A Method for Predicting Postoperative Lung Function and Its Relation to Postoperative Complications in Patients with Lung Cancer

Nakahara, Kazunari; Monden, Yasumasa; Ohno, Kiyoshi; Miyoshi, Shinichiro; Maeda, Hitoshi; Kawashima, Yasunaru

doi:10.1016/s0003-4975(10)62591-x

Cited by 155 publications

(106 citation statements)

References 13 publications

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“…As a result of the findings of these investigators, it was recommended that a ppo FEV1 of .0.8 L is used as the cut-off for surgery. Others have found it more useful to use percentage predicted FEV1, recommending a threshold of .50% pred for FEV1 [10] or .40% pred for ppo FEV1 [9]. For the latter, a value of ,40% was associated with 50% mortality.…”

Section: Discussionmentioning

confidence: 99%

“…This is followed by an exercise test, either a shuttle walking test or a formal cardiopulmonary exercise test. Many previous studies have shown predictive values for specific cut-off levels of FEV1 and DL,CO [6][7][8][9][10][11]. A study performed by PIERCE et al [12] suggested that the product of ppo FEV1 and ppo DL,CO (both % pred) was the most useful predictor of survival from surgery.…”

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confidence: 98%

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Relationship between pulmonary function and lung cancer surgical outcome

Win

Jackson²,

Sharples³

et al. 2005

European Respiratory Journal

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The British Thoracic Society and American College of Chest Physician guidelines outline criteria for investigating patients for lung cancer surgery. However, the guidelines are based on relatively old studies. Therefore, the relationship between pulmonary function test results and surgical outcome were studied prospectively in a large cohort of lung cancer patients.From January 2001 to December 2003, 110 patients underwent surgery for lung cancer. All underwent full lung function testing in order to predict post-operative lung function.The hospital mortality rate was 3% and major complication rate 22%. There was poor overall outcome in 13%. Mean pre-operative lung function values were: forced expiratory volume in one second (FEV1) 2.0 L (79.4% of the predicted value), and carbon monoxide diffusing capacity of the lung (DL,CO) 73.6% pred. The mean post-operative lung function values were: FEV1 1.4 L (55.6% pred), and DL,CO 51.3% pred. All lung function values were better predictors of poor surgical outcome when expressed as a percentage of the predicted value. Using a threshold of preoperative FEV1 of 47% pred resulted in the most useful positive and negative predictive probabilities, 0.90 and 0.67, respectively.Lung function values expressed as a percentage of the predicted value are more useful predictors of post-operative outcome than absolute values. The threshold of predicted forced expiratory volume in one second for surgical intervention could be lower (45-50% pred) than is currently accepted without increased mortality.KEYWORDS: Lung carcinoma, lung function, lung function tests, surgical resection S urgical resection remains the treatment of choice for anatomically resectable nonsmall cell lung cancer [1,2], offering the best prospect of long-term survival. However, many patients have coexisting chronic airflow limitation [3], which is associated with an increased risk from surgery. Loss of lung tissue may grossly impair post-operative ventilatory function in such patients, predisposing to cardiopulmonary complications, including death. The British Thoracic Society (BTS) and American College of Chest Physician guidelines [4,5] outline criteria for investigating patients with borderline lung function. However, many of the studies on which the guidelines are based are relatively old, and often based on predominantly male patients who were significantly younger than patients currently being considered for surgery.The latest BTS guidelines suggest that further investigation is unnecessary if a patient has a forced expiratory volume in one second (FEV1) of .2.0 L for pneumonectomy or .1.5 L for lobectomy. This is because studies have shown a mortality rate of ,5% using these criteria. However, these figures are based mainly on studies involving males, and it is likely that lower values would be more appropriate for females. It is possible that a figure based on a value expressed as a percentage of the predicted value would be better still, since this would also take into account the patient's age, s...

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 98%

Relationship between pulmonary function and lung cancer surgical outcome

Win

Jackson²,

Sharples³

et al. 2005

European Respiratory Journal

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“…ZEIHER et al [121] found this overestimation to be approximately 250 mL after lobectomy and 500 mL after pneumonectomy. This aspect was taken into account by NAKAHARA et al [122], who also estimated the FEV1-ppo nonscintigraphically, but made a distinction between obstructed and normal subsegments; their formula was: FEV1-ppo = (1-(b-n)/(42-n)) × preoperative FEV1 (where n and b are the number of obstructed subsegments and total subsegments, respectively, of the parenchyma to be resected, and 42 the total number of subsegments). In this study, FEV1-ppo was also predictive of postoperative complications.…”

Section: Split-function Studiesmentioning

confidence: 99%

“…MIYOSHI et al [129] (in 1987), NAKAHARA et al [43] and NAKAGAWA et al [130] (in 1992), who were all from the same Japanese group, reported on their protocol in which patients with a VC-ppo of >40% pred were exercised with a 25 W increase every 3 min until the cardiac frequency reached 140 beats·min -1 or the respiratory exchange ratio (R) exceeded 1.0. All patients had catheters in the pulmonary and radial arteries.…”

Section: Submaximal Testsmentioning

confidence: 99%

Functional evaluation of the lung resection candidate

Bolliger¹,

Perruchoud²

1998

Eur Respir J

161

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Advances in operative technique and perioperative care have considerably reduced surgical morbidity and mortality after pulmonary resections. Various single and combined parameters of functional operability have been proposed to assess the surgical risk. Pulmonary function tests adequately assess the pulmonary risk, and baseline or stress electrocardiography, echocardiography and nuclear cardiac studies assess the cardiac risk.Patients with normal or only slightly impaired pulmonary function (forced expiratory volume in one second (FEV1) and transfer factor of the lung for carbon monoxide (TL,CO) ≥80% of predicted) and no cardiovascular risk factors can undergo pulmonary resections up to a pneumonectomy without further investigation. For others, exercise testing, pulmonary split-function studies, or a combination of these two methods are recommended. Exercise testing, most frequently performed as a symptom-limited test with the measurement of maximal oxygen uptake (V 'O 2 ,max), assesses both the pulmonary and cardiovascular reserves. A V'O 2 ,max of <10 mL·kg -1 ·min -1 is generally considered prohibitive for any resection, a value of >20 mL·kg -1 ·min -1 or >75% of predicted normal, safe for major resections. Split-function studies are radionuclide-based estimations of the predicted postoperative (ppo) values of various parameters. The currently used ppo-parameters are FEV1-ppo, TL,CO-ppo and, most recently, V'O 2 ,max-ppo. Suggested cutoff values for safe resection are: for FEV1-ppo and TL,CO-ppo ≥40% pred; and for V 'O 2 ,max ≥35% pred, combined with an absolute value of ≥10 mL·kg -1 ·min -1 . The lowest acceptable ppo-values will still have to be established by additional prospective studies.In the long-term, resections involving not more than one lobe usually lead to an early functional deficit followed by later recovery. The permanent functional loss in pulmonary function is small (≤10%) and exercise capacity is only slightly reduced or not at all. Pneumonectomy, on the other hand, leads to an early permanent loss of about 33% in pulmonary function and 20% in exercise capacity. Thus, pulmonary function tests alone overestimate the functional loss after lung resection. Eur Respir J 1998; 11: 198-212 The dramatic increase in the incidence of bronchogenic carcinoma has made this disease the most frequent malignancy worldwide. In industrialized nations, the majority of lung resection candidates suffer from bronchogenic carcinoma, whereas only some decades ago benign conditions, such as destroyed lung parenchyma after tuberculosis, had to be removed. The prognosis of bronchogenic carcinoma remains sombre as about 75-85% are inoperable at the time of diagnosis [1], and despite recent advances in chemo-and radiotherapy regimens, surgical resection remains the only curative form of treatment [2].Depending on their extent, pulmonary resections lead to permanent loss of pulmonary function. In healthy people, resections up to a pneumonectomy are tolerated remarkably well. Lung cancer patients, however, are...

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“…In this sense, a value of ppo-FEV1 less than 40% of predicted increases the risk of perioperative complications and mortality by 16-50% (Pierce et al, 1994), being higher (60%) when ppo-FEV1 is less than 30% (Nakahara et al, 1985). Even today there is a disagreement about whether ppo-FEV1 is a good predictor of perioperative complications or not.…”

Section: Spirometrymentioning

confidence: 99%