GUIDELINES
ERS/ESTS clinical guidelines on the fitness of patients for radical treatment of lung cancer (surgery and chemo-radiotherapy)
 
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1
Pneumonologist Fellow, 3rd Pneumonology Department, “Sismanogleio” General Hospital of Athens
2
Pneumonologist, Director 3rd Pneumonology Department, “Sismanogleio” General Hospital of Athens
CORRESPONDING AUTHOR
Vlasis Polychronopoulos   

3rd Pneumonology Department Sismanoglio General Hospita
 
Pneumon 2010;23(1):91–102
 
KEYWORDS
Τhis article constitutes a translation and extensive summary of the guidelines of the article "ers/ests clinical guidelines on fitness for radical therapy in lung cancer patients (surgery and chemo-radiotherapy)", Εuropean Respiratory Journal, july 2009;34: 17-41

ABSTRACT
Collaboration of a multidisciplinary team of experts on the functional evaluation of patients with lung cancer was facilitated by the European Respiratory Society (ERS) and the European Society of Thoracic Surgery (ESTS), in order to draw up recommendations and provide clinicians with clear, up-to-date guidelines on their fitness for surgery and chemo-radiotherapy. The subject was divided into various different topics, each of which was then assigned to at least two experts. The authors searched the literature according to their own strategies, with no central literature Review and compiled draft reports on each topic, which were then reviewed, discussed and voted on by the entire expert panel. The evidence supporting each recommendation was summarized, and graded as described by the Scottish Intercollegiate Guidelines Network Grading Review Group. Clinical practice guidelines were generated and finalized in a functional algorithm for risk stratification of the lung resection candidates, with emphasis on the cardiological evaluation, forced expiratory volume in 1 s (FEV1), systematic carbon monoxide lung diffusion capacity (DLCO) and exercise testing. In contrast to lung resection, for which the scientific evidence is more robust, it was not possible to recommend any specific test, cut-off value, or algorithm for chemo-radiotherapy, due to the lack of data. It is highly recommended that patients with lung cancer should be managed in specialized units by experienced multidisciplinary teams.
 
REFERENCES (63)
1.
McFalls EO, Ward HB, Morits TE, et al. Coronary-artery revascularization before elective major vascular surgery. NEJM 2004; 351:2795-2804.
 
2.
Douketis JD, Berger PB, Dunn AS, et al. The perioperative management of antithrombotic therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133(Suppl. 6):299S-339S.
 
3.
Poldermans D, Boersma E, Bax JJ, et al. The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group. NEJM 1999; 341:1789-1794.
 
4.
Juul AB, Wetterslev J, Gluud C, et al. Effect of perioperative betablockade in patients with diabetes undergoing major non-cardiac surgery: randomised placebo controlled, blinded multicentre trial. BMJ 2006; 332:1482.
 
5.
Devereaux PJ, Yang H, Yusuf S, et al. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet 2008; 371:1839-1847.
 
6.
Wallace AW, Galindez D, Salahieh A, et al. Effect of clonidine on cardiovascular morbidity and mortality after non-cardiac surgery. Anesthesiology 2004; 101:284-293.
 
7.
Codice GL, Shafazand S, Griffin JP, et al. Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: ACCP evidenced-based clinical practice guidelines (2th Edition). Chest 2007; 132(Suppl 3):161-177S.
 
8.
Bollinger CT, Jordan P, Soler M, et al. Exercise capacity as a preditor of postoperative complications in lung resection candidates. ΑJRCCM 1995; 151:1472-1480.
 
9.
Nakahara K, Ohno K, Hashimoto J, et al. Prediction of postoperative respiratory failure in patients undergoing lung resection for lung cancer. Ann Thor Surg1988; 46:549-552.
 
10.
Brunelli A, Al Refai M, Monteverde M, et al. Predictors of early morbidity after major lung resection in patients with and without airflow limitation. Ann Thor Surg 2002; 74:999-1003.
 
11.
Varela G, Brunelli G, Rocco G et al. Evidence of lower alteration of expiratory volume in patients with airflow limitation in the immediate period after lobectomy. Ann Thor Surg 2007; 84:417-422.
 
12.
Brunelli A, Refai MA, Salati M, et al. Carbon monoxide lung diffusion capacity improves risk stratification in patients without airflow limitation: evidence for systematic measurement before lung resection. EJ Cardiothor Surg 2006; 29:567-570.
 
13.
Varela G, Brunelli A, Rocco G, et al. Predicted versus observed FEV1 in the immediate postoperative period after pulmonary lobectomy. EJ Cardiothor Surg 2006; 30:644-648.
 
14.
Varela G, Brunelli A, Rocco G, et al. Measured FEV1, in the first postoperative day, and not ppo FEV1, is the best predictor of cardio-respiratory morbidity after lung resection. EJ Cardiothor Surg 2007; 31:518-521.
 
15.
Brunelli A, Varela G, Rocco G, et al. A model to predict the immediate postoperative FEV1 following major lung resections. EJ Cardiothor Surg 2007; 32:783-786.
 
16.
Ferguson MK, Reeder LB, Mick R. Optimizing selection of patients for major lung resection. J Thorac Cardio Surg 1995; 109:275-281.
 
17.
Benzo R, Kelly GA, Recchi L, et al. Complications of lung resection and exercise capacity: a meta-analysis. Resp Μed 2007; 101:1790-1797.
 
18.
Win T, Jackson A, Sharples L, et al. Cardiopulmonary exercise tests and lung cancer surgical outcome. Chest 2005; 127:1159- 1165.
 
19.
Loewen GM, Watson D, Kohman L, et al. Preoperative exercise VO2 measurement for lung resection candidates: results of Cancer and Leucemia Group B Protocol 9238. J Thor Onc 2007;2:619-625.
 
20.
Brunelli A, Belardinelli R, Refai M, et al. Peak oxygen consumption during cardiopulmonary exercise test improves risk stratification in candidates to major lung resection. Chest 2008; [Epub ahead of print PMID: 19029436].
 
21.
Holden DA, Rice TW, Stelmach K, et al. Exercise testing, 6-min walk, and stair climb in the evaluation of patients at high risk for pulmonary resection. Chest 1992; 102:1774-1779.
 
22.
Pierce RJ, Copland JM, Sharpe K, et al. Preoperative risk evaluation for lung cancer resection: predicted postoperative product as a predictor of surgical mortality. AJRCCM 1994; 150:947-955.
 
23.
Bagg LR. The 12-min walking distance; its use in the preoperative assessment of patients with bronchial carcinoma before lung resection. Respiration 1984; 46:342-345.
 
24.
Brunelli A, Refai M, Xiume F, et al. Performance at symptomlimited stair-climbing test is associated with increased cardiopulmonary complications, mortality, and costs after major lung resection. Ann Thor Surg 2008; 86:240-247.
 
25.
Ninan M, Sommers KE, Landreneau RJ, et al. Standardized exercise oximetry predicts postpneumonectomy outcome. Ann Thor Surg 1997; 64:328-332.
 
26.
Brunelli A, Refai M, Xiume F, et al. Oxygen desaturation during maximal srair-climbing test and complications after major lung resections. EJ Cardiothor Surg 2008; 33:77-82.
 
27.
ATS/ACCP Statement on cardiopulmonary exercise testing. AJRCCM 2003; 167:211-277.
 
28.
Wang JS, Abboud RT, Evans KG, et al. Role of CO diffusing capacity during exercise in the preoperative evaluation for lung resection. AJRCCM 2000; 162: 1435-1444.
 
29.
Varela G, Ballesteros E, Jimenez MF, et al. Cost-effectiveness analysis of prophylastic respiratory physiotherapy in pulmonary lobectomy. EJ Cardiothor Surg 2006; 29:216-220.
 
30.
Hulzebos EH, Helders PJ, Favie NJ, et al. Preoperative intensive inspiratory muscle training to prevent postoperative pulmonary complications in high-risk patients undergoing CABG surgery: a randomized clinical trial. JAMA 2006; 296:1851-1857.
 
31.
Bobbio A, Chetta A, Ampollini L, et al. Preoperative pulmonary rehabilitation in patients undergoing lung resection for nonsmall cell lung cancer. EJ Cardiothor Surg 2008; 33:95-98.
 
32.
Sekine Y, Chino M, Iwata T, et al. Preoperative rehabilitation and physiotherapy for lung cancer patients with chronic obstructive pulmonary disease. Jpn J Thorac Cardiovasc Surg 2005; 53:237-243.
 
33.
Larsen KR, Svendsen UG, Milman N, et al. Cardiopulmonary function at rest and during exercise after resection for bronchial carcinoma. Ann Thor Surg 1997; 64:960-964.
 
34.
Win T, Groves AM, Ritchie AJ, et al. The effect of lung resection on pulmonary function and exercise capacity in the lung cancer patients. Resp Care 2007; 52:720-726.
 
35.
Brunelli A, Xiume F, Refai M, et al. Evaluation of expiratory volume, diffusion capacity, and exercise tolerance following major lung resection: a prospective follow-up analysis. Chest 2007; 131:141-147.
 
36.
Bollinger CT, Jordan P, Soler M, et al. Pulmonary function and exercise capacity after lung resection. ERJ 1996; 9:415-421.
 
37.
Sugimura H, Yang P. Long-term-survivorship in lung cancer :a review. Chest 2006; 129:1088-1097.
 
38.
Brunelli A, Socci L, Refai M, et al. Quality of life before and after major lung resection for lung cancer: a prospective follow-up analysis. Ann Thor Surg 2007; 84:410-416.
 
39.
Handy JR, Asaph JW, Skokan L, et al. What happens to patients undergoing lung cancer surgery? Outcomes and quality of life before and after surgery. Chest 2002; 122:21-30.
 
40.
Sarna L, Padilla G, Holmes C, et al. Quality of life of long-term survivors of non-small-cell lung cancer. J Clin Oncol 2002; 20:2920-2929.
 
41.
Meyers BF, Yusen RD, Guthrie TJ, et al. Results of lung volume reduction surgery in patients meeting a national emphysema treatment trial high-risk criterion. J Thor Cardiovasc Surg 2004; 127:829-835.
 
42.
DeRose JJ Jr, Argenziano M, El-Amir N, et al. Lung reduction operation and resection of pulmonary nodules in patients with severe emphysema. Ann Thor Surg 1998; 65:314-318.
 
43.
Baldi S, Ruffini E, Harari S, et al. Does lobectomy for lung cancer in patients with chronic obstructive pulmonary disease affect lung function? A multicenter national study. J Thor Cardiovasc Surg 2005; 130:1616-1622.
 
44.
Subotic DR, Mandaric DV, Eminovic TM, et al. Influence of chronic obstructive pulmonary disease on postoperative lung function and complications in patients undergoing operations for primary non-small cell lung cancer. J Thor Card Surg 2007; 134:1292-1299.
 
45.
Ohno Y, Koyama H, Nogami M, et al. Postoperative lung function in lung cancer patients: comparative analysis of predictive capability of MRI, CT, and SPECT. AJR Am J Roentgenol 2007; 189:400-408.
 
46.
Ginsberg RJ, Rubinstein LV. Randomized trial of lobectomy versus limited resection for T1 N0 non-small cell lung cancer. Lung Cancer Study Group. Ann Thorac Surg 1995; 60:615- 622.
 
47.
Griffin JP, Eastridge CE, Tolley EA, et al. Wedge resection for nonsmall cell lung cancer in patients with pulmonary insufficiency: prospective ten-year survival. J Thor Onc 2006; 1:960-964.
 
48.
Martin-Ucar AE, Nakas A, Pilling JE, et al. A case-matched study of anatomical segmentectomy versus lobectomy for stage I lung cancer in high-risk patients. EJ Cardiothor Surg 2005; 27:675-679.
 
49.
Okada M, Nishio W, Sakamoto T, et al. Effect of tumor size on prognosis in patients with non-small cell lung cancer: the role of segmentectomy as a type of lesser resection. J Thor Cardioν Surg 2005; 129: 87-93.
 
50.
Nakayama H, Yamada K, Saito H, et al. Sublobar resection for patients with peripheral small adenocarcinomas of the lung: surgical outcome is associated with features on computed tomographic imaging. Ann Thor Surg 2007; 84:1675-1679.
 
51.
Burdett S, Stewart LA, Rydzewska L. A systemic review and meta-analysis of the literature: chemotherapy and surgery versus surgery alone in non-small cell lung cancer. J Thor Onc 2006; 1:611-621.
 
52.
Martin J, Ginberg RJ, Abolhoda A, et al. Morbidity and mortality after neoadjuvant therapy for lung cancer: the risk of right pneumonectomy. Ann Thor Surg 2001; 72:1149-1154.
 
53.
Stamatis G. Risks of neoadjuvant chemotherapy and radiation therapy. Thor Surg Clin 2008; 18:71-80.
 
54.
Gilligan D, Nicolson M, Smith I, et al. Preoperative chemotherapy in patients with resectable non-small cell lung cancer: results of the MRC LU22/ NVALT 2/ EORTC 08012 multicentre randomised trial and update of systematic review. Lancet 2007; 369:1929-1937.
 
55.
Garrido P, Gonzalez-Larriba JL, Insa A, et al. Long-term survival associated with complete resection after induction chemotherapy in stage IIIA (N2) and IIIB (T4N0-1) non-small-cell lung cancer patients: the Spanish Lung Cancer Group Trial 9901. J Clin Onc 2007; 25: 4736-4742.
 
56.
McDonald S, Rubin P, Phillips TL, et al. Injury to the lung from cancer therapy: clinical syndromes, measurable endpoints, and potential scoring systems. Int J Rad Onc Biol Phys 1995; 31:1187-1203.
 
57.
Leo F, Solli P, Spaggiari L, et al. Respiratory function changes after chemotherapy: an additional risk for postoperative respiratory complications? Ann Thor Surg 2004; 77:260-265.
 
58.
Borst GR, De Jaeger K, Belderbos JS, et al. Pulmonary function changes after radiotherapy in non-small-cell lung cancer patients with long-term disease-free survival. Int J Rad Onc Biol Phys 2005; 62:639-644.
 
59.
Abratt RP, Willcox PA, Smith JA. Lung cancer in patients with borderline lung functions - zonal lung perfusion scans at presentation and lung function after high dose irradiation. Radioth Onc 1990; 19:317-322.
 
60.
Videtic GM, Stitt LW, Ash RB, et al. Impaired diffusion capacity predicts for decreased treatment tolerance and survival in limited stage small cell lung cancer patients treated with concurrent chemoradiation. Lung Cancer: Amsterdam 2004; 43:159-166.
 
61.
Rowell NP, Williams CJ. Radical radiotherapy for stage I/II non-small cell lung cancer in patients not sufficiently fit for or declining surgery (medically inoperable): a systematic review. Thorax 2001; 56:628-638.
 
62.
Saunders M, Dische S, Barrett A, et al. Continuous, hyperfractionated, accelerated radiotherapy (CHART) versus conventional radiotherapy in non-small cell lung cancer: mature data from the randomised multicentre trial. CHART Steering committee. Radioth Onc 1999; 52:137-148.
 
63.
Brunelli A, Sabbatini A, Xiume F, et al. Inability to perform maximal stair climbing test before lung resection: a propensity score analysis on early outcome. EJ Cardiothor Surg 2005; 27:367-372.
 
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