Andréanne Gagné, MD PhD
Andréanne Gagné*, Robert F. Padera, Rachel K. Putman, Lynette M. Sholl
Lynette M. Sholl
Pulmonary thrombotic arteriopathy (PTA) may be detected incidentally in lung resections. Historic studies largely examined PTA in autopsies, thus the prevalence in surgical samples, particularly in the modern era of lung cancer screening, is poorly defined. Detection of PTA in surgical samples provides an opportunity for diagnostic and therapeutic intervention, but the impact of this finding on clinical management is unknown.
We retrospectively examined consecutive patients with a lung surgical resection and an incidental finding of PTA between 2019-2022. Data collected included standard clinicopathological characteristics and history of systemic thromboembolism. Slides were reviewed to describe the thromboembolic disease. Impact of the pathology findings on post-surgical management was defined as the addition of imaging studies, other relevant tests, or anticoagulation therapy. The associations between clinicopathological characteristics and clinical manifestations of PTA were assessed by chi-square tests and ROC curves.
Among 2324 pulmonary resections, 68 (2.93%) contained PTA. Among samples with PTA, clinically-recognized thromboembolic disease was identified in 36.8% of patients; clinicopathologic features were similar between patients with and without clinically-recognized disease. Early organizing thrombi or thrombi of varied age (p=0.038) and affecting proximal arteries (p=0.009) are more likely to be associated with clinically-recognized disease, while the number of thrombus (area under the curve = 0.554), distance to tumor (p=0.907), presence of infarct (p=0.078), and concomitant pulmonary arterial hypertensive changes (p=0.751) were not. Reporting of incidental PTA led to clinical intervention in five patients (7.4%) and confirmed systemic thromboembolic disease in two. Moreover, two patients with PTA and without additional postoperative workup subsequently developed pulmonary embolism.
Pulmonary thrombotic arteriopathy is incidentally detected in <3% of surgical lung resections; in most cases, there is no antecedent clinical suspicion for thromboembolic disease. The pathologic findings only rarely led to a clinical intervention, suggesting a need for improved communication of incidental pathology findings.
This work represents one of the first contemporary study of pulmonary thrombotic arteriopathy (PTA) in lung resections, as the actual incidence and clinical impact of this finding was unknown, particularly in the modern era of lung cancer screening. Our work addresses important questions about how to interpret and how to report this incidental finding in pathology reports. We found that pathologic review appears to be more sensitive than imaging for detection of subclinical thromboembolic disease. We also identified pathological characteristics of PTA that are associated with clinically-recognized thromboembolic disease, providing guidance for pathologists about how to interpret their findings. We also found there is a need for improved communication of this finding with clinical teams, as clinical action was taken only in a minority of patients. Moreover, thromboembolic disease was found in two out of five patients for which clinical action was taken.