Publications by authors named "Michael Shackcloth"

62 Publications

Preoperative Anemia is Associated With Worse Long-Term Survival After Lung Cancer Resection: A Multicenter Cohort Study of 5,029 Patients.

J Cardiothorac Vasc Anesth 2021 Aug 23. Epub 2021 Aug 23.

Division of Cardiovascular Sciences, University of Manchester, ERC, Manchester University Hospital NHS Foundation Trust, Manchester, United Kingdom.

Objectives: Although some evidence to suggest an association between preoperative anemia and reduced overall survival exists, contemporary studies investigating the impact of preoperative anemia on outcomes after resection for primary lung cancer are lacking.

Design: A multicenter retrospective review.

Setting: Two tertiary cardiothoracic surgery centers in the Northwest of England.

Participants: A total of 5,029 patients between 2012 and 2018.

Interventions: All patients underwent lung resection for primary lung cancer. Patients were classified as anemic based on the World Health Organization definition. Men with hemoglobin <130 g/L and women with hemoglobin <120 g/L were considered to be anemic.

Measurements And Main Results: Outcomes assessed included perioperative mortality, 90-day mortality, and overall survival. Multivariate logistic and Cox regression analyses were used to assess the impact of preoperative anemia on 90-day mortality and overall survival, respectively. Overall, preoperatively, 24.0% (n = 1207) of patients were anemic. The 90-day mortality for anemic and nonanemic patients was 5.6% and 3.1%, respectively (p < 0.001). After multivariate adjustment, preoperative anemia was not associated with increased 90-day mortality. However, a log-rank analysis demonstrated reduced overall survival for anemic patients (p < 0.001). After multivariate adjustment, preoperative anemia was found to be independently associated with reduced overall survival (hazard ratio 1.287, 95% confidence interval 1.141-1.451, p < 0.001).

Conclusions: Although anemia was not an independent predictor of short-term outcomes, it was independently associated with significantly reduced survival for patients undergoing resection for lung cancer. Further work is required to understand why anemia reduces long-term survival and whether pathways for anemic patients can be adapted to improve long-term outcomes.
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http://dx.doi.org/10.1053/j.jvca.2021.08.029DOI Listing
August 2021

Autologous blood pleurodesis for the treatment of postoperative air leaks. A systematic review and meta-analysis.

Thorac Cancer 2021 Sep 3. Epub 2021 Sep 3.

Division of Thoracic Surgery, Academic Thoracic Center Mainz, University Medical Center Mainz, Johannes Gutenberg University Mainz, Mainz, Germany.

Background: Postoperative air leaks are a common complication after lung surgery. They are associated with prolonged hospital stay, increased postoperative pain and treatment costs. The treatment of prolonged air leaks remains controversial. Several treatments have been proposed including different types of sealants, chemical pleurodesis, or early surgical intervention. The aim of this review was to analyze the impact of autologous blood pleurodesis in a systematic way.

Methods: A systematic review of the literature was conducted until July 2020. Studies with more than five adult patients undergoing lung resections were included. Studies in patients receiving blood pleurodesis for pneumothorax were excluded. The search strategy included proper combinations of the MeSH terms "air leak", "blood transfusion" and "lung surgery".

Results: Ten studies with a total of 198 patients were included in the analysis. The pooled success rate for sealing the air leak within 48 h of the blood pleurodesis was 83.7% (95% CI: 75.7; 90.3). The pooled incidence of the post-interventional empyema was 1.5%, with a pooled incidence of post-interventional fever of 8.6%.

Conclusions: Current evidence supports the idea that autologous blood pleurodesis leads to a faster healing of postoperative air leaks than conservative treatment. The complication rate is very low. Formal recommendations on how to perform the procedure are not possible with the current evidence. A randomized controlled trial in the modern era is necessary to confirm the benefits.
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http://dx.doi.org/10.1111/1759-7714.14138DOI Listing
September 2021

Development and internal validation of a clinical prediction model for 90-day mortality after lung resection: the RESECT-90 score.

Interact Cardiovasc Thorac Surg 2021 Jul 29. Epub 2021 Jul 29.

Division of Cardiovascular Sciences, University of Manchester, ERC, Manchester University Hospital NHS Foundation Trust, Manchester, UK.

Objectives: The ability to accurately estimate the risk of peri-operative mortality after lung resection is important. There are concerns about the performance and validity of existing models developed for this purpose, especially when predicting mortality within 90 days of surgery. The aim of this study was therefore to develop a clinical prediction model for mortality within 90 days of undergoing lung resection.

Methods: A retrospective database of patients undergoing lung resection in two UK centres between 2012 and 2018 was used to develop a multivariable logistic risk prediction model, with bootstrap sampling used for internal validation. Apparent and adjusted measures of discrimination (area under receiving operator characteristic curve) and calibration (calibration-in-the-large and calibration slope) were assessed as measures of model performance.

Results: Data were available for 6600 lung resections for model development. Predictors included in the final model were age, sex, performance status, percentage predicted diffusion capacity of the lung for carbon monoxide, anaemia, serum creatinine, pre-operative arrhythmia, right-sided resection, number of resected bronchopulmonary segments, open approach and malignant diagnosis. Good model performance was demonstrated, with adjusted area under receiving operator characteristic curve, calibration-in-the-large and calibration slope values (95% confidence intervals) of 0.741 (0.700, 0.782), 0.006 (-0.143, 0.156) and 0.870 (0.679, 1.060), respectively.

Conclusions: The RESECT-90 model demonstrates good statistical performance for the prediction of 90-day mortality after lung resection. A project to facilitate large-scale external validation of the model to ensure that the model retains accuracy and is transferable to other centres in different geographical locations is currently underway.
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http://dx.doi.org/10.1093/icvts/ivab200DOI Listing
July 2021

Randomised Controlled Trial Evidence Questions the Assumption that Pulmonary Metastasectomy Benefits Patients with Colorectal Cancer.

Ann Surg Oncol 2021 Jul 15;28(7):4066-4067. Epub 2021 Feb 15.

Clinical Operational Research Unit, University College, London, UK.

Pulmonary metastasectomy for sarcoma is surgery without proven benefit, and in the light of a randomized controlled trial examining pulmonary metastasectomy in colorectal cancer, it should be questioned.
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http://dx.doi.org/10.1245/s10434-020-09521-3DOI Listing
July 2021

Ninety-Day Mortality: Redefining the Perioperative Period After Lung Resection.

Clin Lung Cancer 2021 07 26;22(4):e642-e645. Epub 2020 Dec 26.

Department of Cardiothoracic Surgery, Manchester University Hospital NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK.

Operative mortality is an important outcome for patients, surgeons, healthcare institutions, and policy makers. Although measures of perioperative mortality have conventionally been limited to in-hospital and 30-day mortality (or a composite endpoint combining both), there is a large body of evidence emerging to support the extension of the perioperative period after lung resection to a minimum of 90 days after surgery. Several large-volume studies from centers across the world have reported that 90-day mortality after lung resection is double 30-day mortality. Hence, true perioperative mortality after lung resection is likely to be significantly higher than what is currently reported. In the contemporary era, where new treatment modalities such as stereotactic ablative body radiotherapy are emerging as viable nonsurgical alternatives for the treatment of lung cancer, accurate estimation of perioperative risk and reliable reporting of perioperative mortality are of particular importance. It is likely that shifting the discussion from 30-day to 90-day mortality will lead to altered decision making, particularly for specific patient subgroups at an increased risk of 90-day mortality. We believe that 90-day mortality should be adopted as the standard measure of perioperative mortality after lung resection and that strategies to reduce the risk of mortality within 90 days of surgery should be investigated.
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http://dx.doi.org/10.1016/j.cllc.2020.12.011DOI Listing
July 2021

National variation in pulmonary metastasectomy for colorectal cancer.

Colorectal Dis 2021 06 24;23(6):1306-1316. Epub 2021 Jan 24.

Nuffield Department of Population Health, Big Data Institute, University of Oxford, Oxford, UK.

Aim: Evidence on patterns of use of pulmonary metastasectomy in colorectal cancer patients is limited. This population-based study aims to investigate the use of pulmonary metastasectomy in the colorectal cancer population across the English National Health Service (NHS) and quantify the extent of any variations in practice and outcome.

Methods: All adults who underwent a major resection for colorectal cancer in an NHS hospital between 2005 and 2013 were identified in the COloRECTal cancer data Repository (CORECT-R). All inpatient episodes corresponding to pulmonary metastasectomy, occurring within 3 years of the initial colorectal resection, were identified. Multi-level logistic regression was used to determine patient and organizational factors associated with the use of pulmonary metastasectomy for colorectal cancer, and Kaplan-Meier and Cox models were used to assess survival following pulmonary metastasectomy.

Results: In all, 173 354 individuals had a major colorectal resection over the study period, with 3434 (2.0%) undergoing pulmonary resection within 3 years. The frequency of pulmonary metastasectomy increased from 1.2% of patients undergoing major colorectal resection in 2005 to 2.3% in 2013. Significant variation was observed across hospital providers in the risk-adjusted rates of pulmonary metastasectomy (0.0%-6.8% of patients). Overall 5-year survival following pulmonary resection was 50.8%, with 30-day and 90-day mortality of 0.6% and 1.2% respectively.

Conclusions: This study shows significant variation in the rates of pulmonary metastasectomy for colorectal cancer across the English NHS.
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http://dx.doi.org/10.1111/codi.15506DOI Listing
June 2021

Surgical factors associated with new-onset postoperative atrial fibrillation after lung resection: the EPAFT multicentre study.

Postgrad Med J 2020 Dec 11. Epub 2020 Dec 11.

Department of Thoracic Surgery, Castle Hill Hospital, Cottingham, East Riding of Yorkshire, UK.

Purpose Of The Study: Postoperative atrial fibrillation (POAF) is a recognised complication in approximately 10% of major lung resections. In order to best target preoperative treatment, this study aimed at determining the association of incidence of POAF in patients undergoing lung resection to surgical and anatomical factors, such as surgical approach, extent of resection and laterality.

Study Design: Evaluation of Post-operative Atrial Fibrillation in Thoracic surgery (EPAFT): a multicentre, population-based, retrospective, cross-sectional, observational study including 1367 patients undergoing lung resections between April 2016 and March 2017. The primary outcome was the presence of POAF following resection. POAF was defined as at least one episode of symptomatic or asymptomatic AF confirmed by ECG within 7 days from the thoracic procedure or prior to discharge from the hospital.

Results: POAF was observed in 7.4% of patients: 3.1% in minor resection (video-assisted thoracoscopic surgery (VATS): 2.5%; thoracotomy: 3.8%), 9.0% in simple lobectomy (VATS: 7.3%, thoracotomy: 9.9%), 6.0% in complex resection (thoracotomy: 6.3%) and 11.4% in pneumonectomy. POAF was higher in left (4.0%) vs right (2.4%) minor resections, and in left (9.9%) vs right (8.3%) lobectomy, but higher in right (7.5%) complex resections, and the highest in right pneumonectomy (17.6%). No significant variations were observed as per sex, laterality or resected lobes. A positive univariable and multivariable association was observed for increasing age and increasing extent of resection, but not thoracotomy. Median (Q1-Q3) hospital stay was 9 (7-14) days in POAF and 5 (4-7) days in non-AF patients (p<0.001), with an increased cerebrovascular accident burden (p<0.001) and long-term mortality (p<0.001).

Conclusions: Among patients undergoing lung resection, POAF was significantly associated with age, increasing invasiveness of approach and increasing extent of resection. In addition, POAF carried a significant long-term mortality rate and burden of cerebrovascular accident. Appropriate prophylaxis should be targeted at these groups.
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http://dx.doi.org/10.1136/postgradmedj-2020-138904DOI Listing
December 2020

A systematic review of risk prediction models for perioperative mortality after thoracic surgery.

Interact Cardiovasc Thorac Surg 2021 04;32(3):333-342

Division of Cardiovascular Sciences, University of Manchester, ERC, Manchester University Hospitals Foundation Trust, Manchester, UK.

Objectives: Guidelines advocate that patients being considered for thoracic surgery should undergo a comprehensive preoperative risk assessment. Multiple risk prediction models to estimate the risk of mortality after thoracic surgery have been developed, but their quality and performance has not been reviewed in a systematic way. The objective was to systematically review these models and critically appraise their performance.

Methods: The Cochrane Library and the MEDLINE database were searched for articles published between 1990 and 2019. Studies that developed or validated a model predicting perioperative mortality after thoracic surgery were included. Data were extracted based on the checklist for critical appraisal and data extraction for systematic reviews of prediction modelling studies.

Results: A total of 31 studies describing 22 different risk prediction models were identified. There were 20 models developed specifically for thoracic surgery with two developed in other surgical specialties. A total of 57 different predictors were included across the identified models. Age, sex and pneumonectomy were the most frequently included predictors in 19, 13 and 11 models, respectively. Model performance based on either discrimination or calibration was inadequate for all externally validated models. The most recent data included in validation studies were from 2018. Risk of bias (assessed using Prediction model Risk Of Bias ASsessment Tool) was high for all except two models.

Conclusions: Despite multiple risk prediction models being developed to predict perioperative mortality after thoracic surgery, none could be described as appropriate for contemporary thoracic surgery. Contemporary validation of available models or new model development is required to ensure that appropriate estimates of operative risk are available for contemporary thoracic surgical practice.
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http://dx.doi.org/10.1093/icvts/ivaa273DOI Listing
April 2021

External validation of six existing multivariable clinical prediction models for short-term mortality in patients undergoing lung resection.

Eur J Cardiothorac Surg 2021 05;59(5):1030-1036

Division of Cardiovascular Sciences, University of Manchester, ERC, Manchester University Hospitals Foundation Trust, Manchester, UK.

Objectives: National guidelines advocate the use of clinical prediction models to estimate perioperative mortality for patients undergoing lung resection. Several models have been developed that may potentially be useful but contemporary external validation studies are lacking. The aim of this study was to validate existing models in a multicentre patient cohort.

Methods: The Thoracoscore, Modified Thoracoscore, Eurolung, Modified Eurolung, European Society Objective Score and Brunelli models were validated using a database of 6600 patients who underwent lung resection between 2012 and 2018. Models were validated for in-hospital or 30-day mortality (depending on intended outcome of each model) and also for 90-day mortality. Model calibration (calibration intercept, calibration slope, observed to expected ratio and calibration plots) and discrimination (area under receiver operating characteristic curve) were assessed as measures of model performance.

Results: Mean age was 66.8 years (±10.9 years) and 49.7% (n = 3281) of patients were male. In-hospital, 30-day, perioperative (in-hospital or 30-day) and 90-day mortality were 1.5% (n = 99), 1.4% (n = 93), 1.8% (n = 121) and 3.1% (n = 204), respectively. Model area under the receiver operating characteristic curves ranged from 0.67 to 0.73. Calibration was inadequate in five models and mortality was significantly overestimated in five models. No model was able to adequately predict 90-day mortality.

Conclusions: Five of the validated models were poorly calibrated and had inadequate discriminatory ability. The modified Eurolung model demonstrated adequate statistical performance but lacked clinical validity. Development of accurate models that can be used to estimate the contemporary risk of lung resection is required.
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http://dx.doi.org/10.1093/ejcts/ezaa422DOI Listing
May 2021

European Cancer Organisation Essential Requirements for Quality Cancer Care (ERQCC): Lung cancer.

Lung Cancer 2020 12 4;150:221-239. Epub 2020 Sep 4.

European Cancer Organisation; Iridium Kankernetwerk and University of Antwerp, Wilrijk-Antwerp, Belgium.

European Cancer Organisation Essential Requirements for Quality Cancer Care (ERQCC) are written by experts representing all disciplines involved in cancer care in Europe. They give patients, health professionals, managers and policymakers a guide to essential care throughout the patient journey. Lung cancer is the leading cause of cancer mortality and has a wide variation in treatment and outcomes in Europe. It is a major healthcare burden and has complex diagnosis and treatment challenges. Care must only be carried out in lung cancer units or centres that have a core multidisciplinary team (MDT) and an extended team of health professionals detailed here. Such units are far from universal in European countries. To meet European aspirations for comprehensive cancer control, healthcare organisations must consider the requirements in this paper, paying particular attention to multidisciplinarity and patient-centred pathways from diagnosis, to treatment, to survivorship.
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http://dx.doi.org/10.1016/j.lungcan.2020.08.017DOI Listing
December 2020

Five-year survival of patients in control groups of randomized controlled trials is much higher than that assumed in observational study reports.

Int J Colorectal Dis 2020 May 18;35(5):941-942. Epub 2020 Feb 18.

Clinical Operational Research Unit, University College, London, UK.

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http://dx.doi.org/10.1007/s00384-020-03540-yDOI Listing
May 2020

Risk Stratification of Postoperative Dyspnoea: Is it Time to Change Practice?

EClinicalMedicine 2019 Oct 17;15:5-6. Epub 2019 Oct 17.

Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, United Kingdom of Great Britain and Northern Ireland.

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http://dx.doi.org/10.1016/j.eclinm.2019.09.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6833459PMC
October 2019

Study protocol for VIdeo assisted thoracoscopic lobectomy versus conventional Open LobEcTomy for lung cancer, a UK multicentre randomised controlled trial with an internal pilot (the VIOLET study).

BMJ Open 2019 10 14;9(10):e029507. Epub 2019 Oct 14.

Clinical Trials and Evaluation Unit, Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK.

Introduction: Lung cancer is a leading cause of cancer deaths worldwide and surgery remains the main treatment for early stage disease. Prior to the introduction of video-assisted thoracoscopic surgery (VATS), lung resection for cancer was undertaken through an open thoracotomy. To date, the evidence base supporting the different surgical approaches is based on non-randomised studies, small randomised trials and is focused mainly on short-term in-hospital outcomes.

Methods And Analysis: The VIdeo assisted thoracoscopic lobectomy versus conventional Open LobEcTomy for lung cancer study is a UK multicentre parallel group randomised controlled trial (RCT) with blinding of outcome assessors and participants (to hospital discharge) comparing the effectiveness, cost-effectiveness and acceptability of VATS lobectomy versus open lobectomy for treatment of lung cancer. We will test the hypothesis that VATS lobectomy is superior to open lobectomy with respect to self-reported physical function 5 weeks after randomisation (approximately 1 month after surgery). Secondary outcomes include assessment of efficacy (hospital stay, pain, proportion and time to uptake of chemotherapy), measures of safety (adverse health events), oncological outcomes (proportion of patients upstaged to pathologic N2 (pN2) disease and disease-free survival), overall survival and health related quality of life to 1 year. The QuinteT Recruitment Intervention is integrated into the trial to optimise recruitment.

Ethics And Dissemination: This trial has been approved by the UK (Dulwich) National Research Ethics Service Committee London. Findings will be written-up as methodology papers for conference presentation, and publication in peer-reviewed journals. Many aspects of the feasibility work will inform surgical RCTs in general and these will be reported at methodology meetings. We will also link with lung cancer clinical studies groups. The patient and public involvement group that works with the Respiratory Biomedical Research Unit at the Brompton Hospital will help identify how we can best publicise the findings.

Trial Registration Number: ISRCTN13472721.
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http://dx.doi.org/10.1136/bmjopen-2019-029507DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6797374PMC
October 2019

Unusual endobronchial prostatic metastatic tumor occluding right main bronchus.

Asian Cardiovasc Thorac Ann 2019 Mar 23;27(3):228-230. Epub 2019 Jan 23.

2 Department of Thoracic Surgery, Liverpool Heart & Chest Hospital, Liverpool, UK.

Endobronchial metastasis from extrapulmonary solid tumors is rare, and endobronchial metastasis from the prostate is even more unusual. An 80-year-old patient presented with significant dyspnea secondary to metastatic stromal cell sarcoma of the prostate, which occluded the right main bronchus. The tumor, causing complete collapse of the right lung, was found on computed tomography and confirmed by bronchoscopy. We successfully excised the lesion using cryotherapy, with immediate resolution of symptoms and radiological lung reexpansion.
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http://dx.doi.org/10.1177/0218492319827668DOI Listing
March 2019

Approach to pneumothorax surgery: a national survey of current UK practice.

Asian Cardiovasc Thorac Ann 2019 Mar 19;27(3):180-186. Epub 2019 Jan 19.

3 Liverpool Heart and Chest Hospital, Liverpool, UK.

Background: Pneumothorax is a common condition with various management options. We aimed to determine the current surgical practice in the United Kingdom.

Method: An online questionnaire regarding surgical strategy was sent to all consultants who were members of the Society for Cardiothoracic Surgery (80 thoracic).

Results: Fifty-six consultants, mainly thoracic, responded to the survey. Video-assisted thoracoscopic surgery was unanimously the preferred approach, the majority (59%) using 3 ports. Regarding the timing of surgery, 53 (95%) surgeons would intervene at first presentation with persistent air leak and/or lung collapse, 41 (73%) for a first bilateral pneumothorax, 22 (39%) only for recurrent pneumothorax, and 18 (32%) for the first computed tomography evidence of bullae. Apical bullectomy + pleurectomy was the preferred technique for 26 (46%) surgeons, and apical bullectomy + apical pleurectomy + pleural abrasion was the choice for 13 (23%). Some surgeons were concerned about talc and avoid it. The majority (70%) used a single apical drain with or without 24-48 h suction. Regarding chest radiography, the response was variable but 48% performed immediate postoperative and/or daily chest radiographs. Currently, most surgeons (59%) use digital drains and feel it monitors air leaks better. The perceived chronic pain (1%-3%) and recurrence rates (0%-3%) were stated by 59% and 86%, respectively.

Conclusion: There is variability in the surgical management of pneumothorax among surgeons across the UK, but they all use video-assisted thoracoscopic surgery as the intervention of choice for pneumothorax surgery, and there is a shift towards early surgical intervention.
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http://dx.doi.org/10.1177/0218492319825943DOI Listing
March 2019

A diagnostic cohort study on the accuracy of 18-fluorodeoxyglucose (FDG) positron emission tomography (PET)-CT for evaluation of malignancy in anterior mediastinal lesions: the DECiMaL study.

BMJ Open 2018 02 6;8(2):e019471. Epub 2018 Feb 6.

Imperial College and the Academic Division of Thoracic Surgery, Royal Brompton and Harefield NHS Foundation Trust, London, UK.

Objectives: The aim of this study is to collate multi-institutional data to determine the value by defining the diagnostic performance of fluorodeoxyglucose positron emission tomography (FDG PET)/CT for malignancy in patients undergoing surgery with an anterior mediastinal mass in order to ascertain the clinical utility of PET/CT to differentiate malignant from benign aetiologies in patients presenting with an anterior mediastinal mass SETTING: DECiMaL Study is a multicentre, retrospective, collaborative cohort study in seven UK surgical sites.

Participants: Between January 2002 and June 2015, a total of 134 patients were submitted with a mean age (SD) of 55 years (16) of which 69 (51%) were men. We included all patients undergoing surgery who presented with an anterior mediastinal mass and underwent PET/CT. PET/CT was considered positive for any reported avidity as stated in the official report and the reference was the resected specimen reported by histopathology using WHO criteria.

Primary And Secondary Outcome Measures: Sensitivity, specificity, positive and negative predicted values of [18F]-FDG PET in determining malignant aetiology for an anterior mediastinal mass.

Results: The sensitivity and specificity of PET/CT to correctly classify malignant disease were 83% (95% CI 74 to 89) and 58% (95% CI 37 to 78). The positive and negative predictive values were 90% (95% CI 83% to 95%) and 42% (95% CI 26% to 61%).

Conclusions: The results of our study suggest reasonable sensitivity but no specificity implying that a negative PET/CT is useful to rule out the diagnosis of malignant disease whereas a positive result has no value in the discrimination between malignant and benign diseases of the anterior mediastinum.
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http://dx.doi.org/10.1136/bmjopen-2017-019471DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5829887PMC
February 2018

Video-Assisted Thoracoscopic Versus Robotic-Assisted Thoracoscopic Thymectomy: Systematic Review and Meta-analysis.

Innovations (Phila) 2017 Jul/Aug;12(4):259-264

From the *Thoracic Aortic Aneurysm Service, Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; †Cardiothoracic Surgery, Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; and ‡General Thoracic & Oesophageal Surgery, Liverpool Heart & Chest Hospital, Liverpool, United Kingdom.

Objective: Minimally invasive thoracic surgical procedures, performed with or without the assistance of a robot, have gained popularity over the last decade. They have increasingly become the choice of intervention for a number of thoracic surgical operations. Minimally invasive surgery decreases postoperative pain, hospital stay and leads to a faster recovery in comparison with conventional open methods. Minimally invasive techniques to perform a thymectomy include video-assisted thoracoscopic surgery (VATS) or robotic-assisted thoracoscopic surgery (RATS). In this study, we aim to systematically review and interrogate the literature on minimally invasive thymectomy and draw a meta-analysis on the outcomes between the two approaches.

Methods: An extensive electronic health database search was performed on all articles published from inception to May 2015 for studies describing outcomes in VATS and RATS thymectomy.

Results: A total of 350 patients were included in this study, for which 182 and 168 patients underwent RATS and VATS thymectomy, respectively. There were no recorded in-hospital deaths for either procedure. There was no statistical difference in conversion to open, length of hospital stay, or postoperative pneumonia. Operational times for RATS thymectomy were longer.

Conclusions: The VATS and RATS thymectomy offer good and safe operative and perioperative outcomes. There is little difference between the two groups. However, there is poor evidence basis for the long-term outcomes in minimally invasive procedures for thymectomy. It is imperative that future studies evaluate oncological outcomes both short and long term as well as those related to safety.
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http://dx.doi.org/10.1097/IMI.0000000000000382DOI Listing
May 2018

Does neoadjuvant chemoradiotherapy increase survival in patients with resectable oesophageal cancer?

Interact Cardiovasc Thorac Surg 2017 01 13;24(1):115-120. Epub 2016 Sep 13.

Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK.

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether trimodal therapy [neoadjuvant chemoradiotherapy (nCRT) in addition to surgery] improves survival in patients with resectable oesophageal cancer. Altogether 565 studies were identified using the below-mentioned search. Eleven represented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group, relevant outcomes and weaknesses are tabulated. All 11 studies were randomized controlled trials comparing surgery with trimodal therapy, 5 of which showed a survival advantage with combined treatment. The remaining six randomized controlled trials showed no difference between trimodal therapy and surgery alone. The 3-year survival for trimodal treatment varied between 19.3 and 58% compared with that for surgery alone which varied between 7 and 53%. Five of these studies compared trimodal therapy with surgery in terms of resection margins, three of which showed that trimodal therapy led to increased R0 resection rate. One study focused on the differences between adenocarcinoma and squamous cell tumours, and described equivalent effects of trimodal therapy in terms of survival. One randomized controlled trial showed improved survival in patients with complete regression of their tumour following induction treatment. Two studies suggested that induction treatment may lead to a higher operative mortality; however, an increase in disease-free survival was noted in one of the two studies. We conclude that trimodal therapy for resectable oesophageal cancer offers similar or even improved results compared with surgery alone in terms of survival. Furthermore, it is likely that there is an advantage for those patients who have a complete pathological response following induction treatment.
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http://dx.doi.org/10.1093/icvts/ivw281DOI Listing
January 2017

Does induction chemoradiotherapy increase survival in patients with Pancoast tumour?

Interact Cardiovasc Thorac Surg 2016 11 29;23(5):821-825. Epub 2016 Jun 29.

Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK.

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether induction (neoadjuvant) chemoradiotherapy (iCRT) compared with other therapeutic strategies improves survival in patients with Pancoast tumours. Altogether 248 papers were identified using the below-mentioned search. Ten of them represented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group, relevant outcomes and weaknesses were tabulated. Four studies were retrospective comparative studies of induction chemoradiotherapy and surgery (trimodal therapy) versus other therapeutic strategies. Two studies were retrospective and four were prospective investigating trimodal therapy. These papers comprised a total of 550 patients. The overall survival was better with trimodal therapy compared with RT (radiotherapy) followed by surgery group in all three comparative studies. The 2-year survival varied in the trimodal therapy group from 70 to 93%, in comparison to RT group where variation was from 22 to 49%. Five-year survival for trimodal therapy varied between 36.4 and 84% in the results of two comparative studies, compared with 11 and 49% for RT and surgery, respectively. One paper looked at survival in patients who underwent surgery alone [30% at 2-year and 20% at 4-year overall survival (OS)]. The 5-year OS in the retrospective group varied between 38 and 59%. Similar results were reported for the prospective group with 5-year OS between 44 and 56%. Despite a large variation in pCR (complete pathological response) (15-93%) and R0 (77-100%) reported, both represented a positive prognostic factor for survival. Three papers looked at the impact of staging following induction chemoradiotherapy. The majority of patients had T3 disease. An advantage in survival was seen in patients with early disease compared with advanced stage. No randomized controlled trials were identified. All the 10 articles suggested there was a benefit in trimodal therapy with improvement in overall survival. We conclude that combining induction chemoradiotherapy with surgery for Pancoast tumour may offer a survival benefit compared with radiotherapy with surgery or surgery alone.
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http://dx.doi.org/10.1093/icvts/ivw216DOI Listing
November 2016

Test performance of PET-CT for mediastinal lymph node staging of pulmonary carcinoid tumours.

Thorax 2015 Apr 14;70(4):379-81. Epub 2014 Aug 14.

Department of Thoracic Surgery, Royal Brompton & Harefield NHS Foundation Trust, London, UK National Heart and Lung Division, Imperial College, London, UK.

Positron emission tomography-CT (PET-CT) is one of the initial mediastinal staging modality for non-small cell lung cancer; however, the clinical utility in carcinoid tumours is uncertain. We sought to determine the test performance of PET-CT for mediastinal lymph node staging of pulmonary carcinoid tumours. We collated data from seven institutions, performing a retrospective search on pathological databases for a consecutive series of patients who underwent thoracic surgery (with lymph nodal dissection) for carcinoid tumours with preoperative PET-CT staging. PET-CT results were compared with the reference standard of pathologic results obtained from lymph node dissection and test performance reported using sensitivity and specificity. From November 1999 to January 2013, 247 patients from seven institutions underwent surgery for carcinoid tumours with a corresponding preoperative PET-CT scan. The mean age of the patients was 61 (SD 15, range 73) and 84 were male patients (34%). The pathologic subtype was typical carcinoid in 217 patients (88%) and atypical carcinoid in 30 patients (12%). Results from lymph node dissection were obtained in 207 patients. The calculated sensitivity and specificity of PET-CT to identify mediastinal lymph node disease was 33% (95% CI 4% to 78%) and 94% (95% CI 89% to 97%), respectively. Our results indicate that PET-CT has a poor sensitivity but good specificity to detect the presence of mediastinal lymph node metastases in pulmonary carcinoid tumours. Mediastinal lymph node metastases cannot be ruled out with negative PET-CT uptake, and if the absence of mediastinal lymph node disease is a prerequisite for directing management, tissue sampling should be undertaken.
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http://dx.doi.org/10.1136/thoraxjnl-2014-205899DOI Listing
April 2015

Metastatic index of non-small-cell lung cancer and long-term survival.

Asian Cardiovasc Thorac Ann 2015 Feb 7;23(2):185-90. Epub 2014 Aug 7.

Liverpool Heart and Chest Hospital, Liverpool, UK.

Aim: We aimed to determine whether metastatic index is a factor determining long-term survival in patients undergoing curative resection for non-small-cell lung cancer.

Methods: There were 2695 consecutive pulmonary resections performed between October 2001 and September 2011 in our institution; 1795 were potentially curative resections for non-small-cell lung cancer with bronchial margin length data available. Benchmarking against the International Association for the Study of Lung Cancer data set was performed. Cox multivariate analysis was undertaken. Metastatic index was defined as N stage× bronchial resection margin length.

Results: Benchmarking failed to reveal any significant differences between our data and the International Association for the Study of Lung Cancer data set. Univariate analysis identified metastatic index as a significant factor determining long-term survival (p = 0.04). Cox regression demonstrated that metastatic index (hazard ratio 1.29, p = 0.0002), age (hazard ratio 1.02, p < 0.0001), body mass index (hazard ratio 0.98, p = 0.006), female sex (hazard ratio 0.65, p < 0.0001), T1 stage (hazard ratio 0.67, p < 0.0001), T2 stage (hazard ratio 2.13, p < 0.0001), T3 stage (hazard ratio 1.59, p = 0.03), forced expiratory volume in 1 s (hazard ratio 0.70, p < 0.0001), pneumonectomy (hazard ratio 1.43, p = 0.001), histology subtype adenosquamous (hazard ratio 3.77, p = 0.01) and squamous (hazard ratio 0.83, p = 0.03) were all significant determinants of long-term survival.

Conclusion: Metastatic index is a significant factor determining long-term survival in patents with adenocarcinoma undergoing potentially curative surgery with a lobectomy.
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http://dx.doi.org/10.1177/0218492314545833DOI Listing
February 2015

Endobronchial ultrasound-guided biopsy to diagnose large posterior mediastinal parathyroid adenoma prior to video-assisted thoracoscopic resection.

BMJ Case Rep 2014 May 13;2014. Epub 2014 May 13.

Department of Thoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK.

A 65-year-old woman was referred with hypercalcaemia and found to have a four cm retrotracheal mass on CT. The patient also suffered from neurofibromatosis and a recently diagnosed gastric mass. Tc(99) sestamibi scintigraphy revealed an area of intense uptake in the right upper mediastinum. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) was used to confirm the diagnosis of parathyroid adenoma and thoracoscopic resection was subsequently performed. EBUS-TBNA biopsy can be a helpful diagnostic tool to confirm diagnosis of mediastinal parathyroid masses in patients with atypical or complex clinical presentations.
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http://dx.doi.org/10.1136/bcr-2013-200131DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4025209PMC
May 2014

Pneumonectomy: risk factor or innocent bystander?

Asian Cardiovasc Thorac Ann 2014 Jan 3;22(1):49-54. Epub 2013 Sep 3.

Liverpool Heart and Chest Hospital, Liverpool, UK.

Background: Pneumonectomy is associated with a higher operative mortality rate and worse 5-year survival after resection for non-small-cell lung cancer, compared to lobectomy. We investigated whether pneumonectomy is an independent risk factor for hospital mortality and poor long-term survival, after risk factor adjustment.

Methods: We analyzed a prospectively validated thoracic surgery database. Kaplan-Meier survival curves were constructed for patients who had undergone lobectomy (n = 1484) or pneumonectomy (n = 266). Logistic and Cox multivariate regression analysis and propensity matching were performed on hospital mortality and long-term survival data.

Results: Univariate analysis demonstrated that pneumonectomy was a significant risk factor for hospital death (p = 0.02) and long-term survival (p < 0.001). Logistic regression failed to demonstrate pneumonectomy as a risk factor for hospital mortality. Cox regression analysis failed to identify pneumonectomy as a statistically significant risk factor. Propensity analysis (n = 266 in each group with 1:1 matching) demonstrated that pneumonectomy was not associated with hospital mortality (p = 0.37) or poorer long-term survival (p = 0.19) compared to lobectomy.

Conclusion: Pneumonectomy is not an independent risk factor for hospital mortality or long-term survival, after adjustment for confounding factors.
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http://dx.doi.org/10.1177/0218492313477102DOI Listing
January 2014

Wedge resection verses lobectomy for stage 1 non-small-cell lung cancer.

Asian Cardiovasc Thorac Ann 2013 Oct 11;21(5):566-73. Epub 2013 Jul 11.

Liverpool Heart and Chest Hospital, Liverpool, UK.

Background: Lobectomy remains the gold standard with regard to potentially curative resection of non-small-cell lung carcinoma. We aimed to investigate whether there is a survival difference in stage 1 non-small-cell lung cancer patients who undergo lobectomy compared to a wedge resection.

Methods: We retrospectively analyzed a prospective database of 1283 patients who had potentially curative resection for stage 1 non-small-cell lung cancer. Only patients with adenocarcinoma, squamous or adenosquamous carcinoma were included. We benchmarked our 5-year survival against the 6th International Association for the Study of Lung Cancer results. Three techniques were used to assess the effect of a lobectomy compared to a wedge resection with regard to long-term survival: Cox multivariate regression analysis, neuronal network analysis, and propensity matching.

Results: Benchmarking failed to reveal any significant difference compared to the 6th International Association for the Study of Lung Cancer results. Crude analysis demonstrated superiority of lobectomy compared to wedge resection, p = 0.02. Cox regression analysis confirmed that age, body mass index, female sex, being a current smoker, tumor diameter, and preoperative forced expiratory volume in 1 s were all significant factors determining long-term survival. Wedge resection was not a significant factor. Neuronal network analysis concurred with the Cox regression analysis. Propensity matching with 1:1 matching demonstrated that wedge resections was not inferior to a lobectomy, p = 0.10.

Conclusions: Cox regression analysis, neuronal network analysis, and propensity matching in stage 1 non-small-cell lung cancer demonstrate no difference in long-term survival after wedge resection compared to lobectomy.
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http://dx.doi.org/10.1177/0218492312466861DOI Listing
October 2013

Should males ever undergo wedge resection for stage 1 non-small-cell lung cancer? A propensity analysis.

Eur J Cardiothorac Surg 2014 Aug 12;46(2):267-73; discussion 273. Epub 2014 Jan 12.

Liverpool Heart and Chest Hospital, Liverpool, UK

Objectives: Wedge resections are frequently performed for small peripheral lesions in patients unfit for a more extensive resection. We aimed to investigate whether patient sex and histology type are important factors determining survival in patients undergoing a wedge resection for stage I lung cancer.

Methods: We retrospectively analysed a prospective thoracic database of patients (n = 2859) who had undergone potentially curative wedge resection for stage I non-small-cell lung cancer. Only patients with adenocarcinoma or squamous carcinoma were included (n = 540). We benchmarked our 5-year survival against the sixth International Association for the Study of Lung Cancer results. Kaplan-Meier, Cox multivariate regression analysis and propensity analysis were utilized to assess the effect of sex and histology on survival post-wedge resection with regard to long-term survival.

Results: Cox regression of patients who had undergone wedge resection demonstrated that adenocarcinoma (odds ratio [OR]: 2.16, 95% confidence interval [CI]: 1.11-4.19), P = 0.02 was the only significant term determining long-term survival. Cox regression of male patients identified adenocarcinoma (OR: 3.29, 95% CI: 1.22-8.86), P = 0.02 as the only significant term determining long-term survival. Cox regression of female patients failed to identify any significant factors that determine long-term survival. Propensity matching based on gender identified that gender had no effect on survival, P = 0.46; however, histology was associated with a difference in survival, P = 0.02. This effect occurred in males, P = 0.02, but not females, P = 0.26. Propensity matching based on histology identified that gender had no effect on survival, P = 0.29; however, histology was associated with a difference in survival, P = 0.01. This effect occurred in males, P = 0.01, but not females, P = 0.26. Differing life expectancy between males and females was adjusted for by the use of the Framingham-predicted life expectancy.

Conclusions: Long-term survival of patients with stage I non-small-cell lung cancer who undergo a wedge resection is affected by gender and histological type. Male patients undergoing wedge resections for adenocarcinoma have outcomes inferior to those of patients with squamous carcinoma. Histology type does not affect survival in female patients undergoing wedge resections.
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http://dx.doi.org/10.1093/ejcts/ezt603DOI Listing
August 2014

Preoperative red cell distribution width in patients undergoing pulmonary resections for non-small-cell lung cancer.

Eur J Cardiothorac Surg 2014 Jan 27;45(1):108-13. Epub 2013 May 27.

Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK.

Objectives: Red cell distribution width (RDW) has been identified as an independent risk factor with regard to prognosis in patients with cardiac disease. We sought to investigate the association of RDW in patients undergoing lung resections for non-small-cell lung cancer with respect to in-hospital morbidity, mortality and long-term survival.

Methods: Analysis of consecutive patients on a validated prospective thoracic surgery database was performed for those undergoing potentially curative resections at a single institution. Univariate and multivariate analyses were performed for postoperative invasive and non-invasive ventilation, superficial wound infections, length of hospital stay, in-hospital mortality and long-term survival.

Results: Overall mortality was 1.9% for all cases (n = 917). The median follow-up was 6.8 years. Univariate analysis demonstrated that RDW has a significant effect on hospital length of stay (P < 0.001), in-hospital mortality rates (P < 0.001), postoperative invasive and non-invasive ventilation (P < 0.001), superficial wound infections (P = 0.06) and long-term survival (P < 0.0001). Multivariate analysis revealed that RDW is a significant factor determining postoperative invasive and non-invasive ventilation, superficial wound infections, length of hospital stay, in-hospital mortality and long-term survival. Confounding factor analysis revealed that in the absence of anaemia, RDW was still a significant factor in the above analysis.

Conclusions: RDW is a significant factor after risk adjustment, determining in-hospital morbidity, mortality and long-term survival in patients post-potentially curative resections for non-small-cell lung cancer. Further work is needed to elucidate the exact mechanism of RDW impact on in-hospital morbidity, mortality and long-term survival. We speculate that subtle bone marrow dysfunction may be an issue.
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http://dx.doi.org/10.1093/ejcts/ezt275DOI Listing
January 2014

Pulmonary artery tumor embolism in a patient with previous fibroblastic osteosarcoma.

Ann Thorac Surg 2013 Jun;95(6):2155-7

Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.

A 48-year-old man was referred for left pulmonary metastasis and a left pulmonary artery embolus. The patient had T-cell acute lymphoblastic leukemia and fibroblastic osteosarcoma. A left pneumonectomy was performed successfully and the histologic report concluded that an embolic deposit of osteosarcoma was present. Pulmonary artery tumor embolism is a rare presentation in patients with previous fibroblastic osteosarcoma. It is important to suspect this diagnosis in a patient with cancer who presents with a pulmonary artery embolus.
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http://dx.doi.org/10.1016/j.athoracsur.2012.10.062DOI Listing
June 2013

The impact of positive circumferential margin on survival following oesophagectomy using the new 7th TNM classification.

Eur J Cardiothorac Surg 2013 Nov 5;44(5):855-9. Epub 2013 May 5.

Cardiothoracic Department, The Liverpool Heart & Chest Hospital, Liverpool, U K.

Objectives: Previous studies looking at the influence of positive circumferential margin (CRM) on survival after oesophagectomy are conflicting. This may be due to the fact that older versions of the TNM classification were used, which do not predict survival as accurately as the new 7th edition. We examine whether CRM involvement has an impact on survival when the 7th TNM classification is used.

Methods: Over a 10-year period, 199 patients who had undergone potentially curative resection for oesophageal cancer with postoperative histopathological T3 were identified. A total of 151 (75.9%) were found to have CRM involvement (<1 mm), and these were compared with patients in whom the CRM was free of tumour. Cancers were staged according to the International Union against Cancer TNM 7th edition. First, univariate and then multivariate Cox regression analysis were performed to assess the factors influencing survival. Potentially significant predictors (P < 0.1) from the univariate analysis were inserted in the forward-stepwise Cox regression model and was allowed to remain in the final model if a P-value of <0.05 was achieved. A sub-group analysis was also performed for different N-stages (N0-N3).

Results: After all analyses were performed, CRM involvement was found to have no effect on survival following oesophagectomy [hazard ratio 1.28 (95% CI: 0.82-2.01) (P = 0.28)]. This was seen for all N-stages. Stage of disease, age at operation, % predicted forced expiratory volume in 1 second and shortness of breath [(according to New York Heart Association classification)] were all significant predictors of survival.

Conclusions: With this study, it became clear that CRM involvement does not affect long-term survival of patients after oesophagectomy. Patients with CRM involvement should not necessarily be considered to have had an incomplete resection.
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http://dx.doi.org/10.1093/ejcts/ezt164DOI Listing
November 2013

Female sex and long-term survival post curative resection for non-small-cell lung cancer.

Eur J Cardiothorac Surg 2013 Oct 18;44(4):624-30. Epub 2013 Mar 18.

Liverpool Heart and Chest Hospital, Liverpool, UK.

Objectives: To determine whether patient sex has a significant effect on long-term outcomes post curative resection of non-small-cell lung cancer.

Methods: We retrospectively analysed a prospectively validated thoracic surgery database (n = 4212), from a single institution, from September 2001 to October 2012. Univariate, Cox multivariate and propensity analysis was performed. Long-term follow-up was carried out via the National Strategic Tracing Service that operates in the United Kingdom.

Results: One hundred per cent follow-up was achieved. Overall institutional in-hospital mortality was 2.0% for all thoracic resections. Median survival was 2.78 years (range 0-13 years). Two thousand two hundred and thirty-three males and 1979 females were included. Kaplan-Meier survival of all the patients demonstrated superior survival of females for all stages, P = 0.0003, and stage I, P = 0.0006. Female sex conferred no survival advantage in stage II, P = 0.7, and IIIa, P = 0.1. Sub-analysis by histological type demonstrated that females had superior survival with adenocarcinoma compared with males, P < 0.001, but no sex difference existed with squamous carcinomas, P = 0.2. Cox analyses demonstrated that female sex was an advantageous prognostic factor for the entire study group [hazard ratio (HR) 0.82, 95% confidence interval (CI) 0.69-0.96] and Stage I only (HR 0.70, 95% CI 0.57-0.63). Sex was of no significance in Stage II and IIIa disease with regard to survival. Sub-analysis demonstrated that female sex was not a significant factor determining survival in patients with squamous carcinoma; however, it was significantly associated with increased survival in patients with adenocarcinoma (HR 0.63, 95% CI 0.51-0.78). A 1:1 propensity analysis confirmed the above findings.

Conclusion: Propensity matching and Cox multivariate regression analysis confirmed the univariate finding that female sex is only associated with improved survival in patients with Stage I adenocarcinoma. Patient sex does not affect survival of patients with squamous carcinoma.
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http://dx.doi.org/10.1093/ejcts/ezt139DOI Listing
October 2013

Prediction of in-hospital mortality following pulmonary resections: improving on current risk models.

Eur J Cardiothorac Surg 2013 Aug 22;44(2):238-42; discussion 242-3. Epub 2013 Jan 22.

Liverpool Heart and Chest Hospital, Liverpool, UK.

Objectives: Using a large, prospectively collected and independently validated thoracic database, we created a risk-prediction tool for in-hospital mortality with the aim of improving on the accuracy of Thoracoscore.

Methods: A prospectively collected and independently validated database containing lung resections was utilized, N = 2574. Logistic regression analysis with bootstrapping, and by the use of a random training and test set was utilized. Comparisons against the Thoracoscore, ESOS.01 and the Society of Thoracic Surgeons (STS) models were performed.

Results: A logistic model identified age [odds ratio (OR) 1.1, 95% confidence interval (CI) 1.0-1.2, P = 0.0002], sex (OR 0.34, 95% CI 0.14-0.83, P = 0.02), predicted postoperative FEV1 (OR 0.96, 95% CI 0.94-0.99, P = 0.002), emphysema (OR 3.2, 95% CI 1.0-9.9, P = 0.04), excess alcohol consumption (OR 1.0, 95% CI 1.0-1.0, P = 0.04), pre-existing renal disease (OR 4.3, 95% CI 1.1-17.1, P = 0.04), predicted in-hospital mortality with an receiver operating curve (ROC) of 0.81 and a Hosmer-Lemeshow test of 0.9. Bootstrap analysis confirmed the above risk factors (ROC 0.82 and Hosmer-Lemeshow 0.2). Comparisons between Thoracoscore, ESOS.01 and the STS risk models demonstrated that none was very accurate, as all had low ROC values of 0.69, 0.70 and 0.61, respectively. The STS risk model does not apply to our population (ROC 0.61, Hosmer-Lemeshow, P = 0.004), and the ESOS.01 has poor predictive power (Hosmer-Lemeshow, P < 0.0001).

Conclusions: Logistic regression based on age, sex, predicted postoperative FEV1, alcohol consumption and pre-existing renal disease predicts in-hospital mortality with improved accuracy compared with the use of Thoracoscore, ESOS.01 and the STS risk model.
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http://dx.doi.org/10.1093/ejcts/ezs658DOI Listing
August 2013
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