Michal Hubka

Lung Resection Outcomes and Costs in Washington State: A Case for Regional Quality Improvement

BACKGROUND A regional quality improvement effort does not exist for thoracic surgery in the United States. To initiate the development of one, we sought to describe temporal trends and hospital-level variability in associated outcomes and costs of pulmonary resection in Washington (WA) State. METHODS A cohort study (2000-2011) was conducted of operated-on lung cancer patients. The WA State discharge database was used to describe outcomes and costs for operations performed at all nonfederal hospitals within the state. RESULTS Over 12 years, 8,457 lung cancer patients underwent pulmonary resection across 49 hospitals. Inpatient deaths decreased over time (adjusted p-trend=0.023) but prolonged length of stay did not (adjusted p-trend=0.880). Inflation-adjusted hospital costs increased over time (adjusted p-trend<0.001). Among 24 hospitals performing at least 1 resection per year, 5 hospitals were statistical outliers in rates of death (4 lower and 1 higher than the state average), and 13 were outliers with respect to prolonged length of stay (7 higher and 6 lower than the state average) and costs (5 higher and 8 lower than the state average). When evaluated for rates of death and costs, there were hospitals with fewer deaths/lower costs, fewer deaths/higher costs, more deaths/lower costs, and more deaths/higher costs. CONCLUSIONS Variability in outcomes and costs over time and across hospitals suggest opportunities to improve the quality and value of thoracic surgery in WA State. Examples from cardiac surgery suggest that a regional quality improvement collaborative is an effective way to meaningfully and rapidly act upon these opportunities.

Variability in invasive mediastinal staging for lung cancer: A multicenter regional study

Objective: Prior studies have reported underuse of—but not variability in—invasive mediastinal staging in the pretreatment evaluation of patients with lung cancer. We sought to compare rates of invasive mediastinal staging for lung cancer across hospitals participating in a regional quality improvement and research collaborative. Methods: We conducted a retrospective study (2011–2013) of patients undergoing resected lung cancer from the Surgical Clinical Outcomes and Assessment Program in Washington State. Invasive mediastinal staging included mediastinoscopy and/or endobronchial/esophageal ultrasound‐guided nodal aspiration. We used a mixed‐effects model to mitigate the influence of small sample sizes at any 1 hospital on rates of invasive staging and to adjust for hospital‐level differences in the frequency of clinical stage IA disease. Results: A total of 406 patients (mean age, 68 years; 69% clinical stage IA; and 67% lobectomy) underwent resection at 5 hospitals (4 community and 1 academic). Invasive staging occurred in 66% of patients (95% confidence interval [CI], 61%‐71%). CI inspection revealed that 2 hospitals performed invasive staging significantly more often than the overall average (94%, [95% CI, 89%‐96%] and 84% [95% CI, 78%‐88%]), whereas 2 hospitals performed invasive staging significantly less often than overall average (31% [95% CI, 21%‐44%] and 17% [95% CI, 7%‐36%]). Conclusions: Rates of invasive mediastinal staging varied significantly across hospitals providing surgical care for patients with lung cancer. Future studies that aim to understand the reasons underlying variability in care may inform quality improvement initiatives or lead to the development of novel staging algorithms.

Improvement in TNM staging of pulmonary neuroendocrine tumors requires histology and regrouping of tumor size

Objective Neuroendocrine tumors of the lung are currently staged with the 7th edition TNM non–small cell lung cancer staging system. This decision, based on data analysis without data on histology or disease‐specific survival, makes its applicability limited. This study proposes a specific staging system for these tumors. Methods We retrospectively analyzed 510 consecutive patients (female/male, 313/197; median age, 61 years; interquartile range, 51‐70) undergoing lung resection for a primary neuroendocrine tumor between 2000 and 2015 in 8 centers. Multivariable analysis was performed using a Cox proportional hazard model to identify factors associated with disease‐specific survival. A new staging system was proposed on the basis of the results of this analysis. Kaplan–Meier disease‐specific survival was analyzed by stage using the proposed and the 7th TNM staging system. Results Follow‐up was completed in 490 of 510 patients at a median of 51 months (interquartile range, 18‐99). Histology (G1‐typical carcinoid vs G2‐atypical carcinoid vs G3‐large‐cell neuroendocrine carcinoma) and pT were independently associated with survival, but pN was not. After regrouping histology and pT, we proposed the following staging system: IA (pT1‐2G1), IB (pT3G1, pT1G2), IIA (pT4G1, pT2‐3G2, pT1G3), IIB (pT4G2, pT2‐3G3), and III (pT4G3). The 5‐year survivals were 97.9%, 81.0%, 69.1%, 51.8%, and 0%, respectively. By using the 7th TNM, 5‐year survivals were 95.0%, 92.3%, 67.7%, 70.9%, and 65.1% for stage IA, IB, IIA, IIB, and III, respectively. Conclusions Incorporating histology and regrouping tumor stage create a unique neuroendocrine tumor staging system that seems to predict survival better than the 7th TNM classification.

The Importance of Age on Short-Term Outcomes Associated With Repair of Giant Paraesophageal Hernias

BACKGROUND Older patients have an increased incidence of paraesophageal hernia (PEH) and can be denied surgical assessment due to the perception of increased complications and mortality. This study examines the influence of age and comorbidities on early complications and other short-term outcomes of PEH repair. METHODS From 2000 to 2016, data of surgically treated patients with PEH were prospectively recorded in an Institutional Review Board-approved database. Only patients whose hernia involved over 50% of the stomach were included. Patients were stratified by age (<70, 70 to 79, ≥80 years of age) and compared in univariate and multivariate analyses. RESULTS Overall, 524 patients underwent surgical PEH repair (<70: 261 [50%]; 70 to 79: 163 [31%]; ≥80: 100 [19%]). Patients greater than or equal to 80 years of age had higher American Society of Anesthesiologists class, more comorbidities, larger hernias, and higher incidences of type IV PEH and acute presentation. Patients greater than or equal to 80 years of age had more postoperative complications, but not higher grade complications (Clavien-Dindo grade ≥IIIa). Median length of stay was 1 day longer for patients greater than or equal to 80 years of age (5 days versus 4 days for patients <70 and 70 to 79 years of age, respectively). Objective, radiologic hernia recurrence at 4.3 months postoperation was 17.3% and was not increased in the greater than or equal to 80 years of age group. After adjustment for comorbidities and other factors, age greater than or equal to 80 years was not a significant factor in predicting severe complications, readmission within 30 days, or early recurrence. CONCLUSIONS PEH repair is safe in physiologically stable patients, irrespective of age. Incidence of complications is higher in older patients, but complication severity and mortality are similar to those of younger patients. Patients with giant PEH should be given the opportunity to review treatments options with an experienced surgeon.

Is there a role for traditional nuclear medicine imaging in the management of pulmonary carcinoid tumours

OBJECTIVES The clinical utility of fluorodeoxyglucose-positron emission tomography (FDG-PET) and somatostatin receptor scintigraphy (SRS) in pulmonary carcinoids staging is unclear. This study aims to determine the role of FDG-PET and SRS in detecting hilar-mediastinal lymph node metastasis from these tumours. METHODS We retrospectively collected the data of 380 patients who underwent lung resection for primary pulmonary carcinoid in seven centres between 2000 and 2015. Patients without nodal sampling ( n  = 78) were excluded. In 302 patients [35% men, median age 58 (interquartile range 47-68) years] the results of preoperative computed tomography (CT) scan, FDG-PET and SRS were analysed and compared to the pathological findings after resection to determine the respective utility of these two nuclear tests. RESULTS The sensitivity, specificity and negative predictive value in detecting N1 and N2 disease were respectively 33% and 46%, 93% and 90%, 88% and 95% for computed-tomography-scan, 38% and 60%, 93% and 95%, 88% and 95% for FDG-PET, 22% and 33%, 95% and 98%, 84% and 87% for SRS. The diagnostic accuracy for N1 and N2 disease of CT scan was not significantly different from that of FDG-PET ( P  =   1.0 and P  =   0.37 for N1 and N2 disease respectively) and of SRS ( P  =   0.47 and P  =   0.35 for N1 and N2 disease respectively). The sensitivity and specificity of these imaging tests were also similar when analysed by typical vs atypical histology. CONCLUSIONS CT scan, FDG-PET and SRS showed similar performance in terms of nodal staging for pulmonary carcinoid. These findings suggest that additional nuclear imaging beyond CT scan is not required as long as a lymphadenectomy or nodal sampling is completed at resection.

PS01.25: Large Cell Neuroendocrine Carcinoma of the Lung: Prognostic Factors of Survival and Recurrence After R0 Surgical Resection: Topic: Surgery

Maria Cattoni, Eric Vallieres, Lisa M. Brown, Amir A. Sarkeshik, Stefano Margaritora, Alessandra Siciliani, Pier Luigi Filosso, Francesco Guerrera, Andrea Imperatori, Nicola Rotolo, Farhood Farjah, Grace Wandell, Kimberly Costas, Catherine Mann, Michal Hubka, Stephen Kaplan, Alexander S. Farivar, Ralph W. Aye, Brian Louie Swedish Cancer Institute, Seattle, WA/United States of America, UC Davis Medical Center, Sacramento, CA/United States of America, Catholic University ‘Sacred Heart’, Rome/Italy, San Giovanni Battista Hospital, Torino/Italy, University of Insubria, Ospedale di Circolo, Varese/Italy, University of Washington Medical Center, Seattle, WA/United States of America, Providence Regional Medical Center, Everett, WA/United States of America, Virginia Mason Hospital & Seattle Medical Center, Seattle, WA/United States of America