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Elective thoracic surgery is safe in well-selected elderly patients. The association of frailty with postoperative morbidity in elective-lobectomy patients is understudied. We examined frailty as defined by abbreviated modified frailty index (mFI-5), mFI-11 in the thoracic surgery population, and the correlation between frailty and postoperative complications.We studied outcomes of patients in two cohorts, 2010-2012 and 2013-2019, from the National Surgical Quality Improvement Program (NSQIP) database and used multivariable logistic regression models to predict all postoperative morbidity, mortality, and major morbidity. The mFI-5 could be calculated for all subjects (both 2010-2012, and 2013-2019); the mFI-11 could only be calculated for the 2010-2012 cohort. Patient frailty was defined as mFI≥3 (with either index). We used odds ratios (ORs) to examine associations of preoperative characteristics with postoperative complications and C-statistics to assess overall predictive power.Complications were less prevalent in the 2013-2019 cohort (17.9% versus 19.5%, P = 0.008). Open lobectomies were more common in the 2010-2012 cohort (53.9% versus 34.6%) and were strongly associated with postoperative morbidity and mortality (ORs1.5) in both cohorts. Each frailty measure was associated with morbidity and mortality (ORs1.4) after adjusting for other significant preoperative factors. Models on the 2010-2012 cohort had nearly identical C-statistics using the mFI-11 versus mFI-5 frailty indices (0.6142 versus 0.6139; P 0.8).Frailty, as captured in the mFI-5, is a significant associated factor of postoperative morbidity and mortality following elective lobectomies. As a modifiable risk factor, frailty should be considered in surgical decision-making and when counseling patients regarding perioperative risks.

Rapid onsite evaluation (ROSE) generally uses smears made at the site of the procedure ("smear-based ROSE"). It requires considerable time, generally 2 individuals, technical expertise, and it can be difficult to estimate material available for ancillary studies. We developed an alternative ROSE using liquid-based cytology ThinPrep with hematoxylin and eosin (Hamp;E) stain ("liquid-based ROSE") and assessed its advantages.Clinicians rinse the sample(s) into CytoRich Red and send to Pathology. A defined proportion of the needle rinse is removed for a ThinPrep stained with a rapid Hamp;E. Adequacy and diagnosis were compared to final outcome. Total time was recorded.Among 52 liquid-based ROSE readings, 28 (53.8%) were interpreted as "adequate" with final as adequate; 17 (32.7%) were interpreted as "inadequate" with final as inadequate; 7 (13.5%) were interpreted as "inadequate" with final as adequate. Of 23 readings provided with onsite diagnosis, 15 (65.2%) were interpreted as definitive positive or negative diagnoses; 6 (26%) were interpreted as nondiagnostic; and 2 (8.7%) were interpreted as atypical. All definitive diagnoses were concordant with final diagnoses. The time for liquid ROSE performance ranges from 6 to 22 minutes (mean: 13 minutes) and required only 1 individual.Liquid-based ROSE allows accurate adequacy determination and diagnosis, takes about 15 minutes of cytologist time, and can be performed by just 1 person. The technique produces well-preserved and stained slides, it may allow a better estimation of the total amount of material in the specimen vial and may provide a better platform for telecytology.

Background Frail older surgical patients face more than a two-fold increase in postoperative complications, including myocardial infarction, deep vein thrombosis, pulmonary embolism, pneumonia, ileus, and others. Many of these complications occur because of postoperative loss of stamina and poor mobility. Preoperative exercise may better prepare these vulnerable patients for surgery. We present the protocol for our ongoing randomized trial to assess the impact of a preoperative walking intervention with remote coaching and pedometer on outcomes of stamina (six-minute walk distance- 6MWD) and mobility (postoperative steps) in older adults with frailty traits. Methods We will be conducting a randomized clinical trial with a total of 120 patients permitting up to a 33% rate of attrition, to reach a final sample size of 80 (with 40 patients for each study arm). We will include patients who are age 60 or higher, score 4 or greater on the Edmonton Frailty Scale assessment, and will be undergoing a surgical operation that requires a 2 or more night hospital stay to be eligible for our trial. Using block randomization stratified on baseline 6MWD, we will assign patients to wear a pedometer. At the end of three baseline days, an athletic trainer (AT) will provide a daily step count goal reflecting a 10–20% increase from baseline. Subsequently, the AT will call weekly to further titrate the goal or calls more frequently if the patient is not meeting the prescribed goal. Controls will receive general walking advice. Our main outcome is change in 6MWD on postoperative day (POD) 2/3 vs. baseline. We will also collect 6MWD approximately 4 weeks after surgery and daily in-hospital steps. Conclusion If changes in a 6MWD and step counts are significantly higher for the intervention group, we believe this will confirm our hypothesis that the intervention leads to decreased loss of stamina and mobility. Once confirmed, we anticipate expanding to multiple centers to assess the interventional impact on clinical endpoints. Trial registration The randomized clinical trial was registered on clinicaltrials.gov under the identifier NCT03892187 on March 27, 2019.

With the advancement of robotic surgery, some thoracic surgeons have been slow to adopt to this new operative approach, in part because they are un-scrubbed and away from the patient while operating. Aiming to allay surgeon concerns of intra-operative emergencies, an insitu simulation-based clinical system's test (SbCST) can be completed to test the current clinical system, and to practice low-frequency, high-stakes clinical scenarios with the entire operating room (OR) team.Six different OR teams completed an insitu SbCST of an intra-operative pulmonary artery injury during a robot-assisted thoracic surgery at a single tertiary care center. The OR team consisted of an attending thoracic surgeon, surgery resident, anesthesia attending, anesthesia resident, circulating nurse, and a scrub technician. This test was conducted with an entire OR team along with study observers and simulation center staff. Outcomes included the identified latent safety threats (LSTs) and possible solutions for each LST, culminating in a complete failure mode and effects analysis (FMEA). A Risk Priority Number (RPN) was determined for each LST identified. Pre- and post-simulation surveys using Likert scales were also collected.The six FMEAs identified 28 potential LSTs in four categories. Of these 28 LSTs, nine were considered high priority based on their Risk Priority Number (RPN) with seven of the nine being repeated multiple times. Pre- and post-simulation survey responses were similar, with the majority of participants (94%) agreeing that high fidelity simulation of intra-operative emergencies is helpful and provides an opportunity to train for high-stakes, low-frequency events. After completing the SbCST, more participants felt confident that they knew their role during an intra-operative emergency than their pre-simulation survey responses. All participants agreed that simulation is an important part of continuing education and is helpful for learning skills that are infrequently used. Following the SbCST, more participants agreed that they knew how to safely undock the da Vinci robot during an emergency.SbCSTs provide an opportunity to test the current clinical system with a low-frequency, high-stakes event and allow medical personnels to practice their skills and teamwork. By completing multiple SbCSTs, we were able to identify multiple LSTs within different OR teams, allowing for a broader review of the current clinical systems in place. The use of these SbCSTs in conjunction with debriefing sessions and FMEA completion allows for the most significant potential improvement of the current system. This study shows that SbCST with FMEA completion can be used to test current systems and create better systems for patient safety.

Explore the impact of the Lung Cancer Screening Trial (NLST-September-2011) and the Medicare approval for CT-screening (CT-LCS-AP-February-2015) on lung cancer incidence rates, mortality, and the percentage of early-stage lung cancer diagnosis (ESLCD-T1-T2N0M0).Retrospective interrupted time series analysis using SEER-18 database. All individuals with lung cancer (LC) diagnosis from 2006 to 2016 were included. The effect of NLST and CT-AP-2015 on the monthly percentage of early-stage ESLCD was the primary outcome, additionally LC incidence and mortality rates were calculated. The analysis was performed by age, sex, race, marital status, insurance status, and household income. Bivariate and multivariate models were used to identify predictors of ESLCD.The study cohort was composed by 388,207 individuals, 69 years old in average, 46.6 % female, and 81.1 % white. LC incidence and mortality rates declined from 2006 to 2016 without association with NLST-September-2011 and CT-LCS-AP-February-2015. The percentage of ESLCD increased over time for all groups. Overall rates of ESLCD started at 18 % in January-2006 and increased to 25 % by December-2016. The intervention NLST-2011 did not show an impact in the ESLCD while the CT-AP-2015 showed a significant impact in the ESLCD trend (p 0.001). ESLCD was associated with female, white, insurance, and household incomes above median. Medicare expansion was a significant factor for insured group, married patients and those from households under the median income level.Medicare approval for CT screening was found to have a statistically significant effect on the diagnosis of early-stage lung cancer and neither NLST-September-2011 nor CT-AP-2015-February-2015 impacted the incidence nor mortality rates.To improve early-stage lung cancer diagnosis, it is vital to invest in health policies to increase Lung Cancer Screening implementation and to reduce disparities in access to diagnosis. Furthermore, policies that facilitate access to diagnosis and treatment are crucial to reduce lung cancer mortality.

BACKGROUND Frail older surgical patients face more than a two-fold increase in postoperative complications, including myocardial infarction, deep vein thrombosis, pulmonary embolism, pneumonia, ileus, and others. Many of these complications occur because of postoperative loss of stamina and poor mobility. Preoperative exercise may better prepare these vulnerable patients for surgery. OBJECTIVE We present the protocol for our ongoing randomized trial to assess the impact of a preoperative walking intervention with remote coaching and pedometer on outcomes of stamina (six-minute walk distance- 6MWD) and mobility (postoperative steps) in older adults with frailty traits. METHODS We plan to conduct a randomized clinical trial. Eligible patients are age 60 or higher, scoring 4 or greater on the Edmonton Frailty Scale assessment, and undergoing a surgical operation that requires a 2 or more night hospital stay. Using block randomization stratified on baseline 6MWD, we assign patients to wear a pedometer. At the end of three baseline days, an athletic trainer (AT) provides a daily step count goal reflecting a 10-20% increase from baseline. Subsequently, the AT calls weekly to further titrate the goal or calls more frequently if the patient is not meeting the prescribed goal. Controls receive general walking advice. Our main outcome is change in 6MWD on postoperative day (POD) 2/3 vs. baseline. We also collect 6MWD approximately 4 weeks after surgery and daily in-hospital steps. RESULTS After an initial pilot phase that ran from June 2019 to December 2019, as of July 2020, we have enrolled 14 patients. We have a total of 6 intervention patients and 8 control patients participating in the trial. Funding has been secured till December 2020. CONCLUSIONS If changes in 6MWD and step counts are significantly higher for the intervention group, we believe this will confirm our hypothesis that the intervention leads to decreased loss of stamina and mobility. Once confirmed, we anticipate expanding to multiple centers to assess the interventional impact on clinical endpoints. CLINICALTRIAL The randomized clinical trial was registered on clinicaltrials.gov under the identifier NCT03892187 on March 27, 2019. URL: https://clinicaltrials.gov/ct2/show/NCT03892187

e18677 Background: Lung cancer has the highest mortality among the leading cancers in the U.S. Its detection in the early stages is one of the strategies to increase survival. This study aims to identify whether the implementation of a structured Lung Cancer Screening Program impacted the percentage of Early Stage Lung Cancer Diagnosis (ESLCD). Methods: Retrospective cohort study aiming to identify changes over time considering the following indicators: a) percentage of ESLCD; b) the percentage of lung resections for ESLCD. In October 2019, there was a restructuring of our institutional Lung Cancer Screening Program (LCSP). We analyzed quarterly incident lung cancer cases at our institution between October 2017 and December 2019. Descriptive, bivariate, and multivariate analyses were performed. Results: Our cohort comprised 736 patients. The age average was 69.3 years, 54.6% female, 96.5% white. Clinical Stage 1A to 2B corresponded to 43.3% of patients. 71.9% had their diagnosis and treatment in the institution. Factors associated with ESLCD were being in the LCSP (OR 4.4 [95%CI 2.3-8.1]); diagnosis and treatment in the institution (OR 2.2 [95%CI 1.6-3.2]); having 3 or less comorbidities (OR 1.6 [95%CI 1.2-2.1]) and female (OR 1.4 [95%CI 1.1-1.9]). In the last Quarter of 2017, the percentage of ESLCD through LCSP was 2.6%, and in the last Quarter of 2019 (2019Q4), 28.8%, representing a 1025% growth. Also, in 2019Q4, 44.8 % of the ESLCD cases that had surgery came through the LCSP, which is a significant increase from prior quarters. Conclusions: The restructuring of our LCSP may have resulted in an increase in ESLCD and the number of curative surgeries for Lung Cancer. Identification of opportunities for improvement of health care delivery can help to increase ESLCD; a longer time for follow-up is needed to observe if the upward trend is sustained and its effects on patient survival. Selected indicators by quarter, 2017 to 2019.[Table: see text]

Background The benefits of screening for non-small cell lung cancer (NSCLC) have been established for high-risk individuals, and recent guidelines advocate continued surveillance after curative therapy. Yet the optimal posttreatment surveillance strategy remains to be determined. We compared patterns of recurrence and modes of detection in surgically treated patients with pathologic early-stage and locally advanced NSCLC. Methods Consecutive patients who had undergone resection for stage I–IIIA NSCLC from 2004 to 2009 were identified from a prospectively maintained institutional database. All patients received interval chest computed tomography (CT) scans every 6 to 12 months after treatment. Results In total, 1,640 patients were identified: 181 of 346 patients with stage IIIA NSCLC (52%) and 257 of 1,294 patients with stage I–II NSCLC (20%) experienced recurrences. Surveillance CT detected asymptomatic recurrences in 157 stage I–II patients (61%) and 89 stage IIIA patients (49%) ( p = 0.045). Symptoms led to detection of recurrences more often in stage IIIA patients (73, 40%) than in stage I–II patients (81, 32%). Distant recurrences were more common in stage IIIA patients than in stage I–II patients (153, 85%, vs 190, 74%; p = 0.01). In stage IIIA patients, the risk of recurrence was highest during the first 2 years after operation, but it remained substantial into year 4. Conclusions Stage IIIA patients had fewer recurrences detected by surveillance CT, a higher rate of symptomatic presentation, a markedly higher risk of recurrence, and a higher propensity for distant recurrence. Surveillance strategies may need to account for stage-specific differences.

6598 Background: Lung cancer has the highest mortality among the leading cancers in the U.S. Surgical resection is considered as the most effective treatment for lung cancer in early stages, providing greater long-term survival. Clinical guidelines on delays in resection of early-stage lung cancer do not exist. This work aims to assess whether increasing time between diagnosis/first doctor visit and surgery for early stage non-small cell lung cancer (NSCLC) is associated with poorer survival. Methods: We identified a retrospective cohort of incident lung cancer cases who had surgical treatment for lung cancer at our institution between January 2009 and December 2017, and no prior radiation or chemotherapy. We assessed overall survival (OS) and predictors included a) time from first contact to surgery; and b) time from diagnosis to surgery. The association between time from diagnosis and time from first contact to surgery, and survival for patients with early stage NSCLC was assessed using multivariable Cox proportional hazard. We investigated four cut-off points: surgery within 15 days, 30 days, 60 days and 90 days. We controlled for sociodemographic characteristics as well as clinical outcomes. Results: Our cohort comprised 491 patients. The age average was 66.9 years, 61% female, 94.7% white, and 9% never smoked. Clinical Stage 1A and 1B corresponded to 86.5% of patients while in pathological stage it was 76%. The 5-year overall survival was 56.0%. Surgery occurred a median 40 days after the diagnosis and 43 days after the first visit and within 35 days if the first appointment was with a thoracic surgeon. The threshold time associated with statistically significant worse survival was 60 days after diagnosis. Surgery was performed more than 60 days of diagnosis in 115 (25.7%) patients, their OS was significantly worse than patients who had surgery earlier (HR=1.7 [95% CI: 1.1-2.6]). Conclusions: Greater intervals between diagnosis of early-stage NSCLC and surgery are associated with worse survival. Efforts to minimize delays, particularly factors that prolong the period from diagnosis to first contact with a lung cancer provider may improve survival. [Table: see text]

1569 Background: The Lung Cancer Screening Trial (NLST) demonstrated improved overall survival (OS) and lung cancer specific survival (LCSS), likely due to finding early-stage NSCLC. Our study investigates the impact of the NLST publication in 2011 on the lung cancer outcomes in the general US Population by assessing the incidence rates, ratio of early/late stage, and lung cancer mortality in the years immediately prior to and following this publication. Methods: Rate sessions from the SEER18 database were accessed during the years 2008-2015. We analyzed overall lung cancer incidence and mortality rates. The ratio of early/late stage was obtained by dividing the number of stage I and II cases by the number of stage III and IV diagnosed by year. We investigate changes in level and trend using interrupted time series in STATA12, considering 2011 as the intervention. In addition, we performed a T-test for averages ratios comparing the years 2007-2010 to the years 2012-2015 for the entire lung cancer population and for subgroups by median family, ethnicity, Sex, Age and SEER Registry. Results: Although the overall lung cancer rates remained stable during the study period, a significant increase in the ratio of early/late stage was observed following the release of NLST for the overall lung cancer population (p=0.006) and for the screening age group (p= 0.014). The effects of ratio of early/late stage as noted in the overall group persisted for all patient subgroups, except for patients associated with a median income

Background The current guidelines for follow-up care after treatment of non-small cell lung cancer recommend continued surveillance for detection of recurrent or metachronous disease. However, carcinoid tumors, especially those with a typical histologic profile, tend to be less aggressive. Our goal was to determine the patterns of relapse and the manner of detection of recurrences, to guide follow-up care after resection. Methods Patients who underwent operations for pulmonary carcinoids at our institution were identified from a prospectively maintained database, and their medical records were reviewed for relapse patterns, detection methods, and outcomes. Results A total of 337 patients who underwent resection between 1993 and 2010 were included, with a median follow-up time of 3.5 years. Typical and atypical carcinoids were present in 291 (86%) and 46 (14%) patients, respectively. Recurrences occurred in 21 patients (6%), with distant metastases in 20 patients (95%) and locoregional recurrence in only 1 patient. Most recurrences (15 [76%]) were not detected through scheduled surveillance imaging but after the presentation of symptoms (7 [33%]) or incidentally by studies performed for unrelated reasons (8 [38%]). The risk of recurrence increased with positive lymph nodes and atypical histologic type. Only 9 of 291 patients (3%) with typical carcinoids experienced recurrences, with a median time to recurrence of 4 years (range, 0.8–12 years). Conversely, 12 of 46 patients (26%) with atypical carcinoids experienced recurrences, with a median time to recurrence of 1.8 years (range, 0.2–7 years). Conclusions After complete resection, scheduled surveillance imaging failed to detect most recurrences. Recurrence was rare in patients with node-negative typical carcinoids. Given the low risk of recurrence and the unclear efficacy of surveillance imaging, routine surveillance imaging may not be warranted in this cohort.

Introduction:Guidance is limited for invasive staging in patients with lung cancer without mediastinal disease by positron emission tomography (PET). We developed and validated a prediction model for pathologic N2 disease (pN2), using six previously described risk factors: tumor location and size by computed tomography (CT), nodal disease by CT, maximum standardized uptake value of the primary tumor, N1 by PET, and histology.Methods:A cohort study (2004–2009) was performed in patients with T1/T2 by CT and N0/N1 by PET. Logistic regression analysis was used to develop a prediction model for pN2 among a random development set (n = 625). The model was validated in both the development set, which comprised two thirds of the patients and the validation set (n = 313), which comprised the remaining one third. Model performance was assessed in terms of discrimination and calibration.Results:Among 938 patients, 9.9% had pN2 (9 detected by invasive staging and 84 intraoperatively). In the development set, univariate analyses demonstrated a significant association between pN2 and increasing tumor size (p < 0.001), nodal status by CT (p = 0.007), maximum standardized uptake value of the primary tumor (p = 0.027), and N1 by PET (p < 0.001); however, only N1 by PET was associated with pN2 (p < 0.001) in the multivariate prediction model. The model performed reasonably well in the development (c-statistic, 0.70; 95% confidence interval, 0.63–0.77; goodness of fit p = 0.61) and validation (c-statistic, 0.65; 95% confidence interval, 0.56–0.74; goodness-of-fit p = 0.19) sets.Conclusion:A prediction model for pN2 based on six previously described risk factors has reasonable performance characteristics. Observations from this study may guide prospective, multicenter development and validation of a prediction model for pN2.

7043 Background: Pathologic downstaging following induction chemotherapy in patients with stage III-N2 NSCLC is a well-known positive prognostic indicator. However, the predictive factors for locoregional recurrence (LRR) in these patients are largely unknown. Methods: Between 1998-2008, 153 patients with clinically or pathologically-staged III-N2 NSCLC from two cancer centers in the United States were treated with induction chemotherapy and surgery. All patients had pathologic N0-1 disease, and no one received postoperative radiotherapy. LRR were defined as disease recurrence at the surgical site, lymph nodes (levels 1-14 including supraclavicular) or both. Overall survival (OS) was calculated using the Kaplan and Meier method and comparisons were made using the log-rank test. Univariate and multivariate Cox proportional hazards model were used to assess the association of LRR and risk factors. Results: The median follow up time for survivors was 39.3 months. Baseline pretreatment N2 nodal involvement was staged by either pathologic confirmation (18.2%) or PET/CT (81.8%). Overall, the 5 year LRR rate was 30.8% (n=38), with LRR being the first site of failure in 51% (22 of 43). The 5 year OS for patients with LRR compared to those without was 21% versus 60.1%, respectively (p

Background Operative mortality rates are of great interest to surgeons, patients, policy makers, and payers as a metric for quality assessment. Thirty-day mortality and discharge mortality have been presumed to capture procedure-related deaths. However, many patients die after the 30-day mark or are transferred to other facilities or to home and die there, leading to the underreporting of surgically related deaths. We hypothesized that a longer period of observation would address these concerns and provide a more accurate measure of operative mortality. Methods We retrospectively reviewed institutional databases of patients undergoing resection for lung cancer, esophageal cancer, and mesothelioma. Mortality rates at 30 and 90 days were calculated with 95% confidence intervals (CIs). Results From 1999 to 2012, 7,646 surgical resections were performed: 6,119 for lung cancer, 1,258 for esophageal cancer, and 269 for mesothelioma. Among the different cancers and across operations, the additional mortality from day 31 to 90 (1.4%; 95% CI, 1.2% to 1.8%; n = 111) was similar to that by day 30 (1.2%; 95% CI, 1.0% to 1.5%; n = 95), resulting in overall 90-day mortality (2.7%; 95% CI, 2.3% to 3.1%; n = 206) that was more than double the 30-day mortality. Conclusions Among patients who have undergone operations for thoracic malignancies, mortality attributable to the operation occurs beyond the first 30 postsurgical days as well as after hospital discharge. Because cancer operations constitute a large portion of general thoracic surgery, we recommend national databases consider the inclusion of 90-day mortality in their data collection.

Background Smokers have a higher risk of developing non-small cell lung cancer (NSCLC) than never-smokers, but the relative risk of developing second primary lung cancer (SPLC) is unclear. Determining the risk of SPLC in smokers versus never-smokers after treatment of an initial cancer may help guide recommendations for long-term surveillance. Methods Patients who underwent resection for stage I adenocarcinoma were identified from a prospectively maintained institutional database. Patients with other histologies, synchronous lesions, or who received neoadjuvant or adjuvant therapy were excluded. The SPLCs were identified based on Martini criteria. Results From 1995 to 2012, a total of 2,151 patients underwent resection for stage I adenocarcinoma (308 never-smokers [14%] and 1,843 ever-smokers [86%]). SPLC developed in 30 never-smokers (9.9%) and 145 ever-smokers (7.8%). The SPLC was detected by surveillance computed tomography scan in the majority of patients (161; 92%). In total, 87% of never-smokers and 83% of ever-smokers had stage I SPLC. There was no significant difference in the cumulative incidence of SPLC between never-smokers and ever-smokers ( p = 0.18) in a competing-risks analysis. The cumulative incidence at 10 years was 20.3% for never-smokers and 18.2% for ever-smokers. Conclusions Although smokers have a greater risk of NSCLC, the risk of a second primary cancer developing after resection of stage I lung cancer is comparable between smokers and never-smokers. The majority of these second primary cancers are detectable at a curable stage. Ongoing postoperative surveillance should be recommended for all patients regardless of smoking status.

Introduction: After definitive treatment of esophageal cancer, patients are at high risk for recurrence. Consistent follow-up is important for detection and treatment of recurrence. The optimal surveillance regimen remains undefined. We investigated posttreatment recurrence patterns and methods of detection in survivors of esophageal cancer. Methods: We retrospectively studied a cohort of patients who had undergone surgical resection for esophageal cancer at our institution between 1996 and 2010. Routine computed tomography scan and upper endoscopy were performed for surveillance. Results: In total, 1147 patients with resected esophageal adenocarcinoma or squamous cell carcinoma were included (median follow-up, 46 months). Of these, 723 patients (63%) had received neoadjuvant therapy before surgery. During follow-up, there were 595 deaths (52%) and 435 recurrences (38%) (distant [55%], locoregional [28%], or both [17%]). Half of recurrences were detected as a result of symptoms ( n = 217), 45% by routine chest and abdominal computed tomography scan ( n = 194), and 1% by surveillance upper endoscopy ( n = 6). The recurrence rate decreased from 27 per 100 person-years in posttreatment year 1 to 4 per 100 person-years in year 6. In the first 2 years, the rate of recurrence was higher among patients who had received neoadjuvant therapy (35 per 100 person-years) than among those who had not (14 per 100 person-years) ( p Conclusions: The incidence of recurrence is high after esophagectomy for cancer. Surveillance endoscopy has limited value for detection of asymptomatic local recurrence. The yield from follow-up scans diminishes significantly after the sixth year; surveillance scans after that point are likely unnecessary.

Objective At present, there is no consensus on the optimal strategy for follow-up care after curative resection for lung cancer. We sought to understand the patterns of recurrence and second primary lung cancer, and their mode of detection, after resection for early-stage non–small cell lung cancer in patients who were followed by routine surveillance computed tomography scan. Methods We reviewed the outcomes of consecutive patients who underwent resection for early-stage non–small cell lung cancer at Memorial Sloan-Kettering Cancer Center between 2004 and 2009. Results A total of 1294 consecutive patients with early-stage non–small cell lung cancer underwent resection. The median length of follow-up was 35 months. Recurrence was diagnosed in 257 patients (20%), and second primary lung cancer was diagnosed in 91 patients (7%). The majority of new primary cancers (85 [93%]) were identified by scheduled routine computed tomography scan, as were a smaller majority of recurrences (157 [61%]). During the first 4 years after surgery, the risk of recurrence ranged from 6% to 10% per person-year but decreased thereafter to 2%. Conversely, the risk of second primary lung cancer ranged from 3% to 6% per person-year and did not diminish over time. Additional testing after false-positive surveillance computed tomography scan results was performed for 329 patients (25%), but only 4 of these patients (0.3%) experienced complications as a result of subsequent invasive diagnostic procedures. Conclusions Almost all second primary cancers and the majority of recurrences were detected by post-therapeutic surveillance computed tomography scan. The risk of recurrence for early-stage non–small cell lung cancer survivors persisted during the first 4 years after resection, and vigilance in surveillance should be maintained.

The National Quality Forum endorses prolonged length of stay of more than 14 days (PLOS) as a quality metric for lobectomy for lung cancer. Because PLOS rates are lower than complication rates, we hypothesized that PLOS misses a significant proportion of clinically important events.A retrospective study was performed on patients undergoing lobectomy (2000 to 2009). The severity of adverse events was based on the National Cancer Institute common terminology criteria for adverse events (grade 2 or higher indicates symptoms or need for medical intervention; grade 5 indicates death).Among 2,667 patients, 163 (6%) experienced PLOS and 773 (29%) experienced an adverse event. Although the frequency of adverse events was higher among the PLOS group (99% [161 of 163] versus 24% [612 of 2504]), 79% (612 of 773) of adverse events occurred in the non-PLOS group. Whereas PLOS was associated with more severe events, 89% of those in the non-PLOS group experienced a grade 2 or higher event. Likewise, although PLOS was associated with the lowest 5-year survival rate (31%), patients in the non-PLOS group who had an adverse event had significantly lower survival rates than patients in the non-PLOS group who did not have any adverse events (55% versus 68%, p0.001; adjusted hazard ratio 1.3 [95% confidence interval: 1.1 to 1.6]).The PLOS missed a high proportion of adverse events defined by the need for ongoing inpatient therapy and an association with poor long-term survival. These findings have implications for efficient and fair performance assessment in the setting of a quality improvement program.

7570 Background: Deciding to operate for lung cancer in patients with a prior lung cancer resection is influenced by the extent of disease at 1st resection and the certainty that the new lesion is a 2nd primary lung cancer. While the Martini and Melamed (M&M) criteria (J Thorac Cardiovasc Surg 1975) guide the decision whether a new lesion represents a 2nd lung cancer, improvements, incorporating detailed clinical and molecular analyses, are needed. Methods: From a prospective database, we identified 130 patients who underwent two curative resections from 1995 to 2009 for non-small cell lung cancers. We examined associations between clinical factors and patterns of recurrence/DFS/OS following 2nd surgery. Results: Patient characteristics: median age 66; 42% men; and 8% never smokers. See Table for stage, histology, and completeness of resection. DFS and OS were not associated with smoking status, surgical procedure, and histology. Stage at 1st resection was not associated with patterns of recurrence (none vs local vs distant, p=0.77), DFS (p=0.61), or OS (p=0.37). Earlier stage at 2nd resection was associated with improved DFS (p