New research was presented at AATS 2020, the virtual Annual Meeting of the American Association for Thoracic Surgery, from May 22-23. The features below highlight some of the studies presented via the online conference that focus on respiratory disease.



Eurolung Risk Score Predicts Long-Term Survival After Curative Lung Cancer Resection
The European Society of Thoracic Surgeons developed the Eurolung risk score to stratify immediate postoperative mortality risk following lung resection. To verify whether the Eurolung aggregate score is also associated with overall survival following lung cancer resection, researchers analyzed data on more than 1,300 consecutive patients undergoing anatomic lung resection between 2014 and 2018 at a single center and followed through August 2019. Patients were grouped by Eurolung score: A (0-2.5), B (3-5), C (5.5-6.5), $ (7-11.5). Mortality rates at 30 days were 0.9%, 5.4%, 9.7%, and 14.0% for those in categories A, B, C, and D, respectively. Corresponding 3-year survival rates were 78%, 61%, 40%, and 36%. Incremental mortality risk across the categories was observed in those with and without negative nodal disease. In those with positive nodes, 3-year survival rates were 59%, 44%, 26%, and 35% in categories A, B, C, and D. “This information may be valuable in the shared decision-making process when discussing with patients their treatment options and to assist the multidisciplinary team to select the most appropriate radical treatment in high-risk patients,” write the study authors.

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Laryngotracheal Resection for Benign Sublottic Stenosis

Despite evidence suggesting it to be the definitive curative treatment for benign subglottic stenosis, laryngotracheal resection is considered by many to be a challenging operation, with only a few high-volume institutions reporting large series of patients in this setting. With novel surgical techniques for the treatment of very-high-level stenosis and the proposal of new trends in the intra- and postoperative management of the airway have emerged in recent years, researchers assessed data on patients who underwent laryngotracheal resection for subglottic stenosis between 1991 and May 2019, nearly 60% of whom underwent surgery during the last 5 years of the study period. Among all patients, the complication rate was 9.6%, and the airway complication rate was 7.8%, with no cases of perioperative mortality. Definitive excellent or good results were achieved in approximately 99% of patients.

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Invasive Procedures Rare in Patients With Benign Disease on Lung Cancer Screening
Although data indicate that lung cancer screening with low-dose chest CT appears to improve survival in appropriate patients, evidence suggests that concern over false positive results and subsequent unnecessary intervention hinders universal acceptance of lung cancer screening. For a study aimed at determining the rate of surgery or other invasive procedures performed in patients found to have benign disease, investigators reviewed data on patients who underwent lung cancer screening between 2012 and 2017. Among participants, 8.1% had findings concerning for malignancy, 2.3% were diagnosed with lung cancer, and 2.1% underwent lung surgery. The incidence of surgery for benign disease was 0.37%, with another 1.4% undergoing at least one invasive diagnostic procedure but no surgery, bringing the incidence of undergoing any invasive diagnostic or therapeutic procedure for benign disease to 0.49%. No procedure related deaths were reported within 30 days.

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Tumor Size & Resection Type in Patients With Early NSCLC

Data on the role that should be played by tumor size in offering segmentectomy versus lobectomy in patients with early non-small cell lung cancer (NSCLC) are conflicting. To determine whether there exists a threshold in tumor size, stratified by histology, beyond which lobectomy is associated with improved survival over segmentectomy, study investigators analyzed data on patients who underwent either procedure for NSCLC between 2004 and 2015. The 5% of patients who underwent segmentectomy were more likely to have tumors on the left side (53% vs 41%) and have smaller tumors (median 20 mm vs 25 mm). A multivariable Cox model of the entire cohort found a significant interaction term between tumor size and type of surgery, suggesting that tumor size mediates the relationship between extent of surgery and overall survival. Upon histology examination, lobectomy was associated with superior survival compared with segementectomy beyond approximately 10 mm for adenocarcinoma and 20 mm for squamous cell carcinoma. A clear size threshold was not identified for large cell, carcinoid, or lepidic histologies. “Based on these data, tumor size can be used, in part, to allocate patients with adenocarcinoma or squamous cell carcinoma to segmental vs. lobar resection for early disease,” write the study authors.

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Modified Limited Surgery for Crawford Extent I Thoraco-Abdominal Aneurysm Repair
To evaluate the role of a modified limited (thoracotomy-crus-splitting, TCS) surgical approach for Crawford extent I thoraco-abdominal-aneurysm (TAAA) repair, when compared with a conventional (thoraco-phreno-laparotomy, TPL) approach, researchers reviewed mortality and major adverse event data on patients who underwent TPL or TCS between 1997 and 2019. While pre- and intraoperative variables were similar between the groups, aortic cross-clamp time was shorter with TCS. Outcomes for TCS were similar to those for TPL, including operative mortality (5.2% vs 3.6%), myocardial infarction (0.0% vs 0.9%), stroke (2.1% vs 1.4%), spinal cord injury (2.1% vs 3.6%), tracheostomy (5.2% vs 11.3%), dialysis (6.3% vs 4.1%) and major adverse events (18.8% vs 19.8%). Upon propensity-score matching, operative outcomes were similar between the groups, with the exception of tracheostomy, which had a lower rate with TCS (3.4% vs 12.4%). The highest risk factors for tracheostomy were female sex (odds ratio [OR], 6.21), TPL approach (OR, 4.79) and FEV1 less than 50% (OR, 3.86). “TCS is a safe and reproducible approach to repair extent I TAAAs” conclude the study authors.