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To determine the prevalence of metastases to the cervical and recurrent laryngeal cervicothoracic (CT) nodes as well as survival and recurrence patterns after esophagectomy with three-field lymph node dissection (TFD) in patients with predominately adenocarcinoma (AC) of the esophagus.Although esophagectomy with TFD is commonly practiced in Japan and Southeast Asia for squamous cell cancer of the esophagus (SCC), there are only a handful of reports about its' utilization and survival benefit in North American patients.This is a retrospective case series of patients who had an esophagectomy with TFD. The primary outcomes of interest were the prevalence of nodal metastases to the CT nodes as well as overall (OS) and disease-free survival (DFS). Secondary outcomes included time to recurrence, recurrence patterns, operative morbidity as well as 30 and 90-day mortality.242 patients with esophageal cancer (AC:67%) underwent esophagectomy with TFD. Metastases to the CT nodes were present in 56 patients (23%: AC 20% and SCC 30%). Positive CT nodes were present in 14% of pT1/T2 tumors and 30% of pT3 tumors. For the 56 patients with CT positive nodes, 5-year OS was 25% (AC:16%; SCC:39%). Fifteen of 56 (26.7%) patients with metastases to the CT nodes were alive and disease-free at a minimum of five years postoperatively. Ten-year OS was 43% for all patients with SCC and 28% for patients with AC.Metastases to the CT nodes are common in both SCC and AC of the esophagus and may be present in at least 14% of early lesions. Five-year survival is encouraging particularly for patients with esophageal SCC cancer.

Background Stapling across lung parenchyma may lead to tissue granulation, which could be confused radiographically with recurrence. We sought to define the time course and radiographic characteristics of such thickening and to determine their association with recurrence. Methods Patients who underwent limited resection for non-small cell lung cancer were included. Surveillance computed tomography scans were reviewed to characterize the morphology and size of staple line granulation tissue. Radiological and clinical findings were analyzed and univariate predictors of recurrence were examined. Results We characterized 78 patients for tissue granulation a total of 314 times in serial scans. On initial postoperative scans, 3.8% (n = 3) of staple lines showed no thickening and 17.9% (n = 14) showed thickening less than 2 mm, whereas 78.2% (n = 61) showed thickening 2 mm or greater. Of the 75 staple lines with thickening, soft tissue was characterized as linear in 32.0% (n = 24), focal along the pleura, hilum, or parenchyma in 24.0% (n = 18), and nodular in 44.0% (n = 33). Subsequent scans revealed that 25.3% of these areas (n = 19) did not change in shape or size over time, 58.7% (n = 44) showed regressive changes, and 16.0% (n = 12) showed progressive changes, the thickening of which in all 12 of these patients showed an increase in the largest dimension by 2 mm or greater. Among the 78 patients, 7.7% (n = 6) had biopsy-proven recurrence along the staple line. An increase in the largest dimension by 2 mm or greater (83.3% versus 9.7%; P = .001) and radiologic concern for malignancy (66.7% versus 11.1%; P = .001) predicted staple line recurrence. Conclusions Staple line thickening is a frequent occurrence after pulmonary limited resection, but rarely indicative of recurrence. The characteristics and initial size of granulation tissue do not predict recurrence. Increases in tissue 2 mm or greater at the staple line over time predict local recurrence, which typically occurs after a prolonged time interval.

Several trials have recently reported the safety of pulmonary resection after neoadjuvant immunotherapy with encouraging major pathological response rates. We report the detailed adverse events profile from a recently conducted randomized phase II trial in patients with resectable non-small cell lung cancer treated with neoadjuvant durvalumab alone or with sub-ablative radiation.We conducted a randomized phase II trial in patients with non-small cell lung cancer clinical stages I to IIIA who were randomly assigned to receive neoadjuvant durvalumab alone or with sub-ablative radiation (8Gyx3). Secondary end points included the safety of 2 cycles of preoperative durvalumab with and without radiation followed by pulmonary resection. Postoperative adverse events within 30 days were recorded according to the National Cancer Institute Common Terminology Criteria for Adverse Events (version 4.0).Sixty patients were enrolled and randomly assigned, with planned resection performed in 26 patients in each arm. Baseline demographics and clinical variables were balanced between groups. The median operative time was similar between arms: 128 minutes (97-201) versus 146 minutes (109-214) (P = .314). There was no 30- or 90-day mortality. Grade 3/4 adverse events occurred in 10 of 26 patients (38%) after monotherapy and in 10 of 26 patients (38%) after dual therapy. Anemia requiring transfusion and hypotension were the 2 most common adverse events. The median length of stay was similar between arms (5 days vs 4 days, P = .172).In this randomized trial, the addition of sub-ablative focal radiation to durvalumab in the neoadjuvant setting was not associated with increased mortality or morbidity compared with neoadjuvant durvalumab alone.

Minimal literature exists evaluating the impact of the extent of resection on survival in patients with small, early-stage non-small cell lung cancer (NSCLC) found to have occult nodal disease. We hypothesized that sublobar resection has comparable overall survival to patients undergoing lobectomy for clinical stage IA NSCLC that harbors occult nodal disease.The National Cancer Database was reviewed for identification of patients with clinical stage IA NSCLC who underwent wedge resection, segmentectomy, or lobectomy and were found to have occult nodal disease. Overall survival was compared between groups, and a multivariate Cox regression model identified factors associated with worse survival.Occult nodal disease occurred in 6.1% of all patients with clinical stage IA disease undergoing resection. Patients undergoing wedge resection and segmentectomy found to have occult nodal disease were older (67.6 ± 9.6 years of age vs 66.1 ± 9.3 years of age vs 65.6 ± 9.5 years of age; P = .004) and had more advanced pathologic stage (pStage III: 68.7% vs 50.5% vs 41.5%; P.001) than those receiving lobectomy. There was no difference in the median overall survival between segmentectomy and lobectomy (68.5 months vs 57.6 months; P = .200). However, wedge resection was independently associated with worse overall survival when controlling for other preoperative variables (hazard ratio, 1.23; 95% confidence interval, 1.01-1.51; P = .042).Review of the National Cancer Database suggests that there is no improvement in overall survival in patients undergoing lobectomy vs segmentectomy in carefully selected patients with clinical stage IA NSCLC harboring occult nodal disease. However, those undergoing wedge resection may have worse overall survival than those undergoing both lobectomy and segmentectomy.

MINI In patients with esophageal cancer who received neoadjuvant chemoradiation, the total number of resected nodes is a significant determinant of improved survival regardless of clinical nodal status. OBJECTIVES The aim of this study was to explore the potential value of extended nodal-dissection following neoadjuvant chemoradiation (CRT), by analyzing data from the National Cancer Database (NCDB). BACKGROUND A CROSS-trial post-hoc analysis showed that the number of dissected lymph nodes was associated with improved survival in patients undergoing upfront surgery but not in those treated with neoadjuvant CRT. METHODS The NCDB was queried (2004-2014) for patients who underwent esophagectomy following induction CRT. Predictors of overall survival (OS) were assessed. The optimal number of dissected LNs associated with highest survival benefit was determined by multiple regression analyses and receiver-operating characteristic curve analysis. The whole cohort was divided into 2 groups based on the predefined cutoff number. The two groups were propensity-matched (PMs). RESULTS Esophagectomy following induction-CRT was performed in 14,503 patients. The number of resected nodes was associated with improved OS in the multivariable analysis (hazard ratio for every 10 nodes: 0.95 (95% confidence interval: 0.93-0.98). The cutoff number of resected LNs that was associated with the highest survival benefit was 20 nodes. In the PM groups, patients in the "≥20 LNs" group had a 14% relative-increase in OS (P = 0.002), despite having more advanced pathological stages (stage II-IV: 76% vs 72%, P < 0.001), and higher number of positive nodes (0-2 vs 0-1, P < 0.001). CONCLUSIONS The total number of resected nodes is a significant determinant of improved survival following induction CRT in patients with either node negative or node positive disease. In the matched groups, patients with higher number of resected lymph nodes had higher OS rate, despite having more advanced pathological disease and higher number of resected positive lymph nodes.

To investigate changes in the tumor microenvironment (TME) during lung cancer progression, we interrogate tumors from two chest computed tomography (CT)-defined groups. Pure non-solid (pNS) CT density nodules contain preinvasive/minimally invasive cancers, and solid density nodules contain invasive cancers. Profiling data reveal a dynamic interaction between the tumor and its TME throughout progression. Alterations in genes regulating the extracellular matrix and genes regulating fibroblasts are central at the preinvasive state. T cell-mediated immune suppression is initiated in preinvasive nodules and sustained with rising intensity through progression to invasive tumors. Reduced T cell infiltration of the cancer cell nests is more frequently associated with preinvasive cancers, possibly until tumor evolution leads to a durable, viable invasive phenotype accompanied by more varied and robust immune suppression. Upregulation of immune checkpoints occurs only in the invasive nodules. Throughout progression, an effector immune response is present but is effectively thwarted by the immune-suppressive elements.

OBJECTIVES Sublobar resection (SLR) is an alternative to lobectomy for non-small-cell lung cancer (NSCLC). Outcomes following SLR for tumours >2 cm are not well described. We sought to determine the utilization of SLR for stage I tumours >2–5 cm in size and to determine predictors of outcome. METHODS We utilized the Surveillance, Epidemiology and End Results Program (SEER)-Medicare database to identify NSCLC patients with primary lung cancer ≥66 years old with stage I cancers >2–5 cm in size. We evaluated overall survival and cancer-specific survival among cohorts undergoing lobectomy versus SLR. Propensity score matching was performed. We compared patient characteristics and survival between groups. RESULTS For the study time period (2007–2012), among patients with tumours >2 cm and ≤5 cm (n = 4582), 3890 lobectomies (85%) and 692 SLR (15%) were performed. Patients undergoing SLR were older, had smaller tumours and more comorbidities. Patients undergoing lobectomy were much more likely to have any lymph nodes removed (95.6% vs 65.6%, P 10 nodes removed (29.6% vs 7.5%, P CONCLUSIONS In pathologically staged patients, SLR appears inferior to lobectomy for stage I NSCLC 2–5 cm in size. SLR is associated with less extensive lymphadenectomy and with worse survival than lobectomy in this cohort of patients. However, the 76.5% 3-year cancer-specific survival in patients undergoing SLR may exceed that of other localized treatment options for NSCLC. As such, SLR may be an appropriate option for high-risk patients with carefully staged 2–5 cm N0 tumours.

OBJECTIVES: Despite the recent increased rate of adoption of robotic approaches for the resection of thymic tumours, their use is still limited to large-volume academic centres. To date, a large-scale analysis of the robotic approach has not been performed. We assessed the recent trends and outcomes of robotic thymectomies in the United States compared to those of open and video-assisted thoracoscopic surgical (VATS) approaches. METHODS: The National Cancer Database was queried for patients who underwent resection for thymic tumours (2010–2014). Predictors of using the robotic approach were estimated by logistic regression analysis. Propensity matching analysis (robotic versus open and robotic versus VATS) was done (1:1—caliper 0.05), controlling for age, gender, comorbidity index, induction treatment, tumour size and tumour extension. RESULTS: A total of 2558 thymectomies were performed (robotic = 300, VATS = 280, open = 1978). The use of a robotic approach increased from 6% (2010) to 14% (2014). The number of hospitals performing at least 1 robotic thymectomy increased from 22 (2010) to 52 (2014). Independent predictors influencing the choice of a robotic approach included an academic research/integrated cancer programme [odds ratio (OR) 1.66, confidence interval (CI) 1.22–2.27], later year of diagnosis (2014; OR 2.23, CI 1.31–3.80) and a patient’s race (Asian) (OR 1.68, CI 1.05–2.69). A robotic approach was less likely to be utilized in midwestern hospitals (OR 0.65, CI 0.42–0.99), in larger tumours (cm) (OR 0.85, CI 0.80–0.90), with invasion of adjacent organs (OR 0.55, CI 0.37–0.82), thymic carcinoma (OR 0.62, CI 0.40–0.97) and following induction chemotherapy (OR 0.22, CI 0.08–0.61). In a propensity-matched analysis, there were no differences in the incidence of positive margins, nodal dissection, 30-day readmission rates and 30-/90-day mortality rates between the groups. However, a robotic approach was associated with fewer conversions compared to VATS, with a trend towards a shorter length of stay compared to an open approach. There were no differences in the 5-year overall survival rate between the matched groups (robotic 93% vs VATS 94%; P = 0.571; robotic 91% vs open 80%; P = 0.094). CONCLUSIONS: Over a 4-year study period, there was a significant increase in robotic utilization for thymectomies and an increase in the number of hospitals performing the procedure. In a matched analysis, a robotic approach was comparable to a VATS or an open approach. Current trends demonstrate increased robotic utilization for small thymomas with excellent perioperative results.

Background: There is a paucity of data regarding the role of wedge resection (WR) in the management of bronchial carcinoid (BC) tumors. In this study, we queried the Surveillance, Epidemiology, and End Results (SEER) database to compare the oncologic outcomes of patients with BC tumors treated with WR or anatomic resection. Methods: The SEER database was retrospectively reviewed for patients with BC treated with surgical resection between 1973–2013. Patients who underwent WR were compared to those who underwent lobectomy or segmentectomy (Lob/Seg). Patients with multiple primaries and those who underwent pneumonectomy or have an unspecified surgical procedure were excluded. Differences in demographics and clinicopathological data were compared using Chi (χ 2 ) test or Mann Whitney U test. Overall and cancer specific survival (OS, CSS) were estimated using Kaplan-Meier method and differences were compared using log-rank test. Cox-regression multivariable analysis (MVA) was performed to explore factors associated with worse CSS. Propensity-score matching analysis was done to compare survival differences between WR and Lob/Seg. Results: A total of 22,350 patients with BC were identified, of them 4,450 met our inclusion criteria (3,511 Lob/Seg, vs. 939 WR). The median age was 59.0 years [interquartile range (IQR) =49.0–68.0], 67.6% were females and the median tumor size was 2 cm (1.5–3 cm). 4,119 patients had typical carcinoid (TC) and 331 had atypical carcinoid (AC). WR was performed more frequently in elderly patients, females, lower lobe tumors, TC’s and in earlier stage disease. For patients with TC, there was no difference in CSS between WR and Lob/Seg in both the entire cohort (P=0.654) and in the propensity matched groups (P=0.900). However, for patients with AC, Lob/Seg was associated with better CSS compared to WR both in the entire cohort (P

OBJECTIVES: Minimum volume standards for thoracic surgical procedures have been advocated to improve outcomes. However, such standards are controversial within the thoracic surgery literature, and the methodology to determine cut points between high- and low-volume hospitals has been criticized. Furthermore, while multiple studies have examined hospital volume and its relationship with outcomes, there have been very few attempts to study this issue from the perspective of the individual thoracic surgeon. The aim of this study was to determine if surgeon volume is associated with differences in outcomes using a large state-wide database. METHODS: The study utilized the New York State Department of Health Statewide Planning and Research Cooperative (SPARCS) data for analysis. Patients who underwent major lung resections including sublobar resection, lobectomy and pneumonectomy from 1995 to 2014 were included and were categorized into 3 subgroups based on the extent of resection. Patient characteristics included age, gender, race, insurance and comorbidities. Surgeon information was obtained by using a unique identifier. Average annual surgical volumes of sublobar resection, lobectomy and pneumonectomy were calculated separately and grouped into 3 categories based on the tertiles. Demographic data and comorbidities were compared between the various volume groups to analyse the resulting complications. Primary outcomes were in-hospital mortality and 30-day readmission. RESULTS: There were a total of 99 576 major lung resections performed between 1995 and 2014 in the SPARCS database. Among these, the majority were wedge or segmental resections (n = 54 953, 55.2%) followed by lobectomy (n = 40 421, 40.6%) and pneumonectomy (n = 4202, 4.2%). In-hospital mortality was significantly greater for low-volume surgeons compared to high-volume surgeons for all resection groups. Additionally, low-volume surgeons had higher 30-day readmission rates for patients undergoing lobectomy and pneumonectomy. However, low-volume surgeons as a group were more likely to operate on black patients and patients with Medicaid, and black race was an independent predictor of mortality across all resection groups. The vast majority of surgeons performing lobectomy (89.5%) were in the low-volume group. CONCLUSIONS: Low-volume surgeons had higher rates of in-hospital mortality compared to their high-volume counterparts. However, the vast majority of surgeons performing lobectomy (89.5%) were in the low-volume group, and low-volume surgeons operated on higher percentages of black patients. These findings suggest that minimal volume standards would significantly impact the current delivery of thoracic surgery in the US.

The influence of SARS-CoV-2 on surgery for non-small cell lung cancer needs to be understood to inform clinical decision making during and after the COVID-19 pandemic.This study reports on the 90-day rate of infection as well as the morbidity and mortality of lung surgery for cancer in a tertiary care hospital located in a pandemic epicenter.We conducted a retrospective review of a prospective database to identify consecutive patients who underwent lung cancer resection before (January 1, 2020-March 10, 2020, group 1; 57 patients) and during the COVID-19 pandemic (March 11, 2020-June 10, 2020, group 2; 41 patients). The primary end point was the occurrence of SARS-CoV-2 infection during the first 90-days after surgery. The secondary outcome measure was 90-day perioperative morbidity and mortality.Patient characteristics were not significantly different between the groups. Ninety-day COVID-19 infection rates was 7.3% (3 out of 41) for patients undergoing an operation during the pandemic and 3.5% (2 out of 57) in patients operated on immediately before the pandemic. All patients tested positive 10 to 62 days after the index surgical procedure following hospital discharge. Four COVID-19-positive patients were symptomatic and 4 out of 5 patients required hospitalization, were men, previous or current smokers with hyperlipidemia, and underwent a sublobar resection. Univariate analysis did not identify any differences in postoperative complications before or during the COVID-19 pandemic. Ninety-day mortality was 5% (2 out of 41) for lung cancer surgery performed during the pandemic, with all deaths occurring due to COVID-19, compared with 0% (0 out of 57) mortality in patients who underwent an operation before the pandemic.During the COVID-19 pandemic, COVID-19 infections occurred in 7.3% of patients who underwent surgery for non-small cell lung cancer. In this series all infections occurred after hospital discharge. Our results suggest that COVID-19 infections occurring within 90 days of surgery portend a 40% mortality, warranting close postoperative surveillance.

Routine mutation profiling for resected lung cancers is not widespread despite an increasing array of targeted therapies. We report the incidence of epidermal growth factor receptor mutations (EGFRmu+) in resected lung adenocarcinomas and their outcomes at a large North American cancer center to characterize this population now eligible for targeted adjuvant therapy.Among 1036 pulmonary resections performed between 2015 and 2019, 647 patients (62%) had adenocarcinomas that underwent molecular profiling by next-generation sequencing. Clinical and pathologic characteristics, along with survival, were analyzed.EGFRmu+ were identified in 238 patients (37%). Patients with EGFRmu+ were more likely to be Asian than those with EGFR wild-type (79/238 [33%] vs 37/409 [9%], respectively; P.001) and more likely to be never-smokers (115/238 [48%] vs 73/409 [18%], P.001). However, most patients with EGFRmu+ in our cohort were White (45%) and had a history of smoking (52%). A statistically nonsignificant trend was observed toward improved 3-year overall survival for pathologic stage IB to III cancers with EGFRmu+ (91% vs 77%, P = .09). Patients with pathologic stage IB lung cancers with EGFRmu+ had a 97% rate of 3-year disease-free survival, with only 1 recurrence in the first 3 years of follow-up. EGFR mutation subtype was not associated with survival differences.Although Asians and never-smokers comprised a disproportionately large group of patients with lung adenocarcinomas with EGFRmu+, most EGFR mutations within our cohort were found in patients who were White or with a smoking history, supporting a routine rather than selective approach to mutation profiling. Patients with surgically resected stage IA and IB lung adenocarcinomas enjoy excellent survival regardless of their mutational status.

Sublobar resection is frequently offered to patients with small, peripheral lung cancers, despite the lack of outcome data from ongoing randomized clinical trials. Sublobar resection may be a particularly attractive surgical strategy for screen-detected lung cancers, which have been suggested to be less biologically aggressive than cancers detected by other means. Using prospective data collected from patients undergoing surgery in the National Lung Screening Trial, we sought to determine whether extent of resection affected survival for patients with screen-detected lung cancer.The National Lung Screening Trial database was queried for patients who underwent surgical resection for confirmed lung cancer. Propensity score matching analysis (lobectomy vs sublobar resection) was done (nearest neighbor, 1:1, matching with no replacement, caliper 0.2). Demographics, clinicopathologic and perioperative outcomes, and long-term survival were compared in the entire cohort and in the propensity-matched groups. Multivariable logistic regression analysis was done to identify factors associated with increased postoperative morbidity or mortality.We identified 1029 patients who underwent resection for lung cancer in the National Lung Screening Trial, including 821 patients (80%) who had lobectomy and 166 patients (16%) who had sublobar resection, predominantly wedge resection (n = 114, 69% of sublobar resection). Patients who underwent sublobar resection were more likely to be female (53% vs 41%, P = .004) and had smaller tumors (1.5 cm vs 2 cm, P .001). The sublobar resection group had fewer postoperative complications (22% vs 32%, P = .010) and fewer cardiac complications (4% vs 9%, P = .033). For stage I patients undergoing sublobar resection, there was no difference in 5-year overall survival (77% for both groups, P = .89) or cancer-specific survival (83% for both groups, P = .96) compared with patients undergoing lobectomy. On multivariable logistic regression analysis, sublobar resection was the only factor associated with lower postoperative morbidity/mortality (odds ratio, 0.63; 95% confidence interval, 0.40-0.98). To compare surgical strategies in balanced patient populations, we propensity matched 127 patients from each group undergoing sublobar resection and lobectomy. There were no differences in demographics or clinical and tumor characteristics among matched groups. There was again no difference in 5-year overall survival (71% vs 65%, P = .40) or cancer-specific survival (75% vs 73%, P = .89) for patients undergoing lobectomy and sublobar resection, respectively.For patients with screen-detected lung cancer, sublobar resection confers survival similar to lobectomy. By decreasing perioperative complications and potentially preserving lung function, sublobar resection may provide distinct advantages in a screened patient cohort.

OBJECTIVES Oesophagectomy following induction chemoradiation therapy (CRT) is technically challenging. To date, little data exist to describe the feasibility of a robotic approach in this setting. In this study, we assessed national trends and outcomes of robotic oesophagectomy following induction CRT compared to the traditional open approach. METHODS The National Cancer Database was queried for patients who underwent oesophagectomy following induction CRT (2010–2014). Trends of robotic utilization were assessed by a Mantel–Haenszel test of trend. Propensity matching controlled for differences in age, gender, comorbidity, stage, histology and tumour location between the robotic and open groups. Overall survival was estimated by Kaplan–Meier analysis and compared by a log-rank test RESULTS Oesophagectomy following induction CRT was performed in 6958 patients. Of them, 555 patients (8%) underwent robotic surgery (5% converted to an open approach). Between 2010 and 2014, utilization of a robotic approach increased from 3% to 11% (Mantel–Haenszel, P CONCLUSIONS Robotic oesophagectomy after induction CRT is feasible and associated with shorter hospitalization compared to an open approach, and does not compromise the adequacy of oncological resection, perioperative outcomes or long-term survival.

Background Recurrent esophageal carcinoma (EC) has a dismal prognosis. However, prior studies showed that selected patients with isolated recurrence may benefit from definitive therapy. The aim of this study was to identify the predictors of postrecurrence survival (PRS) in patients with isolated EC recurrence who were treated with curative intent. Methods A retrospective review of a prospective database (1988 to 2015) was performed to identify all recurrent EC patients after curative esophagectomy. Demographic and clinicopathologic data were reviewed. The probability of PRS was estimated with the Kaplan-Meier method. Predictors of PRS after definitive therapy for isolated EC recurrence were determined by the multivariable Cox proportional hazards model. Results Of the 640 curative esophagectomies, 241 patients (37.7%) experienced recurrences (median follow-up 50 months). Fifty-six patients (9%) received definitive treatment of isolated EC recurrence (31 were treated surgically with or without chemotherapy-radiotherapy [CTRT] and 25 received definitive CTRT alone). Median time to recurrence (TTR) was 19 months. The 1- and 3-year PRSs were 78% and 38% (median survival 26 months). On multivariable analysis; TTR was the only significant independent predictor for survival after recurrence (hazards ratio 0.98, 95% confidence interval: 0.96 to 0.99, p = 0.034). No pronounced difference was found in disease-free survival or in PRS between recurrent patients treated with operation with or without CTRT and patients who received definitive CTRT. Conclusions A select subgroup of patients with isolated EC recurrence can be treated with curative intent. TTR was the best predictor for PRS.

OBJECTIVES Pulmonary sarcomatoid carcinoma (PSC) is a rare malignant neoplasm that accounts for a small percentage of non-small-cell lung carcinoma (NSCLC). At least 10% of PSCs has a spindle and/or giant cell component, which is often associated with a poor prognosis. We reviewed the Surveillance, Epidemiology, and End Results (SEER) database for the clinicopathological characteristics and surgical outcomes of PSCs. METHODS The SEER database (1973-2013) was queried for PSC. A comparison between PSC and other NSCLC patients was performed. Cox regression for overall survival (OS) and logistic regression for node-positive predictors were performed. A propensity-matched (1:2) analysis (including age, gender, grade and stage) among surgically treated cases was done to compare OS in PSC versus other NSCLCs. RESULTS A total of 955 899 NSCLC patients were identified; of these, 4987 patients had been diagnosed with PSC (0.52%). Men represented 60.9% of cases, with a median age of 68 years. The median size of the tumour was 5 cm and 3.5 cm in PSCs and NSCLCs, respectively (P

OBJECTIVES We sought to examine changes over time in the proportion of never smokers among surgical lung cancer patients and to determine whether smoking history affected survival. METHODS We performed a retrospective review of a prospective database. Among never smokers and smokers, demographic and pathological data were compared. Disease-free survival (DFS) and cancer-specific survival (CSS) were analysed. Propensity matching was performed for further comparison of survival in a matched cohort. RESULTS Among 3232 patients, we identified 718 never smokers (22%), 993 smokers with

Background Despite the relatively high sensitivity of fluorodeoxyglucose-positron emission tomography (PET) and computed tomography (CT) scans used for staging of non-small cell lung cancer (NSCLC), a subset of patients with peripherally located clinical T1a N0 will be upstaged due to pathologic nodal disease. It is important to study this risk of upstaging, especially if local treatments, such as wedge resection or stereotactic body radiation therapy, are potential treatment modalities. Our aim was to determine the rate of pathologic N1/N2 disease in peripherally located clinical T1a N0 NSCLC and predictive factors for nodal metastasis. Methods A retrospective review of a prospective database (2000 to 2015) identified 1,342 patients with clinical T1a N0 NSCLC, and 914 (68%) underwent lobectomy. Among this group, 449 patients had peripherally located tumors and were deemed node negative by fluorodeoxyglucose-PET/CT scan. The relationship between clinicopathologic features and the PET maximal-standardized uptake value (SUVmax) of the primary tumor was investigated. Predictors for nodal metastasis were determined by multivariable logistic regression analysis. The receiver operating characteristic curve was used to assess the cutoff value of PET-SUVmax on the incidence of nodal metastasis. Results Nodal metastasis was detected in 9.6% (43 of 449) of the patients: 4.5% (n = 20) had pN1 and 5.1% (n = 23) had pN2 metastasis. The relationship between SUVmax and development of pathologic nodal metastasis was calculated using the receiver operating characteristic curve with cutoff point at SUVmax of 3.3. In multivariable analysis, PET-SUVmax exceeding 3.3 was the only independent predictor for N1/N2 metastasis ( p = 0.016). Disease-free survival showed a trend of poor survival for patients with nodal metastasis ( p = 0.068). Conclusions High PET-SUVmax of the primary tumor is associated with elevated risk of nodal disease for peripheral T1a N0 NSCLC patients. Further diagnostic procedures, such as endobronchial ultrasound, may be required, especially if wedge resection or stereotactic body radiation therapy are being considered.

The majority of patients with operable esophageal cancers present with locally advanced disease, for which surgical resection as a sole treatment modality has been historically associated with poor survival. Even following radical resection, most of these patients will eventually succumb to their disease due to distant metastasis. For this reason, there has been intense interest in the role of neoadjuvant therapy. Neoadjuvant therapy primarily consists of either chemotherapy, radiation therapy, or a combination of the two. Multiple studies of variable scope, design, and patient characteristics have been conducted to determine whether neoadjuvant therapy is warranted, and—if so—what is the best modality of treatment. Despite nearly three decades of study, decisions regarding neoadjuvant therapy for esophageal cancer remain controversial. Regardless, the available evidence provided by large, prospective studies supports preoperative chemotherapy as opposed to surgery alone. Therefore, in our opinion, there is no longer any question as to whether induction therapy is appropriate for locally advanced esophageal cancer. Less clear, however, is the evidence that the addition of radiation to chemotherapy in the preoperative setting is superior to neoadjuvant chemotherapy alone. Our group generally advocates for neoadjuvant chemotherapy alone followed by radical esophageal resection. The data for adjuvant therapy are soft, and particularly troubling is the high rate of treatment drop out in trials studying adjuvant therapy. Therefore, we strongly prefer neoadjuvant chemotherapy and reserve adjuvant chemotherapy for those rare, highly selected patients—patients with T1 tumors, for example—who do not receive neoadjuvant treatment and are found to have occult nodal disease at the time of surgery.

Surgery may be underused for stage IIIA non-small cell lung cancer. Although an argument can be made for definitive chemoradiation for N2/3 mediastinal nodal disease, the role of a nonsurgical strategy is less clear in patients with cT3N1M0 stage IIIA given a lack of randomized data. We sought to determine the outcomes of patients with cT3N1M0 by treatment type from the National Cancer Database.The National Cancer Database (2004-2014) was queried for patients with cT3N1M0 non-small cell lung cancer, known treatment modalities, and sequence. Comparisons between groups were performed using Mann-Whitney and chi-square tests. Cox regression was performed to identify predictors of overall survival. Propensity score matching analysis was performed to compare overall survival in surgery versus definitive chemoradiation.We identified 1937 patients undergoing surgery (1518 up-front and 419 after neoadjuvant treatment) and 1844 patients undergoing definitive chemoradiation. Among patients undergoing surgery without prior treatment, 19% were overstaged and were found to have pN0, whereas 9.6% had pN2/3. Median overall survival was 33.1 months in the surgery group (± adjuvant/neoadjuvant) versus 18 months in definitive chemoradiation. To compare outcomes in balanced groups, we propensity matched 1081 pairs of patients. Median overall survival was 31.1 months in the surgery group compared with 19.1 months in the definitive chemoradiation group (P .001). By multivariable analysis, surgery (hazard ratio, 0.65; confidence interval, 0.59-0.73), female sex (hazard ratio, 0.88; confidence interval, 0.79-0.98), age (hazard ratio, 1.02; confidence interval, 1.01-1.03), squamous histology (hazard ratio, 1.22; confidence interval, 1.07-1.38), and Charlson score of 2 (hazard ratio, 1.31; confidence interval, 1.11-1.54) were predictors of survival.In the National Cancer Database, approximately half of patients with clinical T3N1M0 were treated with definitive chemoradiation rather than surgery. This practice should be avoided in operable patients, because surgical resection is associated with better survival.

Our patient is a 58-year-old woman with metastatic uterine leiomyosarcoma with prior resection found to have an isolated metastatic lesion in the upper lobe of the right lung. She underwent a thoracotomy with right upper and middle lobectomy. After her procedure, she developed acute ischemia of her left lower extremity secondary to an embolized tumor. The patient was treated with thrombectomy and fasciotomy, and she recovered without loss of function of the limb. A literature review demonstrates that acute limb ischemia secondary to tumor emboli remains a rare but potentially devastating complication of metastatic disease.

Purpose Previous studies have reported that psychological and social distresses associated with a cancer diagnosis have led to an increase in suicides compared to the general population. We sought to explore lung cancer-associated suicide rates in a large national database compared to the general population, and to the three most prevalent non-skin cancers [breast, prostate and colorectal cancer (CRC)]. Methods The Surveillance, Epidemiology and End Results (SEER) database (1973–2013) was retrospectively reviewed to identify cancer-associated suicide deaths in all cancers combined, as well as for each of lung, prostate, breast or CRCs. Suicide incidence and standardised mortality ratio (SMR) were estimated using SEER*Stat-8.3.2 program. Suicidal trends over time and timing from cancer diagnosis to suicide were estimated for each cancer type. Results Among 3,640,229 cancer patients, 6,661 committed suicide. The cancer-associated suicide rate was 27.5/100,000 person years (SMR = 1.57). The highest suicide risk was observed in patients with lung cancer (SMR = 4.17) followed by CRC (SMR = 1.41), breast cancer (SMR = 1.40) and prostate cancer (SMR = 1.18). Median time to suicide was 7 months in lung cancer, 56 months in prostate cancer, 52 months in breast cancer and 37 months in CRC (p < 0.001). We noticed a decreasing trend in suicide SMR over time, which is most notable for lung cancer compared to the other three cancers. In lung cancer, suicide SMR was higher in elderly patients (70–75 years; SMR = 12), males (SMR = 8.8), Asians (SMR = 13.7), widowed patients (SMR = 11.6), undifferentiated tumours (SMR = 8.6), small-cell lung cancer (SMR = 11.2) or metastatic disease (SMR = 13.9) and in patients who refused surgery (SMR = 13). Conclusion The cancer-associated suicide rate is nearly twice that of the general population of the United States of America. The suicide risk is highest among the patients with lung cancer, particularly elderly, widowed, male patients and patients with unfavourable tumour characteristics. The identification of high-risk patients is of extreme importance to provide proper psychological assessment, support and counselling to reduce these rates.

Since 1995, lobar resection became the standard of care for medically fit patients with early stage lung cancer. This was based on the results of a single randomized trial comparing lobectomy and sublobar resection (SLR) in stage I lung cancer conducted by the lung cancer study group between 1982 and 1988. The conclusions of the study included a statistically significant tripling in loco-regional recurrence (LR) after limited resection but no difference between the two arms of the trial in systemic recurrence. Although both overall survival and cancer specific survival favored lobectomy, neither achieved statistical significance. Regardless, this landmark trial established lobectomy as the preferred oncological resection for early stage lung cancer. The practice of thoracic surgery has evolved significantly since the study period of the Lung Cancer Study Group, and this has led some surgeons to question its relevance to contemporary practice. The increased detection of smaller more precisely staged tumors combined with the rising segment of the population that is elderly with limited cardiopulmonary reserve has renewed interest in sub-lobar resection including wedge resection as either a definitive therapeutic strategy or as a compromise approach in patients with poor performance status. The interest in wedge resections is also to some extent further fueled by the emergence and increased utilization of competing technologies of local control such as stereotactic radiation or percutaneous and trans-bronchial ablative techniques. Although the results of the LCSG still cast a long shadow over the soundness of wedge resection as a cancer operation, much literature has been published in the subsequent years on this topic. We present in this review an overview of the conflicting data and offer our perspective on the role of wedge resection in early stage lung cancer.

Recent studies have suggested that lobectomy and segmentectomy hold equivalent oncologic outcomes, particularly for small, peripheral, subsolid nodules. However, for hypermetabolic nodules that are frequently associated with high rates of nodal disease, recurrence, or mortality, the optimum oncologic procedure was not assessed. We hypothesize that for hypermetabolic, cT1 N0 adenocarcinoma, lobectomy and segmentectomy are associated with comparable outcomes.A prospectively collected database was queried for patients with clinical stage IA lung adenocarcinoma who underwent lobectomy or segmentectomy (2000 to 2016) for hypermetabolic tumors (maximum standard uptake value [SUVmax] ≥ 3g/dL). To obtain balanced groups of patients, a propensity matching analysis was done.A total of 414 patients had hypermetabolic tumors and underwent lobectomy or segmentectomy. Patients were propensity matched (4:1) (lobectomy: n = 156, segmentectomy: n = 46). Patients in the lobectomy group had a higher rate of pathologic nodal upstaging (17% versus 7%, p = 0.085) and a higher pathologic upstaging rate (38% versus 26%, p = 0.143) than the segmentectomy group. In addition, the lobectomy group had a higher number of resected lymph nodes than the segmentectomy group (median lymph nodes resected: 14 versus 7, p0.001). No differences were found in in 5-year recurrence-free survival (RFS; 72% versus 69%, p = 0.679) or in 5-year cancer-specific survival (CSS; 92% versus 83%, p = 0.557) between patients who underwent lobectomy or segmentectomy, respectively.Our data show that lobectomy and segmentectomy are comparable oncologic procedures for patients with carefully staged cT1 N0 lung adenocarcinoma with hypermetabolic tumors (SUVmax ≥ 3g/dL). Although lobectomy was associated with a more thorough lymph node dissection, this did not translate into a higher rate of RFS or CSS compared with segmentectomy.

Controversy exists over the optimal neoadjuvant therapy in patients with locally advanced esophageal cancer (EC). Although most groups favor neoadjuvant chemoradiation (nCRT), some prefer preoperative chemotherapy (nCT) without radiation. The objective of this study was to compare outcomes in EC patients undergoing either regimen, followed by surgery.We reviewed a prospectively collected database of EC patients undergoing esophagectomy after nCT or nCRT from 1989 to 2016. Choice of therapy was at the discretion of the multidisciplinary team. Disease-free survival (DFS) and cancer-specific survival (CSS) were compared by the Kaplan-Meier log-rank test. Independent predictors of CSS were estimated by Cox regression analysis.Among 700 EC patients 338 patients were treated with nCRT (n = 112) or nCT (n = 226) followed by surgery. Patients were well matched for age, gender, and clinical stage, although patients with squamous cell carcinoma were more likely to receive nCRT (49% vs 26%, p0.001). At surgery 90% and 91% of nCRT and nCT patients, respectively, underwent transthoracic esophagectomy. nCRT, in comparison with nCT, was associated with similar rates of Calvien-Dindo grade III/IV complications (34% vs 33%, p = 0.423) but with a trend toward higher perioperative mortality (5% vs 1%, p = 0.064). Among adenocarcinoma patients (n = 239) the use of nCRT was associated with higher rates of complete clinical response (18% vs 7.4%), pathologically negative lymph nodes (52% vs 30%, p = 0.001), and complete pathologic response (21% vs 5.1%, p0.001). However, there was no difference between nCRT and nCT for 5-year DFS (28% vs 31%, p = 0.636) or CSS (51% vs 52%, p = 0.824) among adenocarcinoma patients. For patients with squamous cell carcinoma (n = 98), nCRT and nCT had similar rates of complete clinical response (31% vs 26%, p = 0.205), but the rates of negative nodes (65% vs 46%, p = 0.064) and of complete pathologic response (42% vs 12%, p0.05) were higher with nCRT. For these patients nCRT was associated with no statistical difference in 5-year DFS (57% vs 40%, p = 0.595) but with improved 5-year CSS (87% vs 68%, p = 0.019) compared with nCT. On multivariable analysis for CSS, nCRT predicted improved survival for patients with squamous cell carcinoma (hazard ratio, 0.242; 95% confidence interval, 0.071-0.830) but not for those with adenocarcinoma (univariate hazard ratio, 0.940; 95% confidence interval, 0.544-1.623).For adenocarcinoma patients undergoing surgery for EC, nCRT leads to increased local tumor response compared with nCT alone but with no difference in survival. For squamous carcinoma patients nCRT appears to improve CSS compared with nCT. For patients with locally advanced EC targeted neoadjuvant regimens should be used depending on tumor histology.

Background Given the potential morbidity of esophagectomy, patients may pursue other treatments. We sought to determine predictors and outcomes of esophageal cancer patients who refused esophagectomy. Methods The National Cancer Database (2004 to 2014) was queried for locally advanced esophageal cancer patients. A unique field allows identification of patients recommended to have surgery but who refused. Comparisons between the entire cohort and between propensity matched groups were performed using analysis of variance and χ2 tests. Survival was compared using Kaplan-Meier curves. Logistic regression was performed to identify predictors of refusing surgery. Results We identified 18,459 patients with esophageal cancer meeting criteria, including 708 (3.8) who were recommended but refused surgery. By multivariate analysis, elderly, female, nonwhite race, squamous histology, early year of diagnosis, absence of insurance, treatment at nonacademic centers, lower income, and clinical stage I/II predicted refusal of surgery. Median survival was worse for patients who refused surgery compared with patients undergoing surgery. Among propensity matched groups (n = 525 each), median survival was better for patients undergoing surgery versus patients who refused (32 versus 21 months, p Conclusions Although patients may be reluctant to undergo esophagectomy for esophageal cancer, refusal of surgery when offered comes at the expense of decreased survival. These data allow for a discussion of alternative outcomes with those patients in the context of shared decision making.

Background Pulmonary carcinoid tumors are often considered indolent tumors. The prognostic significance of lymph node (LN) metastases and the need for mediastinal dissection is controversial. We sought to determine the incidence, risk factors, and prognosis of LN metastases in resected carcinoid patients. Methods Patients undergoing lung resection for carcinoid and removal of ≥10 LNs were identified in the National Cancer Database from 2004 to 2014. Typical (TCs) and atypical carcinoids (ACs) were included. Clinical and pathologic LN status was assessed. Overall survival (OS) was analyzed using log-rank test and Cox hazard regression analysis. Results A total of 3,335 patients (TC 2,893; AC 442), underwent resection (lobectomy/bilobectomy 84%, pneumonectomy 8%, sublobar resection 8%). LN involvement was present in 21% of patients (N1 15%, N2 6%) and increased with tumor size and AC histology. Tumor size was an independent predictor of LN disease. The rate of nodal upstaging was 13% (TC 11%, AC 24%). Independent predictors of OS were AC type (HR 3.25 [95% CI 2.19-4.78]) and LN metastases (HR 2.3 [1.49-3.58]). LN disease was associated with worse survival for TC > 2 cm (5-year OS 87% versus 94%, p = 0.005) and AC (58% versus 88%, p = 0.001), but not for small (≤ 2 cm) TC patients (5-year OS 93% versus 92%, p = 0.67). Conclusions A substantial number of well-staged carcinoid patients had LN metastases. Large tumor size is a valuable predictor of carcinoid nodal disease. LN involvement was an independent predictor of worse survival. Nodal dissection in tumors > 2 cm and in atypical subtype can yield important prognostic information.

OBJECTIVES Historically, surgical resection has been the mainstay of treatment for T1N0 oesophageal cancer (OC). More recently, oesophageal sparing endoscopic techniques have shown value for local control in a large institutional series. However, the effect of their utilization upon survival rates in large population series is largely unknown. METHODS The surveillance, epidemiology, and end results (SEER) database was queried for T1N0M0-OC patients (1988-2013). Patients with multiple treatment types were excluded. Time periods were divided by 5-year increments. Overall survival and cancer-specific survival (CSS) were compared in the group as a whole and in propensity-matched subgroups. Independent predictors of cancer-specific mortality were studied by the Cox proportional hazard models. RESULTS We identified 5497 patients with cT1N0M0 OC. Treatment modalities used were changed significantly over time. The ratio of oesophagectomy when compared with local therapy decreased from 15:1 in 1998-92 to 1.4:1 in 2008-13. The proportion of patients treated with radiation slightly increased (35% vs 41%) between 1988-92 and 2008-13. In the propensity-matched groups, 5-year CSS was similar in patients treated with oesophagectomy and local therapy (81% vs 89%; P = 0.257) (n = 216 in each group), whereas oesophagectomy had superior 5-year CSS compared with radiation alone (73% vs 38%; P

The treatment of esophageal perforation (EP) remains a significant clinical challenge. While a number of investigators have previously documented efficient approaches, these were mostly single-center experiences reported prior to the introduction of newer technologies: specifically endoluminal stents. This study was designed to document contemporary practice in the diagnosis and management of EP at multiple institutions around the world and includes early clinical outcomes. A five-year (2009-2013) multicenter retrospective review of management and outcomes for patients with thoracic or abdominal esophageal perforation was conducted. Demographics, etiology, diagnostic modalities, treatments, subsequent early outcomes as well as morbidity and mortality were captured and analyzed. During the study period, 199 patients from 10 centers in the United States, Canada, and Europe were identified. Mechanisms of perforation included Boerhaave syndrome (60, 30.1%), iatrogenic injury (65, 32.6%), and penetrating trauma (25, 12.6%). Perforation was isolated to the thoracic segment alone in 124 (62.3%), with 62 (31.2%) involving the thoracoabdominal esophagus. Mean perforation length was 2.5 cm. Observation was selected as initial management in 65 (32.7%), with only two failures. Direct operative intervention was initial management in 65 patients (32.6%), while 29 (14.6%) underwent esophageal stent coverage. Compared to operative intervention, esophageal stent patients were significantly more likely to be older (61.3 vs. 48.3 years old, P < 0.001) and have sustained iatrogenic mechanisms of esophageal perforation (48.3% vs.15.4%). Secondary intervention requirement for patients with perforation was 33.7% overall (66). Complications included sepsis (56, 28.1%), pneumonia (34, 17.1%) and multi-organ failure (23, 11.6%). Overall mortality was 15.1% (30). In contemporary practice, diagnostic and management approaches to esophageal perforation vary widely. Despite the introduction of endoluminal strategies, it continues to carry a high risk of mortality, morbidity, and need for secondary intervention. A concerted multi-institutional, prospectively collected database is ideal for further investigation.

There is an author's name misspelled in the published paper, Shyam Varadarajula should be Shyam Varadarajulu.

Sublobar resection (SLR) is an alternative to lobectomy for early non-small cell lung cancer. Comparative effectiveness of these 2 approaches might be modified by the extent of lymph node dissection.We utilized the Surveillance, Epidemiology, and End Results Program-Medicare dataset to identify patients with stage I non-small cell lung cancer aged 66 years or older with tumor size ≤2 cm. We compared patient characteristics with t tests for continuous variables and χAmong 2757 lobectomies and 1229 SLR procedures performed for stage I tumors ≤2 cm, we propensity-matched 1124 patients from each group. Patients undergoing SLR were more likely to have no lymph nodes sampled (46.9% vs 6.4%; P .001). OS (hazard ratio [HR], 1.48; 95% confidence interval [CI], 1.29-1.69) and CSS (HR, 2.06; 95% CI, 1.41-3.02) were worse following SLR. When propensity-matched cohorts of patients with at least 1 lymph node removed (n = 567 each group) were examined, the HRs for survival for SLR decreased (OS HR, 1.38; 95% CI, 1.12-1.69; CSS HR, 1.58; 95% CI, 0.97-2.57). Finally, when cohorts were propensity matched for ≥9 lymph nodes examined (n = 103 each group), there was no difference in OS (HR, 0.84; 95% CI, 0.50-1.39) or CSS (HR, 1.10; 95% CI, 0.35-3.41).SLR leads to fewer lymph node removed and is associated with inferior survival compared with lobectomy. A more extensive lymphadenectomy may be associated with equivalent survival between matched patients undergoing SLR and lobectomy.

Introduction Surgical data from the National Lung Screening Trial (NLST) has yet to be closely examined. We sought to analyze surgical procedures and complications from the NLST to determine their relevance to modern surgical practice. Methods The NLST database was queried for patients who underwent surgical resection for confirmed lung cancer, specifically evaluating postoperative complications. Numerical variables were compared using the Mann–Whitney U test. Categorical variables were compared using the χ2 test. Logistic regression uni- and multivariable analysis of independent risk factors of postoperative complications was performed. Results At operation, 80% of patients (n = 821) had lobectomy, 4.1% (n = 42) had pneumonectomy, and 16.1% (n = 166) had sublobar resection, among whom 69% (n = 114) had wedge resection. Only 29.6% (n = 305) of the cohort had a thoracoscopic resection. Although the overall rate of surgical patients with any complication was 31% (n = 318), only 15.5% of patients (n = 160) had major complications, most commonly prolonged air leaks (n = 67, 6.5%). Respiratory failure (n = 28, 2.7%), prolonged ventilation (n = 9, 0.9%), myocardial infarction or cardiac arrest (n = 7, 0.7%), and stroke (n = 2, 0.2%) were rare events. Overall 30-day mortality in patients undergoing resection was 1.7% (n = 18). On multivariable analysis, greater smoking pack history (odds ratio [OR], 1.01; 95% confidence interval [CI], 1.001-1.01) and pulmonary comorbidities (OR, 1.34; 95% CI, 0.98-1.82) were significant or approached significance for an association with complications/death, whereas sublobar resection (OR, 0.59; 95% CI, 0.38-0.94) and video-assisted thoracoscopic surgery approach (OR, 0.76; 95% CI, 0.56-1.04) were significant or approached significance for an association with decreased rates of complications/death. Conclusions Operative mortality and postoperative morbidity were very low in patients undergoing resection for screen-detected lung cancer. Increased use of sublobar resection and minimally invasive surgical approaches may be associated with fewer complications.