Annals of Thoracic Surgery最新文献

Background: The use of local consolidative therapy (LCT) in patients with oligometastatic non-small cell lung cancer (NSCLC) is rapidly evolving, with a preponderance of data supporting the benefits of such therapeutic approaches incorporating pulmonary resection for appropriately selected candidates. However, practices vary widely institutionally and regionally, and evidence-based guidelines are lacking.

Methods: The Society of Thoracic Surgeons assembled a panel of thoracic surgical oncologists to evaluate and synthesize the available evidence regarding the role of pulmonary resection as LCT. Clinical and research questions of interest were identified, and a complete literature review was conducted. Best practice guidelines were developed accordingly.

Results: The panel identified 7 areas of controversy, and data were assimilated to support the best recommended practices related to these clinical issues. Ultimately, a number of issues in this realm were found to have a high level of evidence to support the role for surgical therapy in patients with stage IV lung cancer. However, the nuances of how these operations are conducted remain in equipoise, without ample evidence to support the extent of resection or nodal dissection.

Conclusions: Clear data exist to support the use of surgical resection of the primary lung tumor as LCT in stage IV lung cancer. Evidence-based recommendations have been provided to guide multidisciplinary teams on the implementation of treatment plans as well as to guide researchers on areas of ongoing need for further investigation.

With the publication of CALGB 140503, an increase in wedge resections for small, peripheral non-small cell lung cancer is expected; however, a relative paucity of data exists as to what defines a high quality oncologic wedge resection. The Thoracic Surgery Outcomes Research Network (ThORN), through expert discussion, guided by review of what limited data does exist, and through use of a modified Delphi process, provides these consensus statements defining an oncologically sound, high quality wedge resection. The statements are classified into five categories: 1) Preoperative Considerations 2) Technical Aspects 3) Lymph Node Assessment 4) Margin Assessment and 5) Tissue Handling by Pathology.

Background: Statistical risk models for durable left ventricular assist device (LVAD) implantation inform candidate selection, quality improvement, and evaluation of provider performance. We developed a 90-day mortality risk model utilizing The Society of Thoracic Surgeons National Intermacs Database (STS Intermacs).

Methods: STS Intermacs was queried for primary durable LVAD implants from 1/ 2019 - 9/2023. Multivariable logistic regression was used to derive a model based upon pre-implant risk factors using derivation (2019-2021 implants) and validation (2022-2023 implants) cohorts. Model performance (derivation and validation cohorts) was assessed using C-statistics, Brier Scores, and calibration plots. A refined model (all patients) was generated to calculate observed/expected [O/E, 95% confidence intervals (CI)] ratios for each center.

Results: The study population consisted of 11,342 patients from 2019-2023 sequentially divided in time into derivation (n=6,775) and validation (n=4,567). Ninety-day mortality was 8.0% (9.2% in derivation cohort vs. 7.4% in validation cohort; p=0.001). Logistic regression applied to derivation and validation cohorts produced similar discrimination (area under the curve (AUC) 0.714, CI: 0.69-0.74 and AUC 0.707, CI: 0.67-0.72, respectively) and calibration (Brier score .08 vs .07), with overestimation of risk among patients with predicted risk > 0.4. The O/E analysis identified 22 (12.5%) centers with worse-than-expected mortality with a CI > 1.0 and 14 centers (8.0%) with better-than-expected mortality with a CI < 1.0 (all p < 0.05).

Conclusions: The STS Intermacs Risk Model demonstrated satisfactory discrimination and calibration. This tool may be used to inform candidate selection, facilitate quality improvement, and assess provider performance.