What is the next appropriate step in management for a 71-year-old woman with a 1.7 cm spiculated mass in the left upper lobe and impaired lung function, as indicated by a postoperative DLCO of 57% of predicted?

Management of a 71-Year-Old Woman with Lung Mass and Impaired Lung Function

The next appropriate step in management for this patient with a 1.7 cm spiculated mass in the left upper lobe and a postoperative DLCO of 57% predicted is to order a cardiopulmonary exercise test (CPET). 1

Assessment of Operative Risk

Initial Pulmonary Function Evaluation

• The patient has a postoperative DLCO of 57% predicted, which falls between 30-60% predicted
• According to the American College of Chest Physicians (ACCP) guidelines, when either the predicted postoperative (PPO) FEV1 or PPO DLCO is between 30% and 60%, further assessment with exercise testing is indicated 1
• This patient's DLCO value of 57% places her in a moderate risk category that requires additional evaluation before proceeding with surgery

Risk Stratification Algorithm

1. DLCO between 30-60% predicted: Requires additional functional assessment

   • This patient's DLCO of 57% falls in this range
   • Not low enough to immediately disqualify from surgery (would need to be <30%)
   • Not high enough to proceed directly to surgery (would need to be >60%)

2. Next step: Cardiopulmonary exercise testing

   • CPET provides the most comprehensive assessment of exercise capacity and cardiopulmonary reserve
   • Measures maximal oxygen consumption (VO₂max), which is the strongest predictor of postoperative outcomes 1

Why CPET is the Correct Choice

• The ACCP guidelines clearly state that when PPO DLCO is between 30-60%, a low technology exercise test should be performed as a screening test, followed by CPET if needed 1
• CPET provides objective measurement of cardiopulmonary reserve and helps determine if the patient can tolerate the physiologic stress of surgery
• A VO₂max >20 mL/kg/min or >75% predicted indicates low risk for surgery
• A VO₂max <10 mL/kg/min or <35% predicted indicates high risk 1, 2

Why Other Options Are Not Appropriate

• Informing the patient she's ineligible for surgery: Premature without further testing. A DLCO of 57% does not automatically disqualify a patient from surgery 1
• Proceeding immediately with surgery: Risky without further assessment of cardiopulmonary reserve in a patient with compromised lung function
• Ordering stereotactic body radiation therapy (SBRT): Should only be considered after complete evaluation determines the patient is not a surgical candidate, as surgery remains the gold standard for early-stage lung cancer 1

Importance of Complete Evaluation

• Surgical resection remains the cornerstone of treatment for early-stage NSCLC for patients who can tolerate the procedure 1
• Even patients with compromised lung function may benefit from surgery if proper assessment and selection are performed
• The European Society for Medical Oncology (ESMO) guidelines also recommend complete functional evaluation before determining inoperability 1

Common Pitfalls to Avoid

1. Relying solely on DLCO or FEV1: Both parameters should be considered together with exercise capacity
2. Assuming patients with borderline lung function are automatically inoperable: Many patients with compromised lung function can still undergo surgery safely with proper selection
3. Overlooking the potential "lung volume reduction effect": Some COPD patients may experience improved pulmonary function after lobectomy if the most affected lung tissue is removed 2
4. Failing to consider surgical approach: Video-assisted thoracoscopic surgery (VATS) may be associated with lower complication rates than open thoracotomy in patients with compromised lung function 1

By ordering a CPET, you will obtain the most comprehensive assessment of this patient's ability to tolerate surgery, allowing for an informed decision about the most appropriate treatment approach for her lung mass.