Ann Thorac Surg 2006;81:1837-1838
© 2006 The Society of Thoracic Surgeons
Original article: General thoracic
Invited commentary
Gaetano Rocco, MD, FRCS (Ed), FECTS
Division of Thoracic Surgery, National Cancer Institute, Pascale Foundation, Via Semmola 81, 80131 Naples, Italy
(Email: gaetano.rocco{at}btopenworld.com).
The article by Licker and colleagues [1] describes the evolution of the surgical management of lung cancer in the perennial search of the functional Holy Graal (ie, the single preoperative predictor of mortality and severe morbidity after pulmonary surgery). Indeed, the results of this rigorous observational study are important not so much for the emphasis on the predictive value of the 60% preoperative forced expiratory volume in 1 second (FEV1) cut-off but rather for its historical value in detailing the sequence of events in the thoracic surgical practice that have ameliorated the postoperative care and the operative survival of our patients, as demonstrated by the excellent results obtained in their large series by the authors. In this setting, this experience mirrors what all thoracic surgeons go through at some point in their careers. As an example, we are supported by the literature in acknowledging the negative prognostic influence of advanced age, pneumonectomy, impaired cardiopulmonary reserve, and, the "protective" impact of thoracic epidural analgesia especially in the more functionally compromised patients.
However, in a fashion similar to retrospective studies published in the past, the paper by Licker et al. presents analogous flaws and surprising findings, such as the arbitrary choice of a FEV1 cut-off value, and, the lack of statistical significance of ppoFEV1 on multivariate analysis. In this setting, this paper should be considered one of the conclusive reference articles based on the predictive impact of preoperative FEV1 only. In fact, in order not to unnecessarily deny surgery to lung cancer patients, COPD should be investigated as a cardiopulmonary disease in line with the lessons learnt from lung volume reduction surgery. The advancing age of the surgical candidates, the increasing impact of patient comorbidities, the complexity of the case mix, and, the need for extended surgery after neoadjuvant treatment may warrant the routine inclusion in the preoperative work-up of additional functional indicators (i.e., DLCO and VO2max) which are already used in the current clinical practice to substantiate the surgical decision-making process. Therefore, future efforts need to be aimed at devising updated risk-adjusted models based on prospectively collected data from large, international cooperative series. These models should then be validated in order to compare outcomes within the thoracic surgical community in order to identify the best preoperative work-up for lung cancer surgery.
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References
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- Licker MJ, Widikker I, Robert J, et al. Operative mortality and respiratory complications after lung resection for cancerimpact of chronic obstructive pulmonary disease and time trends. Ann Thorac Surg 2006;81:1830-1838.[Abstract/Free Full Text]
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