Mark F. Berry

8511 Background: Differences in the use and impact of surgery versus optimal medical management (concurrent chemoradiation) for patients with cT1-2N0M0 SCLC have never been evaluated in population-based studies. Using the National Cancer Data Base (NCDB), we tested the hypothesis that surgery is rarely used but offers a survival advantage over concurrent chemoradiation for patients with cT1-2N0M0 SCLC. Methods: Overall survival (OS) of patients with cT1-2N0M0 SCLC who underwent concurrent chemoradiation versus surgery with adjuvant chemotherapy ± radiation in the NCDB from 2003 to 2011 was assessed using propensity-score-matched analysis. Groups were matched for common prognostic covariates (age, sex, race, year of diagnosis, insurance type, median household income, education, treatment facility type, distance from facility, hospital volume, clinical T status, and Charlson/Deyo comorbidity condition score). Results: Of 4,729 patients who were treated for cT1-2N0M0 SCLC during the study period, 681 (14.4%) patients underwent surgery with adjuvant chemotherapy ± radiation and 1,620 (34.3%) underwent concurrent chemoradiation. After propensity-score matching by surgery with adjuvant chemotherapy with or without radiation versus concurrent chemoradiation, all 12 covariates were well balanced between the surgery (n = 545) and concurrent chemoradiation (n = 545) groups. Surgery was associated with a significantly higher OS than concurrent chemoradiation (5-year OS 48.9% vs 30.0%, log-rank p < .001). To minimize treatment selection bias due to comorbidities, we limited the propensity-matched analysis to 536 patients with no comorbidities; surgery remained significantly associated with a higher OS than concurrent chemoradiation (5-year OS 48.8% vs 30.4%, log-rank p < .01). Conclusions: In a propensity-matched analysis of a national population-based cancer database, surgery with adjuvant chemotherapy ± radiation was found to be used rarely. Patients who underwent surgery with adjuvant chemotherapy ± radiation for node-negative SCLC had improved outcomes when compared to concurrent chemoradiation. These results support an increased role of surgery in multimodality therapy for T1-2N0M0 small cell lung cancer.

Pneumonectomy for benign disease is often complicated by inflammatory processes that obscure operative planes. We reviewed our experience to evaluate the impact of requiring urgent or emergent pneumonectomy on outcomes. All pneumonectomies for benign conditions from 1997 to 2012 at a single institution were retrospectively reviewed. Mortality was assessed using multivariable logistic regression that included laterality, age, and surgery status, which was emergent if performed within 24 hours of initial evaluation, urgent if performed after 24 hours but within the same hospital stay, and otherwise elective. Among 42 pneumonectomies, completion pneumonectomy after previous ipsilateral lung resection was performed in 14 patients (33%). Resection was elective in 22 patients (52%), urgent in 12 (28%), and emergent in 8 (19%). The most common indication was for necrotic lung (n = 12; 29%). Muscle flaps were used in 26 patients (62%). Perioperative mortality for the entire cohort was 29% (n = 12) and was significantly higher when surgery was urgent (5 of 12; 42%) or emergent (5 of 8; 62.5%) compared with elective (2 of 22; 9.1%) (p = 0.03). Requiring urgent or emergent surgery remained a significant predictor of mortality in multivariable analysis (odds ratio 10.4, p = 0.01). Pneumonectomy for benign disease has significant risk for mortality, particularly when not performed electively. Although surgery cannot be planned in the setting of trauma or some situations of acute infection, patients known to have conditions that are likely to require pneumonectomy should be considered for surgery earlier in their disease course, before developing an acute problem that requires urgent or emergent resection.

Treatment patterns and outcomes in a population-based database were examined to identify patients likely to benefit from surgical resection of locally advanced (T3N0–2) non-small-cell lung cancer (NSCLC). Factors predicting the use of surgery for patients with T3N0–2M0 NSCLC in the Surveillance, Epidemiology and End Results (SEER) database from 1988 to 2010 were assessed using a multivariable logistic regression model. Survival was analysed using the Kaplan–Meier approach and Cox proportional hazard models. Propensity matching was used to compare outcomes after surgery and outcomes in patients who refused surgery and underwent radiation therapy (RT). Of 17 378 patients identified for study inclusion [8597 (50%) T3N0, 2304 (13%) T3N1 and 6477 (37%) T3N2], surgery was used in 7120 (41%). Only female sex and being married predicted the use of surgery, while older age, black race and N2 nodal disease predicted non-surgical management. Surgical patients overall had better long-term survival than non-surgical patients [odds ratio (OR) 0.42, 95% confidence interval (CI): 0.41–0.45, P < 0.001]. After propensity adjustment, patients who refused surgery and instead were treated with RT had significantly worse long-term survival than matched surgery patients (OR 0.65, 95% CI: 0.48–0.89, P = 0.0074). Sublobar resection and pneumonectomy predicted worse survival in patients who had surgery. Nodal disease also predicted worse survival after surgery, but surgery maintained an association with better overall survival compared with non-operative therapy among patients with both N1 (OR 0.53, P < 0.001) and N2 disease (OR 0.50, P < 0.001) in separate analyses stratified by nodal status. Older age also predicted worse survival after surgery, but patients older than 75 who were treated with surgery had significantly better long-term survival than non-operative patients (OR 0.49, 95% CI: 0.45–0.53, P < 0.001). Surgery is used in a minority of patients with locally advanced NSCLC, but is associated with better survival than non-surgical treatment, even for patients older than 75 and patients with nodal disease. Given the very poor outcomes observed with non-operative management, surgical resection should be carefully considered in all patients with locally advanced NSCLC and should not necessarily be denied because of patient age or nodal disease.