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Delaying Esophagectomy After CXRT May Be Okay, Study Finds
FROM THE ANNUAL MEETING OF THE SOCIETY OF THORACIC SURGEONS
SAN DIEGO - An interval between neoadjuvant chemoradiation and esophagectomy that extends beyond 8 weeks is not associated with increased perioperative complications, increased pathological complete response, or change in overall survival, results from a long-term single-center study showed.
"For patients who have not yet recovered from neoadjuvant chemoradiation, it is safe to delay surgery to allow them to improve their performance status," Dr. Jae Y. Kim said at the meeting.
Traditionally, he said, surgery has been recommended within 8 weeks after completing neoadjuvant chemoradiation for esophageal cancer, yet many patients choose to delay their surgery.
Some patients have not yet recovered from chemoradiation, while others are delayed for personal or logistical reasons, explained Dr. Kim, a thoracic surgery fellow at the University of Texas M.D. Anderson Cancer Center, Houston. "The impact of this delay on outcomes is unknown." Radiation-induced tumor necrosis increases over time, he said, and there is evidence from rectal cancer that a longer interval may increase the rate of pathological complete response. "On the other hand, there are theoretical concerns that this delay may lead to increased radiation fibrosis and cause a more difficult operation. It is also possible that a delay would allow for tumor regrowth."
In an effort to determine whether an increased interval between chemoradiation and surgery is associated with risk of major perioperative complications or overall survival, Dr. Kim and his associates conducted a retrospective study of 266 patients with esophageal cancer followed by neoadjuvant chemoradiation who were treated at M.D. Anderson in 2002-2008. They divided the patients into two groups: a "short-interval" group of 150 who underwent esophagectomy within 8 weeks of chemoradiation, and a "delayed" group of 116 who underwent esophagectomy more than 8 weeks following chemoradiation.
"Most patients were clustered around 4-11 weeks," Dr. Kim said. "No patient had surgery more than 46 weeks after completing neoadjuvant chemoradiation."
The median interval from completion of neoadjuvant therapy to surgery was 46 days in the short-interval group and 76 days in the delayed group. In both groups, more than 95% of patients were staged with PET-CT and endoscopic ultrasound.
The researchers compared the two groups in terms of perioperative complications, rate of pathological complete response, and overall survival.
The two groups were similar in 18 of 22 baseline characteristics examined, but they were different in four areas. Compared with their counterparts in the short-interval group, the patients in the delayed group were slightly older (mean age, 60 years vs. 57 years, respectively), had more coronary artery disease (17% vs. 7%), had less adenocarcinoma histology (87% vs. 97%), and weighed less (53% with a body mass index of 25 kg/m2 or greater vs. 75% of their counterparts in the short-interval group).
By any objective measure used to gauge the difficulty of the operation, the two groups were similar, including mean OR time (390 minutes in the short-interval group vs. 398 minutes in the delayed group), mean number of lymph nodes removed (21% vs. 20%), and mean estimated blood loss (505 mL vs. 478 mL).
The rates of major complications also were similar between the two groups, including perioperative mortality (2% in the short-interval group vs. 3% in the delayed group), median length of stay (11 days in each group), and rate of anastomotic leak (11% vs. 16%).
The rate of pathological complete response was similar between the two groups (21% vs. 23%).
Overall 5-year survival in the short-interval group was 46%, compared with 36% in the delayed-surgery group, a nonsignificant difference. Disease-free 5-year survival in the short-interval group was 44%, compared with 36% in the delayed group.
"The timing of surgery, both as a continuous and a dichotomous variable, was not associated" with perioperative complication or death, pathological complete response, or overall survival, Dr. Kim added.
On multivariable analysis, older age, more involved lymph nodes, and advanced pathological stage were independently associated with decreased survival.
The researchers performed a subgroup analysis of patients with adenocarcinoma histology and found that the results were similar.
Dr. Kim said that he had no relevant financial disclosures.
The authors point out that it is often difficult to standardize timing of esophagectomy in this setting because of a variety of difficult-to-anticipate events, particularly induction therapy toxicities. That most patients still had their esophagectomies performed by 3 months following the end of therapy suggests that the two groups might not be expected to be vastly different, although it is comforting to now have data to support this contention. Perhaps a future study might be to compare morbidity/mortality of esophagectomy following induction therapy versus that performed as a salvage strategy for patients who have failed chemoradiotherapy as definitive treatment. Those two groups are far more distinct. Late local recurrence following definitive chemoradiation therapy is, unfortunately, not that uncommon and has few other treatment options.
Dr. Sudish Murthy is an ACS Fellow and surgical director of the Center for Major Airway Disease, Cleveland Clinic.
The authors point out that it is often difficult to standardize timing of esophagectomy in this setting because of a variety of difficult-to-anticipate events, particularly induction therapy toxicities. That most patients still had their esophagectomies performed by 3 months following the end of therapy suggests that the two groups might not be expected to be vastly different, although it is comforting to now have data to support this contention. Perhaps a future study might be to compare morbidity/mortality of esophagectomy following induction therapy versus that performed as a salvage strategy for patients who have failed chemoradiotherapy as definitive treatment. Those two groups are far more distinct. Late local recurrence following definitive chemoradiation therapy is, unfortunately, not that uncommon and has few other treatment options.
Dr. Sudish Murthy is an ACS Fellow and surgical director of the Center for Major Airway Disease, Cleveland Clinic.
The authors point out that it is often difficult to standardize timing of esophagectomy in this setting because of a variety of difficult-to-anticipate events, particularly induction therapy toxicities. That most patients still had their esophagectomies performed by 3 months following the end of therapy suggests that the two groups might not be expected to be vastly different, although it is comforting to now have data to support this contention. Perhaps a future study might be to compare morbidity/mortality of esophagectomy following induction therapy versus that performed as a salvage strategy for patients who have failed chemoradiotherapy as definitive treatment. Those two groups are far more distinct. Late local recurrence following definitive chemoradiation therapy is, unfortunately, not that uncommon and has few other treatment options.
Dr. Sudish Murthy is an ACS Fellow and surgical director of the Center for Major Airway Disease, Cleveland Clinic.
FROM THE ANNUAL MEETING OF THE SOCIETY OF THORACIC SURGEONS
SAN DIEGO - An interval between neoadjuvant chemoradiation and esophagectomy that extends beyond 8 weeks is not associated with increased perioperative complications, increased pathological complete response, or change in overall survival, results from a long-term single-center study showed.
"For patients who have not yet recovered from neoadjuvant chemoradiation, it is safe to delay surgery to allow them to improve their performance status," Dr. Jae Y. Kim said at the meeting.
Traditionally, he said, surgery has been recommended within 8 weeks after completing neoadjuvant chemoradiation for esophageal cancer, yet many patients choose to delay their surgery.
Some patients have not yet recovered from chemoradiation, while others are delayed for personal or logistical reasons, explained Dr. Kim, a thoracic surgery fellow at the University of Texas M.D. Anderson Cancer Center, Houston. "The impact of this delay on outcomes is unknown." Radiation-induced tumor necrosis increases over time, he said, and there is evidence from rectal cancer that a longer interval may increase the rate of pathological complete response. "On the other hand, there are theoretical concerns that this delay may lead to increased radiation fibrosis and cause a more difficult operation. It is also possible that a delay would allow for tumor regrowth."
In an effort to determine whether an increased interval between chemoradiation and surgery is associated with risk of major perioperative complications or overall survival, Dr. Kim and his associates conducted a retrospective study of 266 patients with esophageal cancer followed by neoadjuvant chemoradiation who were treated at M.D. Anderson in 2002-2008. They divided the patients into two groups: a "short-interval" group of 150 who underwent esophagectomy within 8 weeks of chemoradiation, and a "delayed" group of 116 who underwent esophagectomy more than 8 weeks following chemoradiation.
"Most patients were clustered around 4-11 weeks," Dr. Kim said. "No patient had surgery more than 46 weeks after completing neoadjuvant chemoradiation."
The median interval from completion of neoadjuvant therapy to surgery was 46 days in the short-interval group and 76 days in the delayed group. In both groups, more than 95% of patients were staged with PET-CT and endoscopic ultrasound.
The researchers compared the two groups in terms of perioperative complications, rate of pathological complete response, and overall survival.
The two groups were similar in 18 of 22 baseline characteristics examined, but they were different in four areas. Compared with their counterparts in the short-interval group, the patients in the delayed group were slightly older (mean age, 60 years vs. 57 years, respectively), had more coronary artery disease (17% vs. 7%), had less adenocarcinoma histology (87% vs. 97%), and weighed less (53% with a body mass index of 25 kg/m2 or greater vs. 75% of their counterparts in the short-interval group).
By any objective measure used to gauge the difficulty of the operation, the two groups were similar, including mean OR time (390 minutes in the short-interval group vs. 398 minutes in the delayed group), mean number of lymph nodes removed (21% vs. 20%), and mean estimated blood loss (505 mL vs. 478 mL).
The rates of major complications also were similar between the two groups, including perioperative mortality (2% in the short-interval group vs. 3% in the delayed group), median length of stay (11 days in each group), and rate of anastomotic leak (11% vs. 16%).
The rate of pathological complete response was similar between the two groups (21% vs. 23%).
Overall 5-year survival in the short-interval group was 46%, compared with 36% in the delayed-surgery group, a nonsignificant difference. Disease-free 5-year survival in the short-interval group was 44%, compared with 36% in the delayed group.
"The timing of surgery, both as a continuous and a dichotomous variable, was not associated" with perioperative complication or death, pathological complete response, or overall survival, Dr. Kim added.
On multivariable analysis, older age, more involved lymph nodes, and advanced pathological stage were independently associated with decreased survival.
The researchers performed a subgroup analysis of patients with adenocarcinoma histology and found that the results were similar.
Dr. Kim said that he had no relevant financial disclosures.
FROM THE ANNUAL MEETING OF THE SOCIETY OF THORACIC SURGEONS
SAN DIEGO - An interval between neoadjuvant chemoradiation and esophagectomy that extends beyond 8 weeks is not associated with increased perioperative complications, increased pathological complete response, or change in overall survival, results from a long-term single-center study showed.
"For patients who have not yet recovered from neoadjuvant chemoradiation, it is safe to delay surgery to allow them to improve their performance status," Dr. Jae Y. Kim said at the meeting.
Traditionally, he said, surgery has been recommended within 8 weeks after completing neoadjuvant chemoradiation for esophageal cancer, yet many patients choose to delay their surgery.
Some patients have not yet recovered from chemoradiation, while others are delayed for personal or logistical reasons, explained Dr. Kim, a thoracic surgery fellow at the University of Texas M.D. Anderson Cancer Center, Houston. "The impact of this delay on outcomes is unknown." Radiation-induced tumor necrosis increases over time, he said, and there is evidence from rectal cancer that a longer interval may increase the rate of pathological complete response. "On the other hand, there are theoretical concerns that this delay may lead to increased radiation fibrosis and cause a more difficult operation. It is also possible that a delay would allow for tumor regrowth."
In an effort to determine whether an increased interval between chemoradiation and surgery is associated with risk of major perioperative complications or overall survival, Dr. Kim and his associates conducted a retrospective study of 266 patients with esophageal cancer followed by neoadjuvant chemoradiation who were treated at M.D. Anderson in 2002-2008. They divided the patients into two groups: a "short-interval" group of 150 who underwent esophagectomy within 8 weeks of chemoradiation, and a "delayed" group of 116 who underwent esophagectomy more than 8 weeks following chemoradiation.
"Most patients were clustered around 4-11 weeks," Dr. Kim said. "No patient had surgery more than 46 weeks after completing neoadjuvant chemoradiation."
The median interval from completion of neoadjuvant therapy to surgery was 46 days in the short-interval group and 76 days in the delayed group. In both groups, more than 95% of patients were staged with PET-CT and endoscopic ultrasound.
The researchers compared the two groups in terms of perioperative complications, rate of pathological complete response, and overall survival.
The two groups were similar in 18 of 22 baseline characteristics examined, but they were different in four areas. Compared with their counterparts in the short-interval group, the patients in the delayed group were slightly older (mean age, 60 years vs. 57 years, respectively), had more coronary artery disease (17% vs. 7%), had less adenocarcinoma histology (87% vs. 97%), and weighed less (53% with a body mass index of 25 kg/m2 or greater vs. 75% of their counterparts in the short-interval group).
By any objective measure used to gauge the difficulty of the operation, the two groups were similar, including mean OR time (390 minutes in the short-interval group vs. 398 minutes in the delayed group), mean number of lymph nodes removed (21% vs. 20%), and mean estimated blood loss (505 mL vs. 478 mL).
The rates of major complications also were similar between the two groups, including perioperative mortality (2% in the short-interval group vs. 3% in the delayed group), median length of stay (11 days in each group), and rate of anastomotic leak (11% vs. 16%).
The rate of pathological complete response was similar between the two groups (21% vs. 23%).
Overall 5-year survival in the short-interval group was 46%, compared with 36% in the delayed-surgery group, a nonsignificant difference. Disease-free 5-year survival in the short-interval group was 44%, compared with 36% in the delayed group.
"The timing of surgery, both as a continuous and a dichotomous variable, was not associated" with perioperative complication or death, pathological complete response, or overall survival, Dr. Kim added.
On multivariable analysis, older age, more involved lymph nodes, and advanced pathological stage were independently associated with decreased survival.
The researchers performed a subgroup analysis of patients with adenocarcinoma histology and found that the results were similar.
Dr. Kim said that he had no relevant financial disclosures.
Delaying Esophagectomy After CXRT May Be Okay, Study Finds
FROM THE ANNUAL MEETING OF THE SOCIETY OF THORACIC SURGEONS
SAN DIEGO - An interval between neoadjuvant chemoradiation and esophagectomy that extends beyond 8 weeks is not associated with increased perioperative complications, increased pathological complete response, or change in overall survival, results from a long-term single-center study showed.
"For patients who have not yet recovered from neoadjuvant chemoradiation, it is safe to delay surgery to allow them to improve their performance status," Dr. Jae Y. Kim said at the meeting.
Traditionally, he said, surgery has been recommended within 8 weeks after completing neoadjuvant chemoradiation for esophageal cancer, yet many patients choose to delay their surgery.
Some patients have not yet recovered from chemoradiation, while others are delayed for personal or logistical reasons, explained Dr. Kim, a thoracic surgery fellow at the University of Texas M.D. Anderson Cancer Center, Houston. "The impact of this delay on outcomes is unknown." Radiation-induced tumor necrosis increases over time, he said, and there is evidence from rectal cancer that a longer interval may increase the rate of pathological complete response. "On the other hand, there are theoretical concerns that this delay may lead to increased radiation fibrosis and cause a more difficult operation. It is also possible that a delay would allow for tumor regrowth."
In an effort to determine whether an increased interval between chemoradiation and surgery is associated with risk of major perioperative complications or overall survival, Dr. Kim and his associates conducted a retrospective study of 266 patients with esophageal cancer followed by neoadjuvant chemoradiation who were treated at M.D. Anderson in 2002-2008. They divided the patients into two groups: a "short-interval" group of 150 who underwent esophagectomy within 8 weeks of chemoradiation, and a "delayed" group of 116 who underwent esophagectomy more than 8 weeks following chemoradiation.
"Most patients were clustered around 4-11 weeks," Dr. Kim said. "No patient had surgery more than 46 weeks after completing neoadjuvant chemoradiation."
The median interval from completion of neoadjuvant therapy to surgery was 46 days in the short-interval group and 76 days in the delayed group. In both groups, more than 95% of patients were staged with PET-CT and endoscopic ultrasound.
The researchers compared the two groups in terms of perioperative complications, rate of pathological complete response, and overall survival.
The two groups were similar in 18 of 22 baseline characteristics examined, but they were different in four areas. Compared with their counterparts in the short-interval group, the patients in the delayed group were slightly older (mean age, 60 years vs. 57 years, respectively), had more coronary artery disease (17% vs. 7%), had less adenocarcinoma histology (87% vs. 97%), and weighed less (53% with a body mass index of 25 kg/m2 or greater vs. 75% of their counterparts in the short-interval group).
By any objective measure used to gauge the difficulty of the operation, the two groups were similar, including mean OR time (390 minutes in the short-interval group vs. 398 minutes in the delayed group), mean number of lymph nodes removed (21% vs. 20%), and mean estimated blood loss (505 mL vs. 478 mL).
The rates of major complications also were similar between the two groups, including perioperative mortality (2% in the short-interval group vs. 3% in the delayed group), median length of stay (11 days in each group), and rate of anastomotic leak (11% vs. 16%).
The rate of pathological complete response was similar between the two groups (21% vs. 23%).
Overall 5-year survival in the short-interval group was 46%, compared with 36% in the delayed-surgery group, a nonsignificant difference. Disease-free 5-year survival in the short-interval group was 44%, compared with 36% in the delayed group.
"The timing of surgery, both as a continuous and a dichotomous variable, was not associated" with perioperative complication or death, pathological complete response, or overall survival, Dr. Kim added.
On multivariable analysis, older age, more involved lymph nodes, and advanced pathological stage were independently associated with decreased survival.
The researchers performed a subgroup analysis of patients with adenocarcinoma histology and found that the results were similar.
Dr. Kim said that he had no relevant financial disclosures.
The authors point out that it is often difficult to standardize timing of esophagectomy in this setting because of a variety of difficult-to-anticipate events, particularly induction therapy toxicities. That most patients still had their esophagectomies performed by 3 months following the end of therapy suggests that the two groups might not be expected to be vastly different, although it is comforting to now have data to support this contention. Perhaps a future study might be to compare morbidity/mortality of esophagectomy following induction therapy versus that performed as a salvage strategy for patients who have failed chemoradiotherapy as definitive treatment. Those two groups are far more distinct. Late local recurrence following definitive chemoradiation therapy is, unfortunately, not that uncommon and has few other treatment options.
Dr. Sudish Murthy is an ACS Fellow and surgical director of the Center for Major Airway Disease, Cleveland Clinic.
The authors point out that it is often difficult to standardize timing of esophagectomy in this setting because of a variety of difficult-to-anticipate events, particularly induction therapy toxicities. That most patients still had their esophagectomies performed by 3 months following the end of therapy suggests that the two groups might not be expected to be vastly different, although it is comforting to now have data to support this contention. Perhaps a future study might be to compare morbidity/mortality of esophagectomy following induction therapy versus that performed as a salvage strategy for patients who have failed chemoradiotherapy as definitive treatment. Those two groups are far more distinct. Late local recurrence following definitive chemoradiation therapy is, unfortunately, not that uncommon and has few other treatment options.
Dr. Sudish Murthy is an ACS Fellow and surgical director of the Center for Major Airway Disease, Cleveland Clinic.
The authors point out that it is often difficult to standardize timing of esophagectomy in this setting because of a variety of difficult-to-anticipate events, particularly induction therapy toxicities. That most patients still had their esophagectomies performed by 3 months following the end of therapy suggests that the two groups might not be expected to be vastly different, although it is comforting to now have data to support this contention. Perhaps a future study might be to compare morbidity/mortality of esophagectomy following induction therapy versus that performed as a salvage strategy for patients who have failed chemoradiotherapy as definitive treatment. Those two groups are far more distinct. Late local recurrence following definitive chemoradiation therapy is, unfortunately, not that uncommon and has few other treatment options.
Dr. Sudish Murthy is an ACS Fellow and surgical director of the Center for Major Airway Disease, Cleveland Clinic.
FROM THE ANNUAL MEETING OF THE SOCIETY OF THORACIC SURGEONS
SAN DIEGO - An interval between neoadjuvant chemoradiation and esophagectomy that extends beyond 8 weeks is not associated with increased perioperative complications, increased pathological complete response, or change in overall survival, results from a long-term single-center study showed.
"For patients who have not yet recovered from neoadjuvant chemoradiation, it is safe to delay surgery to allow them to improve their performance status," Dr. Jae Y. Kim said at the meeting.
Traditionally, he said, surgery has been recommended within 8 weeks after completing neoadjuvant chemoradiation for esophageal cancer, yet many patients choose to delay their surgery.
Some patients have not yet recovered from chemoradiation, while others are delayed for personal or logistical reasons, explained Dr. Kim, a thoracic surgery fellow at the University of Texas M.D. Anderson Cancer Center, Houston. "The impact of this delay on outcomes is unknown." Radiation-induced tumor necrosis increases over time, he said, and there is evidence from rectal cancer that a longer interval may increase the rate of pathological complete response. "On the other hand, there are theoretical concerns that this delay may lead to increased radiation fibrosis and cause a more difficult operation. It is also possible that a delay would allow for tumor regrowth."
In an effort to determine whether an increased interval between chemoradiation and surgery is associated with risk of major perioperative complications or overall survival, Dr. Kim and his associates conducted a retrospective study of 266 patients with esophageal cancer followed by neoadjuvant chemoradiation who were treated at M.D. Anderson in 2002-2008. They divided the patients into two groups: a "short-interval" group of 150 who underwent esophagectomy within 8 weeks of chemoradiation, and a "delayed" group of 116 who underwent esophagectomy more than 8 weeks following chemoradiation.
"Most patients were clustered around 4-11 weeks," Dr. Kim said. "No patient had surgery more than 46 weeks after completing neoadjuvant chemoradiation."
The median interval from completion of neoadjuvant therapy to surgery was 46 days in the short-interval group and 76 days in the delayed group. In both groups, more than 95% of patients were staged with PET-CT and endoscopic ultrasound.
The researchers compared the two groups in terms of perioperative complications, rate of pathological complete response, and overall survival.
The two groups were similar in 18 of 22 baseline characteristics examined, but they were different in four areas. Compared with their counterparts in the short-interval group, the patients in the delayed group were slightly older (mean age, 60 years vs. 57 years, respectively), had more coronary artery disease (17% vs. 7%), had less adenocarcinoma histology (87% vs. 97%), and weighed less (53% with a body mass index of 25 kg/m2 or greater vs. 75% of their counterparts in the short-interval group).
By any objective measure used to gauge the difficulty of the operation, the two groups were similar, including mean OR time (390 minutes in the short-interval group vs. 398 minutes in the delayed group), mean number of lymph nodes removed (21% vs. 20%), and mean estimated blood loss (505 mL vs. 478 mL).
The rates of major complications also were similar between the two groups, including perioperative mortality (2% in the short-interval group vs. 3% in the delayed group), median length of stay (11 days in each group), and rate of anastomotic leak (11% vs. 16%).
The rate of pathological complete response was similar between the two groups (21% vs. 23%).
Overall 5-year survival in the short-interval group was 46%, compared with 36% in the delayed-surgery group, a nonsignificant difference. Disease-free 5-year survival in the short-interval group was 44%, compared with 36% in the delayed group.
"The timing of surgery, both as a continuous and a dichotomous variable, was not associated" with perioperative complication or death, pathological complete response, or overall survival, Dr. Kim added.
On multivariable analysis, older age, more involved lymph nodes, and advanced pathological stage were independently associated with decreased survival.
The researchers performed a subgroup analysis of patients with adenocarcinoma histology and found that the results were similar.
Dr. Kim said that he had no relevant financial disclosures.
FROM THE ANNUAL MEETING OF THE SOCIETY OF THORACIC SURGEONS
SAN DIEGO - An interval between neoadjuvant chemoradiation and esophagectomy that extends beyond 8 weeks is not associated with increased perioperative complications, increased pathological complete response, or change in overall survival, results from a long-term single-center study showed.
"For patients who have not yet recovered from neoadjuvant chemoradiation, it is safe to delay surgery to allow them to improve their performance status," Dr. Jae Y. Kim said at the meeting.
Traditionally, he said, surgery has been recommended within 8 weeks after completing neoadjuvant chemoradiation for esophageal cancer, yet many patients choose to delay their surgery.
Some patients have not yet recovered from chemoradiation, while others are delayed for personal or logistical reasons, explained Dr. Kim, a thoracic surgery fellow at the University of Texas M.D. Anderson Cancer Center, Houston. "The impact of this delay on outcomes is unknown." Radiation-induced tumor necrosis increases over time, he said, and there is evidence from rectal cancer that a longer interval may increase the rate of pathological complete response. "On the other hand, there are theoretical concerns that this delay may lead to increased radiation fibrosis and cause a more difficult operation. It is also possible that a delay would allow for tumor regrowth."
In an effort to determine whether an increased interval between chemoradiation and surgery is associated with risk of major perioperative complications or overall survival, Dr. Kim and his associates conducted a retrospective study of 266 patients with esophageal cancer followed by neoadjuvant chemoradiation who were treated at M.D. Anderson in 2002-2008. They divided the patients into two groups: a "short-interval" group of 150 who underwent esophagectomy within 8 weeks of chemoradiation, and a "delayed" group of 116 who underwent esophagectomy more than 8 weeks following chemoradiation.
"Most patients were clustered around 4-11 weeks," Dr. Kim said. "No patient had surgery more than 46 weeks after completing neoadjuvant chemoradiation."
The median interval from completion of neoadjuvant therapy to surgery was 46 days in the short-interval group and 76 days in the delayed group. In both groups, more than 95% of patients were staged with PET-CT and endoscopic ultrasound.
The researchers compared the two groups in terms of perioperative complications, rate of pathological complete response, and overall survival.
The two groups were similar in 18 of 22 baseline characteristics examined, but they were different in four areas. Compared with their counterparts in the short-interval group, the patients in the delayed group were slightly older (mean age, 60 years vs. 57 years, respectively), had more coronary artery disease (17% vs. 7%), had less adenocarcinoma histology (87% vs. 97%), and weighed less (53% with a body mass index of 25 kg/m2 or greater vs. 75% of their counterparts in the short-interval group).
By any objective measure used to gauge the difficulty of the operation, the two groups were similar, including mean OR time (390 minutes in the short-interval group vs. 398 minutes in the delayed group), mean number of lymph nodes removed (21% vs. 20%), and mean estimated blood loss (505 mL vs. 478 mL).
The rates of major complications also were similar between the two groups, including perioperative mortality (2% in the short-interval group vs. 3% in the delayed group), median length of stay (11 days in each group), and rate of anastomotic leak (11% vs. 16%).
The rate of pathological complete response was similar between the two groups (21% vs. 23%).
Overall 5-year survival in the short-interval group was 46%, compared with 36% in the delayed-surgery group, a nonsignificant difference. Disease-free 5-year survival in the short-interval group was 44%, compared with 36% in the delayed group.
"The timing of surgery, both as a continuous and a dichotomous variable, was not associated" with perioperative complication or death, pathological complete response, or overall survival, Dr. Kim added.
On multivariable analysis, older age, more involved lymph nodes, and advanced pathological stage were independently associated with decreased survival.
The researchers performed a subgroup analysis of patients with adenocarcinoma histology and found that the results were similar.
Dr. Kim said that he had no relevant financial disclosures.
MIE Oncologically Safe, Gave Better Postop Outcomes
A minimally invasive esophagectomy resulted in improved postoperative outcomes and a complete resection rate (R0) that was just as high as with open surgery, plus a significantly greater harvest of lymph nodes.
Compared with those who had open surgery, patients who underwent the minimally invasive surgery had significantly less blood loss, shorter hospital stays, and fewer major complications, said Dr. Adam C. Berger at the annual meeting of the Southern Surgical Association.
Although further studies are needed to confirm the benefits of such an approach, "Our current practice is to attempt minimally invasive esophagectomies in all patients," said Dr. Berger of the Kimmel Cancer Center at the Thomas Jefferson University Hospital in Philadelphia.
He and his colleagues presented a retrospective study comparing surgical and oncologic outcomes in two groups of patients with esophageal cancer. This comprised 65 patients who underwent esophagectomy with a thoracoscopic component (11 thoracoscopy/laparotomy, 2 Ivor-Lewis thoracoscopy/laparoscopy, and 52 three-hole thoracoscopy/laparoscopy) compared with 53 patients who underwent open surgery (15 Ivor-Lewis and 38 three-hole esophagectomy) during the same time period.
Mean patient age was 61 years. Neoadjuvant therapy was administered in 28 (43%) of the minimally invasive esophagectomy (MIE) group and 43 (81%) of the open surgery group. Adenocarcinoma was present in most patients (85% MIE and 74% open). Squamous cell carcinoma occurred in 6% of the MIE group and 26% of the open group; there were five cases (8%) of high-grade dysplasia in the MIE group. One patient had MIE for esophageal melanoma.
During the thoracoscopy, Dr. Berger uses 10-mm ports in the anterior axillary line at the fourth and eighth intercostal spaces and at the posterior axillary line. "A 5-mm port is placed at the tip of the scapula, and a suction port can be placed between the ports in the anterior axillary line," he said. "Finally, a suture is placed in the tendinous portion of the diaphragm to maintain retraction."
He uses a Penrose drain to encircle and retract the esophagus. The azygous vein is divided, and the aortic branches are divided or clipped. "The subcarinal lymph node package is dissected under direct vision and removed, and paraesophageal lymph nodes and tissue dissected up with the specimen."
During the subsequent laparoscopy, he places a 5-mm port in the right lateral subcostal area to accommodate a liver retractor, a 12-mm port in the umbilicus for the camera, an additional 12-mm working port in the right subcostal region, and a 5-mm port in the left subcostal region. "Once the gastric mobilization is complete, we often enlarge the 12-mm right subcostal port to about 5 cm and place a Lap Disk."
After dissecting the neck, he isolates and divides the esophagus. The completed reconstruction involves sewing the tip of the gastric tube to the chest tube and pulling that tube back up into the neck for a side-to-side esophagectomy. Anastomosis is in the neck with the gastric tube in the posterior mediastinum.
Mortality was similar in both groups of patients (8%). While the overall rate of complications was not significantly different (48% MIE vs. 60% open), the rate of major complications was (20% vs. 41%). Respiratory failure or acute respiratory distress syndrome occurred in a significantly smaller percentage of MIE patients (8% vs. 21%). There were also fewer cases of pneumonia among the MIE patients, but this was not a significant difference (8% vs. 18%). "Interestingly, there was a significant increase in the number of patients with a deep venous thrombosis or pulmonary embolism in the open group (2% vs. 11%)," Dr. Berger said. "This may have something to do with earlier postoperative mobilization for patients with MIE."
MIE patients also fared significantly better in terms of blood loss (182 mL vs. 619 mL) and median length of stay (9 vs. 16 days). Oncologic outcomes were as good as, or better than, those seen in open surgery. "There was no difference in R0 resection rates," Dr. Berger pointed out (97% MIE vs. 94% open). "We also saw a more than doubling of the number of examined lymph nodes in the MIE group, which was highly significant (20 vs. 9; P less than .0001)."
Dr. Berger pointed out a major limitation of the study. Because his group attempts the MIE approach in all patients, "It's impossible to find a concurrent group of patients who had open surgery for comparison." Also, he noted, "Pathology standards have changed and, thus, the importance of lymph nodes has become more recognized. Higher node yields are shown to be an important prognostic factor for survival. Therefore, our pathologists are now more diligent in finding the lymph nodes in the specimen."
Dr. Berger had no disclosures.
The authors report that the complete resection rates (R0) were similar between patients who underwent minimally invasive esophagectomy (MIE) and those who underwent an open transthoracic esophagectomy (more than 94%). However, the number of lymph nodes resected was significantly higher in the MIE group, which had fewer serious complications and a shorter length of hospital stay. In their conclusion, the authors highlight similar R0 resection rates, improved lymphadenectomy, and improved perioperative outcomes with a minimally invasive approach.
This is an interesting study, but it has some important limitations. First, it is a retrospective comparison, not a randomized study. The approaches were adopted in different time periods with potential differences in practice patterns - such as pathologic evaluation of specimens or policies regarding hospital discharge - that may have accounted for some of the differences observed. Second, although the open and MIE groups were matched for age and gender, there may be important differences between them. Neoadjuvant chemoradiation was used nearly twice as often in the open transthoracic group as in the MIE group, and this different rate might confound the analysis because it may reflect a more advanced clinical stage and be associated with an increase in perioperative complications.
The 8% mortality appears high, compared with recent series. For example, mortality was 2% in the multicenter MIE trial conducted by the Eastern Cooperative Oncology Group (ECOG 2202). Although the authors describe oncologic efficacy in terms of completeness of resection, the lack of longer-term outcome data on recurrence and survival is a major limitation.
Dr. James D. Luketich is Henry T. Bahnson Professor and chairman, department of cardiothoracic surgery, University of Pittsburgh Medical Center.
The authors report that the complete resection rates (R0) were similar between patients who underwent minimally invasive esophagectomy (MIE) and those who underwent an open transthoracic esophagectomy (more than 94%). However, the number of lymph nodes resected was significantly higher in the MIE group, which had fewer serious complications and a shorter length of hospital stay. In their conclusion, the authors highlight similar R0 resection rates, improved lymphadenectomy, and improved perioperative outcomes with a minimally invasive approach.
This is an interesting study, but it has some important limitations. First, it is a retrospective comparison, not a randomized study. The approaches were adopted in different time periods with potential differences in practice patterns - such as pathologic evaluation of specimens or policies regarding hospital discharge - that may have accounted for some of the differences observed. Second, although the open and MIE groups were matched for age and gender, there may be important differences between them. Neoadjuvant chemoradiation was used nearly twice as often in the open transthoracic group as in the MIE group, and this different rate might confound the analysis because it may reflect a more advanced clinical stage and be associated with an increase in perioperative complications.
The 8% mortality appears high, compared with recent series. For example, mortality was 2% in the multicenter MIE trial conducted by the Eastern Cooperative Oncology Group (ECOG 2202). Although the authors describe oncologic efficacy in terms of completeness of resection, the lack of longer-term outcome data on recurrence and survival is a major limitation.
Dr. James D. Luketich is Henry T. Bahnson Professor and chairman, department of cardiothoracic surgery, University of Pittsburgh Medical Center.
The authors report that the complete resection rates (R0) were similar between patients who underwent minimally invasive esophagectomy (MIE) and those who underwent an open transthoracic esophagectomy (more than 94%). However, the number of lymph nodes resected was significantly higher in the MIE group, which had fewer serious complications and a shorter length of hospital stay. In their conclusion, the authors highlight similar R0 resection rates, improved lymphadenectomy, and improved perioperative outcomes with a minimally invasive approach.
This is an interesting study, but it has some important limitations. First, it is a retrospective comparison, not a randomized study. The approaches were adopted in different time periods with potential differences in practice patterns - such as pathologic evaluation of specimens or policies regarding hospital discharge - that may have accounted for some of the differences observed. Second, although the open and MIE groups were matched for age and gender, there may be important differences between them. Neoadjuvant chemoradiation was used nearly twice as often in the open transthoracic group as in the MIE group, and this different rate might confound the analysis because it may reflect a more advanced clinical stage and be associated with an increase in perioperative complications.
The 8% mortality appears high, compared with recent series. For example, mortality was 2% in the multicenter MIE trial conducted by the Eastern Cooperative Oncology Group (ECOG 2202). Although the authors describe oncologic efficacy in terms of completeness of resection, the lack of longer-term outcome data on recurrence and survival is a major limitation.
Dr. James D. Luketich is Henry T. Bahnson Professor and chairman, department of cardiothoracic surgery, University of Pittsburgh Medical Center.
A minimally invasive esophagectomy resulted in improved postoperative outcomes and a complete resection rate (R0) that was just as high as with open surgery, plus a significantly greater harvest of lymph nodes.
Compared with those who had open surgery, patients who underwent the minimally invasive surgery had significantly less blood loss, shorter hospital stays, and fewer major complications, said Dr. Adam C. Berger at the annual meeting of the Southern Surgical Association.
Although further studies are needed to confirm the benefits of such an approach, "Our current practice is to attempt minimally invasive esophagectomies in all patients," said Dr. Berger of the Kimmel Cancer Center at the Thomas Jefferson University Hospital in Philadelphia.
He and his colleagues presented a retrospective study comparing surgical and oncologic outcomes in two groups of patients with esophageal cancer. This comprised 65 patients who underwent esophagectomy with a thoracoscopic component (11 thoracoscopy/laparotomy, 2 Ivor-Lewis thoracoscopy/laparoscopy, and 52 three-hole thoracoscopy/laparoscopy) compared with 53 patients who underwent open surgery (15 Ivor-Lewis and 38 three-hole esophagectomy) during the same time period.
Mean patient age was 61 years. Neoadjuvant therapy was administered in 28 (43%) of the minimally invasive esophagectomy (MIE) group and 43 (81%) of the open surgery group. Adenocarcinoma was present in most patients (85% MIE and 74% open). Squamous cell carcinoma occurred in 6% of the MIE group and 26% of the open group; there were five cases (8%) of high-grade dysplasia in the MIE group. One patient had MIE for esophageal melanoma.
During the thoracoscopy, Dr. Berger uses 10-mm ports in the anterior axillary line at the fourth and eighth intercostal spaces and at the posterior axillary line. "A 5-mm port is placed at the tip of the scapula, and a suction port can be placed between the ports in the anterior axillary line," he said. "Finally, a suture is placed in the tendinous portion of the diaphragm to maintain retraction."
He uses a Penrose drain to encircle and retract the esophagus. The azygous vein is divided, and the aortic branches are divided or clipped. "The subcarinal lymph node package is dissected under direct vision and removed, and paraesophageal lymph nodes and tissue dissected up with the specimen."
During the subsequent laparoscopy, he places a 5-mm port in the right lateral subcostal area to accommodate a liver retractor, a 12-mm port in the umbilicus for the camera, an additional 12-mm working port in the right subcostal region, and a 5-mm port in the left subcostal region. "Once the gastric mobilization is complete, we often enlarge the 12-mm right subcostal port to about 5 cm and place a Lap Disk."
After dissecting the neck, he isolates and divides the esophagus. The completed reconstruction involves sewing the tip of the gastric tube to the chest tube and pulling that tube back up into the neck for a side-to-side esophagectomy. Anastomosis is in the neck with the gastric tube in the posterior mediastinum.
Mortality was similar in both groups of patients (8%). While the overall rate of complications was not significantly different (48% MIE vs. 60% open), the rate of major complications was (20% vs. 41%). Respiratory failure or acute respiratory distress syndrome occurred in a significantly smaller percentage of MIE patients (8% vs. 21%). There were also fewer cases of pneumonia among the MIE patients, but this was not a significant difference (8% vs. 18%). "Interestingly, there was a significant increase in the number of patients with a deep venous thrombosis or pulmonary embolism in the open group (2% vs. 11%)," Dr. Berger said. "This may have something to do with earlier postoperative mobilization for patients with MIE."
MIE patients also fared significantly better in terms of blood loss (182 mL vs. 619 mL) and median length of stay (9 vs. 16 days). Oncologic outcomes were as good as, or better than, those seen in open surgery. "There was no difference in R0 resection rates," Dr. Berger pointed out (97% MIE vs. 94% open). "We also saw a more than doubling of the number of examined lymph nodes in the MIE group, which was highly significant (20 vs. 9; P less than .0001)."
Dr. Berger pointed out a major limitation of the study. Because his group attempts the MIE approach in all patients, "It's impossible to find a concurrent group of patients who had open surgery for comparison." Also, he noted, "Pathology standards have changed and, thus, the importance of lymph nodes has become more recognized. Higher node yields are shown to be an important prognostic factor for survival. Therefore, our pathologists are now more diligent in finding the lymph nodes in the specimen."
Dr. Berger had no disclosures.
A minimally invasive esophagectomy resulted in improved postoperative outcomes and a complete resection rate (R0) that was just as high as with open surgery, plus a significantly greater harvest of lymph nodes.
Compared with those who had open surgery, patients who underwent the minimally invasive surgery had significantly less blood loss, shorter hospital stays, and fewer major complications, said Dr. Adam C. Berger at the annual meeting of the Southern Surgical Association.
Although further studies are needed to confirm the benefits of such an approach, "Our current practice is to attempt minimally invasive esophagectomies in all patients," said Dr. Berger of the Kimmel Cancer Center at the Thomas Jefferson University Hospital in Philadelphia.
He and his colleagues presented a retrospective study comparing surgical and oncologic outcomes in two groups of patients with esophageal cancer. This comprised 65 patients who underwent esophagectomy with a thoracoscopic component (11 thoracoscopy/laparotomy, 2 Ivor-Lewis thoracoscopy/laparoscopy, and 52 three-hole thoracoscopy/laparoscopy) compared with 53 patients who underwent open surgery (15 Ivor-Lewis and 38 three-hole esophagectomy) during the same time period.
Mean patient age was 61 years. Neoadjuvant therapy was administered in 28 (43%) of the minimally invasive esophagectomy (MIE) group and 43 (81%) of the open surgery group. Adenocarcinoma was present in most patients (85% MIE and 74% open). Squamous cell carcinoma occurred in 6% of the MIE group and 26% of the open group; there were five cases (8%) of high-grade dysplasia in the MIE group. One patient had MIE for esophageal melanoma.
During the thoracoscopy, Dr. Berger uses 10-mm ports in the anterior axillary line at the fourth and eighth intercostal spaces and at the posterior axillary line. "A 5-mm port is placed at the tip of the scapula, and a suction port can be placed between the ports in the anterior axillary line," he said. "Finally, a suture is placed in the tendinous portion of the diaphragm to maintain retraction."
He uses a Penrose drain to encircle and retract the esophagus. The azygous vein is divided, and the aortic branches are divided or clipped. "The subcarinal lymph node package is dissected under direct vision and removed, and paraesophageal lymph nodes and tissue dissected up with the specimen."
During the subsequent laparoscopy, he places a 5-mm port in the right lateral subcostal area to accommodate a liver retractor, a 12-mm port in the umbilicus for the camera, an additional 12-mm working port in the right subcostal region, and a 5-mm port in the left subcostal region. "Once the gastric mobilization is complete, we often enlarge the 12-mm right subcostal port to about 5 cm and place a Lap Disk."
After dissecting the neck, he isolates and divides the esophagus. The completed reconstruction involves sewing the tip of the gastric tube to the chest tube and pulling that tube back up into the neck for a side-to-side esophagectomy. Anastomosis is in the neck with the gastric tube in the posterior mediastinum.
Mortality was similar in both groups of patients (8%). While the overall rate of complications was not significantly different (48% MIE vs. 60% open), the rate of major complications was (20% vs. 41%). Respiratory failure or acute respiratory distress syndrome occurred in a significantly smaller percentage of MIE patients (8% vs. 21%). There were also fewer cases of pneumonia among the MIE patients, but this was not a significant difference (8% vs. 18%). "Interestingly, there was a significant increase in the number of patients with a deep venous thrombosis or pulmonary embolism in the open group (2% vs. 11%)," Dr. Berger said. "This may have something to do with earlier postoperative mobilization for patients with MIE."
MIE patients also fared significantly better in terms of blood loss (182 mL vs. 619 mL) and median length of stay (9 vs. 16 days). Oncologic outcomes were as good as, or better than, those seen in open surgery. "There was no difference in R0 resection rates," Dr. Berger pointed out (97% MIE vs. 94% open). "We also saw a more than doubling of the number of examined lymph nodes in the MIE group, which was highly significant (20 vs. 9; P less than .0001)."
Dr. Berger pointed out a major limitation of the study. Because his group attempts the MIE approach in all patients, "It's impossible to find a concurrent group of patients who had open surgery for comparison." Also, he noted, "Pathology standards have changed and, thus, the importance of lymph nodes has become more recognized. Higher node yields are shown to be an important prognostic factor for survival. Therefore, our pathologists are now more diligent in finding the lymph nodes in the specimen."
Dr. Berger had no disclosures.
MIE Oncologically Safe, Gave Better Postop Outcomes
A minimally invasive esophagectomy resulted in improved postoperative outcomes and a complete resection rate (R0) that was just as high as with open surgery, plus a significantly greater harvest of lymph nodes.
Compared with those who had open surgery, patients who underwent the minimally invasive surgery had significantly less blood loss, shorter hospital stays, and fewer major complications, said Dr. Adam C. Berger at the annual meeting of the Southern Surgical Association.
Although further studies are needed to confirm the benefits of such an approach, "Our current practice is to attempt minimally invasive esophagectomies in all patients," said Dr. Berger of the Kimmel Cancer Center at the Thomas Jefferson University Hospital in Philadelphia.
He and his colleagues presented a retrospective study comparing surgical and oncologic outcomes in two groups of patients with esophageal cancer. This comprised 65 patients who underwent esophagectomy with a thoracoscopic component (11 thoracoscopy/laparotomy, 2 Ivor-Lewis thoracoscopy/laparoscopy, and 52 three-hole thoracoscopy/laparoscopy) compared with 53 patients who underwent open surgery (15 Ivor-Lewis and 38 three-hole esophagectomy) during the same time period.
Mean patient age was 61 years. Neoadjuvant therapy was administered in 28 (43%) of the minimally invasive esophagectomy (MIE) group and 43 (81%) of the open surgery group. Adenocarcinoma was present in most patients (85% MIE and 74% open). Squamous cell carcinoma occurred in 6% of the MIE group and 26% of the open group; there were five cases (8%) of high-grade dysplasia in the MIE group. One patient had MIE for esophageal melanoma.
During the thoracoscopy, Dr. Berger uses 10-mm ports in the anterior axillary line at the fourth and eighth intercostal spaces and at the posterior axillary line. "A 5-mm port is placed at the tip of the scapula, and a suction port can be placed between the ports in the anterior axillary line," he said. "Finally, a suture is placed in the tendinous portion of the diaphragm to maintain retraction."
He uses a Penrose drain to encircle and retract the esophagus. The azygous vein is divided, and the aortic branches are divided or clipped. "The subcarinal lymph node package is dissected under direct vision and removed, and paraesophageal lymph nodes and tissue dissected up with the specimen."
During the subsequent laparoscopy, he places a 5-mm port in the right lateral subcostal area to accommodate a liver retractor, a 12-mm port in the umbilicus for the camera, an additional 12-mm working port in the right subcostal region, and a 5-mm port in the left subcostal region. "Once the gastric mobilization is complete, we often enlarge the 12-mm right subcostal port to about 5 cm and place a Lap Disk."
After dissecting the neck, he isolates and divides the esophagus. The completed reconstruction involves sewing the tip of the gastric tube to the chest tube and pulling that tube back up into the neck for a side-to-side esophagectomy. Anastomosis is in the neck with the gastric tube in the posterior mediastinum.
Mortality was similar in both groups of patients (8%). While the overall rate of complications was not significantly different (48% MIE vs. 60% open), the rate of major complications was (20% vs. 41%). Respiratory failure or acute respiratory distress syndrome occurred in a significantly smaller percentage of MIE patients (8% vs. 21%). There were also fewer cases of pneumonia among the MIE patients, but this was not a significant difference (8% vs. 18%). "Interestingly, there was a significant increase in the number of patients with a deep venous thrombosis or pulmonary embolism in the open group (2% vs. 11%)," Dr. Berger said. "This may have something to do with earlier postoperative mobilization for patients with MIE."
MIE patients also fared significantly better in terms of blood loss (182 mL vs. 619 mL) and median length of stay (9 vs. 16 days). Oncologic outcomes were as good as, or better than, those seen in open surgery. "There was no difference in R0 resection rates," Dr. Berger pointed out (97% MIE vs. 94% open). "We also saw a more than doubling of the number of examined lymph nodes in the MIE group, which was highly significant (20 vs. 9; P less than .0001)."
Dr. Berger pointed out a major limitation of the study. Because his group attempts the MIE approach in all patients, "It's impossible to find a concurrent group of patients who had open surgery for comparison." Also, he noted, "Pathology standards have changed and, thus, the importance of lymph nodes has become more recognized. Higher node yields are shown to be an important prognostic factor for survival. Therefore, our pathologists are now more diligent in finding the lymph nodes in the specimen."
Dr. Berger had no disclosures.
The authors report that the complete resection rates (R0) were similar between patients who underwent minimally invasive esophagectomy (MIE) and those who underwent an open transthoracic esophagectomy (more than 94%). However, the number of lymph nodes resected was significantly higher in the MIE group, which had fewer serious complications and a shorter length of hospital stay. In their conclusion, the authors highlight similar R0 resection rates, improved lymphadenectomy, and improved perioperative outcomes with a minimally invasive approach.
This is an interesting study, but it has some important limitations. First, it is a retrospective comparison, not a randomized study. The approaches were adopted in different time periods with potential differences in practice patterns - such as pathologic evaluation of specimens or policies regarding hospital discharge - that may have accounted for some of the differences observed. Second, although the open and MIE groups were matched for age and gender, there may be important differences between them. Neoadjuvant chemoradiation was used nearly twice as often in the open transthoracic group as in the MIE group, and this different rate might confound the analysis because it may reflect a more advanced clinical stage and be associated with an increase in perioperative complications.
The 8% mortality appears high, compared with recent series. For example, mortality was 2% in the multicenter MIE trial conducted by the Eastern Cooperative Oncology Group (ECOG 2202). Although the authors describe oncologic efficacy in terms of completeness of resection, the lack of longer-term outcome data on recurrence and survival is a major limitation.
Dr. James D. Luketich is Henry T. Bahnson Professor and chairman, department of cardiothoracic surgery, University of Pittsburgh Medical Center.
The authors report that the complete resection rates (R0) were similar between patients who underwent minimally invasive esophagectomy (MIE) and those who underwent an open transthoracic esophagectomy (more than 94%). However, the number of lymph nodes resected was significantly higher in the MIE group, which had fewer serious complications and a shorter length of hospital stay. In their conclusion, the authors highlight similar R0 resection rates, improved lymphadenectomy, and improved perioperative outcomes with a minimally invasive approach.
This is an interesting study, but it has some important limitations. First, it is a retrospective comparison, not a randomized study. The approaches were adopted in different time periods with potential differences in practice patterns - such as pathologic evaluation of specimens or policies regarding hospital discharge - that may have accounted for some of the differences observed. Second, although the open and MIE groups were matched for age and gender, there may be important differences between them. Neoadjuvant chemoradiation was used nearly twice as often in the open transthoracic group as in the MIE group, and this different rate might confound the analysis because it may reflect a more advanced clinical stage and be associated with an increase in perioperative complications.
The 8% mortality appears high, compared with recent series. For example, mortality was 2% in the multicenter MIE trial conducted by the Eastern Cooperative Oncology Group (ECOG 2202). Although the authors describe oncologic efficacy in terms of completeness of resection, the lack of longer-term outcome data on recurrence and survival is a major limitation.
Dr. James D. Luketich is Henry T. Bahnson Professor and chairman, department of cardiothoracic surgery, University of Pittsburgh Medical Center.
The authors report that the complete resection rates (R0) were similar between patients who underwent minimally invasive esophagectomy (MIE) and those who underwent an open transthoracic esophagectomy (more than 94%). However, the number of lymph nodes resected was significantly higher in the MIE group, which had fewer serious complications and a shorter length of hospital stay. In their conclusion, the authors highlight similar R0 resection rates, improved lymphadenectomy, and improved perioperative outcomes with a minimally invasive approach.
This is an interesting study, but it has some important limitations. First, it is a retrospective comparison, not a randomized study. The approaches were adopted in different time periods with potential differences in practice patterns - such as pathologic evaluation of specimens or policies regarding hospital discharge - that may have accounted for some of the differences observed. Second, although the open and MIE groups were matched for age and gender, there may be important differences between them. Neoadjuvant chemoradiation was used nearly twice as often in the open transthoracic group as in the MIE group, and this different rate might confound the analysis because it may reflect a more advanced clinical stage and be associated with an increase in perioperative complications.
The 8% mortality appears high, compared with recent series. For example, mortality was 2% in the multicenter MIE trial conducted by the Eastern Cooperative Oncology Group (ECOG 2202). Although the authors describe oncologic efficacy in terms of completeness of resection, the lack of longer-term outcome data on recurrence and survival is a major limitation.
Dr. James D. Luketich is Henry T. Bahnson Professor and chairman, department of cardiothoracic surgery, University of Pittsburgh Medical Center.
A minimally invasive esophagectomy resulted in improved postoperative outcomes and a complete resection rate (R0) that was just as high as with open surgery, plus a significantly greater harvest of lymph nodes.
Compared with those who had open surgery, patients who underwent the minimally invasive surgery had significantly less blood loss, shorter hospital stays, and fewer major complications, said Dr. Adam C. Berger at the annual meeting of the Southern Surgical Association.
Although further studies are needed to confirm the benefits of such an approach, "Our current practice is to attempt minimally invasive esophagectomies in all patients," said Dr. Berger of the Kimmel Cancer Center at the Thomas Jefferson University Hospital in Philadelphia.
He and his colleagues presented a retrospective study comparing surgical and oncologic outcomes in two groups of patients with esophageal cancer. This comprised 65 patients who underwent esophagectomy with a thoracoscopic component (11 thoracoscopy/laparotomy, 2 Ivor-Lewis thoracoscopy/laparoscopy, and 52 three-hole thoracoscopy/laparoscopy) compared with 53 patients who underwent open surgery (15 Ivor-Lewis and 38 three-hole esophagectomy) during the same time period.
Mean patient age was 61 years. Neoadjuvant therapy was administered in 28 (43%) of the minimally invasive esophagectomy (MIE) group and 43 (81%) of the open surgery group. Adenocarcinoma was present in most patients (85% MIE and 74% open). Squamous cell carcinoma occurred in 6% of the MIE group and 26% of the open group; there were five cases (8%) of high-grade dysplasia in the MIE group. One patient had MIE for esophageal melanoma.
During the thoracoscopy, Dr. Berger uses 10-mm ports in the anterior axillary line at the fourth and eighth intercostal spaces and at the posterior axillary line. "A 5-mm port is placed at the tip of the scapula, and a suction port can be placed between the ports in the anterior axillary line," he said. "Finally, a suture is placed in the tendinous portion of the diaphragm to maintain retraction."
He uses a Penrose drain to encircle and retract the esophagus. The azygous vein is divided, and the aortic branches are divided or clipped. "The subcarinal lymph node package is dissected under direct vision and removed, and paraesophageal lymph nodes and tissue dissected up with the specimen."
During the subsequent laparoscopy, he places a 5-mm port in the right lateral subcostal area to accommodate a liver retractor, a 12-mm port in the umbilicus for the camera, an additional 12-mm working port in the right subcostal region, and a 5-mm port in the left subcostal region. "Once the gastric mobilization is complete, we often enlarge the 12-mm right subcostal port to about 5 cm and place a Lap Disk."
After dissecting the neck, he isolates and divides the esophagus. The completed reconstruction involves sewing the tip of the gastric tube to the chest tube and pulling that tube back up into the neck for a side-to-side esophagectomy. Anastomosis is in the neck with the gastric tube in the posterior mediastinum.
Mortality was similar in both groups of patients (8%). While the overall rate of complications was not significantly different (48% MIE vs. 60% open), the rate of major complications was (20% vs. 41%). Respiratory failure or acute respiratory distress syndrome occurred in a significantly smaller percentage of MIE patients (8% vs. 21%). There were also fewer cases of pneumonia among the MIE patients, but this was not a significant difference (8% vs. 18%). "Interestingly, there was a significant increase in the number of patients with a deep venous thrombosis or pulmonary embolism in the open group (2% vs. 11%)," Dr. Berger said. "This may have something to do with earlier postoperative mobilization for patients with MIE."
MIE patients also fared significantly better in terms of blood loss (182 mL vs. 619 mL) and median length of stay (9 vs. 16 days). Oncologic outcomes were as good as, or better than, those seen in open surgery. "There was no difference in R0 resection rates," Dr. Berger pointed out (97% MIE vs. 94% open). "We also saw a more than doubling of the number of examined lymph nodes in the MIE group, which was highly significant (20 vs. 9; P less than .0001)."
Dr. Berger pointed out a major limitation of the study. Because his group attempts the MIE approach in all patients, "It's impossible to find a concurrent group of patients who had open surgery for comparison." Also, he noted, "Pathology standards have changed and, thus, the importance of lymph nodes has become more recognized. Higher node yields are shown to be an important prognostic factor for survival. Therefore, our pathologists are now more diligent in finding the lymph nodes in the specimen."
Dr. Berger had no disclosures.
A minimally invasive esophagectomy resulted in improved postoperative outcomes and a complete resection rate (R0) that was just as high as with open surgery, plus a significantly greater harvest of lymph nodes.
Compared with those who had open surgery, patients who underwent the minimally invasive surgery had significantly less blood loss, shorter hospital stays, and fewer major complications, said Dr. Adam C. Berger at the annual meeting of the Southern Surgical Association.
Although further studies are needed to confirm the benefits of such an approach, "Our current practice is to attempt minimally invasive esophagectomies in all patients," said Dr. Berger of the Kimmel Cancer Center at the Thomas Jefferson University Hospital in Philadelphia.
He and his colleagues presented a retrospective study comparing surgical and oncologic outcomes in two groups of patients with esophageal cancer. This comprised 65 patients who underwent esophagectomy with a thoracoscopic component (11 thoracoscopy/laparotomy, 2 Ivor-Lewis thoracoscopy/laparoscopy, and 52 three-hole thoracoscopy/laparoscopy) compared with 53 patients who underwent open surgery (15 Ivor-Lewis and 38 three-hole esophagectomy) during the same time period.
Mean patient age was 61 years. Neoadjuvant therapy was administered in 28 (43%) of the minimally invasive esophagectomy (MIE) group and 43 (81%) of the open surgery group. Adenocarcinoma was present in most patients (85% MIE and 74% open). Squamous cell carcinoma occurred in 6% of the MIE group and 26% of the open group; there were five cases (8%) of high-grade dysplasia in the MIE group. One patient had MIE for esophageal melanoma.
During the thoracoscopy, Dr. Berger uses 10-mm ports in the anterior axillary line at the fourth and eighth intercostal spaces and at the posterior axillary line. "A 5-mm port is placed at the tip of the scapula, and a suction port can be placed between the ports in the anterior axillary line," he said. "Finally, a suture is placed in the tendinous portion of the diaphragm to maintain retraction."
He uses a Penrose drain to encircle and retract the esophagus. The azygous vein is divided, and the aortic branches are divided or clipped. "The subcarinal lymph node package is dissected under direct vision and removed, and paraesophageal lymph nodes and tissue dissected up with the specimen."
During the subsequent laparoscopy, he places a 5-mm port in the right lateral subcostal area to accommodate a liver retractor, a 12-mm port in the umbilicus for the camera, an additional 12-mm working port in the right subcostal region, and a 5-mm port in the left subcostal region. "Once the gastric mobilization is complete, we often enlarge the 12-mm right subcostal port to about 5 cm and place a Lap Disk."
After dissecting the neck, he isolates and divides the esophagus. The completed reconstruction involves sewing the tip of the gastric tube to the chest tube and pulling that tube back up into the neck for a side-to-side esophagectomy. Anastomosis is in the neck with the gastric tube in the posterior mediastinum.
Mortality was similar in both groups of patients (8%). While the overall rate of complications was not significantly different (48% MIE vs. 60% open), the rate of major complications was (20% vs. 41%). Respiratory failure or acute respiratory distress syndrome occurred in a significantly smaller percentage of MIE patients (8% vs. 21%). There were also fewer cases of pneumonia among the MIE patients, but this was not a significant difference (8% vs. 18%). "Interestingly, there was a significant increase in the number of patients with a deep venous thrombosis or pulmonary embolism in the open group (2% vs. 11%)," Dr. Berger said. "This may have something to do with earlier postoperative mobilization for patients with MIE."
MIE patients also fared significantly better in terms of blood loss (182 mL vs. 619 mL) and median length of stay (9 vs. 16 days). Oncologic outcomes were as good as, or better than, those seen in open surgery. "There was no difference in R0 resection rates," Dr. Berger pointed out (97% MIE vs. 94% open). "We also saw a more than doubling of the number of examined lymph nodes in the MIE group, which was highly significant (20 vs. 9; P less than .0001)."
Dr. Berger pointed out a major limitation of the study. Because his group attempts the MIE approach in all patients, "It's impossible to find a concurrent group of patients who had open surgery for comparison." Also, he noted, "Pathology standards have changed and, thus, the importance of lymph nodes has become more recognized. Higher node yields are shown to be an important prognostic factor for survival. Therefore, our pathologists are now more diligent in finding the lymph nodes in the specimen."
Dr. Berger had no disclosures.
MIE Oncologically Safe, Gave Better Postop Outcomes
A minimally invasive esophagectomy resulted in improved postoperative outcomes and a complete resection rate (R0) that was just as high as with open surgery, plus a significantly greater harvest of lymph nodes.
Compared with those who had open surgery, patients who underwent the minimally invasive surgery had significantly less blood loss, shorter hospital stays, and fewer major complications, said Dr. Adam C. Berger at the annual meeting of the Southern Surgical Association.
Although further studies are needed to confirm the benefits of such an approach, "Our current practice is to attempt minimally invasive esophagectomies in all patients," said Dr. Berger of the Kimmel Cancer Center at the Thomas Jefferson University Hospital in Philadelphia.
He and his colleagues presented a retrospective study comparing surgical and oncologic outcomes in two groups of patients with esophageal cancer. This comprised 65 patients who underwent esophagectomy with a thoracoscopic component (11 thoracoscopy/laparotomy, 2 Ivor-Lewis thoracoscopy/laparoscopy, and 52 three-hole thoracoscopy/laparoscopy) compared with 53 patients who underwent open surgery (15 Ivor-Lewis and 38 three-hole esophagectomy) during the same time period.
Mean patient age was 61 years. Neoadjuvant therapy was administered in 28 (43%) of the minimally invasive esophagectomy (MIE) group and 43 (81%) of the open surgery group. Adenocarcinoma was present in most patients (85% MIE and 74% open). Squamous cell carcinoma occurred in 6% of the MIE group and 26% of the open group; there were five cases (8%) of high-grade dysplasia in the MIE group. One patient had MIE for esophageal melanoma.
During the thoracoscopy, Dr. Berger uses 10-mm ports in the anterior axillary line at the fourth and eighth intercostal spaces and at the posterior axillary line. "A 5-mm port is placed at the tip of the scapula, and a suction port can be placed between the ports in the anterior axillary line," he said. "Finally, a suture is placed in the tendinous portion of the diaphragm to maintain retraction."
He uses a Penrose drain to encircle and retract the esophagus. The azygous vein is divided, and the aortic branches are divided or clipped. "The subcarinal lymph node package is dissected under direct vision and removed, and paraesophageal lymph nodes and tissue dissected up with the specimen."
During the subsequent laparoscopy, he places a 5-mm port in the right lateral subcostal area to accommodate a liver retractor, a 12-mm port in the umbilicus for the camera, an additional 12-mm working port in the right subcostal region, and a 5-mm port in the left subcostal region. "Once the gastric mobilization is complete, we often enlarge the 12-mm right subcostal port to about 5 cm and place a Lap Disk."
After dissecting the neck, he isolates and divides the esophagus. The completed reconstruction involves sewing the tip of the gastric tube to the chest tube and pulling that tube back up into the neck for a side-to-side esophagectomy. Anastomosis is in the neck with the gastric tube in the posterior mediastinum.
Mortality was similar in both groups of patients (8%). While the overall rate of complications was not significantly different (48% MIE vs. 60% open), the rate of major complications was (20% vs. 41%). Respiratory failure or acute respiratory distress syndrome occurred in a significantly smaller percentage of MIE patients (8% vs. 21%). There were also fewer cases of pneumonia among the MIE patients, but this was not a significant difference (8% vs. 18%). "Interestingly, there was a significant increase in the number of patients with a deep venous thrombosis or pulmonary embolism in the open group (2% vs. 11%)," Dr. Berger said. "This may have something to do with earlier postoperative mobilization for patients with MIE."
MIE patients also fared significantly better in terms of blood loss (182 mL vs. 619 mL) and median length of stay (9 vs. 16 days). Oncologic outcomes were as good as, or better than, those seen in open surgery. "There was no difference in R0 resection rates," Dr. Berger pointed out (97% MIE vs. 94% open). "We also saw a more than doubling of the number of examined lymph nodes in the MIE group, which was highly significant (20 vs. 9; P less than .0001)."
Dr. Berger pointed out a major limitation of the study. Because his group attempts the MIE approach in all patients, "It's impossible to find a concurrent group of patients who had open surgery for comparison." Also, he noted, "Pathology standards have changed and, thus, the importance of lymph nodes has become more recognized. Higher node yields are shown to be an important prognostic factor for survival. Therefore, our pathologists are now more diligent in finding the lymph nodes in the specimen."
Dr. Berger had no disclosures.
The authors report that the complete resection rates (R0) were similar between patients who underwent minimally invasive esophagectomy (MIE) and those who underwent an open transthoracic esophagectomy (more than 94%). However, the number of lymph nodes resected was significantly higher in the MIE group, which had fewer serious complications and a shorter length of hospital stay. In their conclusion, the authors highlight similar R0 resection rates, improved lymphadenectomy, and improved perioperative outcomes with a minimally invasive approach.
This is an interesting study, but it has some important limitations. First, it is a retrospective comparison, not a randomized study. The approaches were adopted in different time periods with potential differences in practice patterns - such as pathologic evaluation of specimens or policies regarding hospital discharge - that may have accounted for some of the differences observed. Second, although the open and MIE groups were matched for age and gender, there may be important differences between them. Neoadjuvant chemoradiation was used nearly twice as often in the open transthoracic group as in the MIE group, and this different rate might confound the analysis because it may reflect a more advanced clinical stage and be associated with an increase in perioperative complications.
The 8% mortality appears high, compared with recent series. For example, mortality was 2% in the multicenter MIE trial conducted by the Eastern Cooperative Oncology Group (ECOG 2202). Although the authors describe oncologic efficacy in terms of completeness of resection, the lack of longer-term outcome data on recurrence and survival is a major limitation.
Dr. James D. Luketich is Henry T. Bahnson Professor and chairman, department of cardiothoracic surgery, University of Pittsburgh Medical Center.
The authors report that the complete resection rates (R0) were similar between patients who underwent minimally invasive esophagectomy (MIE) and those who underwent an open transthoracic esophagectomy (more than 94%). However, the number of lymph nodes resected was significantly higher in the MIE group, which had fewer serious complications and a shorter length of hospital stay. In their conclusion, the authors highlight similar R0 resection rates, improved lymphadenectomy, and improved perioperative outcomes with a minimally invasive approach.
This is an interesting study, but it has some important limitations. First, it is a retrospective comparison, not a randomized study. The approaches were adopted in different time periods with potential differences in practice patterns - such as pathologic evaluation of specimens or policies regarding hospital discharge - that may have accounted for some of the differences observed. Second, although the open and MIE groups were matched for age and gender, there may be important differences between them. Neoadjuvant chemoradiation was used nearly twice as often in the open transthoracic group as in the MIE group, and this different rate might confound the analysis because it may reflect a more advanced clinical stage and be associated with an increase in perioperative complications.
The 8% mortality appears high, compared with recent series. For example, mortality was 2% in the multicenter MIE trial conducted by the Eastern Cooperative Oncology Group (ECOG 2202). Although the authors describe oncologic efficacy in terms of completeness of resection, the lack of longer-term outcome data on recurrence and survival is a major limitation.
Dr. James D. Luketich is Henry T. Bahnson Professor and chairman, department of cardiothoracic surgery, University of Pittsburgh Medical Center.
The authors report that the complete resection rates (R0) were similar between patients who underwent minimally invasive esophagectomy (MIE) and those who underwent an open transthoracic esophagectomy (more than 94%). However, the number of lymph nodes resected was significantly higher in the MIE group, which had fewer serious complications and a shorter length of hospital stay. In their conclusion, the authors highlight similar R0 resection rates, improved lymphadenectomy, and improved perioperative outcomes with a minimally invasive approach.
This is an interesting study, but it has some important limitations. First, it is a retrospective comparison, not a randomized study. The approaches were adopted in different time periods with potential differences in practice patterns - such as pathologic evaluation of specimens or policies regarding hospital discharge - that may have accounted for some of the differences observed. Second, although the open and MIE groups were matched for age and gender, there may be important differences between them. Neoadjuvant chemoradiation was used nearly twice as often in the open transthoracic group as in the MIE group, and this different rate might confound the analysis because it may reflect a more advanced clinical stage and be associated with an increase in perioperative complications.
The 8% mortality appears high, compared with recent series. For example, mortality was 2% in the multicenter MIE trial conducted by the Eastern Cooperative Oncology Group (ECOG 2202). Although the authors describe oncologic efficacy in terms of completeness of resection, the lack of longer-term outcome data on recurrence and survival is a major limitation.
Dr. James D. Luketich is Henry T. Bahnson Professor and chairman, department of cardiothoracic surgery, University of Pittsburgh Medical Center.
A minimally invasive esophagectomy resulted in improved postoperative outcomes and a complete resection rate (R0) that was just as high as with open surgery, plus a significantly greater harvest of lymph nodes.
Compared with those who had open surgery, patients who underwent the minimally invasive surgery had significantly less blood loss, shorter hospital stays, and fewer major complications, said Dr. Adam C. Berger at the annual meeting of the Southern Surgical Association.
Although further studies are needed to confirm the benefits of such an approach, "Our current practice is to attempt minimally invasive esophagectomies in all patients," said Dr. Berger of the Kimmel Cancer Center at the Thomas Jefferson University Hospital in Philadelphia.
He and his colleagues presented a retrospective study comparing surgical and oncologic outcomes in two groups of patients with esophageal cancer. This comprised 65 patients who underwent esophagectomy with a thoracoscopic component (11 thoracoscopy/laparotomy, 2 Ivor-Lewis thoracoscopy/laparoscopy, and 52 three-hole thoracoscopy/laparoscopy) compared with 53 patients who underwent open surgery (15 Ivor-Lewis and 38 three-hole esophagectomy) during the same time period.
Mean patient age was 61 years. Neoadjuvant therapy was administered in 28 (43%) of the minimally invasive esophagectomy (MIE) group and 43 (81%) of the open surgery group. Adenocarcinoma was present in most patients (85% MIE and 74% open). Squamous cell carcinoma occurred in 6% of the MIE group and 26% of the open group; there were five cases (8%) of high-grade dysplasia in the MIE group. One patient had MIE for esophageal melanoma.
During the thoracoscopy, Dr. Berger uses 10-mm ports in the anterior axillary line at the fourth and eighth intercostal spaces and at the posterior axillary line. "A 5-mm port is placed at the tip of the scapula, and a suction port can be placed between the ports in the anterior axillary line," he said. "Finally, a suture is placed in the tendinous portion of the diaphragm to maintain retraction."
He uses a Penrose drain to encircle and retract the esophagus. The azygous vein is divided, and the aortic branches are divided or clipped. "The subcarinal lymph node package is dissected under direct vision and removed, and paraesophageal lymph nodes and tissue dissected up with the specimen."
During the subsequent laparoscopy, he places a 5-mm port in the right lateral subcostal area to accommodate a liver retractor, a 12-mm port in the umbilicus for the camera, an additional 12-mm working port in the right subcostal region, and a 5-mm port in the left subcostal region. "Once the gastric mobilization is complete, we often enlarge the 12-mm right subcostal port to about 5 cm and place a Lap Disk."
After dissecting the neck, he isolates and divides the esophagus. The completed reconstruction involves sewing the tip of the gastric tube to the chest tube and pulling that tube back up into the neck for a side-to-side esophagectomy. Anastomosis is in the neck with the gastric tube in the posterior mediastinum.
Mortality was similar in both groups of patients (8%). While the overall rate of complications was not significantly different (48% MIE vs. 60% open), the rate of major complications was (20% vs. 41%). Respiratory failure or acute respiratory distress syndrome occurred in a significantly smaller percentage of MIE patients (8% vs. 21%). There were also fewer cases of pneumonia among the MIE patients, but this was not a significant difference (8% vs. 18%). "Interestingly, there was a significant increase in the number of patients with a deep venous thrombosis or pulmonary embolism in the open group (2% vs. 11%)," Dr. Berger said. "This may have something to do with earlier postoperative mobilization for patients with MIE."
MIE patients also fared significantly better in terms of blood loss (182 mL vs. 619 mL) and median length of stay (9 vs. 16 days). Oncologic outcomes were as good as, or better than, those seen in open surgery. "There was no difference in R0 resection rates," Dr. Berger pointed out (97% MIE vs. 94% open). "We also saw a more than doubling of the number of examined lymph nodes in the MIE group, which was highly significant (20 vs. 9; P less than .0001)."
Dr. Berger pointed out a major limitation of the study. Because his group attempts the MIE approach in all patients, "It's impossible to find a concurrent group of patients who had open surgery for comparison." Also, he noted, "Pathology standards have changed and, thus, the importance of lymph nodes has become more recognized. Higher node yields are shown to be an important prognostic factor for survival. Therefore, our pathologists are now more diligent in finding the lymph nodes in the specimen."
Dr. Berger had no disclosures.
A minimally invasive esophagectomy resulted in improved postoperative outcomes and a complete resection rate (R0) that was just as high as with open surgery, plus a significantly greater harvest of lymph nodes.
Compared with those who had open surgery, patients who underwent the minimally invasive surgery had significantly less blood loss, shorter hospital stays, and fewer major complications, said Dr. Adam C. Berger at the annual meeting of the Southern Surgical Association.
Although further studies are needed to confirm the benefits of such an approach, "Our current practice is to attempt minimally invasive esophagectomies in all patients," said Dr. Berger of the Kimmel Cancer Center at the Thomas Jefferson University Hospital in Philadelphia.
He and his colleagues presented a retrospective study comparing surgical and oncologic outcomes in two groups of patients with esophageal cancer. This comprised 65 patients who underwent esophagectomy with a thoracoscopic component (11 thoracoscopy/laparotomy, 2 Ivor-Lewis thoracoscopy/laparoscopy, and 52 three-hole thoracoscopy/laparoscopy) compared with 53 patients who underwent open surgery (15 Ivor-Lewis and 38 three-hole esophagectomy) during the same time period.
Mean patient age was 61 years. Neoadjuvant therapy was administered in 28 (43%) of the minimally invasive esophagectomy (MIE) group and 43 (81%) of the open surgery group. Adenocarcinoma was present in most patients (85% MIE and 74% open). Squamous cell carcinoma occurred in 6% of the MIE group and 26% of the open group; there were five cases (8%) of high-grade dysplasia in the MIE group. One patient had MIE for esophageal melanoma.
During the thoracoscopy, Dr. Berger uses 10-mm ports in the anterior axillary line at the fourth and eighth intercostal spaces and at the posterior axillary line. "A 5-mm port is placed at the tip of the scapula, and a suction port can be placed between the ports in the anterior axillary line," he said. "Finally, a suture is placed in the tendinous portion of the diaphragm to maintain retraction."
He uses a Penrose drain to encircle and retract the esophagus. The azygous vein is divided, and the aortic branches are divided or clipped. "The subcarinal lymph node package is dissected under direct vision and removed, and paraesophageal lymph nodes and tissue dissected up with the specimen."
During the subsequent laparoscopy, he places a 5-mm port in the right lateral subcostal area to accommodate a liver retractor, a 12-mm port in the umbilicus for the camera, an additional 12-mm working port in the right subcostal region, and a 5-mm port in the left subcostal region. "Once the gastric mobilization is complete, we often enlarge the 12-mm right subcostal port to about 5 cm and place a Lap Disk."
After dissecting the neck, he isolates and divides the esophagus. The completed reconstruction involves sewing the tip of the gastric tube to the chest tube and pulling that tube back up into the neck for a side-to-side esophagectomy. Anastomosis is in the neck with the gastric tube in the posterior mediastinum.
Mortality was similar in both groups of patients (8%). While the overall rate of complications was not significantly different (48% MIE vs. 60% open), the rate of major complications was (20% vs. 41%). Respiratory failure or acute respiratory distress syndrome occurred in a significantly smaller percentage of MIE patients (8% vs. 21%). There were also fewer cases of pneumonia among the MIE patients, but this was not a significant difference (8% vs. 18%). "Interestingly, there was a significant increase in the number of patients with a deep venous thrombosis or pulmonary embolism in the open group (2% vs. 11%)," Dr. Berger said. "This may have something to do with earlier postoperative mobilization for patients with MIE."
MIE patients also fared significantly better in terms of blood loss (182 mL vs. 619 mL) and median length of stay (9 vs. 16 days). Oncologic outcomes were as good as, or better than, those seen in open surgery. "There was no difference in R0 resection rates," Dr. Berger pointed out (97% MIE vs. 94% open). "We also saw a more than doubling of the number of examined lymph nodes in the MIE group, which was highly significant (20 vs. 9; P less than .0001)."
Dr. Berger pointed out a major limitation of the study. Because his group attempts the MIE approach in all patients, "It's impossible to find a concurrent group of patients who had open surgery for comparison." Also, he noted, "Pathology standards have changed and, thus, the importance of lymph nodes has become more recognized. Higher node yields are shown to be an important prognostic factor for survival. Therefore, our pathologists are now more diligent in finding the lymph nodes in the specimen."
Dr. Berger had no disclosures.
New Adenocarcinoma Classification
A joint effort by three medical groups has enabled a variety of specialists to join pathologists in revising the classification of lung adenocarcinoma, and they've made some major changes.
A new section addresses diagnosis and classification of non-small cell lung carcinoma (NSCLC) in small biopsies and cytology, including criteria to distinguish adenocarcinoma from squamous cell carcinoma.
The new classification also recommends epidermal growth factor receptor (EGFR) mutation testing in patients with advanced lung adenocarcinoma to help predict response to tyrosine kinase inhibitors.
And it dumps the term �bronchioalveolar carcinoma� while elsewhere adding some new terms (adenocarcinoma in situ and minimally invasive adenocarcinoma) in the document published in the February issue of the Journal of Thoracic Oncology (J. Thorac. Oncol. 2011;6:244-85).
The International Association for the Study of Lung Cancer convened the multidisciplinary panel of experts to revise the previous World Health Organization classification of lung adenocarcinoma, with support and scientific oversight from the American Thoracic Society and the European Respiratory Society. Pathologists, oncologists, pulmonologists, radiologists, thoracic surgeons, and molecular biologists joined the effort.
The revisions should make it easier to stratify patients and to individualize treatment, Dr. William D. Travis, chair of the expert panel, said in an interview. The changes also could significantly influence the next revision of the TNM (tumor, node, metastases) staging system, �not only for pathologic staging but also for clinical staging,� said Dr. Travis, a thoracic pathologist at Memorial Sloan-Kettering Cancer Center, New York.
The new section on small biopsies and cytology specimens is especially important because 70% of lung cancers are diagnosed in samples like these, the consensus panel's statement said. New criteria for diagnosing adenocarcinoma vs. squamous cell carcinoma include the use of special stains in difficult cases, and emphasize the importance of preserving tissue for molecular studies.
Dr. Travis outlined three important clinical reasons to distinguish adenocarcinomas from squamous cell carcinoma, especially in advanced disease.
P Patients with advanced lung adenocarcinoma or unspecified NSCLC who test positive for EGFR mutation are more likely to respond to treatment with tyrosine kinase inhibitors than are patients without mutation.
P Patients with adenocarcinoma or unspecific NSCLC are more likely to respond to pemetrexed (Alimta) than are patients with squamous cell carcinoma.
P Bevacizumab is contraindicated in patients with squamous cell carcinoma because it can lead to life-threatening hemorrhage, he said.
The statement attempts to banish the term bronchioloalveolar carcinoma from histopathology because it is used in ways that confuse five distinct categories: adenocarcinoma in situ; minimally invasive adenocarcinoma; lepidic predominant adenocarcinoma; adenocarcinoma that is predominantly invasive with some nonmucinous lepidic component; and invasive mucinous adenocarcinoma.
�Adenocarcinoma in situ� and �minimally invasive adenocarcinoma� appear in the classification for the first time for small solitary adenocarcinomas with either pure lepidic growth or predominant lepidic growth and no more than 5 mm invasion, because these terms identify patients who have nearly a sure shot at disease-free survival after complete resection.
The statement recommends a new approach for classification of resected invasive lung adenocarcinomas using comprehensive histologic subtyping and classification according to the predominant histologic subtype.
�This allows for improved stratification of patients compared to the 2004 WHO classification, and allows for identification of subtypes that have prognostic significance and that can be correlated with molecular findings,� according to Dr. Travis.
Introducing the concept of in situ carcinoma raised the consideration that tumor size measured according to the size of the invasive component may be a better approach than measuring total tumor size in predicting survival for patients with small solitary adenocarcinomas with a lepidic component. This concept potentially could affect both pathologic and clinical staging in the next TNM, he said.
Using CT, prognosis may be better predicted by the size of the solid component in partly solid nodules rather than by total tumor size including the ground-glass component, Dr. Travis explained.
�Hopefully, this will be investigated by lung cancer groups around the world in the next 5 years, so the TNM committee can address this issue in developing the 8th edition of TNM based on validated data,� he said.
One of the consensus committee members, Dr. Giorgio Scagliotti, has received honoraria from Sanofi-Aventis, Roche, Eli Lilly, and AstraZeneca.
Another committee member, Dr. David Yankelevitz, is a named inventor on some patents related to the evaluation of diseases; the patents are licensed to General Electric and may produce compensation if they are commercialized.
The rest of the committee reported no financial conflicts of interest.
A joint effort by three medical groups has enabled a variety of specialists to join pathologists in revising the classification of lung adenocarcinoma, and they've made some major changes.
A new section addresses diagnosis and classification of non-small cell lung carcinoma (NSCLC) in small biopsies and cytology, including criteria to distinguish adenocarcinoma from squamous cell carcinoma.
The new classification also recommends epidermal growth factor receptor (EGFR) mutation testing in patients with advanced lung adenocarcinoma to help predict response to tyrosine kinase inhibitors.
And it dumps the term �bronchioalveolar carcinoma� while elsewhere adding some new terms (adenocarcinoma in situ and minimally invasive adenocarcinoma) in the document published in the February issue of the Journal of Thoracic Oncology (J. Thorac. Oncol. 2011;6:244-85).
The International Association for the Study of Lung Cancer convened the multidisciplinary panel of experts to revise the previous World Health Organization classification of lung adenocarcinoma, with support and scientific oversight from the American Thoracic Society and the European Respiratory Society. Pathologists, oncologists, pulmonologists, radiologists, thoracic surgeons, and molecular biologists joined the effort.
The revisions should make it easier to stratify patients and to individualize treatment, Dr. William D. Travis, chair of the expert panel, said in an interview. The changes also could significantly influence the next revision of the TNM (tumor, node, metastases) staging system, �not only for pathologic staging but also for clinical staging,� said Dr. Travis, a thoracic pathologist at Memorial Sloan-Kettering Cancer Center, New York.
The new section on small biopsies and cytology specimens is especially important because 70% of lung cancers are diagnosed in samples like these, the consensus panel's statement said. New criteria for diagnosing adenocarcinoma vs. squamous cell carcinoma include the use of special stains in difficult cases, and emphasize the importance of preserving tissue for molecular studies.
Dr. Travis outlined three important clinical reasons to distinguish adenocarcinomas from squamous cell carcinoma, especially in advanced disease.
P Patients with advanced lung adenocarcinoma or unspecified NSCLC who test positive for EGFR mutation are more likely to respond to treatment with tyrosine kinase inhibitors than are patients without mutation.
P Patients with adenocarcinoma or unspecific NSCLC are more likely to respond to pemetrexed (Alimta) than are patients with squamous cell carcinoma.
P Bevacizumab is contraindicated in patients with squamous cell carcinoma because it can lead to life-threatening hemorrhage, he said.
The statement attempts to banish the term bronchioloalveolar carcinoma from histopathology because it is used in ways that confuse five distinct categories: adenocarcinoma in situ; minimally invasive adenocarcinoma; lepidic predominant adenocarcinoma; adenocarcinoma that is predominantly invasive with some nonmucinous lepidic component; and invasive mucinous adenocarcinoma.
�Adenocarcinoma in situ� and �minimally invasive adenocarcinoma� appear in the classification for the first time for small solitary adenocarcinomas with either pure lepidic growth or predominant lepidic growth and no more than 5 mm invasion, because these terms identify patients who have nearly a sure shot at disease-free survival after complete resection.
The statement recommends a new approach for classification of resected invasive lung adenocarcinomas using comprehensive histologic subtyping and classification according to the predominant histologic subtype.
�This allows for improved stratification of patients compared to the 2004 WHO classification, and allows for identification of subtypes that have prognostic significance and that can be correlated with molecular findings,� according to Dr. Travis.
Introducing the concept of in situ carcinoma raised the consideration that tumor size measured according to the size of the invasive component may be a better approach than measuring total tumor size in predicting survival for patients with small solitary adenocarcinomas with a lepidic component. This concept potentially could affect both pathologic and clinical staging in the next TNM, he said.
Using CT, prognosis may be better predicted by the size of the solid component in partly solid nodules rather than by total tumor size including the ground-glass component, Dr. Travis explained.
�Hopefully, this will be investigated by lung cancer groups around the world in the next 5 years, so the TNM committee can address this issue in developing the 8th edition of TNM based on validated data,� he said.
One of the consensus committee members, Dr. Giorgio Scagliotti, has received honoraria from Sanofi-Aventis, Roche, Eli Lilly, and AstraZeneca.
Another committee member, Dr. David Yankelevitz, is a named inventor on some patents related to the evaluation of diseases; the patents are licensed to General Electric and may produce compensation if they are commercialized.
The rest of the committee reported no financial conflicts of interest.
A joint effort by three medical groups has enabled a variety of specialists to join pathologists in revising the classification of lung adenocarcinoma, and they've made some major changes.
A new section addresses diagnosis and classification of non-small cell lung carcinoma (NSCLC) in small biopsies and cytology, including criteria to distinguish adenocarcinoma from squamous cell carcinoma.
The new classification also recommends epidermal growth factor receptor (EGFR) mutation testing in patients with advanced lung adenocarcinoma to help predict response to tyrosine kinase inhibitors.
And it dumps the term �bronchioalveolar carcinoma� while elsewhere adding some new terms (adenocarcinoma in situ and minimally invasive adenocarcinoma) in the document published in the February issue of the Journal of Thoracic Oncology (J. Thorac. Oncol. 2011;6:244-85).
The International Association for the Study of Lung Cancer convened the multidisciplinary panel of experts to revise the previous World Health Organization classification of lung adenocarcinoma, with support and scientific oversight from the American Thoracic Society and the European Respiratory Society. Pathologists, oncologists, pulmonologists, radiologists, thoracic surgeons, and molecular biologists joined the effort.
The revisions should make it easier to stratify patients and to individualize treatment, Dr. William D. Travis, chair of the expert panel, said in an interview. The changes also could significantly influence the next revision of the TNM (tumor, node, metastases) staging system, �not only for pathologic staging but also for clinical staging,� said Dr. Travis, a thoracic pathologist at Memorial Sloan-Kettering Cancer Center, New York.
The new section on small biopsies and cytology specimens is especially important because 70% of lung cancers are diagnosed in samples like these, the consensus panel's statement said. New criteria for diagnosing adenocarcinoma vs. squamous cell carcinoma include the use of special stains in difficult cases, and emphasize the importance of preserving tissue for molecular studies.
Dr. Travis outlined three important clinical reasons to distinguish adenocarcinomas from squamous cell carcinoma, especially in advanced disease.
P Patients with advanced lung adenocarcinoma or unspecified NSCLC who test positive for EGFR mutation are more likely to respond to treatment with tyrosine kinase inhibitors than are patients without mutation.
P Patients with adenocarcinoma or unspecific NSCLC are more likely to respond to pemetrexed (Alimta) than are patients with squamous cell carcinoma.
P Bevacizumab is contraindicated in patients with squamous cell carcinoma because it can lead to life-threatening hemorrhage, he said.
The statement attempts to banish the term bronchioloalveolar carcinoma from histopathology because it is used in ways that confuse five distinct categories: adenocarcinoma in situ; minimally invasive adenocarcinoma; lepidic predominant adenocarcinoma; adenocarcinoma that is predominantly invasive with some nonmucinous lepidic component; and invasive mucinous adenocarcinoma.
�Adenocarcinoma in situ� and �minimally invasive adenocarcinoma� appear in the classification for the first time for small solitary adenocarcinomas with either pure lepidic growth or predominant lepidic growth and no more than 5 mm invasion, because these terms identify patients who have nearly a sure shot at disease-free survival after complete resection.
The statement recommends a new approach for classification of resected invasive lung adenocarcinomas using comprehensive histologic subtyping and classification according to the predominant histologic subtype.
�This allows for improved stratification of patients compared to the 2004 WHO classification, and allows for identification of subtypes that have prognostic significance and that can be correlated with molecular findings,� according to Dr. Travis.
Introducing the concept of in situ carcinoma raised the consideration that tumor size measured according to the size of the invasive component may be a better approach than measuring total tumor size in predicting survival for patients with small solitary adenocarcinomas with a lepidic component. This concept potentially could affect both pathologic and clinical staging in the next TNM, he said.
Using CT, prognosis may be better predicted by the size of the solid component in partly solid nodules rather than by total tumor size including the ground-glass component, Dr. Travis explained.
�Hopefully, this will be investigated by lung cancer groups around the world in the next 5 years, so the TNM committee can address this issue in developing the 8th edition of TNM based on validated data,� he said.
One of the consensus committee members, Dr. Giorgio Scagliotti, has received honoraria from Sanofi-Aventis, Roche, Eli Lilly, and AstraZeneca.
Another committee member, Dr. David Yankelevitz, is a named inventor on some patents related to the evaluation of diseases; the patents are licensed to General Electric and may produce compensation if they are commercialized.
The rest of the committee reported no financial conflicts of interest.
New Adenocarcinoma Classification
A joint effort by three medical groups has enabled a variety of specialists to join pathologists in revising the classification of lung adenocarcinoma, and they've made some major changes.
A new section addresses diagnosis and classification of non-small cell lung carcinoma (NSCLC) in small biopsies and cytology, including criteria to distinguish adenocarcinoma from squamous cell carcinoma.
The new classification also recommends epidermal growth factor receptor (EGFR) mutation testing in patients with advanced lung adenocarcinoma to help predict response to tyrosine kinase inhibitors.
And it dumps the term �bronchioalveolar carcinoma� while elsewhere adding some new terms (adenocarcinoma in situ and minimally invasive adenocarcinoma) in the document published in the February issue of the Journal of Thoracic Oncology (J. Thorac. Oncol. 2011;6:244-85).
The International Association for the Study of Lung Cancer convened the multidisciplinary panel of experts to revise the previous World Health Organization classification of lung adenocarcinoma, with support and scientific oversight from the American Thoracic Society and the European Respiratory Society. Pathologists, oncologists, pulmonologists, radiologists, thoracic surgeons, and molecular biologists joined the effort.
The revisions should make it easier to stratify patients and to individualize treatment, Dr. William D. Travis, chair of the expert panel, said in an interview. The changes also could significantly influence the next revision of the TNM (tumor, node, metastases) staging system, �not only for pathologic staging but also for clinical staging,� said Dr. Travis, a thoracic pathologist at Memorial Sloan-Kettering Cancer Center, New York.
The new section on small biopsies and cytology specimens is especially important because 70% of lung cancers are diagnosed in samples like these, the consensus panel's statement said. New criteria for diagnosing adenocarcinoma vs. squamous cell carcinoma include the use of special stains in difficult cases, and emphasize the importance of preserving tissue for molecular studies.
Dr. Travis outlined three important clinical reasons to distinguish adenocarcinomas from squamous cell carcinoma, especially in advanced disease.
P Patients with advanced lung adenocarcinoma or unspecified NSCLC who test positive for EGFR mutation are more likely to respond to treatment with tyrosine kinase inhibitors than are patients without mutation.
P Patients with adenocarcinoma or unspecific NSCLC are more likely to respond to pemetrexed (Alimta) than are patients with squamous cell carcinoma.
P Bevacizumab is contraindicated in patients with squamous cell carcinoma because it can lead to life-threatening hemorrhage, he said.
The statement attempts to banish the term bronchioloalveolar carcinoma from histopathology because it is used in ways that confuse five distinct categories: adenocarcinoma in situ; minimally invasive adenocarcinoma; lepidic predominant adenocarcinoma; adenocarcinoma that is predominantly invasive with some nonmucinous lepidic component; and invasive mucinous adenocarcinoma.
�Adenocarcinoma in situ� and �minimally invasive adenocarcinoma� appear in the classification for the first time for small solitary adenocarcinomas with either pure lepidic growth or predominant lepidic growth and no more than 5 mm invasion, because these terms identify patients who have nearly a sure shot at disease-free survival after complete resection.
The statement recommends a new approach for classification of resected invasive lung adenocarcinomas using comprehensive histologic subtyping and classification according to the predominant histologic subtype.
�This allows for improved stratification of patients compared to the 2004 WHO classification, and allows for identification of subtypes that have prognostic significance and that can be correlated with molecular findings,� according to Dr. Travis.
Introducing the concept of in situ carcinoma raised the consideration that tumor size measured according to the size of the invasive component may be a better approach than measuring total tumor size in predicting survival for patients with small solitary adenocarcinomas with a lepidic component. This concept potentially could affect both pathologic and clinical staging in the next TNM, he said.
Using CT, prognosis may be better predicted by the size of the solid component in partly solid nodules rather than by total tumor size including the ground-glass component, Dr. Travis explained.
�Hopefully, this will be investigated by lung cancer groups around the world in the next 5 years, so the TNM committee can address this issue in developing the 8th edition of TNM based on validated data,� he said.
One of the consensus committee members, Dr. Giorgio Scagliotti, has received honoraria from Sanofi-Aventis, Roche, Eli Lilly, and AstraZeneca.
Another committee member, Dr. David Yankelevitz, is a named inventor on some patents related to the evaluation of diseases; the patents are licensed to General Electric and may produce compensation if they are commercialized.
The rest of the committee reported no financial conflicts of interest.
A joint effort by three medical groups has enabled a variety of specialists to join pathologists in revising the classification of lung adenocarcinoma, and they've made some major changes.
A new section addresses diagnosis and classification of non-small cell lung carcinoma (NSCLC) in small biopsies and cytology, including criteria to distinguish adenocarcinoma from squamous cell carcinoma.
The new classification also recommends epidermal growth factor receptor (EGFR) mutation testing in patients with advanced lung adenocarcinoma to help predict response to tyrosine kinase inhibitors.
And it dumps the term �bronchioalveolar carcinoma� while elsewhere adding some new terms (adenocarcinoma in situ and minimally invasive adenocarcinoma) in the document published in the February issue of the Journal of Thoracic Oncology (J. Thorac. Oncol. 2011;6:244-85).
The International Association for the Study of Lung Cancer convened the multidisciplinary panel of experts to revise the previous World Health Organization classification of lung adenocarcinoma, with support and scientific oversight from the American Thoracic Society and the European Respiratory Society. Pathologists, oncologists, pulmonologists, radiologists, thoracic surgeons, and molecular biologists joined the effort.
The revisions should make it easier to stratify patients and to individualize treatment, Dr. William D. Travis, chair of the expert panel, said in an interview. The changes also could significantly influence the next revision of the TNM (tumor, node, metastases) staging system, �not only for pathologic staging but also for clinical staging,� said Dr. Travis, a thoracic pathologist at Memorial Sloan-Kettering Cancer Center, New York.
The new section on small biopsies and cytology specimens is especially important because 70% of lung cancers are diagnosed in samples like these, the consensus panel's statement said. New criteria for diagnosing adenocarcinoma vs. squamous cell carcinoma include the use of special stains in difficult cases, and emphasize the importance of preserving tissue for molecular studies.
Dr. Travis outlined three important clinical reasons to distinguish adenocarcinomas from squamous cell carcinoma, especially in advanced disease.
P Patients with advanced lung adenocarcinoma or unspecified NSCLC who test positive for EGFR mutation are more likely to respond to treatment with tyrosine kinase inhibitors than are patients without mutation.
P Patients with adenocarcinoma or unspecific NSCLC are more likely to respond to pemetrexed (Alimta) than are patients with squamous cell carcinoma.
P Bevacizumab is contraindicated in patients with squamous cell carcinoma because it can lead to life-threatening hemorrhage, he said.
The statement attempts to banish the term bronchioloalveolar carcinoma from histopathology because it is used in ways that confuse five distinct categories: adenocarcinoma in situ; minimally invasive adenocarcinoma; lepidic predominant adenocarcinoma; adenocarcinoma that is predominantly invasive with some nonmucinous lepidic component; and invasive mucinous adenocarcinoma.
�Adenocarcinoma in situ� and �minimally invasive adenocarcinoma� appear in the classification for the first time for small solitary adenocarcinomas with either pure lepidic growth or predominant lepidic growth and no more than 5 mm invasion, because these terms identify patients who have nearly a sure shot at disease-free survival after complete resection.
The statement recommends a new approach for classification of resected invasive lung adenocarcinomas using comprehensive histologic subtyping and classification according to the predominant histologic subtype.
�This allows for improved stratification of patients compared to the 2004 WHO classification, and allows for identification of subtypes that have prognostic significance and that can be correlated with molecular findings,� according to Dr. Travis.
Introducing the concept of in situ carcinoma raised the consideration that tumor size measured according to the size of the invasive component may be a better approach than measuring total tumor size in predicting survival for patients with small solitary adenocarcinomas with a lepidic component. This concept potentially could affect both pathologic and clinical staging in the next TNM, he said.
Using CT, prognosis may be better predicted by the size of the solid component in partly solid nodules rather than by total tumor size including the ground-glass component, Dr. Travis explained.
�Hopefully, this will be investigated by lung cancer groups around the world in the next 5 years, so the TNM committee can address this issue in developing the 8th edition of TNM based on validated data,� he said.
One of the consensus committee members, Dr. Giorgio Scagliotti, has received honoraria from Sanofi-Aventis, Roche, Eli Lilly, and AstraZeneca.
Another committee member, Dr. David Yankelevitz, is a named inventor on some patents related to the evaluation of diseases; the patents are licensed to General Electric and may produce compensation if they are commercialized.
The rest of the committee reported no financial conflicts of interest.
A joint effort by three medical groups has enabled a variety of specialists to join pathologists in revising the classification of lung adenocarcinoma, and they've made some major changes.
A new section addresses diagnosis and classification of non-small cell lung carcinoma (NSCLC) in small biopsies and cytology, including criteria to distinguish adenocarcinoma from squamous cell carcinoma.
The new classification also recommends epidermal growth factor receptor (EGFR) mutation testing in patients with advanced lung adenocarcinoma to help predict response to tyrosine kinase inhibitors.
And it dumps the term �bronchioalveolar carcinoma� while elsewhere adding some new terms (adenocarcinoma in situ and minimally invasive adenocarcinoma) in the document published in the February issue of the Journal of Thoracic Oncology (J. Thorac. Oncol. 2011;6:244-85).
The International Association for the Study of Lung Cancer convened the multidisciplinary panel of experts to revise the previous World Health Organization classification of lung adenocarcinoma, with support and scientific oversight from the American Thoracic Society and the European Respiratory Society. Pathologists, oncologists, pulmonologists, radiologists, thoracic surgeons, and molecular biologists joined the effort.
The revisions should make it easier to stratify patients and to individualize treatment, Dr. William D. Travis, chair of the expert panel, said in an interview. The changes also could significantly influence the next revision of the TNM (tumor, node, metastases) staging system, �not only for pathologic staging but also for clinical staging,� said Dr. Travis, a thoracic pathologist at Memorial Sloan-Kettering Cancer Center, New York.
The new section on small biopsies and cytology specimens is especially important because 70% of lung cancers are diagnosed in samples like these, the consensus panel's statement said. New criteria for diagnosing adenocarcinoma vs. squamous cell carcinoma include the use of special stains in difficult cases, and emphasize the importance of preserving tissue for molecular studies.
Dr. Travis outlined three important clinical reasons to distinguish adenocarcinomas from squamous cell carcinoma, especially in advanced disease.
P Patients with advanced lung adenocarcinoma or unspecified NSCLC who test positive for EGFR mutation are more likely to respond to treatment with tyrosine kinase inhibitors than are patients without mutation.
P Patients with adenocarcinoma or unspecific NSCLC are more likely to respond to pemetrexed (Alimta) than are patients with squamous cell carcinoma.
P Bevacizumab is contraindicated in patients with squamous cell carcinoma because it can lead to life-threatening hemorrhage, he said.
The statement attempts to banish the term bronchioloalveolar carcinoma from histopathology because it is used in ways that confuse five distinct categories: adenocarcinoma in situ; minimally invasive adenocarcinoma; lepidic predominant adenocarcinoma; adenocarcinoma that is predominantly invasive with some nonmucinous lepidic component; and invasive mucinous adenocarcinoma.
�Adenocarcinoma in situ� and �minimally invasive adenocarcinoma� appear in the classification for the first time for small solitary adenocarcinomas with either pure lepidic growth or predominant lepidic growth and no more than 5 mm invasion, because these terms identify patients who have nearly a sure shot at disease-free survival after complete resection.
The statement recommends a new approach for classification of resected invasive lung adenocarcinomas using comprehensive histologic subtyping and classification according to the predominant histologic subtype.
�This allows for improved stratification of patients compared to the 2004 WHO classification, and allows for identification of subtypes that have prognostic significance and that can be correlated with molecular findings,� according to Dr. Travis.
Introducing the concept of in situ carcinoma raised the consideration that tumor size measured according to the size of the invasive component may be a better approach than measuring total tumor size in predicting survival for patients with small solitary adenocarcinomas with a lepidic component. This concept potentially could affect both pathologic and clinical staging in the next TNM, he said.
Using CT, prognosis may be better predicted by the size of the solid component in partly solid nodules rather than by total tumor size including the ground-glass component, Dr. Travis explained.
�Hopefully, this will be investigated by lung cancer groups around the world in the next 5 years, so the TNM committee can address this issue in developing the 8th edition of TNM based on validated data,� he said.
One of the consensus committee members, Dr. Giorgio Scagliotti, has received honoraria from Sanofi-Aventis, Roche, Eli Lilly, and AstraZeneca.
Another committee member, Dr. David Yankelevitz, is a named inventor on some patents related to the evaluation of diseases; the patents are licensed to General Electric and may produce compensation if they are commercialized.
The rest of the committee reported no financial conflicts of interest.
New Adenocarcinoma Classification
A joint effort by three medical groups has enabled a variety of specialists to join pathologists in revising the classification of lung adenocarcinoma, and they've made some major changes.
A new section addresses diagnosis and classification of non-small cell lung carcinoma (NSCLC) in small biopsies and cytology, including criteria to distinguish adenocarcinoma from squamous cell carcinoma.
The new classification also recommends epidermal growth factor receptor (EGFR) mutation testing in patients with advanced lung adenocarcinoma to help predict response to tyrosine kinase inhibitors.
And it dumps the term �bronchioalveolar carcinoma� while elsewhere adding some new terms (adenocarcinoma in situ and minimally invasive adenocarcinoma) in the document published in the February issue of the Journal of Thoracic Oncology (J. Thorac. Oncol. 2011;6:244-85).
The International Association for the Study of Lung Cancer convened the multidisciplinary panel of experts to revise the previous World Health Organization classification of lung adenocarcinoma, with support and scientific oversight from the American Thoracic Society and the European Respiratory Society. Pathologists, oncologists, pulmonologists, radiologists, thoracic surgeons, and molecular biologists joined the effort.
The revisions should make it easier to stratify patients and to individualize treatment, Dr. William D. Travis, chair of the expert panel, said in an interview. The changes also could significantly influence the next revision of the TNM (tumor, node, metastases) staging system, �not only for pathologic staging but also for clinical staging,� said Dr. Travis, a thoracic pathologist at Memorial Sloan-Kettering Cancer Center, New York.
The new section on small biopsies and cytology specimens is especially important because 70% of lung cancers are diagnosed in samples like these, the consensus panel's statement said. New criteria for diagnosing adenocarcinoma vs. squamous cell carcinoma include the use of special stains in difficult cases, and emphasize the importance of preserving tissue for molecular studies.
Dr. Travis outlined three important clinical reasons to distinguish adenocarcinomas from squamous cell carcinoma, especially in advanced disease.
P Patients with advanced lung adenocarcinoma or unspecified NSCLC who test positive for EGFR mutation are more likely to respond to treatment with tyrosine kinase inhibitors than are patients without mutation.
P Patients with adenocarcinoma or unspecific NSCLC are more likely to respond to pemetrexed (Alimta) than are patients with squamous cell carcinoma.
P Bevacizumab is contraindicated in patients with squamous cell carcinoma because it can lead to life-threatening hemorrhage, he said.
The statement attempts to banish the term bronchioloalveolar carcinoma from histopathology because it is used in ways that confuse five distinct categories: adenocarcinoma in situ; minimally invasive adenocarcinoma; lepidic predominant adenocarcinoma; adenocarcinoma that is predominantly invasive with some nonmucinous lepidic component; and invasive mucinous adenocarcinoma.
�Adenocarcinoma in situ� and �minimally invasive adenocarcinoma� appear in the classification for the first time for small solitary adenocarcinomas with either pure lepidic growth or predominant lepidic growth and no more than 5 mm invasion, because these terms identify patients who have nearly a sure shot at disease-free survival after complete resection.
The statement recommends a new approach for classification of resected invasive lung adenocarcinomas using comprehensive histologic subtyping and classification according to the predominant histologic subtype.
�This allows for improved stratification of patients compared to the 2004 WHO classification, and allows for identification of subtypes that have prognostic significance and that can be correlated with molecular findings,� according to Dr. Travis.
Introducing the concept of in situ carcinoma raised the consideration that tumor size measured according to the size of the invasive component may be a better approach than measuring total tumor size in predicting survival for patients with small solitary adenocarcinomas with a lepidic component. This concept potentially could affect both pathologic and clinical staging in the next TNM, he said.
Using CT, prognosis may be better predicted by the size of the solid component in partly solid nodules rather than by total tumor size including the ground-glass component, Dr. Travis explained.
�Hopefully, this will be investigated by lung cancer groups around the world in the next 5 years, so the TNM committee can address this issue in developing the 8th edition of TNM based on validated data,� he said.
One of the consensus committee members, Dr. Giorgio Scagliotti, has received honoraria from Sanofi-Aventis, Roche, Eli Lilly, and AstraZeneca.
Another committee member, Dr. David Yankelevitz, is a named inventor on some patents related to the evaluation of diseases; the patents are licensed to General Electric and may produce compensation if they are commercialized.
The rest of the committee reported no financial conflicts of interest.
A joint effort by three medical groups has enabled a variety of specialists to join pathologists in revising the classification of lung adenocarcinoma, and they've made some major changes.
A new section addresses diagnosis and classification of non-small cell lung carcinoma (NSCLC) in small biopsies and cytology, including criteria to distinguish adenocarcinoma from squamous cell carcinoma.
The new classification also recommends epidermal growth factor receptor (EGFR) mutation testing in patients with advanced lung adenocarcinoma to help predict response to tyrosine kinase inhibitors.
And it dumps the term �bronchioalveolar carcinoma� while elsewhere adding some new terms (adenocarcinoma in situ and minimally invasive adenocarcinoma) in the document published in the February issue of the Journal of Thoracic Oncology (J. Thorac. Oncol. 2011;6:244-85).
The International Association for the Study of Lung Cancer convened the multidisciplinary panel of experts to revise the previous World Health Organization classification of lung adenocarcinoma, with support and scientific oversight from the American Thoracic Society and the European Respiratory Society. Pathologists, oncologists, pulmonologists, radiologists, thoracic surgeons, and molecular biologists joined the effort.
The revisions should make it easier to stratify patients and to individualize treatment, Dr. William D. Travis, chair of the expert panel, said in an interview. The changes also could significantly influence the next revision of the TNM (tumor, node, metastases) staging system, �not only for pathologic staging but also for clinical staging,� said Dr. Travis, a thoracic pathologist at Memorial Sloan-Kettering Cancer Center, New York.
The new section on small biopsies and cytology specimens is especially important because 70% of lung cancers are diagnosed in samples like these, the consensus panel's statement said. New criteria for diagnosing adenocarcinoma vs. squamous cell carcinoma include the use of special stains in difficult cases, and emphasize the importance of preserving tissue for molecular studies.
Dr. Travis outlined three important clinical reasons to distinguish adenocarcinomas from squamous cell carcinoma, especially in advanced disease.
P Patients with advanced lung adenocarcinoma or unspecified NSCLC who test positive for EGFR mutation are more likely to respond to treatment with tyrosine kinase inhibitors than are patients without mutation.
P Patients with adenocarcinoma or unspecific NSCLC are more likely to respond to pemetrexed (Alimta) than are patients with squamous cell carcinoma.
P Bevacizumab is contraindicated in patients with squamous cell carcinoma because it can lead to life-threatening hemorrhage, he said.
The statement attempts to banish the term bronchioloalveolar carcinoma from histopathology because it is used in ways that confuse five distinct categories: adenocarcinoma in situ; minimally invasive adenocarcinoma; lepidic predominant adenocarcinoma; adenocarcinoma that is predominantly invasive with some nonmucinous lepidic component; and invasive mucinous adenocarcinoma.
�Adenocarcinoma in situ� and �minimally invasive adenocarcinoma� appear in the classification for the first time for small solitary adenocarcinomas with either pure lepidic growth or predominant lepidic growth and no more than 5 mm invasion, because these terms identify patients who have nearly a sure shot at disease-free survival after complete resection.
The statement recommends a new approach for classification of resected invasive lung adenocarcinomas using comprehensive histologic subtyping and classification according to the predominant histologic subtype.
�This allows for improved stratification of patients compared to the 2004 WHO classification, and allows for identification of subtypes that have prognostic significance and that can be correlated with molecular findings,� according to Dr. Travis.
Introducing the concept of in situ carcinoma raised the consideration that tumor size measured according to the size of the invasive component may be a better approach than measuring total tumor size in predicting survival for patients with small solitary adenocarcinomas with a lepidic component. This concept potentially could affect both pathologic and clinical staging in the next TNM, he said.
Using CT, prognosis may be better predicted by the size of the solid component in partly solid nodules rather than by total tumor size including the ground-glass component, Dr. Travis explained.
�Hopefully, this will be investigated by lung cancer groups around the world in the next 5 years, so the TNM committee can address this issue in developing the 8th edition of TNM based on validated data,� he said.
One of the consensus committee members, Dr. Giorgio Scagliotti, has received honoraria from Sanofi-Aventis, Roche, Eli Lilly, and AstraZeneca.
Another committee member, Dr. David Yankelevitz, is a named inventor on some patents related to the evaluation of diseases; the patents are licensed to General Electric and may produce compensation if they are commercialized.
The rest of the committee reported no financial conflicts of interest.
A joint effort by three medical groups has enabled a variety of specialists to join pathologists in revising the classification of lung adenocarcinoma, and they've made some major changes.
A new section addresses diagnosis and classification of non-small cell lung carcinoma (NSCLC) in small biopsies and cytology, including criteria to distinguish adenocarcinoma from squamous cell carcinoma.
The new classification also recommends epidermal growth factor receptor (EGFR) mutation testing in patients with advanced lung adenocarcinoma to help predict response to tyrosine kinase inhibitors.
And it dumps the term �bronchioalveolar carcinoma� while elsewhere adding some new terms (adenocarcinoma in situ and minimally invasive adenocarcinoma) in the document published in the February issue of the Journal of Thoracic Oncology (J. Thorac. Oncol. 2011;6:244-85).
The International Association for the Study of Lung Cancer convened the multidisciplinary panel of experts to revise the previous World Health Organization classification of lung adenocarcinoma, with support and scientific oversight from the American Thoracic Society and the European Respiratory Society. Pathologists, oncologists, pulmonologists, radiologists, thoracic surgeons, and molecular biologists joined the effort.
The revisions should make it easier to stratify patients and to individualize treatment, Dr. William D. Travis, chair of the expert panel, said in an interview. The changes also could significantly influence the next revision of the TNM (tumor, node, metastases) staging system, �not only for pathologic staging but also for clinical staging,� said Dr. Travis, a thoracic pathologist at Memorial Sloan-Kettering Cancer Center, New York.
The new section on small biopsies and cytology specimens is especially important because 70% of lung cancers are diagnosed in samples like these, the consensus panel's statement said. New criteria for diagnosing adenocarcinoma vs. squamous cell carcinoma include the use of special stains in difficult cases, and emphasize the importance of preserving tissue for molecular studies.
Dr. Travis outlined three important clinical reasons to distinguish adenocarcinomas from squamous cell carcinoma, especially in advanced disease.
P Patients with advanced lung adenocarcinoma or unspecified NSCLC who test positive for EGFR mutation are more likely to respond to treatment with tyrosine kinase inhibitors than are patients without mutation.
P Patients with adenocarcinoma or unspecific NSCLC are more likely to respond to pemetrexed (Alimta) than are patients with squamous cell carcinoma.
P Bevacizumab is contraindicated in patients with squamous cell carcinoma because it can lead to life-threatening hemorrhage, he said.
The statement attempts to banish the term bronchioloalveolar carcinoma from histopathology because it is used in ways that confuse five distinct categories: adenocarcinoma in situ; minimally invasive adenocarcinoma; lepidic predominant adenocarcinoma; adenocarcinoma that is predominantly invasive with some nonmucinous lepidic component; and invasive mucinous adenocarcinoma.
�Adenocarcinoma in situ� and �minimally invasive adenocarcinoma� appear in the classification for the first time for small solitary adenocarcinomas with either pure lepidic growth or predominant lepidic growth and no more than 5 mm invasion, because these terms identify patients who have nearly a sure shot at disease-free survival after complete resection.
The statement recommends a new approach for classification of resected invasive lung adenocarcinomas using comprehensive histologic subtyping and classification according to the predominant histologic subtype.
�This allows for improved stratification of patients compared to the 2004 WHO classification, and allows for identification of subtypes that have prognostic significance and that can be correlated with molecular findings,� according to Dr. Travis.
Introducing the concept of in situ carcinoma raised the consideration that tumor size measured according to the size of the invasive component may be a better approach than measuring total tumor size in predicting survival for patients with small solitary adenocarcinomas with a lepidic component. This concept potentially could affect both pathologic and clinical staging in the next TNM, he said.
Using CT, prognosis may be better predicted by the size of the solid component in partly solid nodules rather than by total tumor size including the ground-glass component, Dr. Travis explained.
�Hopefully, this will be investigated by lung cancer groups around the world in the next 5 years, so the TNM committee can address this issue in developing the 8th edition of TNM based on validated data,� he said.
One of the consensus committee members, Dr. Giorgio Scagliotti, has received honoraria from Sanofi-Aventis, Roche, Eli Lilly, and AstraZeneca.
Another committee member, Dr. David Yankelevitz, is a named inventor on some patents related to the evaluation of diseases; the patents are licensed to General Electric and may produce compensation if they are commercialized.
The rest of the committee reported no financial conflicts of interest.
Lung Resection Mortality Rate Varies by Surgeon Specialty
SAN DIEGO - General surgeons perform the majority of lung resections for cancer in the United States, yet lung cancer resections performed by thoracic surgeons had significantly lower in-hospital mortality rates than did those performed by general surgeons and cardiac surgeons, according to results of a large analysis of national hospital data.
When performing a lung cancer resection, thoracic surgeons performed lymphadenectomy significantly more often than did general surgeons and cardiac surgeons.
"Lymph node status in lung cancer is the main determinant of stage, prognosis, and need for further therapy," Dr. Michelle Ellis said at the annual meeting of the Society of Thoracic Surgeons.
"The performance of lymphadenectomy at the time of lung cancer resection can be considered a process measure of quality."
Previously published studies have demonstrated that general surgeons perform the majority of thoracic cases in the United States, while surgeons who specialize in thoracic surgery have lower perioperative morbidity and mortality.
"Furthermore, patients who have their lung resection performed by a board-certified cardiothoracic surgeon specializing in general thoracic surgery have longer overall and cancer-specific survival," said Dr. Ellis of Oregon Health and Science University, Portland.
"We hypothesized that the completeness of intraoperative oncologic staging at the time of primary lung cancer resection varies by surgeon specialty, and may explain the observed differences in outcome."
To test the hypothesis, Dr. Ellis, with the assistance of Dr. Paul H. Schipper and Dr. John T. Vetto, reviewed 222,233 primary lung cancer cases from the Nationwide Inpatient Sample from 1998 to 2007 who were treated surgically with limited lung resection, lobectomy, or pneumonectomy.
The main outcome measure was the presence of lymphadenectomy or mediastinoscopy performed during the same admission.
The researchers divided the surgeons into three main groups based on their case mix of thoracic, cardiac, or other types of surgery. A thoracic surgeon was defined as someone who performed greater than 75% general thoracic surgery operations and less than 10% cardiac operations; a general surgeon was defined as someone who performed fewer than 75% thoracic operations and fewer than 10% cardiac operations, and a cardiac surgeon was defined as someone who performed greater than 10% cardiac operations.
Dr. Ellis reported that lung cancer resections were performed by general surgeons in 62% of cases, by cardiac surgeons in 35% of cases, and by thoracic surgeons in 3% of cases.
The median annual case volume was 21 for thoracic surgeons, 23 for cardiac surgeons, and 8 for general surgeons.
In-hospital mortality rates for thoracic, cardiac, and general surgeons were 2.3%, 3.4%, and 4.0%, respectively. This translated into an odds ratio for in-hospital mortality of 1.33 for cases performed by cardiac surgeons and 1.55 for those performed by general surgeons.
Thoracic surgeons performed lymphadenectomy significantly more often than did their counterparts (73% vs. 55% for both cardiac and general surgeons). Thoracic surgeons also performed mediastinoscopy significantly more often (16% vs. 10% by cardiac surgeons and 11% by general surgeons).
Multivariate analysis revealed that patients were significantly less likely to undergo lymphadenectomy if they were in the lowest two quartiles of household income (odds ratio, 0.74); insured by Medicare (OR, 0.93); received their care at a rural hospital (OR, 0.60) or at an urban nonteaching hospital (OR, 0.74); or had their resection performed by a general surgeon (OR, 0.47) or by a cardiac surgeon (OR, 0.47).
"A patient was more than twice as likely to have a lymphadenectomy performed if the lung cancer resection was performed by a thoracic surgeon," Dr. Ellis said.
Next, the researchers assessed the impact of case volume on their multivariate model. They determined that for every doubling of thoracic surgery case volume, there was a significant increase in the likelihood that a lymphadenectomy would be performed (OR, 1.28).
On the other hand, for every doubling of general surgery case volume, there was a significant decrease in lymphadenectomy rates (OR, 0.95). Doubling of cardiac surgery case volume did not affect lymphadenectomy rates.
"Lymphadenectomy rates for all surgeon groups did improve over the study period," Dr. Ellis said.
"However, despite these improvements, cardiac and general surgeons still have lymphadenectomy rates significantly lower than [those of] cardiac surgeons. The next step is to ensure that all patients receive adequate staging of the mediastinum, possibly through disseminating knowledge, creating centers of excellence, or providing opportunities to learn the skills necessary to perform adequate lung cancer surgery."
She acknowledged certain limitations of the study, including the fact that it contains only single-admission information. "It also has limited cancer-specific data such as stage, and has no mechanism for long-term follow-up," she said. In addition, surgeons are anonymous in the database, so board certification could not be determined.
Dr. Ellis said that she had no relevant financial disclosures to make.
SAN DIEGO - General surgeons perform the majority of lung resections for cancer in the United States, yet lung cancer resections performed by thoracic surgeons had significantly lower in-hospital mortality rates than did those performed by general surgeons and cardiac surgeons, according to results of a large analysis of national hospital data.
When performing a lung cancer resection, thoracic surgeons performed lymphadenectomy significantly more often than did general surgeons and cardiac surgeons.
"Lymph node status in lung cancer is the main determinant of stage, prognosis, and need for further therapy," Dr. Michelle Ellis said at the annual meeting of the Society of Thoracic Surgeons.
"The performance of lymphadenectomy at the time of lung cancer resection can be considered a process measure of quality."
Previously published studies have demonstrated that general surgeons perform the majority of thoracic cases in the United States, while surgeons who specialize in thoracic surgery have lower perioperative morbidity and mortality.
"Furthermore, patients who have their lung resection performed by a board-certified cardiothoracic surgeon specializing in general thoracic surgery have longer overall and cancer-specific survival," said Dr. Ellis of Oregon Health and Science University, Portland.
"We hypothesized that the completeness of intraoperative oncologic staging at the time of primary lung cancer resection varies by surgeon specialty, and may explain the observed differences in outcome."
To test the hypothesis, Dr. Ellis, with the assistance of Dr. Paul H. Schipper and Dr. John T. Vetto, reviewed 222,233 primary lung cancer cases from the Nationwide Inpatient Sample from 1998 to 2007 who were treated surgically with limited lung resection, lobectomy, or pneumonectomy.
The main outcome measure was the presence of lymphadenectomy or mediastinoscopy performed during the same admission.
The researchers divided the surgeons into three main groups based on their case mix of thoracic, cardiac, or other types of surgery. A thoracic surgeon was defined as someone who performed greater than 75% general thoracic surgery operations and less than 10% cardiac operations; a general surgeon was defined as someone who performed fewer than 75% thoracic operations and fewer than 10% cardiac operations, and a cardiac surgeon was defined as someone who performed greater than 10% cardiac operations.
Dr. Ellis reported that lung cancer resections were performed by general surgeons in 62% of cases, by cardiac surgeons in 35% of cases, and by thoracic surgeons in 3% of cases.
The median annual case volume was 21 for thoracic surgeons, 23 for cardiac surgeons, and 8 for general surgeons.
In-hospital mortality rates for thoracic, cardiac, and general surgeons were 2.3%, 3.4%, and 4.0%, respectively. This translated into an odds ratio for in-hospital mortality of 1.33 for cases performed by cardiac surgeons and 1.55 for those performed by general surgeons.
Thoracic surgeons performed lymphadenectomy significantly more often than did their counterparts (73% vs. 55% for both cardiac and general surgeons). Thoracic surgeons also performed mediastinoscopy significantly more often (16% vs. 10% by cardiac surgeons and 11% by general surgeons).
Multivariate analysis revealed that patients were significantly less likely to undergo lymphadenectomy if they were in the lowest two quartiles of household income (odds ratio, 0.74); insured by Medicare (OR, 0.93); received their care at a rural hospital (OR, 0.60) or at an urban nonteaching hospital (OR, 0.74); or had their resection performed by a general surgeon (OR, 0.47) or by a cardiac surgeon (OR, 0.47).
"A patient was more than twice as likely to have a lymphadenectomy performed if the lung cancer resection was performed by a thoracic surgeon," Dr. Ellis said.
Next, the researchers assessed the impact of case volume on their multivariate model. They determined that for every doubling of thoracic surgery case volume, there was a significant increase in the likelihood that a lymphadenectomy would be performed (OR, 1.28).
On the other hand, for every doubling of general surgery case volume, there was a significant decrease in lymphadenectomy rates (OR, 0.95). Doubling of cardiac surgery case volume did not affect lymphadenectomy rates.
"Lymphadenectomy rates for all surgeon groups did improve over the study period," Dr. Ellis said.
"However, despite these improvements, cardiac and general surgeons still have lymphadenectomy rates significantly lower than [those of] cardiac surgeons. The next step is to ensure that all patients receive adequate staging of the mediastinum, possibly through disseminating knowledge, creating centers of excellence, or providing opportunities to learn the skills necessary to perform adequate lung cancer surgery."
She acknowledged certain limitations of the study, including the fact that it contains only single-admission information. "It also has limited cancer-specific data such as stage, and has no mechanism for long-term follow-up," she said. In addition, surgeons are anonymous in the database, so board certification could not be determined.
Dr. Ellis said that she had no relevant financial disclosures to make.
SAN DIEGO - General surgeons perform the majority of lung resections for cancer in the United States, yet lung cancer resections performed by thoracic surgeons had significantly lower in-hospital mortality rates than did those performed by general surgeons and cardiac surgeons, according to results of a large analysis of national hospital data.
When performing a lung cancer resection, thoracic surgeons performed lymphadenectomy significantly more often than did general surgeons and cardiac surgeons.
"Lymph node status in lung cancer is the main determinant of stage, prognosis, and need for further therapy," Dr. Michelle Ellis said at the annual meeting of the Society of Thoracic Surgeons.
"The performance of lymphadenectomy at the time of lung cancer resection can be considered a process measure of quality."
Previously published studies have demonstrated that general surgeons perform the majority of thoracic cases in the United States, while surgeons who specialize in thoracic surgery have lower perioperative morbidity and mortality.
"Furthermore, patients who have their lung resection performed by a board-certified cardiothoracic surgeon specializing in general thoracic surgery have longer overall and cancer-specific survival," said Dr. Ellis of Oregon Health and Science University, Portland.
"We hypothesized that the completeness of intraoperative oncologic staging at the time of primary lung cancer resection varies by surgeon specialty, and may explain the observed differences in outcome."
To test the hypothesis, Dr. Ellis, with the assistance of Dr. Paul H. Schipper and Dr. John T. Vetto, reviewed 222,233 primary lung cancer cases from the Nationwide Inpatient Sample from 1998 to 2007 who were treated surgically with limited lung resection, lobectomy, or pneumonectomy.
The main outcome measure was the presence of lymphadenectomy or mediastinoscopy performed during the same admission.
The researchers divided the surgeons into three main groups based on their case mix of thoracic, cardiac, or other types of surgery. A thoracic surgeon was defined as someone who performed greater than 75% general thoracic surgery operations and less than 10% cardiac operations; a general surgeon was defined as someone who performed fewer than 75% thoracic operations and fewer than 10% cardiac operations, and a cardiac surgeon was defined as someone who performed greater than 10% cardiac operations.
Dr. Ellis reported that lung cancer resections were performed by general surgeons in 62% of cases, by cardiac surgeons in 35% of cases, and by thoracic surgeons in 3% of cases.
The median annual case volume was 21 for thoracic surgeons, 23 for cardiac surgeons, and 8 for general surgeons.
In-hospital mortality rates for thoracic, cardiac, and general surgeons were 2.3%, 3.4%, and 4.0%, respectively. This translated into an odds ratio for in-hospital mortality of 1.33 for cases performed by cardiac surgeons and 1.55 for those performed by general surgeons.
Thoracic surgeons performed lymphadenectomy significantly more often than did their counterparts (73% vs. 55% for both cardiac and general surgeons). Thoracic surgeons also performed mediastinoscopy significantly more often (16% vs. 10% by cardiac surgeons and 11% by general surgeons).
Multivariate analysis revealed that patients were significantly less likely to undergo lymphadenectomy if they were in the lowest two quartiles of household income (odds ratio, 0.74); insured by Medicare (OR, 0.93); received their care at a rural hospital (OR, 0.60) or at an urban nonteaching hospital (OR, 0.74); or had their resection performed by a general surgeon (OR, 0.47) or by a cardiac surgeon (OR, 0.47).
"A patient was more than twice as likely to have a lymphadenectomy performed if the lung cancer resection was performed by a thoracic surgeon," Dr. Ellis said.
Next, the researchers assessed the impact of case volume on their multivariate model. They determined that for every doubling of thoracic surgery case volume, there was a significant increase in the likelihood that a lymphadenectomy would be performed (OR, 1.28).
On the other hand, for every doubling of general surgery case volume, there was a significant decrease in lymphadenectomy rates (OR, 0.95). Doubling of cardiac surgery case volume did not affect lymphadenectomy rates.
"Lymphadenectomy rates for all surgeon groups did improve over the study period," Dr. Ellis said.
"However, despite these improvements, cardiac and general surgeons still have lymphadenectomy rates significantly lower than [those of] cardiac surgeons. The next step is to ensure that all patients receive adequate staging of the mediastinum, possibly through disseminating knowledge, creating centers of excellence, or providing opportunities to learn the skills necessary to perform adequate lung cancer surgery."
She acknowledged certain limitations of the study, including the fact that it contains only single-admission information. "It also has limited cancer-specific data such as stage, and has no mechanism for long-term follow-up," she said. In addition, surgeons are anonymous in the database, so board certification could not be determined.
Dr. Ellis said that she had no relevant financial disclosures to make.
Lung Resection Mortality Rate Varies by Surgeon Specialty
SAN DIEGO - General surgeons perform the majority of lung resections for cancer in the United States, yet lung cancer resections performed by thoracic surgeons had significantly lower in-hospital mortality rates than did those performed by general surgeons and cardiac surgeons, according to results of a large analysis of national hospital data.
When performing a lung cancer resection, thoracic surgeons performed lymphadenectomy significantly more often than did general surgeons and cardiac surgeons.
"Lymph node status in lung cancer is the main determinant of stage, prognosis, and need for further therapy," Dr. Michelle Ellis said at the annual meeting of the Society of Thoracic Surgeons.
"The performance of lymphadenectomy at the time of lung cancer resection can be considered a process measure of quality."
Previously published studies have demonstrated that general surgeons perform the majority of thoracic cases in the United States, while surgeons who specialize in thoracic surgery have lower perioperative morbidity and mortality.
"Furthermore, patients who have their lung resection performed by a board-certified cardiothoracic surgeon specializing in general thoracic surgery have longer overall and cancer-specific survival," said Dr. Ellis of Oregon Health and Science University, Portland.
"We hypothesized that the completeness of intraoperative oncologic staging at the time of primary lung cancer resection varies by surgeon specialty, and may explain the observed differences in outcome."
To test the hypothesis, Dr. Ellis, with the assistance of Dr. Paul H. Schipper and Dr. John T. Vetto, reviewed 222,233 primary lung cancer cases from the Nationwide Inpatient Sample from 1998 to 2007 who were treated surgically with limited lung resection, lobectomy, or pneumonectomy.
The main outcome measure was the presence of lymphadenectomy or mediastinoscopy performed during the same admission.
The researchers divided the surgeons into three main groups based on their case mix of thoracic, cardiac, or other types of surgery. A thoracic surgeon was defined as someone who performed greater than 75% general thoracic surgery operations and less than 10% cardiac operations; a general surgeon was defined as someone who performed fewer than 75% thoracic operations and fewer than 10% cardiac operations, and a cardiac surgeon was defined as someone who performed greater than 10% cardiac operations.
Dr. Ellis reported that lung cancer resections were performed by general surgeons in 62% of cases, by cardiac surgeons in 35% of cases, and by thoracic surgeons in 3% of cases.
The median annual case volume was 21 for thoracic surgeons, 23 for cardiac surgeons, and 8 for general surgeons.
In-hospital mortality rates for thoracic, cardiac, and general surgeons were 2.3%, 3.4%, and 4.0%, respectively. This translated into an odds ratio for in-hospital mortality of 1.33 for cases performed by cardiac surgeons and 1.55 for those performed by general surgeons.
Thoracic surgeons performed lymphadenectomy significantly more often than did their counterparts (73% vs. 55% for both cardiac and general surgeons). Thoracic surgeons also performed mediastinoscopy significantly more often (16% vs. 10% by cardiac surgeons and 11% by general surgeons).
Multivariate analysis revealed that patients were significantly less likely to undergo lymphadenectomy if they were in the lowest two quartiles of household income (odds ratio, 0.74); insured by Medicare (OR, 0.93); received their care at a rural hospital (OR, 0.60) or at an urban nonteaching hospital (OR, 0.74); or had their resection performed by a general surgeon (OR, 0.47) or by a cardiac surgeon (OR, 0.47).
"A patient was more than twice as likely to have a lymphadenectomy performed if the lung cancer resection was performed by a thoracic surgeon," Dr. Ellis said.
Next, the researchers assessed the impact of case volume on their multivariate model. They determined that for every doubling of thoracic surgery case volume, there was a significant increase in the likelihood that a lymphadenectomy would be performed (OR, 1.28).
On the other hand, for every doubling of general surgery case volume, there was a significant decrease in lymphadenectomy rates (OR, 0.95). Doubling of cardiac surgery case volume did not affect lymphadenectomy rates.
"Lymphadenectomy rates for all surgeon groups did improve over the study period," Dr. Ellis said.
"However, despite these improvements, cardiac and general surgeons still have lymphadenectomy rates significantly lower than [those of] cardiac surgeons. The next step is to ensure that all patients receive adequate staging of the mediastinum, possibly through disseminating knowledge, creating centers of excellence, or providing opportunities to learn the skills necessary to perform adequate lung cancer surgery."
She acknowledged certain limitations of the study, including the fact that it contains only single-admission information. "It also has limited cancer-specific data such as stage, and has no mechanism for long-term follow-up," she said. In addition, surgeons are anonymous in the database, so board certification could not be determined.
Dr. Ellis said that she had no relevant financial disclosures to make.
SAN DIEGO - General surgeons perform the majority of lung resections for cancer in the United States, yet lung cancer resections performed by thoracic surgeons had significantly lower in-hospital mortality rates than did those performed by general surgeons and cardiac surgeons, according to results of a large analysis of national hospital data.
When performing a lung cancer resection, thoracic surgeons performed lymphadenectomy significantly more often than did general surgeons and cardiac surgeons.
"Lymph node status in lung cancer is the main determinant of stage, prognosis, and need for further therapy," Dr. Michelle Ellis said at the annual meeting of the Society of Thoracic Surgeons.
"The performance of lymphadenectomy at the time of lung cancer resection can be considered a process measure of quality."
Previously published studies have demonstrated that general surgeons perform the majority of thoracic cases in the United States, while surgeons who specialize in thoracic surgery have lower perioperative morbidity and mortality.
"Furthermore, patients who have their lung resection performed by a board-certified cardiothoracic surgeon specializing in general thoracic surgery have longer overall and cancer-specific survival," said Dr. Ellis of Oregon Health and Science University, Portland.
"We hypothesized that the completeness of intraoperative oncologic staging at the time of primary lung cancer resection varies by surgeon specialty, and may explain the observed differences in outcome."
To test the hypothesis, Dr. Ellis, with the assistance of Dr. Paul H. Schipper and Dr. John T. Vetto, reviewed 222,233 primary lung cancer cases from the Nationwide Inpatient Sample from 1998 to 2007 who were treated surgically with limited lung resection, lobectomy, or pneumonectomy.
The main outcome measure was the presence of lymphadenectomy or mediastinoscopy performed during the same admission.
The researchers divided the surgeons into three main groups based on their case mix of thoracic, cardiac, or other types of surgery. A thoracic surgeon was defined as someone who performed greater than 75% general thoracic surgery operations and less than 10% cardiac operations; a general surgeon was defined as someone who performed fewer than 75% thoracic operations and fewer than 10% cardiac operations, and a cardiac surgeon was defined as someone who performed greater than 10% cardiac operations.
Dr. Ellis reported that lung cancer resections were performed by general surgeons in 62% of cases, by cardiac surgeons in 35% of cases, and by thoracic surgeons in 3% of cases.
The median annual case volume was 21 for thoracic surgeons, 23 for cardiac surgeons, and 8 for general surgeons.
In-hospital mortality rates for thoracic, cardiac, and general surgeons were 2.3%, 3.4%, and 4.0%, respectively. This translated into an odds ratio for in-hospital mortality of 1.33 for cases performed by cardiac surgeons and 1.55 for those performed by general surgeons.
Thoracic surgeons performed lymphadenectomy significantly more often than did their counterparts (73% vs. 55% for both cardiac and general surgeons). Thoracic surgeons also performed mediastinoscopy significantly more often (16% vs. 10% by cardiac surgeons and 11% by general surgeons).
Multivariate analysis revealed that patients were significantly less likely to undergo lymphadenectomy if they were in the lowest two quartiles of household income (odds ratio, 0.74); insured by Medicare (OR, 0.93); received their care at a rural hospital (OR, 0.60) or at an urban nonteaching hospital (OR, 0.74); or had their resection performed by a general surgeon (OR, 0.47) or by a cardiac surgeon (OR, 0.47).
"A patient was more than twice as likely to have a lymphadenectomy performed if the lung cancer resection was performed by a thoracic surgeon," Dr. Ellis said.
Next, the researchers assessed the impact of case volume on their multivariate model. They determined that for every doubling of thoracic surgery case volume, there was a significant increase in the likelihood that a lymphadenectomy would be performed (OR, 1.28).
On the other hand, for every doubling of general surgery case volume, there was a significant decrease in lymphadenectomy rates (OR, 0.95). Doubling of cardiac surgery case volume did not affect lymphadenectomy rates.
"Lymphadenectomy rates for all surgeon groups did improve over the study period," Dr. Ellis said.
"However, despite these improvements, cardiac and general surgeons still have lymphadenectomy rates significantly lower than [those of] cardiac surgeons. The next step is to ensure that all patients receive adequate staging of the mediastinum, possibly through disseminating knowledge, creating centers of excellence, or providing opportunities to learn the skills necessary to perform adequate lung cancer surgery."
She acknowledged certain limitations of the study, including the fact that it contains only single-admission information. "It also has limited cancer-specific data such as stage, and has no mechanism for long-term follow-up," she said. In addition, surgeons are anonymous in the database, so board certification could not be determined.
Dr. Ellis said that she had no relevant financial disclosures to make.
SAN DIEGO - General surgeons perform the majority of lung resections for cancer in the United States, yet lung cancer resections performed by thoracic surgeons had significantly lower in-hospital mortality rates than did those performed by general surgeons and cardiac surgeons, according to results of a large analysis of national hospital data.
When performing a lung cancer resection, thoracic surgeons performed lymphadenectomy significantly more often than did general surgeons and cardiac surgeons.
"Lymph node status in lung cancer is the main determinant of stage, prognosis, and need for further therapy," Dr. Michelle Ellis said at the annual meeting of the Society of Thoracic Surgeons.
"The performance of lymphadenectomy at the time of lung cancer resection can be considered a process measure of quality."
Previously published studies have demonstrated that general surgeons perform the majority of thoracic cases in the United States, while surgeons who specialize in thoracic surgery have lower perioperative morbidity and mortality.
"Furthermore, patients who have their lung resection performed by a board-certified cardiothoracic surgeon specializing in general thoracic surgery have longer overall and cancer-specific survival," said Dr. Ellis of Oregon Health and Science University, Portland.
"We hypothesized that the completeness of intraoperative oncologic staging at the time of primary lung cancer resection varies by surgeon specialty, and may explain the observed differences in outcome."
To test the hypothesis, Dr. Ellis, with the assistance of Dr. Paul H. Schipper and Dr. John T. Vetto, reviewed 222,233 primary lung cancer cases from the Nationwide Inpatient Sample from 1998 to 2007 who were treated surgically with limited lung resection, lobectomy, or pneumonectomy.
The main outcome measure was the presence of lymphadenectomy or mediastinoscopy performed during the same admission.
The researchers divided the surgeons into three main groups based on their case mix of thoracic, cardiac, or other types of surgery. A thoracic surgeon was defined as someone who performed greater than 75% general thoracic surgery operations and less than 10% cardiac operations; a general surgeon was defined as someone who performed fewer than 75% thoracic operations and fewer than 10% cardiac operations, and a cardiac surgeon was defined as someone who performed greater than 10% cardiac operations.
Dr. Ellis reported that lung cancer resections were performed by general surgeons in 62% of cases, by cardiac surgeons in 35% of cases, and by thoracic surgeons in 3% of cases.
The median annual case volume was 21 for thoracic surgeons, 23 for cardiac surgeons, and 8 for general surgeons.
In-hospital mortality rates for thoracic, cardiac, and general surgeons were 2.3%, 3.4%, and 4.0%, respectively. This translated into an odds ratio for in-hospital mortality of 1.33 for cases performed by cardiac surgeons and 1.55 for those performed by general surgeons.
Thoracic surgeons performed lymphadenectomy significantly more often than did their counterparts (73% vs. 55% for both cardiac and general surgeons). Thoracic surgeons also performed mediastinoscopy significantly more often (16% vs. 10% by cardiac surgeons and 11% by general surgeons).
Multivariate analysis revealed that patients were significantly less likely to undergo lymphadenectomy if they were in the lowest two quartiles of household income (odds ratio, 0.74); insured by Medicare (OR, 0.93); received their care at a rural hospital (OR, 0.60) or at an urban nonteaching hospital (OR, 0.74); or had their resection performed by a general surgeon (OR, 0.47) or by a cardiac surgeon (OR, 0.47).
"A patient was more than twice as likely to have a lymphadenectomy performed if the lung cancer resection was performed by a thoracic surgeon," Dr. Ellis said.
Next, the researchers assessed the impact of case volume on their multivariate model. They determined that for every doubling of thoracic surgery case volume, there was a significant increase in the likelihood that a lymphadenectomy would be performed (OR, 1.28).
On the other hand, for every doubling of general surgery case volume, there was a significant decrease in lymphadenectomy rates (OR, 0.95). Doubling of cardiac surgery case volume did not affect lymphadenectomy rates.
"Lymphadenectomy rates for all surgeon groups did improve over the study period," Dr. Ellis said.
"However, despite these improvements, cardiac and general surgeons still have lymphadenectomy rates significantly lower than [those of] cardiac surgeons. The next step is to ensure that all patients receive adequate staging of the mediastinum, possibly through disseminating knowledge, creating centers of excellence, or providing opportunities to learn the skills necessary to perform adequate lung cancer surgery."
She acknowledged certain limitations of the study, including the fact that it contains only single-admission information. "It also has limited cancer-specific data such as stage, and has no mechanism for long-term follow-up," she said. In addition, surgeons are anonymous in the database, so board certification could not be determined.
Dr. Ellis said that she had no relevant financial disclosures to make.