Preoperative evaluation for lung resection
- Steven E Weinberger, MD
Steven E Weinberger, MD
- Adjunct Professor of Medicine
- University of Pennsylvania School of Medicine
- Executive Vice President and CEO Emeritus
- American College of Physicians
Lung cancer is currently the leading cause of cancer death in the United States . Surgical resection remains the only potentially curative therapy for patients with localized non–small cell lung cancer (NSCLC). Due to the shared risk factor from tobacco smoking for both lung cancer and chronic obstructive pulmonary disease (COPD), however, the clinician is often faced with contemplating surgical resection in patients with impaired pulmonary function and an increased risk for lung resection.
Ever since Graham and Singer's report in 1933 of the first successful pneumonectomy for the treatment of lung cancer , the search has been ongoing for the ideal preoperative test to identify those patients at greatest risk for postoperative complications. Based on the assumption that a level of pulmonary impairment exists beyond which the risk of surgical intervention is prohibitive, efforts have been wide-ranging to identify the best predictive tests and to define the threshold values necessary for minimizing surgical risk [3,4].
Suggested tests have included measurement of preoperative pulmonary function, calculation of predicted postoperative (postresectional) pulmonary function, measures of gas exchange, and exercise testing . The utility of each of these tests and a recommended approach will be presented here.
General concepts regarding preoperative pulmonary assessment and factors that estimate the risk of postoperative pulmonary complications are discussed separately. (See "Evaluation of preoperative pulmonary risk" and "Evaluation of preoperative pulmonary risk", section on 'Assessment of postoperative pulmonary risk'.)
Preoperative pulmonary function — We agree with both the American College of Chest Physicians (ACCP) and the British Thoracic Society (BTS) that the forced expiratory volume in one second (FEV1) and the diffusing capacity for carbon monoxide (DLCO) be measured in all patients with lung cancer in whom resectional surgery is being considered [6,7].
Subscribers log in hereLiterature review current through: Nov 2017. | This topic last updated: Nov 02, 2017.References
- Siegel RL, Miller KD, Jemal A. Cancer statistics, 2015. CA Cancer J Clin 2015; 65:5.
- Graham, EA, Singer, JJ. Successful removal of an entire lung for carcinoma of the bronchus. JAMA 1933; 101:137.
- Bolliger CT, Koegelenberg CF, Kendal R. Preoperative assessment for lung cancer surgery. Curr Opin Pulm Med 2005; 11:301.
- Mazzone P. Preoperative evaluation of the lung resection candidate. Cleve Clin J Med 2012; 79 Electronic Suppl 1:eS17.
- Datta D, Lahiri B. Preoperative evaluation of patients undergoing lung resection surgery. Chest 2003; 123:2096.
- British Thoracic Society, Society of Cardiothoracic Surgeons of Great Britain and Ireland Working Party. BTS guidelines: guidelines on the selection of patients with lung cancer for surgery. Thorax 2001; 56:89.
- Brunelli A, Kim AW, Berger KI, Addrizzo-Harris DJ. Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013; 143:e166S.
- GAENSLER EA, CUGELL DW, LINDGREN I, et al. The role of pulmonary insufficiency in mortality and invalidism following surgery for pulmonary tuberculosis. J Thorac Surg 1955; 29:163.
- Zhang R, Lee SM, Wigfield C, et al. Lung function predicts pulmonary complications regardless of the surgical approach. Ann Thorac Surg 2015; 99:1761.
- Berry MF, Villamizar-Ortiz NR, Tong BC, et al. Pulmonary function tests do not predict pulmonary complications after thoracoscopic lobectomy. Ann Thorac Surg 2010; 89:1044.
- Boysen PG, Block AJ, Olsen GN, et al. Prospective evaluation for pneumonectomy using the 99mtechnetium quantitative perfusion lung scan. Chest 1977; 72:422.
- Lockwood P. Lung function test results and the risk of post-thoracotomy complications. Respiration 1973; 30:529.
- MITTMAN C. Assessment of operative risk in thoracic surgery. Am Rev Respir Dis 1961; 84:197.
- Boushy SF, Billig DM, North LB, Helgason AH. Clinical course related to preoperative and postoperative pulmonary function in patients with bronchogenic carcinoma. Chest 1971; 59:383.
- Colman NC, Schraufnagel DE, Rivington RN, Pardy RL. Exercise testing in evaluation of patients for lung resection. Am Rev Respir Dis 1982; 125:604.
- Keagy BA, Lores ME, Starek PJ, et al. Elective pulmonary lobectomy: factors associated with morbidity and operative mortality. Ann Thorac Surg 1985; 40:349.
- Boysen PG, Block AJ, Moulder PV. Relationship between preoperative pulmonary function tests and complications after thoracotomy. Surg Gynecol Obstet 1981; 152:813.
- Miller JI, Grossman GD, Hatcher CR. Pulmonary function test criteria for operability and pulmonary resection. Surg Gynecol Obstet 1981; 153:893.
- Olsen GN, Block AJ, Swenson EW, et al. Pulmonary function evaluation of the lung resection candidate: a prospective study. Am Rev Respir Dis 1975; 111:379.
- Ferguson MK, Little L, Rizzo L, et al. Diffusing capacity predicts morbidity and mortality after pulmonary resection. J Thorac Cardiovasc Surg 1988; 96:894.
- Ferguson MK, Vigneswaran WT. Diffusing capacity predicts morbidity after lung resection in patients without obstructive lung disease. Ann Thorac Surg 2008; 85:1158.
- Liptay MJ, Basu S, Hoaglin MC, et al. Diffusion lung capacity for carbon monoxide (DLCO) is an independent prognostic factor for long-term survival after curative lung resection for cancer. J Surg Oncol 2009; 100:703.
- Linden PA, Bueno R, Colson YL, et al. Lung resection in patients with preoperative FEV1 < 35% predicted. Chest 2005; 127:1984.
- Win T, Jackson A, Sharples L, et al. Relationship between pulmonary function and lung cancer surgical outcome. Eur Respir J 2005; 25:594.
- Colice GL, Shafazand S, Griffin JP, et al. Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: ACCP evidenced-based clinical practice guidelines (2nd edition). Chest 2007; 132:161S.
- Miller JI Jr. Physiologic evaluation of pulmonary function in the candidate for lung resection. J Thorac Cardiovasc Surg 1993; 105:347.
- Ali MK, Mountain CF, Ewer MS, et al. Predicting loss of pulmonary function after pulmonary resection for bronchogenic carcinoma. Chest 1980; 77:337.
- Markos J, Mullan BP, Hillman DR, et al. Preoperative assessment as a predictor of mortality and morbidity after lung resection. Am Rev Respir Dis 1989; 139:902.
- Beckles MA, Spiro SG, Colice GL, et al. The physiologic evaluation of patients with lung cancer being considered for resectional surgery. Chest 2003; 123:105S.
- Kearney DJ, Lee TH, Reilly JJ, et al. Assessment of operative risk in patients undergoing lung resection. Importance of predicted pulmonary function. Chest 1994; 105:753.
- Pierce RJ, Copland JM, Sharpe K, Barter CE. Preoperative risk evaluation for lung cancer resection: predicted postoperative product as a predictor of surgical mortality. Am J Respir Crit Care Med 1994; 150:947.
- Brunelli A, Charloux A, Bolliger CT, et al. ERS/ESTS clinical guidelines on fitness for radical therapy in lung cancer patients (surgery and chemo-radiotherapy). Eur Respir J 2009; 34:17.
- Tisi GM. Preoperative evaluation of pulmonary function. Validity, indications, and benefits. Am Rev Respir Dis 1979; 119:293.
- Dunn WF, Scanlon PD. Preoperative pulmonary function testing for patients with lung cancer. Mayo Clin Proc 1993; 68:371.
- Marshall MC, Olsen GN. The physiologic evaluation of the lung resection candidate. Clin Chest Med 1993; 14:305.
- Wyser C, Stulz P, Solèr M, et al. Prospective evaluation of an algorithm for the functional assessment of lung resection candidates. Am J Respir Crit Care Med 1999; 159:1450.
- Van Nostrand D, Kjelsberg MO, Humphrey EW. Preresectional evaluation of risk from pneumonectomy. Surg Gynecol Obstet 1968; 127:306.
- Olsen GN, Bolton JW, Weiman DS, Hornung CA. Stair climbing as an exercise test to predict the postoperative complications of lung resection. Two years' experience. Chest 1991; 99:587.
- Brunelli A, Al Refai M, Monteverde M, et al. Stair climbing test predicts cardiopulmonary complications after lung resection. Chest 2002; 121:1106.
- Brunelli A, Refai M, Xiumé F, et al. Performance at symptom-limited stair-climbing test is associated with increased cardiopulmonary complications, mortality, and costs after major lung resection. Ann Thorac Surg 2008; 86:240.
- Brunelli A, Xiumé F, Refai M, et al. Peak oxygen consumption measured during the stair-climbing test in lung resection candidates. Respiration 2010; 80:207.
- Bernasconi M, Koegelenberg CF, von Groote-Bidlingmaier F, et al. Speed of ascent during stair climbing identifies operable lung resection candidates. Respiration 2012; 84:117.
- Ribas J, Díaz O, Barberà JA, et al. Invasive exercise testing in the evaluation of patients at high-risk for lung resection. Eur Respir J 1998; 12:1429.
- Eugene H, Brown SE, Light RW, et al. Maximum oxygen consumption: A physiologic guide to pulmonary resection. Surg Forum 1982; 33:260.
- Smith TP, Kinasewitz GT, Tucker WY, et al. Exercise capacity as a predictor of post-thoracotomy morbidity. Am Rev Respir Dis 1984; 129:730.
- Walsh GL, Morice RC, Putnam JB Jr, et al. Resection of lung cancer is justified in high-risk patients selected by exercise oxygen consumption. Ann Thorac Surg 1994; 58:704.
- Brunelli A, Belardinelli R, Refai M, et al. Peak oxygen consumption during cardiopulmonary exercise test improves risk stratification in candidates to major lung resection. Chest 2009; 135:1260.
- Schuurmans MM, Diacon AH, Bolliger CT. Functional evaluation before lung resection. Clin Chest Med 2002; 23:159.
- Bolliger CT, Jordan P, Solèr M, et al. Exercise capacity as a predictor of postoperative complications in lung resection candidates. Am J Respir Crit Care Med 1995; 151:1472.
- Villani F, De Maria P, Busia A. Exercise testing as a predictor of surgical risk after pneumonectomy for bronchogenic carcinoma. Respir Med 2003; 97:1296.
- Win T, Jackson A, Sharples L, et al. Cardiopulmonary exercise tests and lung cancer surgical outcome. Chest 2005; 127:1159.
- Edwards JG, Duthie DJ, Waller DA. Lobar volume reduction surgery: a method of increasing the lung cancer resection rate in patients with emphysema. Thorax 2001; 56:791.
- DeRose JJ Jr, Argenziano M, El-Amir N, et al. Lung reduction operation and resection of pulmonary nodules in patients with severe emphysema. Ann Thorac Surg 1998; 65:314.
- Brenner M, Yusen R, McKenna R Jr, et al. Lung volume reduction surgery for emphysema. Chest 1996; 110:205.
- McKenna RJ Jr, Fischel RJ, Brenner M, Gelb AF. Combined operations for lung volume reduction surgery and lung cancer. Chest 1996; 110:885.
- DeMeester SR, Patterson GA, Sundaresan RS, Cooper JD. Lobectomy combined with volume reduction for patients with lung cancer and advanced emphysema. J Thorac Cardiovasc Surg 1998; 115:681.
- PULMONARY FUNCTION
- Preoperative pulmonary function
- - Spirometry
- - Diffusing capacity
- - Predicted postoperative pulmonary function
- MEASUREMENT OF GAS EXCHANGE
- Arterial PO2
- Arterial PCO2
- EXERCISE TESTING
- Stair climbing
- Incremental shuttle walk test
- Integrated cardiopulmonary exercise testing
- CONCOMITANT VOLUME REDUCTION SURGERY
- CARDIOVASCULAR RISK
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS