1

2
3
4
5
6
7
8
9 9
10
ln pauenLs belng consldered for lung cancer resecuon, splromeLry

should be
performed. lf Lhe lLv
1
ls > 80 predlcLed normal

or > 2 L, Lhe pauenL ls sulLable for
resecuon lncludlng

pneumonecLomy wlLhouL furLher evaluauon. lf Lhe lLv
1
ls >

1.3 L,
Lhe pauenL ls sulLable for a lobecLomy wlLhouL furLher

evaluauon. Level of evldence,
falr, beneL, subsLanual, grade

of recommendauon, 8



ln pauenLs belng consldered for lung

cancer resecuon, lf Lhere

ls evldence of
lnLersuual lung

dlsease on radlographlc sLudles

or undue dyspnea on exeruon,

even
Lhough Lhe lLv
1
mlghL be

adequaLe, uLCC should be measured.

Level of evldence,
falr,

beneL, subsLanual, grade of recommendauon,

8



ln pauenLs belng consldered for lung cancer resecuon,

lf elLher

Lhe lLv
1
or uLCC are <
80 predlcLed, posLoperauve

lung

funcuon should be predlcLed Lhrough addluonal
Lesung.

Level

of evldence, falr, beneL, subsLanual, grade of recommendauon,

8



10
11 11
12 12
13
1he preoperauve physlologlc assessmenL of a pauenL belng consldered for surglcal resecuon of lung cancer musL conslder Lhe
lmmedlaLe perloperauve rlsks from comorbld cardlopulmonary dlsease, Lhe long-Lerm rlsks of pulmonary dlsablllLy, and Lhe
LhreaL Lo survlval due Lo lnadequaLely LreaLed lung cancer. As wlLh any planned ma[or operauon, especlally ln a populauon
predlsposed Lo aLherosclerouc cardlovascular dlsease by clgareue smoklng, a cardlovascular evaluauon ls an lmporLanL
componenL ln assesslng perloperauve rlsks. Measurlng Lhe lLv(1) and Lhe dluslng capaclLy of Lhe lung for carbon monoxlde
(uLCC) measuremenLs should be vlewed as complemenLary physlologlc LesLs for assesslng rlsk relaLed Lo pulmonary funcuon. lf
Lhere ls evldence of lnLersuual lung dlsease on radlographlc sLudles or undue dyspnea on exeruon, even Lhough Lhe lLv(1) may
be adequaLe, a uLCC should be obLalned. ln pauenLs wlLh abnormallues ln lLv(1) or uLCC ldenued preoperauvely, lL ls
essenual Lo esumaLe Lhe llkely posLresecuon pulmonary reserve. 1he amounL of lung funcuon losL ln lung cancer resecuon can
be esumaLed by uslng elLher a perfuslon scan or Lhe number of segmenLs removed. A predlcLed posLoperauve lLv(1) or uLCC <
40 lndlcaLes an lncreased rlsk for perloperauve compllcauons, lncludlng deaLh, from lung cancer resecuon. Lxerclse Lesung
should be performed ln Lhese pauenLs Lo furLher dene Lhe perloperauve rlsks prlor Lo surgery. lormal cardlopulmonary
exerclse Lesung ls a sophlsucaLed physlologlc Lesung Lechnlque LhaL lncludes recordlng Lhe exerclse LCC, hearL raLe response Lo
exerclse, mlnuLe venulauon, and oxygen upLake per mlnuLe, and allows calculauon of maxlmal oxygen consumpuon
(.vC(2)max). 8lsk for perloperauve compllcauons can generally be sLraued by .vC(2)max. auenLs wlLh
preoperauve .vC(2)max > 20 mL/kg/mln are noL aL lncreased rlsk of compllcauons or deaLh, .vC(2)max< 13 mL/kg/mln lndlcaLes
an lncreased rlsk of perloperauve compllcauons, and pauenLs wlLh .vC(2)max < 10 mL/kg/mln have a very hlgh rlsk for
posLoperauve compllcauons. AlLernauve Lypes of exerclse Lesung lnclude sLalr cllmblng, Lhe shuule walk, and Lhe 6-mln walk.
AlLhough oen noL performed ln a sLandardlzed manner, sLalr cllmblng can predlcL .vC(2)max. ln general Lerms, pauenLs who
can cllmb ve lghLs of sLalrs have C(2)max > 20 mL/kg/mln. Conversely, pauenLs who cannoL cllmb one lghL of sLalrs
have .vC(2)max < 10 mL/kg/mln. uaLa on Lhe shuule walk and 6-mln walk are llmlLed, buL pauenLs who cannoL compleLe 23
shuules on Lwo occaslons wlll have .vC(2)max < 10 mL/kg/mln. uesaLurauon durlng an exerclse LesL has been assoclaLed wlLh an
lncreased rlsk for perloperauve compllcauons. Lung volume reducuon surgery (Lv8S) for pauenLs wlLh severe emphysema ls a
conLroverslal procedure. Some reporLs documenL subsLanual lmprovemenLs ln lung funcuon, exerclse capablllLy, and quallLy of
llfe ln hlghly selecLed pauenLs wlLh emphysema followlng Lv8S. Case serles of pauenLs referred for Lv8S lndlcaLe LhaL perhaps 3
Lo 6 of Lhese pauenLs may have coexlsung lung cancer. AnecdoLal experlence from Lhese case serles suggesL LhaL pauenLs wlLh
exLremely poor lung funcuon can LoleraLe comblned Lv8S and resecuon of Lhe lung cancer wlLh an accepLable morLallLy raLe
and good posLoperauve ouLcomes. Comblnlng Lv8S and lung cancer resecuon should probably be llmlLed Lo Lhose pauenLs wlLh
heLerogeneous emphysema, parucularly emphysema llmlLed Lo Lhe lobe conLalnlng Lhe Lumor.

lf CL1 ls unavallable, anoLher Lype of exerclse LesL should

be consldered. SLalr cllmblng has hlsLorlcally been used as

a surrogaLe
CL1. lf pauenLs were able Lo cllmb Lhree lghLs

of sLalrs, Lhey were consldered sulLable candldaLes for lobecLomy.

neumonecLomy candldaLes were expecLed Lo be able Lo cllmb ve

lghLs of sLalrs. 1hls approach was found Lo correlaLe wlLh

lung funcuon: cllmblng Lhree lghLs reecLed an lLv
1
>

1.7 L and ve lghLs lndlcaLed an lLv
1
> 2 L.
47
Powever,

sLalr cllmblng ls
noL performed ln a sLandardlzed manner. 1he

durauon of Lhe LesL, speed of ascenL, number of sLeps per lghL,

helghL of each
sLep, and crlLerla for sLopplng Lhe LesL have

noL been well dened. Powever, ln general Lerms, pauenLs who

can cllmb ve lghLs
of sLalrs wlll have a C
2
max

> 20 mL/kg/mln. Conversely, pauenLs who cannoL cllmb one

lghL of sLalrs wlll have a C
2
max < 10

mL/
kg/mln.
48

13
14
15 13
16
ACC Lung Cancer lll Culdellnes: lf elLher Lhe C lLv 1 or C u LCC are , 60
predlcLed and boLh are above 30 predlcLed, lL ls recommended LhaL a low
Lechnology exerclse LesL (sLalr cllmb or shuule walk LesL [SW1]) should be performed.
ln pauenLs wlLh lung cancer belng consldered for surgery, wlLh elLher a C lLv 1
<30 predlcLed or a C uLCC < 30 predlcLed performance of a formal
cardlopulmonary exerclse LesL (CL1) wlLh measuremenL of maxlmal oxygen
consumpuon ls recommended
17
18
19
MvC2 ls Maxlmal oxygen consumpuon
19
20
Low rlsk: esumaLed morLallLy < 1
ModeraLe rlsk: morbldlLy and morLallLy vary accordlng Lo values of spllL lung funclLon, exerclse
Lolerance and exLenL of resecuon
Plgh rlsk: rlsk of morLallLy > 10. Counsel pauenLs re alLernauve surglcal (mlnlmally lnvaslve /
sublobar resecuon) and non-surglcal opuons
20
1hough 230m ls a common cuL-o, Lhe false + raLe ls 24. As such, oLhers
recommend uslng 380m (0 false + raLe)
21
22 22
23 23
24
because

lncreased alr and decreased uld are cardlnal slgns of bronchopleural

sLula,
lL ls lmporLanL Lo monlLor changes ln Lhe alr-uld

level ln pauenLs who have
undergone a pneumonecLomy
24
25 23
26 26
27
ulerenL pauenL, normal progresslon of lncreaslng uld aer le pneumonecLomy
27
Crlglnal pauenL: lncreaslng alr aer rlghL pneumonecLomy
28
8l: poollng of secreuons / colonlzauon and bacLerlal overgrowLh
29
30
ls

characLerlzed on C1 lmages by an expanslon of Lhe posLpneumonecLomy

space,
wlLh a mass eecL, convexlLy or sLralghLenlng of Lhe

normally concave medlasunal
border of Lhe posLpneumonecLomy

space, lrregularly lncreased Lhlckenlng of Lhe
pleural space

Lmpyema ln a 74-year-old man aer le pneumonecLomy for sarcomaLold
carclnoma. ChesL radlograph on posLoperauve day 21 shows a mldllne posluon of
Lhe Lrachea, medlasunum, and LracheosLomy Lube and LoLal opaclcauon of Lhe
posLpneumonecLomy space. ChesL radlograph on posLoperauve day 30 shows a
rlghLward devlauon of Lhe Lrachea wlLh LracheosLomy Lube and of Lhe medlasunum
because of overexpanslon of Lhe posLpneumonecLomy space. Axlal C1 lmage on
posLoperauve day 32 shows lrregular pleural Lhlckenlng ln Lhe posLpneumonecLomy
space and an abscess (arrow) ln Lhe posLerlor chesL wall, ndlngs suggesuve of
empyema. A chesL Lube was lnserLed for dralnage.

bronchopleural or esophagopleural sLula may elLher cause or coexlsL wlLh empyema
30
31 31
32 32
33 33
34
35
C1 lmages

show abnormal narrowlng of Lhe dlsLal parL of Lhe Lrachea and

Lhe le
maln bronchus because of compresslon of Lhe alrway

beLween Lhe pulmonary arLery
anLerlorly and Lhe aorLa and splne

posLerlorly

Sallne-lled

expandable prosLhesls are noL suspecLed Lo cause compllcauons

such as
'lmmune relaLed or connecuve ussue dlsorders'

llke slllcone gel-lled lmplanLs
of Lhe Lrachea and

Lhe le maln bronchus because of compresslon of Lhe alrway

beLween Lhe pulmonary arLery anLerlorly and Lhe aorLa and splne

posLerlorly
33
36 36
37
8lghL upper lobe Lorslon ln a 33-year-old woman who had undergone rlghL mlddle lobecLomy for
bronchloloalveolar carclnoma. ChesL radlograph obLalned lmmedlaLely aer surgery shows chesL
Lubes ln Lhe rlghL hemlLhorax, subcuLaneous emphysema ln Lhe rlghL chesL wall, and an epldural
caLheLer ln Lhe sLernal area. no slgnlcanL abnormallLy ls seen ln Lhe lungs. ChesL radlograph
obLalned 1 day laLer shows rapldly developlng consolldauon wlLh volume expanslon ln Lhe rlghL upper
lobe. A neossure ls seen bulglng downward (arrow), lndlcaung a volume lncrease ln Lhe rlghL upper
lobe. lnLravenous conLrasL-enhanced C1 scan shows alrspace consolldauon ln Lhe rlghL upper lobe.
noLe also Lhe posLerlor bulglng of Lhe neossure (arrow). C1 scan obLalned aL Lhe level of Lhe
bronchus lnLermedlus shows obsLrucuon of Lhe rlghL upper lobar pulmonary arLery (arrow) wlLh
surroundlng so-ussue auenuauon. noLe also Lhe Lhlckenlng of Lhe posLerlor wall of Lhe bronchus
lnLermedlus (arrowhead). hoLograph of Lhe gross speclmen shows hemorrhaglc lnfarcuon wlLh
congesuon (arrows).
37
38 38
39 39
40 40
41
ln Lhe rare case LhaL a chesL x-ray ls obLalned safely, ndlngs can lnclude lpsllaLeral
lung collapse aL Lhe hllum, Lrachea and medlasunum devlauon Lo Lhe conLralaLeral
slde, and wldened lnLercosLal spaces on Lhe aecLed slde. WlLh a le hemlLhorax, Lhe
le hemldlaphragm may be depressed, buL Lhe llver prevenLs Lhls occurrence on Lhe
rlghL slde
41
42 42
43 43
44 44
45 43
46 46
47 47
48
Cround glass
ueep consolldauon
ulmonary lacerauon
48
49 49
50 30
51
Surgery works: lmproved morLallLy ln Lhe rlghL populauon. auenLs aren'L
belng referred
32
53
AL leasL Lwo maln concepLs have been publlshed Lo suggesL Lhe posslblllLy of a
LLv8 procedure.
34
33
56
37
38
39
60
61
62
63
64
65 63
66 66
67
68
69
70
71