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Guideline |
a Division of Thoracic Surgery, Umberto I Regional Hospital, Ancona, Italy
b Service de Physiologie et d’Explorations Fonctionnelles Hopitaux Universitaires de Strasbourg, France
c Division of Pulmonology, Department of Medicine, Faculty of Health Sciences, University of Stellenbosch, Cape Town, South Africa
d Division of Thoracic Surgery, National Cancer Institute, Pascale Foundation, Naples, Italy
e Department of Intensive Care Unit and Thoracic Oncology, Institut Jules Bordet, Centre des Tumeurs de l’Université Libre de Bruxelles (ULB), Brussels, Belgium
f Division of Thoracic Surgery, Salamanca University Hospital, Spain
g Department of Anesthesiology, Pharmacology and Intensive Care, Faculty of Medicine, University Hospital of Geneva, Switzerland
h Department of Surgery, The University of Chicago, USA
i Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, UK
j Division of Respiratory Medicine, Medizinische Klinik-Innenstadt, Ludwig-Maximilians-University, Munich, Germany
k Institute of Respiratory Diseases, University of Modena-Reggio Emilia, Pavullo, Italy
l Respiratory Medicine, Lister Hospital, Stevenage, UK
m Department of Radiation Oncology (Maastro clinic), Maastricht University Medical Center, GROW, Maastricht, The Netherlands
n Division of General Internal Medicine, Columbia University, New York, USA
Received 5 March 2009; received in revised form 14 April 2009; accepted 15 April 2009.
* Corresponding author. Tel.: +39 0715964433; fax: +39 0715964481. (Email: alexit_2000{at}yahoo.com; anne.Charloux{at}chru-strasbourg.fr).
** Corresponding author. Address: Pôle de Pathologie Thoracique, Service de Physiologie et d’Explorations Fonctionnelles, Nouvel Hopital Civil, Hopitaux Universitaires de Strasbourg, BP426, Strasbourg Cedex 67091, France. Tel.: +33 0 3 88 69 55 08 79. (Email: alexit_2000{at}yahoo.com; anne.Charloux{at}chru-strasbourg.fr).
Abstract
The European Respiratory Society (ERS) and the European Society of Thoracic Surgeons (ESTS) established a joint task force with the purpose to develop clinical evidence-based guidelines on evaluation of fitness for radical therapy in patients with lung cancer. The following topics were discussed, and are summarized in the final report along with graded recommendations: Cardiologic evaluation before lung resection; lung function tests and exercise tests (limitations of ppoFEV1; DLCO: systematic or selective?; split function studies; exercise tests: systematic; low-tech exercise tests; cardiopulmonary (high tech) exercise tests); future trends in preoperative work-up; physiotherapy/rehabilitation and smoking cessation; scoring systems; advanced care management (ICU/HDU); quality of life in patients submitted to radical treatment; combined cancer surgery and lung volume reduction surgery; compromised parenchymal sparing resections and minimally invasive techniques: the balance between oncological radicality and functional reserve; neoadjuvant chemotherapy and complications; definitive chemo and radiotherapy: functional selection criteria and definition of risk; should surgical criteria be re-calibrated for radiotherapy?; the patient at prohibitive surgical risk: alternatives to surgery; who should treat thoracic patients and where these patients should be treated?
Key Words: Lung cancer • Pulmonary resection • Radical treatment • Preoperative evaluation • Functional evaluation
The paper published in the July issue of the European Respiratory Journal entitled ‘ERS-ESTS clinical guidelines on fitness for radical therapy in lung cancer patients (surgery and radiochemotherapy)’ [1] summarizes the work of the joint task force created by the European Respiratory Society (ERS) and the European Society of Thoracic Surgeons (ESTS). The objective of this working group, which was composed of leading multidisciplinary experts on functional evaluation of lung cancer patients, was to develop up-to-date clinical guidelines on fitness for surgery and chemoradiotherapy.
The subject was divided into different topics, which were in turn assigned to at least two members of the task force. The authors searched the literature according to their own strategies; no central literature review was performed. The draft reports written by the experts on each topic were then reviewed, discussed, and voted by the entire expert panel. The evidence supporting each recommendation was summarized, and was graded as described by the Scottish Intercollegiate Guidelines Network (SIGN) Grading Review Group: grades of recommendation were based on the strength of supporting evidence, taking into account its overall level and the considered judgment of the guideline developers [2].
The following topics were discussed, and are summarized in the final report along with graded recommendations: Cardiologic evaluation before lung resection; lung function tests and exercise tests (limitations of ppoFEV1; DLCO: systematic or selective?; split function studies; exercise tests: systematic; low-tech exercise tests; cardiopulmonary (high tech) exercise tests); future trends in preoperative work-up; physiotherapy/rehabilitation and smoking cessation; scoring systems; advanced care management (ICU/HDU); quality of life in patients submitted to radical treatment; combined cancer surgery and lung volume reduction surgery; compromised parenchymal sparing resections and minimally invasive techniques: the balance between oncological radicality and functional reserve; neoadjuvant chemotherapy and complications; definitive chemo and radiotherapy: functional selection criteria and definition of risk; should surgical criteria be re-calibrated for radiotherapy?; the patient at prohibitive surgical risk: alternatives to surgery; who should treat thoracic patients and where these patients should be treated?
A summary of the most important recommendations is reported in Table 1 . We recommend readers to refer to the primary publication [1] for a detailed background of these levels of evidences.
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Patients with peak VO2 lower than 35% of predicted value or lower than 10 ml/kg/min and those with ppoFEV1 or ppoDLCO or both lower than 30% of predicted values in association with ppoVO2 peak lower than 35% of predicted value or lower than 10 ml/kg/min are to be regarded at prohibitive risk for major lung resection (lobectomy or pneumonectomy) and other therapeutic options should be considered.
A certain proportion of lung resection candidates may be unable to perform any type of reliable exercise test due to concomitant incapacitating co-morbidities. As such patients have been shown to have an increased risk of death after major lung resection, after a careful selection based on the available cardiac and pulmonary parameters, they should be regarded as high-risk patients and monitored in an advanced care management setting.
Although these guidelines were designed to be broadly accepted, implemented and validated in all European centers, the scientific evidence upon which they were based were mainly generated in settings specialized in the management of lung cancer patients. Based on best scientific evidence, treatment of these patients outside specialized settings or multidisciplinary environments is strongly discouraged and application of our guidelines and recommendations outside specialized centers is discouraged.
References
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