Risk Stratification in Lung Resection

Surgical intervention for lung cancer in patients aged 75 and above: potential associations with increased mortality rates-a single-center observational study

BACKGROUND

Lung cancer, which is diagnosed two to three times more frequently in patients over the age of 70, is a leading cause of cancer-specific mortality. Given the elevated risk of morbidity and mortality, surgical intervention may not always be the most appropriate primary treatment option. This study aims to evaluate specific risk factors associated with postoperative morbidity and mortality in elderly patients and to optimize patient selection therefore improving surgical outcomes.

PATIENTS AND METHODS

The study encompassed a cohort of 73 patients aged 75 and above who underwent surgical treatment for non-small cell lung cancer (NSCLC) at the Department of Thoracic Surgery of the P. Hertsen Moscow Oncological Research Institute between 2015 and 2021. All patients underwent preoperative evaluation, including PET/CT staging and functional assessment, carried out by a multidisciplinary team comprising thoracic surgeons, anesthesiologists, and other medical specialists.

RESULTS

The investigation revealed a postoperative mortality rate of 5.5% and a postoperative morbidity incidence of 16.4%, with occurrences of atrial fibrillation in 41.6%, persistent air leak in 33.3%, and pneumonia in 25% of complicated cases. At the one-year follow-up, 88% of patients remained free from relapse, whereas at three years, this rate stood at 66%. During the follow-up period, 16 patients (22%) passed away, with a median survival duration of 44 months. Survival rates at one year, three years, and five years were 71%, 66%, and 35%, respectively. Multivariate analysis disclosed several significant factors predicting a complex postoperative period, including stage IIIb (p = 0.023), pN1 (p = 0.049), pN2 (p = 0.030), and central location (p = 0.007). Additionally, overall survival was primarily influenced by a Charlson comorbidity index of 6 (p = 0.044), stage Ia2 (p = 0.033), and the necessity for thoracotomy (p = 0.045).

CONCLUSION

Each case of lung cancer in patients aged 75 and older necessitates an individualized approach. Given the higher mortality rate relative to younger patients, comprehensive risk assessment and preoperative management of underlying comorbidities are imperative, with the involvement of anesthesiologists, intensive care physicians, cardiologists, and other relevant specialists as needed.

Levels of circulating angiotensin-converting enzyme 2 are affected by acute exercise and correlate with markers of physical fitness in male athletes

While under physiological conditions angiotensin-converting enzyme 2 (ACE2) is an antagonist of vasoconstrictive agents in the renin-angiotensin-aldosterone system (RAAS), in the context of SARS coronavirus 2 (SARS-CoV-2) ACE2 serves as the gateway into cells. Furthermore, RAAS has previously been shown to be influenced by exercise training and is suggested to be involved in skeletal muscle mass maintenance. Given this connection, the investigation of circulating ACE2 plasma protein concentration before and following acute and chronic endurance and resistance exercise could increase the understanding of the implications of the exposure of athletes to SARS-CoV-2. Therefore, this study investigated levels of circulating ACE2 in lifelong high-level trained endurance and resistance athletes and control subjects in response to either acute endurance or resistance exercise. Results show no baseline differences in absolute ACE2 concentration between groups, but a strong negative correlation with levels of fitness and positive correlation with BMI in control subjects. Furthermore, acute endurance exercise significantly increased ACE2 levels across all groups, but only in the strength group in response to resistance exercise. This indicates that circulating ACE2 plasma levels are influenced by levels of fitness and health, and that acute endurance exercise has a stronger effect on plasma ACE2 levels than resistance exercise.

Preoperative frailty screening in elderly patients with non-small cell lung cancer surgery: an essential step for a good surgical outcome

INTRODUCTION

Non-small cell lung cancer (NSCLC) is a disease commonly diagnosed in the elderly, often in advanced stages. However, elderly patients with lung cancer can benefit from surgery, provided that postoperative risks are assessed appropriately before surgery. Frailty is a measure of age-related impaired functional status and a predictor of mortality and morbidity. However, its importance as a preoperative marker is not well defined.

AREAS COVERED

This systematic review discusses the importance of preoperative frailty screening in elderly patients with NSCLC. A literature search was performed on the MEDLINE database in June 2023, and relevant studies on frailty or preoperative assessment of NSCLC which were published between 2000 and 2023 were retained and discussed in this review.

EXPERT OPINION

Among the types of existing methods used to assess frailty those on the geriatric assessment seem to be the most appropriate; however, they are unable to fully capture the 'surgical' frailty; thus, other instruments should be developed and validated in NSCLC.

VE/VCO2 slope threshold optimization for preoperative evaluation in lung cancer surgery: identifying true high- and low-risk groups

Background

Cardiopulmonary exercise testing (CPET) enables measurement of the slope of the increase in minute ventilation in relation to carbon dioxide elimination during exercise (the VE/VCO2 slope). Several studies have shown that the VE/VCO2 slope is a strong marker for postoperative complications and mortality. However, current thresholds for adverse outcomes are generated from historical data in heart failure patients.

Methods

This was a retrospective analysis of 158 patients with lung cancer who underwent lobectomy or pneumonectomy during 2008-2020. The main outcome was major pulmonary complications (MPC) or death ≤30 days of cancer surgery. Patients were first categorized using two different single threshold approaches; the traditional threshold of 35 and the highest Youden value from the receiver operating curve (ROC) analysis. Secondly, patients were categorized into three risk groups using two thresholds. These two thresholds were determined in an ROC analysis, where the VE/VCO2 slope values generating either a 90% sensitivity (lower threshold) or a 90% specificity (upper threshold) for the main outcome were chosen. The frequency of complications was compared using Chi2. The overall model quality was evaluated by an area under the curve (AUC) analysis. Positive predictive values (PPVs) and negative predictive values (NPVs) are presented.

Results

The two thresholds, <30 (90% sensitivity) and >41 (90% specificity), created three risk groups: low risk (VE/VCO2 slope <30, n=44, 28%); intermediate risk (VE/VCO2 slope 30-41, n=95, 60%) and high risk (VE/VCO2 slope >41, n=19, 12%). The frequency of complications differed between groups: 5%, 16% and 47% (P<0.001). Using two thresholds compared to one threshold increased the overall model quality (reaching AUC 0.70, 95% confidence interval: 0.59-0.81), and identified a high sensitivity threshold (VE/VCO2 slope <30) which generated a NPV of 95% but importantly, also a high specificity threshold (VE/VCO2 slope >41) with a PPV of 47%.

Conclusions

Risk stratification based on three risk groups from the preoperative VE/VCO2 slope increased the model quality, was more discriminative and generated better PPV and NPV compared to traditional risk stratification into two risk groups.

Peak oxygen uptake in combination with ventilatory efficiency improve risk stratification in major abdominal surgery

This pilot study aimed to evaluate if peak VO2 and ventilatory efficiency in combination would improve preoperative risk stratification beyond only relying on peak VO2 . This was a single-center retrospective cohort study including all patients who underwent cardiopulmonary exercise testing (CPET) as part of preoperative risk evaluation before major upper abdominal surgery during years 2008-2021. The primary outcome was any major cardiopulmonary complication during hospitalization. Forty-nine patients had a preoperative CPET before decision to pursue to surgery (cancer in esophagus [n = 18], stomach [6], pancreas [16], or liver [9]). Twenty-five were selected for operation. Patients who suffered any major cardiopulmonary complication had lower ventilatory efficiency (i.e., higher VE/VCO2 slope, 37.3 vs. 29.7, p = 0.031) compared to those without complications. In patients with a low aerobic capacity (i.e., peak VO2  < 20 mL/kg/min) and a VE/VCO2 slope ≥ 39, 80% developed a major cardiopulmonary complication. In this pilot study of patients with preoperative CPET before major upper abdominal surgery, patients who experienced a major cardiopulmonary complication had significantly lower ventilatory efficiency compared to those who did not. A low aerobic capacity in combination with low ventilatory efficiency was associated with a very high risk (80%) of having a major cardiopulmonary complication.

Performance Comparison of Pulmonary Risk Scoring Systems in Lung Resection

OBJECTIVE

To validate and compare the performance of different pulmonary risk scoring systems to predict postoperative pulmonary complications (PPCs) in lung resection surgery.

DESIGN

Retrospective cohort study SETTING: A historic single-center cohort of lung resection surgeries PARTICIPANTS: Adult patients undergoing lung resection surgery under 1-lung ventilation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The accuracy of the following pulmonary risk scoring systems were used to predict pulmonary complications: the ARISCAT (Assess respiratory RIsk in Surgical patients in CATalonia), the LAS VEGAS (Local Assessment of VEntilatory management during General Anesthesia for Surgery), the SPORC (Score for Prediction of Postoperative Respiratory Complications), and a recent thoracic-specific risk score, named CARDOT. Discrimination and calibration were assessed using the concordance (c) index and the intercept of LOESS (locally estimated scatterplot)-smoothed curves, respectively. Additional models were constructed that incorporated predicted postoperative forced expiratory volume (ppoFEV1) into each scoring system. Of the 2,104 patients undergoing lung surgery, 123 developed postoperative pulmonary complications (PPCs; 5.9%). All scoring systems had poor discriminatory power to predict PPCs (ARISCAT c-index 0.60, 95% confidence interval [CI] 0.55-0.65; LAS VEGAS c-index 0.68, 95% CI 0.63-0.73; SPORC c-index 0.63, 95% CI 0.59-0.68; CARDOT c-index 0.64, 95% CI 0.58-0.70), but the inclusion of ppoFEV1 slightly improved the performance of LAS VEGAS (c-index 0.70, 95% CI 0.66-0.75) and CARDOT (c-index 0.68, 95% CI 0.62-0.73). Analysis of calibration showed a slight overestimation when using ARISCAT (intercept -0.28) and LAS VEGAS (intercept -0.27).

CONCLUSIONS

None of the scoring systems appeared to have adequate discriminatory power to predict PPCs among patients undergoing lung resection. An alternative risk score is necessary to better predict patients at risk of PPCs after thoracic surgery.

Cardiopulmonary exercise testing applied to respiratory medicine: Myths and facts

Cardiopulmonary exercise testing (CPET) remains poorly understood and, consequently, largely underused in respiratory medicine. In addition to a widespread lack of knowledge of integrative physiology, several tenets of CPET interpretation have relevant controversies and limitations which should be appropriately recognized. With the intent to provide a roadmap for the pulmonologist to realistically calibrate their expectations towards CPET, a collection of deeply entrenched beliefs is critically discussed. They include a) the actual role of CPET in uncovering the cause(s) of dyspnoea of unknown origin, b) peak O₂ uptake as the key metric of cardiorespiratory capacity, c) the value of low lactate ("anaerobic") threshold to differentiate cardiocirculatory from respiratory causes of exercise limitation, d) the challenges of interpreting heart rate-based indexes of cardiovascular performance, e) the meaning of peak breathing reserve in dyspnoeic patients, f) the merits and drawbacks of measuring operating lung volumes during exercise, g) how best interpret the metrics of gas exchange inefficiency such as the ventilation-CO₂ output relationship, h) when (and why) measurements of arterial blood gases are required, and i) the advantages of recording submaximal dyspnoea "quantity" and "quality". Based on a conceptual framework that links exertional dyspnoea to "excessive" and/or "restrained" breathing, I outline the approaches to CPET performance and interpretation that proved clinically more helpful in each of these scenarios. CPET to answer clinically relevant questions in pulmonology is a largely uncharted research field: I, therefore, finalize by highlighting some lines of inquiry to improve its diagnostic and prognostic yield.

Early outcomes of “low-risk” patients undergoing lung resection assessed by cardiopulmonary exercise testing: Single-institution experience

Objective

Cardiopulmonary exercise testing (CPET) is currently recommended for all patients undergoing lung resection with either respiratory comorbidities or functional limitations. The main parameter evaluated is oxygen consumption at peak (VO2peak). Patients with VO2peak above 20 ml/kg/min are classified as low risk surgical candidates. The aims of this study were to evaluate postoperative outcomes of low-risk patients, and to compare their outcomes with those of patients without pulmonary impairment at respiratory function testing.

Methods

Retrospective monocentric observational study was designed, evaluating outcomes of patients undergoing lung resection at San Paolo University Hospital, Milan, Italy, between January 2016 and November 2021, preoperatively assessed by CPET, according to 2009 ERS/ESTS guidelines. All low-risk patients undergoing any extent surgical lung resection for pulmonary nodules were enrolled. Postoperative major cardiopulmonary complications or death, occurring within 30 days from surgery, were assessed. A case-control study was nested, matching 1:1 for type of surgery the cohort population with control patients without functional respiratory impairment consecutively undergoing surgery at the same centre in the study period.

Results

A total of 80 patients were enrolled: 40 subjects were preoperatively assessed by CPET and deemed at low risk, whereas 40 subjects represented the control group. Among the first, 4 patients (10%) developed major cardiopulmonary complications, and 1 patient (2.5%) died within 30 days from surgery. In the control group, 2 patients (5%) developed complications and none of the patients (0%) died. The differences in morbidity and mortality rates did not reach statistically significance. Instead, age, weight, BMI, smoking history, COPD incidence, surgical approach, FEV1, Tiffenau, DLCO and length of hospital stay resulted significantly different between the two groups. At a case-by-case analysis, CPET revealed a pathological pattern in each complicated patient, in spite of VO2peak above target for safe surgery.

Conclusions

Postoperative outcomes of low-risk patients undergoing lung resections are comparable to those of patients without any pulmonary functional impairment; nonetheless the formers represent a dramatically different category of individuals from the latter and may harbour few patients with worse outcomes. CPET variables overall interpretation may add to the VO2peak in identifying higher risk patients, even in this subgroup.

Emerging precision neoadjuvant systemic therapy for patients with resectable non-small cell lung cancer: current status and perspectives

Over the past decade, targeted therapy for oncogene-driven NSCLC and immune checkpoint inhibitors for non-oncogene-driven NSCLC, respectively, have greatly improved the survival and quality of life for patients with unresectable NSCLC. Increasingly, these biomarker-guided systemic therapies given before or after surgery have been used in patients with early-stage NSCLC. In March 2022, the US FDA granted the approval of neoadjuvant nivolumab and chemotherapy for patients with stage IB-IIIA NSCLC. Several phase II/III trials are evaluating the clinical efficacy of various neoadjuvant immune checkpoint inhibitor combinations for non-oncogene-driven NSCLC and neoadjuvant molecular targeted therapies for oncogene-driven NSCLC, respectively. However, clinical application of precision neoadjuvant treatment requires a paradigm shift in the biomarker testing and multidisciplinary collaboration at the diagnosis of early-stage NSCLC. In this comprehensive review, we summarize the current diagnosis and treatment landscape, recent advances, new challenges in biomarker testing and endpoint selections, practical considerations for a timely multidisciplinary collaboration at diagnosis, and perspectives in emerging neoadjuvant precision systemic therapy for patients with resectable, early-stage NSCLC. These biomarker-guided neoadjuvant therapies hold the promise to improve surgical and pathological outcomes, reduce systemic recurrences, guide postoperative therapy, and improve cure rates in patients with resectable NSCLC.

[Anatomical resection for non-small cell lung cancer: cardiopulmonary exercise testing in assessing the risk of respiratory complications]

OBJECTIVE

To assess the role of cardiopulmonary exercise testing in examination of patients with high risk of respiratory complications in anatomical resections for non-small cell lung cancer.

MATERIAL AND METHODS

A non-randomized retrospective single-center study was devoted to immediate results of surgical treatment of patients with NSCLC between December 2020 and April 2021. Median age of patients was 65 (84; 30) years, male-to-female ratio - 129 (57%)/98 (43%). All patients were examined according to a unified algorithm recommended by the American (ATS) and European (ESTS) societies of thoracic surgeons. At the first stage, we analyzed airflow rate and performed non-invasive exercise tests (6-minute walk and/or stair test). Resections of lungs were performed in 231 patients, anatomic lung resections - in 227 patients (lobectomy - 199, bilobectomy - 4, segmentectomy - 17, pneumonectomy - 7). We excluded 4 patients who underwent non-anatomic lung resections (marginal resections).

RESULTS

Among 236 patients referred for anatomical lung resections, 34 (14.4%) ones were selected for cardiopulmonary testing. Selection was based on low exercise tolerance and/or severe decrease in predictive respiratory parameters (FEV<50%). Patients were divided into 4 groups depending on peak oxygen consumption. There were 5 (2%), 10 (29.4%), 11 (32.3%) and 8 (23.5%) patients with extremely high, high, moderate and low risk of respiratory complications, respectively. Surgeries were performed for IA1 (n=6), IA2 (n=50), IA3 (n=37), IB (n=31), IIA (n=19), IIB (n=37), IIIA (n=25) and IIIB (n=4) stages. The overall incidence of postoperative complications was 23% (95% CI: 18-28.8). Complications Clavien-Dindo grade I, IIIA, IIIB, IVA, IVB and V prevailed in both groups. Median postoperative hospital-stay (6 (6; 8) vs. 7 (6; 8) days) and time of pleural drainage (4 (2; 5) vs. 3 (3; 4) days) were similar. Organ-sparing procedures prevailed in the main group (5 (26%) out of 19 (95% CI: 11.81-48.8) vs. 12 (6.7%) out of 180 (95% CI: 3.8-11.3)). Overall mortality (n=231) was 1.7% (95% CI: 0.7-4.4). Mortality throughout the first postoperative year was 24% (95% CI: 12.2-42.1) and 7.4% (95% CI: 4.2-11.3), respectively.

CONCLUSION

Cardiopulmonary exercise testing makes it possible to objectively assess exercise tolerance and identify high-risk patients for respiratory complications. These data are valuable when planning the treatment of patients with non-small cell lung cancer.

Ventilatory efficiency in combination with peak oxygen uptake improves risk stratification in patients undergoing lobectomy

Objective

We aimed to evaluate whether or not using the slope of the increase in minute ventilation in relation to carbon dioxide (VE/VCo₂-slope), with a cutoff value of 35, could improve risk stratification for major pulmonary complications or death following lobectomy in lung cancer patients at moderate risk (Vo_2peak = 10-20 mL/kg/min).

Methods

Single center, retrospective analysis of 146 patients with lung cancer who underwent lobectomy and preoperative cardiopulmonary exercise testing in 2008-2020. The main outcome was any major pulmonary complication or death within 30 days of surgery. Patients were categorized based on their preoperative cardiopulmonary exercise testing as: low-risk group, peak oxygen uptake >20 mL/kg/min; low-moderate risk, peak oxygen uptake 10 to 20 mL/kg/min and VE/VCo₂-slope <35; and moderate-high risk, peak oxygen uptake 10 to 20 mL/kg/min and VE/VCo₂-slope ≥35. The frequency of complications between groups was compared using χ² test. Logistic regression was used to calculate the odds ratio with 95% CI for the main outcome based on the cardiopulmonary exercise testing group.

Results

Overall, 25 patients (17%) experienced a major pulmonary complication or died (2 deaths). The frequency of complications differed between the cardiopulmonary exercise testing groups: 29%, 13%, and 8% in the moderate-high, low-moderate, and low-risk group, respectively (P = .023). Using the low-risk group as reference, the adjusted odds ratio for the low-moderate risk group was 3.44 (95% CI, 0.66-17.90), whereas the odds ratio for the moderate-high risk group was 8.87 (95% CI, 1.86-42.39).

Conclusions

Using the VE/VCo₂-slope with a cutoff value of 35 improved risk stratification for major pulmonary complications following lobectomy in lung cancer patients with moderate risk based on a peak oxygen uptake of 10 to 20 mL/kg/min. This suggests that the VE/VCo₂-slope can be used for preoperative risk evaluation in lung cancer lobectomy.

Cell Trajectory-Related Genes of Lung Adenocarcinoma Predict Tumor Immune Microenvironment and Prognosis of Patients

Background

Lung adenocarcinoma (LUAD) is the most common subtype of lung cancer which typically exhibits a diverse progression trajectory. Our study sought to explore the cell differentiation trajectory of LUAD and its clinical relevance.

Methods

Utilizing a single-cell RNA-sequencing dataset (GSE117570), we identified LUAD cells of distinct differential status along with differentiation-related genes (DRGs). DRGs were applied to the analysis of bulk-tissue RNA-sequencing dataset (GSE72094) to classify tumors into different subtypes, whose clinical relevance was further analyzed. DRGs were also applied to gene co-expression network analysis (WGCNA) using another bulk-tissue RNA-sequencing dataset (TCGA-LUAD). Genes from modules that demonstrated a significant correlation with clinical traits and were differentially expressed between normal tissue and tumors were identified. Among these, genes with significant prognostic relevance were used for the development of a prognostic nomogram, which was tested on TCGA-LUAD dataset and validated in GSE72094. Finally, CCK-8, EdU, cell apoptosis, cell colony formation, and Transwell assays were used to verify the functions of the identified genes.

Results

Four clusters of cells with distinct differentiation status were characterized, whose DRGs were predominantly correlated with pathways of immune regulation. Based on DRGs, tumors could be clustered into four subtypes associated with distinct immune microenvironment and clinical outcomes. DRGs were categorized into four modules. A total of nine DRGs (SFTPB, WFDC2, HLA-DPA1, TIMP1, MS4A7, HLA-DQA1, VCAN, KRT8, and FABP5) with most significant survival-predicting power were integrated to develop a prognostic model, which outperformed the traditional parameters in predicting clinical outcomes. Finally, we verified that knockdown of WFDC2 inhibited proliferation, migration, and invasion but promoted the apoptosis of A549 cells in vitro.

Conclusion

The cellular composition and cellular differentiation status of tumor mass can predict the clinical outcomes of LUAD patients. It also plays an important role in shaping the tumor immune microenvironment.

Is Age-Predicted Maximal Heart Rate Applicable in Patients With Heart or Lung Disease?

Objective

To compare the predicted and actual maximal heart rate (HRmax) values in the cardiopulmonary exercise test (CPET).

Methods

We retrospectively investigated 1,060 patients who underwent a CPET between January 2016 and April 2020 at our institution’s cardiopulmonary rehabilitation center. The following patients were included: those aged >20 years, those tested with a treadmill, and those who underwent symptom-limited maximum exercise testing— reaching ≥85% of the predicted HRmax (62% if taking beta-blockers) and highest respiratory exchange ratio ≥1.1. Ultimately, 827 patients were included in this study. Data on diagnosis, history of taking beta-blockers, age, body mass index (BMI), and CPET parameters were collected. Subgroup analysis was performed according to age, betablockers, BMI (low <18.5 kg/m², normal, and high ≥25 kg/m²), and risk classification.

Results

There was a significant difference between the actual HRmax and the predicted value (p<0.001). Betablocker administration resulted in a significant difference in the actual HRmax (p<0.001). There were significant differences in the moderate-to-high-risk and low-risk groups and the normal BMI and high BMI groups (p<0.001). There was no significant difference between the elderly and younger groups. We suggest new formulae for HRmax of cardiopulmonary patients: estimated HRmax=183-0.76×age (the beta-blocker group) and etimated HRmax=210-0.91×age (the non-beta-blocker group).

Conclusion

Age-predicted HRmax was significantly different from the actual HRmax of patients with cardiopulmonary disease, especially in the beta-blocker group. For participants with high BMI and moderate-tosevere risk, the actual HRmax was significantly lower than the predicted HRmax.

Prognostic value of key variables from cardiopulmonary exercise testing in patients with COPD: 42-month follow-up

AIM

To identify better predictors of early death in patients with chronic obstructive pulmonary disease (COPD) using potential predictors derived from key measures obtained from cardiopulmonary exercise testing (CPET).

METHODS

This is a prospective, cohort study with 42-month follow-up in 126 COPD patients. Every patient completed the clinical evaluation, followed by a pulmonary function test and CPET. CPET was performed on a cycle ergometer with electromagnetic braking and ventilatory expired analysis was measured breath-by-breath using a computer-based system. Peak oxygen consumption (V̇O_2, mlO_2. kg^-1_. min^-1), minute ventilation/carbon dioxide production and the, minute ventilation (V̇_E, L/min), and the V̇_E/carbon dioxide production (V̇_E/V̇CO₂) slope were obtained from CPET.

RESULTS

48 (38%) patients died during the 42-month follow-up. Kaplan Meier analysis revealed a V̇_E/V̇CO₂ slope ≥30, peak V̇_E ≤ 25.7L/min and peak V̇O₂ ≤ 13.8 mlO_2. kg^-1_. min^-1were strong predictors of mortality in COPD patients. Cox regression revealed that the V̇O₂ peak ≤13.8 mlO_2. kg^-1_. min^-1 (CI 95% 0.08-0.93), V̇_E/V̇CO₂ slope ≥30 (CI 95% 0.07-0.94), V̇_E peak ≤25.7 L/min (CI 95% 0.01-0.15), Sex (CI 95% 0.04-0.55) and Age (CI 95% 1.03-1.2) were the main predictors of mortality risk.

CONCLUSION

Diminished exercise capacity and peak ventilation as well as ventilatory inefficiency are independent prognostic markers. Similar to patients with heart failure, CPET may be a valuable clinical assessment in the COPD population.

Preoperative evaluation in thoracic surgery: limits of the patient's functional operability and consequence for perioperative anaesthesiologic management

PURPOSE OF REVIEW

Preoperative evaluation of older and more morbid patients in thoracic surgery is getting more advanced. In this context, early risk stratification has a crucial role for adequate informed decision-making, and thus for generating favourable effects of clinical outcome.

RECENT FINDINGS

Recent findings confirm that many risk factors impair mortality and morbidity beyond classical medical findings like results of lung function tests and values of the revised cardiac risk index. Especially results from holistic views on patients' functional status like frailty assessments are linked with long-term survival after lung resection.

SUMMARY

A comprehensive risk stratification by anaesthesiologists generates valuable guidance for the best strategy of clinical treatment. This includes preoperative, peri-operative and postoperative interventions, provided by interdisciplinary healthcare providers, resulting in an Early Risk Stratification and Strategy ('ERSAS') pathway.

Prediction of Postoperative Complications: Ventilatory Efficiency and Rest End-tidal Carbon Dioxide

BACKGROUND

Cardiopulmonary exercise testing parameters including ventilatory efficiency (V_E/VCO₂ slope) are used for risk assessment of lung resection candidates. However, many patients are unable or unwilling to undergo exercise. V_E/VCO₂ slope is closely related to the partial pressure of end-tidal carbon dioxide (P_ETCO₂). We hypothesized P_ETCO₂ at rest predicts postoperative pulmonary complications.

METHODS

Consecutive lung resection candidates were included in this prospective multicenter study. Postoperative respiratory complications were assessed from the first 30 postoperative days or from the hospital stay. Student t test or Mann-Whitney U test was used for comparison. Multivariate stepwise logistic regression analysis was used to analyze association with the development of postoperative pulmonary complications. The De Long test was used to compare area under the curve (AUC). Data are summarized as median (interquartile range).

RESULTS

Three hundred fifty-three patients were analyzed, of which 59 (17%) developed postoperative pulmonary complications. P_ETCO₂ at rest was significantly lower (27 [24-30] vs 29 [26-32] mm Hg; P < .01) and V_E/VCO₂ slope during exercise significantly higher (35 [30-40] vs 29 [25-33]; P < .01) in patients who developed postoperative pulmonary complications. Both rest P_ETCO₂ with odds ratio 0.90 (95% confidence interval [CI] 0.83-0.97); P = .01 and V_E/VCO₂ slope with odds ratio 1.10 (95% CI 1.05-1.16); P < .01 were independently associated with postoperative pulmonary complications by multivariate stepwise logistic regression analysis. There was no significant difference between AUC of both models (rest P_ETCO₂: AUC = 0.79 (95% CI 0.74-0.85); V_E/VCO₂ slope: AUC = 0.81 (95% CI 0.75-0.86); P = .48).

CONCLUSIONS

P_ETCO₂ at rest has similar prognostic utility as V_E/VCO₂ slope, suggesting rest P_ETCO₂ may be used for postoperative pulmonary complications prediction in lung resection candidates.

VATS lobectomy morbidity and mortality is lower in patients with the same ppoDLCO: Analysis of the database of the Spanish Video-Assisted Thoracic Surgery Group

INTRODUCTION

Measuring predicted post-operative diffusion capacity of the lung for carbon monoxide (ppoDLCO) is essential to determine patient operability and to stratify the risk of patients who are candidates for major lung cancer surgery. Studies that established surgical risk variables were based on open surgery series. The aim of our study was to analyze morbidity and mortality as a function of ppoDLCO and to compare its behavior in open and video-assisted thoracic surgery (VATS).

METHODS

We compared 90-day mortality and morbidity in patients undergoing open surgery versus VATS as a function of decline in ppoDLCO. Propensity score matching (using age, ASA, arterial vascular disease, BMI, gender, stage, ppoDLCO, and ppoFEV₁) was applied to create comparable open surgery and VATS groups.

RESULTS

Of 2,530 patients with lung cancer and ppoDLCO values, a sample of 1,624 (812 per group) was obtained after score matching. The relative risk of mortality associated with thoracotomy in patients with ppoDLCO < 60 is 2.66 (p < 0.02) compared to VATS. The risk of thoracotomy in terms of overall and cardiac and respiratory morbidity is higher than that of VATS for almost all ppoDLCO values.

CONCLUSIONS

Major resection by VATS shows lower morbidity and mortality in patients with the same ppoDLCO. A steady rise in the risk of mortality begins to occur at higher ppoDLCO values in thoracotomy (∼60) than in VATS (∼45).

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.

Early discharge after thoracoscopic anatomical pulmonary resection for non-small-cell lung cancer

OBJECTIVES

Although video-assisted thoracic surgery (VATS) has shortened hospitalization duration for non-small-cell lung cancer (NSCLC) patients, the factors associated with early discharge remain unclear. This study aimed to identify patients eligible for a 72-h stay after VATS anatomical resection.

METHODS

Monocentric retrospective study including all consecutive patients undergoing VATS anatomical resection for NSCLC between February 2010 and December 2019. Two groups were defined according to the discharge: 'early discharge' (within 72 postoperative hours) and 'routine discharge' (at >72 postoperative hours).

RESULTS

A total of 660 patients with a median age of 66.5 years (interquartile range 60-73 years) (female/male: 321/339) underwent VATS anatomical pulmonary resection for NSCLC [segmentectomy in 169 (25.6%), lobectomy in 481 (72.9%), bilobectomy in 8 (1.2%) and pneumonectomy in 2 (0.3%) patients]. The cardiopulmonary and Clavien-Dindo III-IV postoperative complication rates were 32.6% and 7.7%, respectively. The median postoperative length of stay was 6 days (interquartile range 4-10 days). In total, 119 patients (18%) could be discharged within 72 h of surgery. On multivariable analysis, the factors significantly associated with an increased likelihood of early discharge were: body mass index >20 kg/m2 [odds ratio (OR) 2.37], absence of prior cardiopathy (OR 2), diffusing capacity of the lung for carbon monoxide >60% (OR 1.82), inclusion in an enhanced recovery after surgery protocol (OR 2.23), use of a single chest tube (OR 5.73) and postoperative transfer to the ward (OR 4.84). Factors significantly associated with a decreased likelihood of early discharge were: age >60 years (OR 0.53), American Society of Anaesthesiologists score >2 (OR 0.46) and use of an epidural catheter (OR 0.41). Readmission rates were not statistically different between both groups (5.9% vs 3.1%; P = 0.17).

CONCLUSIONS

Age, pulmonary functions and comorbidities may influence discharge after VATS anatomical resection. The early discharge does not increase readmission rates.

Predictive Accuracy of the Sport Concussion Assessment Tool 3 and Vestibular/Ocular-Motor Screening, Individually and In Combination: A National Collegiate Athletic Association-Department of Defense Concussion Assessment, Research and Education Consortium Analysis

BACKGROUND

Vestibular and ocular symptoms in sport-related concussions are common. The Vestibular/Ocular-Motor Screening (VOMS) tool is a rapid, free, pen-and-paper tool that directly assesses these symptoms and shows consistent utility in concussion identification, prognosis, and management. However, a VOMS validation study in the acute concussion period of a large sample is lacking.

PURPOSE

To examine VOMS validity among collegiate student-athletes, concussed and nonconcussed, from the multisite National Collegiate Athletic Association-Department of Defense Concussion Assessment, Research and Education (CARE) Consortium. A secondary aim was to utilize multidimensional machine learning pattern classifiers to deduce the additive power of the VOMS in relation to components of the Sport Concussion Assessment Tool 3 (SCAT3).

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 3.

METHODS

Preseason and acute concussion assessments were analyzed for 419 student-athletes. Variables in the analysis included the VOMS, Balance Error Scoring System, Standardized Assessment of Concussion, and SCAT3 symptom evaluation score. Descriptive statistics were calculated for all tools, including Kolmogorov-Smirnov significance and Cohen d effect size. Correlations between tools were analyzed with Spearman r, and predictive accuracy was evaluated through an Ada Boosted Tree machine learning model's generated receiver operating characteristic curves.

RESULTS

Total VOMS scores and SCAT3 symptom scores demonstrated significant increases in the acute concussion time frame (Cohen d = 1.23 and 1.06; P < .0001), whereas the Balance Error Scoring System lacked clinical significance (Cohen d = 0.17). Incorporation of VOMS into the full SCAT3 significantly boosted overall diagnostic ability by 4.4% to an area under the curve of 0.848 (P < .0001) and produced a 9% improvement in test sensitivity over the existing SCAT3 battery.

CONCLUSION

The results from this study highlight the relevance of the vestibular and oculomotor systems to concussion and the utility of the VOMS tool. Given the 3.8 million sports-related and 45,121 military-related concussions per year, the addition of VOMS to the SCAT3 is poised to identify up to an additional 304,000 athletes and 3610 servicemembers annually who are concussed, thereby improving concussion assessment and diagnostic rates. Health care providers should consider the addition of VOMS to their concussion assessment toolkits, as its use can positively affect assessment and management of concussions, which may ultimately improve outcomes for this complex and common injury.

VATS Lobectomy Morbidity and Mortality is Lower in Patients with the Same ppoDLCO: Analysis of the Database of the Spanish Video-Assisted Thoracic Surgery Group

INTRODUCTION

Measuring predicted post-operative diffusion capacity of the lung for carbon monoxide (ppoDLCO) is essential to determine patient operability and to stratify the risk of patients who are candidates for major lung cancer surgery. Studies that established surgical risk variables were based on open surgery series. The aim of our study was to analyze morbidity and mortality as a function of ppoDLCO and to compare its behavior in open and video-assisted thoracic surgery (VATS).

METHODS

We compared 90-day mortality and morbidity in patients undergoing open surgery versus VATS as a function of decline in ppoDLCO. Propensity score matching (using age, ASA, arterial vascular disease, BMI, sexo, stage, ppoDLCO, and ppoFEV1) was applied to create comparable open surgery and VATS groups.

RESULTS

Of 2,530 patients with lung cancer and ppoDLCO values, a sample of 1,624 (812 per group) was obtained after score matching. The relative risk of mortality associated with thoracotomy in patients with ppoDLCO<60 is 2.66 (P<.02) compared to VATS. The risk of thoracotomy in terms of overall and cardiac and respiratory morbidity is higher than that of VATS for almost all ppoDLCO values.

CONCLUSIONS

Major resection by VATS shows lower morbidity and mortality in patients with the same ppoDLCO. A steady rise in the risk of mortality begins to occur at higher ppoDLCO values in thoracotomy (∼60) than in VATS (∼45).

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.

"Fit for Surgery? What's New in Preoperative Assessment of the High-Risk Patient Undergoing Pulmonary Resection"

Advances in perioperative assessment and diagnostics, together with developments in anesthetic and surgical techniques, have considerably expanded the pool of patients who may be suitable for pulmonary resection. Thoracic surgical patients frequently are perceived to be at high perioperative risk due to advanced age, level of comorbidity, and the risks associated with pulmonary resection, which predispose them to a significantly increased risk of perioperative complications, increased healthcare resource use, and costs. The definition of what is considered "fit for surgery" in thoracic surgery continually is being challenged. However, no internationally standardized definition of prohibitive risk exists. Perioperative assessment traditionally concentrates on the "three-legged stool" of pulmonary mechanical function, parenchymal function, and cardiopulmonary reserve. However, no single criterion should exclude a patient from surgery, and there are other perioperative factors in addition to the tripartite assessment that need to be considered in order to more accurately assess functional capacity and predict individual perioperative risk. In this review, the authors aim to address some of the more erudite concepts that are important in preoperative risk assessment of the patient at potentially prohibitive risk undergoing pulmonary resection for malignancy.

SABR-BRIDGE: Stereotactic ABlative Radiotherapy Before Resection to AvoId Delay for Early-Stage LunG Cancer or OligomEts During the COVID-19 Pandemic

Surgical resection is the standard-of-care approach for early-stage non-small cell lung cancer (NSCLC). Surgery is also considered an acceptable standard infit patients with oligometastatic lesions in the lungs. The COVID-19 pandemic has led to worldwide issues with access to operating room time, with patients and physicians facing uncertainty as to when surgical resection will be available, with likely delays of months. Further compounding this are concerns about increased risks of respiratory complications with lung cancer surgery during active phases of the pandemic. In this setting, many thoracic oncology teams are embracing a paradigm where stereotactic ablative radiotherapy (SABR) is used as a bridge, to provide radical-intent treatment based on a combination of immediate SABR followed by planned surgery in 3–6 months. This pragmatic approach to treatment has been named SABR-BRIDGE (Stereotactic ABlative Radiotherapy Before Resection to avoId Delay for early-stage lunG cancer or oligomEts). This term has also been applied to the pragmatic study of the outcomes of this approach. In this paper, we discuss the standards of care in treatment of early-stage (NSCLC) and pulmonary oligometastases, the impetus for the SABR-BRIDGE approach, and the controversies surrounding assessment of pathological response to neo-adjuvant radiation therapy.

Evaluation of Risk for Thoracic Surgery

Modern surgical practice places increased emphasis on treatment outcomes. There has been a paradigm shift from paternalistic ways of practicing medicine to patients having a major involvement in decision making and treatment planning. The combination of these two factors undoubtedly leaves the surgeon open to greater scrutiny in respect of results and outcomes. In dealing with this it is important that the surgeon, wider multidisciplinary team, and patient appreciate the idea of surgical risk. This article reviews the latest evidence relating to risk assessment in thoracic surgery and suggests how this should be incorporated into clinical practice.

Impact of Sarcopenia on Early Postoperative Complications in Early-Stage Non-Small-Cell Lung Cancer

Background

Risk assessment for pulmonary resection in patients with early-stage non–small-cell lung cancer (NSCLC) is important for minimizing postoperative morbidity. Depletion of skeletal muscle mass is closely associated with impaired nutritional status and limited physical ability. We evaluated the relationship between skeletal muscle depletion and early postoperative complications in patients with early-stage NSCLC.

Methods

Patients who underwent curative lung resection between 2016 and 2018 and who were diagnosed with pathological stage I/II NSCLC were included, and their records were retrospectively analyzed. The psoas volume index (PVI, cm³/m³) was calculated based on computed tomography images from routine preoperative positron emission tomography-computed tomography. Early postoperative complications, defined as those occurring within 90 days of surgery, were compared between the lowest sex-specific quartile for PVI and the remaining quartiles.

Results

A strong correlation was found between the volume and the cross-sectional area of the psoas muscle (R²=0.816). The overall rate of complications was 57.6% among patients with a low PVI and 32.8% among those with a normal-to-high PVI. The most common complication was prolonged air leak (low PVI, 16.9%; normal-to-high PVI, 9.6%), followed by pneumonia (low PVI, 13.6%; normal-to-high PVI, 7.9%) and recurrent pleural effusion (low PVI, 11.9%; normal-to-high PVI, 6.8%). The predictors of overall complications were low PVI (odds ratio [OR], 2.18; 95% confidence interval [CI], 1.07–4.09; p=0.03), low hemoglobin level (OR, 0.686; 95% CI, 0.54–0.87; p=0.002), and smoking history (OR, 3.93; 95% CI, 2.03–7.58; p<0.001).

Conclusion

Low PVI was associated with a higher rate of early postoperative complications in patients with early-stage NSCLC.

Preoperative Peak Oxygen Consumption: A Predictor of Survival in Resected Lung Cancer

The peak oxygen consumption (VO₂ peak) serves as a prognostic factor in cardio-respiratory diseases and plays an important role in cancer patients. The long-term prognostic relevance of VO₂ peak in lung cancer patients has not been investigated extensively. The aim of this study was to evaluate the impact of the preoperative VO₂ peak on the postoperative long-term survival in patients with operated lung cancer. Retrospective analysis of 342 patients with curatively resected non-small-cell lung cancer using a multivariate Cox proportional hazard model. Results: Preoperative VO₂ peak ranged from 10.2 to 51.8 mL/kg/min (mean: 18.3 ± 4.6), VO₂ peak % of predicted ranged from 32 to 172% (mean: 65.2 ± 18.0%). Overall 10-year survival was 23%. A Log-rank test comparing predicted VO₂ peak ≥ 60% with predicted VO₂ peak < 60% showed overall survival of 30% and 17%, respectively (p < 0.001) and non-tumour-related survival of 71% and 51% (p = 0.001) at 10 years. In multivariable Cox analysis, overall 10-year survival correlated with a high predicted VO₂ peak% (p = 0.001) and low N-stage corresponding to N0 and N1 (p < 0.001). Non-tumour-related death correlated with low VO₂ peak% of predicted (p = 0.001), and age (p < 0.001). Low preoperative VO₂ peak was associated with both decreased postoperative overall survival and decreased non-tumour-related survival during the 10-year follow-up.

Incorporating Lung Diffusing Capacity for Carbon Monoxide in Clinical Decision Making in Chest Medicine

Lung diffusing capacity for carbon monoxide (Dlco) remains the only noninvasive pulmonary function test to provide an integrated picture of gas exchange efficiency in human lungs. Due to its critical dependence on the accessible "alveolar" volume (Va), there remains substantial misunderstanding on the interpretation of Dlco and the diffusion coefficient (Dlco/Va ratio, Kco). This article presents the physiologic and methodologic foundations of Dlco measurement. A clinically friendly approach for Dlco interpretation that takes those caveats into consideration is outlined. The clinical scenarios in which Dlco can effectively assist the chest physician are discussed and illustrative clinical cases are presented.

[Role of preoperative cardiology consultation in patients undergoing cancer surgery]

AIM

To evaluate the effects of preoperative cardiology consultation on the risk of perioperative cardiac complications in patients undergoing cancer surgery.

MATERIALS AND METHODS

74 patients with bronchial, lung, mediastinal and gastrointestinal cancer were referred to the cardiologist as a part of the preoperative management. Patients were assigned either to Group 1 (n=21), who required non - invasive testing or invasive coronary angiography (CAG), or to Group 2 (n=53), who did not have any indications to additional testing.

RESULTS

The median age was 65.8 years in Group 1 and 64.5 years in Group 2, p=0.408. Group 1 patients had higher RCRI than Group 2 patients (7.4±4.5 vs. 2.9±4.5, respectively, p=0.002). Four (19.05%) patients in Group 1 underwent minimally invasive examination without any further indications to CAG. 16 (76.2%) patients underwent CAG. Of them, 5 (23.8%) patients had severe coronary artery stenosis, and 4 (19.0%) patients had severe brachycephalic artery stenosis (≥50%). After CAG findings, one carotid artery and three coronary arteries (14.3%) were stented. Drug therapy was prescribed to one patient. One patient required stenting after the treatment of the underlying disease. Group 2 patients were more likely to achieve the endpoints - heart rhythm disturbances, decompensation of chronic heart failure, cardiac death (5.45% in Group 2 vs. 4.76% in Group 1, p>0.05). Multivariate analysis reported that angina pectoris was an independent factor to refer patients to the additional testing (p.

Comparison of postoperative complications between segmentectomy and lobectomy by video-assisted thoracic surgery: a multicenter study

BACKGROUND

Compared to lobectomy by video-assisted thoracic surgery (VATS), segmentectomy by VATS has a potential higher risk of postoperative atelectasis and air leakage. We compared postoperative complications between these two procedures, and analyzed their risk factors.

METHODS

We reviewed the records of all patients who underwent anatomical pulmonary resections by VATS from January 2014 to March 2018 in two Swiss university hospitals. All complications were reported. A logistic regression model was used to compare the risks of complications for the two interventions. Adjustment for patient characteristics was performed using a propensity score, and by including risk factors separately.

RESULTS

Among 690 patients reviewed, the major indication for lung resection was primary lung cancer (86.4%) followed by metastasis resection (5.8%), benign lesion (3.9%), infection (3.2%) and emphysema (0.7%). Postoperatively, there were 80 instances (33.3%) of complications in 240 segmentectomies, and 171 instances (38.0%) of complications in 450 lobectomies (P = 0.73). After adjustment for the patient's propensity to be treated by segmentectomy rather than lobectomy, the risks of a complication remained comparable for the two techniques (odds ratio for segmentectomy 0.91 (0.61-1.30), p = 0.59). Length of hospital stay and drainage duration were shorter after segmentectomy. On multivariate analysis, an American Society of Anesthesiologists score above 2 and a forced expiratory volume in one second below 80% of predicted value were significantly associated with the occurrence of complications.

CONCLUSIONS

The rate of complications and their grade were similar between segmentectomy and lobectomy by VATS.

Minute ventilation-to-carbon dioxide slope is associated with postoperative survival after anatomical lung resection

OBJECTIVES

The aim of the study was to identify whether ventilation-to-carbon dioxide output (V_E/V _CO2) slope obtained from cardiopulmonary exercise test (CPET) as part of the preoperative functional workup was an independent prognostic factor for short and long-term survival after major lung resection.

PATIENTS AND METHODS

974 consecutive patients undergoing lobectomy (n = 887) or segmentectomy (n = 87) between April 2014 to March 2018 were included. 209 (22%) underwent CPET, and pulmonary function tests and several clinical factors including age, sex, performance status and comorbidities were retrospectively investigated to identify the prognostic factors with a multivariable Cox regression analysis.

RESULTS

Among the patients with measured V_E/V _CO2, the incidence of cardiopulmonary complications in patients with high V_E/V _CO2 slope (>40) was 37% (19 of 51) vs. 27% (33 of 121) in those with lower slope values (p = 0.19). The 90-day mortality in patients with high V_E/V _CO2 slope (n = 8) was 16% vs. 5% (n = 6) in those with lower slope values (p = 0.03). No overall difference in 2-year mortality was identified between the two groups (VE/VCO2 > 40: 70% (54-80) vs. VE/VCO2 ≤ 40: 72% (63-80), log-rank test, p = 0.39). In a Cox regression analysis V_E/V_CO2 values were associated with poorer 2-year survival (HR 1.05, 95% CI 1.01-1.10, p = 0.030).

CONCLUSIONS

We found that V_E/V _CO2 slope was an independent prognostic factor for the 90-day mortality and 2-year survival after anatomic pulmonary resection. This finding may assist during the multidisciplinary treatment decision-making process in high-risk patients with lung cancer.

Effectiveness of pulmonary rehabilitation and correlations in between functional parameters, extent of thoracic surgery and severity of post-operative complications: randomized clinical trial

Background

Pulmonary rehabilitation can be effective in perioperative condition. Our aim was to examine whether the changes of functional markers are significant and search connections between these values and the severity of postoperative complications.

Methods

A total of 238 chronic obstructive pulmonary disease (COPD) patients underwent perioperative pulmonary rehabilitation with thoracic surgery. Health status and the following parameters were examined: lung function (FEV₁, FVC), chest kinematics [chest wall expansion (CWE)], 6-minute walking test (6MWT), breath holding time (BHT), grip strength (GS) and exercise capacity. Patients were separated into three groups: 72 patients had preoperative rehabilitation only (PRE group), 80 had only postoperative rehabilitation (POS group), and 86 patients underwent pre- and postoperative rehabilitation as well (PPO group). Postoperative complications were classed as "severe" and "not severe". We evaluated the changes in functional parameters. Significance was recognized at P<0.05. Connections in between variables and severity of complications were analyzed.

Results

Pulmonary rehabilitation resulted significant changes of all examined parameters in all three groups. The direction of changes were favourable, so all of the changes can be considered to be improvement [PRE: CWE: 4.2±2.3 vs. 5.8±2.2 cm; FEV₁: 63.2±15.6 vs. 70.1±16.6%pred; 6-minute walking distance (6MWD): 392.9±93.5 vs. 443.2±86.6 m; FVC: 83.1±15.9 vs. 90.9±15.6%pred; POS: CWE: 2.9±1.4 vs. 5.0±2.0 cm; FEV₁: 56.4±15.6 vs. 64.6±16.0%pred; 6MWD: 354.7±90.7 vs. 437.0±96.0 m; FVC: 66.2±18.7 vs. 76.1±17.7%pred; PPO: preoperatively: CWE: 4.0±2.1 vs. 5.6±2.6 cm; FEV₁: 58.2±15.1 vs. 67.0±14.6%pred; 6MWD: 378.3±90.5 vs. 441.3±86.4 m; FVC: 82.4±16.7 vs. 93.3±16.7%pred; postoperatively: CWE: 2.7±1.5 vs. 4.4±2.2 cm; FEV₁: 47.4±13.0 vs. 53.4±14.7%pred; 6MWD: 341.4±115.9 vs. 403.3±98.4 m; FVC: 63.6±16.9 vs. 72.6±18.6%pred; P<0.05]. BHT, GS, dyspnoea and health status were also improved significantly. By discriminant analysis 5 of the variables proved to have discriminative value: kilometers travelled via cycle ergometer at the onset of the preoperative rehabilitation, gender, FEV₁ after preoperative rehabilitation, extent of the operation and 6MWD before preoperative rehabilitation. These 5 parameters can predict severe complications correctly in 72.5% of all cases.

Conclusions

Pulmonary rehabilitation can reduce the functional depletion caused by the thoracic surgical operation. Identification of more predictive factors of severe complications can help making preoperative risk stratification more precisely.

Oxygen Uptake Efficiency Slope and Prediction of Post-operative Morbidity and Mortality in Patients with Lung Cancer

OBJECTIVE

Peak oxygen consumption is a very valuable cardiopulmonary functional parameter in pre-operative evaluation of patients with lung cancer. However, it has several critical limitations for operability decision due to failure in achieving maximal level of exercise test for cases. The aim of this study was to reveal the importance of more accurate cardiopulmonary parameters that can be calculated from data of submaximal level test, such as oxygen uptake efficiency slope (OUES) and to determine whether it could be used in the operability decision phase for borderline cases by means of morbidity and mortality.

MATERIALS AND METHODS

One hundred and twenty-five patients who were scheduled to undergo lung surgery due to lung cancer were included in the study. Peak oxygen uptake (pVO₂), heart rate at the anaerobic threshold, and oxygen consumption volume at anaerobic threshold values were obtained after performing the cardiopulmonary exercise test. The OUES value was calculated from the ratio of the peak VO₂ value and logarithmic equivalent of the ventilatory volume (VE). The following equation was used for determining OUES: VO₂/log₁₀ VE.

RESULTS

The peak VO₂ mean value was 21.37 ± 4.20 mL/min/kg in patients. However, OUES mean value was 12.44 ± 2.11. When the metabolic parameters of the patients were compared, a significant correlation was determined between the peak VO₂ value and peak VE, OUES, and survival (p < 0.01).

CONCLUSION

This study demonstrated that OUES is significantly correlated with peak VO₂ and it does not require the performance of maximal exercise and can be used together with peak VO₂ in this patient population when there is difficulty in making decision for surgery in patients with lung cancer.

Office-Based Spirometry: A New Model of Care in Preoperative Assessment for Low-Risk Lung Resections

BACKGROUND

Formal pulmonary function testing with laboratory spirometry (LS) is the standard of care for risk stratification before lung resection. LS and handheld office spirometry (OS) are clinically comparable for forced expiratory volume in 1 second and forced vital capacity. We investigated the safety of preoperative risk stratification based solely on OS.

METHODS

Patients at low-risk for cardiopulmonary complications were enrolled in a single-center prospective study and underwent preoperative OS. Formal LS was not performed when forced expiratory volume in 1 second was more than 60% by OS. Propensity score matching was used to compare patients in the OS group to low-risk institutional database patients (2008 to 2015) who underwent LS and lung resection. Standardized mean differences determined model covariate balance. The McNemar test and log-rank test were performed, respectively, for categorical and continuous paired outcome data.

RESULTS

There were 66 prospectively enrolled patients who received OS and underwent pulmonary resection, and 1,290 patients received preoperative LS, resulting in 52 propensity score-matched pairs (83%). There were no deaths and two 30-day readmissions per group. The major morbidity risk was similar in each group (7.7%). All analyses of discordant pair morbidity had p exceeding 0.56. There was no association between length of stay and exposure to OS vs LS (p = 0.31). The estimated annual institutional cost savings from performing OS only and avoiding LS was $38,000.

CONCLUSIONS

Low-risk patients undergoing lung resection can be adequately and safely assessed using OS without formal LS, with significant cost savings. With upcoming bundled care reimbursement paradigms, such safe and effective strategies are likely to be more widely used.

Survival and prognostic factors following pulmonary metastasectomy for sarcoma

Sarcomas are a heterogeneous group of malignancies with a marked propensity to metastasize to the lungs. Chemotherapy offers only a limited benefit in metastatic disease, whereas lung metastasectomy, in selected cases, can lead to long-term survival. Other local ablative techniques and hybrid therapies have been proposed. A multidisciplinary setting is of paramount importance for choosing the most appropriate treatment for each case. There is no randomized controlled trial providing formal evidence of the effectiveness of lung metastasectomy. Main areas of controversy concern the selection of surgical candidates, the operative approach and the role of chemotherapy. Five-year survival rates range from 15% to 50.9%, as reported mainly in retrospective case-series in which several prognostic factors were identified. In this article, the authors review the surgical management of sarcoma metastases to the lung, with a particular focus on the outcomes and prognostic factors associated with long-term survival after resection. The role of chemotherapy and other adjunctive therapies is also discussed.