Development and Validation of a Risk Score for Predicting Death after Pneumonectomy

Abstract

Pneumonectomy is associated with significant postoperative mortality. This study was undertaken to develop and validate a risk model of mortality following pneumonectomy. We reviewed our prospective database and identified 774 pneumonectomies from a total of 7792 consecutive anatomical lung resections in the years 2003 to 2010 (rate of pneumonectomy: 9.9%). Based on data from 542 pneumonectomies between 2003 and 2007 (i.e., the "discovery set"), a penalized multivariable logistic regression analysis was performed to identify preoperative risk factors. A risk model was developed and validated in an independent data set of 232 pneumonectomies that were performed between 2008 and 2010 (i.e., the "validation set"). Of the 542 patients in the discovery set (DS), 35 patients (6.5%) died after pneumonectomy during the same admission. We developed a risk prediction model for in-hospital mortality following pneumonectomy; that model included age, current alcohol use, coronary artery disease, preoperative leukocyte count and palliative indication as possible risk factors. The risk model was subsequently successfully validated in an independent data set (n = 232) in which 18 patients (7.8%) died following pneumonectomy. For the validation set, the sensitivity of the model was 53.3% (DS: 54.3%), the specificity was 88.0% (DS: 87.4%), the positive predictive value was 26.7% (DS: 22.9%) and the negative predictive value was 95.8% (DS: 96.5%). The Brier score was 0.062 (DS: 0.054). The prediction model is statistically valid and clinically relevant.

Development of a nomogram for predicting the operative mortality of patients who underwent pneumonectomy for lung cancer: a population-based analysis

“…Similar to the findings of a host of previous studies, our multivariate regression analysis also found that the risk of operative mortality increased with male sex, advanced age, right-sided pneumonectomy, and SCC (9,23,25). In addition, the npLNs (≥5) was first identified as a risk factor for postpneumonectomy death, but the traditional node staging did not show this predictive value; similarly, distant metastasis was also associated with higher operative mortality, which cautioned us that the advanced stage was a poor indication not only for long-term survival but also for short-term outcomes.…”

Risk stratification in high-risk patients undergoing lung resection

“…However, there are a number of concerns with regards to model development [limited number of deaths, an outdated method of internal validation (split sample approach) and the inclusion of variables not clinically relevant in the contemporary era (pneumonectomy is now rarely performed as a palliative procedure)] for the Safi model. These factors, when coupled with the model's poor performance in both a recent external validation study (14) and also in this study, mean that the Safi model cannot be recommended as a risk stratification tool for patients undergoing either pneumonectomy or other forms of lung resection. A study validating the performance of the Thoracoscore model in a cohort of patients undergoing pneumonectomy found the model's performance to be similarly inadequate (15).…”

“…Pneumonectomy is recognised as a procedure carrying particularly high peri-operative mortality, with contemporary studies reporting a 90-day mortality rate of around 10% (14). Hence, the Safi model, designed specifically to predict inhospital mortality for patients undergoing pneumonectomy, can be considered to be the only existing model, to the best of our knowledge, developed solely for high-risk patients (11).…”

Pneumonectomy for primary lung cancer: contemporary outcomes, risk factors and model validation

“…Advanced age, poor pulmonary function tests and undergoing a right-sided operation have been associated with adverse outcomes after pneumonectomy [ 4–7 ]. Several clinical prediction models have been developed for perioperative mortality after thoracic surgery that include pneumonectomy as a risk factor [ 8 ]; however, only one model has been designed specifically for patients undergoing pneumonectomy [ 9 ]. No pneumonectomy-specific clinical prediction model for long-term survival has previously been developed.…”