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Ann Thorac Surg 1996;62:348-351
© 1996 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Lung Resection in Patients With Compromised Pulmonary Function

Section of General Thoracic Surgery, Division of Pulmonary Medicine, and Section of Biostatistics, Mayo Clinic and Mayo Foundation, Rochester, Minnesota

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. Some patients are denied curative pulmonary resection for lung carcinoma because of pulmonary insufficiency. To identify factors that affect postoperative morbidity and mortality, we reviewed 85 consecutive patients (53 men and 32 women) with a preoperative forced expiratory volume in 1 second of less than 1.2 L who underwent pulmonary resection for lung cancer between January 1986 and December 1990.

Methods. Median age was 70 years (range, 49 to 82 years). Sixty patients (71%) had been previously denied operation because of pulmonary insufficiency. Preoperative pulmonary function demonstrated a median preoperative forced expiratory volume in 1 second of 1.0 L (44% of predicted normal; range, 0.5 to 1.2 L) and a diffusing capacity of the lung for carbon monoxide of 60% of predicted normal (range, 22% to 104%).

Results. Pneumonectomy was done in 6 patients (7.1%), bilobectomy in 6 (7.1%), lobectomy in 38 (44.7%), segmentectomy in 12 (14.1%), and wedge excision in 23 (27.1%). The median predicted postoperative forced expiratory volume in 1 second was 0.83 L (34% of predicted normal; range, 0.45 to 1.14 L), and the median predicted postoperative diffusing capacity of the lung for carbon monoxide was 48% of predicted normal (range, 19% to 87%). Seventy-two patients (85%) received postoperative epidural analgesia. Median hospitalization was 15 days (range, 5 to 66 days). Operative mortality was 2.4%, and complications occurred in 49%. We did not identify any factors that predicted postoperative morbidity and mortality. Median follow-up was 3.2 years (range, 0.2 to 9 years). Seven patients (8%) required supplemental home oxygen. A predicted postoperative percent forced expiratory volume in 1 second less than 43% correlated with the need for home oxygen (p < 0.05). Overall 5-year survival was 44.0%. Survival for stage I cancer was 54.2%; stage II, 33.1%; and stage IIIa, 21.3%.

Conclusions. We conclude that some patients with lung cancer and compromised pulmonary function can safely undergo pulmonary resection if selected appropriately.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Surgical resection is the treatment of choice for patients with lung cancer. However, patients with limited pulmonary function are often denied curative resection because of the fear of postoperative pulmonary insufficiency. Since the report by Olsen and associates [1] in 1975, many surgeons will not resect tumors in patients with a predicted postoperative forced expiratory volume in 1 second (ppoFEV₁) of less than 800 mL. Although new techniques, such as postoperative epidural analgesia, nonsedating analgesics, minitracheostomy, and oxygen saturation monitors, enhance the safety of pulmonary resection in patients with limited pulmonary function, no single diagnostic preoperative pulmonary function test consistently predicts postoperative morbidity and mortality associated with pulmonary insufficiency. Therefore, we reviewed our experience in patients with poor pulmonary function who underwent lung resection for cancer to better identify those factors that would more accurately predict survival and postoperative morbidity.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Patients
Between January 1986 and December 1990, 85 patients with a preoperative forced expiratory volume in 1 of 1.2 L or less underwent pulmonary resection for lung cancer. These patients represented only 4.0% of the 2,125 pulmonary resections performed at our institution during this time interval. All patients had pulmonary function testing performed at our institution before thoracotomy. Pulmonary function tests were performed using MedGraphics Pulmonary Function System 1070 and 1085 (MedGraphics Corp, St. Paul, MN) and were done according to the specifications of the American Thoracic Society [2, 3].

The medical records of these 85 patients were reviewed for age, sex, preexisting medical conditions, smoking history, operative and pathologic findings, and postoperative outcome. Predicted postoperative forced expiratory volume in 1 second and predicted postoperative diffusing capacity of the lung for carbon monoxide (ppoDLCO) were calculated, based on the amount of functioning lung resected [4, 5]. Follow-up data were obtained from the patients' most recent clinic visits, home health care providers, patient surveys, and telephone interviews.

Patients were postsurgically staged by the TNM classification system of the American Joint Committee for Cancer Staging and End Results Reporting [6]. Operative mortality was defined as any death within 30 days of operation or during the same hospitalization. Survival was estimated by the Kaplan-Meier method with the date of pulmonary resection as the starting time [7]. The influence of variables on survival and morbidity was analyzed using the proportional hazards model of Cox for continuous variables [8] and the log-rank test for discrete variables [9]. Values of p less than 0.05 were considered statistically significant. Data are expressed as medians with ranges.

Clinical Findings
There were 53 men and 32 women whose median age was 70 years (range, 49 to 82 years). Twenty-seven patients (32%) had a previous history of cardiac disease, which included exertional angina in 14, myocardial infarction in 6, atrial fibrillation in 5, and previous coronary artery bypass grafting or moderate mitral regurgitation in 1 each. A history of peptic ulcer disease was present in 5 patients and diabetes mellitus in 4. Fifteen patients were receiving corticosteroids immediately before the operation. Three patients had a preoperative creatinine level of 2.5 mg/dL or greater. Seventy-nine patients (93%) had a median of 50 pack-years (range, 2.5 to 180 pack-years) of cigarette smoking.

Fifteen patients (18%) had a previous malignancy, which included primary lung cancer in 9, skin cancer in 2, and cancer of the uterus, brain, kidney, or prostate in 1 each. Eleven patients had a prior thoracotomy; 2 were ipsilateral and 9 were contralateral. The indication for the previous thoracotomy was lung cancer in 9 patients and exploration for bleeding after blunt trauma in 2. Lobectomy had been previously performed in 7 patients and segmentectomy and wedge excision in 1 each.

Preoperative chest roentgenogram demonstrated a pulmonary mass in all patients, lobar obstruction in 5, and a collapsed lung in 1. Ventilation-perfusion scans were obtained in 3 patients, which demonstrated collapse of an entire lung in 1 patient, lobar collapse in 1, and normal results in 1. Preoperative pulmonary function is summarized in Tables 1 and 2. There were 41 patients (48.2%) whose ppoFEV₁ was less than 0.8 L and 32 patients (37.6%) with a ppoDLCO less than 50%.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

The cancer was located in the right upper lobe in 25 patients (29.4%), the left upper lobe in 22 (25.9%), the right lower lobe in 9 (10.6%), the left lower lobe in 9 (10.6%), and the right middle lobe in 4 (4.7%). In 16 patients (18.8%), the cancer involved more than one lobe. The cell type of the tumor was an adenocarcinoma in 39 patients, squamous cell in 35, undifferentiated cell in 3, large cell in 3, bronchoalveolar cell in 2, and adenosquamous cell, small cell, or carcinoid tumor in 1 each. Four patients had multiple synchronous pulmonary cancers. The tumors were grade I in two patients, II in 16, III in 24, and IV in 43. The tumors were postoperatively classified as stage I in 57 patients (67.1%), stage II in 6 (7.1%), and stage IIIa in 18 (21.2%). The 4 patients with multiple synchronous pulmonary cancers were not staged.

Seventy-two patients (84.7%) had epidural anesthesia. The catheter was left in place for a median of 3 days (range, 1 to 3 days). Sixty-four patients (75.3%) were extubated the day of operation. The remaining 21 patients required mechanical ventilation for a median of 2.2 days (range, 1 to 42 days). The patients remained in the intensive care unit a median of 4.8 days (range, 0 to 43 days). Median hospitalization was 15 days (range, 5 to 66 days). Seven patients required supplemental home oxygen (median, 2 L/min; range, 1 to 4 L/min).

Complications occurred in 42 patients (49.4%) and included atrial fibrillation in 18 patients, a prolonged air leak (10 days or greater) in 18, pulmonary failure requiring reintubation in 6, myocardial infarction in 3, pneumonia in 3, and empyema in 2. Eight patients had more than one complication. There were two perioperative deaths (mortality, 2.4%). The cause of death was myocardial infarction in both patients, both of whom had a previous history of coronary artery disease. One death occurred in a patient with stage II lung cancer who underwent a right upper and right middle bilobectomy; the other had a stage I cancer and underwent a right upper lobectomy.

Follow-up was complete in all patients and ranged from 2.4 months to 9 years (median, 3.2 years). Adjuvant treatment was administered to 19 patients and included radiation in 10, chemotherapy in 6, and a combination of both in 3. Thirty-nine patients (45.9%) are currently alive. Cause of death in 3 patients was progressive chronic obstructive pulmonary disease, which occurred at 2.0, 2.5, and 5.5 years after pulmonary resection. At the time of death in these 3 patients, none had evidence of recurrent cancer. Cause of death in the remaining 41 patients included recurrent lung cancer in 24, cardiac disease in 7, other types of cancer in 4, cerebrovascular disease in 3, cirrhosis in 1, and unknown in 2. Neither of the 2 patients who died of unknown causes had evidence of recurrent lung carcinoma at last follow-up, although neither had an autopsy. Overall 5-year survival was 44.0%. The 5-year survival for patients with stage I lung cancer was 54.2%; stage II, 33.1%; and stage IIIa, 21.3%. All patients with multiple synchronous pulmonary cancers died within 2 years. Factors that adversely affected survival were the presence of cardiac disease (p < 0.05), stage IIIa (p < 0.05), wedge excision (p < 0.05), age greater than 70 years (p < 0.05), and greater than a 50–pack-year history of smoking (p < 0.05). Other than a ppoFEV₁ less than the median of 0.83 L (34%), which correlated with the need for home oxygen (p = 0.05), no preoperative predictors of postoperative complications were present.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Mendenhall [10], in 1968, suggested that no single preoperative pulmonary function test existed that could accurately predict the risk of pulmonary resection for patients with compromised pulmonary function. This statement is still true 28 years later. However, Ferguson and associates [11, 12] clearly demonstrated that ppoDLCO is an important predictor of morbidity and mortality. Although they did not specify a specific value for ppoDLCO, they implied that a patient should have a ppoDLCO of 50% or greater. We were unable to corroborate this finding. However, both of our operative deaths occurred in patients with a ppoDLCO less than 50%.

Others have suggested that the ppoFEV₁ is an important predictor of morbidity. Markos and associates [13], Wahi and colleagues [14], Putnam and co-workers [15], and Kearney and associates [16] have all shown that morbidity and mortality are significantly increased when ppoFEV₁ is less than 40% of predicted normal. In our series, the median ppoFEV₁ was 34% (0.83 L). Although our patients below the median did not have a statistically significant different postoperative morbidity, they were more likely to require home oxygen.

The extent of pulmonary resection a patient can tolerate should be determined preoperatively and is based on both pulmonary function tests and the patient's performance status. The size and location of the lesion and bronchoscopy are often helpful in determining how much parenchyma will be required for complete resection. Once the amount of lung that requires resection is determined and the forced expiratory volume in 1 second and diffusing capacity of the lung for carbon monoxide have been assessed, the surgeon must decide if the patient can tolerate resection. The percent predicted values are a more accurate assessment of pulmonary function than absolute spirometric values. Percent predicted normal values account for small size or weight and aid the surgeon in assessing how much lung resection each particular patient can tolerate. This decision, as described by Peters [17] is "...the indefinable art of clinical judgment, and this type of clinical acumen comes only with careful practice. ...Solutions to these problems do not come from looking at numbers. They require the synthesis of a complexity of information, clinical and laboratory, to make a wise judgment."

New techniques in anesthesiology and critical care have enabled patients with poor pulmonary function to have a better outcome after pulmonary resection. Anesthetic agents with minimal respiratory and cardiac depression have led to early extubation, which avoids tracheobronchitis and nosocomial infection from prolonged mechanical ventilation. In our series, 64 patients (75%) were extubated the day of operation and only 6 required reintubation. Epidural anesthesia, used in our institution throughout the period of this study, has helped reduce postoperative pain and enables patients to clear secretions by an improved cough, deeper inspirations, and early ambulation. Nonsedating analgesics such as Ketorolac tromethamine (Toradol; Syntex Laboratories, Inc, Palo Alto, CA) are often used as a supplement to epidural analgesia, thereby further reducing the risk of hypercapnia in these patients who often are baseline carbon dioxide retainers. Minitracheostomy, which is a percutaneous tracheal catheter inserted at the bedside, allows for easy suctioning without the morbidity of formal tracheostomy. Finally, the increased availability of oxygen saturation monitors enables one to frequently assess the patient's respiratory status without the need for repeated arterial blood gas sampling or an intensive care unit setting.

In summary, selected patients with poor pulmonary function can safely undergo pulmonary resection but not without a significantly greater risk of postoperative complications. The previous concept of a minimal ppoFEV₁ of 0.8 L may no longer be applicable with new anesthetic and critical care techniques. We were unable to identify any specific preoperative pulmonary function test as a predictor of postoperative morbidity. Accurate preoperative assessment and sound clinical judgment remain the "best test" for operability.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Presented at the Poster Session of the Thirty-second Annual Meeting of The Society of Thoracic Surgeons, Orlando, FL, Jan 29–31, 1996.

Address reprint requests to Dr Allen, Department of Surgery, Mayo Clinic, 200 First St, SW, Rochester, MN 55905.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

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3. Crapo RO, Gardner RM, Clausen FL, et al. Single breath carbon monoxide diffusing capacity (transfer factor): recommendations for a standard technique. Am Rev Respir Dis 1987;136:1299–307.[Medline]
4. Mjorner G. ¹³³Xe radiospirometry: a clinical method for studying regional lung function. Scand J Respir Dis 1968;64S:5–84.
5. Wernly JA, DeMeester TR, Kirchner PT, Myerowitz PD, Oxford DE, Golomb HM. Clinical value of quantitative ventilation-perfusion lung scans in the surgical management of bronchogenic carcinoma. J Thorac Cardiovasc Surg 1980;80:535–43.[Medline]
6. Beahrs OH, Myers MH, eds. American Joint Commission on Cancer: manual for staging of cancer, 2nd ed. Philadelphia: Lippincott, 1983:178.
7. Kaplan EL, Meier P. Nonparametric estimation from incomplete observations. J Am Stat Assoc 1958;53:457–81.
8. Cox DR. Regression models and life-table (with discussion). J R Statist Soc, Series B 1972;34:187–220.
9. Peto R, Peto J. Asymptotically efficient rank and invariant procedures. J R Statist Soc, Series A 1972;135:185–201.
10. Mendenhall JT. Evaluation and management of pulmonary insufficiency in surgical patients. Surg Clin North Am 1968;48:773–8.[Medline]
11. Ferguson MK, Little L, Rizzo L, et al. Diffusing capacity predicts morbidity and mortality after pulmonary resection. J Thorac Cardiovasc Surg 1988;96:894–900.[Abstract]
12. Ferguson MK, Reeder LB, Mick R. Optimizing selection of patients for major lung resection. J Thorac Cardiovasc Surg 1995;109:275–83.[Abstract/Free Full Text]
13. Markos J, Mullan BP, Hillman DR, et al. Preoperative assessment as a predictor of mortality and morbidity after lung resection. Am Rev Respir Dis 1989;139:902–10.[Medline]
14. Wahi R, McMurtrey MJ, DeCaro LF, et al. Determinants of perioperative morbidity and mortality after pneumonectomy. Ann Thorac Surg 1989;48:33–7.[Abstract]
15. Putnam JB Jr, Lammermeier DE, Colon R, et al. Predicted pulmonary function and survival after pneumonectomy for primary lung carcinoma. Ann Thorac Surg 1990;49:909–15.[Abstract]
16. Kearney DJ, Lee TH, Reilly JJ, DeCamp MM, Sugarbaker DJ. Assessment of operative risk in patients undergoing lung resection. Chest 1994;105:753–9.[Abstract/Free Full Text]
17. Peters RM. Function of the gas exchange system and its evaluation. In: Baue AE, Geha AS, Hammond GL, Laks H, Naunheim KS, eds. Glenn's thoracic and cardiovascular surgery. Stamford: Appleton & Lange, 1996:20.

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Robert J. Cerfolio Mark S. Allen Victor F. Trastek Claude Deschamps Peter C. Pairolero Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Cerfolio, R. J. Articles by Pairolero, P. C. Search for Related Content PubMed PubMed Citation Articles by Cerfolio, R. J. Articles by Pairolero, P. C.