Review
Managing lung cancer in high-risk patients: what to consider Expert Rev. Respir. Med. 8(4), 443–452 (2014)
Joanna Sesti1 and Jessica S Donington*1,2 1 Department of Cardiothoracic Surgery, NYU School of Medicine, 530 1st Ave, Suite 9V, New York, NY, USA 2 Bellevue Hospital, New York, NY, USA *Author for correspondence: Tel.: +1 212 263 2025 Fax: +1 212 263 8363 [email protected]
Lung cancer patients with medical comorbidity are a challenge for care providers. As with other solid tumors, treatment is stage dependent; but a critical difference is the invasive nature of lung resections and the resulting importance of surgical risk stratification for treatment of early stage disease. External beam radiation was considered the only treatment option for early stage disease in non-operative candidates 10–15 years ago. With recent advances in image-guided technologies, robotics, and the resurgence in interest of sublobar resection there are now numerous treatment options which offer excellent local control and reasonable short and long term survival. Extensive work has been done to clarify interventional risk, and accurately describe anticipated outcomes of these varied treatments in the high risk population. The aim of this article is to review recent literature and provide a better understanding of the considerations used in the management of these patients in the current era. KEYWORDS: high risk • minimally invasive surgery • non-small cell lung cancer • radiofrequency ablation • stereotactic radiotherapy • sublobar resection
Surgical versus nonsurgical therapy
The treatment of choice for early stage nonsmall cell lung cancer (NSCLC) is anatomic resection with systematic evaluation of mediastinal lymph nodes. In patients with adequate pulmonary reserve, this is generally well tolerated with mortality rates 80%), maximal oxygen consumption (VO2max) did not predict complication, but in patients with FEV1 and/or DLCO between 40 and 80% there were five deaths, three of which occurred in patients with VO2max 1.5, any cardiac condition requiring medication, newly suspected cardiac condition or limited exercise tolerance (inability to climb two flights of stairs) should be referred for a cardiac consultation [11]. If the cardiac evaluation is negative or considered low risk, the patient should proceed to PFTs. Patients with ppoFEV1 and ppoDLCO >60% may proceed to surgery. Patients with ppoFEV1 and ppoDLCO between 30 and 60% should have low technology exercise tests, SWT or SCT. If patients perform adequately, they may proceed to surgery; otherwise, they should undergo further stratification with formal CPET. Patients with ppoFEV1 and ppoDLCO 60% OR VO2max >20 ml/kg/min
Managing lung cancer in high-risk patients: what to consider Expert Rev. Respir. Med. 8(4), 443–452 (2014)
Joanna Sesti1 and Jessica S Donington*1,2 1 Department of Cardiothoracic Surgery, NYU School of Medicine, 530 1st Ave, Suite 9V, New York, NY, USA 2 Bellevue Hospital, New York, NY, USA *Author for correspondence: Tel.: +1 212 263 2025 Fax: +1 212 263 8363 [email protected]
Lung cancer patients with medical comorbidity are a challenge for care providers. As with other solid tumors, treatment is stage dependent; but a critical difference is the invasive nature of lung resections and the resulting importance of surgical risk stratification for treatment of early stage disease. External beam radiation was considered the only treatment option for early stage disease in non-operative candidates 10–15 years ago. With recent advances in image-guided technologies, robotics, and the resurgence in interest of sublobar resection there are now numerous treatment options which offer excellent local control and reasonable short and long term survival. Extensive work has been done to clarify interventional risk, and accurately describe anticipated outcomes of these varied treatments in the high risk population. The aim of this article is to review recent literature and provide a better understanding of the considerations used in the management of these patients in the current era. KEYWORDS: high risk • minimally invasive surgery • non-small cell lung cancer • radiofrequency ablation • stereotactic radiotherapy • sublobar resection
Surgical versus nonsurgical therapy
The treatment of choice for early stage nonsmall cell lung cancer (NSCLC) is anatomic resection with systematic evaluation of mediastinal lymph nodes. In patients with adequate pulmonary reserve, this is generally well tolerated with mortality rates 80%), maximal oxygen consumption (VO2max) did not predict complication, but in patients with FEV1 and/or DLCO between 40 and 80% there were five deaths, three of which occurred in patients with VO2max 1.5, any cardiac condition requiring medication, newly suspected cardiac condition or limited exercise tolerance (inability to climb two flights of stairs) should be referred for a cardiac consultation [11]. If the cardiac evaluation is negative or considered low risk, the patient should proceed to PFTs. Patients with ppoFEV1 and ppoDLCO >60% may proceed to surgery. Patients with ppoFEV1 and ppoDLCO between 30 and 60% should have low technology exercise tests, SWT or SCT. If patients perform adequately, they may proceed to surgery; otherwise, they should undergo further stratification with formal CPET. Patients with ppoFEV1 and ppoDLCO 60% OR VO2max >20 ml/kg/min
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