Treatment of Patients With Lung Cancer and Severe Emphysema* Steven J. Mentzer, MD, FCCP; and Scott J. Swanson, MD, FCCP The development of lung cancer and emphysema is associated with the destructive chemical milieu that occurs with smoking. The recent interest in lung volume reduction surgery (LVRS) has stimulated a reassessment of the indications for surgery in patients with early stage lung cancer or emphysema. For patients with both diseases, the issues surrounding LVRS are simplified. The major concern is that the lung cancer can be surgically removed without the need for postoperative ventilation or mortality. A secondary consideration is the potential for longterm postoperative respiratory morbidity. These risks can be estimated by evaluating the anatomic location of the tumor, as well as the physiology of the underlying emphysema. Early results of combined LVRS and lung cancer resections suggest a favorable outcome in carefully selected patients. (CHEST 1999; 116:477S– 479S) Abbreviation: LVRS 5 lung volume reduction surgery cancer is the most commonly occurring cancer L ung and the most common cancer-related cause of death among men and women.1,2 Although the rate of lung cancer in white men in the United States appears to be declining (Fig 1),3,4 it continues to increase among African-American men and both white and African-American women. It is estimated that . 170,000 new cases of lung cancer will be diagnosed and . 160,000 deaths will result from lung cancer in the United States in 1999.1,2 Smoking is associated with . 80% of lung cancers.5 Male and female smokers have a 22-fold and 12-fold increased risk, respectively, of developing lung cancer.1 This risk increases with age and duration of smoke exposure. Although the association between smoking and lung cancer is clear, the mechanism of carcinogenesis remains unclear.6 Cigarette smoke contains . 4,000 different chemicals, many of which are proven carcinogens. Hundreds of other chemicals in cigarette smoke appear to promote carcinogenesis as well as the destruction of lung parenchyma. It is this destructive chemical milieu that results in the concomitant development of lung cancer and emphysema. Emphysema is commonly defined as a condition of the lung characterized by an abnormal increase in the size of the airspaces distal to the terminal bronchiole.7 This * From the Division of Thoracic Surgery, Department of Surgery, Brigham and Women’s Hospital, and the Dana-Farber Cancer Institute, Harvard Medical School Boston, MA. Correspondence to: Steven J. Mentzer, MD, FCCP, Division of Thoracic Surgery, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115; e-mail: [email protected]. harvard.edu Figure 1. Prevalence of emphysema and the incidence of lung cancer in the past 15 years. The prevalence of all people with emphysema is shown. The incidence of lung cancer in white men is shown; the incidence of lung cancer in African-American and white women (not shown) continues to rise. The incidence of lung cancer in African-American men has been relatively stable (not shown). Data from the National Center for Health Statistics.3,4 increase in airway size can be caused by an inherited predisposition, which is observed in a1-antitrypsin deficiency.8 An estimated 50,000 to 100,000 Americans currently have this enzyme deficiency. Alternatively, airway dilatation may result from destruction of the airway walls after smoke-related damage. Smoking is responsible for 82% of all chronic obstructive pulmonary disease (COPD), including emphysema. An estimated 2 million Americans suffer from emphysema,3 and emphysema ranks as the 15th most common chronic condition that contributes to activity limitation.2 Almost half of the patients with emphysema report that their daily activities are substantially limited by the disease.2 The common etiologic factor of cigarette smoke results in an increased risk of bronchogenic carcinoma in patients with emphysema. Epidemiologic studies suggest that 90% of patients with bronchogenic carcinoma have signs and symptoms of COPD. In most cases, symptoms include shortness of breath and cough. With disease progression, the shortness of breath will further decrease activity and exercise. The resulting deconditioning, combined with the diminished underlying lung function, increases the risk of any surgical intervention. An estimated 20% of patients with bronchogenic carcinoma have pulmonary dysfunction sufficiently severe to be considered inoperable by conventional criteria.9,10 Lung Volume Reduction Surgery The development of lung volume reduction surgery (LVRS) for the treatment of emphysema has stimulated a reassessment of the indications and contraindications for surgery in early stage lung cancer. LVRS was first introduced for patients with diffuse emphysema by Brantigan et al11 in the late 1950s. These investigators suspected that the floppy airways in emphysematous lungs resulted from lung hyperinflation. With a loss of elastic recoil caused by CHEST / 116 / 6 / DECEMBER, 1999 SUPPLEMENT Downloaded From: http://journal.publications.chestnet.org/ on 09/09/2014 477S smoke-induced lung destruction, there was a concomitant loss in airway tethering or “parenchymal interdependence.” By surgically reducing the lung volume, these investigators expected a restoration of parenchymal interdependence with improved expiratory airflow and shortness of breath. However, few supportive data, as well as a relatively high perioperative mortality, limited the initial acceptance of the procedure.12 The reintroduction of LVRS by Cooper et al13 was based on the similar concept of reversing the pathophysiologic effects of emphysema. In their initial report, these investigators reported on 20 patients who underwent LVRS via median sternotomy. There was no perioperative mortality, and postoperatively, the patients demonstrated an 82% improvement in FEV1, a 22% increase in 6-min walk distance, and a significant improvement in qualityof-life assessments.13 Subsequent reports have suggested similar benefits in selected patients. The procedure has also been validated using minimally invasive or thoracoscopic approaches.14 Major questions regarding LVRS that remain unanswered include (1) which patients benefit most from LVRS, (2) how durable is the response to LVRS, and (3) what are the relative risks and benefits for any given patient with emphysema? To address these questions, several major clinical trials are currently underway, including the National Emphysema Treatment Trial. The National Emphysema Treatment Trial is a unique collaboration between the administrative agencies for Medicare and the National Institutes of Health. The results of the National Emphysema Treatment Trial are expected in 5 to 7 years. Other regional clinical trials, such as the Overholt Blue Cross/Blue Shield Emphysema Surgery Trial in New England, should offer additional insights into the relative benefits of LVRS. LVRS in Patients With Lung Cancer and Emphysema For the patient with a tumor growing in an emphysematous lung, the issues surrounding LVRS are simplified. The duration and magnitude of the benefits of LVRS are a small consideration. The major concern is that the lung cancer can be surgically removed without postoperative mechanical ventilation or mortality. A secondary consideration is the potential for long-term postoperative respiratory morbidity. These risks can be estimated by evaluating the anatomic location of the lung cancer, as well as the physiology of the underlying emphysema. Although many patients with emphysema will have diffuse involvement of all portions of the lung, the majority of patients will demonstrate differential destruction of the apical portions of the lung. Both gas retention and hypoperfusion of the lung apices characterize the apical predominance of this type of emphysema. Resection of the dysfunctional apical lung tissue is relatively well tolerated because the apical portions contribute little or nothing to gas exchange. In selected patients, reducing the overall lung volume by resecting the apex has several beneficial effects. First, the decreased volume of lung tissue allows the distended chest wall and diaphragm to return to more 478S Downloaded From: http://journal.publications.chestnet.org/ on 09/09/2014 normal anatomic positions. The improved position of the chest wall and diaphragm can result in a significant improvement in ventilatory mechanics. Second, the smaller lung more effectively tethers the small airways, which results in improved expiratory airflow. Thus, the patient with apical emphysema and a lung cancer in the upper lobe is a potential candidate for surgical resection (Fig 2). In addition to the anatomic location of the tumor, an important consideration is the underlying cause of airflow obstruction. The vast majority of patients with emphysema have airflow obstruction, which is reflected by their relatively slow expiratory flow (eg, low FEV1). The generally accepted definition of emphysema suggests that expiratory flow limitation is caused by the collapse of floppy airways. Dilated, floppy airways appear to be the mechanism of flow limitation in most patients. There is evidence, however, that a subset of patients have a different mechanism of expiratory flow limitation.15 These patients appear to have high-resistance airways secondary to inflammation or scarring. Despite two distinct mechanisms of airflow obstruction, patients with emphysema will have indistinguishable expiratory spirometry. The practical clinical problem is that patients with dilated and floppy airways have a potential to respond to LVRS. In contrast, patients with fixed small airway disease appear unlikely to benefit and may worsen on lung volume reduction. To distinguish between these two groups of patients, Ingenito and colleagues15 at the Brigham and Women’s Hospital are studying airflow obstruction during both inspiration and expiration. Patients with scarred small airways would be expected to have high resistance during both inspiration and expiration. Patients with floppy airways would be expected to have airflow obstruction limited to expiration. Early clinical results support these predictions.15 Figure 2. Chest CT scan showing a squamous cell carcinoma in the left upper lobe of a patient with a baseline FEV1 of 430 mL. The combined tumor resection and LVRS resulted in a 3-day hospital stay, negative margins, and slightly improved dyspnea. Multimodality Therapy of Chest Malignancies—Update ’98 Table 1—Combined LVRS and Nodule Resection Inclusion Criteria Severe dyspnea Hyperinflation with flow obstruction Oxygen requirement Heterogeneous emphysema Pulmonary nodule Ambulatory potential Exclusion Criteria Irreversible small airway obstruction Obliterated pleural space Intractable hypercarbia Unresectable locoregional disease Evidence of metastatic disease Hilar tumor Indications or Early Results for LVRS in Lung Cancer The indications for combined LVRS and resection of a bronchogenic carcinoma are based on the generally accepted criteria for LVRS (Table 1). Patients may have severe dyspnea. The arterial blood gas abnormalities can include hypoxemia and hypercarbia. In addition, conventional spirometry may demonstrate FEV1 , 20% of predicted values. However, the most important predictor for improvement after LVRS is the presence of recruitable elastance, which is the relatively preserved tissue remaining in the lung. It is these relatively preserved areas of lung tissue that are compromised by the hyperinflated emphysematous portions of the lung. In addition to the exclusion of metastatic disease, contraindications for combined LVRS and cancer resections include total disability because of lung disease (Table 1). Patients who are largely wheelchair bound but have ambulatory potential can be enrolled in a pulmonary rehabilitation program. Pulmonary rehabilitation can result in substantial improvements in preoperative condition and surgical risk. Patients who do not have ambulatory potential are at prohibitive risk for postoperative respiratory failure. Relative contraindications include the presence of hilar masses and large masses that require the anatomic resection of residual functioning lung tissue. The early results of combined LVRS and lung cancer resections suggest a favorable outcome in most patients. McKenna and colleagues16 reported the resection of 51 masses in 325 patients undergoing LVRS. Eleven of these lesions were non–small cell lung cancer. The mortality from this operation was 3.5%, and there was no evidence of recurrent carcinoma during a 9-month follow-up period.14 DeRose et al17 resected 14 patients with lung cancer with combined LVRS. Nine of resected lesions were non–small cell lung cancer. There was one mediastinal recurrence at 12 months, but substantial improvements in dyspnea indexes, expiratory spirometry (FEV1), and functional capacity (6-min walk test) were reported. These and other early results suggest that the indications and contraindications for the resection of bronchogenic carcinoma must be carefully reassessed. In particular, patients with end-stage emphysema must be evaluated in the context of their physiologic potential and the possible benefits of LVRS. References 1 Trends in lung cancer: morbidity and mortality. 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