Predicted Versus Observed FEV1 and Dlco After Major Lung Resection: A Prospective Evaluation at Different Postoperative Periods

A New Functional Threshold for Minimally Invasive Lobectomy

OBJECTIVE

To assess the performance of a lower predicted postoperative (ppo) forced expiratory volume in 1 second (FEV 1 ) or diffusion capacity of the lung for carbon monoxide (DLCO) (ppoFEV 1 /ppoDLCO) threshold to predict cardiopulmonary complications after minimally invasive surgery (MIS) lobectomy.

BACKGROUND

Although MIS is associated with better postoperative outcomes than open surgery, MIS uses risk-assessment algorithms developed for open surgery. Moreover, several different definitions of cardiopulmonary complications are used for assessment.

METHODS

All patients who underwent MIS lobectomy for clinical stage I to II lung cancer from 2018 to 2022 at our institution were considered. The performance of a ppoFEV 1 /ppoDLCO threshold of <45% was compared against that of the current guideline threshold of <60%. Three different definitions of cardiopulmonary complications were compared: Society of Thoracic Surgeons (STS), European Society of Thoracic Surgeons (ESTS), and Berry and colleagues' study.

RESULTS

In 946 patients, the ppoFEV 1 /ppoDLCO threshold of <45% was associated with a higher proportion correctly classified [79% (95% CI, 76%-81%) vs 65% (95% CI, 62%-68%); P <0.001]. The complication with the biggest difference in incidence between ppoFEV 1 /ppoDLCO of 45% to 60% and >60% was prolonged air leak [33 (13%) vs 34 (6%); P <0.001]. The predicted probability curves for cardiopulmonary complications were higher for the STS definition than for the ESTS or Berry definitions across ppoFEV 1 and ppoDLCO values.

CONCLUSIONS

The ppoFEV 1 /ppoDLCO threshold of <45% more accurately classified patients for cardiopulmonary complications after MIS lobectomy, emphasizing the need for updated risk-assessment guidelines for MIS lobectomy to optimize additional cardiopulmonary function evaluation.

Longitudinal changes in the volume of residual lung lobes after lobectomy for lung cancer: a retrospective cohort study

It is unclear how the residual lobe volume changes over time after lobectomy. This study aims to clarify the temporal patterns of volume changes in each remaining lung lobe post-lobectomy. A retrospective review was conducted on patients who underwent lobectomy for lung cancer at Yueyang Central Hospital from January to December 2021. Lung CT images were reconstructed in three dimensions to calculate the volumes of each lung lobe preoperatively and at 1, 6, and 12 months postoperatively. A total of 182 patients were included. Postoperatively, the median total lung volume change rates relative to preoperative values were -20.1%, -9.3%, and -5.9% at 1, 6, and 12 months, respectively. Except for the right middle lobe in patients who underwent right upper lobectomy, the volumes of individual lung lobes exceeded preoperative values. The volume growth of the lung on the side of the resection was significantly more than that of the lung on the opposite side. For left lobectomy patients, the right lower lobe's volume change rate exceeded that of the right upper and middle lobes. Among right lobectomy patients, the left lower lobe and the relatively inferior lobe of right lung had higher volume change rates than the superior one. Right middle lobe change rate was more in patients with right lower lobectomy than right upper lobectomy. Six months postoperatively, FEV1% and right middle lobectomy were positively correlated with the overall volume change rate. One year postoperatively, only age was negatively correlated with the overall volume change rate. 75 patients had pulmonary function tests. Postoperative FEV1 change linearly correlated with 1-year lung volume change rate, but not with theoretical total lung volume change rate or segmental method calculated FEV1 change. Time-dependent compensatory volume changes occur in remaining lung lobe post-lobectomy, with stronger compensation observed in the relatively inferior lobe compared to the superior one(s). Preoperative lung function and age may affect compensation level.

SABR for Early Non-Small Cell Lung Cancer: Changes in Pulmonary Function, Dyspnea, and Quality of Life

PURPOSE

The aim of this study was to report pulmonary function tests (PFTs) and clinician-reported and patient-reported quality-of-life (QoL) outcomes on a cohort of patients with non-small cell lung cancer (NSCLC) treated with SABR.

METHODS AND MATERIALS

A total of 119 patients with NSCLC were treated with SABR in the prospective cohort SSBROC study of patients with T1-T2N0M0 NSCLC. PFTs and QoL measures were obtained at baseline pretreatment and at 6-month intervals. Here we report on the 6- to 18-month time points. Analysis of covariance (ANCOVA) methods adjusting for baseline analyzed potential predictors on outcomes of PFTs and patient-reported dyspnea at 18 months.

RESULTS

The only statistically significant decline in PFTs was seen in forced expiratory volume in 1 second (FEV1) at 18 months post-SABR, with a decline of -0.11 L (P = .0087; 95% CI, -0.18 to -0.02). Of potential predictors of decline, only a 1-unit increase in smoking pack-years resulted in a -0.12 change in diffusing capacity for carbon monoxide (P = .026; 95% CI, -0.02 to -0.23) and a 0.003 decrease in FEV1 (P = .026; 95% CI, -0.006 to -0.0004). For patient-reported outcomes, statistically significant worsening in both the European Organisation for Research and Treatment of Cancer Quality of Life Core Questionnaire (QLQ-C30 Version 3) and the lung module (QLQ-LC13) dyspnea scores occurred at the 18-month time point, but not earlier. No potential predictors of worsening dyspnea were statistically significant. There was no statistically significant decline in clinician-reported outcomes or global QoL scores.

CONCLUSIONS

We found a statistically significant decline in FEV1 at 18 months posttreatment. Smoking pack-years was a predictor for decline in diffusing capacity for carbon monoxide and FEV1 at 18 months. Worsening of patient-reported dyspnea scores was observed, consistent with the expected progression of lung comorbid disease.

Predictive factors inhibiting recovery of the respiratory function after anatomical pulmonary resection

PURPOSE

Some patients have worse actual observed postoperative (apo) respiratory function values than predicted postoperative (ppo) values. The present study therefore clarified the predictive factors that hinder the recovery of the postoperative respiratory function.

METHODS

This study enrolled 255 patients who underwent anatomical pulmonary resection for lung cancer. A pulmonary function test (PFT) was carried out before surgery and at one, three, and six months after surgery. In each surgical procedures, the forced expiratory volume in 1 s (FEV1) ratio was calculated as the apo value divided by the ppo value. In addition, we investigated the predictive factors that inhibited postoperative respiratory function improvement in patients with an FEV1 ratio < 1.0 at 6 months after surgery.

RESULTS

The FEV1 ratio gradually improved over time in all surgical procedures. However, 49 of 196 patients who underwent a PFT at 6 months after surgery had an FEV1 ratio < 1.0. In a multivariate analysis, right side, upper lobe, segmentectomy and pleurodesis for prolonged air leakage were independent significant predictors of a decreased FEV1 ratio (p = 0.003, 0.006, 0.001, and 0.009, respectively).

CONCLUSION

Pleurodesis was the only controllable factor that might help preserve the postoperative respiratory function. Thus, the intraoperative management of air leakage is important.

Relationship Between the Diffusing Capacity of the Lung for Carbon Monoxide (DLCO) and Lung Adenocarcinoma Patterns: New Possible Insights

INTRODUCTION

This study aimed to evaluate a potential relationship between the diffusing capacity of the lung for carbon monoxide (DLCO) and the aggressiveness of lung adenocarcinoma (ADC).

METHODS

Patients who underwent radical surgery for lung ADC between 2001 and 2018 were retrospectively reviewed. DLCO values were dichotomized into DLCO_low (<80% of predicted) and DLCO_normal (≥80%). Relationships between DLCO and ADC histopathological features, clinical features, as well as with overall survival (OS), were evaluated.

RESULTS

Four-hundred and sixty patients were enrolled, of which 193 (42%) were included in the DLCO_low group. DLCO_low was associated with smoking status, low FEV₁, micropapillary and solid ADC, tumour grade 3, high tumour lymphoid infiltrate and presence of tumour desmoplasia. In addition, DLCO values were higher in low-grade ADC and progressively decreased in intermediate and high-grade ADC (p=0.024). After adjusting for clinical variables, at multivariable logistic regression analysis, DLCO_low still showed a significant correlation with high lymphoid infiltrate (p=0.017), presence of desmoplasia (p=0.065), tumour grade 3 (p=0.062), micropapillary and solid ADC subtypes (p=0.008). To exclude the association between non-smokers and well-differentiated ADC, the relationship between DLCO and histopathological ADC patterns was confirmed in the subset of 377 former and current smokers (p=0.021). At univariate analysis, gender, DLCO, FEV₁, ADC histotype, tumour grade, stage, pleural invasion, tumour necrosis, tumour desmoplasia, lymphatic and blood invasion were significantly related with OS. At multivariate analysis, only gender (p<0.001), tumour stage (p<0.001) and DLCO (p=0.050) were significantly related with the OS.

CONCLUSIONS

We found a relationship between DLCO and ADC patterns as well as with tumour grade, tumour lymphoid infiltrate and desmoplasia, suggesting that lung damage may be associated with tumour aggressiveness.

Sublobar Resections

Sublobar resections are commonly performed operations that have seen an increase in applicability. The sublobar approach, comprising segmentectomy and wedge resections, can provide lung preservation and thus is better tolerated in select patients in comparison to lobectomy. These operations are offered for a variety of benign and malignant lesions. Understanding the indications and technical aspects of these approaches is paramount as improvements in lung cancer screening protocols and the imaging modalities has led to an increase in the detection of early-stage cancer. In this article, we discuss the anatomy, indications, technical approaches, and outcomes for sublobar resection.

Lung Cancer in the Course of COPD-Emerging Problems Today

Tobacco smoking remains the main cause of tobacco-dependent diseases like lung cancer, chronic obstructive pulmonary disease (COPD), in addition to cardiovascular diseases and other cancers. Whilst the majority of smokers will not develop either COPD or lung cancer, they are closely related diseases, occurring as co-morbidities at a higher rate than if they were independently triggered by smoking. A patient with COPD has a four- to six-fold greater risk of developing lung cancer independent of smoking exposure, when compared to matched smokers with normal lung function. The 10 year risk is about 8.8% in the COPD group and only 2% in patients with normal lung function. COPD is not a uniform disorder: there are different phenotypes. One of them is manifested by the prevalence of emphysema and this is complicated by malignant processes most often. Here, we present and discuss the clinical problems of COPD in patients with lung cancer and against lung cancer in the course of COPD. There are common pathological pathways in both diseases. These are inflammation with participation of macrophages and neutrophils and proteases. It is known that anticancer immune regulation is distorted towards immunosuppression, while in COPD the elements of autoimmunity are described. Cytotoxic T cells, lymphocytes B and regulatory T cells with the important role of check point molecules are involved in both processes. A growing number of lung cancer patients are treated with immune check point inhibitors (ICIs), and it was found that COPD patients may have benefits from this treatment. Altogether, the data point to the necessity for deeper analysis and intensive research studies to limit the burden of these serious diseases by prevention and by elaboration of specific therapeutic options.

A guide for managing patients with stage I NSCLC: deciding between lobectomy, segmentectomy, wedge, SBRT and ablation-part 3: systematic review of evidence regarding surgery in compromised patients or specific tumors

Background

Clinical decision-making for patients with stage I lung cancer is complex. It involves multiple options [lobectomy, segmentectomy, wedge, stereotactic body radiotherapy (SBRT), thermal ablation], weighing multiple outcomes (e.g., short-, intermediate-, long-term) and multiple aspects of each (e.g., magnitude of a difference, the degree of confidence in the evidence, and the applicability to the patient and setting at hand). A structure is needed to summarize the relevant evidence for an individual patient and to identify which outcomes have the greatest impact on the decision-making.

Methods

A PubMed systematic review from 2000-2021 of outcomes after lobectomy, segmentectomy and wedge resection in older patients, patients with limited pulmonary reserve and favorable tumors is the focus of this paper. Evidence was abstracted from randomized trials and non-randomized comparisons (NRCs) with adjustment for confounders. The analysis involved careful assessment, including characteristics of patients, settings, residual confounding etc. to expose degrees of uncertainty and applicability to individual patients. Evidence is summarized that provides an at-a-glance overall impression as well as the ability to delve into layers of details of the patients, settings and treatments involved.

Results

In older patients, perioperative mortality is minimally altered by resection extent and only slightly affected by increasing age; sublobar resection may slightly decrease morbidity. Long-term outcomes are worse after lesser resection; the difference is slightly attenuated with increasing age. Reported short-term outcomes are quite acceptable in (selected) patients with severely limited pulmonary reserve, not clearly altered by resection extent but substantially improved by a minimally invasive approach. Quality-of-life (QOL) and impact on pulmonary function hasn't been well studied, but there appears to be little difference by resection extent in older or compromised patients. Patient selection is paramount but not well defined. Ground-glass and screen-detected tumors exhibit favorable long-term outcomes regardless of resection extent; however solid tumors <1 cm are not a reliably favorable group.

Conclusions

A systematic, comprehensive summary of evidence regarding resection extent in compromised patients and favorable tumors with attention to aspects of applicability, uncertainty and effect modifiers provides a foundation for a framework for individualized decision-making.

Clinical guide to perioperative management for videothoracoscopy lung resection (Section of Cardiac, Vascular and Thoracic Anesthesia, SEDAR; Spanish Society of Thoracic Surgery, SECT; Spanish Society of Physiotherapy)

The introduction of video-assisted thoracoscopic (VATS) techniques has led to a new approach in thoracic surgery. VATS is performed by inserting a thoracoscope through a small incisions in the chest wall, thus maximizing the preservation of muscle and tissue. Because of its low rate of morbidity and mortality, VATS is currently the technique of choice in most thoracic procedures. Lung resection by VATS reduces prolonged air leaks, arrhythmia, pneumonia, postoperative pain and inflammatory markers. This reduction in postoperative complications shortens hospital length of stay, and is particularly beneficial in high-risk patients with low tolerance to thoracotomy. Compared with conventional thoracotomy, the oncological results of VATS surgery are similar or even superior to those of open surgery. This aim of this multidisciplinary position statement produced by the thoracic surgery working group of the Spanish Society of Anesthesiology and Reanimation (SEDAR), the Spanish Society of Thoracic Surgery (SECT), and the Spanish Association of Physiotherapy (AEF) is to standardize and disseminate a series of perioperative anaesthesia management guidelines for patients undergoing VATS lung resection surgery. Each recommendation is based on an in-depth review of the available literature by the authors. In this document, the care of patients undergoing VATS surgery is organized in sections, starting with the surgical approach, and followed by the three pillars of anaesthesia management: preoperative, intraoperative, and postoperative anaesthesia.

Preoperative electromagnetic navigation bronchoscopy-guided one-stage multiple-dye localization for resection of subsolid nodules: A single-center pilot study

Background

Electromagnetic navigation bronchoscopy (ENB)‐guided transbronchial dye marking and video‐assisted thoracoscopic surgery (VATS) is an emerging technique that enables successful resection of multiple small subsolid pulmonary nodules. The aim of this study was to evaluate the accuracy and safety of preoperative ENB‐guided transbronchial multiple dye localization for VATS resection of subsolid pulmonary nodules.

Methods

As a single‐center pilot study, we recruited patients with at least two small or subsolid pulmonary nodules. Multiple‐dye localization was performed by intraoperative ENB‐guided transbronchial injection of an indigo carmine dye. The patients underwent VATS for sublobar resection immediately after localization. The accuracy of ENB‐guided dye marking was checked.

Results

ENB‐guided one‐stage multiple dye localization was conducted for 18 pulmonary nodules in seven patients between September 2018 and December 2019. The mean diameter of the pulmonary nodules was 9.3 mm (range, 4–18) and the mean distance from the pleura to pulmonary nodule was 6 mm (range, 1–17 mm). ENB‐guided transbronchial multiple dye localization was successfully performed in 94.4% (17/18), and the accuracy of ENB‐guided dye marking was 88.2% (15/17). When two nodules were not seen in intraoperative fields, anatomical sublobar resection was performed. There was no conversion to thoracotomy and operative mortalities. Among the seven patients, only one patient showed mild intrabronchial bleeding but stopped spontaneously. The changes in lung function after multiple wedge resections (−1.6% to 24.8%) were tolerable level.

Conclusions

ENB‐guided one‐stage transbronchial dye localization showed accurate and safe intraoperative identification of multiple subsolid pulmonary nodules. A large scale prospective clinical study is warranted.

A Modified Calculation Improves the Accuracy of Predicted Postoperative Lung Function Values in Lung Cancer Patients

PURPOSE

Preoperative pulmonary function testing is mandatory for non-small cell lung cancer (NSCLC) surgery. The predicted postoperative FEV1 (ppoFEV1) is used for further risk stratification. We compared the ppoFEV1 with the postoperative FEV1 (postFEV1) in order to improve the calculation of the ppoFEV1.

METHODS

87 patients voluntarily received an FEV1 assessment 1 year after surgery. ppoFEV1 was calculated according to the Brunelli calculation. Baseline characteristics and surgical procedure were compared in a uni- and multivariate analysis between different accuracy levels of the ppoFEV1. Parameters which remained significant in the multinominal regression analysis were evaluated for a modification of the ppoFEV1 calculation.

RESULTS

Independent factors for a more inaccurate ppoFEV1 were preoperative active smoking (odds ratio (OR) 4.1, confidence interval (CI) 3.6-6.41; p = 0.01), packyears (OR 4.1, CI 3.6-6.41; p = 0.008), younger age (OR 1.1, CI 1.01-1.12; p = 0.03), and patients undergoing pneumectomy (OR 5.55, CI 1.35-23.6; p = 0.01). For the customized ppoFEV1 we excluded pneumonectomies. For patients < 60 years, an additional lung segment was added to the calculation. ppoFEV1 = preFEV1 × [Formula: see text]. For actively smoking patients with more than 30 packyears we subtracted one lung segment from the calculation ppoFEV1 = PreFEV1 × [Formula: see text].

CONCLUSION

We were able to enhance the predictability of the ppoFEV1 with modifications. The modified ppoFEV1 (1.828 l ± 0.479 l) closely approximates the postFEV1 of 1.823 l ± 0.476 l, (0.27%) while the original ppoFEV1 calculation is at 1.78 l ± 0.53 (2.19%). However, if patients require pneumectomy, more complex techniques to determine the ppoFEV1 should be included to stratify risk.

Clinical guide to perioperative management for videothoracoscopy lung resection (Section of Cardiac, Vascular and Thoracic Anesthesia, SEDAR; Spanish Society of Thoracic Surgery, SECT; Spanish Society of Physiotherapy)

The introduction of video-assisted thoracoscopic (VATS) techniques has led to a new approach in thoracic surgery. VATS is performed by inserting a thoracoscope through a small incisions in the chest wall, thus maximizing the preservation of muscle and tissue. Because of its low rate of morbidity and mortality, VATS is currently the technique of choice in most thoracic procedures. Lung resection by VATS reduces prolonged air leaks, arrhythmia, pneumonia, postoperative pain and inflammatory markers. This reduction in postoperative complications shortens hospital length of stay, and is particularly beneficial in high-risk patients with low tolerance to thoracotomy. Compared with conventional thoracotomy, the oncological results of VATS surgery are similar or even superior to those of open surgery. This aim of this multidisciplinary position statement produced by the thoracic surgery working group of the Spanish Society of Anesthesiology and Reanimation (SEDAR), the Spanish Society of Thoracic Surgery (SECT), and the Spanish Association of Physiotherapy (AEF) is to standardize and disseminate a series of perioperative anaesthesia management guidelines for patients undergoing VATS lung resection surgery. Each recommendation is based on an in-depth review of the available literature by the authors. In this document, the care of patients undergoing VATS surgery is organized in sections, starting with the surgical approach, and followed by the three pillars of anaesthesia management: preoperative, intraoperative, and postoperative anaesthesia.

A systematic review of risk prediction models for perioperative mortality after thoracic surgery

OBJECTIVES

Guidelines advocate that patients being considered for thoracic surgery should undergo a comprehensive preoperative risk assessment. Multiple risk prediction models to estimate the risk of mortality after thoracic surgery have been developed, but their quality and performance has not been reviewed in a systematic way. The objective was to systematically review these models and critically appraise their performance.

METHODS

The Cochrane Library and the MEDLINE database were searched for articles published between 1990 and 2019. Studies that developed or validated a model predicting perioperative mortality after thoracic surgery were included. Data were extracted based on the checklist for critical appraisal and data extraction for systematic reviews of prediction modelling studies.

RESULTS

A total of 31 studies describing 22 different risk prediction models were identified. There were 20 models developed specifically for thoracic surgery with two developed in other surgical specialties. A total of 57 different predictors were included across the identified models. Age, sex and pneumonectomy were the most frequently included predictors in 19, 13 and 11 models, respectively. Model performance based on either discrimination or calibration was inadequate for all externally validated models. The most recent data included in validation studies were from 2018. Risk of bias (assessed using Prediction model Risk Of Bias ASsessment Tool) was high for all except two models.

CONCLUSIONS

Despite multiple risk prediction models being developed to predict perioperative mortality after thoracic surgery, none could be described as appropriate for contemporary thoracic surgery. Contemporary validation of available models or new model development is required to ensure that appropriate estimates of operative risk are available for contemporary thoracic surgical practice.

Measured versus predicted postoperative pulmonary function at repeated times up to 1 year after lobectomy

OBJECTIVES

Postoperative pulmonary function is difficult to predict accurately, because it changes from the time of the operation and is also affected by various factors. The objective of this study was to assess the accuracy of predicted postoperative forced expiratory volume in 1 s (FEV1) at different postoperative times after lobectomy.

METHODS

This retrospective study enrolled 104 patients who underwent lobectomy by video-assisted thoracic surgery. Pulmonary function tests were performed preoperatively and postoperatively at 3, 6 and 12 months. We investigated time-dependent changes in FEV1. In addition, the ratio of measured to predicted postoperative FEV1 calculated by the subsegmental method was evaluated to identify the factors associated with variations in postoperative FEV1.

RESULTS

Compared with the predicted postoperative FEV1, the measured postoperative FEV1 was 8% higher at 3 months, 11% higher at 6 months and 13% higher at 12 months. The measured postoperative FEV1 significantly increased from 3 to 6 months (P = 0.002) and from 6 to 12 months (P = 0.015) after lobectomy resected lobe, smoking history and body mass index were significant factors associated with the ratio of measured to predicted postoperative FEV1 at 12 months (P < 0.001, P = 0.036 and P = 0.025, respectively).

CONCLUSIONS

Postoperative FEV1 increased up to 12 months after lobectomy by video-assisted thoracic surgery. The predicted postoperative pulmonary function was underestimated after 3 months, particularly after lower lobectomy.

A preliminary study identifies early postoperative lung volume changes in patients with non-small cell lung cancer following video-assisted thoracic surgery using CT volumetry

The present study aimed to investigate the changes in early postoperative lung volume in patients with non-small cell lung cancer (NSCLC) following video-assisted thoracic surgery (VATS) and to analyze the effects of the clinical characteristics on the lung volume of the patients. Therefore, 38 patients with NSCLC, who planned to undergo VATS at the Department of Thoracic Surgery, The Affiliated Hospital of Guizhou Medical University in June 2019, were enrolled into the present study. The clinical and computed tomography (CT) scan data from the patients was prospectively collected within 1 week preoperatively, and at 1, 3 and 6 months following surgery, then subsequently analyzed. A total of 34 patients successfully completed follow-up and were included in the datasets. The results showed that the volume of the right lung was larger compared with that in the left one, at each observational time point. The whole, right and left lung held the same trendline of volume changes, which was sharply decreased during the first postoperative month, increased quickly over the next 3 months, and slowly increased from months 3 to 6. There were 7 patients, whose whole lung volume was increased at 6 months following surgery compared with that preoperatively. In addition, significant differences were observed between males and females in the whole, right and left lung volume. However, the differences on the postoperative net expansion volume of the whole lung were not significant among sex, age, body mass index (BMI), smoking status and surgical side subgroups. The early changes of the postoperative lung volume were not linear, since the lung volume was significantly reduced during the first postoperative month, quickly increased in the next 3 months, and slowly increased from months 3 to 6. Sex, age, BMI, smoking status and surgical sides was not found to affect the postoperative volume and net expansion of the whole lung following VATS lobectomy.

Recommendations from the Italian intersociety consensus on Perioperative Anesthesia Care in Thoracic surgery (PACTS) part 1: preadmission and preoperative care

INTRODUCTION

Anesthetic care in patients undergoing thoracic surgery presents specific challenges that necessitate standardized, multidisciplionary, and continuously updated guidelines for perioperative care.

METHODS

A multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, comprising 24 members from 19 Italian centers, was established to develop recommendations for anesthesia practice in patients undergoing thoracic surgery (specifically lung resection for cancer). The project focused on preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and PubMed and Embase literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventative Services Task Force criteria.

RESULTS

Recommendations for preoperative care focus on risk assessment, patient preparation (prehabilitation), and the choice of procedure (open thoracotomy vs. video-assisted thoracic surgery).

CONCLUSIONS

These recommendations should help pulmonologists to improve preoperative management in thoracic surgery patients. Further refinement of the recommendations can be anticipated as the literature continues to evolve.

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.

Prediction of postoperative lung function in lung cancer patients using perfusion scintigraphy

BACKGROUND

Predicting postoperative lung function is critical in lung cancer patients. Perfusion scintigraphy has been used to estimate postoperative function after lung resection.

PURPOSE

To evaluate the usefulness of the posterior oblique method in relation to other conventional processing methods for predicting postoperative lung function using lung perfusion scintigraphy.

MATERIAL AND METHODS

Fifty-five patients with non-small-cell lung cancer who underwent lobectomy were enrolled. Forced expiratory volume in 1 s (FEV1) values were obtained from preoperative and postoperative pulmonary function tests. After performing lung perfusion scintigraphy, predicted FEV1 values were calculated using the segment, conventional, posterior, and posterior oblique methods. Postoperative FEV1 values were compared with predicted FEV1 values.

RESULTS

The mean value of the preoperative FEV1 was 2.29 L and that of the postoperative FEV1 was 1.89 L. The mean values of the predicted postoperative FEV1 values for the segment, conventional, posterior, and posterior oblique were 1.83 L, 1.94 L, 1.88 L, and 1.89 L, respectively. Between the observed and predicted FEV1 values, there was a strong correlation without significant difference except for conventional method. Bland-Altman analysis showed that segment and posterior methods underestimated the FEV1, whereas conventional and posterior oblique methods overestimated the FEV1.

CONCLUSION

Predictions with each processing method of lung perfusion scintigraphy showed nearly similar results to the actual postoperative lung function. The posterior oblique method of lung perfusion scintigraphy showed a very small difference to such an extent as to be equal to the observed FEV1, implying that this method may be applied for predicting postoperative lung function in lung cancer patients.

Postoperative pulmonary function changes according to the resected lobe: a 1-year follow-up study of lobectomized patients

Background

Pulmonary function and patient complaints appear to improve up to 12 months after lobectomy but long-term prospective studies based on clinical data are scarce. Improvement in pulmonary function may depend on the area and extent of the resection and the time from the operation. This prospective study aimed to determine pulmonary function changes according to the resected lobe.

Methods

This prospective study included 59 patients requiring single lobectomy. Total volume and low-attenuation volume (LAV) for each lobe and the entire lungs were calculated based on helical computed tomography images. Vital capacity (VC), forced expiratory volume in one second (FEV₁), percent FEV₁ (%FEV₁), percent lung diffusion capacity for carbon monoxide (%DL_co), %DL_co divided by the alveolar volume (%DL_co/V_A), modified Medical Research Council (mMRC) grades, and COPD Assessment Test (CAT) scores were compared at 3, 6, and 12 months after surgery.

Results

VC was higher at 12 months than at 3 months after right upper lobectomy (RUL) or right lower lobectomy (RLL). FEV₁ and %FEV₁ were higher at 12 months than at 6 months after left lower lobectomy (LLL). %DL_co was higher at 12 months than at 3 months after RUL or left upper lobectomy (LUL). DL_co/V_A, mMRC grades, and CAT scores did not change significantly in the period from 3 to 12 months after any lobectomy procedure. Compared to the predicted postoperative values, the observed values of VC for RUL, RLL, and LUL; FEV₁ for RLL; %FEV₁ for RLL and LUL; %DL_co for LUL; and %DL_co/V_A for all lobectomy procedures were higher at 12 months.

Conclusions

Improvements in pulmonary function and symptoms varied according to the resected lobe. Some of the observed pulmonary function values were higher than the predicted postoperative values. Pulmonary function changes may be related to the location, volume, and extent of emphysematous changes.

Prediction of postoperative lung function after major lung resection for lung cancer using volumetric computed tomography

OBJECTIVES

The study objectives were to assess the accuracy of volumetric computed tomography to predict postoperative lung function in patients with lung cancer in relation to anatomic segments counting and perfusion scintigraphy, to generate specific predictive equations for each functional parameter, and to evaluate accuracy and precision of these in a validation cohort.

METHODS

We assessed pulmonary functions preoperatively and 3 to 4 months postoperatively after lung resection for lung cancer (n = 114). Absolute and relative lung volumes (total and upper/middle/lower) were determined using volumetric software analysis for staging thoracic computed tomography scans. Predicted postoperative function was calculated by segments counting, scintigraphy, and volumetric computed tomography.

RESULTS

Volumetric computed tomography achieves a higher correlation and precision with measured postoperative lung function than segments counting or scintigraphy (correlation and intraclass correlation coefficients, 0.779-0.969 and 0.776-0.969; 0.573-0.887 and 0.552-0.882; and 0.578-0.834 and 0.532-0.815, respectively), as well as greater accuracy, determined by narrower agreement coefficients for forced vital capacity, forced expiratory volume in 1 second, lung diffusing capacity, and peak oxygen uptake. After validation in an independent cohort (n = 43), adjusted linear regression including volumetric estimation of decreased postoperative ventilation for postoperative lung function parameters explains 98% to 99% of variance.

CONCLUSIONS

Volumetric computed tomography is a reliable and accurate method to predict postoperative lung function in patients undergoing lung resection that provides better accuracy than conventional procedures. Because lung computed tomography is systematically performed in the staging of patients with suspected lung cancer, this volumetric analysis might simultaneously provide the information necessary to evaluate operability.

Lung function in the late postoperative phase and influencing factors in patients undergoing pulmonary lobectomy

BACKGROUND

Lung function in the late postoperative phase after pulmonary lobectomy is insufficiently characterized. This study aimed to appraise lung function in the late postoperative phase according to vital capacity (VC) and forced expiratory volume in 1 second (FEV1) in patients who underwent pulmonary lobectomy.

METHODS

Pre- and postoperative VC and FEV1 were reviewed in 112 patients who underwent pulmonary lobectomy. Postoperative lung volume was assessed >1 year after surgery. Postoperative decreases in VC and FEV1 were compared with preoperative predicted values among patients who underwent resection of specific lobe. Determinants effecting a decrease in lung function were also investigated.

RESULTS

A mean postoperative decreased VC of 10.5%±1.8% was recorded in patients who underwent right upper lobectomy (RU), 7.2%±1.5% for right middle lobectomy (RM), 14.3%±2.3% for right lower lobectomy (RL), 16.6%±3.0% for left upper lobectomy (LU), and 14.7%±2.5% for left lower lobectomy (LL). Corresponding FEV1 values were 14.8%±1.8% for RU, 11.9%±4.0% for RM, 14.9%±2.3% for RL, 17.9%±2.9% for LU, and 15.1%±2.4% for LL. The actual decreasing rate of VC was overestimated in patients who underwent RU, RL, LU, and LL. In contrast, FEV1 was overestimated only in patients who underwent RL and LL. Patients with chronic obstructive pulmonary disease (COPD) exhibited significantly better preservation of FEV1.

CONCLUSIONS

Patients scheduled for RL and LL, or those with COPD, appeared to exhibit preserved lung function in the late postoperative phase after pulmonary lobectomy.

Assessing the use of 4DCT-ventilation in pre-operative surgical lung cancer evaluation

PURPOSE

A primary treatment option for lung cancer patients is surgical resection. Patients who have poor lung function prior to surgery are at increased risk of developing serious and life-threatening complications after surgical resection. Surgeons use nuclear medicine ventilation-perfusion (VQ) scans along with pulmonary function test (PFT) information to assess a patient's pre-surgical lung function. The nuclear medicine images and pre-surgery PFTs are used to calculate percent predicted postoperative (%PPO) PFT values by estimating the amount of functioning lung tissue that would be lost with surgical resection. Nuclear medicine imaging is currently considered the standard of care when evaluating the amount of ventilation that would be lost due to surgery. A novel lung function imaging modality has been developed in radiation oncology that uses 4-Dimensional computed tomography data to calculate ventilation maps (4DCT-ventilation). Compared to nuclear medicine, 4DCT-ventilation is cheaper, does not require a radioactive contrast agent, provides a faster imaging procedure, and has improved spatial resolution. In this work we perform a retrospective study to assess the use of 4DCT-ventilation as a pre-operative surgical lung function evaluation tool. Specifically, the purpose of our study was to compare %PPO PFT values calculated with 4DCT-ventilation and %PPO PFT values calculated with nuclear medicine ventilation-perfusion imaging.

METHODS

The study included 16 lung cancer patients that had undergone 4DCT imaging, nuclear medicine imaging, and had Forced Expiratory Volume in 1 second (FEV₁ ) acquired as part of a standard PFT. The 4DCT datasets, spatial registration, and a density-change-based model were used to compute 4DCT-ventilation maps. Both 4DCT-ventilation and nuclear medicine images were used to calculate %PPO FEV₁ . The %PPO FEV₁ was calculated by scaling the pre-surgical FEV₁ by (1-fraction of total resected ventilation); where the resected ventilation was determined using either the 4DCT-ventilation or nuclear medicine imaging. Calculations were done assuming both lobectomy and pneumonectomy resections. The %PPO FEV₁ values were compared between the 4DCT-ventilation-based calculations and the nuclear medicine-based calculations using correlation coefficients, average differences, and Receiver Operating Characteristic (ROC) analysis.

RESULTS

Overall the 4DCT-ventilation derived %PPO FEV₁ values agreed well with nuclear medicine-derived %PPO FEV₁ data with correlations of 0.99 and 0.81 for lobectomy and pneumonectomy, respectively. The average differences between the 4DCT-ventilation and nuclear medicine-based calculation for %PPO FEV₁ were less than 5%. ROC analysis revealed predictive accuracy that ranged from 87.5% to 100% when assessing the ability of 4DCT-ventilation to predict for nuclear medicine-based %PPO FEV₁ values.

CONCLUSIONS

4DCT-ventilation is an innovative technology developed in radiation oncology that has great potential to translate to the surgical domain. The high correlation results when comparing 4DCT-ventilation to the current standard of care provide a strong rationale for a prospective clinical trial assessing 4DCT-ventilation in the clinical setting. 4DCT-ventilation can reduce the cost and imaging time for patients while providing improved spatial accuracy and quantitative results for surgeons.

Evaluation of postoperative lung volume and perfusion changes by dual-energy computed tomography in patients with lung cancer

PURPOSE

The aim of our study was to retrospectively evaluate postoperative physiologic changes in lung cancer patients using dual-energy CT (DECT), and develop modified methods reflecting postoperative change for predicting pulmonary function.

METHODS AND MATERIALS

88 patients (M:F=64:24; mean age, 63.5 years) with lung cancer who underwent DECT and pulmonary function tests before and after operation were included. Volume and iodine values for perfusion of each lobe were quantified. The predicted postoperative FEV1 using the current method was calculated by multiplying the preoperative FEV1 by the fractional contribution of perfusion of the remaining lung. The modified method reflecting postoperative volume change was compared to the current method.

RESULTS

Postoperative lung volume showed compensatory increases in the contralateral and remaining ipsilateral lobes, with a significantly greater increase in the ipsilateral lobe than contralateral lobe (21.8%±46.2% vs. 10.0%±20.8%, P=0.031). Perfusion analysis showed blood volume increases in both ipsilateral and contralateral lobes without statistical differences (blood volume ratio difference, 29.2%±26.7 vs. 24.6%±16.5, P=0.368). The performance of the modified method considering postoperative lung volume change was comparable to that of the current method in the development and validation datasets (95% CI, -24.5% to 37.1% vs. -33.3% to 22.2% and -23.6% to 32.0% vs. -31.9% to 16.0%, respectively).

CONCLUSIONS

Postoperative compensatory increases in lung volume and perfusion occur in different ways. Our modified method incorporating postoperative lung volume changes can be considered a comparable method for prediction of postoperative lung function.

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.

Risk Stratification in Lung Resection

PURPOSE OF REVIEW

Surgery is considered the best treatment option for patients with early stage lung cancer. Nevertheless, lung resection may cause a variable functional impairment that could influence the whole cardio-respiratory system with potential life-threatening complications. The aim of the present study is to review the most relevant evidences about the evaluation of surgical risk before lung resection, in order to define a practical approach for the preoperative functional assessment in lung cancer patients.

RECENT FINDINGS

The first step in the preoperative functional evaluation of a lung resection candidate is a cardiac risk assessment. The predicted postoperative values of forced expiratory volume in one second and carbon monoxide lung diffusion capacity should be estimated next. If both values are greater than 60 % of the predicted values, the patients are regarded to be at low surgical risk. If either or both of them result in values lower than 60 %, then a cardiopulmonary exercise test is recommended. Patients with VO2max >20 mL/kg/min are regarded to be at low risk, while those with VO2max <10 mL/kg/min at high risk. Values of VO2max between 10 and 20 mL/kg/min require further risk stratification by the VE/VCO2 slope. A VE/VCO2 <35 indicates an intermediate-low risk, while values above 35 an intermediate-high risk.

SUMMARY

The recent scientific evidence confirms that the cardiologic evaluation, the pulmonary function test with DLCO measurement, and the cardiopulmonary exercise test are the cornerstones of the preoperative functional evaluation before lung resection. We present a simplified functional algorithm for the surgical risk stratification in lung resection candidates.

Assessment and Optimisation of Lung Cancer Patients for Treatment with Curative Intent

Over the past decade the field of lung cancer management has seen many developments. Coupled with an ageing population and increasing rates of comorbid illness, the work-up for treatments with curative intent has become more complex and detailed. As well as improvements in imaging and staging techniques, developments in both surgery and radiotherapy may now allow patients who would previously have been considered unfit or not appropriate for treatment with curative intent to undergo radical therapies. This overview will highlight published studies relating to investigation and staging techniques, together with assessments of fitness, with the aim of helping clinicians to determine the most appropriate treatments for each patient. We also highlight areas where further research may be required.

Impact of Sublobar Resection on Pulmonary Function: Long-Term Results from American College of Surgeons Oncology Group Z4032 (Alliance)

BACKGROUND

Sublobar resection (SR) in high-risk operable patients may result in a long-term decrease in pulmonary function. We previously reported 3-month pulmonary function outcomes from a randomized phase III study of SR alone compared with SR with brachytherapy in patients with non-small cell lung cancer. We now report long-term pulmonary function after SR.

METHODS

Pulmonary function was measured at baseline and at 3, 12, and 24 months. A decline of 10% or more from baseline in the percentage predicted forced expiratory volume of 1 percentage or in the diffusion capacity of the lung for carbon monoxide was considered clinically meaningful. The effect of study arm, tumor location, size, approach (video-assisted thoracoscopic surgery vs thoracotomy), and SR type (wedge vs segmentectomy) on pulmonary function was assessed using a Wilcoxon rank sum test. A generalized estimating equation model was used to assess the effect of each factor on longitudinal data, including all four time points.

RESULTS

Complete pulmonary function data at all time points was available in 69 patients. No significant differences were observed in pulmonary function between SR and SR with brachytherapy, thus the study arms were combined for all analyses. A decline of 10% or more (p = 0.02) in the percentage predicted forced expiratory volume in 1 second was demonstrated for lower-lobe resections at 3 months but was not at 12 or 24 months. A decline of 10% or more (p = 0.05) in the percentage predicted diffusion capacity of the lung for carbon monoxide was seen for thoracotomy at 3 months but was not at 12 or 24 months.

CONCLUSIONS

Clinically meaningful declines in pulmonary function occurred after lower lobe resection and after thoracotomy at 3 months but subsequently recovered. This study suggests that SR does not result in sustained decreased pulmonary function in high-risk operable patients.

Bronchial sleeve resection or pneumonectomy for non-small cell lung cancer: a propensity-matched analysis of long-term results, survival and quality of life

BACKGROUND

No randomized studies exist comparing pneumonectomy (PN) and sleeve lobectomy (SL). We evaluated surgical results and long-term quality of life in patients operated on for central non-small cell lung cancer (NSCLC) using either SL or PN.

METHODS

A total of 641 NSCLC patients underwent surgery 2000-2010. SL was performed in 40 (6.2%) and PN in 67 (10.5%). In 2011, all surviving patients were sent a 15D Quality of Life Questionnaire which 83% replied. Propensity-score-matching analysis was utilized to compare the groups.

RESULTS

Thirty-two bronchial (18 right/14 left), seven vasculobronchial (3 right/4 left), one right wedge SL, and 18 right and 22 left PN were performed. Preoperatively, the Charlson Comorbidity Index (CCI) score, forced expiratory volume in 1 s (FEV1) and diffusion capacity did not differ between groups. The perioperative complication rate and pattern were similar, but SL group had less major complications (P<0.027). One perioperative death (2.5%) occurred in SL group and four (6%) in PN. The 90-day mortality rate was 5% (n=2) for SL and 7.5% (n=5) for PN. In the follow-up total cancer recurrence did not differ (P=0.187). Quality of life measured by 15D showed no significant difference in separate dimensions or total score, except tendency to favor SL in moving or breathing. The 5-year survival did not differ between groups (P=0.458), but no deaths were observed in SL group after 5 years.

CONCLUSIONS

Due to less major operative complications and better long-term survival, we would advocate using SL when feasible, but in patients tolerating PN it should be considered if SL seems not to be oncologically sufficiently radical.

Effect of a postoperative outpatient pulmonary rehabilitation program on physical activity in patients who underwent pulmonary resection for lung cancer

AIM

Physical activity (PA) has been associated with an improvement in survival for individuals with cancer. However, little is known about the effect of postoperative pulmonary rehabilitation on PA after lobectomy in patients with lung cancer. The present study investigated the effect of outpatient rehabilitation on PA in patients with cancer after lung resection.

METHODS

A total of 19 patients with lung cancer were recruited for this study and completed a preoperative rehabilitation program. One group of nine patients completed a postoperative outpatient pulmonary rehabilitation program (rehabilitation) and another group of 10 patients did not (control), but were similarly followed up. Preoperative lung function, assessed by forced expiratory volume in 1 s (FEV1 ), body mass index (BMI) and St. George's Respiratory Questionnaire (SGRQ) score were not different between groups. PA was measured before and 2 months after surgery using a three-axis accelerometer for 5-6 days. PA level (PAL) was defined as total energy expenditure divided by basal metabolic rate.

RESULTS

Preoperative PAL was not different between groups. However, postoperative versus preoperative PAL was significantly lower in the control versus the rehabilitation group (P < 0.01), and PAL decline was less for the rehabilitation versus the control group (P < 0.001). A subgroup analysis showed improvement in postoperative PAL in rehabilitation patients aged <75 years and older.

CONCLUSIONS

Two months after lung resection surgery, patients had not recovered to the preoperative PAL. However, compared with the control group, there was an improvement in the postoperative PAL in patients, including older patients, who underwent outpatient pulmonary rehabilitation. Geriatr Gerontol Int 2016; 16: 550-555.

Prediction of postoperative dyspnea and chronic respiratory failure

BACKGROUND

Even among patients considered to be functionally eligible for major lung resection, some experience postoperative dyspnea. Based on our previous study with quantitative computed tomography (CT), we hypothesized that postoperative dyspnea is associated with the collapse of the remaining lung, and thus, prediction of the postoperative lung volume may contribute to risk assessment for postoperative dyspnea.

METHODS

We measured the emphysematous lung volume and functional lung volume (FLV) separately on whole lung CT using an image analysis software in 290 patients undergoing major lung resection for cancer between January 2006 and December 2012. The postoperative FLV was predicted by a stepwise multiple regression analysis.

RESULTS

Fourteen patients complained of postoperative dyspnea (complicated group), five of them presented with chronic respiratory failure. The postoperatively measured FLV was significantly lower in the complicated group than in the control group (P < 0.01). The postoperative FLV could be calculated using preoperative variables, including the forced vital capacity, number of resected segments, FLV, and emphysematous lung volume. The predicted postoperative FLV was significantly lower in the complicated group than in the control group (P < 0.01, area under the curve = 0.78; sensitivity 86%; specificity 73%). The predicted postoperative FLV was also useful in distinguishing complicated patients from matched-control patients who had similar preoperative pulmonary function (P = 0.02).

CONCLUSIONS

Postoperative dyspnea is likely accompanied by a collapse of the remaining lung. Quantitative assessment of the lung morphology on preoperative CT is useful to screen for patients at risk of postoperative dyspnea.

Lobar analysis of collapsibility indices to assess functional lung volumes in COPD patients

Background

We investigated correlations between lung volume collapsibility indices and pulmonary function test (PFT) results and assessed lobar differences in chronic obstructive pulmonary disease (COPD) patients, using paired inspiratory and expiratory three dimensional (3D) computed tomography (CT) images.

Methods

We retrospectively assessed 28 COPD patients who underwent paired inspiratory and expiratory CT and PFT exams on the same day. A computer-aided diagnostic system calculated total lobar volume and emphysematous lobar volume (ELV). Normal lobar volume (NLV) was determined by subtracting ELV from total lobar volume, both for inspiratory phase (NLV_I) and for expiratory phase (NLV_E). We also determined lobar collapsibility indices: NLV collapsibility ratio (NLV_CR) (%) = (1 − NLV_E/NLV_I) × 100%. Associations between lobar volumes and PFT results, and collapsibility indices and PFT results were determined by Pearson correlation analysis.

Results

NLV_CR values were significantly correlated with PFT results. Forced expiratory volume in 1 second, measured as percent of predicted results (FEV₁%P) was significantly correlated with NLV_CR values for the lower lobes (P<0.01), whereas this correlation was not significant for the upper lobes (P=0.05). FEV₁%P results were also moderately correlated with inspiratory, expiratory ELV (ELV_I,E) for the lower lobes (P<0.05). In contrast, the ratio of the diffusion capacity for carbon monoxide to alveolar gas volume, measured as percent of predicted (DL_CO/V_A%P) results were strongly correlated with ELV_I for the upper lobes (P<0.001), whereas this correlation with NLV_CR values was weaker for upper lobes (P<0.01) and was not significant for the lower lobes (P=0.26).

Conclusion

FEV₁%P results were correlated with NLV collapsibility indices for lower lobes, whereas DL_CO/V_A%P results were correlated with NLV collapsibility indices and ELV for upper lobes. Thus, evaluating lobar NLV collapsibility might be useful for estimating pulmonary function in COPD patients.

Preoperative evaluation for lung cancer resection

During the last decades lung cancer is the leading cause of death worldwide for both sexes. Even though cigarette smoking has been proved to be the main causative factor, many other agents (e.g., occupational exposure to asbestos or heavy metals, indoor exposure to radon gas radiation, particulate air pollution) have been associated with its development. Recently screening programs proved to reduce mortality among heavy-smokers although establishment of such strategies in everyday clinical practice is much more difficult and unknown if it is cost effective compared to other neoplasms (e.g., breast or prostate cancer). Adding severe comorbidities (coronary heart disease, COPD) to the above reasons as cigarette smoking is a common causative factor, we could explain the low surgical resection rates (approximately 20-30%) for lung cancer patients. Three clinical guidelines reports of different associations have been published (American College of Chest Physisians, British Thoracic Society and European Respiratory Society/European Society of Thoracic Surgery) providing detailed algorithms for preoperative assessment. In the current mini review, we will comment on the preoperative evaluation of lung cancer patients.

A new method to predict values for postoperative lung function and surgical risk of lung resection by quantitative breath sound measurements

OBJECTIVES

We evaluated quantitative acoustic measurements, as a simpler alternative to perfusion scintigraphy, for estimation of predicted postoperative (ppo) lung function after resection surgery in our patient population.

METHODS

Patients with lung cancer, considered as candidates for lung resection, were enrolled in the study. All patients underwent lung function testing and quantitative breath sound testing by vibration response imaging (VRI) on the same day. A subset of patients also had perfusion testing. Forced expiratory volume in 1 second (FEV(1)) and diffusing capacity of the lung for carbon monoxide (DLCO) predictions derived from VRI testing were compared with perfusion values and actual FEV(1) values at 1 month postoperatively.

RESULTS

Fifty-three subjects (40 males; age 66±8 y) participated. There was high correlation between both methods for the calculation of ppoFEV(1)% (R=0.94; n=39) and ppoFEV (L) (R=0.90; n=39). PpoFEV(1) were 58±18% versus 56±20% and 1.69±0.49 L versus 1.62±0.52 L, based on perfusion and VRI methods, respectively. In 92% (36/39) of calculations, the difference between the 2 methods was <10%. High correlations also existed between VRI and perfusion for the calculation of ppoDLCO% (R=0.95; n=37) and ppoDLCO mL/min/mm Hg (R=0.90; n=37). VRI predictions showed good correlation for the 34 patients with actual postoperative lung function (R=0.88 and R=0.80 for FEV(1)% and FEV(1)L, respectively). Accuracy of the VRI to predict surgical risk (<40% cutoff threshold for ppo values) compared with actual postoperative values was 85% (29/34).

CONCLUSIONS

Predictions of postoperative lung function using VRI agree well with radionuclide techniques and actual measured postoperative values. VRI may provide a noninvasive, simpler alternative for estimation of ppo values, particularly when perfusion testing is not readily available.

American College of Chest Physicians and Society of Thoracic Surgeons consensus statement for evaluation and management for high-risk patients with stage I non-small cell lung cancer

BACKGROUND

The standard treatment of stage I non-small cell lung cancer (NSCLC) is lobectomy with systematic mediastinal lymph node evaluation. Unfortunately, up to 25% of patients with stage I NSCLC are not candidates for lobectomy because of severe medical comorbidity.

METHODS

A panel of experts was convened through the Thoracic Oncology Network of the American College of Chest Physicians and the Workforce on Evidence-Based Surgery of the Society of Thoracic Surgeons. Following a literature review, the panel developed 13 suggestions for evaluation and treatment through iterative discussion and debate until unanimous agreement was achieved.

RESULTS

Pretreatment evaluation should focus primarily on measures of cardiopulmonary physiology, as respiratory failure represents the greatest interventional risk. Alternative treatment options to lobectomy for high-risk patients include sublobar resection with or without brachytherapy, stereotactic body radiation therapy, and radiofrequency ablation. Each is associated with decreased procedural morbidity and mortality but increased risk for involved lobe and regional recurrence compared with lobectomy, but direct comparisons between modalities are lacking.

CONCLUSIONS

Therapeutic options for the treatment of high-risk patients are evolving quickly. Improved radiographic staging and the diagnosis of smaller and more indolent tumors push the risk-benefit decision toward parenchymal-sparing or nonoperative therapies in high-risk patients. Unbiased assessment of treatment options requires uniform reporting of treatment populations and outcomes in clinical series, which has been lacking to date.

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.

Vibration response imaging in prediction of pulmonary function after pulmonary resection

BACKGROUND

Vibration response imaging (VRI) is a new technique that captures lung sounds generated by the flow of air through the lungs. It predicts postoperative values for an intended lung resection. In this study, we measured the predicted postoperative pulmonary function as determined by a perfusion lung scan and the VRI, and compared with results from the postoperative pulmonary function.

METHODS

This study was performed prospectively in patients who were candidates for major pulmonary resection. Each patient underwent a pulmonary function test, perfusion scintigraphy, and VRI within 1 week before operation. Postoperative lung function was measured at 4 to 6 weeks.

RESULTS

The study enrolled 44 patients. There were no significant differences for predicted postoperative forced expiratory volume in 1 second (ppoFEV(1)) and predicted postoperative diffusion capacity of the lung for carbon monoxide (ppoDlco) between scan and VRI. Both ppoFEV(1) and ppoDlco using a scan and VRI predicted the postoperative results well, respectively. The postoperative FEV(1) was correlated with ppoFEV(1) using a scan (r = 0.83, p < 0.001), and the ppoFEV(1) using a VRI (r = 0.83, p < 0.001). The postoperative Dlco was correlated with the ppoDlco using a scan (r = 0.85, p < 0.001), and the ppoDlco using a VRI (r = 0.80, p < 0.001).

CONCLUSIONS

The VRI was highly predictive of postoperative FEV(1) and Dlco for lung resection.

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.