Background The aim of this study is to create models for perioperative risk of lung cancer resection using the STS GTDB (Society of Thoracic Surgeons General Thoracic Database). Methods The STS GTDB ...was queried for all patients treated with resection for primary lung cancer between January 1, 2002 and June 30, 2008. Three separate multivariable risk models were constructed (mortality, major morbidity, and composite mortality or major morbidity). Results There were 18,800 lung cancer resections performed at 111 participating centers. Perioperative mortality was 413 of 18,800 (2.2%). Composite major morbidity or mortality occurred in 1,612 patients (8.6%). Predictors of mortality include the following: pneumonectomy ( p < 0.001), bilobectomy ( p < 0.001), American Society of Anesthesiology rating ( p < 0.018), Zubrod performance status ( p < 0.001), renal dysfunction ( p = 0.001), induction chemoradiation therapy ( p = 0.01), steroids ( p = 0.002), age ( p < 0.001), urgent procedures ( p = 0.015), male gender ( p = 0.013), forced expiratory volume in one second ( p < 0.001), and body mass index ( p = 0.015). Conclusions Thoracic surgeons participating in the STS GTDB perform lung cancer resections with a low mortality and morbidity. The risk-adjustment models created have excellent performance characteristics and identify important predictors of mortality and major morbidity for lung cancer resections. These models may be used to inform clinical decisions and to compare risk-adjusted outcomes for quality improvement purposes.
To compare, using the National Cancer Database, survival, pathologic, and surgical outcomes in patients with stage IIIA non-small cell lung cancer treated with differential doses of neoadjuvant ...chemoradiation therapy, with the aim to discern whether radiation dose escalation was associated with a comparative effectiveness benefit and/or toxicity risk.
Patients in the National Cancer Database with stage IIIA non-small cell lung cancer treated with neoadjuvant chemoradiation therapy and surgery between 1998 and 2005 were analyzed. Dose strata were divided between 36 to 45 Gy (low-dose radiation therapy, LD-RT), 45 to 54 Gy (inclusive, standard-dose, SD-RT), and 54 to 74 Gy (high-dose, HD-RT). Outcomes included overall survival, residual nodal disease, positive surgical margin status, hospital length of stay, and adverse surgical outcomes (30-day mortality or readmission).
The cohort consisted of 1041 patients: 233 (22%) LD-RT, 584 (56%) SD-RT, and 230 (22%) HD-RT. The median, 3-year, and 5-year overall survival outcomes were 34.9 months, 48%, and 37%, respectively. On univariable analysis, patients treated with SD-RT experienced prolonged overall survival (median 38.3 vs 31.8 vs 29.0 months for SD-RT, LD-RT, and HD-RT, respectively, P=.0089), which was confirmed on multivariable analysis (hazard ratios 0.77 and 0.81 vs LD and HD, respectively). Residual nodal disease was seen less often after HD-RT (25.5% vs 31.8% and 37.5% for HD-RT, LD-RT, and SD-RT, respectively, P=.0038). Patients treated with SD-RT had fewer prolonged hospital stays. There were no differences in positive surgical margin status or adverse surgical outcomes between the cohorts.
Neoadjuvant chemoradiation therapy between 45 and 54 Gy was associated with superior survival in comparison with doses above and below this threshold. Although this conclusion is limited by selection bias, clear candidates for trimodality therapy do not seem to achieve additional benefit with dose escalation.
Background. Malignant pleural mesothelioma is uncommon, and presently, no standard treatment of this disease exists. The objective of our analysis was to study the patterns of failure for malignant ...pleural mesothelioma after trimodality treatment consisting of extrapleural pneumonectomy, chemotherapy, and radiation therapy.
Methods. Between 1987 and 1993, 49 patients with malignant pleural mesothelioma underwent extrapleural pneumonectomy. There were two perioperative deaths, and 1 patient died 5 weeks after extrapleural pneumonectomy. Thirty-five of the surviving patients received adjuvant chemotherapy (32/35 received cyclophosphamide, doxorubicin, and cisplatin) followed by hemithorax radiation therapy. Ten patients received chemotherapy but no radiation therapy, and 1 patient received no adjuvant therapy. Median follow-up time for the 23 living patients from the date of operation was 18 months.
Results. Of the 46 evaluable patients, 25 had recurrence (54%), with a median time to first failure of 19 months (range, 5 to 51 months). The sites of first recurrence were local in 35% of patients, abdominal in 26%, the contralateral thorax in 17%, and other distant sites in 8%. (Some patients had recurrence in multiple sites simultaneously.)
Conclusions. The most common site of failure after trimodality therapy was the ipsilateral hemithorax. Isolated distant failures were uncommon. Future strategies should investigate methods of enhancing local tumor control.
(Ann Thorac Surg 1997;63:334–8)
The optimal locoregional therapy for stage IIIA non-small cell lung cancer (NSCLC) is controversial, with definitive chemoradiation therapy (CRT) and neoadjuvant therapy followed by surgery (NT-S) ...serving as competing strategies. In this study, we used the National Cancer Database to determine the prevalence and predictors of NT in a large, modern cohort of patients.
Patients with stage IIIA NSCLC treated with CRT or NT-S between 2003 and 2010 at programs accredited by the Commission on Cancer were included. Predictors were categorized as clinical, time/geographic, socioeconomic, and institutional. In accord with the National Cancer Database, institutions were classified as academic/research program and as comprehensive and noncomprehensive community cancer centers. Logistic regression and random effects multilevel logistic regression were performed for univariable and multivariable analyses, respectively.
The cohort consisted of 18,581 patients, 3,087 (16.6%) of whom underwent NT-S (10.6% induction CRT, 6% induction chemotherapy). The prevalence of NT-S was constant over time, but there were significant relative 31% and 30% decreases in pneumonectomy and right-sided pneumonectomy, respectively, over time (P trend <.02). In addition to younger age, lower T stage, and favorable comorbidity score, indicators of higher socioeconomic status were strong independent predictors of NT-S, including white race, higher income, and private/managed insurance. The type of institution (academic/research program vs comprehensive or noncomprehensive community cancer centers, odds ratio 1.54 and 2.08, respectively) strongly predicted NT-S, but treatment volume did not.
Neoadjuvant therapy followed by surgery was an uncommon treatment approach in Commission on Cancer programs, and the prevalence of postinduction pneumonectomy decreased over time. Higher socioeconomic status and treatment at academic institutions were significant predictors of NT-S. Further research should be performed to enable a better understanding of these disparities.
Abstract Objective There are little clinical data assessing the antineoplastic effect of metformin in patients with non–small cell lung cancer. We hypothesized that in diabetic patients undergoing ...pulmonary resection for early-stage non–small cell lung cancer, metformin exposure is associated with improved survival. Methods An institutional database was used to identify patients with stage I or II non–small cell lung cancer who underwent pulmonary resection between 2004 and 2013. Patients were divided into 3 cohorts: type II diabetic patients with metformin exposure (cohort A, n = 81), type II diabetic patients without metformin exposure (cohort B, n = 57), and nondiabetic individuals (cohort C, n = 77). Univariate, multivariate, and propensity-matched analyses were performed to assess progression-free and overall survivals between groups. Results A total of 215 patients with stage I and II non–small cell lung cancer treated with surgical resection were identified for analysis with a median follow-up of 19.5 months. Patients in cohort A had lower T- and N-stage tumors than those in cohorts B or C. However, on multivariate analysis adjusting for age, gender, and T and N stage, progression-free survival was greater for cohort A than cohort B (hazard ratio HR, 0.410; 95% confidence interval, 0.199-0.874; P = .022) or cohort C (HR, 0.415; 95% confidence interval, 0.201-0.887; P = .017). Likewise, when propensity-matched analyses were performed, cohort A demonstrated a trend toward improved progression-free survival compared with cohort B ( P = .057; HR, 0.44; c-statistic = 0.832) and improved progression-free survival compared with cohort C ( P = .02; HR, 0.41; c-statistic = 0.843). No differences were observed in overall survival. Conclusions Metformin exposure in diabetic patients with early-stage non–small cell lung cancer may be associated with improved progression-free survival, but no effect was seen on overall survival. Further studies are warranted to evaluate if there is a therapeutic role for metformin in the treatment of non–small cell lung cancer.
Background Surgical intervention after chemoradiation for locoregionally advanced non-small cell lung cancer (NSCLC) is controversial. This study evaluated patient survival after neoadjuvant ...chemoradiation and anatomic pulmonary resections for locoregionally advanced NSCLC. Methods Clinicopathologic data were retrospectively collected for 233 patients (110 women, 123 men) with NSCLC who underwent chemoradiation therapy, followed by pneumonectomy, sleeve lobectomy, bilobectomy, and standard lobectomy, from 1989 to 2008. Univariate log-rank analysis of Kaplan-Meier survival curves and multivariate Cox regression analysis was performed. Results Final pathologic stages were complete responders, 52 (22%); I, 56 (24%); II, 39 (17%); and III, 86 (37%). Final pathologic lymph node status was N0, 130 (56%); N1, 28 (12%); and N2, 75 (32%). Overall 5-year survival for the cohort was 43%. The 90-day mortality was 8% (18 of 233). The 5-year survival was 33% for pneumectomy vs 51% for lobectomy ( p = 0.002). Survival rates at 5 years by stage were complete responders, 58%; I, 50%; II, 41%; and III, 32%; by primary tumor status, T0, 50%; T2, 38%; T3, 29%; and T4, 28%; and by final pathologic nodal status, N0, 51%; N1, 40%; N2, 32% (N0 vs N1, p = 0.236; N1 vs N2, p = 0.704; N0 vs N2, p = 0.019; N0 vs N1 + N2, p = 0.020). Multivariate analysis demonstrated pneumonectomy was associated with decreased 5-year survival (hazard risk, 1.5162; 95% confidence interval, 10.05028 to 2.189, p = 0.0263). Conclusions Respectable survival can be achieved after neoadjuvant chemoradiation, followed by anatomic resection, in selected patients with clinically advanced NSCLC. A T0 primary tumor or N0 lymph node status individually, or together as a complete response (T0 N0) status, is associated with the best long-term survival. Survival is most favorable for lobectomies vs pneumonectomies after neoadjuvant chemoradiation therapy.
Early Pneumonectomy for Pulmonary Mucormycosis Vercillo, Michael S., MD; Liptay, Michael J., MD; Seder, Christopher W., MD
The Annals of thoracic surgery,
03/2015, Letnik:
99, Številka:
3
Journal Article
Recenzirano
Mucormycosis is a fungal infection caused by a rare pathogen most commonly affecting immunocompromised hosts. Successful treatment of pulmonary mucormycosis requires rapid diagnosis, reversal of ...predisposing factors, aggressive surgical excision, and antifungal therapy. We present a case of pulmonary mucormycosis affecting a young neutropenic male requiring a pneumonectomy.
Background Insulin-like growth factor 1 (IGF-I), IGF binding proteins (IGFBP) 1 to 7, and C-peptide have been postulated to predict survival in non-small cell lung cancer (NSCLC). Studying serum ...levels in NSCLC patients treated with surgical resection may provide information on the aggressiveness of tumors and be predictive of disease recurrence. Methods Immunobead assays were used to measure pretreatment serum levels of IGF-I, IGFBP1 to IGFBP7, and C-peptide in 100 NSCLC patients. Of these, 59 had no metastatic progression (T1 to T4 N0 M0), whereas 41 had positive lymph nodes (T1 to T4 N1 to N3 M0). Data were analyzed using the Mann-Whitney two-sided rank sum test or Kaplan-Meier curves. Results Low serum IGFBP5 levels correlated strongly with a positive nodal status ( p < 0.001) and any incidence of disease recurrence ( p = 0.003). Low serum levels of IGFBP5 also predicted poor recurrence-free survivals in the overall cohort ( p ≤ 0.001) and in patients with no nodal metastases ( p = 0.027). Conversely, a high serum level of IGFBP7 correlated with positive nodal status ( p = 0.008), but was not prognostic for recurrence-free survival. No significant correlations were found for IGFBP5 or IGFBP7 for sex, age, race, smoking history, tumor histology, or fasting state. Conclusions IGFBP5 and IGFBP7 had value as biomarkers for identifying NSCLC progression and patient outcome.
Background Dysregulation of angiogenesis is known to be associated with tumorigenesis and metastatic progression in multiple carcinomas. The aim of this study was to evaluate the prognostic value of ...circulating angiogenesis biomarkers in lung adenocarcinoma progression. For that, we hypothesize that circulating levels of biomarkers characteristic for discrete processes within angiogenesis are associated with specific phases of disease progression. Appreciation of these profiles may have important implications for disease detection and prognostication. Methods Patients with lung adenocarcinoma enrolled in the study were grouped as follows: node negative (T1a–3N0M0; n = 69), node positive (T1a–4N1–2M0; n = 60), and disseminated disease (TxNxM1; n = 68). All serum specimens were assayed for 17 angiogenesis biomarkers on the Luminex platform and statistically evaluated by analysis of variance for median differences in biomarker concentration at distinct phases of disease progression and by log rank methods for associations with clinical outcome. Results We found circulating hepatocyte growth factor, heparin-binding epidermal growth factor, epidermal growth factor, and vascular endothelial growth factor-C levels significantly elevated ( p < 0.05) in patients with node positive versus node negative disease. Similarly, median serum concentrations of bone morphogenic protein-9, endoglin, fibroblast growth factor-1, fibroblast growth factor-2, interleukin-8, placental growth factor, vascular endothelial growth factor-C, and vascular endothelial growth factor-D were significantly ( p < 0.05) higher in patients with disseminated disease than in patients with node positive disease. Five biomarkers total were strongly prognostic ( p < 0.05) for overall survival in the node negative cohort. Conclusions Angiogenesis is a process central to lung adenocarcinoma progression. We describe the modulation in serum angiogenesis biomarker concentrations through the various phases of non-small cell lung cancer progression. Additional refinement efforts are under way to enhance test performance, followed by additional validation studies.
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