RESUMEN
BACKGROUND: The National Comprehensive Cancer Network guidelines recommend consideration of surgery for clinical T4a esophageal adenocarcinoma. There are limited data on the outcomes of patients with T4a adenocarcinoma treated with surgery vs definitive chemoradiation, however. METHODS: The National Cancer Database was used to identify patients from 2010-2015 with clinical T4aN0-3M0 esophageal adenocarcinoma, and grouped by receipt of surgery (with or without perioperative therapy) or definitive, concurrent chemoradiation. Patients receiving incomplete definitive therapy or with missing survival information were excluded. Overall survival was evaluated with Kaplan-Meier and Cox proportional hazard analyses. RESULTS: Of 182 patients in the study, 85 (47%) underwent esophagectomy and 97 (53%) underwent chemoradiation. In the surgery cohort, 79 patients (93%) received perioperative chemotherapy. Unadjusted and multivariable analyses demonstrated a significant survival benefit associated with surgery compared with definitive chemoradiotherapy (adjusted hazard ratio 0.32; 95% confidence interval 0.21, 0.50). A 1:1 propensity score-matched analysis of 63 patient pairs also revealed a significant overall survival benefit with surgery compared with chemoradiotherapy alone (hazard ratio 0.26; 95% confidence interval 0.16, 0.43). CONCLUSIONS: In this national analysis, surgery for cT4a esophageal adenocarcinoma was associated with improved outcomes when compared with definitive chemoradiation. Surgery should be considered for medically fit patients with cT4aN0-3M0 esophageal adenocarcinoma.
Asunto(s)
Adenocarcinoma/terapia , Neoplasias Esofágicas/terapia , Esofagectomía/métodos , Estadificación de Neoplasias , Vigilancia de la Población , Adenocarcinoma/diagnóstico , Adenocarcinoma/mortalidad , Anciano , Quimioradioterapia , Neoplasias Esofágicas/diagnóstico , Neoplasias Esofágicas/mortalidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Terapia Neoadyuvante , Pronóstico , Puerto Rico/epidemiología , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Current guidelines do not routinely recommend adjuvant therapy for resected stage I large cell lung neuroendocrine cancer (LCNEC). However, data regarding the role of adjuvant therapy in early LCNEC are limited. This National Cancer Database (NCDB) analysis was performed to improve the evidence guiding adjuvant therapy for early LCNEC. METHODS: Overall survival (OS) of patients with pathologic T1-2a N0 M0 LCNEC who underwent resection in the NCDB from 2003 to 2015 was evaluated with Kaplan-Meier and multivariable Cox proportional hazards analyses. Patients who died within 30 days of surgery and with more than R0 resection were excluded. RESULTS: Of 2642 patients meeting study criteria, 481 (18%) received adjuvant therapy. Adjuvant chemotherapy in stage IB patients was associated with a significant increase in OS (hazard ratio, 0.67; 95% confidence interval, 0.50 to 0.90). However, there was no significant difference in survival between adjuvant chemotherapy and no adjuvant therapy for stage IA LCNEC (hazard ratio, 0.92; 95% confidence interval, 0.75 to 1.11). Adjuvant radiotherapy, whether alone or combined with chemotherapy, was not associated with a change in OS. In subgroup analysis, patients receiving adjuvant chemotherapy after lobar resection for stage IB LCNEC had a significant survival benefit compared with patients not receiving adjuvant therapy. CONCLUSIONS: In early-stage LCNEC, adjuvant chemotherapy appears to confer an additional overall survival advantage only in patients with completely resected stage IB LCNEC and not for patients with completely resected stage IA LCNEC.
Asunto(s)
Antineoplásicos/uso terapéutico , Carcinoma de Células Grandes/terapia , Carcinoma Neuroendocrino/terapia , Neoplasias Pulmonares/terapia , Estadificación de Neoplasias , Neumonectomía/métodos , Anciano , Carcinoma de Células Grandes/diagnóstico , Carcinoma de Células Grandes/mortalidad , Carcinoma Neuroendocrino/diagnóstico , Carcinoma Neuroendocrino/mortalidad , Quimioterapia Adyuvante , Femenino , Estudios de Seguimiento , Humanos , Neoplasias Pulmonares/diagnóstico , Neoplasias Pulmonares/mortalidad , Masculino , Persona de Mediana Edad , Puerto Rico/epidemiología , Radioterapia Adyuvante , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
OBJECTIVE: The objective of this study was to compare the long-term survival of open versus thoracoscopic (VATS) lobectomy for early stage non-small-cell lung cancer (NSCLC). BACKGROUND: Data from national studies on long-term survival for VATS versus open lobectomy are limited. METHODS: Outcomes of patients who underwent open versus VATS lobectomy for clinical T1-2, N0, M0 NSCLC in the National Cancer Data Base were evaluated using propensity score matching. RESULTS: The median follow-up of 7114 lobectomies (5566 open and 1548 VATS) was 52.0 months. The VATS approach was associated with a better 5-year survival when compared to the open approach (66.0% vs. 62.5%, P = 0.026). Propensity score matching resulted in 1464 open and 1464 VATS patients who were well matched by 14 common prognostic covariates including tumor size and comorbidities. After propensity score matching, the VATS approach was associated with a shorter median length of stay (5 vs. 6 days, P < 0.001). The VATS approach was not significantly different compared with the open approach with regard to nodal upstaging (11.6% vs 12.3%, P = 0.53), 30-day mortality (1.7% vs 2.3%, P = 0.50) and 5-year survival (66.3% vs 65.8%, P = 0.92). CONCLUSIONS: In this national analysis, VATS lobectomy was used in the minority of patients with stage I NSCLC. VATS lobectomy was associated with shorter length of stay and noninferior long-term survival when compared with open lobectomy. These results support previous findings from smaller single- and multi-institutional studies that suggest that VATS does not compromise oncologic outcomes when used for early-stage lung cancer and suggest the need for broader implementation of VATS techniques.
Asunto(s)
Carcinoma de Pulmón de Células no Pequeñas/mortalidad , Neoplasias Pulmonares/mortalidad , Estadificación de Neoplasias , Neumonectomía/métodos , Puntaje de Propensión , Cirugía Torácica Asistida por Video/métodos , Anciano , Biopsia , Carcinoma de Pulmón de Células no Pequeñas/diagnóstico , Carcinoma de Pulmón de Células no Pequeñas/cirugía , Bases de Datos Factuales , Femenino , Estudios de Seguimiento , Humanos , Neoplasias Pulmonares/diagnóstico , Neoplasias Pulmonares/cirugía , Masculino , Persona de Mediana Edad , Periodo Posoperatorio , Puerto Rico/epidemiología , Estudios Retrospectivos , Tasa de Supervivencia/tendencias , Factores de Tiempo , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
OBJECTIVES: The purpose of this study was to determine the optimal timing of surgical resection of oesophageal adenocarcinoma following neoadjuvant chemoradiotherapy (nCRT). METHODS: nCRT before resection of oesophageal adenocarcinoma yields improved overall and progression-free survival. Despite the wide acceptance of tri-modal therapy, the optimal timing of surgical resection after nCRT is not well defined and existing studies are limited. Adults with Stage II/III oesophageal adenocarcinoma undergoing nCRT before surgery were identified from the National Cancer Database. Multivariable analysis using restricted cubic splines was used to identify an inflection point in clinical outcomes as a function of time between nCRT and surgery, dividing the cohort into short- and long-interval treatment groups, which were then compared. Adjusted rates of survival and margin status were compared between groups using multivariable analysis. RESULTS: Among 2444 patients, restricted cubic splines identified an inflection point at 56 days, dividing our cohort into 1533 short-interval and 911 long-interval patients. Long-interval patients had a higher adjusted incidence of pathologic downstaging (odds ratio 1.38, confidence interval 1.02-1.85, P = 0.04) but no difference in margin positivity compared with short-interval patients (odds ratio 0.91, confidence interval 0.56-1.47, P = 0.69). Worse overall survival was noted in the long-interval subgroup (hazard ratio 1.44, confidence interval 1.22-1.71, P < 0.001), but 30-day postoperative mortality was not statistically different (odds ratio 1.56, confidence interval 0.9-2.72, P = 0.12). CONCLUSIONS: Restricted cubic splines provides an objective mechanism to more accurately delineate optimum timing between nCRT and surgical resection. A time interval of 56 days represents an interval where increased pathologic downstaging is balanced by decreased overall survival.
Asunto(s)
Adenocarcinoma/terapia , Neoplasias Esofágicas/terapia , Esofagectomía/métodos , Estadificación de Neoplasias , Adenocarcinoma/diagnóstico , Adenocarcinoma/mortalidad , Anciano , Quimioradioterapia Adyuvante , Supervivencia sin Enfermedad , Neoplasias Esofágicas/diagnóstico , Neoplasias Esofágicas/mortalidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Terapia Neoadyuvante , Puerto Rico/epidemiología , Tasa de Supervivencia/tendencias , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Previous studies have raised concerns that video-assisted thoracoscopic (VATS) lobectomy may compromise nodal evaluation. The advantages or limitations of robotic lobectomy have not been thoroughly evaluated. METHODS: Perioperative outcomes and survival of patients who underwent open versus minimally-invasive surgery (MIS [VATS and robotic]) lobectomy and VATS versus robotic lobectomy for clinical T1-2, N0 non-small cell lung cancer from 2010 to 2012 in the National Cancer Data Base were evaluated using propensity score matching. RESULTS: Of 30,040 lobectomies, 7,824 were VATS and 2,025 were robotic. After propensity score matching, when compared with the open approach (n = 9,390), MIS (n = 9,390) was found to have increased 30-day readmission rates (5% versus 4%, p < 0.01), shorter median hospital length of stay (5 versus 6 days, p < 0.01), and improved 2-year survival (87% versus 86%, p = 0.04). There were no significant differences in nodal upstaging and 30-day mortality between the two groups. After propensity score matching, when compared with the robotic group (n = 1,938), VATS (n = 1,938) was not significantly different from robotics with regard to nodal upstaging, 30-day mortality, and 2-year survival. CONCLUSIONS: In this population-based analysis, MIS (VATS and robotic) lobectomy was used in the minority of patients for stage I non-small cell lung cancer. MIS lobectomy was associated with shorter length of hospital stay and was not associated with increased perioperative mortality, compromised nodal evaluation, or reduced short-term survival when compared with the open approach. These results suggest the need for broader implementation of MIS techniques.