7. ANEXOS
7.1. Participación Comunitaria y Medidas de Autocuidado
The physiological evaluation must be individualized for each patient. The assessment of a patient's ability to tolerate lung resection from a cardiopulmonary Table 9.6 Lymph node map definitions (see also Figure 9.2)
N2 nodes – all N2 nodes lie within the mediastinal pleural envelope
1 Highest mediastinal nodes: nodes lying above a horizontal line at the upper rim of the bracheocephalic (left innominate) vein where it ascends to the left, crossing in front of the trachea at its midline
2 Upper paratracheal nodes: nodes lying above a horizontal line drawn tangential to the upper margin of the aortic arch and below the inferior boundary of #1 nodes
3 Prevascular and retrotracheal nodes: pre- and retrotracheal nodes may be designated 3A and 3P. Midline nodes are considered to be ipsilateral
4 Lower paratracheal nodes: the lower paratracheal nodes on the right lie to the right of the midline of the trachea between a horizontal line drawn tangential to the upper margin of the aortic arch and a line extending across the right main bronchus at the upper margin of the upper lobe bronchus, and contained within the mediastinal pleural envelope; the lower paratracheal nodes on the left lie to the left of the midline of the trachea between a horizontal line drawn tangential to the upper margin of the aortic arch and a line extending across the left main bronchus at the level of the upper margin of the left upper lobe bronchus, medial to the ligamentum arteriosum and contained within the mediastinal pleural envelope
Researchers may wish to designate the lower paratracheal nodes as No. 4s (superior) and No.4i (inferior) subsets for study purposes; the No. 4s nodes may be defined by a horizontal line extending across the trachea and drawn tangential to the cephalic border of the azygos vein; the No. 4i nodes may be defined by the lower boundary of No. 4s and the lower boundary of No. 4, as described above
Reginal lymph node classification
5 Subaortic (A–P window): subaortic nodes are lateral to the ligamentum arteriosum or the aorta or left pulmonary artery and proximal to the first branch of the left pulmonary artery, and lie within the mediastinal pleural envelope
6 Para-aortic nodes (ascending aorta or phrenic): nodes lying anterior and lateral to the ascending aorta and the aortic arch or the innominate artery, beneath a line tangential to the upper margin of the aortic arch
7 Subcarinal nodes: nodes lying caudal to the carina of the trachea, but not associated with the lower lobe bronchi or arteries within the lung
8 Paraesophageal nodes (below carina): nodes lying adjacent to the wall of the esophagus and to the right or left of the midline, excluding subcarinal nodes
9 Pulmonary ligament nodes: nodes lying within the pulmonary ligament, including those in the posterior wall and lower part of the inferior pulmonary vein
N1 nodes – all N1 nodes lie distal to the mediastinal pleural reflection and within the visceral pleura
10 Hilar nodes: the proximal lobar nodes, distal to the mediastinal pleural reflection and the nodes adjacent to the bronchus intermedius on the right; radiographically, the hilar shadow may be created by enlargement of both hilar and interlobar nodes
11 Interlobar nodes: nodes lying between the lobar bronchi 12 Lobar nodes: nodes adjacent to the distal lobar bronchi 13 Segmental nodes: nodes adjacent to segmental bronchi 14 Subsegmental nodes: nodes around the subsegmental bronchi From references 23 and 24.
standpoint is fundamental to patient selection for surgery.
Patients with advanced pulmonary disease and severe pulmonary dysfunction may have prohibitive risk despite otherwise resectable disease. Cigarette smoking is
associated with increase in the incidence of postopera-tive pulmonary complications after surgery. Preopera-tive smoking abstinence reduces the incidence of complications 34 .
Phrenic nerve
AO
PA 5 6 3
Left
pulmonary artery Ligamentum
arteriosum 12, 13, 14L 12, 13, 14R
10L 11L
9 8 11R
10R Azygos vein
Mediastinal pleura Brachiocophalic
(innominate) artery Mediastinal pleura
4R 2R
7
Figure 9.2 Lymph node (1–14) map for mediastinal lymph node stations. Single digit nodal stations represent mediastinal lymph nodes (N2); double digit nodal stations represent intraparenchymal or intrapleural stations (N1). PA, pulmonary artery; AO, aorta; L; left;
R, right. From references 23 and 24.
Table 9.7 Pathology report. The pathology report is expected to include specific information for demographic and cancer center statistics. An R0 result was accomplished in this patient.
An example is presented of summary findings (from the pathol-ogy report of the patient described in Figure 9.3)
Specimen type: left upper lobectomy
Margins (give distance of tumor from closest margin if uninvolved): 1.0 cm
Direct extension of tumor: through visceral pleura Venous (large vessel invasion): not identified Arterial (large vessel invasion): not identified
Lymphatic (small vessel invasion) (optional): not identified
Advanced age is an independent predictor of mortality after resection for NSCLC 35 and most likely serves as a surrogate marker for additional co-morbidities rather than an independent risk factor. Pulmonary resection may be performed with acceptable rates of morbidity and mortality in patients well beyond the age of 70.
Spirometry is mandatory for patients being considered for pulmonary resection and provides an objective assess-ment of pulmonary function ( Figure 9.3d ). The forced expiratory volume in 1 second (FEV-1) is the historical standard to determine suitability for resection. A pre-dicted postoperative FEV-1 (ppoFEV-1) can be estimated based on the planned extent of resection: ppoFEV1 = preoperative FEV1 × (number of segments remaining/
total segments 34 ). FEV-1 is an independent predictor of mortality from surgery for NSCLC 35 , and serves as the primary determinant of the need for further physiological assessment prior to surgery for NSCLC. The criterion of ppoFEV-1 of at least 0.8l has been widely used in deci-sions for NSCLC resection. However, an absolute value of FEV-1 predicts postresection pulmonary function less accurately than FEV-1 expressed as a percentage of the expected value for age and size. In general, patients with an absolute FEV-1 of greater than 2.0 l are likely to toler-ate pneumonectomy, and those with an FEV-1 > 1.5 l lobectomy 20 , 36 . Patients deemed unable to tolerate lobec-tomy from a pulmonary functional standpoint may be
candidates for more limited resections, such as wedge or anatomic segmental resection. Although such procedures are associated with significantly higher rates of local recurrence and a trend towards decreased survival 37 , 38 , minimally invasive techniques and improved postopera-tive pain management techniques (patient controlled analgesia, epidural anesthesia, etc.) may allow pulmonary resection in many patients previously considered medically inoperable.
Pulmonary diffusing capacity for carbon monoxide (DLCO) provides a measurement of the lung surface area available for gas exchange, and is determined by measuring expired carbon monoxide levels during controlled exhalation. A low DLCO reflects the presence of emphysema, fibrosis, or pulmonary vascular disease. Similar to FEV-1, preoperative DLCO measure-ment is most useful when expressed as a percentage of predicted value 36 and may be used to estimate predicted postoperative DLCO (ppoDLCO).
Cardiopulmonary exercise testing can be extremely useful in evaluating patients who appear more disabled than expected from simple spirometry measurements or with ppoFEV-1 or DLCO < 40% predicted. These stud-ies include exercise electrocardiography, heart rate response to exercise, and the measurements of minute ventilation and oxygen uptake per minute. Maximal oxygen consumption (VO 2max ) evaluates the ‘cardiopul-monary axis’ and may identify clinically occult cardiac disease and provide a more accurate assessment of pulmo-nary function than spirometry and DLCO 39 . A patient's risk of perioperative morbidity and mortality may be stratified by VO 2max . Those with VO 2max above 20 ml/kg/min are not at increased risk for complications or death after resection of NSCLC. A level below 15 ml/kg/
min is associated with an increased risk, and VO 2max
< 10 ml/kg/min indicates very high risk, generally precluding operation 40 , 41 .
Observed performance during stair climbing has historically been utilized in the preoperative assessment of patients with NSCLC. Stair climbing ability has some correlation with values on spirometry 42 , but perhaps is most correlated with a patient's global cardiopulmonary status and determination, both of which are fundamental to a successful outcome after surgery.
Quantitative radionucleotide perfusion scanning, involves the injection of 99m Tc-radiolabeled albumin particles, followed by the visual inspection of planar images ( Figure 9.3e ). Unlike perfusion scanning in the setting of suspected pulmonary thromboembolism, con-comitant ventilation scanning is not routinely performed for preoperative assessment, as studies have demonstrated both are usually well matched and equally effective in assessing function. Quantitative perfusion provides a
(b1)
(b2) (c)
Figure 9.3 A 57-year-old woman with hemoptysis and 20 lb weight loss in the past year. She quit smoking cigarettes with this episode, but previously had smoked two packs per day for 30 years. She has no cough, fever, chills, or subsequent hemoptysis; she has some dyspnea on mild to moderate exertion. The patient also related 3/10 left posterior apical chest discomfort. (a) Chest X-ray posterior–anterior view and lateral view demonstrating a 6.7 cm left upper lobe mass near the lung apex. (b) Computed tomography (CT) of the chest confirmed a left upper lobe mass near the lung apex. A CT-guided biopsy of the lesion was significant for adenocarcinoma. (b) (upper) The mass itself extends to but does not appear to invade the prevertebral fascia. A soft tissue (pleural) plane is identified. A chest wall resection would not be expected, but an extrapleural dissection in this area may be required. (b) (lower) The mediastinal lymph nodes are identified and are enlarged (>1 cm in the pretracheal area). The aortopulmonary window lymph nodes are identified but are non-specific. FDG-PET) would be helpful in determining the extent of metabolic activity in these areas. (c) FDG-PET with integrated CT. CT demonstrates the large left upper lobe mass, and FDG-PET demonstrates significant metabolic activity in this area. No sites of metastases are noted in the mediastinum or elsewhere. Physiological uptake is noted in the brain, bones, liver, spleen, kidney, and musculature, and in the renal collecting system and the bladder. Some activity in the colon is noted as well. Although PET did not identify FDG avid lesions in the mediastinum, CT demonstrated some enlarged >1 cm lymph nodes in the pretracheal space. Based on these findings, additional invasive staging with mediastinoscopy or other mediastinal staging (endobronchial ultrasound, esophageal ultrasound) is warranted. Clinically these findings are associated with reactive adenopathy or subclinical metastases. (d) Pulmonary function studies (spirometry) with diffusing capacity of the lung for carbon monoxide (DLCO). This patient has good pulmonary function despite a long history (60 pack-years) of cigarette smoking.
A flow-volume loop is normal in appearance. FVC, forced vital capacity; FEV1, forced expiratory volume in 1 second; FEF, forced expiratory flow; PEF, peak expiratory flow; TLC, total lung capacity; VC, vital capacity; FRC PL, functional residual capacity; ERV, expiratory reserve volume; RV,; DL,; VA,; IVC,. (e) Quantitative ventilation perfusion scan. The location of the tumor and its proximity to the proximal hilum suggests that pneumonectomy may be required. The ability of the patient to tolerate left pneumonectomy would be determined with pulmonary function studies. A quantitative ventilation perfusion lung scan would be performed. The perfusion phase is shown here. The images are viewed from a posterior to anterior direction. The left upper lung field has marginal function (5.5%). Even if the patient did require a pneumonectomy she would still have sufficient pulmonary reserve in her right lung (56.6%). Her predicted postoperative (ppo) FEV1 would be 1.79 l/sec × 0.566 perfusion in right lung = 1.01 l ppoFEV1 remaining. Cardiology evaluation was not performed given the patient's active lifestyle and no symptoms of cardiovascular disease. Given the overall physiological fitness of the patient, the location of the primary tumor and the ability to remove all disease with a lobectomy or possibly a pneumonectomy, resection is possible. The operation would include bronchoscopy, cervical mediastinal staging with mediastinoscopy or other technique. If negative, pulmonary resection and mediastinal lymph node dissection would be performed to achieve a R0 resection. Should occult lymph node involvement be identified in the postresection specimen, adjuvant chemotherapy would be recommended.
VANDERBILT MEDICAL CENTER PULMONARY LAB
All data is ACCEPTABLE and REPRODUCIBLE according to ATS standards.
Calibration Data: Temp: 22 PBar: 743
measurement of the relative function of each lobe and lung, allowing a prediction of pulmonary function after lung resection.
Arterial blood gas (ABG) analysis is not a mandatory component of preoperative assessment for lung resection.
It may be indicated in marginal candidates, or if there is a clinical suspicion of significant hypoxia or carbon dioxide retention
Cardiovascular evaluation should therefore conform to American College of Cardiology (ACC) and American Heart Association (AHA) guidelines for non-cardiac surgery.
Surgical management of non-small cell lung carcinoma
Fundamentals of surgical management of NSCLC include complete resection with negative margins (R0), system-atic mediastinal lymph node dissection, and integration of multidisciplinary teams in all but the earliest (clinical stage IA) or metastatic (cstage IV) disease. Resection of NSCLC is safe with modern mortality of 1.35%
based upon a multi-institutional prospective randomized trial of over 1000 patients evaluating mediastinal lymph node sampling compared with dissection 43 . Resection of NSCLC can be curative in the earliest stages 44 . Postoperative convalescent care must include aggressive mobilization, pulmonary hygiene and pain control (typically with thoracic epidural catheter).
STAGE-SPECIFIC THERAPY