Short- and Mid-Term Changes in Lung Function after Bilateral Pulmonary Metastasectomy

Abstract

Introduction The resection of pulmonary metastases is associated with a loss of lung function. The amount of functional impairment after bilateral metastasectomy remains unclear. Because only around 35% of those patients may expect long-term survival, it is important to preserve enough pulmonary function for an adequate quality of life. This analysis of 31 bilaterally operated patients was performed to describe the amount of pulmonary function loss.

Methods This is a post-hoc subanalysis and comparison of a population that was published before. All pulmonary metastasectomies were performed through an anteroaxillary thoracotomy in all patients. Resections were performed with staplers, electrocautery, or laser. All patients had pulmonary function tests (PFTs) preoperative and after 3 months at the follow-up visit, including spirometry, diffusing capacity of lung for carbon monoxide (Dlco) and blood gases. Of the 31 bilaterally operated cases, 15 had additional PFTs after each staged operation before discharge from hospital.

Results Altogether, 271 nodules (median 7, mean 8.2) were removed from the 31 patients with a lobectomy in 2, a segmentectomy in 8, and multiple wedge resections in 21 patients, with this being the largest resection. The mean loss of pulmonary function at follow-up visit was forced vital capacity (FVC) − 15.2%, total lung capacity (TLC) − 13.8%, forced expiratory volume in 1 second (FEV₁) − 16.3%, and Dlco − 10.3%, all of which were significant (p = < 0.001). The 15 patients with PFTs after each operation showed a stepwise decrease of volume parameters and Dlco with deepest values after the second surgery of around − -40% from preoperative values. At this time, Po ₂ was also significantly reduced by 10 mm Hg (p = 0.01). Comparing the bilateral group with 86 patients after unilateral metastasectomy, we found significantly more nodules removed in the bilateral group (8.2 vs. 3.1; p < 0.001) and that the loss of volume parameters was twice that of the unilateral group after metastasectomy. Dlco impairment did not differ between the groups (− 10.3 vs. − 9.5%; p = 0.868) after 3 months.

Conclusion Midterm pulmonary function impairment after bilateral pulmonary metastasectomy is 15% of spirometry values and 10% of Dlco. Reduction of spirometry values is almost twice compared with the group after unilateral surgery. Early functional loss after the second intervention causes FVC, TLC, and FEV₁ reduction of around 40% and is associated with lower Po ₂ (− 10 mm Hg). Therefore, bilateral metastasectomy can be offered to patients who do not have greater pulmonary limitations.

Keywords

metastasectomy - lung function - bilateral metastasectomy - functional impairment

• References

• 1 Welter S, Cheufou D, Sommerwerck U, Maletzki F, Stamatis G. Changes in lung function parameters after wedge resections: a prospective evaluation of a patient undergoing metastasectomy. Chest 2012; 141: 1482-1489
• 2 Petrella F, Chieco P, Solli P , et al. Which factors affect pulmonary function after lung metastasectomy?. Eur J Cardiothorac Surg 2009; 35 (5) 792-796
• 3 Nakahara K, Monden Y, Ohno K, Miyoshi S, Maeda H, Kawashima Y. A method for predicting postoperative lung function and its relation to postoperative complications in patients with lung cancer. Ann Thorac Surg 1985; 39 (3) 260-265
• 4 Wyser C, Stulz P, Solèr M , et al. Prospective evaluation of an algorithm for the functional assessment of lung resection candidates. Am J Respir Crit Care Med 1999; 159 (5 Pt 1) 1450-1456
• 5 Welter S, Cheufou D, Ketscher C, Darwiche K, Maletzki F, Stamatis G. Risk factors for impaired lung function after pulmonary metastasectomy: a prospective observational study of 117 cases. Eur J Cardiothorac Surg 2012; 42 (2) e22-e27
• 6 Pastorino U, Buyse M. Long-term results of lung metastasectomy: prognostic analyses based on 5206 cases. The International Registry of Lung Metastases. J Thorac Cardiovasc Surg 1997; 113 (1) 37-49
• 7 Schulte T, Schniewind B, Dohrmann P, Küchler T, Kurdow R. The extent of lung parenchyma resection significantly impacts long-term quality of life in patients with non-small cell lung cancer. Chest 2009; 135 (2) 322-329
• 8 Rusch VW. Pulmonary metastasectomy: a moving target. J Thorac Oncol 2010; 5 (6) (Suppl. 02) S130-S131
• 9 Hornbech K, Ravn J, Steinbrüchel DA. Current status of pulmonary metastasectomy. Eur J Cardiothorac Surg 2011; 39 (6) 955-962
• 10 Kampe S, Lohmer J, Weinreich G, Hahn M, Stamatis G, Welter S. Epidural analgesia is not superior to systemic postoperative analgesia with regard to preventing chronic or neuropathic pain after thoracotomy. J Cardiothorac Surg 2013; 8 (1) 127
• 11 Quanjer PH, Tammeling GJ, Cotes JE, Pedersen OF, Peslin R, Yernault JC. Official Statement of the European Respiratory Society. Lung volumes and forced ventilatory flows. Report Working Party Standardization of Lung Function Tests, European Community for Steel and Coal Official statement of the European Respiratory Society. Eur Respir J Suppl 1993; 16: 5-40
• 12 Pfannschmidt J, Dienemann H, Hoffmann H. Surgical resection of pulmonary metastases from colorectal cancer: a systematic review of published series. Ann Thorac Surg 2007; 84 (1) 324-338
• 13 Rolle A, Pereszlenyi A, Koch R, Richard M, Baier B. Is surgery for multiple lung metastases reasonable? A total of 328 consecutive patients with multiple-laser metastasectomies with a new 1318-nm Nd:YAG laser. J Thorac Cardiovasc Surg 2006; 131 (6) 1236-1242
• 14 Rusch VW. Pulmonary metastasectomy. Current indications. Chest 1995; 107 (6, Suppl): 322S-331S
• 15 Kearney DJ, Lee TH, Reilly JJ, DeCamp MM, Sugarbaker DJ. Assessment of operative risk in patients undergoing lung resection. Importance of predicted pulmonary function. Chest 1994; 105 (3) 753-759
• 16 Ferguson MK, Little L, Rizzo L , et al. Diffusing capacity predicts morbidity and mortality after pulmonary resection. J Thorac Cardiovasc Surg 1988; 96 (6) 894-900
• 17 Brunelli A, Refai MA, Salati M, Sabbatini A, Morgan-Hughes NJ, Rocco G. Carbon monoxide lung diffusion capacity improves risk stratification in patients without airflow limitation: evidence for systematic measurement before lung resection. Eur J Cardiothorac Surg 2006; 29 (4) 567-570
• 18 Bolliger CT. Evaluation of operability before lung resection. Curr Opin Pulm Med 2003; 9 (4) 321-326
• 19 Colice GL, Shafazand S, Griffin FP, Keenan R, Bolliger CT. Physiologic evaluation of the patient with lung cancer being considered for resectional surgery. ACCP Evidenced-Based Clinical Practice Guidelines (2nd Edition). Chest 2007; 132: 161S-177S
• 20 Brunelli A, Charloux A, Bolliger CT , et al; European Society of Thoracic Surgeons Joint Task Force on Fitness For Radical Therapy The European Respiratory Society and European Society of Thoracic Surgeons clinical guidelines for evaluating fitness for radical treatment (surgery and chemoradiotherapy) in patients with lung cancer. Eur J Cardiothorac Surg 2009; 36 (1) 181-184
• 21 Ninomiya M, Nakajima J, Tanaka M , et al. Effects of lung metastasectomy on respiratory function. Jpn J Thorac Cardiovasc Surg 2001; 49 (1) 17-20
• 22 Brunelli A, Refai M, Salati M, Xiumé F, Sabbatini A. Predicted versus observed FEV1 and DLCO after major lung resection: a prospective evaluation at different postoperative periods. Ann Thorac Surg 2007; 83 (3) 1134-1139
• 23 Bolliger CT, Jordan P, Solèr M , et al. Pulmonary function and exercise capacity after lung resection. Eur Respir J 1996; 9 (3) 415-421
• 24 Varela G, Brunelli A, Rocco G , et al. Predicted versus observed FEV1 in the immediate postoperative period after pulmonary lobectomy. Eur J Cardiothorac Surg 2006; 30 (4) 644-648