Preoperative Assessment of Fitness for Pulmonary Resection for Lung Cancer

“If I am presented with two investigations, a CT/PET and a cardio-pulmonary treadmill (CPEST), I am prepared to give an immediate assessment of whether a tumour is resectable and a patient operable.”
However, it never quite works that way! If there was a straightforward, scientific way to accurately assess patients for lung resection respiratory physicians would know it, computers would calculate it and surgeons would all be using it. But there are so many permutations of operation and co-morbidity, and different levels of risk that surgeon and patient are prepared to accept, that strict guidelines cannot apply to all situations. Usually, there is no point performing surgery if the operative risk is greater than the expected five year survival.  But remember, it is unlikely that anything will cure the patient other than surgical resection and surgeons have to be prepared to take risks on behalf of their patients for them to have a chance of cure.
The following has been written giving due consideration to the BTS_guidelines.pdf (pdf file for download) from the British Thoracic Society in conjunction with the Society of Cardio-thoracic Surgeons of Great Britain and Ireland. It is an attempt to put a scientific basis to our assessment techniques. After all the science, the most important factor to consider prior to surgery, radical radiotherapy or aggressive chemotherapy is exercise tolerance.
The optimal management of lung cancer is complete surgical resection by lobectomy. Pneumonectomy is performed when clearance can only be achieved by complete lung resection in patients who are particularly fit. Those not fit for the required operation may be suitable for compromise procedures with the caveat that local recurrence rates will be higher for these procedures:
    Sleeve resection
    Anatomical segmentectomy
    Wedge resection

Preoperative assessment is therefore aimed at determining:
Is the tumour resectable?
Is the patient operable? i.e. Is the risk of perioperative morbidity and mortality acceptable?
Is the long-term risk of respiratory failure acceptable?

In practice the risk of postoperative morbidity and long-term respiratory failure are similar, both being dependent on FEV1, and the transfer factor.

Investigations useful in assessing fitness for required operation
 Spirometry (particularly FEV1)
Transfer factor (DLCO)
Exercise tolerance (e.g. stair test)
Basic cardiac assessment (electrocardiogram, exercise treadmill)

    For the borderline patient ...
postop predicted FEV1
postop predicted DLCO
Cardio-pulmonary exercise treadmill (CPEST)
Ventillation/perfusion lung scan with quantitation
Cardiac assessment (including echocardiogram, coronary angiography)