Jennifer Bell Zoole

Stereotactic body radiation therapy versus surgical resection for stage I non–small cell lung cancer

OBJECTIVES Stereotactic body radiation therapy has been proposed as an alternative local treatment option for high-risk patients with early-stage lung cancer. A direct comparison of outcomes between stereotactic body radiation therapy and surgical resection has not been reported. This study compares short-term outcomes between stereotactic body radiation therapy and surgical treatment of non-small cell lung cancer. METHODS We compared all patients treated with surgery (January 2000-December 2006) or stereotactic body radiation therapy (February 2004-May 2007) with clinical stage IA/B non-small cell lung cancer staged by computed tomography and positron emission tomography. Comorbidity scores were recorded prospectively using the Adult Co-Morbidity Evaluation scoring system. Charts were reviewed to determine local tumor recurrence, disease-specific survival, and overall survival. A propensity score matching analysis was used to adjust estimated treatment hazard ratios for confounding effects of patient age, comorbidity index, and clinical stage. RESULTS A total of 462 patients underwent surgery and 76 received stereotactic body radiation therapy. Overall, surgical patients were younger (P < .001), had lower comorbidity scores (P < .001), and better pulmonary function (forced expiratory volume in 1 second and carbon monoxide diffusion in the lung) (P < .001). Among the surgical and stereotactic body radiation therapy groups, 62.6% (291/462) and 78.9% (60/76) were in clinical stage IA, respectively. Final pathology upstaged 35% (161/462) of the surgery patients. In an unmatched comparison, overall 5-year survival was 55% with surgery, and the 3-year survival was 32% with radiation therapy. Among patients with clinical stage IA disease, 3-year local tumor control was 89% with radiation therapy and 96% with surgery (P = .04). There was no difference in local tumor control in stage IB disease (P = .89). No disease-specific survival differences were found in patients with 1A (P = .33) or IB disease (P = .69). Propensity analysis matched 57 high-risk surgical patients to 57 patients undergoing stereotactic body radiation therapy. In the matched comparison of this subgroup, there was no difference in freedom from local recurrence (88% vs 90%), disease-free survival (77% vs 86%), and overall survival (54% vs 38%) at 3 years. CONCLUSIONS In an unmatched comparison of clinical stage IA disease, surgical patients were healthier and had better local tumor control compared with those receiving stereotactic body radiation therapy. Propensity analysis in clinical stage IA/B non-small cell lung cancer revealed similar rates of local recurrence and disease-specific survival in patients treated with surgery compared with stereotactic body radiation therapy.

Prognostic Value of Preoperative Positron Emission Tomography in Resected Stage I Non-small Cell Lung Cancer

Purpose: Approximately 20 to 40% of patients with surgically resected stage I non-small cell lung cancer (NSCLC) will develop recurrent disease. Positron emission tomography (PET) with 2-[18F] fluoro-2-deoxy-D-glucose (FDG) is used often in staging NSCLC. We conducted this study to determine whether the preoperative maximum tumor standardized uptake value (SUVmax) was associated with recurrence in patients with resected stage I NSCLC. Patients and Methods: We identified consecutive patients who underwent curative surgical resection for stage I NSCLC between 1999 and 2003 who had preoperative FDG-PET imaging. Patients were divided into two cohorts based on SUVmax above or below the median for the group. Recurrence rates were estimated by the Kaplan-Meier method and overall survival was analyzed as a secondary end point. Results: Of 136 patients who met inclusion criteria, 77 (57%) had T1 and 59 (43%) had T2 tumors. The median follow-up time was 46 months and 32 patients had a disease recurrence. The median SUVmax was 5.5. The 5-year estimates of recurrence rates for patients with low and high SUVmax were 14% and 37%, respectively (p = 0.002), with 5-year overall survivals of 74% and 53%, respectively (p = 0.006). In multivariate analyses based on SUVmax, T-classification, age, and histology, high SUVmax was independently associated with recurrence (p = 0.002) and mortality (p = 0.041). Conclusion: High SUVmax (≥5.5) on preoperative FDG-PET is an independent predictor of relapse and death in resected stage I NSCLC. Prospective trials of adjuvant chemotherapy in patients with stage I NSCLC and high SUVmax should be considered.

Lymph node evaluation in video-assisted thoracoscopic lobectomy versus lobectomy by thoracotomy.

BACKGROUND With the emergence of video-assisted thoracic surgery (VATS) lobectomy, concern remains regarding the adequacy of nodal assessment versus thoracotomy. METHODS All clinical stage I non-small cell lung cancer patients treated with VATS or open lobectomy were retrospectively evaluated. Total nodes, N2 nodes, and nodes at each station were evaluated for associations with surgery type and location of involved lobe. RESULTS There were 79 VATS and 464 open lobectomy or segmental resections for stage I tumors. Overall, fewer lymph nodes were sampled with VATS compared with thoracotomy (7.4 +/- 0.6 vs 8.9 +/- 0.2, respectively; p = 0.029), and fewer N2 nodes were sampled with VATS versus thoracotomy as well (2.5 +/- 3.0 vs 3.7 +/- 3.3, p = 0.004). There were no differences in N1 node sampling between the two groups (5.2 +/- 3.6 vs 4.9 +/- 4.2, p = 0.592). Furthermore, there were more station 7 nodes with thoracotomy versus VATS (1.2 +/- 0.1 vs 0.6 +/- 0.1, p = 0.002). Among right-sided lesions, there was no difference in 4R nodes between groups (1.4 +/- 0.4 vs 1.6 +/- 0.2, p = 0.7) although there was a trend toward more level 7 nodes with thoracotomy (1.0 +/- 0.2 vs 1.4 +/- 0.2, p < 0.08). Among left-sided resections there were more station 7 nodes with thoracotomy versus VATS (1.0 +/- 0.1 vs 0.4 +/- 0.1, p < 0.001) and more station 5/6 nodes (1.1 +/- 0.1 vs 0.5 +/- 0.1, p < 0.04). For upper lobe resections, the total nodes (8.9 +/- 0.3 vs 7.4 +/- 0.7, p = 0.05) and station 7 nodes (1.0 +/- 0.1 vs 0.6 +/- 0.1, p < 0.01) were higher with thoracotomy than VATS. There was no difference in 2-year survival between groups (81% vs 83%, p = 0.4). CONCLUSIONS Our early experience with VATS has been associated with fewer lymph nodes sampled compared with open lobectomy although there was no survival difference. Analysis of these differences has directed us toward a more focused lymph node sampling with VATS lobectomy.

Lymph Node Analysis in Esophageal Resection: American College of Surgeons Oncology Group Z0060 Trial

BACKGROUND The American Joint Committee on Cancer staging of esophageal cancer has been criticized for not establishing a minimum standard for lymphadenectomy, and for relying on location of nodes involved rather than their number. The objective of this study was to review the current practice of American surgeons with regard to lymph node assessment during esophageal resection. METHODS The operative and pathology reports of patients who underwent staging by computed tomography and fluorodeoxyglucose-positron emission tomography and subsequent resection for esophageal cancer (multiinstitutional American College of Surgeons Oncology Group Z0060 trial) were analyzed. RESULTS One hundred forty-five patients underwent resection. Operative and pathology reports were unavailable in 11 patients. The results of the remaining 134 resections (Ivor-Lewis, n = 64; transhiatal, n = 59; other, n = 11) were reviewed. Overall, 13 +/- 9 (mean +/- standard deviation) lymph nodes were evaluated per patient. More lymph nodes were evaluated in patients undergoing Ivor-Lewis (15 +/- 9) than transhiatal esophagectomy (9 +/- 7; p < 0.001). The mean number of distinct lymph node stations analyzed per patient was 3 +/- 2. In 38% (51 of 134) of patients the nodes attached to the specimen were evaluated without any distinction among nodal stations. The practice of submitting named packets of nodal material resulted in 16 +/- 9 nodes per case, as opposed to the practice of submitting an entire specimen for the pathologists to dissect, which yielded 10 +/- 8 nodes (p < 0.001). CONCLUSIONS There is considerable variability and room to improve in the extent of resection and pathologic evaluation of esophagectomy specimens. A uniform standard for esophageal cancer resection is warranted to improve the precision and value of pathologic staging.

Risk of Recurrence of Resected Stage I Non-small Cell Lung Cancer in Elderly Patients as Compared with Younger Patients

Purpose: Half of all patients with non-small cell lung cancer (NSCLC) are 70 years or older at the time of diagnosis. Surgery is an option for fit elderly patients with early stage disease, but rates of disease recurrence after surgical resection are not well described. We report the outcomes in elderly patients (70 years or older) with stage I NSCLC after surgical resection. Patients and Methods: We conducted a retrospective study of patients diagnosed with stage I NSCLC after surgical resection at Washington University School of Medicine-Alvin J. Siteman Cancer Center from 1990 to 2000. Demographic, pathologic, treatment, and follow-up data were collected. Recurrence rates and overall survival were calculated by the Kaplan-Meier method. Multivariate Cox proportional hazards models were used to detect associations between potential prognostic factors and survival and recurrence. Results: Of the 715 patients with stage I NSCLC, 286 were 70 years or older at diagnosis. In this elderly cohort, the median age was 74 years (range, 70–89 years) and 140 of them were women (49%). Lobectomy was performed in 237 patients (83%) whereas 43 patients (15%) had a wedge or segmental resection, and six patients (2%) underwent pneumonectomy. Clinical and pathologic characteristics were not statistically different between the elderly and younger cohorts, with the exception that older patients were more likely to be white (90% versus 80%, p = 0.0003) and less likely to be smokers (88% versus 95%, p = 0.019) compared with the younger cohort. With a median follow-up of 4.6 years, the overall 5-year survival rate was 52% with a 5-year recurrence rate of 24%. In comparison, the patients younger than 70 years had a 5-year survival rate of 67% (p < 0.001) and a 5-year recurrence rate of 24%. Conclusions: Although overall survival was worse in elderly patients, estimated disease recurrence rates after resection were identical.

Endoscopic Ultrasound for Early Stage Esophageal Adenocarcinoma: Implications for Staging and Survival

BACKGROUND Patients often receive induction therapy based on endoscopic ultrasound (EUS)-identified nodal spread (N1) or deep tumor invasion (T3), although controversy exists regarding the role of induction therapy for early stage disease. We aim to evaluate the reliability of EUS in identifying early stage disease and the subsequent impact on treatment and outcomes. METHODS We retrospectively studied 149 patients who underwent EUS and esophagectomy for adenocarcinoma between January 2000 and December 2008. Computed tomography (CT) was performed in all patients, whereas positron emission tomography (PET) was performed in 91%. Clinical stage (c), pathologic stage (p), operative mortality, and survival were recorded. RESULTS Unanticipated pathologic nodal disease was similar in patients with cT1N0 and cT2N0 tumors (6/25 [24%] versus 7/18 [38.8%]; p=0.6). Among the 18 cases of cT2N0 disease, 9 (50%) were pathologically staged as T1N0, 8 (44%) were upstaged to pT3N0-1, and 1 (6%) was pT2N0. One case of cT1N0 tumor (4%) was upstaged to pT3N0. Among patients with cT1-2N0 tumors, 5-year disease-free survival for the group that was appropriately staged was 89.8% versus 39.9% for the group that had a higher pathologic stage than their clinical stage (ie, >T2N0) (p<0.001). Operative mortality for patients with cT1-2N0 tumors was 0/43 (0%), which was no different from that in the higher clinical stage groups with (1/37, 2.7%) or without (2/68, 2.9%) induction therapy (p=0.5). Multivariate analysis identified marked/intense uptake on staging PET (odds ratio, 5.76, 95%; confidence interval, 1.25 to 26.52; p=0.021) to be a factor predictive of upstaging of cT1-2N0 tumors. CONCLUSIONS Current staging techniques are inadequate for predicting T1-2N0 disease in esophageal adenocarcinoma. Survival is excellent with operation alone in patients with tumors appropriately staged as T1-2N0, although patients with tumors upstaged to greater than T2N0 have significantly worse survival. Other preoperative factors such as PET uptake may help select patients with cT1-2N0 tumors that will be upstaged at resection.

Risk factors for occult nodal metastasis in clinical T1N0 lung cancer: a negative impact on survival

BACKGROUND The application of CT imaging has increased the identification of patients with clinical T1N0 (cT1N0) lung cancer. The optimal management strategy for these early stage lung cancers remains unclear. We analyzed the impact of occult nodal metastasis on cT1N0 lung cancer patients. METHODS We studied patients with cT1N0 lung cancer enrolled in our database from January 1995 to December 2002. Preoperative staging was confirmed by review of CT and PET scan studies. Pathology specimens were reviewed. Multivariate analysis was performed to determine the risk of occult nodal involvement. Kaplan-Meier method was applied to analyze survival. RESULTS Two hundred and ninety-seven patients with cT1N0 disease were identified. Fifty-eight percent of patients were pathological T1N0. Overall, 15% of patients had occult nodal metastasis. Logistic regression analysis demonstrated a three-fold increase in the risk of having pathologic stage II or stage III disease with every 1.0 cm increase in tumor size (odds ratio 3.2; 95% CI: 2.3-4.6). Multivariate analysis demonstrated tumor size to be a significant predictor of nodal metastasis (adjusted odds ratio 3.5; 95% CI: 2.4-5.1). Median survival was different between pathological stage I (96.3 months), stage II (41.4 months), and stage III (36.1 months) disease (p=0.002). CONCLUSION Clinical T1N0 tumors are often understaged. The risk of occult nodal disease increases with tumor size, and this occult disease negatively impacts survival. Because of the limitations of clinical staging, we believe that lobectomy and lymph node analysis should be offered to cT1N0 lung cancer patients to provide accurate staging and to optimize multimodality adjuvant treatment of lung cancer.

Impact of Video-Assisted Thoracoscopic Surgery on Benign Resections for Solitary Pulmonary Nodules

BACKGROUND Differentiating benign from malignant pulmonary lesions is an important part of surgical decision making. We reviewed our experience of resecting suspicious pulmonary nodules to test the hypothesis that the increased use of video-assisted thoracic surgery (VATS) has increased the resection rate of benign lesions. METHODS A retrospective analysis was carried out on 3,217 patients who underwent resection for focal pulmonary lesions between 1995 and 2009. Resection method, computed tomography (CT) results, positron emission tomography (PET) results, and operative and pathology reports were reviewed. RESULTS Pulmonary resection was by thoracotomy/median sternotomy in 2,632 of 3,217 (82%) patients and by VATS in 585 of 3,217 (18%). Resections performed by VATS increased from 129 of 2,150 (6%) between 1995 and 2005 to 453 of 1,067 (42.4%) between 2006 and 2009. From 2006 to 2009, 31.4% of lobectomies and 63.9% of wedge resections were performed by VATS. Benign lesions were found in 350 of 3,217 (10.8%) patients. Between 1995 and 2005 our resection rate of benign lesions was 192 of 2,150 (8.9%). From 2006 to 2009, it increased to 158 of 1,067 (14.8%), of which 85 of 456 (20.8%) were VATS and 63 of 611(10.3%) were open procedures. The benign lesion resection rate was 91 of 237 (38.3%) for VATS wedges, 49 of 134 (36.6%) for open wedges, 4 of 219 (1.8%) for VATS lobectomies, and 14 of 477 (2.9%) for open lobectomies. 257 of 456 (52.0%) of the VATS resections were wedges compared with 134 of 611 (21.9%) of the open procedures. CONCLUSIONS There has been an increase in pulmonary resections performed by VATS. This is associated with an increase in benign lesion resections. The benign lesion resection rate for VATS was twice that of the open procedure rate. However the benign lesion resection rates for wedge resections and lobectomies were not significantly different in regard to approach. VATS has led to an increase in our overall benign lesion resection rate, which can be explained by the increased number of VATS wedge resections that are being performed.

Lung Herniation After Supraclavicular Thoracic Outlet Decompression

Lung herniation after first rib resection for thoracic outlet syndrome (TOS) has not been reported to our knowledge. We present a unique case of cervical lung herniation causing displacement of the brachial plexus and chronic pain in a patient who had previously undergone supraclavicular thoracic outlet decompression with first rib resection. This was successfully treated with thoracoscopic reduction and resection of the herniated lung and pleural flap closure of the defect.

Recurrent Subcutaneous Air of the Face and Neck

Subcutaneous air of the face and neck can be seen after trauma to the lungs, airway, and esophagus. We present a case of a 29-year-old with recurrent subcutaneous air of the face and neck with minimal pneumomediastinum. In this report, we discuss the workup of this patient and review the literature regarding self-inflicted causes.