What preoperative evaluation and management are recommended before tumor resection?

Preoperative Evaluation and Management Before Tumor Resection

A comprehensive preoperative evaluation for tumor resection should include cardiovascular assessment, pulmonary function testing, imaging studies, and multidisciplinary team review to optimize surgical outcomes and reduce morbidity and mortality.

Initial Assessment and Multidisciplinary Approach

• All patients being considered for tumor resection should be assessed by a multidisciplinary team including a surgeon specializing in the specific cancer type, medical oncologist, radiation oncologist, and pulmonologist 1
• Elderly patients should receive full evaluation regardless of age 1
• Preoperative histologic diagnosis of the mass should be obtained prior to initiating any treatment for most tumors 1

Cardiovascular Evaluation

• Patients with increased perioperative cardiovascular risk require preoperative cardiologic evaluation according to existing guidelines for non-cardiac surgery 1
• For lung cancer patients, cardiovascular evaluation should be the first step in preoperative assessment 1

Pulmonary Function Assessment (for Lung Resection)

Step 1: Initial Pulmonary Testing

• Measure FEV1 and diffusing capacity for carbon monoxide (DLCO) in all patients 1
• Calculate predicted postoperative (PPO) FEV1 and PPO DLCO 1

Step 2: Risk Stratification Based on Pulmonary Function

• If PPO FEV1 and PPO DLCO are both ≥60% predicted: Low risk, no further tests needed 1
• If either PPO FEV1 or PPO DLCO are between 30-60% predicted: Perform low technology exercise test (stair climbing or shuttle walk test) 1
  • Satisfactory performance: stair climbing altitude ≥22m or shuttle walk distance ≥400m indicates low risk 1
  • Unsatisfactory performance: Proceed to cardiopulmonary exercise testing 1
• If PPO FEV1 or PPO DLCO <30% predicted: Perform cardiopulmonary exercise testing 1
  • Peak oxygen consumption (VO2peak) <10 mL/kg/min or <35% predicted indicates high risk 1
  • VO2peak >20 mL/kg/min or >75% predicted indicates low risk 1

Imaging Studies

For Lung Cancer

• Chest CT scan with contrast 1
• PET/CT for staging 2
• Brain MRI (especially for higher stage disease) 2
• Invasive mediastinal staging (EBUS-TBNA or mediastinoscopy) to confirm nodal status 2

For Thymic Malignancies

• Chest CT with contrast 1
• Optional: FDG-PET and radiolabeled octreotide scan 1
• Chest MRI if clinically indicated 1

For Endometrial Cancer

• Evaluation of myometrial invasion 1
• Identification of suspicious lymph nodes 1
• Detection of locoregional advanced disease and distant metastases 1

For Thyroid Cancer

• Neck ultrasound for all patients 1
• For medullary thyroid cancer with lymph node metastases or serum calcitonin >400 pg/ml: chest CT, neck CT, and three-phase contrast enhanced liver CT or MRI 1

Laboratory Testing

General

• Complete blood count and platelets 1

For Specific Cancers

• For thymic malignancies: Serum beta-HCG, AFP if appropriate; TSH, T3, T4 levels as clinically indicated 1
• For thyroid cancer (medullary): Basal serum calcitonin, CEA, calcium, plasma metanephrines and normetanephrines 1

Special Considerations

Smoking Cessation

• For all patients who smoke, especially lung cancer patients: Tobacco dependence treatment is recommended prior to surgery 1
• Smoking cessation is associated with both short-term perioperative and long-term survival benefits 1

Pulmonary Rehabilitation

• For high-risk lung cancer patients (PPO FEV1 or PPO DLCO <60% and VO2max <10 mL/kg/min or <35%), preoperative pulmonary rehabilitation is recommended 1

Neoadjuvant Therapy Considerations

• For breast cancer: Consider preoperative systemic therapy (chemotherapy or endocrine therapy) based on tumor characteristics 1
• For T4 N0 M0 lung adenocarcinoma: Consider neoadjuvant chemotherapy or chemoradiotherapy before surgical resection 2

Perioperative Antibiotic Prophylaxis

• Administer cefazolin 1 gram IV 30-60 minutes prior to surgical incision 3
• For lengthy procedures (≥2 hours), administer additional 500 mg to 1 gram during surgery 3
• For procedures where infection would be particularly devastating (e.g., prosthetic implantation), continue prophylaxis for 24 hours postoperatively 3

Common Pitfalls to Avoid

1. Excluding elderly patients from surgical consideration based solely on age 1
2. Failing to perform invasive mediastinal staging in lung cancer patients being considered for curative resection 1
3. Not calculating predicted postoperative lung function values before lung resection 1
4. Overlooking the impact of previous cancer treatments (chemotherapy or radiation) on perioperative risks 4
5. Inadequate multidisciplinary evaluation before determining resectability 1, 2

By following this comprehensive preoperative evaluation approach, clinicians can identify patients at increased risk with standard tumor resection and enable informed decisions about the appropriate therapeutic approach, ultimately improving morbidity, mortality, and quality of life outcomes.