Cancer pulmonar

The American Journal of Medicine (2005) 118, 578 –583

REVIEW

Lung cancer: Preoperative pulmonary evaluation of the lung resection candidate
Peter J. Mazzone, MD, MPH, FRCP(C), FCCP, Alejandro C. Arroliga, MD, FCCP
Department of Pulmonary, Allergy, and Critical Care Medicine, The Cleveland Clinic Foundation. KEYWORDS:
Lung cancer; Lung resection; Forced expiratory volume in 1 second;Diffusing capacity for carbon monoxide; Exercise testing; Lung volume reduction surgery ABSTRACT: Lung resection provides the best chance of cure for individuals with early stage non–small cell lung cancer. Naturally, lung resection will lead to a decrease in lung function. The population that develops lung cancer often has concomitant lung disease and a reduced ability to tolerate further losses inlung function. The goal of the preoperative pulmonary assessment of individuals with resectable lung cancer is to identify those individuals whose short- and long-term morbidity and mortality would be unacceptably high if surgical resection were to occur. Pulmonary function measures such as the forced expiratory volume in 1 second and the diffusing capacity for carbon monoxide are useful predictorsof postoperative outcome. In situations in which lung function is not normal, the prediction of postoperative lung function from preoperative results and the assessment of exercise capacity can be performed to further clarify risks. Published guidelines help to direct the order of testing, permitting us to offer resection to as many patients as possible. © 2005 Elsevier Inc. All rights reserved.The pre–lung resection pulmonary evaluation of an individual with lung cancer is designed to minimize perioperative and long-term morbidity and mortality. At the same time, the internist must recognize that surgical resection provides by far the greatest chance of cure for this deadly disease. The prognosis for lung cancer when surgery is not an option is poor, even if it found in the earlieststage. The median survival for clinical stage I lung cancer patients who are not surgically treated is 25 months if the cancer is screen detected, and 13 months if it is symptom detected.1 Fiveand 10-year survival rates in screen-detected, non-surgically treated, clinical stage I lung cancer are 16.6% and 7.4%, respectively.2 Unfortunately, only approximately 20% of individuals with lung cancerare determined to be candiRequests for reprints should be addressed to Peter J. Mazzone, The Department of Pulmonary, Allergy, and Critical Care Medicine, The Cleveland Clinic Foundation, 9500 Euclid Ave., A90, Cleveland, OH 44195. Email address: mazzonp@ccf.org.

dates for lung resection.3 For those eligible for resection, operative mortality has been described in the 3%– 4% range,3,4 withpostoperative complications ranging widely, depending on their definition.4 Pulmonary function is affected by lung resection. The decline in lung function varies with the extent of the resection. The greatest decline has been seen with a pneumonectomy. The forced expiratory volume in 1-second (FEV1) has been shown to fall an average of 34%–36%, the forced vital capacity (FVC) 36%-40%, and the maximumoxygen consumption (VO2 max) 20-28%.5,6 If a lobectomy is performed, the FEV1 has been shown to fall an average of 9%-17%, the FVC 7%-11%, and the VO2 max 0%–13%.5,6 Measures of pulmonary function may underestimate functional capacity after resection as determined by exercise testing. The degree of functional loss appears to be less in individuals with poor baseline lung function.7,8 With thisbackground— extremely poor prognosis without resection, low operative mortality, and modest declines in lung function post resection—the internist must help decide who can safely tolerate lung resection. This literature

0002-9343/$ -see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.amjmed.2004.12.024

Mazzone and Arroliga
Table 1 Author Breyer9 Ishida10 Massard11 Pagni12...