Fall in Diffusing Capacity Associated With Induction Therapy for Lung Cancer: A Predictor of Postoperative Complication?

The Short-Term Impact of Neoadjuvant Chemotherapy on the Outcome of Patients Undergoing Pneumonectomy for Lung Cancer: Is It Acceptable Nowadays?

Objective: We aimed at assessing our experience at the European Institute of Oncology in order to evaluate the peri- and immediately post-operative impact of neoadjuvant chemotherapy in patients who underwent pneumonectomy for NSCLC. Materials and methods: We retrospectively reviewed the outcomes and medical records of patients undergoing pneumonectomy (2010-2024). We compared pre-, peri- and post-operative outcomes of patients treated with induction chemotherapy and subsequent pneumonectomy with patients who underwent surgery directly. Differences in their distribution between study arms were assessed using the chi-square test for categorical variables or the Mantel-Haenszel test for trend for ordinal variables. We tested normality of the distribution of continuous variables using the Shapiro-Wilk test. We used logistic regression to quantify the risk of various outcomes (complications, 30-day and 12-day mortality) in patients who received neoadjuvant chemotherapy. Risks were expressed as odds ratios (ORs) with 95% confidence intervals (CIs adjusted for age (<60, 60-64, 65-69, ≥70 years), sex and comorbidities (cardiovascular, pulmonary or previous cancer). Results: We observed a higher frequency of post-operative respiratory complications in patients who underwent neoadjuvant therapy and pneumonectomy compared to those who only underwent surgery (11.4% vs. 18.5%; p = 0.05). After adjustment for age, sex and comorbidities we observed a significantly higher rate of pulmonary complications (OR 1.95; 95% CI 1.09-3.47; p = 0.02), ARDS (OR 2.88; 95% CI 1.26-6.59; p = 0.02) and 30-day mortality rate (OR 8.19; 95% CI 1.33-50.3; p = 0.02) in pre-treated patients. Conclusions: It is therefore strongly recommended to study and select potentially eligible patients in an extremely meticulous way before starting the neoadjuvant treatment, and to thoroughly re-evaluate the cardiorespiratory status after inductive therapy, before surgery.

Six-minute walking distance and desaturation-distance ratio in allogeneic stem cell transplantation

BACKGROUND

Most patients with haematological malignancies who undergo allogeneic haematopoietic stem cell transplant (HSCT) receive chemotherapy before the transplant to control the disease. Certain chemotherapy drugs can cause lung toxicity. Conversely, in patients with chronic respiratory conditions, the 6-min walking test (6MWT) and the desaturation-distance ratio (DDR) have demonstrated prognostic significance. Our objective was to determine whether the 6MWD and DDR, assessed prior to HSCT, have a prognostic impact on survival at 24 months post-HSCT.

METHODS

A prospective experimental study was conducted in consecutive patients referred for allogeneic HSCT at Hospital Clinic, Barcelona, Spain. A complete functional respiratory study, including the 6MWT and DDR, was conducted prior to admission. The area under the curve (AUC) and cut-off points were calculated. Data on patients' characteristics, HSCT details, main events, with a focus on lung complications, and survival at 24 months were analysed.

RESULTS

One hundred and seventy-five patients (39% women) with mean age of 48 ± 13 years old were included. Before HSCT, forced vital capacity and forced expiratory volume in the first second were 96% ± 13% predicted and 92% ± 14% predicted, respectively; corrected diffusing capacity for carbon monoxide 79% ± 15% predicted; 6MWD was 568 ± 83 m and DDR of .27 (.20-.41). The cut-off points for 6MWD and DDR were 566 m, [.58 95% CI (.51-.64)], p = .024 and .306, [.63 95% CI (.55-.70)], p = .0005, respectively. The survival rate at 24 months was 55%.

CONCLUSION

Our results showed that individuals who exhibit a 6MWD shorter than 566 ms or a decline in DDR beyond .306 experienced reduced survival rates at 24 months after HSCT.

Resectable non-stage IV nonsmall cell lung cancer: the surgical perspective

Surgery remains an essential element of the multimodality radical treatment of patients with early-stage nonsmall cell lung cancer. In addition, thoracic surgery is one of the key specialties involved in the lung cancer tumour board. The importance of the surgeon in the setting of a multidisciplinary panel is ever-increasing in light of the crucial concept of resectability, which is at the base of patient selection for neoadjuvant/adjuvant treatments within trials and in real-world practice. This review covers some of the topics which are relevant in the daily practice of a thoracic oncological surgeon and should also be known by the nonsurgical members of the tumour board. It covers the following topics: the pre-operative selection of the surgical candidate in terms of fitness in light of the ever-improving nonsurgical treatment alternatives unfit patients may benefit from; the definition of resectability, which is so important to include patients into trials and to select the most appropriate radical treatment; the impact of surgical access and surgical extension with the evolving role of minimally invasive surgery, sublobar resections and parenchymal-sparing sleeve resections to avoid pneumonectomy.

Impact of admission viral load on respiratory outcomes in hospitalized SARS-CoV-2 infected patients with cancer and without cancer: A 2-, 4- and 6-months follow-up prospective study

BACKGROUND

This prospective follow-up study aimed to determine the temporal changes in respiratory outcomes over 6 months period in patients with and without cancer hospitalized for severe COVID-19 and to determine the associated risk factors based on admission viral load.

METHODS

All adult patients hospitalized with a confirmed diagnosis of severe SARS-CoV-2 infection were investigated using rRT-PCR on nasopharyngeal swab specimens. Patients were divided into three arbitrary groups according to their cycle threshold (C_T) values obtained at admission as high (C_T < 25.0), medium (C_T between 25.0 and 30.0), and low (C_T > 30.0) viral load. Patients had pulmonary function tests, chest high-resolution computed tomography (HRCT), and a 6-minute walking time distance measured at each follow-up visit.

RESULTS

This follow-up study had a total of 112 participants, of which 75 were cancer-free and 37 had active cancer. Overall, 29.5% had a low viral load, compared to 48.2% who had a high viral load, and 22.3% had a medium viral load. For patients who did not have cancer, the mean age was 57.3 (SD 15.4) and for those who had cancer, it was 62.3 (SD 18.4). Most patients had overall better temporal changes in pulmonary function and tolerance, as well as exercise capacity, even though severe and chronic respiratory abnormalities persisted in a fraction of the patients. In patients without cancer who had a high viral load, we have seen a substantial reduction in diffusion capacity of the lungs for carbon monoxide (DLCO) predicted value with a median of 65 (IQR 63-70) while in patients with cancer, it was 60 (IQR 56-67) at 2 months. At 4 and 6 months, the predicted DLCO values for patients without cancer were 65 (IQR 61-70), whereas the predicted DLCO values for patients with active cancer were 62 (IQR 60-67) and 67 (59-73). Importantly, radiological abnormalities persisted in 22 (29%) non-cancer patients and 16 (43%) cancer patients. Multivariate regression analysis showed an increased odds ratio of impaired HRCT associated with a high viral load of 3.04 (95% CI:1.68-6.14; p < 0.001) for patients without cancer and 5.07 (95% CI: 4.04-10.8; p < 0.0001) for patients with cancer. The CT pneumonia score at hospitalization was 2.25 (95% CI:1.76-3.08; p = 0.041) and 2.85 (95% CI:1.89-5.14; p = 0.031) for non-cancer and cancer patients respectively.

CONCLUSIONS

The evidence of persistent pulmonary abnormalities and radiographic changes was found in both patient groups who had high viral load at hospital admission and suggesting that SARS-CoV-2 viral load might serve as a useful indicator to predict the development of respiratory complications in patients with COVID-19.

The evaluation of DLCO changes in patients with relatively higher lung shunt fractions receiving TARE

OBJECTIVE

Transarterial radioembolization (TARE) with Yttrium-90 (⁹⁰Y) labeled microspheres is an effective locoregional treatment option for patients with primary and metastatic liver cancer. However, TARE is also associated with radiation-induced lung injury due to hepatopulmonary shunting. If a large proportion of the injected radionuclide microspheres (more than 15%) is shunted, a rare but lethal complication may develop: radiation-induced pneumonitis (RP). Diffusion capacity of the lungs for carbon monoxide (DLCO) is a valuable test to assess lung function and a decrease in DLCO may indicate an impairment in gas exchange caused by the lung injury. Some previous researches have been reported the most consistent changes in pulmonary function tests after external beam radiotherapy are recorded with DLCO. This study aimed to examine the changes in DLCO after TARE with glass microspheres in newly treated and retreated patients with relatively higher lung shunt fractions.

METHODS

We prospectively analyzed forty consecutive patients with liver malignancies who underwent lobar or superselective TARE with ⁹⁰Y glass microspheres. DLCO tests were performed at baseline and on days 15, 30, and 60 after the treatment. All patients were followed up clinically and radiologically for the development of RP.

RESULTS

A statistically significant decrease was found in the DLCO after the first treatment (81.4 ± 13.66 vs. 75.25 ± 13.22, p = 0.003). The frequency of the patients with impaired DLCO at baseline was significantly increased after the first treatment (37.5 vs 57.5% p < 0.05). In the retreated group (n = 8), neither the DLCO (71.5 ± 10.82 vs. 67.50 ± 11.24, p = 0.115) nor the frequency of patients with impaired DLCO (25 vs 25%, p = 1) did not significantly change. Also, the change in DLCO values did not significantly correlate with lung shunt fraction, administered radiation dose, and absorbed lung dose after the first and second treatments (p > 0.05 for all). None of the patients developed RP.

CONCLUSION

Our study showed that a significant reduction in DLCO after TARE may occur in patients with relatively higher lung shunt fractions. Further studies with larger sample sizes are needed to better investigate the changes in DLCO in patients with high lung shunt fractions.

Comparison of pulmonary function changes between patients receiving neoadjuvant chemotherapy and chemoradiotherapy prior to minimally invasive esophagectomy: a randomized and controlled trial

PURPOSE

Adequate pulmonary function is important for patients undergoing surgical resection of esophageal cancer, especially those that received neoadjuvant therapy. However, it is unknown if pre-operative radiation affects pulmonary function differently compared to chemotherapy. The purpose of this study was to compare changes in pulmonary function between patients undergoing minimally invasive esophagectomy (MIE) who received neoadjuvant chemotherapy or chemoradiotherapy.

METHODS

Between March 2017 and March 2018, esophageal cancer patients requiring neoadjuvant therapy were prospectively enrolled and randomly assigned to receive chemotherapy (CT) or chemoradiotherapy (CRT) before MIE. All patients received pulmonary function testing before and after the neoadjuvant therapy. Changes in pulmonary function, operative data, and pulmonary complications were compared between the 2 groups.

RESULTS

A total of 71 patients were randomized and underwent MIE after receiving CT (n = 34) or CRT (n = 37). Baseline clinical characteristics were comparable between the 2 groups. The CRT group experienced a greater decrease of forced expiratory volume at 1 s (FEV₁) (2.66 to 2.18 L, p = 0.023) and diffusion capacity of the lung for carbon monoxide divided by the mean alveolar volume (DLCO/Va) (17.3%, p < 0.001) than the CT group (FEV₁ 2.53 to 2.41 L; DLCO/Va 4.8%). The incidence of pulmonary complications was higher in the CRT group (13.51 vs. 8.82%), but the difference was not significant (p = 0.532).

CONCLUSIONS

Preoperative CRT affects pulmonary function more than CT alone, but does not increase the risk of pulmonary complications in patients undergoing MIE.

Thoracoscopic Versus Open Lobectomy After Induction Therapy for Nonsmall Cell Lung Cancer: New Study Results and Meta-analysis

INTRODUCTION

The use of video-assisted thoracoscopic surgery (VATS) lobectomy has become a mainstay of modern thoracic surgery practice and the technique of choice for resection of early-stage lung cancers. However, the benefits of VATS following induction therapy are yet to be clarified. This study aims to assess whether VATS lobectomy achieves similar perioperative and oncologic outcomes compared to thoracotomy for nonsmall cell lung cancer after induction therapy.

METHODS

We retrospectively reviewed the outcomes of 72 patients who underwent lung lobectomy after induction therapy in our institution from January 2017 to January 2020. Subsequently, we carried out a comprehensive literature search and pooled our results with available data from previously published studies to perform a meta-analysis.

RESULTS

VATS was associated with reduced intraoperative blood loss (P = 0.05) and less perioperative complications (P = 0.04) in our local institution. The meta-analysis comprised nine studies. A total of 943 patients underwent VATS and 2827 patients underwent open lobectomy. VATS was associated with significant shorter surgery duration (P < 0.0001), shorter chest-tube drainage duration (P < 0.0001), and shorter hospital stays (P < 0.0001). Furthermore, there was significantly less perioperative complications (P = 0.006) and less intraoperative blood loss (P = 0.036) in the VATS group. However, there were no significant differences in 3-y overall survival and 3-y disease-free survival rates.

CONCLUSIONS

In some selected patients undergoing induction therapy, VATS lobectomy could achieve equivalent perioperative outcomes to thoracotomy but evidence is lacking on oncologic outcomes. Further trials with a focus on oncologic outcomes and longer follow-up are required.

Definition and assessment of high risk in patients considered for lobectomy for stage I non-small cell lung cancer: The American Association for Thoracic Surgery expert panel consensus document

OBJECTIVE

Lobectomy is a standard treatment for stage I non-small cell lung cancer, but a significant proportion of patients are considered at high risk for complications, including mortality, after lobectomy and might not be candidates. Identifying who is at risk is important and in evolution. The objective of The American Association for Thoracic Surgery Clinical Practice Standards Committee expert panel was to review important considerations and factors in assessing who is at high risk among patients considered for lobectomy.

METHODS

The American Association for Thoracic Surgery Clinical Practice Standards Committee assembled an expert panel that developed an expert consensus document after systematic review of the literature. The expert panel generated a priori a list of important risk factors in the determination of high risk for lobectomy. A survey was administered, and the expert panel was asked to grade the relative importance of each risk factor. Recommendations were developed using discussion and a modified Delphi method.

RESULTS

The expert panel survey identified the most important factors in the determination of high risk, which included the need for supplemental oxygen because of severe underlying lung disease, low diffusion capacity, the presence of frailty, and the overall assessment of daily activity and functional status. The panel determined that factors, such as age (as a sole factor), were less important in risk assessment.

CONCLUSIONS

Defining who is at high risk for lobectomy for stage I non-small cell lung cancer is challenging, but remains critical. There was impressive strong consensus on identification of important factors and their hierarchical ranking of perceived risk. The panel identified several key factors that can be incorporated in risk assessment. The factors are evolving and as the population ages, factors such as neurocognitive function and frailty become more important. A minimally invasive approach becomes even more critical in this older population to mitigate risk. The determination of risk is a clinical decision and judgement, which should also take into consideration patient perspectives, values, preferences, and quality of life.

Postinduction therapy pulmonary function retesting is necessary before surgical resection for non–small cell lung cancer

OBJECTIVE

Pretreatment-predicted postoperative diffusing capacity of the lung for carbon monoxide (DLCO) has been associated with operative mortality in patients who receive induction therapy for resectable non-small cell lung cancer (NSCLC). It is unknown whether a reduction in pulmonary function after induction therapy and before surgery affects the risk of morbidity or mortality. We sought to determine the relationship between induction therapy and perioperative outcomes as a function of postinduction pulmonary status in patients who underwent surgical resection for NSCLC.

METHODS

We retrospectively reviewed data for 1001 patients with pathologic stage I, II, or III NSCLC who received induction therapy before lung resection. Pulmonary function was defined according to American College of Surgeons Oncology Group major criteria: DLCO ≥50% = normal; DLCO <50% = impaired. Patients were categorized into 5 subgroups according to combined pre- and postinduction DLCO status: normal-normal, normal-impaired, impaired-normal, impaired-impaired, and preinduction only (without postinduction pulmonary function test measurements). Multivariable logistic regression was used to quantify the relationship between DLCO categories and dichotomous end points.

RESULTS

In multivariable analysis, normal-impaired DLCO status was associated with an increased risk of respiratory complications (odds ratio, 2.29 [95% CI, 1.12-4.49]; P = .02) and in-hospital complications (odds ratio, 2.83 [95% CI, 1.55-5.26]; P < .001). Type of neoadjuvant therapy was not associated with an increased risk of complications, compared with conventional chemotherapy.

CONCLUSIONS

Reduced postinduction DLCO might predict perioperative outcomes. The use of repeat pulmonary function testing might identify patients at higher risk of morbidity or mortality.

Early exercise pulmonary diffusing capacity of carbon monoxide after anatomical lung resection: a word of caution for fast-track programmes

OBJECTIVES

In healthy individuals, increasing pulmonary blood flow during exercise also increases the % of the diffusing capacity of the lungs for carbon monoxide (DLCO%), but its evolution after lung resection is unknown. In this study, our goal was to measure changes in exercise DLCO% during the first 3 days after anatomical lung resection.

METHODS

We performed a prospective observational study on consecutive patients with non-small-cell lung cancer scheduled for anatomical resection, except pneumonectomy, during a 6-month period. Patients underwent measurement of the DLCO% by a single-breath technique adjusted by the concentration of haemoglobin-before and after standardized exercise the day before and 3 consecutive days after surgery. The delta (Δ) variation (basal versus exercise) was calculated. The number of functioning resected segments was calculated by bronchoscopy. Postoperative pain and pleural air leak were estimated using a visual analogue scale and graduated conventional pleural drainage systems, respectively, and their influence on ΔDLCO each postoperative day was evaluated by linear regression analysis.

RESULTS

Fifty-seven patients were included. The visual analogue scale of pain and pleural air leaks were not correlated to Δ values (model R2: 0.0048). The evolution of Δ values during 3 postoperative days showed a progressive recovery of values, but on the third day, DLCO% capacity during exercise was still impaired (P < 0.01), especially in patients who underwent a resection of more than 3 functioning segments.

CONCLUSIONS

Physiological increase in DLCO% during exercise is still impaired on the third postoperative day in patients undergoing resection of more than 3 functioning pulmonary segments. This fact should be considered before discharging those patients after anatomical lung resection.

The Outcomes of Induction Chemoradiotherapy Followed by Surgery for Clinical T3-4 Non-Small Cell Lung Cancer

Purpose:

Information on the short- and long-term outcomes of induction chemoradiotherapy followed by surgery for cT3-4 non-small cell lung cancer is limited. We analyzed the short- and long-term outcomes of induction chemoradiotherapy followed by surgery for cT3-4 non-small cell lung cancer.

Methods:

Patients with non-small cell lung cancer who underwent induction chemoradiotherapy followed by surgery for cT3-4 non-small cell lung cancer were retrospectively reviewed (initial treatment group, n = 31). Their results were compared to those patients who underwent surgery as an initial treatment during the same period (initial surgery group, n = 35).

Results:

Downstaging was achieved in 14 (45%) patients in the initial treatment group. R0 resection was achieved in 28 (90%) patients in the initial treatment group and 31 (88%) patients in the initial surgery group. The 90-day mortality rate was 3% in each group. Postoperative complications occurred in 16 (52%) patients in the initial treatment group and 13 (37%) patients in the initial surgery group. The 5-year overall survival rate of the initial treatment group was significantly higher than that of the initial surgery group (62.6% vs 43.5%, P = .04). The 5-year overall survival rates of the initial treatment N0-1 group and the initial surgery N0-1 group were 88.9% and 49.3%, respectively; the difference was statistically significant (P = .02). Multivariate analysis using 4 factors (age [≤65 vs >65], cN [cN0-1 vs cN2], general condition [chemoradiotherapy fit vs chemoradiotherapy unfit], and treatment mode [induction chemoradiotherapy followed by surgery vs surgery as an initial treatment]) revealed that treatment mode (induction chemoradiotherapy followed by surgery) and cN status (cN0-1) were significantly associated with good overall survival and disease-free survival.

Conclusions:

Induction chemoradiotherapy followed by surgery for cT3-4 non-small cell lung cancer could be performed with an acceptable degree of surgical risk. At present, it is thought to be one of the reasonable treatment approaches for selected patients with cT3-4 disease, even those with a cN0-1 status.

Lung function changes after chemoradiation therapy in patients with lung cancer treated by three usual platinum combinations

Background

Reports point out lung toxicity of chemotherapeutic agents and radiation therapy in cancer patients. The aim of our study was to assess lung function after sequential chemoradiation therapy in patients with lung cancer.

Methods

Fifteen lung cancer patients participated the study and underwent lung function assessment before and after sequential treatment of chemotherapy with the 3 most applied platinum-based combinations: of vinorelbine (VN) 6 patients, gemcitabine (GEM) 4 patients and etoposide (EP) 5 patients and radiation therapy. Lung function tests were forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), total lung capacity (TLC), diffusing capacity for carbon monoxide (DL_CO) and carbon monoxide transfer coefficient (Kco).

Results

Mean patients' age was 58±9.4 years (42-75 years). Male patients were 14 (93.3%), all smokers. Overall, after chemoradiation treatment significant changes were noted in FEV1 (P=0.012), FVC (P=0.046), TLC (P=0.04) from baseline. The drop from baseline was more significant after chemoradiation therapy in DLCO (P=0.002) and KCO (P=0.008).

Conclusions

According to our results, sequential chemoradiation causes significant changes in lung function parameters in patients with lung cancer.

The effect of selective internal radiation therapy with yttrium-90 resin microspheres on lung carbon monoxide diffusion capacity

Background

Selective internal radiation therapy (SIRT) with embolization of branches of the hepatic artery is a valuable therapeutic tool for patients with hepatic malignancies; however, it is also associated with lung injury risk due to shunting. Diffusion capacity of the lungs for carbon monoxide (DLCO) is a clinically significant lung function test, and worsening in DLCO is suggested to reflect a limited gas exchange reserve caused by the potential toxicity of chemoradiotherapy or it may be a marker of related lung injury. This study aimed to examine the changes in DLCO during SIRT with resin microspheres in newly treated and retreated patients. Forty consecutive patients who received SIRT for a variety of malignant conditions were included. All subjects were treated with Yttrium-90 labelled resin microspheres. DLCO tests were performed after the procedures. In addition, patients were specifically followed for radiation pneumonitis.

Results

The mean DLCO did not significantly change after the first (82.8 ± 19.4 vs. 83.1 ± 20.9, p = 0.921) and the second treatments (87.4 ± 19.7 vs. 88.6 ± 23.2, p = 0.256). Proportion of patients with impaired DLCO at baseline was not altered significantly after the first (37.5 vs. 45.0%, p = 0.581) and the second treatments (27.3 vs. 27.3%, p = 1.000). Also, percent change in DLCO values did not correlate with radiation dose, lung shunt fraction, or lung exposure dose (p > 0.05 for all comparisons). None of the patients developed radiation pneumonitis.

Conclusions

Our results suggest that no significant change in DLCO in association with SIRT occurs, both after the first or the second treatment sessions. Further larger studies possibly with different protocols are warranted to better delineate DLCO changes after SIRT in a larger spectrum of patients.

Preoperative functional workup for patients with advanced lung cancer

Locally advanced lung cancer remains a surgical indication in selected patients. This condition often demands larger resections. As a consequence preoperative functional workup is of paramount importance to stratify the risk and choose the most appropriate treatment. We reviewed the current evidence on functional evaluation with a special focus on specific aspects related to locally advanced lung cancer stages (i.e., risk after neoadjuvant treatment, pneumonectomy). Evidence is discussed to provide information that could assist clinicians in their preoperative workup of these challenging patients.

Clinical pathway for thoracic surgery in the United States

The paradigm for postoperative care for thoracic surgical patients in the United States has shifted with efforts to reduce hospital length of stay and improve quality of life. The increasing usage of minimally invasive techniques in thoracic surgery has been an important part of this. In this review we will examine our standard practices as well as the evidence behind both general contemporary postoperative care principles and those specific to certain operations.

Airway bacterial colonization in patients with non-small cell lung cancer and the alterations during the perioperative period

BACKGROUND

To observe the alterations in airway bacterial colonization during the perioperative period in patients with non-small cell lung cancer (NSCLC) and evaluate their clinical implications.

METHODS

Patients with resectable primary NSCLC were enrolled from October 2011 to April 2012. Airway secretions were harvested for microbiological study after admission, immediately after surgery, and before endotracheal extubation. Spontaneous sputum was collected when patients presented with signs of postoperative pneumonia (POP). Detailed data on the isolated pathogens were carefully recorded. Risk factors for airway colonization and POP were analyzed.

RESULTS

A total of 78 consecutive patients were enrolled. Fourteen patients (17.9%) had airway colonization at admission, including four cases of fungi and ten cases of Gram-negative bacilli (GNB). Five patients (6.4%) had colonized pathogens at the end of surgery, including three cases of GNB and two cases of Gram-positive cocci. Nine (11.5%) patients had positive culture of airway secretions collected before extubation, including seven cases of GNB and two cases of fungi. Eighteen patients (23.1%) had POP, of whom one suffered from bronchopleural fistula and one died of POP. Pathogens of POP were confirmed in 11 patients, including nine cases of GNB and two cases of fungi. Three patients had the same pathogens as preoperative colonization. The proportion of more antibiotic-resistant strains increased gradually. Advanced age [odds ratio (OR), 2.263; 95% confidence interval (95% CI), 1.030-4.970] and smoking (OR, 2.163; 95% CI, 1.059-4.429) were risk factors for airway colonization. Decreased diffusion capacity of the lung for carbon monoxide (OR, 5.838; 95% CI, 1.318-25.854), prolonged operation time (OR, 6.366; 95% CI, 1.349-30.033), and preoperative airway colonization (OR, 9.448; 95% CI, 2.206-40.465) were risk factors of POP.

CONCLUSIONS

Airway colonized pathogens altered and more antibiotic-resistant GNB emerged during the perioperative period. These pathogens played an important role in the presence of POP.

Extrapleural pneumonectomy after induction chemotherapy: perioperative outcome in 251 mesothelioma patients from three high-volume institutions

BACKGROUND

Several publications have suggested that induction chemotherapy followed by extrapleural pneumonectomy (EPP) for patients with malignant pleural mesothelioma (MPM) patients is associated with exceedingly high morbidity and mortality, and the role of EPP is controversially debated. The present retrospective study analyzed the perioperative outcome in 251 consecutively treated patients at three high-volume mesothelioma centers.

METHODS

251 MPM patients completed EPP after platinum-based induction chemotherapy at three institutions for thoracic surgery over more than 10 years. The rates of 30-day and 90-day mortality and of major morbidities (pulmonary embolism, postoperative bleeding, acute respiratory distress syndrome, empyema, bronchopleural fistula (BPF), chylothorax, patch failure) were recorded. Perioperative outcome was correlated to risk factors such as smoking history (pack years), age at operation, body mass index, spirometry results, C-reactive protein, American Society of Anesthesiologists classification, chemotherapy regimen used, blood loss during operation, duration of operation, and characteristics of the tumor (laterality, histologic subtype, pT and pN stage) to find factors predicting 30-day and 90-day mortality or major morbidity.

RESULTS

The overall 30-day mortality was 5%. Within 90 days after operation, 8% of the patients died. The rates of 30-day and 90-day mortality were significantly higher in patients with high preoperative C-reactive protein values (p=0.001 and p<0.0005). The spirometry values forced expiratory volume in 1 second and forced vital capacity exhaled (FVCex) were both associated with 30-day and 90-day mortality (p=0.001 and p<0.0005; and p=0.002 and p<0.0005). Major morbidity occurred in 30% of the patients, significantly more often after right-sided EPP (p=0.01) and after longer operations (p<0.0005). Empyema (p<0.0005) and acute respiratory distress syndrome (p=0.02) were associated with longer duration of operation.

CONCLUSIONS

EPP after induction chemotherapy is a demanding procedure but can be performed with acceptable morbidity and mortality if patients are well selected and treated at dedicated high-volume MPM centers.

Preoperative Maximal Oxygen Uptake and Exercise-induced Changes in Pulse Oximetry Predict Early Postoperative Respiratory Complications in Lung Cancer Patients

BACKGROUND

Postoperative respiratory complications often arise in lung cancer patients after lung resection, although these are often difficult to predict. We sought to identify reliable predictors of early-onset postoperative respiratory complications in lung cancer patients who had moderate-to-severe preoperative respiratory impairment.

METHODS

This was a prospective observational study that included 107 consecutive lung cancer patients with forced expiratory volume in 1 s <60% of predicted who were scheduled for thoracotomy and lung resection. Preoperative functional assessments included pulmonary function testing by spirometry, single breath diffusion capacity of lung for carbon monoxide, and cardiopulmonary exercise testing. Risk factors for early-onset postoperative respiratory complications that occurred within 30 days postoperatively were sought from among these pulmonary function testing and cardiopulmonary exercise testing results.

RESULTS

By multivariable logistic regression, peak oxygen uptake (V'O_2max%; p < 0.001) and the transcutaneous pulse oxygen saturation difference during load exercise (ΔSPO₂%; p < 0.001) were independent predictors of postoperative respiratory complications. A receiver operating characteristic curve had an area under the curve of 0.846 for the combination of V'O_2max% and ΔSPO₂%, while the area under the curve with V'O_2max% only was 0.726. From this, the probability of postoperative respiratory complications was [Formula: see text]. P_complication ≥ 0.202 for postoperative respiratory complications had a sensitivity of 80.8% and a specificity of 81.5%.

CONCLUSIONS

For lung cancer patients with forced expiratory volume in 1 s <60% of predicted, in addition to common preoperative tests, V'O_2max% and ΔSPO₂% may be an aid for predicting early-onset postoperative respiratory complications.

Impact and safety of adjuvant chemotherapy on pulmonary function in early stage non-small cell lung cancer

BACKGROUND

Pulmonary function may decline after induction chemotherapy and predict perioperative complications in non-small cell lung cancer (NSCLC). The influence of adjuvant chemotherapy is largely indeterminate.

OBJECTIVE

To assess whether adjuvant chemotherapy alters pulmonary function and impacts on treatment-related adverse events.

METHODS

In a trial on adjuvant chemotherapy (the TREAT trial), 132 patients with R0-resected NSCLC were randomised to 4 cycles of cisplatin-vinorelbine (CVb, n = 65) or cisplatin-pemetrexed (CPx, n = 67). Pulmonary function tests (forced expiratory volume in 1 s, FEV1, forced vital capacity, FVC, total lung capacity, TLC, diffusing capacity for carbon monoxide, DLCO, and blood gas analyses, BGA) were analysed before and 30 days after the last chemotherapy, and changes were calculated (Δ = mean differences).

RESULTS

Overall, FVC increased significantly (Δ +290 ml, n = 76; p < 0.0001), while TLC did not change (Δ +220 ml, n = 41; p = 0.174). For CPx, FEV1 increased significantly (Δ +150 ml, n = 47; p = 0.0017), but not for CVb (Δ +30 ml, n = 30). DLCO decreased only for CVb (-8%, n = 6) but not for CPx (-0.39%, n = 17; p = 0.58). BGA did not change (p = 0.99). In a Cox regression analysis, baseline pulmonary function did not influence treatment failure.

CONCLUSIONS

Adjuvant chemotherapy seems not to result in a decrease of pulmonary function parameters. A significant FVC increase was probably due to ongoing postoperative improvement. Decline of DLCO was noted with CVb but not with CPx. Pulmonary function does not impact on treatment failure.

[Correlation between pulmonary function indexes and survival time in patients with advanced lung cancer]

背景与目的

晚期肺癌患者的治疗以提高疗效和改善生活质量为最终目的，肺功能指标是较好的评价指标。本研究探讨晚期肺癌患者肺功能改变及肺功能指标与患者生存期的相关性。

方法

通过对59例晚期肺癌患者的肺功能进行检测，且与患者生存期进行相关性分析，并与63例健康人进行对照。

结果

晚期肺癌患者的肺通气及弥散功能指标明显低于正常，与对照相比有统计学差异。肺功能指标中肺活量（vital capacity, VC）、第1秒用力呼出量（forced expiratory volume in one second, FEV₁）、用力肺活量（gorced vital capacity, FVC）、最大呼气流速（peak expiratory flow, PEF）、最大呼气流速%（peak expiratory flow%, PEF%）、最大通气量（maximal ventilatory volume, MVV）与患者生存期呈正相关（r分别为0.29、0.28、0.28、0.27、0.26、0.28，P < 0.05），残气量/肺总量（residual volume/total lung, RV/TLC）值与患者生存期呈负相关（r=-0.31, P < 0.05）。

结论

肺癌患者存在肺功能的减退，肺癌患者肺功能指标中VC、FEV₁、FVC、PEF、PEF%、MVV、RV/TCL值与患者生存期具有相关性，肺功能的部分指标可作为肺癌患者预后评估的重要因素之一。

Changes in pulmonary function tests predict radiological response to chemotherapy in malignant pleural mesothelioma

OBJECTIVES

Response to chemotherapy in malignant pleural mesothelioma (MPM) is usually evaluated by radiological criteria, but no common agreement exists on their validity, yet. The cytoreductive effect of chemotherapy on pleural thickening may make the lung more expansible, reducing the restrictive ventilatory impairment. The aim of this study was to evaluate the changes in pulmonary function following chemotherapy in patients with MPM and to correlate these findings with radiological changes.

METHODS

Between 2004 and 2011, 62 consecutive patients (74% males, median age 63 years) were prospectively investigated. Modified RECIST criteria were used for radiological evaluation of response to chemotherapy. All patients underwent pulmonary function tests before and after three cycles of platinum-based chemotherapy. Changes between baseline and post-chemotherapy pulmonary function values (Δ) and their differences were assessed by means of Student's paired and unpaired t-test, respectively. Receiver operating characteristic (ROC) curve analysis was performed on spirometric parameters significantly associated with response.

RESULTS

Thirty (48.4%) patients had a radiological stable disease (S), 23 (37.1%) a partial response (R) and 9 (14.5%) a progressive disease (P). ΔFEV1%pred (R: 18.1 ± 18.5%; S: 0.5 ± 9.3%; P: -11 ± 13.5%; P < 0.0001), ΔFVC%pred (R: 16.1 ± 11.8%; S: 0.4 ± 11.2%; P: -9.2 ± 14.6%; P < 0.0001) and ΔVC%pred (R: 12.9 ± 15.7%; S: 1.5 ± 12.1%; P: -6.1 ± 13.2%; P = 0.001) were significantly associated with radiological response. A significant correlation was observed between ΔFEV1%pred (r = 0.46, P = 0.01), ΔFVC%pred (r = 0.43, P = 0.02) and % change in linear tumour measurement. ROC curve analysis using dichotomized radiological response (P/S vs R) as classification variables showed AUC = 0.88 (95%CI: 0.77-0.95) for ΔFEV1%pred (optimal cut-off value: +7%, sensitivity: 83%, specificity: 82%, PPV: 73%, NPV: 89%) and AUC = 0.86 (95%CI: 0.75-0.94) for ΔFVC%pred (optimal cut-off value: +6%, sensitivity: 82%, specificity: 74%, PPV: 64%, NPV: 88%).

CONCLUSIONS

Dynamic lung volumes and radiological changes after chemotherapy seem directly related. Lung function changes could be an additional tool to better evaluate the response to chemotherapy in MPM.

Risk factors for impaired lung function after pulmonary metastasectomy: a prospective observational study of 117 cases

OBJECTIVES

The prediction of postoperative preserved pulmonary function is essential for ascertaining the functional operability of pulmonary metastasectomy candidates. Formulae to predict pulmonary function after metastasectomy have not yet been described. This study was undertaken to provide data about the functional loss after a pulmonary metastasectomy, which often includes non-anatomical resections or combinations with anatomical resections.

METHODS

Pulmonary function tests were performed preoperatively, postoperatively and 3 months after a pulmonary metastasectomy, and the factors potentially influencing the functional outcome were prospectively collected in a database. The functional loss was calculated as the difference in the values between the follow-up visit and the preoperative values, and the influencing factors were tested using the Mann-Whitney test.

RESULTS

A total of 162 patients were prospectively included in the study and 117 completed the study protocol with a follow-up evaluation after a mean of 3.4 months. Of these, 33 patients had bilateral resections, 30 interventions were repeated resections and adhesions were removed in 46. The greatest lung resection performed was a lobectomy in 13, with segmentectomy in 27 and wedge resection in 77 patients. The mean overall functional loss was: forced vital capacity -9.2%, total lung capacity -8.8%, forced expiratory volume in 1 s -10.8% and diffusion capacity for carbon monoxide (DLCO) -9.7%, whereas the diffusion coefficient (KCO) and pO(2) remained unchanged after 3 months. This functional loss was significant (P < 0.001) for all the parameters mentioned. The two factors were inversely found to influence the functional outcome: bilateral resection reduced spirometry values (P < 0.01), postoperative chemotherapy reduced DLCO (P = 0.011) and KCO (P = 0.029).

CONCLUSIONS

A pulmonary metastasectomy leads to a significant loss of pulmonary function after 3 months in an average patient collective. The most important factors for deteriorating lung function are a bilateral operation and postoperative chemotherapy.

Change in diffusing capacity after radiation as an objective measure for grading radiation pneumonitis in patients treated for non-small-cell lung cancer

PURPOSE

Scoring of radiation pneumonitis (RP), a dose-limiting toxicity after thoracic radiochemotherapy, is subjective and thus inconsistent among studies. Here we investigated whether the extent of change in diffusing capacity of the lung for carbon monoxide (DLCO) after radiation therapy (RT) for non-small-cell lung cancer (NSCLC) could be used as an objective means of quantifying RP.

PATIENTS AND METHODS

We analyzed potential correlations between DLCO and RP in 140 patients who received definitive RT (≥ 60 Gy) with or without chemotherapy for primary NSCLC. All underwent DLCO analysis before and after RT. Post-RT DLCO values within 1 week of the RP diagnosis (Grade 0, 1, 2, or 3) were selected and compared with that individual's preradiation values. Percent reductions in DLCO and RP grade were compared by point biserial correlation in the entire patient group and in subgroups stratified according to various clinical factors.

RESULTS

Patients experiencing Grade 0, 1, 2, or 3 RP had median percentage changes in DLCO after RT of 10.7%, 13%, 22.1%, or 35.2%. Percent reduction in DLCO correlated with RP Grade ≤ 1 vs. ≥ 2 (p = 0.0004). This association held for the following subgroups: age ≥ 65 years, advanced stage, smokers, use of chemotherapy, volume of normal lung receiving at least 20 Gy ≥ 30%, and baseline DLCO or forced expiratory volume in 1 second ≥ 60%.

CONCLUSIONS

By correlating percent change in DLCO from pretreatment values at the time of diagnosis of RP with RP grade, we were able to identify categories of RP based on the change in DLCO. These criteria provide a basis for an objective scoring system for RP based on change in DLCO.

Changes in pulmonary function after three-dimensional conformal radiotherapy, intensity-modulated radiotherapy, or proton beam therapy for non-small-cell lung cancer

PURPOSE

To investigate the extent of change in pulmonary function over time after definitive radiotherapy for non-small-cell lung cancer (NSCLC) with modern techniques and to identify predictors of changes in pulmonary function according to patient, tumor, and treatment characteristics.

PATIENTS AND METHODS

We analyzed 250 patients who had received ≥ 60 Gy radio(chemo)therapy for primary NSCLC in 1998-2010 and had undergone pulmonary function tests before and within 1 year after treatment. Ninety-three patients were treated with three-dimensional conformal radiotherapy, 97 with intensity-modulated radiotherapy, and 60 with proton beam therapy. Postradiation pulmonary function test values were evaluated among individual patients compared with the same patient's preradiation value at the following time intervals: 0-4 (T1), 5-8 (T2), and 9-12 (T3) months.

RESULTS

Lung diffusing capacity for carbon monoxide (DLCO) was reduced in the majority of patients along the three time periods after radiation, whereas the forced expiratory volume in 1 s per unit of vital capacity (FEV1/VC) showed an increase and decrease after radiation in a similar percentage of patients. There were baseline differences (stage, radiotherapy dose, concurrent chemotherapy) among the radiation technology groups. On multivariate analysis, the following features were associated with larger posttreatment declines in DLCO: pretreatment DLCO, gross tumor volume, lung and heart dosimetric data, and total radiation dose. Only pretreatment DLCO was associated with larger posttreatment declines in FEV1/VC.

CONCLUSIONS

Lung diffusing capacity for carbon monoxide is reduced in the majority of patients after radiotherapy with modern techniques. Multiple factors, including gross tumor volume, preradiation lung function, and dosimetric parameters, are associated with the DLCO decline. Prospective studies are needed to better understand whether new radiation technology, such as proton beam therapy or intensity-modulated radiotherapy, may decrease the pulmonary impairment through greater lung sparing.

Changes in lung function parameters after wedge resections: a prospective evaluation of patients undergoing metastasectomy

BACKGROUND

Pulmonary metastasectomy with lung-sparing local excisions is a widely accepted method of treating stage IV malignancies in selected cases. The ability to predict postoperative lung function is an unresolved issue, especially when multiple wedge resections are planned. To help develop a method to predict postoperative lung function after wedge resections, we present this prospective observational study.

METHODS

A total of 77 patients who underwent one or more wedge resections to remove lung metastases completed the study protocol. Spirometry results, diffusion capacity of lung for carbon monoxide (Dlco), and blood gases and potential confounding factors were measured prior to, immediately following, and 3 months after the procedure and were analyzed.

RESULTS

Seventy-seven patients with a median age of 61.3 years underwent up to 22 wedge resections. The mean lung function losses were FVC (-7.5%), total lung capacity (TLC) (-7.9%), FEV(1) (-9.2%), and Dlco (-8.8%), and all were statistically significant (P < .001). The lung function losses also differed significantly between those having a single and those with more than eight wedge resections. Using regression analysis, we found that for every additional wedge resection, there was a reduction in FVC of 30 mL (0.7%), in TLC of 44 mL (0.65%), and in FEV(1) of 23 mL (0.58%).

CONCLUSIONS

Metastasectomy by wedge resection significantly reduces lung function parameters. As a benchmark, we can predict a 0.6% decrease in spirometry values and Dlco for every additional wedge resection, and a decrease of approximately 5% that may be attributed to thoracotomy.

Physiologic evaluation of lung resection candidates

This article reviews an evidence-based approach to the physiologic evaluation of patients under consideration for surgical resection of lung cancer. Adequate physiologic evaluation often includes a multidisciplinary evaluation, with complete identification of risk factors for perioperative complications and long-term disability including cardiovascular risk, assessment of pulmonary function, and smoking cessation counseling. Consideration of tumor-related anatomic obstruction, atelectasis, or vascular occlusion may alter measurements. Careful preoperative physiologic assessment helps to identify patients at increased risk of morbidity and mortality after lung resection. These evaluations are helpful in identifying patients who may not benefit from surgical management of their lung cancer.

STS database risk models: predictors of mortality and major morbidity for lung cancer resection

BACKGROUND

The aim of this study is to create models for perioperative risk of lung cancer resection using the STS GTDB (Society of Thoracic Surgeons General Thoracic Database).

METHODS

The STS GTDB was queried for all patients treated with resection for primary lung cancer between January 1, 2002 and June 30, 2008. Three separate multivariable risk models were constructed (mortality, major morbidity, and composite mortality or major morbidity).

RESULTS

There were 18,800 lung cancer resections performed at 111 participating centers. Perioperative mortality was 413 of 18,800 (2.2%). Composite major morbidity or mortality occurred in 1,612 patients (8.6%). Predictors of mortality include the following: pneumonectomy (p < 0.001), bilobectomy (p < 0.001), American Society of Anesthesiology rating (p < 0.018), Zubrod performance status (p < 0.001), renal dysfunction (p = 0.001), induction chemoradiation therapy (p = 0.01), steroids (p = 0.002), age (p < 0.001), urgent procedures (p = 0.015), male gender (p = 0.013), forced expiratory volume in one second (p < 0.001), and body mass index (p = 0.015).

CONCLUSIONS

Thoracic surgeons participating in the STS GTDB perform lung cancer resections with a low mortality and morbidity. The risk-adjustment models created have excellent performance characteristics and identify important predictors of mortality and major morbidity for lung cancer resections. These models may be used to inform clinical decisions and to compare risk-adjusted outcomes for quality improvement purposes.

Respiratory complications after oesophageal surgery

PURPOSE OF REVIEW

The most frequent complications of oesophageal surgery are respiratory and these are associated with increased critical care stay, hospital stay and mortality. This review focuses on the risk factors associated with the development of respiratory complications after oesophageal surgery.

RECENT FINDINGS

An acceptable operative mortality, increased and improved quality of life can be gained in appropriately selected patients. When induction therapy is scheduled, smoking cessation is advised. The preoperative treatment of airway pathogens can reduce postoperative complications and this may be particularly relevant in patients who have received induction chemoradiotherapy. Nonrandomized studies suggest that thoracic epidural analgesia improves outcome. Minimally invasive surgery is increasingly used and appears safe but direct comparisons to open surgery in terms of respiratory complications are awaited. Few randomized studies are available to guide anaesthetic management but anaesthetists should aim to avoid hypoxaemia, hypotension, aspiration and limit blood and fluid administration. Postoperative aspiration is common and steps to reduce it are recommended.

SUMMARY

The multifactorial nature of respiratory complications after oesophageal surgery may mean that a number of interventions are needed to have a detectable influence on outcome, much like a care bundle strategy.

Effect of induction chemotherapy on lung function and exercise capacity in patients affected by malignant pleural mesothelioma

OBJECTIVES

The effect of induction chemotherapy (IC) on lung function and exercise capacity in patients with malignant pleural mesothelioma (MPM) has not been largely examined. The aim of this study was to evaluate the changes in pulmonary function and oxygen consumption following IC in patients with MPM.

METHODS

Between 2004 and 2009, 36 consecutive patients (mean age 62.1 + or - 1.5 years, M/F = 25/11) were prospectively investigated. Data concerning medical history, histology, staging and response to chemotherapy were collected. All patients underwent pulmonary function test before (in the absence of pleural effusion) and after chemotherapy (platinum-based agent plus pemetrexed); 23 out of 36 patients also performed a cardiopulmonary incremental exercise test.

RESULTS

An epithelioid histotype was documented in 88.8% of patients. A partial response to chemotherapy was observed in 44.5% of cases and 36.1% of patients experienced grade 2-3 toxicity. A significant improvement in forced expiratory volume in 1s (FEV(1)) (0.13 + or - 0.30 l; P = 0.01), in VO(2) peak (1.76 + or - 2.91 ml kg(-1) min(-1); P = 0.005), in PaO(2) at rest (4.76 + or - 9.84 mmHg; P = 0.03) and in PaO(2) at peak exercise (6.26 + or - 12.72 mmHg; P = 0.04) was detected. The diffusion capacity of the lung for carbon monoxide (DLCO) also increased (1.25 + or - 4.68 ml min(-1) mmHg(-1)), although not significantly (P = 0.20). The stratified analysis based on the response to IC showed a significant improvement in FEV(1), forced vital capacity (FVC) and vital capacity (VC) (both absolute and percentage of predicted values) only in patients with a partial response.

CONCLUSIONS

An improvement in lung function and exercise capacity was seen after IC in patients with MPM. These data suggest that IC does not compromise cardiopulmonary performance in this subset of patients.

Structural lung damage after chemotherapy fact or fiction?

BACKGROUND

The hypothesis that chemotherapy increases morbidity after pneumonectomy remains under debate, as the results of previous surgical series remain controversial. The hypothesis of the study is that patients who received preoperative chemotherapy may have subclinical parenchymal damage, increasing their risk of respiratory complications.

METHODS

The study population was composed of 10 patients who underwent pneumonectomy after chemotherapy for lung cancer (cisplatin+gemcitabine) randomly selected from our database and compared with 10 matched patients who underwent pneumonectomy without previous chemotherapy during the same period. Healthy lung tissue was obtained from surgical specimens, processed according to standard methods and evaluated on ematossilin and eosin-stained sections. Two pathologists without information on the preoperative treatment were asked to review the slides in order to reach a consensus on the type and extent of lung damage. Relevant information was then compared with functional tests and postoperative outcome.

RESULTS

Severe and diffuse (more than 50% of lung parenchyma) interstitial alterations were detected in the lungs of eight patients, seven of which belonged to the chemotherapy group (70%, p 0.02). Six of these patients developed postoperative respiratory complications. In the chemotherapy group, patterns of interstitial involvement were variable interstitial inflammation and fibrosis associated with obliterative bronchiolitis [Roberts JR, Eustis C, Devore R, et al. Induction chemotherapy increases perioperative complications in patients undergoing resection for non-small cell lung carcinoma. Ann Thorac Surg 2001;72:885-8], bronchiolitis obliterans-organizing pneumonia [Leo F, Solli P, Veronesi G, et al. Does chemotherapy increase the risk of respiratory complications after pneumonectomy? J Thorac Cardiovasc Surg 2006;132:519-23], diffuse alveolar damage [Novoa N, Varela G, Jimenez MF. Morbidity after surgery for non-small cell lung carcinoma is not related to neoadjuvant chemotherapy. Eur J Cardiothor Surg 2001;20:700-4], DIP (desquamative interstitial pneumonia)-like reaction [Roberts JR, Eustis C, Devore R, et al. Induction chemotherapy increases perioperative complications in patients undergoing resection for non-small cell lung carcinoma. Ann Thorac Surg 2001;72:885-8] and UIP (usual interstitial pneumonia)-like changes [Roberts JR, Eustis C, Devore R, et al. Induction chemotherapy increases perioperative complications in patients undergoing resection for non-small cell lung carcinoma. Ann Thorac Surg 2001;72:885-8]. The only preoperative clinical predictor of severe diffuse damage was preoperative diffusion by carbon monoxide (Dlco).

CONCLUSIONS

Preoperative chemotherapy is associated with an increased risk of severe and diffuse pulmonary disease even in the presence of normal spirometric parameters. These alterations may play an important role in the occurrence of postoperative respiratory complications.

Exacerbation of bleomycin-induced injury and fibrosis by pneumonectomy in the residual lung of mice

BACKGROUND

Lung resection after induction chemotherapy and/or radiotherapy for down-staging of locally advanced lung cancer can be complicated with lethal interstitial pneumonia. We studied the effects of pneumonectomy on bleomycin-induced lung injury and fibrosis in mice.

METHODS

The mice underwent left pneumonectomy or a sham thoracotomy after intratracheal administration of saline or bleomycin. Lung permeability index, wet-to-dry weight ratio, histological changes, collagen contents, and concentrations of inflammatory mediators and cell counts in broncho-alveolar lavage (BAL) fluid were assessed in the residual right lung 7 d after surgery.

RESULTS

The index of capillary permeability, lung water content, and inflammatory cell counts in BAL fluid were significantly increased by pneumonectomy. These measurements were highest in the mice with both pneumonectomy and intratracheal administration of bleomycin. Similarly, fibrotic change in lung pathology, as well as an increase in lung collagen content, was most prominent in the mice exposed to both interventions. The BAL fluid concentrations of interleukin-1beta, interleukin-6, RANTES, and high mobility group box 1 were significantly increased by pneumonectomy and enhanced by the additional administration of bleomycin.

CONCLUSIONS

The results of this study indicate that pneumonectomy alone causes noncritical lung injury, which amplifies the inflammatory response to bleomycin and promotes lung fibrosis. Several inflammatory mediators appear to be involved in the exacerbation of bleomycin-induced lung injury and fibrosis.

Oxygen toxicity during one-lung ventilation: is it time to re-evaluate our practice?

Lung cancer remains one of the leading causes of cancer-related mortality. Surgical resection remains the mainstay of non-small cell lung cancer therapy, but an increasing number of patients receive preoperative adjuvant chemotherapy that may predispose these patients to unique organ toxicities. This chemotherapy, along with exposure to high oxygen concentrations, may combine to increase the risk of reactive oxygen species-mediated lung injury. Continued efforts are needed to improve overall outcome in these patients, including a reevaluation of our management of oxygen therapy.

Intersession variability in single-breath diffusing capacity in diabetics without overt lung disease

RATIONALE

American Thoracic Society guidelines state that a 10% or greater intersession change in diffusing capacity of the lung (DL(CO)) should be considered clinically significant. However, little is known about the short-term intersession variability in DL(CO) in untrained subjects or how variability is affected by rigorous external quality control.

OBJECTIVES

To characterize the intersession variability of DL(CO) and the effect of different quality control methods in untrained individuals without significant lung disease.

METHODS

Data were pooled from the comparator arms of 14 preregistration trials of inhaled insulin that included nonsmoking diabetic patients without significant lung disease. A total of 699 participants performed repeated DL(CO) measurements using a highly standardized technique. A total of 948 participants performed repeated measurements using routine clinical testing.

MEASUREMENTS AND MAIN RESULTS

The mean intersession absolute change in DL(CO) using the highly standardized method was 1.45 ml/minute/mm Hg (5.64%) compared with 2.49 ml/minute/mm Hg (9.52%) in the routine testing group (P < 0.0001 for both absolute and percent difference). The variability in absolute intersession change in DL(CO) increased with increasing baseline DL(CO) values, whereas the absolute percentage of intersession change was stable across baseline values. Depending on the method, 15.5 to 35.5% of participants had an intersession change of 10% or greater. A 20% or greater threshold would reduce this percentage of patients to 1 to 10%.

CONCLUSIONS

Intersession variability in DL(CO) measurement is dependent on the method of testing used and baseline DL(CO). Using a more liberal threshold to define meaningful intersession change may reduce the misclassification of normal variation as abnormal change.

Future trends in preoperative evaluation

Preoperative evaluation before lung resection has been frequently addressed in modern medical literature. Actual or predicted pulmonary volumes are considered relevant to predict the risk of surgery. Nevertheless, ppoFEV1 underestimates the real functional loss in the immediate postoperative period when most of the complications occur. Not all patients, however, have comparable functional changes after lobectomy. Minimal impairment or even improvements have been demonstrated in COPD cases after lobectomy. Efforts should be directed to an accurate prediction of the immediate postoperative pulmonary volumes for a better evaluation of high-risk patients caused by respiratory impairment. Future developments are needed on the role of measuring preoperative DLCO and how to evaluate a patient's general cardiorespiratory status. Evidence underlines the relevance of routine evaluation of preoperative DLCO at rest or, better, during exercise for a thorough assessment of patient's capability to adapt to a stressful situation (Fig. 3). Only by improving knowledge about the general condition of the patient, can one assess the physiologic response to surgery. Widespread use of sophisticated or simple exercise tests and measurements or daily activity using motion detectors can identify high-risk patients with otherwise acceptable pulmonary volumes. Another suggested investigation issue is to develop different relevant outcome parameters, not only from the surgeon's point of view but also from the patient's perspective, such as postoperative QOL-related variables or delayed outcomes. Finally, multidisciplinary investigation teams, including experts in mathematical modeling, are essential to improve the quality and validity of the developed models. Although knowledge about perioperative physiologic changes has increased, clinicians are still far from finding a way to put all this knowledge down and make it applicable for an individual patient. Multicentric cooperation and evaluation of large prospectively recorded databases are essential to develop evidence-based clinical guidelines on preoperative evaluation.

Surgery of non-small cell lung cancer in the elderly

PURPOSE OF REVIEW

The aim of this review is to analyze recent evidence for optimal treatment of elderly patients with non-small cell lung cancer, focusing on surgery, and possibly to foresee the future strategies to apply in these patients.

RECENT FINDINGS

Surgery in elderly patients affected by non-small cell lung cancer is safe and feasible when careful preoperative respiratory and cardiac studies have been carried out and the disease has been properly staged. The surgical treatment is not to be denied in elderly patients due to age per se, but when a major contraindication to surgery has been recognized. Long term survival for elderly patients with early stage lung cancer treated by anatomical pulmonary resection is comparable to the survival rate of younger patients. Pneumonectomy, extended surgical procedure or preoperative induction chemotherapy are major risk factors for an increased postoperative morbidity and mortality rate. When co-morbidities are present or a patient is 80 years or older, there is evidence that a non-anatomical resection can be performed without affecting long-term results.

SUMMARY

Due to the aging of the general population, elderly patients will become a large percentage of the cases of non-small cell lung cancer to be treated. Implementing preoperative cardiologic studies and redefining selective respiratory criteria specifically could dramatically improve results.