Incidence and impact of postoperative atrial fibrillation after minimally invasive esophagectomy

Atrial fibrillation (AF) following open esophagectomy has been associated with increased rates of pulmonary and anastomotic complications, and mortality. This study seeks to evaluate effects of AF after minimally invasive esophagectomy (MIE). A retrospective review of patients consecutively treated with MIE for esophageal carcinoma, dysplasia. and benign disease from November 2006 to November 2011 was performed. One hundred twenty-one patients underwent MIE. Median age was 65 years (range 26-88) with 85% being male. Thirty-eight (31.4%) patients developed AF postoperatively. Of these 38 patients, 7 (18.4%) had known AF preoperatively. Patients with postoperative AF were significantly older than those without postoperative AF (68.7 vs. 62.8 years, P = 0.008) and more likely to be male (94.7% vs. 80.7%, P = 0.04). Neoadjuvant chemoradiation showed a trend toward increased risk of AF (73.7% vs 56.6%, P = 0.07). Sixty-day mortality was 2 of 38 (5.3%) in patients with AF and 4 of 83 (6.0%) in the no AF cohort (P = 1.00). The group with AF had increased length of hospitalization (13.4 days vs. 10.6 days P = 0.02). No significant differences in rates of pneumonia (31.6% vs. 21.7% P = 0.24), stricture (13.2% vs. 26.5% P = 0.10), or leak requiring return to operating room (13.2% vs. 8.4% P = 0.51) were noted between groups. We did not find an increased rate of AF in our MIE cohort compared with prior reported rates in open esophagectomy populations. AF did result in an increased length of stay but was not a predictor of other short-term morbidities including anastomotic leak, pulmonary complications, stenosis, or 60-day mortality.

Trimodality treatment for advanced esophageal cancer: Impact of minimally invasive esophagectomy

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Background: Esophageal cancer is best managed by multimodality therapy, frequently with chemotherapy (C) or chemo- radiotherapy (CRT) preceding resection. Minimally invasive esophagectomy (MIE) is increasingly accepted, but studies of MIE in advanced esophageal and gastroesophageal junction cancer after induction CRT are lacking. This report presents the data on MIE as part of tri-modality therapy for esophageal cancer at Mayo Clinic in Arizona (MCA).

Methods: Patients (pts) who underwent CRT before or after MIE for cancer at MCA between November 2006 and May of 2010 were reviewed retrospectively.

Results: 46 pts (40 males, and 6 females) met study criteria and were reviewed. Median age was 62 years (41-88 years). 45 pts (98%) had adenocarcinoma and one pt had squamous carcinoma. Initial clinical stage was IIA in 10 pts (22%), IIB in 3 pts (7%), III in 26 pts (55%), and IVA in 7 pts (15%) with positive celiac nodes. 43 pts (93%) underwent preoperative CRT with additional intra-operative radiotherapy in 4 pts. Median operating time was 354 min (range 211-567 min), median blood loss was 225 ml (range 50-1,400 ml), and median hospital stay was 8 days (range 5-48 days). 19 pts (41%), including the 3 who did not undergo preoperative CRT, received postoperative C or CRT due to either residual disease at resection or to local recurrence. 30 of 43 pts undergoing MIE after CRT were down staged (11 CR [25.6%], 10 near CR [23.3%]) demonstrating a major response to neoadjuvant therapy in 48.9% of pts. One pt died in hospital (from ARDS and sepsis subsequent to aspiration pneumonia) and two pts died within 30 days of surgery (one from pulmonary embolism, and the other from unknown causes) for a 30 day surgical mortality of 6.5%. 29 pts (63%) had a complication of surgery including 11 (24%) minor and 18 (39%) major complications. After a median follow-up of 13 months (range 0.9-43 months) 16 pts were diagnosed with recurrent disease and 10 of these pts have died of their disease.

Conclusions: CRT with MIE is associated with an acceptable morbidity and mortality level for pts with locally advanced esophageal cancer. These results compare favorably with morbidity, mortality, and recurrence rates in open esophagectomy pts.

No significant financial relationships to disclose.

Treatment and outcomes of elderly versus younger patients with advanced NSCLC at Mayo Clinic Arizona (MCA)

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Background: Non-small cell lung cancer (NSCLC) is predominantly a disease of the elderly. Most patients (pts) present with incurable advanced disease, but chemotherapy for good performance status (PS) pts improves quality and quantity of life. Despite good PS, many elderly pts with metastatic NSCLC do not receive chemotherapy. This study compared treatment, outcomes, and survival in elderly vs younger pts with stage IV NSCLC. Methods: All analytic MCA Cancer Registry pts with stage IV NSCLC from 1998–2007 were retrospectively reviewed for type of therapy and outcome. Pts were analyzed by age: <75 vs ≥75 years old. Categorical variables were compared using chi-squared tests and survival was compared by Cox regression. Results: 344 pts with stage IV NSCLC were identified. 234 (68%) pts were <75 years old, and 110 pts (32%) were ≥75 years old. Median survival for all pts was 7 months. Among 302 pts with treatment data available, 60.8% of pts <75 years old received some form of systemic therapy (chemotherapy/targeted therapy) compared to only 32% of pts ≥ 75 years old (p <0.0001). Among pts with PS 0–1, pts <75 years old more frequently received systemic therapy than elderly patients (88.5% vs 32.1%, p<0.0001); whereas a difference was not evident in pts with PS 2–4 (34.1% vs 41.7%, p=0.49). Median survival in the <75 age group was 7 months vs. 3.4 months in the ≥75 age group (p=0.048). In the <75 age group, median survival was 12 months in pts who received chemotherapy vs. 2 months in the other or no treatment group (p<0.0001). In the elderly group, median survival was 10 months in the chemotherapy group vs. 2 months in the pts who received other or no treatment (p=0.0003). Thus, the median survival was significantly improved among the pts who received systemic therapy independent of age. Statistical significance persisted when stratifying by PS. Conclusions: Pts with stage IV NSCLC have improved survival with systemic therapy independent of age. Our results confirm that despite an improvement in survival similar to younger pts, elderly patients with metastatic NSCLC are often undertreated. Prospective trials should be designed to include metastatic NSCLC patients without age discrimination

No significant financial relationships to disclose.