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Ann Thorac Surg 1998;66:898-902
© 1998 The Society of Thoracic Surgeons

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Original articles: General Thoracic

Lobectomy improves ventilatory function in selected patients with severe COPD¹

^a Thoracic Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
^b Pulmonary Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York, USA

Address reprint requests to Dr Ginsberg, Thoracic Service, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021
e-mail: (Ginsberr{at}mskcc.org)

Presented at the Thirty-fourth Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 26–28, 1998.

	Abstract

Top Footnotes Abstract Introduction Material and methods Results Comment References

 
Background. Patients often undergo limited resection instead of lobectomy for non–small cell lung cancer because of a low preoperative forced expiratory volume in 1 second (FEV₁). Our goal is to define criteria that will preoperatively identify a group of patients who will not lose further function after lobectomy.

Methods. Patients who underwent lobectomy with a preoperative FEV₁ of less than 80% of predicted were retrospectively identified. Data collected included preoperative and postoperative pulmonary function tests, age, sex, the lobe resected, and preoperative ventilation–perfusion scan result.

Results. Thirty-two patients were included in this study. The median preoperative FEV₁ was 60% of predicted (1.65 L) and the mean change in FEV₁ was a loss of 7.8% after lobectomy. The patients were divided into two groups. Group 1 (n = 13) had a preoperative FEV₁ of less than or equal to 60% of predicted (median, 49%; 1.35 L) combined with an FEV₁ to forced vital capacity ratio of less than or equal to 0.6. Group 2 (n = 19) includes all other patients (median preoperative FEV₁, 69% of predicted; 1.87 L). The mean changes in FEV₁ after lobectomy were +3.7% and -15.7% for groups 1 and 2, respectively (p < 0.005). A chronic obstructive pulmonary disease index was defined and then calculated for each patient. The relationship between this index and the change in FEV₁ after lobectomy for all 32 patients appears linear (r = -0.43; p = 0.015).

Conclusions. Patients with a very low preoperative FEV₁ and FEV₁ to forced vital capacity ratio are less likely to lose ventilatory function after lobectomy and may actually improve it.

	Introduction

Top Footnotes Abstract Introduction Material and methods Results Comment References

 
Lung cancer is responsible for more cancer deaths in the United States than any other malignancy [1]. To date, complete surgical resection offers the best chance for cure in patients with non–small cell lung cancer (NSCLC), and more specifically, anatomic lobectomy is considered to be the optimal type of resection [2].

Unfortunately, many patients with operable NSCLC also have chronic obstructive pulmonary disease (COPD), which is reflected in the preoperative pulmonary function tests (PFTs) [3]. As a result, many patients with NSCLC are denied lobectomy in favor of a more limited resection on the basis of a low preoperative forced expiratory volume in 1 second (FEV₁). It has been our clinical observation, however, that some patients with a low preoperative FEV₁ will not lose further function, and may actually increase this volume after lobectomy.

The purpose of this study is twofold: first, to verify that there is a group of patients with poor preoperative ventilatory function who will increase FEV₁ after lobectomy, and second, to determine the preoperative PFTs that may help identify patients likely to improve after operation.

	Material and methods

Top Footnotes Abstract Introduction Material and methods Results Comment References

 
All patients who underwent lobectomy at Memorial Sloan-Kettering Cancer Center during a 2-year period for stage I and II NSCLC were selected from the Thoracic Surgery Service database. Of these, patients with a preoperative FEV₁ of less than 80% of predicted were identified using PFT data from office charts, hospital records, and the PFT laboratory database. To reduce potentially confounding factors, patients were excluded if they received radiation or chemotherapy, if they died, if complete preoperative PFT data were not available for review, if they continued to smoke postoperatively, if the postoperative chest roentgenograms revealed findings other than routine postoperative changes (air space, fluid collection), or if they had ongoing acute pulmonary illness during the study interval postoperatively.

Data collected included age, sex, preoperative PFTs, the lobe resected, preoperative ventilation/perfusion scan results (when available), and postoperative PFTs. Only the postbronchodilator spirometry values were used and a standard formula was consistently used to calculate the percent of predicted for all patients. Only patients who underwent postoperative PFTs from 4 months to 2 years after lobectomy (the study interval) were included. Patients who met previously mentioned inclusion criteria and did not have postoperative PFTs were contacted and scheduled for PFTs provided that the test date fell in the study interval.

To grade patients according to the severity and purity of obstructive airway disease, we defined a "COPD index" and calculated it for each patient by adding the preoperative FEV₁ (% of predicted in decimal form) to the preoperative ratio of FEV₁ to forced vital capacity (FVC). Therefore, the patients with the lowest COPD index are those with the most pure and severe obstructive airway disease. For example, if a patient has an FEV₁ of 60% of predicted and the FEV₁/FVC ratio is 0.5, the COPD index would be 0.6 plus 0.5, or 1.1.

The statistical analysis included the independent samples t test for the comparison of means as well as bivariate correlation to assess the relationship between variables. The statistical software package SPSS Advanced Statistics 7.5 (SPSS Inc, Chicago, IL) was used for all analyses.

	Results

Top Footnotes Abstract Introduction Material and methods Results Comment References

 
From January 1, 1995, to December 31, 1996, 344 patients had lobectomies for stage I and II NSCLC. Three hundred twelve patients were excluded for the reasons listed in Table 1. The remaining 32 patients comprise the study group. Excluding the 168 patients with a preoperative FEV₁ of greater than 80% of predicted and the 51 patients with inadequate preoperative PFT data, the remaining 125 patients with a preoperative FEV₁ of less than 80% of predicted had no 30-day operative mortality.

The 32 patients were then divided into two groups. Group 1 consists of patients with a preoperative FEV₁ less than or equal to 60% of predicted combined with a preoperative FEV₁/FVC ratio less than or equal to 0.6. Group 2 includes all other patients. Table 2 shows the characteristics of each group, and Table 3 shows the changes in ventilatory function after lobectomy. In group 1, 2 of 6 patients who underwent upper lobectomies and 4 of 6 who had lower lobes resected increased their FEV₁ after lobectomy. The remaining patient had a middle lobectomy, and the FEV₁ fell by 2.9%.

View larger version (14K): [in this window] [in a new window]   Fig 1. Relationship between the preoperative chronic obstructive pulmonary disease (COPD) index and the change in forced expiratory volume in 1 second (FEV1) after lobectomy in 32 patients. The broken, horizontal line marks zero change in FEV1, and the oblique line marks the line of best fit.

View larger version (13K): [in this window] [in a new window]   Fig 2. Relationship between the percent of total perfusion to the resected lobe as determined by preoperative nuclear medicine scan and the change in forced expiratory volume in 1 second (FEV1) after lobectomy. The broken, horizontal line marks zero change in FEV1, and the oblique line marks the line of best fit.

	Comment

Top Footnotes Abstract Introduction Material and methods Results Comment References

In 1955, Gaensler and associates [4] reported that patients undergoing pulmonary resection for tuberculosis with a preoperative FEV₁ of less than 70% of predicted had a 40% mortality rate. After this initial study, multiple reports throughout the subsequent decades have also implicated a low preoperative FEV₁ as a risk factor for postoperative complications in patients who undergo lobectomy for bronchogenic carcinoma [5–7]. In addition, it is well established that the more severe the obstructive lung disease, the more severe the dyspnea, and the lower the FEV₁ [8]. However, there is also additional literature that suggests no predictive value of this test in determining the risk of lobectomy [9, 10]. Despite this controversy, the criterion most widely used by thoracic surgeons to screen patients for lobectomy remains the preoperative FEV₁.

The use of the preoperative FEV₁ to predict longer term postlobectomy ventilatory function is also questionable. Simple anatomic calculation of the predicted postoperative FEV₁ as well as that determined using functional lung scans has been reported to be able to predict the postlobectomy FEV₁ with accuracy [9, 12]. Bria and coworkers [13] used ventilation–perfusion scanning to calculate the predicted postoperative FEV₁ in patients undergoing lobectomy and reported a high correlation between the actual measured postoperative FEV₁ and the predicted postoperative FEV₁ (r = 0.88). As a result, Bria and coworkers concluded that patients with a preoperative FEV₁ of 1.7 L or less are at more of a risk for postoperative pulmonary insufficiency because the postlobectomy FEV₁ will approach 0.8 L. A close look at Bria and associates’ data, however, reveals that of a total of 10 patients who underwent lobectomy with a preoperative FEV₁ of less than 1.7 L, 4 (40%) actually increased their FEV₁ postoperatively. Only 1 of 8 patients (12.5%) with a preoperative FEV₁ of greater than 1.7 L showed an increase in this value after the procedure. Similarly, Boushy and colleagues [6] evaluated pulmonary function before and after lobectomy in 51 patients. Four of 5 patients with a preoperative FEV₁ of less than 50% of predicted actually increased FEV₁ after lobectomy. Other investigators have also confirmed that a significant percentage of patients with a low preoperative FEV₁ will increase this volume after lobectomy [14; Deslauriers J, personal communication, 1998]. Consequently, the ability to predict longer-term ventilatory function after lobectomy using the preoperative FEV₁ must be questioned.

Additionally, the postoperative level of ventilatory function thought to be prohibitive when considering pulmonary resection (postoperative FEV₁ of 800 mL) must be questioned as well because this is an arbitrary number that was not derived from patients undergoing lung resection. Instead, this level is the published observation that nonsurgical patients with severe COPD and an FEV₁ of less than 0.8 L suffer from decreased exercise tolerance and worsened hypercapnia [15, 16].

The present study confirms these previous reports as well as our prior clinical observation that there are patients who will increase their FEV₁ after lobectomy. In addition, a useful tool for the identification of these patients is available from the preoperative PFTs. These data show that the patients who have severe, as well as the most pure obstructive airway disease (group 1) are most likely to increase FEV₁ after lobectomy. Although group 2 also contains some patients with a preoperative FEV₁ well below 60% of predicted, these patients also have a subnormal FVC as well, implying either restrictive disease, or end-stage COPD with severe parenchymal destruction. The COPD index, as defined herein, is an attempt to identify those patients with the most severe and pure obstructive lung disease. When this index falls below 1.0, there is a high likelihood that either little change will occur in the FEV₁ after lobectomy, or this volume will increase.

When evaluating a patient with a low FEV₁ for lobectomy, caution must be employed when the following two circumstances arise. First, patients with a low preoperative FEV₁ and a COPD index greater than 1.2 are likely to have restrictive disease and can be expected to sustain a 5% to 20% loss of function (FEV₁) after lobectomy. Second, patients with a COPD index of less than 1.0 and a heterogeneous pattern of COPD in which the relatively nonfunctioning lobe is not resected seem to lose a large percentage of their FEV₁ with resection of a functioning lobe. For example, 1 patient in this series lost 58.6% of his preoperative FEV₁ after a left upper lobectomy, despite a COPD index of only 1.03. A close examination of his preoperative ventilation/perfusion scan revealed that his remaining left lower lobe received only 13% of total lung perfusion and only 5.5% of total lung ventilation.

In distinct contrast to the PFT data after classic lung volume reduction operations in which both FEV₁ and FVC increase [17, 18], our severely obstructed patients experience a loss of FVC after lobectomy. This observation has two implications. First, in our patients, some functioning lung tissue is most likely being resected. If only nonfunctioning lung is removed, FVC should increase, as it does in the patients undergoing lung volume reduction. The lack of correlation between the percent perfusion to the resected lobe and the change in FEV₁ after lobectomy as shown in Fig 2 also suggests that functioning lung tissue can be resected and still result in higher FEV₁. Second, a rising FEV₁ in the face of a falling FVC implies that the actual severity of airway obstruction has somehow improved, possibly related to changes in elastic recoil and closing volumes [19].

Criticism of these data must focus around the small, retrospective nature of this study. Because the patients were identified retrospectively, criteria that were used by the surgeons to select patients with a low preoperative FEV₁ for lobectomy may bias the results. As an example, of the 15 patients for whom preoperative nuclear medicine lung scans were performed, 7 had a homogeneous pattern to their COPD, whereas 8 had a heterogeneous pattern with decreased perfusion to the resected lobe. Only 1 patient with available lung scan data had a heterogeneous pattern in which the resected lobe had normal perfusion, and the remaining lobe had little perfusion. Most of these patients with this pattern of emphysema were probably denied lobectomy during the preoperative assessment. Additionally, the 26 patients who died or were lost to follow-up may have suffered complications that could be attributed to poor preoperative ventilatory function, but could not be included because of the obvious lack of postoperative PFTs.

To correct for these biases, a prospective study has been initiated at our institution to confirm these data, as well as to answer the following questions that are raised by these results. First, what is the mechanism of the improved FEV₁ in patients with severe COPD after lobectomy? If FVC increased, as it does in patients who underwent lung volume reduction, one could speculate that nonventilated lung is being resected, allowing the more normal lung to expand and ventilate more efficiently. As FVC falls in our patients, this phenomenon is probably not the active mechanism. Because FEV₁ rises and FVC falls, the actual severity of the airway obstruction seems to improve. The most likely mechanism for the improved obstruction would be the relief of hyperinflation. By selecting patients with a relatively normal preoperative FVC, which the COPD index does, relief of hyperinflation improves airway conductance and allows these patients to expire more volume in 1 second despite losing a small amount of their previously normal vital capacity. Improved chest wall and respiratory muscle mechanics may also play a role, as they do in patients who undergo lung volume reduction [20].

Second, what is the effect of the rising FEV₁ after lobectomy on postoperative morbidity and mortality in patients with severe COPD, or just as important, is the actual postoperative FEV₁ even relevant in determining the risk of lobectomy? In addition, what are the functional results of the improved FEV₁ as measured by parameters such as quality of life, oxygen requirement, and activity level? By answering these questions the opportunity may arise to offer curative lobectomy to a greater number of patients with NSCLC.

In conclusion, this small, retrospective study suggests that patients with a low preoperative FEV₁, properly selected, can undergo lobectomy with the anticipation that further ventilatory function will not be lost. A large, prospective analysis is underway to confirm these findings [11].

	Footnotes

Top Footnotes Abstract Introduction Material and methods Results Comment References

 
This article has been selected for the open discussion forum on the STS Web site: http://www.sts.org/annals

	References

Top Footnotes Abstract Introduction Material and methods Results Comment References

 

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This Article Abstract Full Text (PDF) 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. Korst Robert J. Ginsberg Maneesh Ailawadi Manjit S. Bains Robert J. Downey, Jr Valerie W. Rusch Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Korst, R. J. Articles by Stover, D. Search for Related Content PubMed PubMed Citation Articles by Korst, R. J. Articles by Stover, D.