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DIAGNOSIS AND MANAGEMENT OF LUNG CANCER: ACCP GUIDELINES (2ND EDITION)Physiologic Evaluation of the Patient With Lung Cancer Being Considered for Resectional Surgery: ACCP Evidenced-Based Clinical Practice Guidelines (2nd Edition)
Section snippets
Current Guidelines
Although numerous reviews2, 3, 4, 5, 6, 7 have been published on the preoperative risk assessment of patients with lung cancer being considered for curative-intent surgical resection, most available guidelines8, 9, 10, 11, 12, 13, 14, 15 on the management of non-small cell lung cancer (NSCLC) do not address the preoperative evaluation process. The British Thoracic Society16 and the American College of Chest Physicians1 have provided guidelines with specific recommendations on the steps needed
Multidisciplinary Team
Patients with lung cancer who are seen by a physician with expertise in the management of this disease are more likely to have histologic confirmation of lung cancer and referral for potentially curative treatment.17, 18, 19 Evaluation by a multidisciplinary team, which includes a thoracic surgeon specializing in lung cancer, a medical oncologist, a radiation oncologist, and a pulmonologist, is essential in the risk assessment of patients being evaluated for curative-intent surgery.
Recommendations
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In patients being considered for lung cancer resection, spirometry is recommended. If the FEV1is > 80% predicted or > 2 L and there is no evidence of either undue dyspnea on exertion or interstitial lung disease, the patient is suitable for resection including pneumonectomy without further physiologic evaluation. If the FEV1is > 1.5 L and there is no evidence of either undue dyspnea on exertion or interstitial lung disease, the patient is suitable for a lobectomy without further physiologic
Predicted Postoperative Lung Function
In patients with a preoperative FEV1 or Dlco of < 80% predicted, predicted postoperative (PPO) lung function may be calculated by estimating the amount of functioning lung tissue that would be lost with the surgical resection. The methods used for this purpose, including ventilation scans,56, 60, 61, 62, 63 perfusion scans,56, 60, 61, 62, 63, 64, 65, 66 quantitative CT scans,67, 68 and anatomic estimation, based on counting the number of segments to be removed,65, 69 seem to provide similar
Risk Related to %PPO Lung Function
The perioperative risk increases when the FEV1 is < 40%PPO.60, 65, 66, 79, 80 Markos et al60 and Holden et al79 reported 50% mortality rates (3 of 6 patients and 5 of 10 patients, respectively) when the FEV1 was < 40%PPO. Wahi et al80 found a perioperative mortality rate of 16% in patients with an FEV1 of < 41%PPO vs 3%PPO in those patients with better predicted lung function. Pierce and colleagues65 found that 5 of 13 patients with an FEV1 of < 40%PPO died soon after undergoing the operation,
Recommendations
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In patients with lung cancer who are being considered for surgery, either an FEV1of < 40%PPO or a Dlco of < 40%PPO indicates an increased risk for perioperative death and cardiopulmonary complications with standard lung resection. It is recommended that these patients undergo exercise testing preoperatively. Grade of recommendation, 1C
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In patients with lung cancer being considered for surgery, either a product of %PPO FEV1and %PPO Dlco of < 1,650%PPO or an FEV1of < 30%PPO indicates an increased
Cardiopulmonary Exercise Testing
Formal cardiopulmonary exercise testing (CPET) is a sophisticated physiologic testing technique, which includes recording the exercise ECG, the heart rate response to exercise, minute ventilation, and oxygen uptake per minute. Maximal oxygen consumption (V˙o2max) is measured from this type of exercise test. Previous guidelines1, 16 have recommended the use of CPET as the next step in the preoperative risk assessment process in those patients with either FEV1 or Dlco below 40%PPO.
The risk for
Pulmonary Artery Pressures and Diffusing Capacity
Measurements of pulmonary arterial pressure during exercise have not proven to be helpful in predicting the patients in whom perioperative complications will develop.81, 86, 95 Measuring the Dlco during exercise might be a better predictor of perioperative risk than V˙o2max, but is a technically demanding technique and not readily available.96
Stair Climbing and Walking Tests
If CPET were unavailable, then another type of exercise test should be considered. Stair climbing has historically been used as a surrogate CPET. If a patient were able to climb three flights of stairs, they were considered to be a suitable candidate 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 indicates an FEV1 of > 1.7 L and climbing five flights of stairs
Desaturation
The shuttle walk and 6-min walk tests may be more effective in identifying patients who desaturate during exercise than is the CPET.106 The value of this observation, though, is unclear. Greater than 4% desaturation during exercise had been reported16, 60, 65, 107 to indicate an increased risk for perioperative complications. However, a study108 from the United Kingdom has reported similar perioperative complication rates for patients who desaturated > 4% during a shuttle walk and those who did
Composite Scores
Investigators have proposed using composite scores to predict perioperative complications. Epstein et al109 developed the multifactorial cardiopulmonary risk index, an empirically derived score based on points awarded for cardiac and pulmonary risk. There was a strong association between this score and postoperative complications in a group of 42 patients. Birim et al110 found that patients with more comorbid conditions, identified by the Charlson comorbidity index, were also more likely to
Recommendations
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In patients with lung cancer who are being considered for surgery, a V˙o2 max of < 10 mL/kg/min indicates an increased risk for perioperative death and cardiopulmonary complications with standard lung resection. These patients should be counseled about nonstandard surgery and nonoperative treatment options for their lung cancer. Grade of recommendation, 1C
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Patients with lung cancer who are being considered for surgery who have a V˙o2 max of < 15 mL/kg/min and both an FEV1and a Dlco of < 40%PPO
Arterial Blood Gas Tensions
Historically, hypercapnea (Paco2, > 45 mm Hg) has been quoted as an exclusion criterion for lung resection.16, 114, 115 This recommendation was made on the basis of the association of hypercapnea with poor ventilatory function.116 The few studies that have addressed this issue, however, have suggest that preoperative hypercapnea is not an independent risk factor for increased perioperative complications. Stein et al117 showed that hypercapnea was associated with serious postoperative
Recommendations
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In patients with lung cancer who are being considered for surgery, a Paco2 of > 45 mm Hg is not an independent risk factor for increased perioperative complications. However, it is recommended that these patients undergo further physiologic testing. Grade of recommendation, 1C
- 13
In patients with lung cancer who are being considered for surgery, an Sao2 of < 90% indicates an increased risk for perioperative complications with standard lung resection. It is recommended that these patients undergo
Risk of Long-term Pulmonary Disability
Following lung resection, lung function should be expected to decrease. Serial studies have shown that FEV1 decreases within the first several months following lung cancer resection, but tends to recover to a small extent by 6 months after surgery.77, 120, 121 Although the preoperative physiologic evaluation is usually fairly accurate in predicting the PPO FEV1, some investigators118, 122 have found that the PPO FEV1 will actually underestimate the eventual postoperative FEV1. Exercise capacity
Lung Volume Reduction Surgery
Lung volume reduction surgery (LVRS) for patients with severe emphysema has been shown in a large prospective, randomized, controlled trial125 to provide a survival advantage in selected patients with predominantly upper lobe emphysema and low exercise capacity. Patients with an FEV1 of < 20% predicted and either homogeneous emphysema or a Dlco of < 20% predicted do poorly with LVRS.126 Anecdotal experience has shown that the lung resected during LVRS occasionally contained unsuspected lung
Recommendations
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In patients with very poor lung function and a lung cancer in an area of upper lobe emphysema, it is recommended that combined LVRS and lung cancer resection be considered if both the FEV1and the Dlco are > 20% predicted. Grade of recommendation, 1C
- 15
It is recommended that all patients with lung cancer be counseled regarding smoking cessation. Grade of recommendation, 1C
Summary
Patients with lung cancer often have concomitant diffuse parenchymal and/or obstructive airway disease and atherosclerotic cardiovascular disease as a consequence of their smoking habit. These diseases may place these patients at increased risk for perioperative complications, including death, and long-term pulmonary disability after lung cancer resection. A careful preoperative physiologic assessment will be useful to identify those patients who are at increased risk with standard lung cancer
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The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.
Research Unit (Dr. Bolliger), Tygerberg Academic Hospital and University of Stellenbosch, Cape Town, South Africa.