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OBJECTIVE: Robotic-assisted minimally invasive esophagectomy accounts for a growing proportion of esophagectomies, potentially due to improved technical capabilities simplifying the challenging aspects of standard minimally invasive esophagectomy. However, there is limited evidence directly comparing both operations. The objective is to evaluate the short-term and long-term outcomes of robotic-assisted minimally invasive esophagectomy in comparison with the minimally invasive esophagectomy approach for patients with esophageal cancer over a 7-year period at a high-volume center. The primary end points of this study were overall survival and disease-free survival. Secondary end points included operation-specific morbidity, lymph node yield, readmission status, and in-hospital, 30-day, and 90-day mortality. METHODS: Patients who underwent robotic-assisted minimally invasive esophagectomy or standard minimally invasive esophagectomy over a 7-year period were identified from a prospectively maintained database. Inclusion criteria were patients with stage I to III disease, operations performed past the learning curve, and no evidence of scleroderma or cirrhosis. A 1:3 propensity match (robotic-assisted minimally invasive esophagectomy:minimally invasive esophagectomy) for multiple clinical covariates was performed to identify the final study cohort. Perioperative outcomes were compared between the 2 operations. RESULTS: A total of 734 patients undergoing minimally invasive esophagectomy (n = 630) or robotic-assisted minimally invasive esophagectomy (n = 104) for esophageal cancer were identified. After exclusions and matching, a total cohort of 246 patients undergoing robotic-assisted minimally invasive esophagectomy (n = 65) or minimally invasive esophagectomy (n = 181) were identified. There was no difference in overall survival (P = .69) or disease-free survival (P = .70). There were no significant differences in rates of major morbidity: pneumonia (17% vs 17%, P = .34), chylothorax (8% vs 9%, P = .95), recurrent laryngeal nerve injury (0% vs 1.5%, P = 1), anastomotic leak (5% vs 4%, P = .49), intraoperative complications (9% vs 8%, P = .73), or complete resection rates (99% vs 96%, P = .68). There was no difference in in-hospital (P = .89), 30-day (P = .66) or 90-day mortality (P = .73) between both cohorts. The robotic-assisted minimally invasive esophagectomy cohort yielded a higher median lymph node harvest in comparison with the minimally invasive esophagectomy cohort (32 vs 29, P = .02). CONCLUSIONS: Robotic-assisted minimally invasive esophagectomy may improve lymphadenectomy in patients undergoing esophagectomy for cancer. Minimally invasive esophagectomy and robotic-assisted minimally invasive esophagectomy are otherwise associated with similar mortality, morbidity, and perioperative outcomes. Further prospective study is required to investigate whether improved lymph node resection may translate to improved oncologic outcomes.
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Neoplasias Esofágicas , Procedimentos Cirúrgicos Robóticos , Humanos , Esofagectomia/efeitos adversos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Resultado do Tratamento , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Neoplasias Esofágicas/patologia , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Estudos RetrospectivosRESUMO
OBJECTIVES: Pulmonary sarcomatoid carcinoma (PSC) is a rarely occurring variant of non-small cell lung cancer with sarcoma-like features. Compared with traditional non-small cell lung cancer, PSC patients typically present later and have poorer prognoses, irrespective of stage. The standard of care is resection, but guidelines for the use of adjuvant chemotherapy have not been established. To advance the development of evidence-based management algorithms for PSC after resection, a statistical analysis on a nationwide representative sample of patients was performed. METHODS: A retrospective cohort study was performed by querying the National Cancer Database for patients with a diagnosis of PSC between 2004 and 2015. Patients who received complete anatomical resection with or without adjuvant chemotherapy were included. Multivariable regression was used to detect factors associated with the receipt of adjuvant chemotherapy. Multivariable Cox regression of overall survival and Kaplan-Meier survival analysis on propensity-matched groups was conducted to study the association between adjuvant chemotherapy and prognosis. RESULTS: We included 1497 patients with PSC in the final analysis. Factors associated with receiving adjuvant chemotherapy were age, histology, and receipt of adjuvant radiation. The results of multivariable Cox analysis and Kaplan-Meier analysis on propensity matched groups yielded similar trends: adjuvant chemotherapy was associated with improved 5-year overall survival for stage II and III disease, but not for stage I disease. CONCLUSIONS: Multiple factors are associated with receipt of adjuvant chemotherapy for PSC, and this treatment appears to be associated with improved survival in stage II and stage III, but not stage I patients.
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Carcinoma Pulmonar de Células não Pequenas , Carcinoma , Neoplasias Pulmonares , Carcinoma/tratamento farmacológico , Carcinoma/patologia , Carcinoma/cirurgia , Carcinoma Pulmonar de Células não Pequenas/tratamento farmacológico , Quimioterapia Adjuvante , Humanos , Neoplasias Pulmonares/tratamento farmacológico , Estadiamento de Neoplasias , Estudos RetrospectivosRESUMO
BACKGROUND: The primary curative treatment for thymic malignancies is surgery. For lung and esophageal cancer, substantive disparities in outcomes by race exist. Many of these disparities are attributed to the decreased use of surgery in non-White patients. Although thymic malignancies are treated by the same specialists as lung and esophageal cancer, it is unknown if there are racial disparities in the treatment of thymic malignancies. RESEARCH QUESTION: Do racial disparities exist in the surgical treatment of thymic malignancies? STUDY DESIGN AND METHODS: A retrospective cohort analysis was performed using the National Cancer Data Base of patients diagnosed with thymoma and thymic carcinoma between 2004 and 2016. Univariate comparisons of demographics were compared using χ 2 and rank-sum tests. Multivariable analysis was performed to determine if race was an independent variable associated with receiving surgical resection. Preoperative and postoperative care was compared between races. RESULTS: Seven thousand four hundred eighty-nine patients met inclusion criteria. Four thousand nine hundred sixty-two (66%) were White, 1,311 (18%) were Black, 487 (7%) were Hispanic, 580 (8%) were Asian or Pacific Islander, and 143 (2%) were other races. Black patients with thymic malignancies were more likely to have a median income < $38,000 and not received surgery. Black and Hispanic patients had the lowest median age (54.3 and 53.6 years, respectively) and were most likely to be uninsured (8.2% and 12.5%, respectively). White patients received surgical therapy 1 week sooner and had a postoperative length of stay 1.5 days shorter than Black patients. Multivariable analysis controlling for age, sex, tumor size, insurance status, comorbidity score, histology, and facility type showed that race remained independently associated with the receipt of surgical resection. White patients had the greatest likelihood of receiving surgery with Black patients being least likely to receive surgery (OR, 0.60). INTERPRETATION: A racial disparity exists in surgical therapy for thymic malignancies.
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Disparidades em Assistência à Saúde/etnologia , Neoplasias do Timo/etnologia , Neoplasias do Timo/cirurgia , Adulto , Idoso , Bases de Dados Factuais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Estados UnidosRESUMO
OBJECTIVES: There is a strong association with improved survival for patients with non-small cell lung cancer (NSCLC) who have developed a pathological complete response (pCR) after neoadjuvant therapy. A national database was used to investigate factors associated with long-term survival in this cohort of patients. PATIENTS: Retrospective review was completed of the National Cancer Database of patients who obtained pCR and had neoadjuvant therapy for stage I to stage III NSCLC between 2004 and 2014. All patients had neoadjuvant chemotherapy with or without radiation therapy. METHODS: Univariate and multivariable analysis was performed on factors associated with overall survival (OS), including gender, clinical stage, and nodal count. Patients were divided into 2 groups based on the Commission on Cancer-recommended median number of lymph nodes (LNs) examined: 0 to 9 LNs and ≥10 LNs. Chi-square and Wilcoxon rank-sum tests were used to compare patient, hospital, and clinical variables between groups. RESULTS: Increased age (hazard ratio [HR] 1.02, 95% confidence interval [CI], 1.00-1.03), neoadjuvant radiation therapy (HR 1.48, 95% CI, 1.10-2.00), and pneumonectomy (HR 1.64, 95% CI, 1.22-2.22) were associated with worse survival in the 759-patient cohort. Multivariable regression demonstrated having ≥10 nodes harvested (HR 0.71, 95% CI, 0.56-0.89) was associated with improved survival as was every increase in LN harvest up to 17 LNs. No significant differences in 5-year OS were found between clinical stage I, II, and III, respectively (66.1% vs. 60.9% vs. 58.6%, P = .288). CONCLUSION: This study shows that younger age, increasing LN harvest, female sex, the absence of neoadjuvant radiation therapy and non-pneumonectomy resections are all associated with improved OS in patients with NSCLC who have developed pCR.
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Adenocarcinoma de Pulmão/mortalidade , Carcinoma Pulmonar de Células não Pequenas/mortalidade , Carcinoma de Células Escamosas/mortalidade , Neoplasias Pulmonares/mortalidade , Terapia Neoadjuvante/mortalidade , Pneumonectomia/mortalidade , Adenocarcinoma de Pulmão/patologia , Adenocarcinoma de Pulmão/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Carcinoma Pulmonar de Células não Pequenas/patologia , Carcinoma Pulmonar de Células não Pequenas/terapia , Carcinoma de Células Escamosas/patologia , Carcinoma de Células Escamosas/terapia , Terapia Combinada , Feminino , Seguimentos , Humanos , Neoplasias Pulmonares/patologia , Neoplasias Pulmonares/terapia , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Taxa de SobrevidaRESUMO
BACKGROUND: Segmentectomy for well-selected early stage non-small-cell lung carcinoma (NSCLC) has been shown to have similar oncologic outcomes and survival to lobectomy. However, these data are based on the presumption that the disease is node negative. Few data exist regarding the risk factors for and the outcomes of patients with disease treated with segmentectomy that is found to be node positive. We sought to determine the risk factors for and outcomes of clinical stage I NSCLC patients who are treated with segmentectomy but are determined to be node positive. PATIENTS AND METHODS: We queried patients with clinical stage I NSCLC ≤ 3 cm within the National Cancer Data Base between 2004 and 2014 who were treated with segmentectomy or lobectomy and found to have positive nodes. Kaplan-Meier curves with log-rank tests were used to compare overall survival (OS) between segmentectomy and lobectomy. For comparison only, segmentectomy patients with pathologically node-negative disease were identified to determine predictors of node positivity after segmentectomy via multivariable logistic regression. RESULTS: A total of 4556 patients with node-positive disease were identified, comprising 115 segmentectomy patients and 4441 lobectomy patients. Multivariable analysis identified increasing tumor size, squamous-cell histology, and increasing number lymph nodes sampled as significant predictors of node positivity after segmentectomy. There was no difference in OS between segmentectomy and lobectomy, with 3-year OS rates of 66.3% and 68.1%, respectively (P = .723). CONCLUSION: There are discrete risk factors for discovering positive nodes after segmentectomy. Segmentectomy is associated with similar OS compared to lobectomy for clinical stage I NSCLC found to be node positive.
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Carcinoma Pulmonar de Células não Pequenas/cirurgia , Neoplasias Pulmonares/cirurgia , Linfonodos/patologia , Pneumonectomia/métodos , Idoso , Carcinoma Pulmonar de Células não Pequenas/mortalidade , Carcinoma Pulmonar de Células não Pequenas/patologia , Feminino , Humanos , Neoplasias Pulmonares/mortalidade , Neoplasias Pulmonares/patologia , Linfonodos/cirurgia , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Fatores de Risco , Análise de Sobrevida , Resultado do Tratamento , Carga TumoralRESUMO
OBJECTIVES: Computed tomography-guided fine needle aspiration (CT-FNA) biopsy is a well-established diagnostic technique in the evaluation of lung nodules that is performed by radiologists in most centers. In this series, we analyzed the diagnostic and perioperative outcomes following CT-FNA performed by a dedicated group of thoracic surgeons. METHODS: We conducted a retrospective analysis of 955 patients undergoing CT-FNA by the thoracic surgery service. Primary outcome variables included diagnostic yield and accuracy, number of needle passes, complication rates, and adequacy of specimen for molecular testing. RESULTS: A satisfactory diagnostic specimen was obtained in 94.1% of cases. The average number of needle passes was 3.2 ± 1.5 (range, 1-10 passes). Diagnostic yield was significantly improved by increasing the number of passes from 1 to 2 to 3 passes (P = .0003). CT-FNA diagnostic accuracy was 88.8%. Diagnostic accuracy did not significantly improve with ≥4 passes (P = .20). Molecular testing was successful in 43.1%, and did not improve with ≥4 passes (P = .5). Molecular testing success did improve with the addition of core needle biopsy (P = .005). The pneumothorax rate for CT-FNA alone was 26.4%, and increased with ≥4 passes (P = .009). The median length of stay for CT-FNA alone was 0 days (range, 0-74 days), with same-day discharge in 67.5% of patients. CONCLUSIONS: Thoracic surgeons can perform CT-FNA with excellent diagnostic yield and accuracy. Diagnostic yield, accuracy, and success in molecular testing do not improve with ≥4 CT-FNA passes. Pneumothorax rates do increase with ≥4 passes. The addition of core needle biopsy enhances success with molecular testing.
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OBJECTIVE: Prolonged air leak increases costs and worsens outcomes after pulmonary resection. We aimed to develop a clinical prediction tool for prolonged air leak using pretreatment and intraoperative variables. METHODS: Patients who underwent pulmonary resection for lung cancer/nodules (from January 2009 to June 2014) were stratified by prolonged parenchymal air leak (>5 days). Using backward stepwise logistic regression with bootstrap resampling for internal validation, candidate variables were identified and a nomogram risk calculator was developed. RESULTS: A total of 2317 patients underwent pulmonary resection for lung cancer/nodules. Prolonged air leak (8.6%, n = 200) was associated with significantly longer hospital stay (median 10 vs 4 days; P < .001). Final model variables associated with increased risk included low percent forced expiratory volume in 1 second, smoking history, bilobectomy, higher annual surgeon caseload, previous chest surgery, Zubrod score >2, and interaction terms for right-sided thoracotomy and wedge resection by thoracotomy. Wedge resection, higher body mass index, and unmeasured percent forced expiratory volume in 1 second were protective. Derived nomogram discriminatory accuracy was 76% (95% confidence interval [CI], 0.72-0.79) and facilitated patient stratification into low-, intermediate- and high-risk groups with monotonic increase in observed prolonged air leaks (2.0%, 8.9%, and 19.2%, respectively; P < .001). Patients at intermediate and high risk were 4.80 times (95% CI, 2.86-8.07) and 11.86 times (95% CI, 7.21-19.52) more likely to have prolonged air leak compared with patients at low risk. CONCLUSIONS: Using readily available candidate variables, our nomogram predicts increasing risk of prolonged air leak with good discriminatory ability. Risk stratification can support surgical decision making, and help initiate proactive, patient-specific surgical management.