Lobectomy improves ventilatory function in selected patients with severe COPD

Factors affecting prediction accuracy of postoperative FEV1 and DL,CO in patients undergoing lung resection

INTRODUCTION

Despite significant development in systemic therapy and radiotherapy, surgery is still the cornerstone for curative lung cancer treatment. Although predicted postoperative function (ppo) somewhat exactly correlates with actual postoperative function bigger differences may be a cause of serious clinical outcome.

Predictive factors inhibiting recovery of the respiratory function after anatomical pulmonary resection

PURPOSE

Some patients have worse actual observed postoperative (apo) respiratory function values than predicted postoperative (ppo) values. The present study therefore clarified the predictive factors that hinder the recovery of the postoperative respiratory function.

METHODS

This study enrolled 255 patients who underwent anatomical pulmonary resection for lung cancer. A pulmonary function test (PFT) was carried out before surgery and at one, three, and six months after surgery. In each surgical procedures, the forced expiratory volume in 1 s (FEV1) ratio was calculated as the apo value divided by the ppo value. In addition, we investigated the predictive factors that inhibited postoperative respiratory function improvement in patients with an FEV1 ratio < 1.0 at 6 months after surgery.

RESULTS

The FEV1 ratio gradually improved over time in all surgical procedures. However, 49 of 196 patients who underwent a PFT at 6 months after surgery had an FEV1 ratio < 1.0. In a multivariate analysis, right side, upper lobe, segmentectomy and pleurodesis for prolonged air leakage were independent significant predictors of a decreased FEV1 ratio (p = 0.003, 0.006, 0.001, and 0.009, respectively).

CONCLUSION

Pleurodesis was the only controllable factor that might help preserve the postoperative respiratory function. Thus, the intraoperative management of air leakage is important.

Haplotype-GGGT in long non-coding RNA MALAT1 inhibits brain metastatic lung cancer and lymph nodes of lung cancer via the MALAT1/miR-328/KATNB1

The up-regulation of Katanin P8 has been reported to be correlated with a larger tumor size and lymph node metastasis in non-small-cell lung cancer (NSCLC) patients. And lncRNA MALAT1 was demonstrated to promote the proliferation of chronic myeloid leukemia cells via modulating miR-328. 135 lung cancer patients were divided into 6 groups according to their genotypes of MALAT1. The expression of KATNB1 was negatively correlated with the GGGT genotype of MALAT1. Decreased lymph node size and tumor size of brain metastatic lung were observed in patients with GGGT genotype of MALAT1. The luciferase activities of MALAT1 and KATNB1 were remarkably suppressed by miR-328 in A549 and H460. And the down-regulation of MALAT1 or up-regulation of miR-328 significantly repressed the KATNB1 expression in A549 and H460 cells. MALAT1 expression was reduced in patients carrying haplotype GGGT. A signaling pathway of MALAT1/miR-328/KATNB1 was established to explain the down-regulation of KATNB1 mRNA in patients carrying haplotype GGGT and reduced lymph node size in lung cancer and tumor size in brain metastatic lung cancer.

Preoperative inhalation therapy for patients with chronic obstructive pulmonary disease undergoing lung surgery: a retrospective study

BACKGROUND

Research shows that even the short-term administration of inhaled drugs immediately before surgery can improve respiratory function in surgical candidates with chronic obstructive pulmonary disease (COPD). However, the long-term efficacies of different types of long-acting inhaled agents when used during a short preoperative period remain unclear. Therefore, we evaluated the efficacies of short-term, preoperative long-acting muscarinic antagonists (LAMAs), inhaled corticosteroids with long-acting β2-agonists (ICSs/LABAs), and long-acting muscarinic antagonists with long-acting β2-agonists (LAMAs/LABAs) in patients with COPD after lung resection.

METHODS

Patients who underwent anatomical lung resections between April 2010 and March 2020 were divided into the non-COPD (193 patients) and COPD (241 patients) groups. The COPD group underwent preoperative treatment with either a LAMA (51 patients), an ICS/LABA (112 patients), or a LAMA/LABA (78 patients) for almost 1 month, with pulmonary function tests performed initially, just before surgery, and at 1 and 6 months after surgery. Improvement in preoperative respiratory function by inhalation therapy and the maintenance of improvement in respiratory function after surgery were examined in each group.

RESULTS

The COPD group had significantly higher proportions of men, older patients, smokers, and histopathologic types except for adenocarcinoma than the non-COPD group; however, there were neither differences in sex, age, percentage of smokers, or histopathologic type among the inhalant groups within the COPD group nor were there differences in percentage of GOLD stage, preoperative inhalation period, or percentage of resected lobes in lobectomy. Preoperative increases in forced expiratory volume in 1.0 s (FEV1.0) were significantly higher in the COPD group (129.07 ± 11.29 mL) than in the non-COPD group (-2.32 ± 12.93 mL) (p < 0.0001). At 6 months, there was no significant difference in residual FEV1.0 between the COPD-LAMA/LABA (2017.46 ± 62.43 mL) and non-COPD groups (2046.93 ± 40.53 mL). The FEV1.0 reduction rate was more suppressed in the COPD-LAMA/LABA group than in the non-COPD group at 1 and 6 months after surgery.

CONCLUSIONS

Short-term, preoperative, inhaled pharmacotherapies, particularly LAMAs/LABAs, were effective at improving respiratory function in patients with COPD; thus, these agents are recommended for use in this population.

A guide for managing patients with stage I NSCLC: deciding between lobectomy, segmentectomy, wedge, SBRT and ablation-part 3: systematic review of evidence regarding surgery in compromised patients or specific tumors

Background

Clinical decision-making for patients with stage I lung cancer is complex. It involves multiple options [lobectomy, segmentectomy, wedge, stereotactic body radiotherapy (SBRT), thermal ablation], weighing multiple outcomes (e.g., short-, intermediate-, long-term) and multiple aspects of each (e.g., magnitude of a difference, the degree of confidence in the evidence, and the applicability to the patient and setting at hand). A structure is needed to summarize the relevant evidence for an individual patient and to identify which outcomes have the greatest impact on the decision-making.

Methods

A PubMed systematic review from 2000-2021 of outcomes after lobectomy, segmentectomy and wedge resection in older patients, patients with limited pulmonary reserve and favorable tumors is the focus of this paper. Evidence was abstracted from randomized trials and non-randomized comparisons (NRCs) with adjustment for confounders. The analysis involved careful assessment, including characteristics of patients, settings, residual confounding etc. to expose degrees of uncertainty and applicability to individual patients. Evidence is summarized that provides an at-a-glance overall impression as well as the ability to delve into layers of details of the patients, settings and treatments involved.

Results

In older patients, perioperative mortality is minimally altered by resection extent and only slightly affected by increasing age; sublobar resection may slightly decrease morbidity. Long-term outcomes are worse after lesser resection; the difference is slightly attenuated with increasing age. Reported short-term outcomes are quite acceptable in (selected) patients with severely limited pulmonary reserve, not clearly altered by resection extent but substantially improved by a minimally invasive approach. Quality-of-life (QOL) and impact on pulmonary function hasn't been well studied, but there appears to be little difference by resection extent in older or compromised patients. Patient selection is paramount but not well defined. Ground-glass and screen-detected tumors exhibit favorable long-term outcomes regardless of resection extent; however solid tumors <1 cm are not a reliably favorable group.

Conclusions

A systematic, comprehensive summary of evidence regarding resection extent in compromised patients and favorable tumors with attention to aspects of applicability, uncertainty and effect modifiers provides a foundation for a framework for individualized decision-making.

Risk of Each of the Five Lung Lobectomies: A Society of Thoracic Surgery Database Analysis

BACKGROUND

The perioperative risk of pulmonary lobectomy as a solitary procedure has been extensively studied, yet the differences in outcomes between each lobe, which have unique anatomy and a different amount of lung parenchyma, are entirely unknown. The purpose of this study is to define the risk of each of the five lobectomies.

METHODS

The Society of Thoracic Surgery Database was queried for patients undergoing lobectomy between 2008 and 2018. Patient and disease characteristics, operative variables, major morbidity and 30-day mortality were examined. A multivariable logistic regression model (using the same variables in the current STS lobectomy risk model) was developed to assess for the contribution to lobectomy site to adverse outcomes.

RESULTS

65,006 patients were analyzed. Adjusted perioperative mortality rate is lowest for RML (0.63%) intermediate for RUL, LUL and LLL (1.08-1.24%), and highest for RLL (1.63%). The adjusted major morbidity rate is lowest for RML (5.36%) intermediate for LLL and LUL (7.82-8.33%), and highest for RUL and RLL (8.94-9.32%). Adjusted intraoperative transfusion rate is lowest for RML (1.37%) intermediate for RLL and LLL (1.81-1.94%) and highest for RUL and LUL (2.47-2.72%).

CONCLUSIONS

There are clear differences in postoperative outcomes by lobectomy location. Mortality, major morbidity, and transfusion rate are lowest for RML, but vary across other lobectomies. These differences should be appreciated when evaluating risk of operation, deciding upon best therapy, counseling patients, and comparing outcomes.

Comparison between quantitative computed tomography, scintigraphy, and anatomical methods for prediction of postoperative FEV1 and DLCO: effects of chronic obstructive pulmonary disease status and resected lobes

Background

Postoperative assessment of pulmonary function is important for estimating the risk of thoracic surgery and long-term disability following pulmonary resection, including predicted postoperative (ppo) forced expiratory volume (FEV) in one second (ppoFEV₁) and percent predicted lung diffusion capacity for carbon monoxide (ppo%DLCO) estimation. The ppo values were compared using four different estimation methods between chronic obstructive pulmonary disease (COPD) and non-COPD patients and according to the resected lobe.

Methods

This prospective study included 59 eligible patients requiring single lobectomy and succeeded in performing pulmonary function tests at 3 and 12 months after lobectomy. The ppoFEV₁ and ppo%DLCO were compared with poFEV₁ and po%DLCO obtained at 3 and 12 months after lobectomy. The ppo values were estimated using the four usual methods: the 19-segment anatomical technique (S), perfusion scintigraphy (Q), quantitative CT (CT), and quantitative CT with low attenuation volume (CT_LAV) subtraction.

Results

For non-COPD and COPD patients, the smallest mean difference between ppo and po values was observed by S for FEV₁ and %DLCO. Based on the resected lobe, the smallest mean difference was observed by (I) Q for right upper lobectomy (RUL) excluding %DLCO at 12 months by S, (II) S for left upper lobectomy (LUL), (III) CT and CT_LAV for right lower lobectomy (RLL), and (IV) CT and CT_LAV for left lower lobectomy (LLL) at 12 months. The ppo values calculated by S for RUL (FEV₁ at 3 and 12 months and %DLCO at 3 months) and by all four methods for LLL (FEV₁ and %DLCO at 3 months) were smaller than the po values.

Conclusions

The S method is adequate for calculating ppoFEV₁ and ppo%DLCO when patients are classified as non-COPD and COPD. However, S sometimes overestimates the ppoFEV₁ and ppo%DLCO when patients are classified according to the resected lobe. The CT_LAV method may be the method of choice instead of S for calculating ppoFEV₁ and ppo%DLCO in patients who undergo lung lobectomy despite the presence or absence of airflow limitation.

Airway inflammation and lung function recovery after lobectomy in patients with primary lung cancer

OBJECTIVE

Fractional exhaled nitric oxide (FeNO), which represents airway inflammation, is an indicator of postoperative complication after lung surgery. However, its effects in the late postoperative period are unknown. The aim of this prospective study was to clarify the impact of FeNO on postoperative lung function in patients with lung cancer.

METHODS

We measured preoperative FeNO using NIOX VERO® in patients with primary lung cancer. Patients were divided into two groups according to their potential airway inflammatory status: preoperative FeNO levels below 25 ppb (N group) and above 25 ppb (H group). They were evaluated by spirometry at 3 and 6 months after surgery during follow-up. The relationship between postoperative lung function and preoperative FeNO was evaluated.

RESULTS

Between September 2017 and March 2019, 61 participants were enrolled. All of them underwent lobectomy as a curative surgery. There were no significant background variables between the two groups. Postoperative vital capacity (VC) and forced expiratory volume in 1 s (FEV1) in the H group achieved less predictive values than those in the N group, which were not significant. The postoperative VC and FEV1 from 3 to 6 months in the H group were significantly increased as compared to those in the N group (p < 0.001).

CONCLUSIONS

Preoperative FeNO is a predictor of delayed lung function recovery 3 months after lobectomy in lung cancer patients. The impact had extended to VC and FEV1. Although this impact is temporary, early postoperative intervention is expected to reduce the adverse effect.

Outcomes of lobectomy on pulmonary function for early stage non-small cell lung cancer (NSCLC) patients with chronic obstructive pulmonary disease (COPD)

BACKGROUND

Lung cancer is the first cause of cancer mortality worldwide. Chronic obstructive pulmonary disease (COPD) is an independent risk factor for lung cancer. An epidemiological survey discovered that the presence of COPD increases the risk of lung cancer by 4.5-fold. Lobectomy is considered to be the standard surgical method for early stage non-small cell lung cancer (NSCLC). However, the influence of lobectomy on the loss of pulmonary function has not been fully investigated in NSCLC patients with COPD.

METHODS

We searched the PubMed database using the following strategies: COPD and pulmonary function test (MeSH term) and lobectomy (MeSH term) from 01 January 1990 to 01 January 2019. We selected the articles of patients with COPD. A total of six studies, including 195 patients with COPD, provided lung function values before and after surgery.

RESULTS

Five out of six studies focused on the short-term change of pulmonary function (within 3-6 months) after lobectomy, and the average loss of FEV1 was 0.11 L (range: -0.33-0.09 L). One study investigated the long-term change of pulmonary function (within 1-2 years) after lobectomy, and the average loss of FEV1 was 0.15 L (range: -0.29-0.05 L).

CONCLUSIONS

A short-term (3-6 months) loss of pulmonary function after operation is acceptable for lung cancer patients with COPD. However, there may be a high risk of postoperative complications in NSCLC patients with COPD. Therefore, surgical treatment needs to be carefully considered for these patients.

Airflow limitation and survival after surgery for non-small cell lung cancer: Results from a systematic review and lung cancer screening trial (NLST-ACRIN sub-study)

OBJECTIVE

Lung cancer remains the single greatest cause of cancer mortality where surgery for early stage non-small cell lung cancer achieves the greatest survival. While there is growing optimism for better outcomes with screening using annual computed tomography, the impact of co-existing airflow limitation on survival remains unknown. To compare survival in non-small cell lung cancer patients undergoing surgery stratified according to the presence or absence of pre-surgery airflow limitation.

MATERIALS AND METHODS

We undertook a systematic literature search of non-screen lung cancer that encompassed studies reported between January 1946 and January 2017. Full-text articles were identified following eligibility scoring, with data extracted and analysed using a standardised analytical method (PRISMA). The results of this systematic review in non-screen lung cancers were compared to real-world results from a lung cancer screening cohort (N = 10,054), where outcomes following surgery could be compared after stratification according to pre-surgery airflow limitation.

RESULTS

In the systematic review, 6899 subjects were included from 10 studies; 7 were retrospective, 3 were prospective. Overall survival was 950 (44%) in 2144 people with COPD and 2597 (55%) from 4755 controls (unadjusted P value <0.001). However, the overall meta-analysed random effects odds ratio for overall survival (N = 10) and 5-year survival (N = 4) comparing those with and without COPD was 0.91 (95% CI = 0.84-1.00) and 0.99 (95% CI = 0.79-1.24) respectively. There were no signs of significant heterogeneity (I² = 19.1%, P = 0.27) nor publication bias as assessed by funnel plot and Egger's test (P = 0.19). In the lung cancer screening sub-study of 10,054 screening participants we found no difference in 5-year survival in those with and without airflow limitation (84% and 81% respectively, P = 0.64).

CONCLUSION

Survival after surgery for non-small cell lung cancer is comparable between those with and without spirometry evidence of airflow limitation. This finding was replicated in lung cancer diagnosed during screening.

Postoperative pulmonary function changes according to the resected lobe: a 1-year follow-up study of lobectomized patients

Background

Pulmonary function and patient complaints appear to improve up to 12 months after lobectomy but long-term prospective studies based on clinical data are scarce. Improvement in pulmonary function may depend on the area and extent of the resection and the time from the operation. This prospective study aimed to determine pulmonary function changes according to the resected lobe.

Methods

This prospective study included 59 patients requiring single lobectomy. Total volume and low-attenuation volume (LAV) for each lobe and the entire lungs were calculated based on helical computed tomography images. Vital capacity (VC), forced expiratory volume in one second (FEV₁), percent FEV₁ (%FEV₁), percent lung diffusion capacity for carbon monoxide (%DL_co), %DL_co divided by the alveolar volume (%DL_co/V_A), modified Medical Research Council (mMRC) grades, and COPD Assessment Test (CAT) scores were compared at 3, 6, and 12 months after surgery.

Results

VC was higher at 12 months than at 3 months after right upper lobectomy (RUL) or right lower lobectomy (RLL). FEV₁ and %FEV₁ were higher at 12 months than at 6 months after left lower lobectomy (LLL). %DL_co was higher at 12 months than at 3 months after RUL or left upper lobectomy (LUL). DL_co/V_A, mMRC grades, and CAT scores did not change significantly in the period from 3 to 12 months after any lobectomy procedure. Compared to the predicted postoperative values, the observed values of VC for RUL, RLL, and LUL; FEV₁ for RLL; %FEV₁ for RLL and LUL; %DL_co for LUL; and %DL_co/V_A for all lobectomy procedures were higher at 12 months.

Conclusions

Improvements in pulmonary function and symptoms varied according to the resected lobe. Some of the observed pulmonary function values were higher than the predicted postoperative values. Pulmonary function changes may be related to the location, volume, and extent of emphysematous changes.

Gadolinium-Based Blood Volume Mapping From MRI With Ultrashort TE Versus CT and SPECT for Predicting Postoperative Lung Function in Patients With Non-Small Cell Lung Cancer

OBJECTIVE

The purpose of this study is to directly compare the capability of gadolinium-based blood volume (BV) mapping from MRI (BV-MRI) with ultrashort TE (UTE) with that of CT and perfusion SPECT in predicting the postoperative lung function of patients with non-small cell lung cancer (NSCLC).

SUBJECTS AND METHODS

Unenhanced and contrast-enhanced MRI with UTE, thin-section CT, and perfusion SPECT examinations and measurements of the percentage of forced expiratory volume in 1 second (FEV₁) before and after lung resection were performed for 29 patients with NSCLC (16 men [mean age, 66 years] and 13 women [mean age, 66 years]). BV-MRI with UTE was generated as a percentage of the signal change between unenhanced and contrast-enhanced MRI. The postoperative percentage of FEV₁ was predicted from perfusion fractions derived from BV-MRI with UTE and from SPECT. Quantitatively and qualitatively predicted postoperative percentages of FEV₁ from CT were calculated from the functional lung volumes and the number of segments. Each predicted postoperative percentage of FEV₁ was then correlated with the actual postoperative percentage of FEV₁, and the limits of agreement for each actual and predicted postoperative percentage of FEV₁ were evaluated by Bland-Altman analysis.

RESULTS

Correlations between actual and predicted postoperative percentages of FEV₁ for all methods were strong and significant (0.88 ≤ r ≤ 0.95). The limits of agreement (mean ± 1.96 × SD) for BV-MRI with UTE (4.2% ± 6.5%) and quantitatively assessed CT (4.1% ± 6.5%) were smaller than those for qualitatively assessed CT (4.2% ± 9.8%) and perfusion SPECT (5.7% ± 8.7%).

CONCLUSION

BV-MRI with UTE has the potential to predict the postoperative lung function of patients with NSCLC more accurately than qualitatively assessed CT and SPECT, and it can be considered to be at least as useful as quantitatively assessed CT.

Impact of the favorable prognosis of patients with lung cancer adjoining bullae

Background

Lung cancer adjoining bullae (LC-AB) is an uncommon manifestation. The clinical characteristics and prognosis of LC-AB remain unclear. The aim of this study is to investigate the clinical features and overall survival (OS) of patients with LC-AB following lung resection compared to non-LC-AB group.

Methods

We retrospectively investigated 291 consecutive patients with lung cancer who underwent curative resection in a single institution between April 2007 and March 2015. A total of LC-AB was 52 patients. LC-AB was determined using thin slice computed tomography (CT) imaging and pathological findings. Survival analysis was calculated using the Kaplan-Meier method. We used a Cox proportional hazards model for the univariate and multivariate analysis to identify prognostic factors.

Results

The LC-AB group showed a higher frequency of younger patients (P=0.017), former or current smokers (P=0.011), men (P=0.021), tumor location in the upper lobe (P=0.031), moderately or poorly differentiated tumor histology (P<0.001), pleural indentation (P=0.007), and non-adenocarcinoma histology (P=0.016) than the non-LC-AB group. The 5-year survival and recurrence-free survival (RFS) rates were significantly higher in the LC-AB group than the non-LC-AB group (88.5% vs. 74.9%, P=0.010, 75.4% vs. 61.3%, P=0.030, respectively). Multivariate analysis using a Cox proportional hazard model of OS showed that LC-AB was an independent prognostic factor [hazard ratio (HR): 0.30, 95% confidence interval (CI): 0.12-0.77, P=0.012].

Conclusions

Patients with LC-AB had better OS than those with non-LC-AB. Thus, LC-AB may be an independent favorable prognostic factor following curative resection.

Chronic Obstructive Pulmonary Disease: Clinical Implications for Patients With Lung Cancer

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is the most common smoking-related illness. COPD often is underemphasized as a comorbidity except when considering issues surrounding surgical treatment options.

OBJECTIVES

This article aims to provide nurses with an overview of the pharmacologic and nonpharmacologic treatment implications of COPD.

METHODS

Definitions, differentials, and treatment considerations are provided, and clinical implications and resources are described.

FINDINGS

The added burden of dyspnea, fatigue, and psychological distress related to COPD may affect the overall outcome and quality of life (QOL) of patients with lung cancer. Attention to the prevention, assessment, and treatment of lung cancer and COPD and related symptomatology will help maximize patients' QOL.

Lung segmentectomy: does it offer a real functional benefit over lobectomy?

Anatomical segmentectomy has been developed to offer better pulmonary function preservation than lobectomy, in stage IA lung cancer. Despite the retrospective nature of most of the studies and the lack of randomised studies, a substantial body of literature today allows us to evaluate to what extent lung function decreases after segmentectomy and whether segmentectomy offers a real functional benefit over lobectomy. From the available series, it emerges that the mean decrease in forced expiratory volume in 1 s (FEV1) is low, ranging from −9% to −24% of the initial value within 2 months and −3 to −13% 12 months after segmentectomy. This reduction in lung function is significantly lower than that induced by lobectomy, but saves only a few per cent of pre-operative FEV1. Moreover, the published results do not firmly establish the functional benefit of segmentectomy over lobectomy in patients with poor lung function. Some issues remain to be addressed, including whether video-assisted thoracic surgery (VATS) segmentectomy may preserve lung function better than VATS lobectomy in patients with poor lung function, especially within the early days after surgery, and whether this may translate to lowering the functional limit for surgery. Eventually, trials comparing stereotactic ablative body radiotherapy, radiofrequency ablation and segmentectomy functional consequences are warranted.

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

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

Preoperative functional workup for patients with advanced lung cancer

Locally advanced lung cancer remains a surgical indication in selected patients. This condition often demands larger resections. As a consequence preoperative functional workup is of paramount importance to stratify the risk and choose the most appropriate treatment. We reviewed the current evidence on functional evaluation with a special focus on specific aspects related to locally advanced lung cancer stages (i.e., risk after neoadjuvant treatment, pneumonectomy). Evidence is discussed to provide information that could assist clinicians in their preoperative workup of these challenging patients.

Risk Stratification in Lung Resection

PURPOSE OF REVIEW

Surgery is considered the best treatment option for patients with early stage lung cancer. Nevertheless, lung resection may cause a variable functional impairment that could influence the whole cardio-respiratory system with potential life-threatening complications. The aim of the present study is to review the most relevant evidences about the evaluation of surgical risk before lung resection, in order to define a practical approach for the preoperative functional assessment in lung cancer patients.

RECENT FINDINGS

The first step in the preoperative functional evaluation of a lung resection candidate is a cardiac risk assessment. The predicted postoperative values of forced expiratory volume in one second and carbon monoxide lung diffusion capacity should be estimated next. If both values are greater than 60 % of the predicted values, the patients are regarded to be at low surgical risk. If either or both of them result in values lower than 60 %, then a cardiopulmonary exercise test is recommended. Patients with VO2max >20 mL/kg/min are regarded to be at low risk, while those with VO2max <10 mL/kg/min at high risk. Values of VO2max between 10 and 20 mL/kg/min require further risk stratification by the VE/VCO2 slope. A VE/VCO2 <35 indicates an intermediate-low risk, while values above 35 an intermediate-high risk.

SUMMARY

The recent scientific evidence confirms that the cardiologic evaluation, the pulmonary function test with DLCO measurement, and the cardiopulmonary exercise test are the cornerstones of the preoperative functional evaluation before lung resection. We present a simplified functional algorithm for the surgical risk stratification in lung resection candidates.

Influence of Pulmonary Rehabilitation on Lung Function Changes After the Lung Resection for Primary Lung Cancer in Patients with Chronic Obstructive Pulmonary Disease

Influence of physiotherapy on the outcome of the lung resection is still controversial. Study aim was to assess the influence of physiotherapy program on postoperative lung function and effort tolerance in lung cancer patients with chronic obstructive pulmonary disease (COPD) that are undergoing lobectomy or pneumonectomy. The prospective study included 56 COPD patients who underwent lung resection for primary non small-cell lung cancer after previous physiotherapy (Group A) and 47 COPD patients (Group B) without physiotherapy before lung cancer surgery. In Group A, lung function and effort tolerance on admission were compared with the same parameters after preoperative physiotherapy. Both groups were compared in relation to lung function, effort tolerance and symptoms change after resection. In patients with tumors requiring a lobectomy, after preoperative physiotherapy, a highly significant increase in FEV1, VC, FEF50 and FEF25 of 20%, 17%, 18% and 16% respectively was registered with respect to baseline values. After physiotherapy, a significant improvement in 6-minute walking distance was achieved. After lung resection, the significant loss of FEV1 and VC occurred, together with significant worsening of the small airways function, effort tolerance and symptomatic status. After the surgery, a clear tendency existed towards smaller FEV1 loss in patients with moderate to severe, when compared to patients with mild baseline lung function impairment. A better FEV1 improvement was associated with more significant loss in FEV1. Physiotherapy represents an important part of preoperative and postoperative treatment in COPD patients undergoing a lung resection for primary lung cancer.

Changes in Simple Spirometric Parameters After Lobectomy for Bronchial Carcinoma

Introduction: The purpose of this study was to describe the postoperative changes in lung function after pure open lobectomy for lung carcinoma.

Methods: 30 patients (mean age 64 ± 7 years old, 16 men and 14 women) underwent a left or right lobectomy. They underwent spirometric pulmonary tests preoperatively, and at 1 and 6 months after the operation.

Results: The average preoperative forced expiratory volume in 1 second (FEV1) was 2.55±0.62lt and the mean postoperative FEV1 at 1 and 6 months was 1.97 ± 0.59 L and 2.15±0.66 L respectively. The percentage losses for FEV1 were 22.7% and 15.4% after 1 and 6 months respectively. An average percentage increase of 9.4% for FEV1 was estimated at the time of 6 months in comparison with this of 1 month after the operation. The average preoperative forced vital capacity (FVC) was 3.17 ± 0.81 L and the mean postoperative FVC at 1 and 6 months after the operation was 2.50 ± 0.63 L and 2.72 ± 0.67 L respectively. The percentage losses for FVC were 21.1% and 14.2% after 1 and 6 months respectively. An average percentage increase of 8.7% was observed at the time period of 6 months in comparison with this of 1 month after the operation.

Conclusion: Although, we observed a significant decrease in FEV1 and FVC after the operation, all patients were in excellent clinical status. FEV1 and FVC of 6 months were increased in comparison with the respective values of 1 month after the operation, but did not reach the preoperative values in any patient.

Assessment of volume reduction effect after lung lobectomy for cancer

BACKGROUND

Lung lobectomy results in an unexpected improvement of the remaining lung function in some patients with moderate-to-severe emphysema. Because the lung function is the main limiting factor for therapeutic decision making in patients with lung cancer, it may be advantageous to identify patients who may benefit from the volume reduction effect, particularly those with a poor functional reserve.

METHODS

We measured the regional distribution of the emphysematous lung and normal lung using quantitative computed tomography in 84 patients undergoing lung lobectomy for cancer between January 2010 and December 2012. The volume reduction effect was diagnosed using a combination of radiologic and spirometric parameters.

RESULTS

Eight patients (10%) were favorably affected by the volume reduction effect. The forced expiratory volume in one second increased postoperatively in these eight patients, whereas the forced vital capacity was unchanged, thus resulting in an improvement of the airflow obstruction postoperatively. This improvement was not due to a compensatory expansion of the remaining lung but was associated with a relative decrease in the forced end-expiratory lung volume. According to a multivariate analysis, airflow obstruction and the forced end-expiratory lung volume were independent predictors of the volume reduction effect.

CONCLUSIONS

A combined assessment using spirometry and quantitative computed tomography helped to characterize the respiratory dynamics underlying the volume reduction effect, thus leading to the identification of novel predictors of a volume reduction effect after lobectomy for cancer. Verification of our results by a large-scale prospective study may help to extend the indications for lobectomy in patients with oncologically resectable lung cancer who have a marginal pulmonary function.

Wedge resection and segmentectomy in patients with stage I non-small cell lung carcinoma

The use of sublobar resections as definitive management in stage I non-small cell lung carcinoma is a controversial topic in the medical community. We intend to report the latest developments and trends in relative indications for each of the above-mentioned surgical approaches for the treatment of stage I non-small cell lung carcinoma as well as the results of studies regarding local recurrence, disease-free survival and five-year survival rates. We reviewed 45 prospective and retrospective studies conducted over the last 25 years listed in the Pubmed and Scopus electronic databases. Trials were identified through bibliographies and a manual search in journals. Authors, citations, objectives and results were extracted. No meta-analysis was performed. Validation of results was discussed. Segmentectomies are superior to wedge resections in terms of local recurrences and cancer-related mortality rates. Sublobar resections are superior to lobectomy in preserving the pulmonary parenchyma. High-risk patients should undergo segmentectomy, whereas lobectomies are superior to segmentectomies only for tumors >2 cm (T2bN0M0) in terms of disease-free and overall 5-year survival. In most studies no significant differences were found in tumors <2 cm. Disease-free surgical margins are crucial to prevent local recurrences. Systematic lymphadenectomy is mandatory regardless of the type of resection used. In sublobar resections with less thorough nodal dissections, adjuvant radiotherapy can be used. This approach is preferable in case of prior resection. In pure bronchoalveolar carcinoma, segmentectomy is recommended. Sublobar resections are associated with a shorter hospital stay. The selection of the type of resection in T1aN0M0 tumors should depend on characteristic of the patient and the tumor. Patient age, cardiopulmonary reserve and tumor size are the most important factors to be considered. However further prospective randomized trials are needed to investigate the efficacy of minimal resections in early lung cancer patients.

Forced vital capacity predicts long-term survival for curative-resected NSCLC

We conducted a retrospective study in patients with non-small cell lung cancer (NSCLC) who underwent curative lung resection to seek for better lung function parameters associated with long-term survival after lung resection. From January 2006 to December 2008, 470 patients who underwent lung resection with a postoperative diagnosis of NSCLC were studied. Median survival time was 60 months. Patients with pulmonary function values <80 % of predicted were defined as lung function impairment. Patients with impaired vital capacity, maximal voluntary ventilation, forced vital capacity (FVC), forced expiratory volume in one second (FEV1) or diffusion capacity for carbon monoxide (DLCO) had significant shorter overall survival time (P = 0.024; P = 0.026; P < 0.001; P = 0.027; P = 0.007). In univariate analysis, VC, FVC, FEV1 and DLCO were found to have significant effect on overall survival. In multivariate analysis, FVC (HR, 2.029; 95 % CI 1.126-3.659; P = 0.019) was found to be an independent prognostic predictor of long-term overall survival. For cancer-specific survival, FVC (HR 2.404; 95 % CI 1.300-4.445; P = 0.005) was also found to be an independent prognostic predictor in multivariable analysis. Preoperative FVC, rather than FEV1 or DLCO, is an independent prognostic predictor for long-term survival. FVC is not only an indicator of lung function but also of great value for surgeons to predict survival after lung resection.

Postoperative complications do not influence the pattern of early lung function recovery after lung resection for lung cancer in patients at risk

BACKGROUND

The pattern and factors influencing the lung function recovery in the first postoperative days are still not fully elucidated, especially in patients at increased risk.

METHODS

Prospective study on 60 patients at increased risk, who underwent a lung resection for primary lung cancer.

INCLUSION CRITERIA

complete resection and one or more known risk factors in form of COPD, cardiovascular disorders, advanced age or other comorbidities. Previous myocardial infarction, myocardial revascularization or stenting, cardiac rhythm disorders, arterial hypertension and myocardiopathy determined the increased cardiac risk. The severity of COPD was graded according to GOLD criteria. The trend of the postoperative lung function recovery was assessed by performing spirometry with a portable spirometer.

RESULTS

Cardiac comorbidity existed in 55%, mild and moderate COPD in 20% and 35% of patients respectively. Measured values of FVC% and FEV1% on postoperative days one, three and seven, showed continuous improvement, with significant difference between the days of measurement, especially between days three and seven. There was no difference in the trend of the lung function recovery between patients with and without postoperative complications. Whilst pO2 was decreasing during the first three days in a roughly parallel fashion in patients with respiratory, surgical complications and in patients without complications, a slight hypercapnia registered on the first postoperative day was gradually abolished in all groups except in patients with cardiac complications.

CONCLUSION

Extent of the lung resection and postoperative complications do not significantly influence the trend of the lung function recovery after lung resection for lung cancer.

2nd ESMO Consensus Conference on Lung Cancer: early-stage non-small-cell lung cancer consensus on diagnosis, treatment and follow-up

To complement the existing treatment guidelines for all tumour types, ESMO organises consensus conferences to focus on specific issues in each type of tumour. The 2nd ESMO Consensus Conference on Lung Cancer was held on 11-12 May 2013 in Lugano. A total of 35 experts met to address several questions on non-small-cell lung cancer (NSCLC) in each of four areas: pathology and molecular biomarkers, first-line/second and further lines in advanced disease, early-stage disease and locally advanced disease. For each question, recommendations were made including reference to the grade of recommendation and level of evidence. This consensus paper focuses on early-stage disease.

Thoracoscopic minimally invasive surgery for non-small cell lung cancer in patients with chronic obstructive pulmonary disease

OBJECTIVE

To determine the incidence of peri-operative complications in non-small cell lung cancer (NSCLC) patients with co-existent chronic obstructive pulmonary disease (COPD) who undergo lung resection via traditional and minimally invasive techniques.

METHODS

A retrospective analysis was conducted of 152 NSCLC patients with COPD who underwent thoracoscopic minimally invasive surgery. Particular attention is given to the relationship between disease severity or surgical approach and the incidence of complications.

RESULTS

THE PREVALENCE OF RESPIRATORY AND CARDIAC COMPLICATIONS WAS SIGNIFICANTLY HIGHER IN PATIENTS WITH SEVERE/EXTREMELY SEVERE COPD THAN THOSE WITH MILD TO MODERATE COPD (RESPIRATORY COMPICATIONS: 37.3% vs. 20.4%, P=0.022; cardiac complications: 16.9% vs. 6.5%, P=0.040). Patients who underwent complete-video assisted thoracoscopic surgery (c-VATS) had a significantly lower overall morbidity of adverse reactions than those who had undergone VATS major resection (26.3% vs. 42.1%, P=0.044). Among patients with severe/extremely severe COPD, there was no significant difference in the incidence of any complication between the lobectomy group and wedge resection group (38.8% vs. 70.0%, P=0.072). Overall, the occurrence of adverse reactions was significantly lower in patients who underwent c-VATS than in those who had undergone VATS major resection surgery (34.2% vs. 61.9%, P=0.038).

CONCLUSIONS

VATS techniques are suitable for COPD patients and are demonstrated here to lower the incidence of post-operative complications when compared with more invasive approaches.

What is the most practical, optimal, and cost effective method for performing follow-up after lung cancer surgery, and by whom should it be done?

Surgery is the treatment of choice for early stage non-small cell lung cancer. In this context, postoperative follow-up is important to diagnose late postoperative complications, as well as to detect recurring cancer or new primaries as early as possible. There is, however, no high-quality evidence regarding the benefits of monitoring programs on survival and quality of life. Most studies recommend clinical and radiological follow-up (radiograph or chest computed tomography) performed more intensively during the first two years and annually thereafter. The physician doing the follow-up can be the thoracic surgeon, the diagnosing physician, or the family physician.

Changes in cerebral oxygenation in patients with pulmonary dysfunction after lung resection

Lung resection would be associated with lower jugular bulb oxygen saturation (SjvO₂) values in patients with moderate to severe pulmonary dysfunction. We aimed to study the effects of lung resections on the postoperative changes in SjvO₂, incidence of SjvO₂ < 50%, pulmonary functions, cerebral blood flow equivalent (CBFE), and arterial to jugular difference in oxygen content (AjvDO₂) in the patients with pulmonary dysfunction. Fifty-three patients scheduled for lung resection were allocated on the basis of forced vital capacity (FVC %) and forced expiratory volume in 1 second (FEV(1)%) into the following: good FVC and FEV₁ (n = 14), mild (n = 14), moderate (n = 13), and severe (n = 12) pulmonary dysfunction groups. After lung resections, patients with pulmonary dysfunctions had significantly lower SjvO₂, CBFE, FEV₁, and FVC (P < .001), higher AjvDO₂ (P < .001), and frequent episodes with SjvO₂ < 50% (P < .03). Perioperative changes in FEV₁ had a significant negative correlation with SjvO₂ desaturation (P < .002). Patients with pulmonary dysfunction showed significant SjvO₂ < 50% after lung resection, which is correlated to the perioperative changes in FEV₁.

Surgical resection in combination with lung volume reduction surgery for stage I non-small cell lung cancer

Surgical resection remains the favored option of treatment for stage I lung cancer patients. Co-existing obstructive lung disease can reduce lung function and increase the risk of surgery. Severe emphysema may preclude resection of lung cancer due to concerns about low values of postoperative lung function. However, many patients will experience stable or improved lung function simply by resecting hyper-expanded and relatively functionless lung. This so-called "lung volume reduction effect" may occur after standard resection or after rare instances of formal lung volume reduction surgery concurrent with pulmonary resection of the tumor. This review explores these possibilities and informs the readers of pioneering work in this area.

Lung cancer in chronic obstructive pulmonary disease: enhancing surgical options and outcomes

Patients with chronic obstructive pulmonary disease (COPD) are at increased risk for both the development of primary lung cancer, as well as poor outcome after lung cancer diagnosis and treatment. Because of existing impairments in lung function, patients with COPD often do not meet traditional criteria for tolerance of definitive surgical lung cancer therapy. Emerging information regarding the physiology of lung resection in COPD indicates that postoperative decrements in lung function may be less than anticipated by traditional prediction tools. In patients with COPD, more inclusive consideration for surgical resection with curative intent may be appropriate as limited surgical resections or nonsurgical therapeutic options provide inferior survival. Furthermore, optimizing perioperative COPD medical care according to clinical practice guidelines including smoking cessation can potentially minimize morbidity and improve functional status in this often severely impaired patient population.

Efficacy of perioperative administration of long-acting bronchodilator on postoperative pulmonary function and quality of life in lung cancer patients with chronic obstructive pulmonary disease. Preliminary results of a randomized control study

PURPOSE

Long-acting bronchodilators are recommended as a first-line treatment for chronic obstructive pulmonary disease (COPD), although their effects for postoperative lung cancer patients with COPD are still not well known. A prospective randomized trial was used to examine the efficacy of bronchodilators on postoperative pulmonary function and quality of life (QOL).

METHODS

Twenty lung cancer patients with COPD who had lobectomies were randomized. A control group (n = 10) did not receive bronchodilators. An experimental group (n = 10) received tiotropium and salmeterol. Patients were divided into two COPD grades: stage I COPD and stage II-III COPD. Results for pulmonary function, 6-minute walking test, and the St. George's Respiratory Questionnaire (SGRQ) were compared. Diaphragmatic motion on dynamic magnetic resonance imaging was also analyzed.

RESULTS

The patient demographics were similar in the two groups. Except for pulmonary function results at 2 weeks, no other parameters were significantly different. However, in stage II-III COPD, forced expiratory volume in 1 second, forced vital capacity, inspiratory capacity, the total score of the SGRQ, and diaphragmatic motion in the experimental group (n = 5) were significantly better than those in the control group (n = 4) at various time points (all P < 0.05).

CONCLUSION

The daily inhalation of bronchodilators was effective for maintaining the respiratory function and QOL in lung cancer patients with moderate to severe COPD.

Correlation of computed tomography densitometry and pathological grading of emphysema with the variation of respiratory function after lobectomy for lung cancer

The presence of emphysema may lead to an underestimation of postoperative respiratory function after lobectomy when evaluated by standard functional assessment. The aim of the study was to assess the correlation between computed tomography (CT) densitometry, pathological grading of emphysema and variation of pulmonary function after lobectomy for lung cancer. Forty-one patients entered the study. Respiratory function was assessed preoperatively and after a mean period of 4.04 months following surgery. Postoperative function remained unchanged or increased after surgery in nine patients (Group A). In the remaining 32 patients (Group B) postoperative function was reduced after surgery. Preoperative forced expiratory volume in 1 s (FEV(1))% was 68.5+/-13.1% in Group A and 91.7+/-21.0% in Group B. CT densitometry of the lobe to be resected was -877.8+/-57.6 HU in Group A and -827.5+/-64.4 HU in Group B. Pathological grading of emphysema of the resected lobe (range 0-10) was 4.1+/-2.2 in Group A and 3.1+/-1.2 in Group B. A significant correlation was observed (Spearman rank correlation) between the variation of FEV(1) and preoperative FEV(1) (P=0.003; r=-0.455), CT quantitative assessment (P=0.036; r=-0.430) and pathological grading (P=0.008; r=0.673). Patients with a higher degree of emphysema had a lower reduction of respiratory function after lobectomy and CT densitometry and pathological grading of emphysema correlated with the variation in respiratory function.

Future trends in preoperative evaluation

Preoperative evaluation before lung resection has been frequently addressed in modern medical literature. Actual or predicted pulmonary volumes are considered relevant to predict the risk of surgery. Nevertheless, ppoFEV1 underestimates the real functional loss in the immediate postoperative period when most of the complications occur. Not all patients, however, have comparable functional changes after lobectomy. Minimal impairment or even improvements have been demonstrated in COPD cases after lobectomy. Efforts should be directed to an accurate prediction of the immediate postoperative pulmonary volumes for a better evaluation of high-risk patients caused by respiratory impairment. Future developments are needed on the role of measuring preoperative DLCO and how to evaluate a patient's general cardiorespiratory status. Evidence underlines the relevance of routine evaluation of preoperative DLCO at rest or, better, during exercise for a thorough assessment of patient's capability to adapt to a stressful situation (Fig. 3). Only by improving knowledge about the general condition of the patient, can one assess the physiologic response to surgery. Widespread use of sophisticated or simple exercise tests and measurements or daily activity using motion detectors can identify high-risk patients with otherwise acceptable pulmonary volumes. Another suggested investigation issue is to develop different relevant outcome parameters, not only from the surgeon's point of view but also from the patient's perspective, such as postoperative QOL-related variables or delayed outcomes. Finally, multidisciplinary investigation teams, including experts in mathematical modeling, are essential to improve the quality and validity of the developed models. Although knowledge about perioperative physiologic changes has increased, clinicians are still far from finding a way to put all this knowledge down and make it applicable for an individual patient. Multicentric cooperation and evaluation of large prospectively recorded databases are essential to develop evidence-based clinical guidelines on preoperative evaluation.

Complications in patients with severe emphysema

Thoracic surgeons frequently evaluate patients with severe emphysema and concomitant pathology requiring pulmonary resection. There are no absolute guidelines defining the suitability of a given patient for resection. In this review, we outline our approach to evaluating and treating patients with severe emphysema in need of resection. We describe the lessons learned from lung volume reduction surgery and apply that knowledge to the care of the patient with severe emphysema. Careful preoperative evaluation of the patient's lung anatomy, distribution of emphysematous changes in the lung, and overall health is essential to identifying the appropriate candidate for resection and avoiding postoperative complications.

The European societies subjective and objective scores

This article explores the issue of risk modeling for patients undergoing lung resection. The development of risk stratification in thoracic surgery is discussed together with its application in patient populations and in individual patients. The European Societies Risk Scores (Objective and Subjective) Version 1 are discussed in detail. The development of Version 2 of the risk score is described, and the future role of risk scoring on thoracic surgical practice is considered.

How Accurately Can We Predict Forced Expiratory Volume in One Second after Major Pulmonary Resection?

Standard formulas for predicting postoperative forced expiratory volume in 1 second (po-FEV1) do not consider bronchi obstructed by tumor or chronic obstructive pulmonary disease, e.g., Formula 1 [ppo-FEV1 = (pre-opFEV1) x (# segments remaining)/(# of total segments)] whereas Formula 2 [ppo-FEV1 = (pre-opFEV1) x (# segments remaining)/(# of total unobstructed segments)] does. A retrospective chart review was conducted to determine accuracy of predicting po-FEV1, at a comprehensive cancer center. Predicted po-FEV1 was calculated using different formulas and analyzed using regression analysis and Pearson correlation. We found good correlation between po-FEV1 and predicted po-FEV1 using Formulas 1 and 2. In patients with tumor airway obstruction or chronic obstructive pulmonary disease, predictive accuracy decreased for both formulas. Prediction of FEV1 in patients undergoing pulmonary resection was generally accurate, but major errors were observed in some cases; therefore, better predictive formulas are needed in patients with airway obstruction by tumor or chronic obstructive pulmonary disease.