgery). LVI was not independently associated with LF on multivariate analysis (hazard ratio HR = 1.23, p = 0.25), but was associated with a lower FFDM (HR 1.52, p = 0.005) and OS (HR 1.26, p = 0.015). In addition, multivariate analysis showed that LVI was strongly associated with increased risk of developing distant metastases (HR = 1.75, p = 0.006) and death (HR = 1.53, p = 0.003) in adenocarcinomas but not in squamous carcinomas.
LVI is associated with an increased risk of harboring regional LN involvement. LVI is also an adverse prognostic factor for the development of distant metastases and long-term survival.
Esophagogastrectomy (EG) is a formidable operation with significant morbidity and mortality rates. Risk factor analyses have been performed, but few studies have produced strategies that have ...improved operative results. This study was performed in order to identify prognostic variables that might be used to develop a strategy for optimizing outcomes after EG.
The records of all patients (n = 379) who underwent EG patients at a tertiary medical center between 1996 and 2002 were retrospectively reviewed. Thirty-day morbidity and mortality were determined, and multivariable logistical regression analysis assessed the effect of preoperative and postoperative variables on early mortality.
Operations included Ivor Lewis (n = 179), transhiatal (n = 130), and other approaches (n = 70). Operative mortality was 5.8%; 64% experienced complications, including respiratory complications (28.5%), anastamotic strictures (25%), and leak (14%). Increasing age, anastomotic leak, Charlson comorbidity index 3, worse swallowing scores, and pneumonia were associated with increased risk of mortality by univariate analysis. However, only age (
p = 0.002) and pneumonia (
p = 0.0008) were independently associated with mortality by multivariable analysis. Pneumonia was associated with a 20% incidence of death. Patients with pneumonia had significantly worse deglutition and anastomotic integrity on barium esophagogram compared with patients without pneumonia (
p < 0.001, Mann-Whitney rank sum test).
Morbidity and mortality of EG are significant, but most complications, including anastomotic leak, are not independent predictors of mortality. The most important complication after EG is pneumonia. Strategies to decrease postoperative mortality should include careful assessment of swallowing abnormalities and predisposition to aspiration by cineradiography or fiberoptic endoscopy. After EG, acceptable pharyngeal function and airway protection should be verified before resuming oral intake.
Background: The relationship between prostate-specific antigen (PSA)–defined recurrence and prostate cancer–specific mortality remains unclear. Therefore, we evaluated the hypothesis that a short ...post-treatment PSA doubling time (PSA-DT) after radiation therapy is a surrogate end point for prostate cancer–specific mortality by analyzing two multi-institutional databases. Methods: Baseline, treatment, and follow-up information was compiled on a cohort of 8669 patients with prostate cancer treated with surgery (5918 men) or radiation (2751 men) from January 1, 1988, through January 1, 2002, for localized or locally advanced, non-metastatic prostate cancer. We used a Cox regression analysis to test whether the post-treatment PSA-DT was a prognostic factor that was independent of treatment received. All statistical tests were two-sided. Results: The post-treatment PSA-DT was statistically significantly associated with time to prostate cancer–specific mortality and with time to all-cause mortality (all PCox<.001). However, the treatment received was not statistically significantly associated with time to prostate cancer–specific mortality after PSA-defined disease recurrence for patients with a PSA-DT of less than 3 months (PCox = .90) and for patients with a PSA-DT of 3 months or more (PCox = .28) when controlling for the specific value of the PSA-DT. Furthermore, after a PSA-defined recurrence, a PSA-DT of less than 3 months was statistically significantly associated with time to prostate cancer–specific mortality (median time = 6 years; hazard ratio = 19.6, 95% confidence interval = 12.5 to 30.9). Conclusion: A post-treatment PSA-DT of less than 3 months and the specific value of the post-treatment PSA-DT when it is 3 months or more appear to be surrogate end points for prostate cancer–specific mortality after surgery or radiation therapy. We recommend that consideration be given to initiating androgen suppression therapy at the time of a PSA-defined recurrence when the PSA-DT is less than 3 months to delay the imminent onset of metastatic bone disease.
Cytoplasmic Dynein 1, or Dynein, is a microtubule minus end-directed motor. Dynein motility requires Dynactin and a family of activating adaptors that stabilize the Dynein-Dynactin complex and ...promote regulated interactions with cargo in space and time. How activating adaptors limit Dynein activation to specialized subcellular locales is unclear. Here, we reveal that Spindly, a mitotic Dynein adaptor at the kinetochore corona, exists natively in a closed conformation that occludes binding of Dynein-Dynactin to its CC1 box and Spindly motif. A structure-based analysis identified various mutations promoting an open conformation of Spindly that binds Dynein-Dynactin. A region of Spindly downstream from the Spindly motif and not required for cargo binding faces the CC1 box and stabilizes the intramolecular closed conformation. This region is also required for robust kinetochore localization of Spindly, suggesting that kinetochores promote Spindly activation to recruit Dynein. Thus, our work illustrates how specific Dynein activation at a defined cellular locale may require multiple factors.
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