Chest
Volume 132, Issue 3, Supplement, September 2007, Pages 161S-177S
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DIAGNOSIS AND MANAGEMENT OF LUNG CANCER: ACCP GUIDELINES (2ND EDITION)
Physiologic Evaluation of the Patient With Lung Cancer Being Considered for Resectional Surgery: ACCP Evidenced-Based Clinical Practice Guidelines (2nd Edition)

https://doi.org/10.1378/chest.07-1359Get rights and content

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 FEV1. 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 FEV1, the diffusing capacity of the lung for carbon monoxide (Dlco) should also be measured. In patients with either an FEV1 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 FEV1 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 (V˙o2max) should be performed to further define the perioperative risk of surgery; a V˙o2max 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 V˙o2max 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 V˙o2max 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 FEV1 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.

Section snippets

Current Guidelines

Although numerous reviews2, 3, 4, 5, 6, 7 have been published on the preoperative risk assessment of patients with lung cancer being considered for curative-intent surgical resection, most available guidelines8, 9, 10, 11, 12, 13, 14, 15 on the management of non-small cell lung cancer (NSCLC) do not address the preoperative evaluation process. The British Thoracic Society16 and the American College of Chest Physicians1 have provided guidelines with specific recommendations on the steps needed

Multidisciplinary Team

Patients with lung cancer who are seen by a physician with expertise in the management of this disease are more likely to have histologic confirmation of lung cancer and referral for potentially curative treatment.17, 18, 19 Evaluation by a multidisciplinary team, which includes a thoracic surgeon specializing in lung cancer, a medical oncologist, a radiation oncologist, and a pulmonologist, is essential in the risk assessment of patients being evaluated for curative-intent surgery.

Recommendations

  • 4

    In patients being considered for lung cancer resection, spirometry is recommended. If the FEV1is > 80% predicted or > 2 L and there is no evidence of either undue dyspnea on exertion or interstitial lung disease, the patient is suitable for resection including pneumonectomy without further physiologic evaluation. If the FEV1is > 1.5 L and there is no evidence of either undue dyspnea on exertion or interstitial lung disease, the patient is suitable for a lobectomy without further physiologic

Predicted Postoperative Lung Function

In patients with a preoperative FEV1 or Dlco of < 80% predicted, predicted postoperative (PPO) lung function may be calculated by estimating the amount of functioning lung tissue that would be lost with the surgical resection. The methods used for this purpose, including ventilation scans,56, 60, 61, 62, 63 perfusion scans,56, 60, 61, 62, 63, 64, 65, 66 quantitative CT scans,67, 68 and anatomic estimation, based on counting the number of segments to be removed,65, 69 seem to provide similar

Risk Related to %PPO Lung Function

The perioperative risk increases when the FEV1 is < 40%PPO.60, 65, 66, 79, 80 Markos et al60 and Holden et al79 reported 50% mortality rates (3 of 6 patients and 5 of 10 patients, respectively) when the FEV1 was < 40%PPO. Wahi et al80 found a perioperative mortality rate of 16% in patients with an FEV1 of < 41%PPO vs 3%PPO in those patients with better predicted lung function. Pierce and colleagues65 found that 5 of 13 patients with an FEV1 of < 40%PPO died soon after undergoing the operation,

Recommendations

  • 7

    In patients with lung cancer who are being considered for surgery, either an FEV1of < 40%PPO or a Dlco of < 40%PPO indicates an increased risk for perioperative death and cardiopulmonary complications with standard lung resection. It is recommended that these patients undergo exercise testing preoperatively. Grade of recommendation, 1C

  • 8

    In patients with lung cancer being considered for surgery, either a product of %PPO FEV1and %PPO Dlco of < 1,650%PPO or an FEV1of < 30%PPO indicates an increased

Cardiopulmonary Exercise Testing

Formal cardiopulmonary exercise testing (CPET) is a sophisticated physiologic testing technique, which includes recording the exercise ECG, the heart rate response to exercise, minute ventilation, and oxygen uptake per minute. Maximal oxygen consumption (V˙o2max) is measured from this type of exercise test. Previous guidelines1, 16 have recommended the use of CPET as the next step in the preoperative risk assessment process in those patients with either FEV1 or Dlco below 40%PPO.

The risk for

Pulmonary Artery Pressures and Diffusing Capacity

Measurements of pulmonary arterial pressure during exercise have not proven to be helpful in predicting the patients in whom perioperative complications will develop.81, 86, 95 Measuring the Dlco during exercise might be a better predictor of perioperative risk than V˙o2max, but is a technically demanding technique and not readily available.96

Stair Climbing and Walking Tests

If CPET were unavailable, then another type of exercise test should be considered. Stair climbing has historically been used as a surrogate CPET. If a patient were able to climb three flights of stairs, they were considered to be a suitable candidate for lobectomy. Pneumonectomy candidates were expected to be able to climb five flights of stairs. This approach was found to correlate with lung function; climbing three flights indicates an FEV1 of > 1.7 L and climbing five flights of stairs

Desaturation

The shuttle walk and 6-min walk tests may be more effective in identifying patients who desaturate during exercise than is the CPET.106 The value of this observation, though, is unclear. Greater than 4% desaturation during exercise had been reported16, 60, 65, 107 to indicate an increased risk for perioperative complications. However, a study108 from the United Kingdom has reported similar perioperative complication rates for patients who desaturated > 4% during a shuttle walk and those who did

Composite Scores

Investigators have proposed using composite scores to predict perioperative complications. Epstein et al109 developed the multifactorial cardiopulmonary risk index, an empirically derived score based on points awarded for cardiac and pulmonary risk. There was a strong association between this score and postoperative complications in a group of 42 patients. Birim et al110 found that patients with more comorbid conditions, identified by the Charlson comorbidity index, were also more likely to

Recommendations

  • 9

    In patients with lung cancer who are being considered for surgery, a V˙o2 max of < 10 mL/kg/min indicates an increased risk for perioperative death and cardiopulmonary complications with standard lung resection. These patients should be counseled about nonstandard surgery and nonoperative treatment options for their lung cancer. Grade of recommendation, 1C

  • 10

    Patients with lung cancer who are being considered for surgery who have a V˙o2 max of < 15 mL/kg/min and both an FEV1and a Dlco of < 40%PPO

Arterial Blood Gas Tensions

Historically, hypercapnea (Paco2, > 45 mm Hg) has been quoted as an exclusion criterion for lung resection.16, 114, 115 This recommendation was made on the basis of the association of hypercapnea with poor ventilatory function.116 The few studies that have addressed this issue, however, have suggest that preoperative hypercapnea is not an independent risk factor for increased perioperative complications. Stein et al117 showed that hypercapnea was associated with serious postoperative

Recommendations

  • 12

    In patients with lung cancer who are being considered for surgery, a Paco2 of > 45 mm Hg is not an independent risk factor for increased perioperative complications. However, it is recommended that these patients undergo further physiologic testing. Grade of recommendation, 1C

  • 13

    In patients with lung cancer who are being considered for surgery, an Sao2 of < 90% indicates an increased risk for perioperative complications with standard lung resection. It is recommended that these patients undergo

Risk of Long-term Pulmonary Disability

Following lung resection, lung function should be expected to decrease. Serial studies have shown that FEV1 decreases within the first several months following lung cancer resection, but tends to recover to a small extent by 6 months after surgery.77, 120, 121 Although the preoperative physiologic evaluation is usually fairly accurate in predicting the PPO FEV1, some investigators118, 122 have found that the PPO FEV1 will actually underestimate the eventual postoperative FEV1. Exercise capacity

Lung Volume Reduction Surgery

Lung volume reduction surgery (LVRS) for patients with severe emphysema has been shown in a large prospective, randomized, controlled trial125 to provide a survival advantage in selected patients with predominantly upper lobe emphysema and low exercise capacity. Patients with an FEV1 of < 20% predicted and either homogeneous emphysema or a Dlco of < 20% predicted do poorly with LVRS.126 Anecdotal experience has shown that the lung resected during LVRS occasionally contained unsuspected lung

Recommendations

  • 14

    In patients with very poor lung function and a lung cancer in an area of upper lobe emphysema, it is recommended that combined LVRS and lung cancer resection be considered if both the FEV1and the Dlco are > 20% predicted. Grade of recommendation, 1C

  • 15

    It is recommended that all patients with lung cancer be counseled regarding smoking cessation. Grade of recommendation, 1C

Summary

Patients with lung cancer often have concomitant diffuse parenchymal and/or obstructive airway disease and atherosclerotic cardiovascular disease as a consequence of their smoking habit. These diseases may place these patients at increased risk for perioperative complications, including death, and long-term pulmonary disability after lung cancer resection. A careful preoperative physiologic assessment will be useful to identify those patients who are at increased risk with standard lung cancer

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    The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

    Research Unit (Dr. Bolliger), Tygerberg Academic Hospital and University of Stellenbosch, Cape Town, South Africa.

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