141
DOI: 10.1183/18106838.0602.141 Breathe December 2009 Volume 6 No 2
Commentary: The ERS/ESTS
clinical guidelines for
evaluating fi tness for radical
treatment for lung cancer
The European Respiratory Society (ERS) and
the European Society of Thoracic Surgeons
(ESTS) have recently established a joint task
force, composed of leading multidisciplinary
experts on the functional evaluation of lung
cancer patients, with the purpose of develop-
ing clinical evidence-based guidelines on the
evaluation of fi tness for radical therapy in
patients with lung cancer. The results of this
joint endeavor have been published in the
European Respiratory Journal [1, 2].
Approximately 20–25% of lung cancer
patients are operable; however, lung resection
remains the only curative treatment for lung
cancer, despite advances in alternative treat-
ments. Recent advances in operative and peri-
operative management and the reassessment
of lung function tests and exercise test modali-
ties justify the re-evaluation of the ideal surgical
candidates. Nonsurgical patients are usually
treated with chemo- or radiotherapy, which
have specifi c toxicities that need to be taken
into account. The task force aims to review
acute and long-term risks related to chemo-
and radiotherapy and make recommendations
on alternative nonsurgical treatments. The con-
clusions of the guidelines will be summarised
in this commentary to supplement the interest-
ing and informative review by D. S
UBOTIC in this
edition of Breathe.
Cardiologic evaluation
All available information on the pre-operative
cardiac risk was integrated into a functional
algorithm for evaluation of the lung resec-
tion candidate. This algorithm was generated
based on the best available scientifi c evidence
and consensus opinion of experts and recom-
mends that cardiac evaluation should be the
fi rst step to assess a patients risk for surgery
(fi gure 1) emphasising the importance of pre-
liminary cardiologic assessment.
Lung function tests
The next step for patients with a low car-
diological risk or with optimised cardiological
treatment is to proceed with pulmonary evalua-
tion (fi gure 2). The panel of experts agreed that
predicted post-operative (ppo) forced expiratory
volume in 1 s (FEV
1) is not a reliable predictor
of lung resection complications and should not
be used alone to select lung cancer patients for
surgery. However, it is a useful tool in combina-
tion with other diagnostics.
Diffusing capacity of the lung for carbon
monoxide (D
L,CO) has been found to be an inde-
pendent pre-operative predictor for the mortal-
ity and morbidity of lung resection [3–4]. The
guidelines suggest that D
L,CO should be rou-
tinely measured in lung resection candidates
regardless of the results of spirometry. A cut-off
ppoD
L,CO value of 30% predicted has been rec-
ommended as a high-risk threshold.
Perfusion scintigraphy is the most widely
used method of predicting post-operative
lung function in lung cancer patients prior
to pneumonectomy [5]. However, it has been
reported that lung segment counting can
predict ppoFEV
1 as accurately as perfusion
scintigraphy [6, 7]. Therefore, it has been
recommended that lung segment counting
should be used to calculate residual lung
function and only in patients with borderline
function perfusion scintigraphy should be
used.
Exercise tests
Exercise tests are commonly used to evalu-
ate the whole cardiopulmonary and systemic
oxygen delivery systems under stress in order
to estimate the physiological reserve of the
patient after surgery. It is predicted that if a
patient cannot perform well on an exercise
A. Brunelli
Division of Thoracic Surgery
Ospedali Riuniti
Ancona
Italy
brunellialex@gmail.com
Provenance
Commissioned article , peer
reviewed.
Competing interests
None declared.
142
Breathe December 2009 Volume 6 No 2
Commentary: The ERS/ESTS clinical guidelines for evaluating fi tness for radical treatment for lung cancer
test that they will be unlikely to be able to with-
stand the stresses of surgery. However, a meta-
analysis reported that exercise capacity was
actually lower in patients who developed post-
operative complications after lung resection [8].
Other studies have found a correlation between
exercise capacity and mortality following lung
resection and it is suggested that exercise tests
should be carried out on patients with FEV
1 and
D
L,CO <80% pred.
Low technology exercise tests
Stair, 6-min walk distance and shuttle tests are
the most widely used low technology exercise
tests. The shuttle walk test has not been found
to discriminate between patients with or without
complications after surgery or to be reliable in
estimating exercise capacity at a lower range. It
is only advised for screening and not as a stand
alone test. In contrast, stair climbing has been
found to be superior at predicting the likelihood
of morbidity and mortality after lung resection
compared with spirometry measurements. Stair
climbing is a cost-effective method for fi rst-line
screening to immediately select patients who are
safe to undergo surgery and those who need fur-
ther more sophisticated tests. The 6-min walk test
has not been found to be reliable in distinguish-
ing patients fi t for surgery and therefore should
not be used in pre-operative decisions.
Cardiopulmonary exercise testing
Cardiopulmonary exercise testing is usually per-
formed on a bicycle or treadmill in a controlled
environment allowing for good reproducibility
and standardised results. Maximal oxygen con-
sumption (V
O
2
,peak) is used to measure exercise
capacity. Currently there is a consensus that
V
O
2
,peak >20 mL per kg or >75% pred qualifi es
patients for resection and V
O
2
,peak <10 mL per kg
or <35% pred indicates a high risk for any resec-
tion and these should be used as cut-off values.
V
O
2
,peak measurements should be considered as
the most important factor for exercise capacity for
predicting post-operative complications.
Future trends in pre-operative
workup
The inclusion of daily physical exercise in the pre-
operative work-up could be used as an additional
RCRI [2]
High risk surgery (including
lobectomy or pneumonectomy)
Ischaemic heart disease (prior
myocardial infarction, angina
pectoris)
Heart failure
Insulin-dependent diabetes
Previous stroke of TIA
Creatinine ≥2 mg·dL
-1
History
Physical examination
Baseline ECG
Calculate RCRI
RCRI >2 or:
1) Any cardiac condition
requiring medications
2) A newly suspected cardiac
condition
3) Inability to climb two flights
of stairs
Yes
Cardiac consultation with noninvasive
cardiac testing treatments as per
AHA/ACC guidelines
No
Need for coronary
intervention
(CABG or PCI)
Continue with ongoing cardiac care
Institute any needed new medical
interventions (i.e. beta-blockers,
anticoagulants or statins)
Lung function tests
(fig. 2)
Postpone surgery
for ≥6 weeks
Figure 1
Algorithm for cardiac assessment
before lung resection in lung can-
cer patients. RCRI: Revised cardiac
Risk Index; ECG: electrocardiogram;
AHA: American Heart Association;
ACC: American College of Cardiol-
ogy; CABG: coronary artery bypass
graft; PCI: primary coronary inter-
vention; TIA: transient ischaemic
attack. Taken from [1].
143
Breathe December 2009 Volume 6 No 2
Commentary: The ERS/ESTS clinical guidelines for evaluating fi tness for radical treatment for lung cancer
Surgical techniques
Combined cancer and lung vol-
ume reduction surgery
Lung volume resection surgery (LVRS) produced
signifi cant improvements in exercise capacity
and survival in patients with upper lobe emphy-
sema [16, 17]. Better health status and lung func-
tion has been noted after LVRS compared with
normal medical treatment and rehabilitation
[18, 19]. Long-term survival after LVRS has also
been improved compared with other modalities
of treatment. In selected high-risk patients with
hyperinfl ated lung and a poorly perfused tumour-
containing lobe anatomical lobectomy combined
with LVRS has produced benefi cial effects in
terms of survival. Based on this evidence it was
test to compliment more sophisticated measure-
ments. Exercise D
L,CO could also be an interesting
parameter to measure since impairment of D
L,CO
refl ects poor recruitment of pulmonary capillary
and alveolar volume.
Patient care
management
Rehabilitation before and after
surgery
Currently, evidence is insuffi cient to clearly recom-
mend pulmonary rehabilitation in surgical lung
cancer patients. However, pulmonary rehabilita-
tion in COPD patients has been found to improve
V
O
2
rate before surgery which decreased the
number of late complications after surgery [9].
In addition, pre-operative training programmes
have led to a reduction in the length of hospital
stays and complications in COPD patients with
lung cancer [10]. Smoking cessation before sur-
gery has a positive impact on the rate of com-
plications after surgery [11] and it is therefore
recommended to cease smoking 2–4 weeks prior
to surgery.
Scoring systems
Scoring systems designed specifi cally for lung
resection including the cardiopulmonary risk
index, the predictive respiratory quotient and the
EVAD system (age, FEV
1 and DL,CO) have all been
unreliable at predicting the risk of morbidity and
mortality for individuals [12–15]. Therefore, it is
not recommended that scoring systems should
be used as standard care; however, they may be
a useful tool when assessing a group of patients
for surgery.
Thoracotomies and the intensive
care unit
The guidelines state that systematic admission to
the intensive care unit (ICU) after thoracotomy
should not be implemented and when a high-
dependency unit (HDU) is available no patients
should be admitted to the ICU. Only in an emer-
gency situation such as organ failure, patients
should be admitted to the ICU. Patients with a
high risk of complication, those who have under-
gone complex pulmonary resection and those
with a marginal cardiopulmonary reserve should
be admitted to the HDU after surgery. Low risk
patients should be sent to a specialised thoracic
surgical unit after surgery.
Cardiac assessment:
low risk or
treated patients
(fig. 1)
FEV
1
DL,CO
Both
>80%
Either one <80%
<35% or
<10 mL·kg
-1
·min
-1
35–75% or
10–20 mL·kg
-1
·min
-1
<35% or
<10 mL·kg
-1
·min
-1
<35% or
<10 mL·kg
-1
·min
-1
>75% or
>20 mL·kg
-1
·min
-1
Exercise testing
Peak VO
2
#
Both >30%
At least one <30%
Split function
ppo-FEV
1
ppo-DL,CO
ppo-peak VO
2
Lobectomy or
pneumonectomy are
usually not recommended.
Consider other options
Resection up to
calculated extent
Resection up to
pneumonectomy
Figure 2
Algorithm for assessment of cardiopulmonary reserve before lung resection in lung cancer patients.
#
: If peak VO
2
is not available, cardiopulmonary exercise testing can be replaced by stair climbing;
however, if altitude reaching during stair climbing is ,<22 m, cardiopulmonary exercise testing with
peak V
O
2
measurement is highly recommended. Taken from [1].
144
Breathe December 2009 Volume 6 No 2
Commentary: The ERS/ESTS clinical guidelines for evaluating fi tness for radical treatment for lung cancer
recommended that anatomical lobectomy with
or without LVRS should be performed in well
selected COPD patients with lung cancer.
Compromised parenchymal spar-
ing resections and minimally
invasive techniques
Parenchymal sparing resection or sublobar resec-
tions include segmentectomy and wedge resec-
tion. Patients recommended for segmentectomy
are as follows:
a) Stage IA with margins of resection >1 cm.
b) Stage I patients with poor lung function.
c) Lung resection after prior lobectomy.
Wedge resections are recommended in the
following circumstances:
a) Stage IA (tumours <2 cm)
b) Small peripheral adenocarcinoma with
air-containing image on high-resolution
computed tomography scans.
Chemo- and
radiotherapy
Neoadjuvant chemotherapy
The advantages of neoadjuvant treatments for
resectable and operative lung cancer are currently
being examined in future studies. To date, several
studies have reported advantages for morbidity
and mortality following induction therapy after
pneumonectomy [20–22]. However, in recent tri-
als induction chemotherapy in
pneumonectomy
has led to high levels of mortality and morbidity
especially in right sided
pneumonectomy [23,
24]. More studies are required to make a judge-
ment on the use of induction chemo- and radio-
therapy. It is recommended that after induction
chemo- or radiotherapy, new functional evalua-
tion should be carried out prior to surgery.
Defi nitive radio- and chemo-
therapy
The greatest limitation to defi nitive radiotherapy
is radiotherapy-induced lung toxicity which is het-
erogenic across studies due to different scoring
systems. The risk of developing radiation pneu-
monitis-induced lung toxicity can be estimated
by calculating the dose–volume histogram of the
lung, including V
20 and mean lung dose [25,
26]. Therefore this calculation should be carried
out prior to treatment to determine the risk of tox-
icity. There is too little evidence on the safety of
defi nitive chemotherapy to make a formal recom-
mendation on its use.
Alternatives to surgery
For medically inoperable nonsmall cell lung
cancer (NSCLC) the best established method for
treatment is radiation alone which appears to
increase survival rates. Continuous, hyperfraction-
ated, accelerated radiotherapy (CHART) is the
preferred method compared with conventional
radiotherapy because it has been shown to pro-
vide improved local control and survival. In stage
I NSCLC patients at high surgical risk, stereotac-
tic radiotherapy should be considered as a good
alternative to surgery.
Who should treat
thoracic patients and
where should they be
treated?
Ideally a multidisciplinary team made up of a tho-
racic surgeon specialising in lung cancer, a medical
oncologist, a radiation oncologist and a pulmo-
nologist should manage lung cancer patients.
Lung cancer patients undergoing surgery should
be admitted to specialised centres with qualifi ed
thoracic surgeons, since specialisation has been
shown to improve resectability, post-operative
mortality and long-term survival. Surgery should
also be carried out in centres with an adequate
volume of cases (minimum surgical volume of
20–25 major lung resections per year) as this has
a positive impact on resectability, post-operative
mortality and long-term survival. In addition, there
is also a positive impact of volume on the results
of chemotherapy and radiotherapy. Radiotherapy
should be performed by radiologists that routinely
treat patients with this modality.
Summary
Despite advances in alternative treatments, lung
resection remains the only curative treatment for
lung cancer. Preliminary cardiologic assessment
should be the fi rst step to assess patients for sur-
gery followed by pulmonary evaluation for those
with low cardiological risk. D
L,CO should be rou-
tinely measured in lung resection candidates as it
has been seen to be an independent pre-operative
predictor of mortality and morbidity. Stair climb-
ing can be used for fi rst-line screening to select
patients for more sophisticated tests. V
O
2
, peak is
the most important factor for exercise capacity for
predicting post-operative complications. There is
145
Breathe December 2009 Volume 6 No 2
Commentary: The ERS/ESTS clinical guidelines for evaluating fi tness for radical treatment for lung cancer
judgements on induction chemo- and radiother-
apy and defi nitive chemotherapy. Stereotactic
radiotherapy should be considered as a good
alternative to surgery in stage I NSCLC patients
at high surgical risk. Surgery and radiotherapy
should be carried out by trained specialists who
routinely treat patients with this modality.
no clear evidence for scoring systems or rehabilita-
tion in selecting lung resection candidates. ICUs
should be reserved for patients with major compli-
cations such as organ failure. Anatomical lobec-
tomy with or without LVRS should be performed
in well selected COPD patients with lung cancer.
Additional studies are required to make adequate
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![Figure 2 Algorithm for assessment of cardiopulmonary reserve before lung resection in lung cancer patients. #: If peak VO2 is not available, cardiopulmonary exercise testing can be replaced by stair climbing; however, if altitude reaching during stair climbing is ,<22 m, cardiopulmonary exercise testing with peak VO2 measurement is highly recommended. Taken from [1].](/figures/figure-2-algorithm-for-assessment-of-cardiopulmonary-reserve-31t3f0fi.webp)
![Figure 1 Algorithm for cardiac assessment before lung resection in lung cancer patients. RCRI: Revised cardiac Risk Index; ECG: electrocardiogram; AHA: American Heart Association; ACC: American College of Cardiology; CABG: coronary artery bypass graft; PCI: primary coronary intervention; TIA: transient ischaemic attack. Taken from [1].](/figures/figure-1-algorithm-for-cardiac-assessment-before-lung-2570fdcx.webp)