Is routine chest X-ray after surgical and percutaneous tracheostomy necessary in adults: a systemic review of the current literature

BACKGROUND

For many years, routine post-tracheostomy chest X-ray has been the standard of care for patients in many countries. However, recent evidence suggests that this is unnecessary and cost-ineffective.

OBJECTIVE

To review the current literature and examine the role of routine post-tracheostomy chest X-ray in adult patients.

TYPE OF REVIEW

Systemic review.

SEARCH STRATEGY

Electronic databases (PubMed, EMBASE, Cochrane) were searched using the keywords 'chest X-ray/radiography/radiograph' and 'tracheostomy/tracheotomy' in various permutations. Search period ranged from 1960 to 2012. Inclusion criteria included systematic reviews, meta-analyses, randomised control trials, prospective and retrospective case series. Paediatric and non-English articles were excluded. Abstracts and subsequently full text articles were screened by two of the authors independently. References from obtained articles were also examined.

EVALUATION METHOD

Specific outcome measures were collated to evaluate the usefulness of post-tracheostomy chest X-ray: Chest X-ray detected (tracheostomy-related) complication rates Proportion of cases requiring significant intervention Potential predictors of complications

RESULTS

Routine post-tracheostomy chest X-ray is of a low yield, and its findings had limited impact on patient management. Complication detection rates for surgical and percutaneous tracheostomy are 2.2% and 3.2%, respectively. Only 0.7% and 1.8% of chest X-rays performed in surgical and percutaneous tracheostomy cases, respectively, required intervention. Certain groups of patients, however, are at higher risks of complications, and may benefit from post-tracheostomy chest X-ray. For surgical tracheostomy, these groups include those with post-operative signs and symptoms of complications or had emergent or 'difficult' tracheostomies. For percutaneous tracheostomy, high-risk patients include trauma cases (unspecified), patients with post-procedural signs and symptoms of complications, patients who have high ventilatory requirements, difficult tracheostomy cases or tracheostomy cases performed without bronchoscopic guidance.

CONCLUSION

The practice of routine post-tracheostomy chest X-ray is debatable owing to its low yield and minimal impact on clinical management. However, certain groups of patients appear to be at higher risks of post-tracheostomy complications; currently, there is insufficient evidence to conclude the absolute need for routine chest X-ray in these groups of patients, although it may be prudent to do so based on available evidence in the literature and logical clinical reasoning.

Abstract P6-06-50: Obesity and the influence on tumor biology as determined by the intermediate risk 21-gene recurrence scores (RS) and the 70-gene breast cancer recurrence signature (70-GS) assay

BACKGROUND

Obesity is an apparent risk factor for postmenopausal breast cancer (BC), estrogen receptor (ER) positive BC, larger tumors, lymph node (LN) involvement, as well as recurrence of BC and BC death despite treatment. However, the specific mechanism of these increased risks remains unclear. Our prior work described the negative influence of metabolic syndrome on BC recurrence in patients assessed by a 21 gene recurrence score (RS) in the low risk and intermediate risk tertiles (Lakhani et al PSABCS 2012). The objective of this study was to analyze the interaction of obesity and BC biology in patients assessed by the 70 gene signature (70-GS) for BC recurrence and the 80 gene molecular subtyping.

METHODS

We studied consecutive patients with newly diagnosed ER positive, LN negative BC treated at Loyola University Medical Center between 2005 -2012 who had an intermediate RS. The 70-GS was done on these same paraffin-embedded tumor blocks for risk level and molecular subtype. Standard descriptive statistics are reported. Wilcoxon rank sum tests were performed for the comparison of BMI by groups defined by RS scores (≤24 vs ≥25) and the 70 gene signature assay (high risk vs low risk). In addition, Chi-squared test, or Fisher's exact test as appropriate, was used to examine the association between BMI tertiles and the 70GS or molecular subtype.

RESULTS

From 102 patients with intermediate RS, the 70-GS was successful in 89 samples. The average age was 61 years (range 41-79). The median body mass index (BMI) was 29 (range 18-53). There was a significant association between BMI and RS (p = 0.0110): median BMI = 28 in patients with RS ≤24; median BMI 33 in patients with RS ≥25. There was a significant association between BMI and the 70-GS (p = 0.0116). Median BMI 27 in low risk group; median BMI 32 in high risk group. There was a significant association between the 70-GS and BMI (p = 0.0190).

Association between the 70-GS and BMI70-GS RiskHealthy (18-25)Overweight (26-30)Obese (>30)TotalHigh (n pts)1292950Low (n pts)15131139

There was a significant association between molecular subtype and BMI tertiles (p = 0.0803).

Association between molecular subtype and BMI tertiles HealthyOverweightObeseTotalLuminal A (n pts)14131239Luminal B (n pts)1392648

CONCLUSION

There is a striking interaction of obesity and BC biology as defined by the RS and 70-GS assays. Our data suggest that BC in obese women may have more aggressive tumor biology and higher risk of recurrence than BC in those with a low BMI. Further molecular characterization of the BC from obese patients may elucidate the role obesity plays in BC development and progression, as well as provide rationale for targeted therapeutic trials. Clinical trials targeting known carcinogenic pathways related to obesity (such as metformin and statins) are ongoing. Several genes in the 70-GS are the same genes expressed in obese patients. Additional studies examining the prognostic and predictive value of the 70-GS need to be conducted for this patient population.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-06-50.