This Article Full Text Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My Personal Article Archive Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Colice, G. L. Articles by Bolliger, C. T. Search for Related Content PubMed PubMed Citation Articles by Colice, G. L. Articles by Bolliger, C. T.

Physiologic Evaluation of the Patient With Lung Cancer Being Considered for Resectional Surgery^*

ACCP Evidenced-Based Clinical Practice Guidelines (2nd Edition)

^* From the Division of Pulmonary and Critical Care Medicine (Dr. Colice), Washington Hospital Center and The George Washington University School of Medicine, Washington, DC; the Division of Pulmonary and Critical Care Medicine (Dr. Shafazand), University of Miami, Miller School of Medicine, Miami, FL; the Division of Pulmonary and Critical Care Medicine (Dr. Griffin), Department of Medicine and Preventive Medicine, The University of Tennessee Health Science Center, Memphis, TN; the Division of Thoracic Surgery (Dr. Keenan), Allegheny General Hospital, Pittsburgh, PA; and the Respiratory Research Unit (Dr. Bolliger), Tygerberg Academic Hospital and University of Stellenbosch, Cape Town, South Africa.

Correspondence to: Gene L. Colice, MD, FCCP, Director, Pulmonary, Critical Care, and Respiratory Services, Washington Hospital Center, 110 Irving St NW, Washington, DC 20010; e-mail: Gene.Colice{at}Medstar.net

Background: This section of the guidelines is intended to provide an evidence-based approach to the preoperative physiologic assessment of a patient being considered for surgical resection of lung cancer.

Methods: Current guidelines and medical literature applicable to this issue were identified by computerized search and evaluated using standardized methods. Recommendations were framed using the approach described by the Health and Science Policy Committee.

Results: The preoperative physiologic assessment should begin with a cardiovascular evaluation and spirometry to measure the FEV₁. If diffuse parenchymal lung disease is evident on radiographic studies or if there is dyspnea on exertion that is clinically out of proportion to the FEV₁, the diffusing capacity of the lung for carbon monoxide (DLCO) should also be measured. In patients with either an FEV₁ or DLCO < 80% predicted, the likely postoperative pulmonary reserve should be estimated by either the perfusion scan method for pneumonectomy or the anatomic method, based on counting the number of segments to be removed, for lobectomy. An estimated postoperative FEV₁ or DLCO < 40% predicted indicates an increased risk for perioperative complications, including death, from a standard lung cancer resection (lobectomy or greater removal of lung tissue). Cardiopulmonary exercise testing (CPET) to measure maximal oxygen consumption (O₂max) should be performed to further define the perioperative risk of surgery; a O₂max of < 15 mL/kg/min indicates an increased risk of perioperative complications. Alternative types of exercise testing, such as stair climbing, the shuttle walk, and the 6-min walk, should be considered if CPET is not available. Although often not performed in a standardized manner, patients who cannot climb one flight of stairs are expected to have a O₂max of < 10 mL/kg/min. Data on the shuttle walk and 6-min walk are limited, but patients who cannot complete 25 shuttles on two occasions will likely have a O₂max of < 10 mL/kg/min. Desaturation during an exercise test has not clearly been associated with an increased risk for perioperative complications. Lung volume reduction surgery (LVRS) improves survival in selected patients with severe emphysema. Accumulating experience suggests that patients with extremely poor lung function who are deemed inoperable by conventional criteria might tolerate combined LVRS and curative-intent resection of lung cancer with an acceptable mortality rate and good postoperative outcomes. Combining LVRS and lung cancer resection should be considered in patients with a cancer in an area of upper lobe emphysema, an FEV₁ of > 20% predicted, and a DLCO of > 20% predicted.

Conclusions: A careful preoperative physiologic assessment will be useful to identify those patients who are at increased risk with standard lung cancer resection and to enable an informed decision by the patient about the appropriate therapeutic approach to treating their lung cancer. This preoperative risk assessment must be placed in the context that surgery for early-stage lung cancer is the most effective currently available treatment for this disease.

Key Words: cardiopulmonary exercise testing • diffusing capacity of the lung for carbon monoxide • lung cancer • lung resection surgery • predicted postoperative lung function • preoperative assessment • spirometry