To identify pretreatment prognostic factors associated with improved outcomes in patients with non-small cell lung cancer (NSCLC) tumors larger than 4 cm receiving adjuvant chemotherapy following surgery versus surgery alone.

OBJECTIVES To determine whether there are differences in survival associated with different treatment modalities among patients with lymph node-negative, very large non-small-cell lung cancers (NSCLCs). METHODS The National Cancer DataBase was used to identify patients diagnosed with NSCLCs >7 cm (T3) without lymph node involvement (N0) or metastatic disease (M0) from 1999 to 2006. Surgical therapy included surgery alone, neoadjuvant chemoradiation therapy or chemotherapy, surgery followed by adjuvant chemoradiation therapy or chemotherapy and surgery followed by postoperative radiation therapy (PORT). The 5-year overall survival (OS) was estimated by the Kaplan-Meier method and comparisons were made using log-rank tests and Cox regression models. RESULTS Of the 2296 patients identified with cT3N0M0 disease, 45% underwent surgical therapy. The 5-year OS rate was 38%. Across the different treatment regimens, there was a significant difference in 5-year OS. Neither neoadjuvant chemoradiation therapy or chemotherapy nor adjuvant chemoradiation therapy was associated with improved 5-year OS. The use of adjuvant chemotherapy was associated with improved OS relative to surgery alone [hazard ratio (HR) 0.70; 95% confidence interval (CI) 0.54-0.91, P = 0.008]. PORT alone was associated with a detrimental effect on 5-year OS relative to surgery alone [HR 2.04; 95% CI 1.38-3.03, P < 0.001]. CONCLUSIONS Large T3N0 NSCLCs appear to be optimally treated with surgical resection followed by adjuvant chemotherapy.

INTRODUCTION:Current therapy for small-cell lung cancer (SCLC) relies on chemoradiation therapy, and the role of primary surgical resection in these patients remains controversial. A minority of SCLC patients present without metastatic disease and are candidates for surgery. This study investigates the role of surgical resection in select patients with SCLC, using a national cohort of approximately 2500 resected patients.METHODS:A retrospective study of SCLC patients in the National Cancer Data Base (NCDB) was performed where patients were grouped for comparison by stage and treatment regimen. Survival was estimated by Kaplan-Meier methods and multivariate comparisons using Cox regression.RESULTS:Of 28,621 cases of potentially resectable SCLC, 2476 patients (9%) underwent surgery of the primary site with curative intent. Five-year overall survival for patients after resection was 51%, 25%, and 18% for clinical stages I, II, and IIIA, respectively. Addition of surgery to chemotherapy was associated with decreased likelihood of death (hazard ratio: 0.57, 95% confidence interval: 0.47-0.68), independent of age, stage, and comorbidity score. Lobectomy was associated with a 5-year overall survival of 40% compared with 21% and 22% for sublobar resection and pneumonectomy, respectively. Hazard ratio for death after sublobar resections compared with lobectomy was 1.38 (95% confidence interval: 1.12-1.71).CONCLUSIONS:Patients with stages I, II, and III SCLC, who underwent surgical resection as part of initial treatment with chemotherapy had respectable OS. These data may warrant prospective studies of including surgery in the multimodality treatment of SCLC in specific circumstances.

Background. Preoperative chemotherapy improves the survival of surgically managed stage III non-small cell lung cancer (NSCLC). A proportion of stage III NSCLC patients in the United States have undergone operations primarily and been given chemotherapy postoperatively. It is unclear whether postoperative chemotherapy is as effective as preoperative chemotherapy. Our objective was to determine the survival of resected stage III NSCLC according to the timing of chemotherapy.Methods. The National Cancer Database (NCDB) was queried for clinical T1-4N2M0 NSCLC (cstage III-cN2) undergoing lobectomy or pneumonectomy between 2003 and 2006.Results. 1,356 patients with surgically managed cstage III-cN2 disease who received preoperative chemotherapy were compared with 649 patients receiving postoperative chemotherapy. In a Cox proportional hazards model with adjustment for demographics, comorbidities, and tumor attributes, the results of postoperative chemotherapy appeared similar to those of preoperative chemotherapy (hazard ratio [HR] = [1.05, 95% confidence interval [CI] 0.93-1.19, p = 0.438). In separate Cox models, the results of postoperative chemotherapy alone were similar to those of preoperative chemotherapy alone (HR = 1.106, 95% CI 0.91-1.344, p = 0.3124). The results of postoperative chemotherapy + radiation were similar to those of preoperative chemotherapy + radiation (HR = 1.125, 95% CI 0.949-1.333, p = -0.175).Conclusions. Adjusted comparison of preoperative and postoperative chemotherapy results for cstage III-N2 NSCLC in the NCDB failed to identify a superior chemotherapy approach. This suggests that a more rigorous examination of the widely held view that preoperative chemotherapy is superior may be warranted. (C) 2015 by The Society of Thoracic Surgeons

Background. Incomplete resection of non-small cell lung cancer (NSCLC) portends a dramatic decline in survival. Historically, postoperative radiation and chemotherapy have been offered to treat residual disease at the surgical margins, yet the efficacy is unknown. We examined the survival among incompletely resected NSCLC patients to identify the optimal response to positive NSCLC surgical margins.Methods. The National Cancer Data Base was queried for surgically managed pathologic stage I-III NSCLC between 2003 and 2006 (n = 54,512). The prevalence, predictors, impact, and optimal treatment approaches to positive surgical margins were investigated.Results. A positive surgical margin was identified in 3,102 NSCLC patients (5.7% of resections), including 1,688 with microscopically positive (R1) margins (3.1%). Compared with complete resections, patients with R1 resections had a worse 5-year survival; stage pI (62% vs 37%; p < 0.0001), stage pII (41% vs 29%; p < 0.0001), and stage pIII (33% vs 19%; p < 0.0001). Postoperative administration of both chemotherapy and radiation were associated with superior survival compared with surgery alone at all stages; stage pI (44% vs 35%; p = 0.05), stage pII (33% vs 21%; p = 0.0013), and stage pIII NSCLC (30% vs 12%; p < 0.0001). Administration of chemotherapy or radiation alone was less consistently associated with improved outcome in R1 patients. Of note, radiation alone did not improve survival for stage pI patients with R1 resections (26% vs 35%; p = 0.0399).Conclusions. The administration of both chemotherapy and radiation is associated with an improved survival in patients with microscopically positive surgical margins, irrespective of stage. Further study is needed to clarify the optimal stage-specific adjuvant approach to incompletely resected NSCLC. (C) 2015 by The Society of Thoracic Surgeons

BACKGROUND:Surgical resection represents the standard of care for locoregionally confined non-small cell lung cancer (NSCLC); however, surgical complications may compromise the overall outcome. Adverse events after lung cancer surgery have been studied extensively, yet available databases have significant limitations (with respect to size, provider, patient age, and so forth). The National Cancer Database (NCDB) is the largest cancer registry in the world, capturing 67% of newly diagnosed NSCLC in the United States. We studied surgically managed NSCLC patients in the NCDB to more accurately assess factors that influence perioperative outcomes.METHODS:Patients diagnosed with NSCLC from 2004 to 2009 in the NCDB who were managed with surgical resection were included (n = 119,146). Primary endpoints included death within 30 days of surgery and extended length of stay (more than 14 days).RESULTS:Overall 30-day mortality rate was 3.4% and varied by procedure: lobectomy/bilobectomy (2.6%), wedge resection (4.2%), extended lobectomy/bilobectomy (4%), and pneumonectomy (8.5%). By multivariable analysis, increasing age, male sex, increasing comorbidities, and decreased facility volume were associated with higher 30-day mortality. Of patients who underwent lobectomy, 9.1% had an extended length of stay. On multivariable analysis, increasing age, male sex, increasing comorbidities, decreasing facility volume, and right-sided tumors were associated with increased incidence of extended length of stay.CONCLUSIONS:Adverse events after the surgical treatment of NSCLC in the NCDB occur with a similar frequency and are predicted by similar patient, procedural, and facility variables as have been identified by more restricted data resources. The NCDB appears to be a valuable resource to study NSCLC in the United States.

7533 Background: Neoadjuvant chemotherapy followed by surgery is superior to surgery alone for stage III non-small cell lung cancer (NSCLC) with mediastinal (N2) lymph node involvement. It is unclear, however, if postoperative (adjuvant) chemotherapy is as effective as preoperative (neoadjuvant) chemotherapy in this setting. The objective of this study was to determine the survival of resected stage III NSCLC according to the timing of chemotherapy. Methods: The National Cancer Database (NCDB) was queried for patients with clinical T1-4N2M0 NSCLC (clinical Stage III - N2) undergoing resection via lobectomy or pneumonectomy between 2003 and 2006. Results: The efficacy of post-operative (adjuvant) therapy in clinical Stage III - N2 NSCLC was evaluated in two ways. First we examined a cohort of 698 treatment-naïve (no preoperative treatment) clinical N2 patients confirmed to be pathologic N2 by the surgical resection of primary tumor (cN2pN2). We compared surgery “alone” to surgery followed by adjuvant chemotherapy. The 5-year survival of cN2pN2 patients was significantly higher with adjuvant chemotherapy (36%, n= 212) or chemoradiation (33%, n= 230) than surgery alone (21%, n= 256, p<.0001). In a multivariable analysis adjusting for patient demographics, tumor attributes, a modified Charlson comorbidity index and type of resection, the use of postoperative chemotherapy (HR, 0.66 95%CI [0.52-0.84], p=.0005) and chemoradiation (HR 0.75, 95%CI [0.59-0.95], p=.016) were both superior to surgery alone. There was no significant difference between chemotherapy and chemoradiation. We next directly compared postoperative chemotherapy (adjuvant) to preoperative therapy (neoadjuvant) in clinically staged III – clinical N2 NSCLC. A multivariable Cox model including variables noted above indicated that adjuvant therapy (n = 649) was associated with a similar outcome to neoadjuvant therapy (n = 1,356) HR 1.05, 95% CI [.92 – 1.18], p = .475). Conclusions: Chemotherapy appears to be similarly effective in stage III NSCLC patients with N2 disease when given before or after resection in the NCDB. This finding, could impact the role preoperative mediastinal staging in operable stage III lung cancer.

OBJECTIVES:The minimally invasive oesophagectomy (MIO) approach offers a number of advantages over open approaches including reduced discomfort, shorter length of stay and a faster recovery to baseline status. On the other hand, minimally invasive procedures typically are longer and consume greater disposable instrumentation, potentially resulting in a greater overall cost. The objective of this study was to compare costs associated with various oesophagectomy approaches for oesophageal cancer. METHODS:An institutional Resource Information Management System (RIMS) was queried for cost data relating to hospital expenditures (as opposed to billings or collections). The RIMS was searched for patients undergoing oesophagectomy for oesophageal cancer between 2003 and 2012 via minimally invasive, open transthoracic (OTT) (including Ivor Lewis, modified McKeown or thoracoabdominal) or transhiatal approaches. Patients that were converted from minimally invasive to open, or involved hybrid procedures, were excluded. RESULTS:A total of 160 oesophagectomies were identified, including 61 minimally invasive, 35 open transthoracic and 64 transhiatal. Costs on the day of surgery averaged higher in the MIO group ($12 476 ± 2190) compared with the open groups, OTT ($8202 ± 2512, P < 0.0001) or OTH ($5809 ± 2575, P < 0.0001). The median costs associated with the entire hospitalization also appear to be higher in the MIO group ($25 935) compared with OTT ($24 440) and OTH ($15 248). The average length of stay was lowest in the MIO group (11 ± 9 days) compared with OTT (19 ± 18 days, P = 0.006) and OTH (18 ± 28 days P = 0.07). The operative mortality was similar in the three groups (MIO = 3%, OTT = 9% and OTH = 3%). CONCLUSIONS:The operating theatre costs associated with minimally invasive oesophagectomy are significantly higher than OTT or OTH approaches. Unfortunately, a shorter hospital stay after MIO does not consistently offset higher surgical expense, as total hospital costs trend higher in the MIO patients. In an increasingly strained health care economy, efforts to reduce costs associated with the minimally invasive approach should address the inpatient hospitalization as well as operating theatre expenses.