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The Physiologic Evaluation of Patients With Lung Cancer Being Considered for Resectional Surgery^*

^* From the Department of Respiratory Medicine (Dr. Beckles), Royal Free Hospital, London, UK; Department of Respiratory Medicine (Dr. Spiro), Middlesex Hospital, London, UK; Pulmonary, Critical Care and Respiratory Services (Dr. Colice), Washington Hospital Center, Washington, DC; and Department of Medical Oncology (Dr. Rudd), St. Bartholomew’s Hospital, Smithfield, London, UK.

Correspondence to: Stephen G, Spiro, MD, Department of Respiratory Medicine, The Middlesex Hospital, Mortimer St, London W1T 3AA, United Kingdom; e-mail: stephen.spiro{at}uclh.org

	Abstract

TOP Abstract Introduction General Issues for Lung... Spirometry and Diffusing... Predicted Postoperative Values... Exercise Testing Arterial Blood Gas Tensions Methods To Reduce Perioperative... Summary Summary of Recommendations References

 
The preoperative physiologic assessment of a patient being considered for surgical resection of lung cancer must consider the immediate perioperative risks from comorbid cardiopulmonary disease, the long-term risks of pulmonary disability, and the threat to survival due to inadequately treated lung cancer. As with any planned major operation, especially in a population predisposed to atherosclerotic cardiovascular disease by cigarette smoking, a cardiovascular evaluation is an important component in assessing perioperative risks. Measuring the FEV₁ and the diffusing capacity of the lung for carbon monoxide (DLCO) measurements should be viewed as complementary physiologic tests for assessing risk related to pulmonary function. If there is evidence of interstitial lung disease on radiographic studies or undue dyspnea on exertion, even though the FEV₁ may be adequate, a DLCO should be obtained. In patients with abnormalities in FEV₁ or DLCO identified preoperatively, it is essential to estimate the likely postresection pulmonary reserve. The amount of lung function lost in lung cancer resection can be estimated by using either a perfusion scan or the number of segments removed. A predicted postoperative FEV₁ or DLCO < 40% indicates an increased risk for perioperative complications, including death, from lung cancer resection. Exercise testing should be performed in these patients to further define the perioperative risks prior to surgery. Formal cardiopulmonary exercise testing is a sophisticated physiologic testing technique that includes recording the exercise ECG, heart rate response to exercise, minute ventilation, and oxygen uptake per minute, and allows calculation of maximal oxygen consumption (O₂max). Risk for perioperative complications can generally be stratified by O₂max. Patients with preoperative O₂max > 20 mL/kg/min are not at increased risk of complications or death; O₂max < 15 mL/kg/min indicates an increased risk of perioperative complications; and patients with O₂max < 10 mL/kg/min have a very high risk for postoperative complications. Alternative types of exercise testing include stair climbing, the shuttle walk, and the 6-min walk. Although often not performed in a standardized manner, stair climbing can predict O₂max. In general terms, patients who can climb five flights of stairs have O₂max > 20 mL/kg/min. Conversely, patients who cannot climb one flight of stairs have O₂max < 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 have O₂max < 10 mL/kg/min. Desaturation during an exercise test has been associated with an increased risk for perioperative complications. Lung volume reduction surgery (LVRS) for patients with severe emphysema is a controversial procedure. Some reports document substantial improvements in lung function, exercise capability, and quality of life in highly selected patients with emphysema following LVRS. Case series of patients referred for LVRS indicate that perhaps 3 to 6% of these patients may have coexisting lung cancer. Anecdotal experience from these case series suggest that patients with extremely poor lung function can tolerate combined LVRS and resection of the lung cancer with an acceptable mortality rate and good postoperative outcomes. Combining LVRS and lung cancer resection should probably be limited to those patients with heterogeneous emphysema, particularly emphysema limited to the lobe containing the tumor.

Key Words: cardiopulmonary exercise testing • diffusing capacity • predicted postoperative lung function • preoperative assessment • spirometry

	Introduction

TOP Abstract Introduction General Issues for Lung... Spirometry and Diffusing... Predicted Postoperative Values... Exercise Testing Arterial Blood Gas Tensions Methods To Reduce Perioperative... Summary Summary of Recommendations References

 
While surgery remains the best option for cure for lung cancer, many potentially resectable tumors occur in individuals with abnormal pulmonary function usually due to cigarette smoking. These patients may be at increased risk for immediate perioperative complications and long-term disability following resection of functioning lung tissue. Cigarette smoking will also predispose these patients to other comorbid conditions, specifically atherosclerotic cardiovascular disease, which will further increase the perioperative risks. Consequently, the preoperative physiologic assessment of a patient being considered for surgical resection of lung cancer must consider the immediate perioperative risks from comorbid cardiopulmonary disease, the long-term risks of pulmonary disability, and the threat to survival due to inadequately treated lung cancer.

Little information is available on long-term survival of patients deemed inoperable because of physiologic limitations, especially compared to a group with similar physiologic limitations who underwent surgical resection. One study reported that the long-term survival curve for five high-risk patients undergoing operation was no different than for 39 similar patients deemed inoperable, despite a higher initial mortality in the group undergoing resection.¹ The balance between perioperative risks and inadequate cancer treatment may be shifting, because surgical techniques and anesthetic and postoperative care have improved. Morbidity and mortality rates following lung resection are lower now than in the past.² Postoperative cardiopulmonary complications historically noted to be of greatest concern after lung resection, eg, acute hypercapnea, mechanical ventilation lasting > 48 h, arrhythmias, pneumonia, pulmonary emboli, myocardial infarction, and lobar atelectasis requiring bronchoscopy,³ now may be more effectively managed.

Following lung resection, it is generally accepted that postoperative lung function will decrease. Serial studies have shown that lung function and exercise capability decrease within the first several months following lung cancer resection, but may recover to a small extent by 6 months.^{4 5} It had been assumed that there would be lower limits on the acceptability of postoperative lung function, below which quality of life would be unacceptable due to pulmonary disability.⁶ However, data relating changes in actual quality of life to removal of functioning lung tissue in patients with compromised lung function are limited. This issue has become particularly difficult to interpret with the recent resurgence of interest in lung volume reduction surgery (LVRS), and the possibility of simultaneously resecting a lung cancer and improving lung function with LVRS.

Ideally, the task of the preoperative physiologic assessment is to identify patients at high risk for perioperative complications and long-term disability from lung cancer resection surgery using the least invasive tests possible. The purpose of this preoperative physiologic assessment is twofold: to enable adequate counseling of the patient on treatment options and risks so that they can make a truly informed decision, and to identify possible steps to reduce the risks of perioperative complications and long-term pulmonary disability.

	General Issues for Lung Cancer Surgery

TOP Abstract Introduction General Issues for Lung... Spirometry and Diffusing... Predicted Postoperative Values... Exercise Testing Arterial Blood Gas Tensions Methods To Reduce Perioperative... Summary Summary of Recommendations References

 
All patients with lung cancer should be seen by a physician interested in the management of this disease. Patients seen by specialists will have higher rates of diagnosis, referral to surgeons and oncologists, and treatment with better outcomes.^{7 8} A multidisciplinary team approach is essential in the assessment of these patients. The proposed procedure should be discussed with the patient and relatives.

Age should not be a reason to deny patients with lung cancer access to lung cancer services.⁹ As the population ages, the number of patients 70 years old will rise; it is estimated that 40% of patients with lung cancer in 2005 will be 75 years old.⁸ For elderly patients (> 70 years old), the mortality from reported series for lobectomy is between 4% and 7%, and for pneumonectomy averages 14%.^{2 10 11} These rates are higher than for patients < 70 years old and the differential between the mortality of pneumonectomy and lobectomy is larger in elderly patients when compared to younger patients, but these differences may be more a function of comorbidity than age alone. Information is limited on the mortality rates for lung cancer resection in the very elderly (> 80 years old) but suggest that the very elderly can tolerate lobectomy.¹⁰

As with any planned major operation, especially in a population predisposed to atherosclerotic cardiovascular disease by cigarette smoking, a preoperative cardiovascular risk assessment should be performed. The approach to this risk assessment (Table 1 ) has been described in the American College of Cardiology and American Heart Association guidelines for perioperative cardiovascular evaluation for noncardiac surgery.¹² The presence of coronary artery disease increases the risk of nonfatal myocardial infarction or death within 30 days of noncardiac surgery.

1. Patients with lung cancer should be seen by physicians interested in the management of this disease. Level of evidence, fair; benefit, substantial; grade of recommendation, B
   
2. Patients with lung cancer should be assessed by a multidisciplinary team for their suitability for surgery; there should be liaison between the chest physician, thoracic surgical team, and oncologist in all cases prior to surgery. Level of evidence, poor; benefit, substantial; grade of recommendation, C
   
3. Patients with lung cancer should not be denied lung resection surgery on the grounds of age alone. Level of evidence, fair; benefit, substantial; grade of recommendation, B
   
4. Patients with lung cancer undergoing surgery should have a preoperative cardiologic evaluation carried out according to established guidelines. Level of evidence, fair; benefit, substantial; grade of recommendation, B
   

	Spirometry and Diffusing Capacity

TOP Abstract Introduction General Issues for Lung... Spirometry and Diffusing... Predicted Postoperative Values... Exercise Testing Arterial Blood Gas Tensions Methods To Reduce Perioperative... Summary Summary of Recommendations References

 
The FEV₁ obtained by spirometry is the most commonly used test to assess suitability of patients with lung cancer for surgery. Spirometry should be performed when the patient is in clinically stable condition and receiving maximal bronchodilator therapy. The FEV₁ can be expressed in either absolute values or as a percentage of predicted.

There have been several studies looking at the minimum absolute values of FEV₁ that, as a single measurement, will predict whether a patient will survive a pneumonectomy and still have a good level of habitual activity. Many studies are retrospective and have small numbers of patients. A review of the literature suggests an FEV₁ > 2 L as a safe lower limit for pneumonectomy and > 1.5 L for a lobectomy.^{13 14 15} In the British Thoracic Society (BTS) guidelines, data from > 2,000 patients in three large series in the 1970s have shown that a mortality rate of < 5% can be achieved if the preoperative FEV₁ is > 1.5 L for a lobectomy and > 2 L for a pneumonectomy.¹⁰ A major pragmatic difficulty in assembling our recommendations is that the literature is heavily based on making predictions for resection using absolute values of FEV₁. This approach might bias against older patients, people of small stature, and female patients who might tolerate lower levels of lung function. Although it is not possible to recalculate percentage of predicted values from the BTS data, an FEV₁ > 80% predicted also indicates that the patient should be considered suitable for pneumonectomy without further evaluation.¹⁶

Interest in the diffusing capacity of the lung for carbon monoxide (DLCO) as a useful marker of operative risk was stimulated by a study of Ferguson et al,¹⁷ who related preoperative DLCO to postresection morbidity and mortality in 237 patients. Patients were selected for surgery on the basis of clinical evaluation and spirometry, but not the DLCO, which was also measured. They found the preoperative DLCO expressed as a percentage of predicted to have a higher correlation with postoperative deaths than the FEV₁ expressed as percentage of predicted, or any other factor tested. They noted a DLCO of < 60% predicted was associated with increased mortality. Also, the risk of pulmonary complications increased twofold to threefold with a DLCO < 80% normal.

Spirometry and DLCO measurements should be viewed as complementary physiologic tests. If there is evidence of interstitial lung disease on radiographic studies or undue dyspnea on exertion, even though the FEV₁ may be adequate, a DLCO should be obtained. In a prospective study of 137 patients with operable tumor, those with an FEV₁ > 80% predicted, a DLCO > 80% predicted, and no significant cardiac history were all suitable for pneumonectomy.¹⁶ There were no deaths in this group. In this study, patients with either an FEV₁ or a DLCO < 80% predicted had additional physiologic testing performed.

Recommendations

• In patients being considered for lung cancer resection, spirometry should be performed. If the FEV₁ is > 80% predicted normal or > 2 L, the patient is suitable for resection including pneumonectomy without further evaluation. If the FEV₁ is > 1.5 L, the patient is suitable for a lobectomy without further evaluation. Level of evidence, fair; benefit, substantial; grade of recommendation, B
  
• In patients being considered for lung cancer resection, if there is evidence of interstitial lung disease on radiographic studies or undue dyspnea on exertion, even though the FEV₁ might be adequate, DLCO should be measured. Level of evidence, fair; benefit, substantial; grade of recommendation, B
  
• In patients being considered for lung cancer resection, if either the FEV₁ or DLCO are < 80% predicted, postoperative lung function should be predicted through additional testing. Level of evidence, fair; benefit, substantial; grade of recommendation, B
  

	Predicted Postoperative Values of Lung Function

TOP Abstract Introduction General Issues for Lung... Spirometry and Diffusing... Predicted Postoperative Values... Exercise Testing Arterial Blood Gas Tensions Methods To Reduce Perioperative... Summary Summary of Recommendations References

 
The extent of further evaluation in patients with diminished pulmonary reserve depends on the extent of planned pulmonary resection: pneumonectomy, lobectomy, wedge resection, or segmentectomy. In patients with compromised lung function preoperatively, it is therefore essential to estimate the likely pulmonary reserve postresection. Approaches to obtaining the predicted postoperative (ppo) lung function have relied on several different methods to estimate the amount of functioning lung tissue that would be lost along with the surgical resection. The methods used, including ventilation scans,^{14 18 19 20 21} perfusion scans,^{6 14 18 19 20 21 22 23 24} quantitative CT,^{25 26} and simply counting the number of segments to be removed,^{23 27} seem to provide similar quantitative estimates of ppo lung function. Recommended approaches use a radionuclide perfusion scan with Tc-labeled macroaggregates of albumin to estimate the ppo FEV₁ and DLCO after pneumonectomy and the number of segments remaining for postlobectomy values.¹⁰ The percentage of ppo (%ppo) values for FEV₁ and DLCO are routinely used instead of absolute values.

%ppo FEV₁ After Pneumonectomy
%ppo FEV₁ is calculated using the following formula, which can also be used to calculate ppo and %ppo DLCO:

where ppo FEV₁ is expressed as percentage of predicted to calculate the %ppo FEV₁. The preoperative FEV₁ is taken as the best measure postbronchodilator. A quantitative radionuclide perfusion scan is performed to measure the relative function of each lung. Although several studies have demonstrated good correlation between the actual postoperative FEV₁ and the ppo FEV₁,^{14 19 28} the %ppo values estimated by the perfusion method may be up to 10% less than actual measured values 3 months postresection. This therefore errs on the side of safety.^{23 24 29}

%ppo FEV₁ After Lobectomy
The value of %ppo FEV₁ is strongly correlated with the actual postoperative FEV₁ when considering the number of segments to be removed at operation.^{14 27} Calculating the %ppo FEV₁ by the number of segments removed is similar to the method used for perfusion scan:

where ppo FEV₁ is expressed as a percentage of predicted to give %ppo. The lungs have the following 19 segments: right upper lobe (3 segments), right middle lobe (2 segments), right lower lobe (5 segments), left upper lobe (3 segments), lingual (2 segments), and left lower lobe (4 segments). This method can also be applied to segmentectomies because lobectomy does not cause a significantly greater loss of function when compared to segmentectomy.³⁰ This same formula may be used to calculate ppo and %ppo DLCO.

Olsen et al⁶ suggested a threshold ppo FEV₁ of 0.8 L as the lower limit for surgical resection. However, Pate and colleagues³¹ found that patients with a mean ppo FEV₁ of 0.7 L tolerated thoracotomy for lung cancer resection. This experience might have reflected resection of less lung tissue than anticipated. The main objection to using an absolute value of ppo FEV₁ as a threshold for operability is that it might prevent older patients, small stature people, and females patients, all of whom might tolerate a lower absolute FEV₁, from having a potentially curative lung cancer resection. Consequently, establishing a threshold for lung function expressed as %ppo rather than absolute ppo would be desirable.

Case series with small numbers of patients have shown that perioperative risks increase substantially when the %ppo FEV₁ is < 40% of predicted normal.^{18 23 24 32 33 34} Markos et al¹⁸ reported that three of six patients with a %ppo FEV₁ < 40% died in the perioperative period. Wahi et al³⁴ found a perioperative mortality rate of 16% in patients with a %ppo FEV₁ of < 41%, vs 3% with those with better predicted lung function. Pierce and colleagues²³ found that 5 of 13 patients with a %ppo FEV₁ < 40% died soon after operation, and Bolliger et al²⁴ reported that 2 of 4 patients with similar lung function died of respiratory failure perioperatively. Nakahara et al^{35 36} found an especially high postoperative mortality rate (6 of 10 patients, 60%) when the %ppo FEV₁ was < 30%.

As a result of the observation by Ferguson et al¹⁷ that the DLCO, expressed as the %ppo, was a strong predictor of mortality, others have also found that perioperative risks increase substantially when the %ppo DLCO < 40%.^{17 18 23} Pierce et al²³ suggested that a product of %ppo FEV₁ and %ppo DLCO < 1,650 might serve as a more discriminating threshold for perioperative risk assessment. Others have made a similar observation.³⁷

Although a %ppo FEV₁ or DLCO < 40% indicates increased risk for perioperative complications, including death, from lung cancer resection, these patients can be successfully operated on. Ribas et al³⁷ described a selected group of 65 patients who met these physiologic criteria but still underwent curative intent lobectomy/wedge resection (n = 44) or pneumonectomy (n = 21). There were only four postoperative deaths (6.2% mortality rate), and cardiopulmonary complications occurred in 31 patients (47.7%). Although this study indicates that lung cancer resection can be performed with an acceptable perioperative risk even in patients with poor lung function reserve, it is prudent to more thoroughly evaluate these patients prior to pulmonary resection.

Recommendation

• In patients with lung cancer being considered for surgical resection, either a %ppo FEV₁ < 40% or a %ppo DLCO < 40% indicate a high risk for perioperative death and cardiopulmonary complications. These patients should undergo exercise testing preoperatively. Level of evidence, fair; benefit, substantial; grade of recommendation, B
  
• In patients with lung cancer being considered for surgical resection, either a product of %ppo FEV₁ and %ppo DLCO < 1,650 or a %ppo FEV₁ < 30% indicate a very high risk for perioperative death and cardiopulmonary complications. These patients should be counseled about nonoperative treatment options for their lung cancer. Level of evidence, poor; benefit, substantial; grade of recommendation, C
  

	Exercise Testing

TOP Abstract Introduction General Issues for Lung... Spirometry and Diffusing... Predicted Postoperative Values... Exercise Testing Arterial Blood Gas Tensions Methods To Reduce Perioperative... Summary Summary of Recommendations References

 
Cardiopulmonary Exercise Testing
Formal cardiopulmonary exercise testing (CPET) is a sophisticated physiologic testing technique that includes recording the exercise ECG, heart rate response to exercise, minute ventilation, and oxygen uptake per minute. Maximal oxygen consumption (O₂max) is calculated from this type of exercise test. Algorithms for the preoperative physiologic assessment of patients being considered for lung cancer resection have incorporated use of CPET as an adjunct to estimating the %ppo FEV₁ and DLCO.^{10 16} However, there remains the practical difficulty as to when to recommend CPET, as it is readily acknowledged not to be widely available. We have taken the view of the BTS recommendations that exercise testing should be performed if perfusion lung scanning and calculation of %ppo FEV₁ and DLCO confirms borderline function (< 40%). It is suggested that if an institution is not equipped to perform CPET, patients in high-risk groups should be sent to a specialist center for this evaluation.

Numerous studies have examined the relationship between O₂max and perioperative complications. Risk for perioperative complications can generally be stratified by O₂max. Patients with a preoperative O₂max of > 20 mL/kg/min are not at increased risk of complications or death.^{1 18 31 38 39 40 41} Those patients with O₂max < 10 mL/kg/min have a very high risk for postoperative complications.^{3 10 16 24 32 42 43} Bechard and Wetstein⁴² reported that 2 of 7 patients with O₂max < 10 mL/kg/min died in the postoperative period; Olsen et al⁴³ described deaths in 5 of 11 patients; and Holden and colleagues³² noted deaths in 2 of 4 patients. O₂max < 15 mL/kg/min indicates an increased risk of perioperative complications.^{1 3 44 45} However, it should be noted that not all authors agree that perioperative complication rates can that clearly be stratified by O₂max.³⁷

In patients with borderline lung function, O₂max may be helpful in further evaluating the risk for perioperative complications. Morice et al⁴⁰ showed that in subjects with a ppo FEV₁ < 33%, eight patients underwent lobectomy because O₂max > 15 mL/kg/min was achieved, and no fatal complications occurred. Other studies have made similar observations.^{4 31} In patients with both a low %ppo FEV₁ and a low %ppo DLCO (both < 40% predicted), O₂max < 15 mL/kg/min indicates a group with a very high surgical risk.⁴⁴

Pulmonary Artery Pressures and DLCO
Measurements of pulmonary arterial pressure during exercise have not proven to be helpful in predicting which patients will acquire perioperative complications.^{37 43} A study by Wang et al⁴⁶ found that measuring DLCO during exercise was a better predictor of perioperative risk than O₂max, but is a technically demanding technique and not readily available.

Stair Climbing and Walking Tests
If CPET is unavailable, another type of exercise test should be considered. Stair climbing has historically been used as a surrogate CPET. If patients were able to climb three flights of stairs, they were considered suitable candidates for lobectomy. Pneumonectomy candidates were expected to be able to climb five flights of stairs. This approach was found to correlate with lung function: climbing three flights reflected an FEV₁ > 1.7 L and five flights indicated an FEV₁ > 2 L.⁴⁷ However, stair climbing is not performed in a standardized manner. The duration of the test, speed of ascent, number of steps per flight, height of each step, and criteria for stopping the test have not been well defined. However, in general terms, patients who can climb five flights of stairs will have a O₂max > 20 mL/kg/min. Conversely, patients who cannot climb one flight of stairs will have a O₂max < 10 mL/kg/min.⁴⁸

Other surrogate CPETs are the shuttle walk and the 6-min walk, but data on the value of these tests in predicting O₂max are limited.⁴⁹ The shuttle walk requires that patients walk back and forth between two markers set 10 m apart. The walking speed is paced by an audio signal and the walking speed is increased each minute in a graded fashion. The end of the test occurs when the patient is too breathless to maintain the required speed. In one study, inability to complete 25 shuttles on two occasions suggested a O₂max of < 10 mL/kg/min.⁵⁰ For the 6-min walk, patients are instructed to walk as far as possible in the time allotted. Rest during the test is permissible. Interpretation of the distance walked in 6 min is currently not well standardized.⁵¹

Desaturation
Desaturation during an exercise test has been associated with increased risk for perioperative complications.^{18 23 37 52} Greater than 4% desaturation indicates an increased risk for perioperative complications.¹⁰

Recommendations

• In patients with lung cancer being considered for lung resection, O₂max < 10 mL/kg/min indicates a very high risk for perioperative death and cardiopulmonary complications. These patients should be counseled about nonoperative treatment options for their lung cancer. Level of evidence, poor; benefit, substantial; grade of recommendation, C
  
• Patients being considered for lung cancer resection who have O₂max < 15 mL/kg/min and both a %ppo FEV₁ and DLCO < 40% should be considered at very high risk for perioperative death and cardiopulmonary complications. These patients should be counseled about nonoperative treatment options for their lung cancer. Level of evidence, poor; benefit, substantial; grade of recommendation, C
  
• Patients being considered for lung cancer resection who walk < 25 shuttles on two shuttle walks or < one flight of stairs should be considered at very high risk for perioperative death and cardiopulmonary complications. These patients should be counseled about nonoperative treatment options for their lung cancer. Level of evidence, poor; benefit, substantial; grade of recommendation, C
  

	Arterial Blood Gas Tensions

TOP Abstract Introduction General Issues for Lung... Spirometry and Diffusing... Predicted Postoperative Values... Exercise Testing Arterial Blood Gas Tensions Methods To Reduce Perioperative... Summary Summary of Recommendations References

 
Historically, hypercapnea (PaCO₂ > 45 mm Hg) has been quoted as an exclusion criterion for lung resection.^{16 53 54} This recommendation was made on the basis of the association of hypercapnea with poor ventilatory function.⁵⁵ The few studies that address this issue, however, suggest that preoperative hypercapnea is not an independent risk factor for increased perioperative complications. Stein et al⁵⁶ showed hypercapnea was associated with serious postoperative respiratory difficulties in five patients; there were no deaths, despite a PaCO₂ > 45 mm Hg. In two series of lung cancer patients undergoing surgery,^{57 58} perioperative complications were not higher in patients with preoperative hypercapnea. Preoperative hypoxemia, an arterial oxygen saturation (SaO₂) < 90%, has been associated with an increased risk of postoperative complications.⁵²

Recommendations

• In patients being considered for lung cancer surgery, PaCO₂ > 45 mm Hg is not an independent risk factor for increased perioperative complications. However, further physiologic testing is advised. Level of evidence, poor; benefit, substantial; grade of recommendation, C
  
• In patients being considered for lung cancer surgery, SaO₂ < 90% indicates an increased risk for perioperative complications, and further physiologic testing is advised. Level of evidence, poor; benefit, substantial; grade of recommendation, C
  

	Methods To Reduce Perioperative Risks

TOP Abstract Introduction General Issues for Lung... Spirometry and Diffusing... Predicted Postoperative Values... Exercise Testing Arterial Blood Gas Tensions Methods To Reduce Perioperative... Summary Summary of Recommendations References

 
LVRS
LVRS for patients with severe emphysema is a controversial procedure. Some reports document substantial improvements in lung function, exercise capability, and quality of life in highly selected patients with emphysema following LVRS.⁵⁹ However, recently published results from a larger prospective, randomized, controlled trial indicate an increased mortality rate after LVRS in patients with either homogenous emphysema or a low DLCO.⁶⁰ Case series of patients referred for LVRS indicate that perhaps 3 to 6% of these patients may have coexisting lung cancer.^{61 62} Anecdotal experience from these case series suggest that patients with extremely poor lung function can tolerate combined LVRS and resection of the lung cancer with an acceptable mortality rate and surprisingly good postoperative outcomes.^{61 62 63 64 65 66 67}

McKenna et al⁶¹ reported 11 cases of lung cancer (3%) in their group of 325 patients referred for LVRS. These 11 patients had an average preoperative FEV₁ of 0.65 L (range of FEV₁ percent predicted of 12 to 29%). None of these patients would have been acceptable for lung cancer resection based on traditional criteria but all underwent combined LVRS and resection of stage 1 lung cancers, either with lobectomy or wedge resection. There were no deaths or major complications; lung function and exercise capability were improved postoperatively. There have been other promising reports on the combination of LVRS and lung cancer resection in patients with very poor lung function.^{62 63 64 65 66 67} Combining LVRS and lung cancer resection should probably be limited to those patients with heterogeneous emphysema, particularly emphysema limited to the lobe containing the tumor.^{67 68}

Smoking Cessation
While smoking is strongly associated with lung cancer, it is also associated with an increased risk of postoperative complications. However there is little clinical evidence to suggest that smoking cessation before surgery is beneficial. One study in cardiac patients found that cessation of smoking 8 weeks prior to surgery decreased the perioperative complication rate; this is an impractical length of time in the context of surgery for lung cancer.⁶⁹

Pulmonary Rehabilitation
As yet, there are no robust data to recommend the routine use of preoperative pulmonary rehabilitation for patients with lung cancer.

Recommendation

• In patients with very poor lung function, combined LVRS and lung cancer resection may be considered if emphysema is heterogeneous and involves primarily the lobe to be resected. Level of evidence, poor; benefit, substantial; grade of recommendation, C
  

	Summary

TOP Abstract Introduction General Issues for Lung... Spirometry and Diffusing... Predicted Postoperative Values... Exercise Testing Arterial Blood Gas Tensions Methods To Reduce Perioperative... Summary Summary of Recommendations References

 
Patients with lung cancer often have concomitant obstructive lung disease and/or atherosclerotic cardiovascular disease as a consequence of their smoking habit. These diseases may place these patients at increased risk for perioperative complications, including death, after lung cancer resection. A careful preoperative physiologic assessment will be useful to identify those patients at increased risk 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 lung cancer surgery is the most effective currently available treatment for this disease.

	Summary of Recommendations

TOP Abstract Introduction General Issues for Lung... Spirometry and Diffusing... Predicted Postoperative Values... Exercise Testing Arterial Blood Gas Tensions Methods To Reduce Perioperative... Summary Summary of Recommendations References

 

1. Patients with lung cancer should be seen by physicians interested in the management of this disease. Level of evidence, fair; benefit, substantial; grade of recommendation, B
   
2. Patients with lung cancer should be assessed by a multidisciplinary team for their suitability for surgery; there should be liaison between the chest physician, thoracic surgical team, and oncologist in all cases prior to surgery. Level of evidence, poor; benefit, substantial; grade of recommendation, C
   
3. Patients with lung cancer should not be denied lung resection surgery on the grounds of age alone. Level of evidence, fair; benefit, substantial; grade of recommendation, B
   
4. Patients with lung cancer undergoing surgery should have a preoperative cardiologic evaluation carried out according to established guidelines. Level of evidence, fair; benefit, substantial; grade of recommendation, B
   
5. In patients being considered for lung cancer resection, spirometry should be performed. If the FEV₁ is > 80% predicted normal or > 2 L, the patient is suitable for resection including pneumonectomy without further evaluation. If the FEV₁ is > 1.5 L, the patient is suitable for a lobectomy without further evaluation. Level of evidence, fair; benefit, substantial; grade of recommendation, B
   
6. In patients being considered for lung cancer resection, if there is evidence of interstitial lung disease on radiographic studies or undue dyspnea on exertion, even though the FEV₁ might be adequate, DLCO should be measured. Level of evidence, fair; benefit, substantial; grade of recommendation, B
   
7. In patients being considered for lung cancer resection, if either the FEV₁ or DLCO are < 80% predicted, postoperative lung function should be predicted through additional testing. Level of evidence, fair; benefit, substantial; grade of recommendation, B
   
8. In patients with lung cancer being considered for surgical resection, either %ppo FEV₁ < 40% or %ppo DLCO < 40% indicate a high risk for perioperative death and cardiopulmonary complications. These patients should undergo exercise testing preoperatively. Level of evidence, fair; benefit, substantial; grade of recommendation, B
   
9. In patients with lung cancer being considered for surgical resection, either a product of %ppo FEV₁ and %ppo DLCO < 1,650 or %ppo FEV₁ < 30% indicate a very high risk for perioperative death and cardiopulmonary complications. These patients should be counseled about nonoperative treatment options. Level of evidence, poor; benefit, substantial; grade of recommendation, C
   
10. In patients with lung cancer being considered for lung resection, O₂max < 10 mL/kg/min indicates a very high risk for perioperative death and cardiopulmonary complications. These patients should be counseled about nonoperative treatment options. Level of evidence, poor; benefit, substantial; grade of recommendation, C
    
11. Patients being considered for lung cancer resection who have O₂max < 15 mL/kg/min and both %ppo FEV₁ and DLCO < 40% should be considered at very high risk for perioperative death and cardiopulmonary complications. These patients should be counseled about nonoperative treatment options. Level of evidence, poor; benefit, substantial; grade of recommendation, C
    
12. Patients being considered for lung cancer resection who walk < 25 shuttles on two shuttle walks or less than one flight of stairs should be considered at very high risk for perioperative death and cardiopulmonary complications. These patients should be counseled about nonoperative treatment options. Level of evidence, poor; benefit, substantial; grade of recommendation, C
    
13. In patients being considered for lung cancer surgery, PaCO₂ > 45 mm Hg is not an independent risk factor for increased perioperative complications; however, further physiologic testing is advised. Level of evidence, poor; benefit, substantial; grade of recommendation, C
    
14. In patients being considered for lung cancer surgery, SaO₂ < 90% indicates an increased risk for perioperative complications, and further physiologic testing is advised. Level of evidence, poor; benefit, substantial; grade of recommendation, C
    
15. In patients with very poor lung function, combined LVRS and lung cancer resection may be considered if emphysema is heterogeneous and involves primarily the lobe to be resected. Level of evidence, poor; benefit, substantial; grade of recommendation, C
    

	Footnotes

 
Abbreviations: BTS = British Thoracic Society; CPET = cardiopulmonary exercise test; DLCO = diffusing capacity of the lung for carbon monoxide; LVRS = lung volume reduction surgery; ppo = predicted postoperative; %ppo = percentage of predicted postoperative; SaO₂ = arterial oxygen saturation; O₂max = maximal oxygen consumption

	References

TOP Abstract Introduction General Issues for Lung... Spirometry and Diffusing... Predicted Postoperative Values... Exercise Testing Arterial Blood Gas Tensions Methods To Reduce Perioperative... Summary Summary of Recommendations References

 

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