David B. Nelson

Long-term survival outcomes of cancer-directed surgery for malignant pleural mesothelioma: Propensity score matching analysis

Purpose Small observational studies have shown a survival advantage to undergoing cancer-directed surgery for malignant pleural mesothelioma (MPM); however, it is unclear if these results are generalizable. Our purpose was to evaluate survival after treatment of MPM with cancer-directed surgery and to explore the effect surgery interaction with chemotherapy or radiation therapy on survival by using the National Cancer Database. Patients and Methods Patients with microscopically proven MPM were identified within the National Cancer Database (2004 to 2014). Propensity score matching was performed 1:2 and among this cohort, a Cox proportional hazards regression model was used to identify predictors of survival. Median survival was calculated by using the Kaplan-Meier method. Results Of 20,561 patients with MPM, 6,645 were identified in the matched cohort, among whom 2,166 underwent no therapy, 2,015 underwent chemotherapy alone, 850 underwent cancer-directed surgery alone, 988 underwent surgery with chemotherapy, and 274 underwent trimodality therapy. The remaining 352 patients underwent another combination of surgery, radiation, or chemotherapy. Thirty-day and 90-day mortality rates were 6.3% and 15.5%. Cancer-directed surgery, chemotherapy, and radiation therapy were independently associated with improved survival (hazard ratio, 0.77, 0.74, and 0.88, respectively). Stratified analysis revealed that surgery-based multimodality therapy demonstrated an improved survival compared with surgery alone, with no significant difference between surgery-based multimodality therapies; however, the largest estimated effect was when cancer-directed surgery, chemotherapy, and radiation therapy were combined (hazard ratio, 0.52). For patients with the epithelial subtype who underwent trimodality therapy, median survival was extended from 14.5 months to 23.4 months. Conclusion MPM is an aggressive and rapidly fatal disease. Surgery-based multimodality therapy was associated with improved survival and may offer therapeutic benefit among carefully selected patients.

Outcomes after endoscopic mucosal resection or esophagectomy for submucosal esophageal adenocarcinoma

Objectives: Endoscopic mucosal resection (EMR) is a diagnostic and potentially therapeutic option for patients with submucosal esophageal adenocarcinoma. However, there are significant concerns regarding the risk of lymph node metastasis. Our purpose was to construct a comparative effectiveness analysis comparing recurrence patterns after therapeutic EMR or esophagectomy. Methods: Patients who underwent therapeutic EMR or esophagectomy from 2007 to 2015 with pathologically staged submucosal adenocarcinoma were identified from a departmental database. Cancer‐related outcomes were compared among an unmatched as well as a propensity matched cohort. Risk stratification was also used to compare results among those with a low, medium, or high risk of nodal metastasis. Results: Seventy‐two patients met criteria for analysis, among whom 23 underwent therapeutic EMR with esophageal preservation and 49 underwent esophagectomy. Median follow‐up was 43 months. Patients who underwent esophagectomy had larger, deeper tumors. Esophageal preservation was associated with an increased risk of local recurrence (P = .01), but not distant recurrence (P = .44). After propensity matching, there continued to be no difference in distant recurrence rate (P = .66). In a risk‐stratified analysis, low‐risk patients showed no recurrences or cancer‐related deaths, however, high‐risk patients showed a trend toward increased distant recurrence after therapeutic EMR. Conclusions: Esophageal preservation after therapeutic EMR was associated with an increased risk of local recurrence. Among low‐risk patients, either strategy resulted in excellent cancer control. However, among high‐risk patients, esophageal preservation showed a trend toward increased distant failure. These findings should prompt further investigation to determine optimal treatment for patients with submucosal esophageal adenocarcinoma.

Clinicoradiographic Predictors of Aggressive Biology in Lung Cancer with Ground Glass Components

BACKGROUNDnGround glass opacities pose diagnostic challenges, and even after malignancy is confirmed, prognosis is often unclear. We sought to identify clinicoradiographic features that could predict aggressive tumor biology in lung adenocarcinoma with associated ground glass components.nnnMETHODSnA retrospective review of patients with resected lung adenocarcinoma from 2008 to 2013 was performed. Detailed radiographic features were reviewed by two radiologists. Logistic regression was used to identify risks of poor differentiation or a composite outcome of nodal metastases and lymphovascular invasion.nnnRESULTSnIn all, 79 patients met criteria for analysis. Larger tumor size (pxa0= 0.04), increasing solid component (pxa0= 0.01), pleural tags (pxa0= 0.03), spiculation (pxa0= 0.01), lobulation (p < 0.05), history of coronary artery disease (pxa0= 0.04), and increasing number of pack-years smoking (p < 0.05) were associated with poorly differentiated tumors. However, after adjustment for size of the solid component, the associations between pleural tags, spiculation, and lobulation with poorly differentiated tumors were negated, whereas number of pack-years and history of coronary artery disease remained statistically significant (pxa0= 0.01 and pxa0= 0.03, respectively). There were no identified clinical or radiographic features associated with lymphovascular invasion/nodal metastasis.nnnCONCLUSIONSnSeveral radiographic features were associated with aggressive tumor biology, a well-known finding. However, we found that none of these radiographic features remained relevant after we adjusted for the size of the solid component, indicating that radiographic features are not as important as previously believed. Further research will be required to identify reliable markers associated with favorable tumor biology. These studies will ultimately be critical in informing prognosis or guiding extent of resection.

Natural History of Ground Glass Lesions among Patients with Previous Lung Cancer

BACKGROUNDnAmong patients with previous lung cancer, the malignant potential of subsequent ground-glass opacities (GGOs) on computed tomography remains unknown, with a lack of consensus regarding surveillance and intervention. This study sought to describe the natural history of GGO in patients with a history of lung cancer.nnnMETHODSnA retrospective review was performed of 210 patients with a history of lung cancer and ensuing computed tomography evidence of pure or mixed GGOs between 2007 and 2013. Computed tomography reports were reviewed to determine the fate of the GGOs, by classifying all lesions as stable, resolved, or progressive over the course of the study. Multivariable analysis was performed to identify predictors of GGO progression and resolution.nnnRESULTSnThe mean follow-up time was 13 months. During this period, 55 (26%) patients GGOs were stable, 131 (62%) resolved, and 24 (11%) progressed. Of the 24 GGOs that progressed, three were subsequently diagnosed as adenocarcinoma. Patients of black race (odds ratio [OR], 0.26) and other races besides white (OR, 0.89) had smaller odds of GGO resolution (pxa0= 0.033), whereas patients with previous lung squamous cell carcinoma (OR, 5.16) or small cell carcinoma (OR, 5.36) were more likely to experience GGO resolution (p < 0.001). On multivariable analysis, only a history of adenocarcinoma was an independent predictor of GGO progression (OR, 6.9; pxa0= 0.011).nnnCONCLUSIONSnAmong patients with a history of lung cancer, prior adenocarcinoma emerged as a predictor of GGO progression, whereas a history of squamous cell carcinoma or small cell carcinoma and white race were identified as predictors of GGO resolution.

Predictors of trimodality therapy and trends in therapy for malignant pleural mesothelioma

OBJECTIVESnMalignant pleural mesothelioma is an aggressive and rare malignancy that frequently recurs despite aggressive therapy. We evaluated the frequency of treatment with surgery, radiation or chemotherapy, changes in therapy and survival over time and factors associated with the receipt of trimodality therapy.nnnMETHODSnThe National Cancer Database (NCDB) was used to query patients with histologically proven malignant pleural mesothelioma (2004-14). Treatment over time was evaluated using the Armitage trend test. Factors associated with the receipt of trimodality therapy were analysed using logistic regression.nnnRESULTSnAmong 20xa0561 patients, only 4028 (20%) underwent cancer-directed surgery; 533 (2.6%) of whom received trimodality therapy. From 2004 to 2014, the use of surgery with chemotherapy increased 87% (Pu2009<u20090.01), with no statistically significant change in the use of trimodality therapy. Median survival also increased from 8u2009months to 11u2009months (Pu2009<u20090.01). Patients who were treated at an academic centre or who travel >26 miles for treatment were more likely to undergo trimodality therapy. Additional factors associated with the receipt of trimodality therapy include age less than 70, Charlson comorbidity score of 0 and presence of private insurance.nnnCONCLUSIONSnMany malignant pleural mesothelioma patients are not treated with trimodality therapy, with significant variation in treatment patterns. Referrals to high-volume and specialized centres may help offer more therapeutic options and trial or registry enrolment.

Perioperative Outcomes for Stage I Non-Small Cell Lung Cancer: Differences between Men and Women

BACKGROUNDnPrevious studies have highlighted important biologic and survival-related differences among men and women with non-small cell lung cancer (NSCLC). However, differences in perioperative or short-term outcomes have not been as well characterized. In this study, we investigated differences in the perioperative period and postoperative emergency department (ED) visits among men and women after lobectomy for stage I NSCLC.nnnMETHODSnA retrospective review was performed of patients who underwent a lobectomy for clinical stage I NSCLC at a single institution from 2010 toxa02015.nnnRESULTSnWe identified 559 patients for inclusion, including 293 women (52%) and 266 men (48%). Women were more likely to present with clinical T1 status (pxa0= 0.005) and to undergo a minimally invasive operation (pxa0= 0.058). To reduce confounding, 206 case-matched pairs were identified. After matching, no differences were found in length of stay (pxa0= 0.551) or pulmonary complications (pxa0= 0.509); however, men experienced more cardiac complications (18% versus 7%, pxa0= 0.001). Of importance, although rates of 30- and 90-day ED visits between sexes were similar (pxa0= 0.531, pxa0= 0.890, respectively) and no sex-related differences were found in presenting symptom on return to the ED (pxa0= 0.478), women were more likely to be readmitted after presenting to the ED within 30 days (pxa0= 0.038).nnnCONCLUSIONSnWomen demonstrated an increased likelihood of being admitted after presenting to the ED within 30 days after discharge, indicating important differences between men and women in the short-term period after lobectomy. Further research will be required to further understand the cause for these differences.

Multimodality Therapy for N2 Non-Small Cell Lung Cancer: An Evolving Paradigm.

BACKGROUNDnInduction chemoradiation for resectable N2 non-small cell lung cancer (NSCLC) is used with the intent to optimize locoregional control, whereas induction chemotherapy given in systemic doses is meant to optimally target potential distant disease. However, the optimal preoperative treatment regimen is still unknown and practice patterns continue to vary widely. We compared multiinstitutional oncologic outcomes for N2 NSCLC from 4 experienced lung cancer treatment centers.nnnMETHODSnThis collaborative retrospective study unites 4 major thoracic oncology centers. Patients with N2 NSCLC undergoing surgical resection after induction chemotherapy (CxT) or concurrent chemoradiation (CxRT) were included. Primary outcomes were overall and disease-free survival (OS and DFS).nnnRESULTSn822 patients were identified (CxTxa0= 662 and CxRTxa0= 160). There were no differences in 5-year OS (CxT 39.9% versus CxRT 42.9%, pxa0= 0.250) nor in DFS (CxT 28.7% versus 29.8%, pxa0= 0.207). Recurrence rates (CxT 46.8% versus CxRT 51.6%, pxa0= 0.282) and recurrence patterns were not significantly different (Local: CxT 9.8%xa0versus CxRT 9.7%; and Distant: CxT 30.4% versus CxRT 33.1%, pxa0= 0.764). There was no difference in perioperative mortality. In the analyses of patients who underwent pretreatment invasive mediastinal staging (nxa0= 555), there were still no significant differences in OS (pxa0= 0.341) and DFS (pxa0= 0.455) between the 2 treatment strategies.nnnCONCLUSIONSnBoth treatment strategies produce equivalent and better than expected outcomes compared with historical controls for N2 NSCLC, with no differences in recurrence patterns. How these conventional therapeutic strategies will compare with those involving immunotherapy combined with surgical locoregional disease control for N2 disease remains to be determined.

Predictors of survival after resection of primary sarcomas of the chest wall-A large, single-institution series: SHEWALE et al.

Chest wall sarcomas are rare and may demonstrate heterogeneous features. Surgery remains the mainstay of treatment with chemotherapy and radiotherapy used as adjuncts. Herein, we report outcomes of a large cohort of patients with primary chest wall sarcoma who underwent resection.