Pulmonary Dysfunction as a Major Cause of Inoperability Among Patients with Non–Small-Cell Lung Cancer

doi:10.3816/CLC.2006.n.017

Clinical Lung Cancer

Volume 7, Issue 5, March 2006, Pages 344-349

https://doi.org/10.3816/CLC.2006.n.017 Get rights and content

Abstract

Purpose

We wanted to assess the prevalence of pulmonary dysfunction as the underlying reason for inoperability among patients with non–small-cell lung cancer (NSCLC) who were considered for surgical treatment at the time of diagnosis.

Patients and Methods

This is a retrospective analysis of all patients with NSCLC referred to our pulmonary function laboratory for preoperative evaluation between January 2001 and November 2001. Pulmonary function testing consisted of measurement of spirometric indices (forced expiratory volume in 1 second [FEV<sub>1</sub>]), lung volumes and diffusing capacity for carbon monoxide, Xenon-133 quantitative ventilation and perfusion studies, and exercise testing when indicated. Patient demographics and clinical characteristics at the time of the evaluation were reviewed.

Results

The group comprised 206 consecutive potential surgical candidates (mean age, 64.7 years ± 10.1 years) with NSCLC. Nearly half (45.6%) of the patients had early-stage (I/II) disease, and the remainder had late-stage disease at the time of pulmonary evaluation. The average predicted FEV<sub>1</sub> among all patients was 70.3% ± 19.6% (range, 25%-123%). One hundred eight patients (52.4%) were deemed surgically inoperable after the preoperative assessment. Severe pulmonary function impairment was identified as the reason for surgical inoperability in more than one third of these patients (40 of 108).

Conclusion

A substantial number of patients with anatomically resectable NSCLC are deemed surgically ineligible based on poor lung function. Recognition of the magnitude of this problem is fundamental to the development of effective treatment options, which might include preoperative management strategies that could better prepare patients for surgery or, alternatively, aggressive nonsurgical approaches.

References (31)

D Datta et al.
Preoperative evaluation of patients undergoing lung resection surgery
Chest
(2003)
M Semik et al.
Lung cancer surgery–preoperative risk assessment and patient selection
Lung Cancer
(2001)
PS Romano et al.
Patient and hospital characteristics related to in-hospital mortality after lung cancer resection
Chest
(1992)
J Whittle et al.
Use of Medicare claims data to evaluate outcomes in elderly patients undergoing lung resection for lung cancer
Chest
(1991)
RC Morice et al.
Exercise testing in the evaluation of patients at high risk for complications from lung resection
Chest
(1992)
MA Beckles et al.
American College of Chest Physicians. The physiologic evaluation of patients with lung cancer being considered for resectional surgery
Chest
(2003)
JR Burke et al.
Preoperative risk assessment for marginal patients requiring pulmonary resection
Ann Thorac Surg
(2003)
C Mountain
Revisions in the International System for Staging Lung Cancer
Chest
(1997)
MK Ali et al.
Regional and overall pulmonary function changes in lung cancer. Correlations with tumor stage, extent of pulmonary resection, and patient survival
J Thorac Cardiovasc Surg
(1983)
MK Ali et al.
Predicting loss of pulmonary function after pulmonary resection for bronchogenic carcinoma
Chest
(1980)

RC McGarry et al.

Observation-only management of early stage, medically inoperable lung cancer: poor outcome

Chest

(2002)

BJ Flehinger et al.

The effect of surgical treatment on survival from early lung cancer. Implications for screening

Chest

(1992)

P Solli et al.

Impact of limited pulmonary function on the management of resectable lung cancer

Lung Cancer

(2003)

J Reardon et al.

The effect of comprehensive outpatient pulmonary rehabilitation on dyspnea

Chest

(1994)

GT Ferguson

Recommendations for the management of COPD

Chest

(2000)

Cited by (34)

3D-Quantitated Single Photon Emission Computed Tomography/Computed Tomography: Impact on intended Management Compared to Lung Perfusion Scan in Marginal Candidates for Pulmonary Resection
2023, Clinical Lung Cancer
Based on previous studies, single-photon emission computed tomography/computed tomography (SPECT/CT) has been proven more accurate and reproducible than planar lung perfusion scintigraphy to assess lobar perfusion. However, the impact of 3D-quantitated SPECT/CT on intended management in functionally marginal candidates for pulmonary resection is unknown. The evaluation of this impact was the main aim of this study.
Consecutive candidates for lung resection underwent preoperative evaluation according to ERS/ESTS Algorithm and underwent preoperative lung perfusion imaging. The lobar contribution to the total lung perfusion was estimated using established planar scintigraphic methods and 3-dimensional quantitative SPECT/CT method (CT Pulmo3D and xSPECT-Quant, Siemens). The difference in estimated lobar perfusion with resulting changes in predicted postoperative (ppo) lung function and extent of lung resection were analyzed to reveal possible changes in operability. In-hospital outcome was assessed.
One hundred twenty patients (46 females) were enrolled. The mean age (±SD) of patients was 68 ± 9 years, target lesions were in upper lobes in 57.7% and in lower lobes in 33.5%. The median FEV1 (forced expiratory volume in 1 second) was 70.5% (IQR 52-84) and median DLCO (diffusion capacity of lung for carbon monoxide) was 56.6% [47.1-67.4]. The planar posterior oblique method, compared to 3D-quantitated SPECT/CT, underestimated the perfusion of upper lobes by a median difference of 5% (right [2-9], left [2.5-8]; P = <.0001), while it overestimated the perfusion of lower lobes (left by 4% [2-7], right by 6% [2-9]; P = <.0001). In contrast to planar scintigraphy-based evaluation, 4 patients (3.3%), all with upper lobe lesions, were classified as inoperable when 3D-quantitated SPECT/CT was used for calculation of the ppo lung function.
In selected patients with upper lobe lesions, 3D-quantitated SPECT/CT would have changed the treatment strategy from operable to inoperable. Importantly, postoperative mortality in this particular subgroup was disproportionally high. 3D-quantitated SPECT/CT shall be further evaluated as it might improve preoperative risk stratification in functionally marginal candidates.
“Fit for Surgery? What's New in Preoperative Assessment of the High-Risk Patient Undergoing Pulmonary Resection”
2021, Journal of Cardiothoracic and Vascular Anesthesia
Citation Excerpt :
However, uncertainty exists regarding the upper age limit for screening, and the risk-benefit in those with significant comorbidity and functional limitation.5 Up to 40% of patients with anatomically resectable lung cancer may be considered inoperable on the basis of severe pulmonary dysfunction alone.6 Parenchymal- sparing surgery, minimally invasive thoracoscopic surgery, and improvements in perioperative management have increased the pool of high-risk cases that may be amenable to surgical management.7
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.
CT Densitometry and Morphology of Radiofrequency-Ablated Stage IA Non–Small Cell Lung Cancer: Results from the American College of Surgeons Oncology Group Z4033 (Alliance) Trial
2020, Journal of Vascular and Interventional Radiology
Citation Excerpt :
Key among them is preservation of lung function and, thus, functional state, especially in patients with emphysema and low pulmonary reserve (3,7). A single-institution retrospective study discovered that 37% of patients with anatomically resectable tumors were deemed nonsurgical candidates secondary to poor lung function (20). Many patients with lung cancer have concomitant pulmonary disease and dysfunction, thus an alternative treatment modality for nonsurgical patients that preserves functioning parenchyma is critical.
To evaluate tumor and ablation zone morphology and densitometry related to tumor recurrence in participants with Stage IA non–small cell lung cancer undergoing radiofrequency ablation in a prospective, multicenter trial.
Forty-five participants (median 76 years old; 25 women; 20 men) from 16 sites were followed for 2 years (December 2006 to November 2010) with computed tomography (CT) densitometry. Imaging findings before and after ablation were recorded, including maximum CT attenuation (in Hounsfield units) at precontrast and 45-, 90-, 180-, and 300-s postcontrast.
Every 1-cm increase in the largest axial diameter of the ablation zone at 3-months’ follow-up compared to the index tumor reduced the odds of 2-year recurrence by 52% (P = .02). A 1-cm difference performed the best (sensitivity, 0.56; specificity, 0.93; positive likelihood ratio of 8). CT densitometry precontrast and at 45 seconds showed significantly different enhancement patterns in a comparison among pretreated lung cancer (delta = +61.2 HU), tumor recurrence (delta = +57 HU), and treated tumor/ablation zone (delta [change in attenuation] = +16.9 HU), (P < .0001). Densitometry from 45 to 300 s was also different among pretreated tumor (delta = −6.8 HU), recurrence (delta = −11.2 HU), and treated tumor (delta = +12.1 HU; P = .01). Untreated and residual tumor demonstrated washout, whereas treated tumor demonstrated increased attenuation.
An ablation zone ≥1 cm larger than the initial tumor, based on 3-month follow-up imaging, is recommended to decrease odds of recurrence. CT densitometry can delineate tumor versus treatment zones.
Cancer of the Lung: Non-Small Cell Lung Cancer and Small Cell Lung Cancer
2019, Abeloff’s Clinical Oncology
Lung cancer is a highly incident disease, and the major cause of cancer death worldwide. Trends in lung cancer incidence and mortality follow an epidemiological link to the history of tobacco consumption, although a recent increase of cases in never smokers has been observed. Throughout this chapter, readers will have the chance to appreciate the major changes and advances that took place in the presentation, diagnosis, and treatment of lung cancer in the past decades. The pathology and staging classification of lung cancer has evolved over time, as has the knowledge on its genomic landscape. The discovery of driver mutations such as EGFR and ALK has revolutionized the field of targeted therapy. Molecular testing has become a standard in non-squamous NSCLC, and results are now essential to link patients to better-suited therapies. The greater understanding of cancer immunology also impacted lung cancer therapy. Immune checkpoint inhibitors are now a routine in most lung cancer cases, including metastatic and locally advanced NSCLC. The advance in imaging diagnostics and intervention allowed better detection (including screening programs), staging (mainly due to PET-CT), and treatment. Minimally invasive techniques are commonly used to help diagnose and stage lung cancer. Daily examples include CT-guided biopsies, EBUS, EUS, video-assisted and robotic surgery. Modern radiation devices have enabled the application of highly precise doses to localized nodules, adding new treatment opportunities to different disease stages. Altogether, lung cancer control requires multidisciplinary care and continuous research effort.
Cancer of the Lung: Non-Small Cell Lung Cancer and Small Cell Lung Cancer
2013, Abeloff's Clinical Oncology: Fifth Edition
When Should Pulmonary Function Tests Be Performed Preoperatively?
2013, Evidence-Based Practice of Anesthesiology

View all citing articles on Scopus

Electronic forwarding or copying is a violation of US and International Copyright Laws.

Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by CIG Media Group, LP, ISSN #1525-7304, provided the appropriate fee is paid directly to Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923 USA 978-750-8400.

View full text

Original ContributionPulmonary Dysfunction as a Major Cause of Inoperability Among Patients with Non–Small-Cell Lung Cancer

Abstract

Purpose

Patients and Methods

Results

Conclusion

Chest

Lung Cancer

Chest

Chest

Chest

Chest

Ann Thorac Surg

Chest

J Thorac Cardiovasc Surg

Chest

Chest

Chest

Lung Cancer

Chest

Chest

Original Contribution
Pulmonary Dysfunction as a Major Cause of Inoperability Among Patients with Non–Small-Cell Lung Cancer