Preoperative CT-based emphysema score: a tool to inform not determine prolonged air leak risk after lung cancer resection
We thank the authors for their thoughtful and constructive commentary on our study, “CT-based emphysema score is associated with prolonged air leak after lung resection: a retrospective cohort study” (1,2). We appreciate their careful appraisal of our findings and their emphasis on the clinical interpretation of computed tomography (CT)-based emphysema quantification in the context of perioperative decision-making. In our study, we aimed to evaluate CT-based emphysema score as an objective, preoperative imaging-derived parameter associated with the risk of prolonged air leak (PAL) following lung cancer resection. By focusing on ipsilateral lung emphysema burden in a large contemporary North American cohort, we sought to refine prior approaches and explore how quantitative emphysema assessment might complement established clinical risk stratification.
We agree with the authors’ interpretation that the proposed 16% emphysema cut-point should not be viewed as a definitive trigger for intraoperative intervention. As highlighted in our Results and Discussion, the modest sensitivity and incremental improvement in model discrimination underscore that the emphysema score is best interpreted as a risk-stratification adjunct, rather than a standalone determinant of operative strategy. Importantly, the relatively high specificity of this threshold supports its potential utility in identifying patients at lower risk of PAL, which may help guide selective use of preventive measures and avoid unnecessary resource utilization in low-risk cases.
We also concur that PAL is a multifactorial postoperative outcome influenced by both patient-related factors and surgical technique. While CT-based emphysema scoring provides an objective measure of parenchymal vulnerability, its clinical impact is necessarily modulated by intraoperative technique and postoperative management strategies, including fissure handling, stapling approach and reinforcement methods. As these variables were not uniformly captured in our dataset, the emphysema score should be interpreted as reflecting baseline susceptibility rather than an isolated or deterministic predictor of PAL.
The authors’ comments regarding the subgroup of patients with borderline pulmonary function are well taken. Although our findings suggest that emphysema score may offer additional discriminatory value in patients with both forced expiratory volume in one second (FEV1) and diffusing capacity of the lung carbon monoxide (DLCO) <60%, we agree that these results should be considered exploratory given the limited sample size. Further validation in larger, independent cohorts will be essential before broader application of this observation in surgical decision-making.
In summary, we appreciate the authors’ commentary, which aligns closely with the intent and conclusions of our study. We believe that CT-based emphysema quantification holds promise as a tool to augment preoperative risk assessment, particularly for identifying patients unlikely to develop PAL, while emphasizing that operative judgment and comprehensive perioperative management remain central to optimizing outcomes. Future prospective and multicenter studies incorporating operative and postoperative variables will be critical to defining how emphysema scoring can be most effectively integrated into comprehensive surgical risk-stratification frameworks.
Acknowledgments
None.
Footnote
Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Thoracic Disease. The article did not undergo external peer review.
Funding: None.
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1-2776/coif). The authors have no conflicts of interest to declare.
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References
- Wang J, Guo H. Surgical implications of CT-based emphysema scoring in predicting prolonged air leak—defining its role as a risk stratification tool rather than a decision trigger. J Thorac Dis 2026; [Crossref]
- Naeem W, Khan AA, Ansari M, et al. CT-based emphysema score is associated with prolonged air leak after lung resection: a retrospective cohort study. J Thorac Dis 2025;17:9397-410. [Crossref] [PubMed]
