What is the recommended approach for lung resection in patients with lung cancer?

Recommended Approach for Lung Resection in Patients with Lung Cancer

For patients with lung cancer, the recommended approach for lung resection should begin with a comprehensive preoperative physiologic assessment including cardiovascular evaluation, spirometry (FEV1), and diffusing capacity (DLCO) measurements, followed by calculation of predicted postoperative values to determine surgical candidacy. 1

Preoperative Assessment Algorithm

Step 1: Initial Pulmonary Function Testing

• Measure FEV1 and DLCO in all patients 1
• If post-bronchodilator FEV1 >1.5L for lobectomy or >2.0L for pneumonectomy with no evidence of interstitial lung disease, no further respiratory testing is needed 1

Step 2: Calculate Predicted Postoperative Values

• Calculate predicted postoperative FEV1 (PPO FEV1) and DLCO (PPO DLCO) using the formula:
  • PPO value = preoperative value × (19 - segments to be removed)/19 1
  • Or: preoperative value × (1 - proportion of lung to be resected) 1

Step 3: Risk Stratification Based on PPO Values

• Low risk: If PPO FEV1 and PPO DLCO both ≥60% predicted
  • Proceed with anatomic lung resection without further testing 1
• Intermediate risk: If PPO FEV1 or PPO DLCO between 30-60% predicted
  • Perform low-technology exercise test (stair climbing or shuttle walk test) 1
  • If stair climbing ≥22m or shuttle walk distance ≥400m, proceed with resection 1
• High risk: If PPO FEV1 or PPO DLCO <30% predicted or poor performance on low-tech exercise test
  • Perform cardiopulmonary exercise test (CPET) with VO2max measurement 1
  • If VO2max >20 mL/kg/min or >75% predicted: low risk 1
  • If VO2max <10 mL/kg/min or <35% predicted: high risk, consider alternatives 1

Surgical Approach Selection

Extent of Resection

• Anatomical resection (lobectomy) is preferred over wedge resection for solid tumors ≥2cm 1
• Sublobar resection (segmentectomy or wide wedge) is acceptable for:
  • Pure ground-glass opacity (GGO) lesions
  • Adenocarcinoma in situ or minimally invasive adenocarcinoma
  • Patients with limited pulmonary reserve 1

Surgical Access

• Either open thoracotomy or VATS (video-assisted thoracic surgery) can be performed based on surgeon expertise 1
• VATS should be the approach of choice for stage I tumors 1

Special Considerations

Age

• Age alone should not be a contraindication to surgery 1
• Elderly patients (>70 years) with stage I and II disease should be considered for surgical treatment 1
• Even patients >80 years can undergo lobectomy or wedge resection for stage I disease 1
• Pneumonectomy carries higher risk in elderly patients 1

Patients with Emphysema

• In patients with emphysema and limited pulmonary function, resection of the lung cancer within emphysematous tissue may provide a lung volume reduction effect 1
• This can be particularly beneficial in patients with heterogeneous emphysema 1

Multidisciplinary Approach

• All patients should be assessed by a multidisciplinary team including a thoracic surgeon, medical oncologist, radiation oncologist, and pulmonologist 1
• Patients with multiple adverse medical factors should have their management discussed formally at a multidisciplinary meeting 1

Perioperative Considerations

Smoking Cessation

• Tobacco dependence treatment is recommended for all patients who are actively smoking 1
• Smoking cessation provides both short-term perioperative and long-term survival benefits 1

Pulmonary Rehabilitation

• Preoperative or postoperative pulmonary rehabilitation is recommended for high-risk patients 1
• This can improve exercise performance, symptoms, and potentially pulmonary function 1

Common Pitfalls and Caveats

1. Overreliance on a single test: No single pulmonary function test can accurately predict postoperative complications. A comprehensive assessment is essential 2

2. Inadequate lymph node evaluation: Systematic lymph node dissection at the time of lung resection is essential for accurate staging 1

3. Underestimating cardiovascular risk: Cardiac assessment using the recalibrated thoracic RCRI is recommended before considering surgical resection 1

4. Failure to consider alternative approaches: In patients with severely limited pulmonary function, consider alternative approaches such as sublobar resection, sleeve lobectomy, or non-surgical options 3

5. Neglecting nutritional status: Poor nutritional status (low BMI, low albumin) increases risk of postoperative complications and should be assessed preoperatively 1, 3

By following this systematic approach to preoperative assessment and surgical planning, clinicians can optimize outcomes for patients undergoing lung resection for lung cancer while minimizing morbidity and mortality.