Prospective Evaluation for Pneumonectomy Using Perfusion Scanning: Follow-Up beyond One Year

doi:10.1378/chest.80.2.163

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Volume 80, Issue 2, August 1981, Pages 163-166

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Thirty-eight high-risk patients (forced expiratory volume in one second [FEV₁] less than 2.0L or maximum voluntary ventilation [MVV] less than 50 percent of predicted) were observed for a minimum of one year after pneumonectomy for carcinoma of the lung. Operability was assessed by calculating a predicted postoperative FEV₁ (based on the right-center fractional perfusion estimated by a perfusion lung scan) and requiring this predicted postoperative value to exceed 800 ml. No other invasive physiologic studies were performed before surgery. At one year, 23 of 38 patients were still alive, and 13 of 38 patients survived to the end of the second year. At five years, two of 15 patients were alive with no evidence of metastatic disease. This simple physiologic approach involves widely available techniques and, in patients with lung cancer who have compromised pulmonary function, appears to result in acceptable survival over a longer period.

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MATERIALS AND METHODS

During the evaluation before surgery, all patients underwent routine testing of pulmonary function. Spirometric evaluation was performed with the patients seated and was repeated several times to obtain a maximal effort. Best effort was used to determine the forced vital capacity (FVC) and the forced expiratory volume at one second (FEV₁). Spirometric testing was then repeated after a nebulized bronchodilator drug was administered. The functional

residual capacity was determined by the

RESULTS

This group of patients included 38 who underwent pneumonectomy. Their mean age was 61 years, and there were 33 men and five women. Twenty-two patients underwent left pneumonectomy, and 16 underwent right pneumonectomy. The mean preoperative FEV₁ was 1.68 L (range, 1.23 to 1.96 L, and the mean predicted postoperative FEV₁ was 1.09 L (range, 0.86 to 1.69 L). Two patients were lost to follow-up, one during the third and one during the fourth postoperative year.

Of the original group, 23 (61

DISCUSSION

For most patients with suspected or proven carcinoma of the lung, surgery remains the best hope for cure. If contiguous spread of the disease or distant metastases are not evident, the patient’s ability to withstand pneumonectomy should be evaluated. One always hopes that less extensive resectional surgery may suffice, but often this is not known before the operation. Obviously, the preoperative assessment of cardiopulmonary function is of primary importance in trying to predict postoperative

REFERENCES (18)

EA Gaensler et al.
The role of pulmonary insufficiency in mortality and invalidism following surgery for pulmonary tuberculosis.
J Thorac Surg
(1955)
H Neuhaus et al.
A bronchospirometric method of estimating the effect of pneumonectomy on the maximum breathing capacity.
J Thorac Cardiovasc Surg
(1968)
S Kristersson et al.
Prediction of pulmonary function loss due to pneumonectomy using ¹³³Xe radiospirometry.
Chest
(1972)
H Sloan et al.
Temporary unilateral occlusion of the pulmonary artery in the preoperative evaluation of thoracic patients.
J Thorac Surg
(1955)
GN Olsen et al.
Prediction of postpneumonectomy pulmonary function using quantitative macroaggregate lung scanning.
Chest
(1974)
PG Boysen et al.
Prospective evaluation for pneumonectomy using the ⁹⁹Tc quantitative perfusion scan.
Chest
(1977)
SF Boushy et al.
Clinical course related to preoperative and post-operative pulmonary function in patients with bronchogenic carcinoma.
Chest
(1971)
TR DeMeester et al.
Preoperative evaluation with differential pulmonary function.
Ann Thorac Surg
(1974)
JM Marion et al.
Unilateral lung function: comparison of the lateral position test with radionuclide ventilation-perfusion studies.
Chest
(1976)

There are more references available in the full text version of this article.

Cited by (44)

Pneumonectomy for Non–Small Cell Lung Cancer
2016, Surgical Oncology Clinics of North America
Citation Excerpt :
For patients with a low or borderline FEV1 it is useful to calculate the predicted postoperative lung function and diffusing capacity of the lung for carbon monoxide because these parameters were shown to correlate with postoperative complications after pneumonectomy.37–39 Patients with a predicted postoperative FEV1 of more than 800 mL have been shown to have adequate pulmonary reserve to undergo resection in long-term follow-up.40 Most patients requiring a pneumonectomy have obstructing cancers and are thus compensating for the loss of substantial lung function in the affected lung by depending primarily on the unaffected lung for respiration.
Pulmonary Pathophysiology and Lung Mechanics in Anesthesiology. A Case-Based Overview
2012, Anesthesiology Clinics
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Less invasive methods are now available with radionuclide lung scanning. These techniques allow determination of the fraction of ventilation (as measured with inhaled 133Xe11–15) or perfusion (as measured with 99mTc-macroaggregates16–18) of the lung portion to be resected. PPO FEV1 has been shown to predict postoperative complications in one large study.19
Quantitative perfusion scintigraphy or anatomic segment method in lung cancer resection
2011, Lung Cancer
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The two most frequently used techniques to estimate ppo pulmonary function are the Quantitative Perfusion Scintigraphy (QPS) and the Anatomic Segment Method (ASM). QPS [6–12] is the current gold standard in predicting postoperative lung function [3–5,13], uses intravenously injected albumin macroaggregates marked with 99mTechnetium [12] and accounts for the effects of the tumour and smoking-induced alterations on ventilation perfusion inequalities [9,14]. Disadvantages to QPS as radiation, workload and cost make ASM, a technique that assumes each segment of both lungs to contribute equally to lung function, an interesting alternative.
Quantitative Perfusion Scintigraphy (QPS) and Anatomic Segment Method (ASM) are two techniques for estimating postoperative pulmonary function. QPS is gold standard, but holds disadvantages.
Could ASM substitute QPS in the preoperative work-up of NSCLC?
Retrospective study in patients with NSCLC or mesothelioma undergoing resection. FEV1 and DL,CO were estimated by QPS and ASM and compared to pulmonary function measured 3 months after resection. Correlation tests and Bland–Altman analyses were performed.
40 patients (23 lobectomies, 14 pneumonectomies). Both methods correlated similarly with postoperative FEV₁ (QPSρ = 0.69; ASMρ = 0.75) and DL,CO (QPSρ = 0.70; ASMρ = 0.74). Correlation between both methods was high (ppoFEV₁ρ = 0.89; ppoDL,COρ = 0.89). The same principles applied in a subgroup analysis of patients with COPD. Bland–Altman analyses showed that ASM underestimated postoperative FEV₁ and DL,CO more than QPS in all groups.
QPS and ASM are remarkably similar in predicting postoperative pulmonary function. As ASM underestimates pulmonary function more, it could be a safe alternative from a cost-benefit point of view. Based on these results, it appears that QPS could be restricted to patients in whom ASM suggests functional inoperability, although further prospective studies are necessary.
Pulmonary assessment for general thoracic surgery
2010, Surgical Clinics of North America
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The estimation of the postoperative FEV1 (FEV1-ppo) as percent predicted in patients who undergo pneumonectomy can be calculated by obtaining preoperative FEV1 and the quantitative ventilation perfusion scan to obtain the fraction of the total lung perfusion present in the lung to be resected, using the following formula:26% FEV1-ppo = FEV1-pre × (1– fraction of total perfusion resected lung) For pneumonectomy there is a strong correlation between the postoperative FEV1 expressed as percent predicted and calculated from the quantitative lung perfusion scans, and the actual values.2,17,26–28 Estimated postoperative FEV1 (FEV1-ppo) expressed as percent after lobectomy can be calculated by different arithmetic calculations.
What to do with "surprise" N2? Intraoperative management of patients with non-small cell lung cancer
2008, Journal of Thoracic Oncology
Citation Excerpt :
There is no formal data concerning the short-term morbidity of recovering from an exploratory thoracotomy versus a resection, but there is little reason to expect there to be a difference. Not undergoing a resection carries a psychologic burden of loss of hope, whereas resection is associated with loss of lung function, However, the majority of studies11,13–16 demonstrate good long-term functional capacity even in patients with limited pulmonary reserve (with only a few exceptions).17,18 Long-term survival of patients with pN2 disease (i.e., postresection N2 disease) varies markedly according to preoperative factors and the extent of preoperative staging investigations.
There is debate about how patients should be managed when malignant involvement of mediastinal lymph nodes is encountered at the time of lung resection. A comprehensive review of the literature demonstrates that differences in which outcomes are reported and how extensively patients were staged preoperatively explain much of the conflicting data. Certain negative and positive prognostic factors can be defined, but in general the outcomes justify proceeding with resection unless it is clear that disease will be left behind. Reasonable arguments can be made that the approach should include a mediastinal lymph node dissection and adjuvant therapy.
Lung cancer: Preoperative pulmonary evaluation of the lung resection candidate
2005, American Journal of Medicine
Citation Excerpt :
The ppoFEV1 has been used to permit individuals to have resection who may have been denied on the basis of their absolute FEV1 value alone. A study evaluating pneumonectomy complications in which individuals with an FEV1 < 2L were allowed to have surgery if their ppoFEV1 was > 800 cc’s showed an operative mortality of 15%, 61% survival at 1 year, 34% at 2 years, and 5% at 5 years.27 Another study allowed resection if the ppoFEV1 was > 1L.
Lung resection provides the best chance of cure for individuals with early stage non-small cell lung cancer. Naturally, lung resection will lead to a decrease in lung function. The population that develops lung cancer often has concomitant lung disease and a reduced ability to tolerate further losses in lung function. The goal of the preoperative pulmonary assessment of individuals with resectable lung cancer is to identify those individuals whose short- and long-term morbidity and mortality would be unacceptably high if surgical resection were to occur. Pulmonary function measures such as the forced expiratory volume in 1 second and the diffusing capacity for carbon monoxide are useful predictors of postoperative outcome. In situations in which lung function is not normal, the prediction of postoperative lung function from preoperative results and the assessment of exercise capacity can be performed to further clarify risks. Published guidelines help to direct the order of testing, permitting us to offer resection to as many patients as possible.

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Supported by the Medical Research Service of the Veterans Administration.

Presented at the 74th annual meeting, American Thoracic Society, Las Vegas, May 15, 1979, and published in abstract form in the American Review of Respiratory Diseases (suppl) 1979; 119:96.

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Prospective Evaluation for Pneumonectomy Using Perfusion Scanning: Follow-Up beyond One Year

Section snippets

MATERIALS AND METHODS

RESULTS

DISCUSSION

J Thorac Surg

J Thorac Cardiovasc Surg

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J Thorac Surg

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Ann Thorac Surg

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