Quality of life after tailored combined surgery for stage I non–small-cell lung cancer and severe emphysema

Lung emphysema and lung cancer: what do we know about it?

Emphysema and lung cancer (LC) are two diseases which share common risk factors, e.g., smoking. In recent years, many studies have sought to analyse this association. By way of illustration, we conducted a review of the scientific literature of the studies published to date, whose main designated aim was to demonstrate the relationship between emphysema and LC, and this association's influence on the histology, prognosis and molecular mechanisms responsible. We included over 40 studies (ranging from case-control and cohort studies to systematic reviews and meta-analyses), which highlight the association between emphysema and LC, independently of smoking habit. These studies also report a possible influence on histology, with adenocarcinoma being the most frequent lineage, and an association with poor prognosis, which affects both survival and post-operative complications. Oxidative stress, which generates chronic inflammatory status as well as the presence of certain polymorphisms in various genes (CYP1A1, TERT, CLPTM1L, ERK), gives rise-in the case of patients with emphysema-to alteration of cellular repair mechanisms, which in turn favours the proliferation of neoplastic epithelial cells responsible for the origin of LC.

A Review of Quality of Life Measures used in Surgical Outcomes for Stage I Lung Cancers

This review summarizes the literature on QoL in early stage lung cancer patients who underwent surgery. PubMed and PsycINFO were searched. Twelve articles from 10 distinct studies were identified for a total of 992 patients. Five QoL measures were used. One study reported only on pre-surgical QoL, six only on post-surgical QoL and three studies reported on both pre- and post-surgical QoL. Timing for the administration of post-surgical QoL surveys varied. The literature on QoL in Stage I non-small-cell lung cancer patients is very sparse. Additional research is needed to explore the impact of different surgical approaches on QoL.

Lung cancer and chronic obstructive pulmonary disease: From a clinical perspective

Chronic obstructive pulmonary disease (COPD) and lung cancer are devastating pulmonary diseases that commonly coexist and present a number of clinical challenges. COPD confers a higher risk for lung cancer development, but available chemopreventive measures remain rudimentary. Current studies have shown a marked benefit of cancer screening in the COPD population, although challenges remain, including the common underdiagnosis of COPD. COPD-associated lung cancer presents distinct clinical features. Treatment for lung cancer coexisting with COPD is challenging as COPD may increase postoperative morbidities and decrease survival. In this review, we outline current progress in the understanding of the clinical association between COPD and lung cancer, and suggest possible cancer prevention strategies in this patient population.

Surgical treatment of early-stage non-small-cell lung cancer

Surgical resection remains the standard of care for functionally operable early-stage non-small-cell lung cancer (NSCLC) and resectable stage IIIA disease. The role of invasive staging and restaging techniques is currently being debated, but they provide the largest biopsy samples which allow for precise mediastinal staging. Different types of operative procedures are currently available to the thoracic surgeon, and some of these interventions can be performed by video-assisted thoracic surgery (VATS) with the same oncological results as those by open thoracotomy. The principal aim of surgical treatment for NSCLC is to obtain a complete resection which has been precisely defined by a working group of the International Association for the Study of Lung Cancer (IASLC). Intraoperative staging of lung cancer is of utmost importance to decide on the extent of resection according to the intraoperative tumour (T) and nodal (N) status. Systematic nodal dissection is generally advocated to evaluate the hilar and mediastinal lymph nodes which are subdivided into seven zones according to the most recent 7th tumour-node-metastasis (TNM) classification. Lymph-node involvement not only determines prognosis but also the administration of adjuvant therapy.

In 2011, a new multidisciplinary adenocarcinoma classification was published introducing the concepts of adenocarcinoma in situ and minimally invasive adenocarcinoma. This classification has profound surgical implications. The role of limited or sublobar resection, comprising anatomical segmentectomy and wide wedge resection, is reconsidered for early-stage lesions which are more frequently encountered with the recently introduced large screening programmes. Numerous retrospective non-randomised studies suggest that sublobar resection may be an acceptable surgical treatment for early lung cancers, also when performed by VATS.

More tailored, personalised therapy has recently been introduced. Quality-of-life parameters and surgical quality indicators become increasingly important to determine the short-term and long-term impact of a surgical procedure. International databases currently collect extensive surgical data, allowing more precise calculation of mortality and morbidity according to predefined risk factors. Centralisation of care has been shown to improve results. Evidence-based guidelines should be further developed to provide optimal staging and therapeutic algorithms.

Incidence, treatment options, and outcomes of lung cancer in patients with chronic obstructive pulmonary disease

PURPOSE OF REVIEW

An associative and mechanistic link between chronic obstructive pulmonary disease (COPD) and lung cancer has long been suspected. This review describes the current understanding of the incidence, mechanism of association, treatment options, and outcome for lung cancer with COPD.

RECENT FINDINGS

COPD patients have an increased risk of lung cancer that is independent of smoking. New evidence suggests that there is an inverse relationship between the severity of airflow obstruction and the risk of lung cancer. Chronic inflammation associated with COPD may play a role in the development of lung cancer, and targeting airway inflammation with inhaled corticosteroids has been suggested as a possible preventive strategy. Although surgical lobectomy remains the standard of care for early stage lung cancer, less invasive approaches such as sublobar resection, stereotactic body radiation therapy, and radiofrequency ablation are promising techniques for patients with limited pulmonary reserve.

SUMMARY

Progress is being made in identifying mechanistic links between COPD and lung cancer, which may lead to novel therapeutic strategies for both disorders. Patients with COPD are likely to benefit from less-invasive surgical and nonsurgical treatment strategies for lung cancer, but further study is needed to determine the safety and efficacy of these procedures.

Fatigue and functional impairment in early-stage non-small cell lung cancer survivors

CONTEXT

Fatigue is the most common sequela among non-small cell lung cancer (NSCLC) survivors one to six years post-treatment and is associated with functional limitations.

OBJECTIVES

This study examined the prevalence, severity, and correlates of fatigue among early stage NSCLC survivors.

METHODS

Three-hundred fifty individuals diagnosed and surgically treated for Stage IA or IB NSCLC completed a survey that included the Brief Fatigue Inventory (BFI) to assess the prevalence and severity of fatigue. The Karnofsky Self-Reported Performance Rating scale (SR-KPS) was used as a measure of functional status and was compared with the severity of fatigue through Chi-squared analyses. Demographic, psychological, and medical correlates of fatigue were examined using logistic regression.

RESULTS

The prevalence of fatigue was 57%. Forty-one percent (n=142) of participants had mild fatigue and 16.8% (n=59) had moderate or severe fatigue (BFI≥4). Among the individuals reporting moderate or severe fatigue, 23.7% (n=14) had significant functional impairment (SR-KPS≤70%) compared with 2.8% (n=8) with mild or no fatigue (χ(2)=58.1, P<0.001). In the multivariate analysis, NSCLC survivors with pulmonary disease (odds ratio [OR]=2.28), depressive symptoms (OR=6.99), and anxiety symptoms (OR=2.31) were more likely to report experiencing clinically significant fatigue, whereas those who met physical activity guidelines (OR=0.29) reported less fatigue.

CONCLUSION

Fatigue is highly prevalent among NSCLC survivors and associated with more functional impairment. A comprehensive approach to the treatment of fatigue includes the screening and management of anxious and depressive symptoms, and pulmonary disorders such as chronic obstructive pulmonary disease.

Radiographic evaluation of the potential lung volume reduction surgery candidate

Delineating the extent and distribution of emphysema is an essential component of the evaluation of candidates for lung volume reduction surgery (LVRS). Imaging also may identify contraindications to LVRS, including bronchiectasis and pleural scarring. The chest X-ray is of limited utility in LVRS evaluation. Chest computed tomography (CT) scanning is an essential component of the evaluation, demonstrating the presence of emphysema and its amount and distribution. Clinical experience has shown that a substantial minority of chest CT scans will also demonstrate pulmonary nodules, some of which represent lung cancers. Published series, including the National Emphysema Treatment Trial, consistently demonstrate that patients with upper lobe predominant or heterogeneous emphysema are most likely to benefit from LVRS. Heterogeneity and distribution can also be assessed by radionuclide ventilation perfusion scanning, but this modality adds little additional information to CT scanning.

Lung transplantation and lung volume reduction surgery versus transplantation in chronic obstructive pulmonary disease

Lung transplantation and lung volume reduction surgery are surgical options for patients with advanced chronic obstructive pulmonary disease that is refractory to medical treatment. In this review, we discuss the differential indications for each procedure, as well as compare their risks and benefits. We also present an algorithm for selecting the most appropriate procedure for individual patients. Finally, we discuss the feasibility and role of lung transplantation after lung volume reduction surgery in the management of selected patients with chronic obstructive pulmonary disease.

Is video-assisted thoracic surgery lobectomy better? Quality of life considerations

Video-assisted thoracic surgery lobectomy has controversial advantages over traditional open surgical approaches. Subjective concerns such as pain, dyspnea, physical functioning, and overall satisfaction generally favor VATS but vary depending on survey timing. Independence, a major quality of life component, favors video-assisted thoracic surgery because fewer objective hospital and discharge resources are needed because pulmonary function, activity level, muscle strength, and walking capacity are better. Video-assisted thoracic surgery often hastens return to work and facilitates adjuvant chemotherapy or subsequent urgent surgical procedures. Video-assisted thoracic surgery-related quality of life benefits are amplified by advanced age (or other frailties) and reduced by advanced cancer stage or comorbid illness.

Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: ACCP evidenced-based clinical practice guidelines (2nd edition)

BACKGROUND

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

METHODS

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

RESULTS

The preoperative physiologic assessment should begin with a cardiovascular evaluation and spirometry to measure the FEV(1). If diffuse parenchymal lung disease is evident on radiographic studies or if there is dyspnea on exertion that is clinically out of proportion to the FEV(1), the diffusing capacity of the lung for carbon monoxide (Dlco) should also be measured. In patients with either an FEV(1) or Dlco < 80% predicted, the likely postoperative pulmonary reserve should be estimated by either the perfusion scan method for pneumonectomy or the anatomic method, based on counting the number of segments to be removed, for lobectomy. An estimated postoperative FEV(1) or Dlco < 40% predicted indicates an increased risk for perioperative complications, including death, from a standard lung cancer resection (lobectomy or greater removal of lung tissue). Cardiopulmonary exercise testing (CPET) to measure maximal oxygen consumption (Vo(2)max) should be performed to further define the perioperative risk of surgery; a Vo(2)max of < 15 mL/kg/min indicates an increased risk of perioperative complications. Alternative types of exercise testing, such as stair climbing, the shuttle walk, and the 6-min walk, should be considered if CPET is not available. Although often not performed in a standardized manner, patients who cannot climb one flight of stairs are expected to have a Vo(2)max of < 10 mL/kg/min. Data on the shuttle walk and 6-min walk are limited, but patients who cannot complete 25 shuttles on two occasions will likely have a Vo(2)max of < 10 mL/kg/min. Desaturation during an exercise test has not clearly been associated with an increased risk for perioperative complications. Lung volume reduction surgery (LVRS) improves survival in selected patients with severe emphysema. Accumulating experience suggests that patients with extremely poor lung function who are deemed inoperable by conventional criteria might tolerate combined LVRS and curative-intent resection of lung cancer with an acceptable mortality rate and good postoperative outcomes. Combining LVRS and lung cancer resection should be considered in patients with a cancer in an area of upper lobe emphysema, an FEV(1) of > 20% predicted, and a Dlco of > 20% predicted.

CONCLUSIONS

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

Is the initial feasibility of lobectomy for stage I non-small cell lung cancer in severe heterogeneous emphysema justified by long-term survival?

BACKGROUND

The feasibility of anatomical lobectomy in patients with bronchial carcinoma in an area of severe heterogeneous emphysema whose respiratory reserve is outside operability guidelines has previously been confirmed. A review was undertaken to determine whether this approach is justified by long-term survival.

METHODS

A single surgeon's 8 year experience of 118 consecutive patients (74 men) of median age 70 years (range 45-84) who underwent upper lobectomy for pathological stage I non-small cell lung cancer (NSCLC) was reviewed. The preoperative characteristics, perioperative course and survival of the 27 cases with severe heterogeneous emphysema of apical distribution and a predicted postoperative forced expiratory volume in 1 s (ppoFEV(1)) of <40% (lobarLVRS group) were compared with the remaining 91 cases with a ppoFEV(1) of >40% (control group).

RESULTS

Postoperative mortality was 1 of 27 in the lobarLVRS group and 2 of 91 in the control group (p = NS). Five-year survival in the lobarLVRS group was 35% compared with 65% in the control group without concomitant severe emphysema (p = 0.001), although rates of tumour recurrence were similar.

CONCLUSIONS

Long-term survival after lobarLVRS for stage I lung cancer is limited by physiological rather than oncological factors. However, outcomes are still better than those reported for any other modality of treatment in this group of high-risk patients. This finding justifies the decision to offer lobectomy in these selected cases.

Predictors of quality-of-life improvement following pulmonary resection due to lung cancer

CONTEXT AND OBJECTIVE

There is increasing involvement of health professionals in organizing protocols to determine the impact of lung surgery on functional state and activities of daily living, with the aim of improving quality of life (QoL). The objective of this study was to investigate predictors of QoL improvement among patients undergoing parenchyma resection due to lung cancer.

DESIGN AND SETTING

Prospective study, at teaching hospital of Universidade Estadual de Campinas (Unicamp).

METHODS

36 patients with lung cancer diagnosis were assessed before surgery and on the 30th, 90th and 180th days after surgery. The Short-Form Health Survey (SF-36) was used as the dependent variable. The independent variables were the Hospital Anxiety and Depression (HAD) scale, a six-minute walking test (6-MWT), a visual analogue scale for pain, forced vital capacity (FVC), type of surgery and use of radiotherapy and chemotherapy. Generalized estimation equations (GEE) were utilized.

RESULTS

The median age for these 20 men and 16 women was 55.5 +/- 13.4 years. Both FVC and 6-MWT were predictors of improvement in the physical dimensions of QoL (p = 0.011 and 0.0003, respectively), as was smaller extent of surgical resection (p = 0.04). The social component of QoL had improved by the third postoperative month (p = 0.0005).

CONCLUSION

The predictors that affected QoL positively were better FVC and 6-MWT results and less extensive lung resection. Three months after the surgery, an improvement in social life was already seen.

Lung volume reduction surgery allows esophageal tumor resection in selected esophageal carcinoma with severe emphysema

BACKGROUND

Esophageal carcinoma patients with coexisting severe emphysema are high risk surgical candidates. We hypothesize that simultaneous unilateral lung volume reduction surgery (LVRS) allows us to offer esophageal tumor resection to patients previously considered inoperable.

METHODS

Twenty-one patients with esophageal carcinoma were recruited. All patients had severe emphysema with impaired respiratory function and health-related quality of life (HRQL). Esophageal tumor resection with gastroesophagostomy in the thorax and then unilateral LVRS were performed at the same anesthesia. Dyspnea index, exercise capacity, pulmonary function, and HRQL were assessed at baseline and every three months up to one year postoperatively.

RESULTS

There was no perioperative death or significant morbidity. Clinical improvements were observed at 3, 6, and 12 months, in terms of dyspnea index, forced expiratory volume in 1 second, residual volume, partial pressure of oxygen, arterial, partial pressure of carbon dioxide, arterial, 6-minute walking distance, dysphagia, and odynophagia (p < 0.01 or p < 0.05). The Karnofsky Performance Status score improved from baseline 36 +/- 3 to 53 +/- 3 at 3 months, 67 +/- 5 at 6 months, and 63 +/- 8 at 12 months (p < 0.01). Significant improvement was seen in all the Short-Form 36-item Health Survey HRQL domains at 3 months (p < 0.01 or p < 0.05). These improvements remained significant for up to 6 months, and for up to 12 months for physical functioning and general health. The Psychosocial Adjustment to Illness Scale score and all the scales were improved after surgery (p < 0.01).

CONCLUSIONS

Our study shows that in selected patients with esophageal carcinoma who suffer from severe emphysema, simultaneous unilateral LVRS renders esophageal tumor resection safe and effective. Also, these patients may experience early improvement in pulmonary function and HRQL.

Effect of lung cancer surgery on quality of life

BACKGROUND

Health related quality of life (HRQOL) after surgery is important, although very limited data are available on the QOL after lung cancer surgery.

METHODS

The effect of surgery on HRQOL was assessed in a prospective study of 110 patients undergoing potentially curative lung cancer surgery at Papworth Hospital, 30% of whom had borderline lung function as judged by forced expiratory volume in 1 second. All patients completed the EORTC QLQ-C30 and LC13 lung cancer module before surgery and again at 1, 3 and 6 months postoperatively.

RESULTS

On average, patients had high levels of functioning and low levels of symptoms. Global QOL had deteriorated significantly 1 month after surgery (p = 0.001) but had returned to preoperative levels by 3 months (p = 0.93). Symptoms had worsened significantly at 1 month after surgery but had returned to baseline levels by 6 months. Low values on the preoperative HRQOL scales were not significantly associated with poor surgical outcome. However, patients with low preoperative HRQOL functioning scales and high preoperative symptom scores were more likely to have poor postoperative (6 months) QOL. The only lung function measurement to show a marginally statistically significant association with quality of life at 6 months after surgery was percentage predicted carbon monoxide transfer factor (Tlco).

CONCLUSION

Although surgery had short term negative effects on quality of life, by 6 months HRQOL had returned to preoperative values. Patients with low HRQOL functioning scales, high preoperative symptom scores, and preoperative percentage predicted Tlco may be associated with worse postoperative HRQOL.

Management strategies for the solitary pulmonary nodule

PURPOSE OF REVIEW

The challenge of diagnosis and management of solitary pulmonary nodules is among the most common yet most important areas of pulmonary medicine. Ideally, the goal of diagnosis and management is to promptly bring to surgery all patients with operable malignant nodules while avoiding unnecessary thoracotomy in patients with benign disease.

RECENT FINDINGS

Effective management of the solitary pulmonary nodule depends upon an understanding of decision analysis principles so that diverse technologies can be integrated into a systematic approach.

SUMMARY

In almost all patients computed tomography (CT) is the best first step. Three key questions can then help guide the workup of the SPN. These are what is the pretest probability of cancer, what is the risk of surgical complications, and does the appearance of the nodule on CT scan suggest a benign or malignant etiology. In patients with average surgical risk, positron emission tomography (PET) scan is warranted when there is discordance between pretest probability of cancer and the appearance of the nodule on CT scan. Thus, when either the patient has a low risk of cancer and the CT suggests a malignant origin, or when there is high risk of cancer and the CT appears benign, PET scan will be cost effective. In most other situations, PET scanning is only marginally more effective than CT and fine needle aspiration strategies but costs much more.