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Preoperative evaluation of the lung resection candidate

May 1, 2012|Cleveland Clinic Journal of Medicine
Peter Mazzone, MD, MPH, FCCP
Author and Disclosure Information

Peter Mazzone, MD, MPH, FCCP
Director of Education, Lung Cancer Program, and Pulmonary Rehabilitation Program; Respiratory Institute, Cleveland Clinic, Cleveland, OH

Correspondence: Peter Mazzone, MD, MPH, FCCP, Critical Care Medicine, Cleveland Clinic, 9500 Euclid Avenue, A90, Cleveland, OH 44195; mazzonp@ccf.org

Dr. Mazzone reported that he has been a member of advisory committees for Boehringer Ingelheim and Oncimmune. He has research supported by Metabolomx.

This article was developed from an audio transcript of Dr. Mazzone’s presentation at the “Advances in Lung Cancer Evaluation and Management” symposium held in Cleveland, Ohio, on April 30, 2011. The transcript was formatted and edited by Cleveland Clinic Journal of Medicine staff for clarity and conciseness and was then reviewed, revised, and approved by Dr. Mazzone.

ABSTRACTLung resection provides the greatest likelihood of cure for patients with localized lung cancer, but is associated with a risk of mortality, decreased postoperative lung function, and other complications. Lung function testing using spirometry, diffusing capacity of the lung for carbon monoxide, and peak oxygen consumption helps predict the risk of postoperative complications including mortality. Predicting postoperative lung function using the proportion of lung segments to be resected, radionuclide scanning, or other methods is important for assessing surgical risk. The American College of Chest Physicians, the European Respiratory Society/European Society of Thoracic Surgeons and the British Thoracic Society guidelines provide detailed algorithms for preoperative risk assessment, but their recommended approaches differ somewhat. Smoking cessation and pulmonary rehabilitation are perioperative measures that can improve patients’ the short- and long-term outcomes.

ALGORITHMS FOR TESTING

The ACCP, ERS/ESTS, and BTS guidelines all include algorithms for the preoperative evaluation of candidates for lung cancer resection.27–29 The guidelines differ from each other in many ways, including when to obtain a Dlco and cardiopulmonary exercise test, and in some of the cutoff values for various pulmonary function measures. ACCP guidelines begin with spirometry testing, supporting lobectomy in patients with spirometry results above the cutoff value of FEV1 greater than 1.5 L and pneumonectomy in those with a cutoff value of FEV1 greater than 2 L, and greater than 80% of predicted, unless the patient has dyspnea or evidence of interstitial lung disease. Measurement of the Dlco is recommended for those who do not meet the FEV1 cutoffs, or in those with unexplained dyspnea or diffuse parenchymal disease on chest radiograph or CT.27

A systematic review and set of treatment recommendations for high-risk patients with stage I lung cancer, developed by the Thoracic Oncology Network of the ACCP and the Workforce on Evidence-Based Surgery of the Society of Thoracic Surgeons, currently under review, will provide additional guidance regarding the use of lung function testing to evaluate risk of morbidity and mortality. These guidelines note that FEV1, Dlco, and peak VO2 all predict morbidity and mortality following major lung resection. Assessment of FEV1 and Dlco, including calculation of the estimated postoperative value, is strongly recommended before resection. The predictive value of peak VO2 is strongest in patients with impaired FEV1 or Dlco, and assessment of peak VO2 before major lung resection is recommended for these patients.

INTERVENTIONS TO DECREASE PERIOPERATIVE RISK

The impact of smoking cessation on perioperative outcome has been a matter of considerable debate. One large study found that the incidence of postoperative complications was actually greater when patients stopped smoking within 8 weeks before cardiac surgery.46 However, a recent meta-analysis including lung resection patients found no relationship between smoking cessation in the weeks before surgery and worse clinical outcomes.47 When a shorter duration of smoking cessation is examined, thoracotomy studies note that patients who continue to smoke within 1 month of pneumonectomy are at increased risk of major pulmonary events.48,49 An examination of perioperative mortality or major complications using data from the Society of Thoracic Surgeons found that smoking cessation within 1 month preceding surgery did not significantly affect perioperative morbidity or mortality, whereas longer abstention from tobacco use was associated with better surgical outcomes.50 The ACCP recommends that all patients with lung cancer be counseled regarding smoking cessation.27 ERS/ESTS guidelines recommend smoking cessation for at least 2 to 4 weeks before surgery, since this may change perioperative smoking behavior and decrease the risk of postoperative complications.28 Pulmonary rehabiliatation in the perioperative period has been shown to improve measures of activity tolerance, allowing resection of marginal candidates, and improving functional outcomes after resection.51 The ERS/ESTS guidelines state that early pre- and postoperative rehabilitation may produce functional benefits in resectable lung cancer patients.28

SUMMARY AND CONCLUSIONS

Lung function testing helps predict the risk of postoperative mortality, perioperative complications, and long-term dyspnea for patients with lung cancer undergoing surgical resection. Predicted postoperative FEV1 and Dlco should be evaluated in most resection candidates. Exercise testing adds to standard lung function testing in those with borderline values, discordance between standard measures, or discordance between subjective and objective lung function. Algorithms for preoperative assessment have been developed by the ACCP, the ERS/ESTS, and the BTS, which differ somewhat in the order of testing and specific testing cutoff values. Smoking cessation and pulmonary rehabilitation can help to reduce perioperative and long-term risks.

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