Is the condition inoperable?

Determining Operability: A Disease-Specific Approach

Whether a condition is "inoperable" depends entirely on the specific disease, tumor stage, patient factors, and institutional expertise—there is no universal definition of inoperability across all conditions.

Key Principles for Assessing Operability

The determination of operability requires systematic evaluation across multiple dimensions:

Disease-Specific Factors

For malignant pleural mesothelioma (MPM):

• Stage IV disease and sarcomatoid histology are considered inoperable; chemotherapy is the recommended treatment for these patients 1
• Early-stage disease (stage I, confined to pleural envelope, no N2 involvement) with epithelioid histology, good performance status, and absence of comorbidities represents the most favorable operative candidates 1
• Stages II-III disease may be operable, but pleurectomy/decortication (P/D) is preferred over extrapleural pneumonectomy (EPP) due to lower morbidity and mortality 1

For salivary gland malignancies:

• Patients may be deemed inoperable based on extent of disease, presence of metastatic disease, or underlying medical comorbidities, with 7-30% of patients falling into this category depending on histology and primary site 1
• For inoperable salivary gland malignancies, definitive radiotherapy to curative dose (approximately 70 Gy) provides local control benefit and cause-specific survival of approximately 40% at 10 years 1

For early-stage non-small cell lung cancer:

• Medical inoperability is defined by severe comorbidities that preclude safe surgical resection 1
• For medically inoperable patients with stage T1-2N0M0 NSCLC, stereotactic ablative radiation therapy (SABR) should be preferred to standard external beam radiotherapy 1
• Surgery remains standard for medically operable patients, as SABR has insufficient comparative data to be considered equivalent 1

Patient-Related Factors

Performance status and comorbidities are critical determinants:

• Good performance status and absence of comorbidities favor operative intervention across disease types 1
• Poor performance status, significant comorbidities, advanced age (though not absolute contraindications), renal insufficiency, and hepatic dysfunction increase operative risk 1
• For MPM, EPP is recommended only for select good-risk patients with good performance status and absence of comorbidities, not for those with comorbid conditions 1

Institutional and Technical Factors

Surgical expertise significantly impacts operability determination:

• For chronic thromboembolic pulmonary hypertension (CTEPH), severe hemodynamic or echocardiographic abnormalities should not be used by physicians to deem a patient "inoperable"—this determination requires evaluation at an experienced center 1
• The preoperative differentiation of operable from inoperable CTEPH depends on surgical expertise and the degree of microvascular disease versus macroscopic disease in surgically accessible vessels 1
• Patients with CTEPH should be referred for surgical evaluation at an experienced center as soon as possible, even if symptoms are mild 1

Common Pitfalls in Operability Assessment

Avoid Premature Declarations of Inoperability

• Do not declare patients inoperable based solely on imaging findings or hemodynamic parameters without expert surgical consultation 1
• For CTEPH, there is no upper limit of pulmonary vascular resistance or degree of right ventricular dysfunction that excludes a patient from surgery at an experienced center 1
• Patients with suprasystemic pulmonary artery pressures can safely undergo pulmonary endarterectomy at experienced centers 1

Consider Alternative Definitions

"Medically inoperable" versus "technically inoperable":

• Medically inoperable refers to patients whose comorbidities preclude safe anesthesia and surgery 1
• Technically inoperable refers to disease extent that cannot be adequately resected 1
• These distinctions guide different treatment pathways (medical therapy, radiation, or observation) 1

Disease-Specific Nuances

For desmoid-type aggressive fibromatosis:

• Primary disease amenable only to surgery with significant functional losses has multiple options: wide excision, radiation therapy, observation, isolated limb perfusion (if extremity-confined), or systemic therapy 1
• For inoperable desmoid disease, radiation therapy, isolated limb perfusion (if extremity-confined), systemic therapies, and observation are all valid options 1
• The non-metastasizing nature of this disease makes observation a reasonable option in selected cases 1

Treatment Pathways for Inoperable Disease

When disease is deemed truly inoperable, specific alternatives exist:

• For inoperable MPM (stages I-IV) and sarcomatoid histology: chemotherapy alone with cisplatin/pemetrexed as the gold standard 1
• For inoperable salivary gland malignancies: definitive radiotherapy to 70 Gy covering gross disease with margin 1
• For medically inoperable early-stage NSCLC: SABR with biological equivalent dose (BED10) of at least 100 Gy 1
• For inoperable CTEPH: indefinite therapeutic anticoagulation and consideration of pulmonary arterial hypertension-specific medical therapy 1

The determination requires multidisciplinary evaluation including surgical expertise, careful assessment of disease extent, patient functional status, and institutional capabilities—premature declarations of inoperability should be avoided, particularly for complex conditions requiring specialized surgical expertise.