Background Understanding recurrence of surgically “cured” stage I adenocarcinoma of the lung is important given expected benefits of adjuvant therapy for advanced disease. Therefore, this study ...characterizes cancer recurrence and its risks, assesses survival after recurrence, and contextualizes overall survival and its risks. Methods From 1991 to 2001, 285 patients underwent resection of stage I adenocarcinoma (pathologic) of the lung. They were followed cross-sectionally for evidence of cancer recurrence (mean follow-up 7.7 ± 4.3 years). Risk factors for recurrence and all-cause mortality were sought among demographic, medical history, cancer pathology, and surgical procedure data. Results Cancer recurred in 99 patients. Freedom from recurrence was 92%, 72%, and 57% at 1, 5, and 10 years. Two phases of risk were found: an early hazard phase and an essentially constant late phase after 5 years, with recurrences equally distributed. Early recurrence was associated with larger tumor size in patients who did not undergo mediastinal lymphadenectomy (p = 0.004). Late recurrence was more common in patients with higher pack-years of smoking (p = 0.007). Survival after recurrence was 40% and 17% at 1 and 5 years. Overall survival (65% and 40% at 5 and 10 years) depended not only on variables related to cancer recurrence, but also those of vitality (older age, pulmonary dysfunction, postpneumonectomy state). Conclusions Stage I adenocarcinoma of the lung recurs. Identifying high-risk patients will simplify decision making for adjuvant therapy and surveillance. Thorough mediastinal lymphadenectomy dissociates tumor size as a predictor of survival and may itself provide an important survival benefit.
Background There are no systemic therapies approved in the United States to treat pediatric psoriasis. Objective We sought to evaluate long-term safety and efficacy of etanercept in children and ...adolescents with moderate to severe plaque psoriasis. Methods This 5-year, open-label extension study enrolled patients aged 4 to 17 years who had participated in a 48-week parent study. End points included occurrence of adverse events (AEs) and serious AEs including infections, and rates of 75% and 90% improvement in Psoriasis Area and Severity Index score and clear/almost clear on static physician global assessment. Results Of 182 patients enrolled, 181 received etanercept and 69 completed 264 weeks. Through week 264, 161 (89.0%) patients reported an AE, most commonly upper respiratory tract infection (37.6%), nasopharyngitis (26.0%), and headache (21.5%). Seven patients reported 8 serious AEs; only 1 (cellulitis) was considered treatment-related. No cases of opportunistic infections or malignancy were reported. Rates of 75% improvement in Psoriasis Area and Severity Index score (∼60%–70%) and 90% improvement in Psoriasis Area and Severity Index score (∼30%–40%) and static physician global assessment status clear/almost clear (∼40%–50%) were maintained through week 264. Limitations The number of patients remaining on study at week 264 was small. Conclusion Etanercept in pediatric patients was generally well tolerated and efficacy was maintained in those who remained in the study for up to 264 weeks.
To discern the effectiveness and toxicity of stereotactic ablative radiation therapy (SABR) in the elderly population (aged ≥75 years) and to consider how SABR outcomes compare with surgical outcomes ...historically reported in the elderly.
A total of 772 patients with clinical early-stage I-II non-small cell lung cancer (NSCLC; stage T1-T3N0M0) underwent SABR (50 Gy in 4 fractions or 70 Gy in 10 fractions) from 2004 to 2014 at our center (n=442, aged <75 years; n=330, aged ≥75 years). The primary endpoints included overall survival (OS), time-to-progression, and grade ≥3 toxicity. The median follow-up time was approximately 55 months.
Compared with patients aged <75 years, those aged ≥75 years had no difference in the time-to-progression (P=.419), lung cancer-specific survival (P=.275), or toxicity (P=.536). OS was the same between both age groups at 2 years of follow-up but diverged thereafter, with patients aged <75 years when treatment began having greater OS rates at 5 years. The median OS rates for patients aged ≥75 years were 86% at 1 year, 57.5% at 3 years, and 39.5% at 5 years. The median OS rates for patients aged <75 years were 87.3% at 1 year, 67.6% at 3 years, and 51.5% at 5 years. No patient aged ≥75 years experienced any grade 4 or 5 toxicity.
The effectiveness of SABR was the same for the elderly as for the average-age population according to lung cancer-specific survival and time-to-progression. It also poses no increased toxicity. Compared with the historical outcomes with surgery in the elderly, SABR outcomes can be considered comparable for stage I-II disease but with less morbidity.
Background Patients with non-small cell lung cancer (NSCLC) being evaluated for stereotactic ablative body radiotherapy (SABR) are typically staged noninvasively with positron emission ...tomography/computed tomography (PET/CT). Incorporating endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) into the staging workup of these patients has not been evaluated. Our primary objective was to compare the performance of PET/CT with EBUS-TBNA for intrathoracic nodal assessment among SABR-eligible patients. Methods This was a retrospective study consisting of two parts. First, we assessed the concordance for nodal metastasis of PET/CT and EBUS-TBNA. Second, we evaluated clinical outcomes among patients who underwent SABR with and without a prior EBUS-TBNA. Results We identified 246 eligible patients. Compared with PET/CT, EBUS-TBNA led to a stage shift in 48 of 246 patients (19%). Of 174 N0 patients by PET/CT, 6 (3.4%) had nodal metastasis on EBUS-TBNA. Among 72 clinical N1 patients, 36 (50%) were downstaged to N0 after EBUS-TBNA, therefore becoming eligible for SABR. Concordance between PET/CT and EBUS-TBNA for nodal metastasis was 83% (κ = 0.53). Clinical outcomes of patients who underwent SABR with or without a prior EBUS-TBNA did not differ significantly. Conclusions Concordance of PET/CT and EBUS-TBNA for nodal disease was only moderate. Incorporating EBUS-TBNA into the staging workup was beneficial in identifying occult nodal metastasis that would otherwise be left untreated with SABR and in expanding the pool of potentially SABR-eligible patients.
Background Endoscopic resection is increasingly utilized for treating early stage esophageal cancer, and endoscopic ultrasound (EUS) frequently guides treatment selection. Studies report greater than ...80% sensitivity and 90% specificity, but our experience suggests less accuracy at the gastroesophageal (GE) junction. The objective of this study is to determine the accuracy of EUS for depth of GE junction cancer and the potential treatment implications. Methods A retrospective review of a prospective database was performed for patients from 1995 to 2014 with GE junction esophageal cancer that underwent EUS staging and resection (surgical or endoscopic) without neo-adjuvant therapy. Patient, tumor, EUS, and pathologic characteristics were examined. Results For the 181 patients that met criteria, the median age was 66 years, 17% were female, 91% white, and 98% had adenocarcinoma. Concordance between EUS (u) T and pathologic (p) T was 48%, with 23% under-staged and 29% over-staged. The EUS was accurate in the following: uT0 6% (1 of 18); uT1a 56% (23 of 41); uT1b 58% (41 of 71); uT2 10% (2 of 21); and uT3 70% (21 of 30). Inaccurate EUS depth had potential to lead to over-treatment in 38% (27 of 71) of uT1b and 76% (16 of 21) of uT2. In 50% of pT1a tumors, EUS depth was T1b or greater. Logistic regression revealed tumor length (continuous variable) to be associated with inaccurate uT ( p = 0.016). Accurately staged tumors were significantly longer than inaccurately staged tumors (2.7 vs 1.7 cm, p = 0.011). Conclusions Early to intermediate GE junction tumors are frequently over-staged. This highlights the importance of diagnostic endoscopic resection for determining accurate tumor depth and selecting correct therapy.
Abstract Objectives Measuring patient-reported outcomes (PROs) has become increasingly important for assessing quality of care and guiding patient management. However, PROs have yet to be integrated ...with traditional clinical outcomes (such as length of hospital stay), to evaluate perioperative care. This study aimed to use longitudinal PRO assessments to define the postoperative symptom recovery trajectory in patients undergoing thoracic surgery for lung cancer. Methods Newly diagnosed patients (N = 60) with stage I or II non–small cell lung cancer who underwent either standard open thoracotomy or video-assisted thoracoscopic surgery lobectomy reported multiple symptoms from before surgery to 3 months after surgery, using the MD Anderson Symptom Inventory. We conducted Kaplan–Meier analyses to determine when symptoms returned to presurgical levels and to mild-severity levels during recovery. Results The most-severe postoperative symptoms were fatigue, pain, shortness of breath, disturbed sleep, and drowsiness. The median time to return to mild symptom severity for these 5 symptoms was shorter than the time to return to baseline severity, with fatigue taking longer. Recovery from pain occurred more quickly for patients who underwent lobectomy versus thoracotomy (8 vs 18 days, respectively; P = .022). Patients who had poor preoperative performance status or comorbidities reported higher postoperative pain (all P < .05). Conclusions Assessing symptoms from the patient's perspective throughout the postoperative recovery period is an effective strategy for evaluating perioperative care. This study demonstrates that the MD Anderson Symptom Inventory is a sensitive tool for detecting symptomatic recovery, with an expected relationship among surgery type, preoperative performance status, and comorbid conditions.
Background Smoking cessation is presumed to be beneficial before resection of lung cancer. The effect of smoking cessation on outcome was investigated. Methods From January 1999 to July 2007, ...in-hospital outcomes for 7990 primary resections for lung cancer in adults were reported to the Society of Thoracic Surgeons General Thoracic Surgery Database. Risk of hospital death and respiratory complications was assessed according to timing of smoking cessation, adjusted for clinical confounders. Results Hospital mortality was 1.4% (n = 109), but 1.5% in patients who had smoked (105 of 6965) vs 0.39% in those who had not (4 of 1025). Compared with the latter, risk-adjusted odds ratios were 3.5 ( p = 0.03), 4.6 ( p = 0.03), 2.6 ( p = 0.7), and 2.5 ( p = 0.11) for those whose timing of smoking cessation was categorized as current smoker, quit from 14 days to 1 month, 1 to 12 months, or more than 12 months preoperatively, respectively. Prevalence of major pulmonary complications was 5.7% (456 of 7965) overall, but 6.2% in patients who had smoked (429 of 6941) vs 2.5%% in those who had not (27 of 1024). Compared with the latter, risk-adjusted odds ratios were 1.80 ( p = 0.03), 1.62 ( p = 0.14), 1.51 ( p = 0.20), and 1.29 ( p = 0.3) for those whose timing of smoking cessation was categorized as above. Conclusions Risks of hospital death and pulmonary complications after lung cancer resection were increased by smoking and mitigated slowly by preoperative cessation. No optimal interval of smoking cessation was identifiable. Patients should be counseled to stop smoking irrespective of surgical timing.
Background After neoadjuvant chemoradiation (CXRT) for esophageal cancer, surgery has traditionally been recommended to be performed within 8 weeks. However, surgery is often delayed for various ...reasons. Data from other cancers suggest that delaying surgery may increase the pathologic complete response rate. However, there are theoretical concerns that waiting longer after radiation may lead to a more difficult operation and more complications. The optimal timing of esophagectomy after CXRT is unknown. Methods From a prospective database, we analyzed 266 patients with resected esophageal cancer who were treated with neoadjuvant CXRT from 2002 to 2008. Salvage resections were excluded from this analysis. We compared patients who had surgery within 8 weeks of CXRT and those who had surgery after 8 weeks. We used multivariable analysis to determine whether increased interval between chemoradiation and surgery was independently associated with perioperative complication, pathologic response, or overall survival. Results One hundred fifty patients were resected within 8 weeks and 116 were resected greater than 8 weeks after completing CXRT. Mean length of operation, intraoperative blood loss, anastomotic leak rate, and perioperative complication rate were similar for the two groups. Pathologic complete response rate and overall survival were also similar for the two groups ( p = not significant). In multivariable analysis, timing of surgery was not an independent predictor of perioperative complication, pathologic complete response, or overall survival. Conclusions The timing of esophagectomy after neoadjuvant CXRT is not associated with perioperative complication, pathologic response, or overall survival. It may be reasonable to delay esophagectomy beyond 8 weeks for patients who have not yet recovered from chemoradiation.
Background Resection of pulmonary colorectal carcinoma metastases may provide long-term benefit, but patient selection remains controversial. The objective of this study was to identify preoperative ...predictors of survival and lung recurrence for patients undergoing resection of such lesions. Methods A prospectively collected database was retrospectively reviewed to identify patients who underwent their first colorectal carcinoma pulmonary metastasectomy. Two multivariate logistic analyses were performed to identify preoperative predictors of survival and lung recurrence. Preoperative factors, pathologic colorectal carcinoma stage, additional sites of metastases, timing of metastatic occurrence, and premetastasectomy disease-free interval were included in the univariate analyses. Results From January 2000 to December 2010, 229 patients met inclusion criteria. The mean age was 60 years, and 100 patients (43.7%) were women. The overall median time and 5-year survival rate were 70.1 months and 55.4%, respectively, after the first pulmonary metastasectomy. Median follow-up was 37.2 months. Age older than 60 years (hazard ratio HR, 1.03; 95% confidence interval CI, 1.005 to 1.052; p = 0.016), male sex (HR, 1.84; 95% CI, 1.089 to 3.094; p = 0.023), and more than three lung metastases (HR, 1.15; 95% CI, 1.024 to 1.282; p = 0.018) predicted survival at 5 years in one multivariate analysis. In the second, more than three lung metastases present at first metastasectomy (HR, 1.19; 95% CI, 1.071 to 1.321; p = 0.001) and the preoperative disease-free interval of less than 3 years (HR, 0.99; 95% CI, 0.973 to 0.997; p = 0.013) predicted lung recurrence. Conclusions Older age, male sex, and more lung metastases predict poorer survival after resection of pulmonary colorectal cancer metastases. The number of lung metastases present at the first metastasectomy and the preoperative disease-free interval predicted recurrence in the lung.
Background Emerging technologies for prosthetic reconstruction after chest wall resection have yielded a wide variety of reconstructive options for thoracic surgeons. The ideal chest wall ...reconstruction and its impact on perioperative outcomes has not been well defined. Our goal was to determine whether mesh characteristics such as rigidity or absorbability altered perioperative pulmonary and infectious outcomes. Methods Our institutional database was queried for patients who underwent chest wall resection and reconstruction for primary or secondary chest wall tumors between the years 1998 and 2013. A focused chart review supplied clinical and perioperative variables. The main study outcomes focused on perioperative pulmonary and wound/implant infectious complications. Univariate and multivariate analyses were performed to identify variables associated with outcome. Results We identified 1,096 patients who underwent chest wall resection during the study period, of which 427 required chest wall reconstruction. Pulmonary complications occurred in 24% (n = 102 of 427) of patients. We observed no significant difference in pulmonary complications between those that had a rigid versus flexible chest wall reconstruction ( p = 0.401; OR, 1.43; 95% CI, 0.83–2.43). The odds of pulmonary complications increased with each additional resected rib (OR, 1.43; 95% CI, 1.2–1.71). Multivariable analysis identified the number of resected ribs (OR, 1.26; 95% CI, 1.00–1.59) and concomitant lobectomy (OR, 3.59; 95% CI, 1.62–7.92) as variables associated with perioperative pulmonary morbidity. Infectious complications occurred in 13 patients and were not predicted by the use of permanent versus absorbable prosthetic materials ( p = 0.575). Conclusions The type of reconstructive material, whether with rigid, flexible, permanent, or biologic characteristics, does not appear to influence perioperative pulmonary or infectious wound complications. Rather, the number of resected ribs and the concomitant lung parenchymal resection predict pulmonary morbidity following chest wall resection. Depending on the circumstances, an effective chest wall reconstruction can be achieved with either rigid or flexible prosthetic material.
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