Pneumologie 2019; 73(09): 523-532
DOI: 10.1055/a-0916-1434
Übersicht
© Georg Thieme Verlag KG Stuttgart · New York

Umfassende präoperative Evaluation von Patienten mit Lungenkrebs

Comprehensive Preoperative Evaluation of Patients with Lung Cancer
S. Ewig
1   Kliniken für Innere Medizin, Pneumologie und Infektiologie, Thoraxzentrum Ruhrgebiet, Herne und Bochum
,
S. Larrosa-Lombardi
1   Kliniken für Innere Medizin, Pneumologie und Infektiologie, Thoraxzentrum Ruhrgebiet, Herne und Bochum
,
A. Halboos
2   Klinik für Innere Medizin, Kardiologie, Herne
,
E. Hecker
3   Klinik für Thoraxchirurgie, Thoraxzentrum Ruhrgebiet, Herne und Bochum
› Author Affiliations
Further Information

Publication History

eingereicht 02 May 2019

akzeptiert nach Revision 09 May 2019

Publication Date:
17 June 2019 (online)

Zusammenfassung

Anatomische Resektionsverfahren sind unverändert etablierter Standard in der kurativen Behandlung des nichtkleinzelligen Lungenkarzinoms in den Stadien I – III und einiger kleinzelliger Lungenkarzinome.

Die Angaben in der Literatur zur Letalität sowie den Komplikationsraten der Resektionsverfahren schwanken jedoch erheblich. Eine Variable, die das Operationsergebnis maßgeblich beeinflusst, ist die Auswahl der Kandidaten für eine Resektion sowie die Bestimmung des Umfangs der Resektion auf dem Boden einer adäquaten Durchführung und Interpretation einer umfassenden mehrdimensionalen präoperativen Evaluation.

Elemente dieser Evaluation sind entsprechend verfügbarer Daten und Leitlinien: der ECOG-Score; kardiales Assessment, ggf. zerebrovaskuläres Assessment; pulmonales Assessment, ggf. mit Ergebnissen der Split-Funktionsanalysen, jeweils ggf. nach Therapie bzw. Adjustierung einer Therapie; bei Patienten über 70 Jahren: Score zur allgemeinen Funktionalität (IADL).

Im Rahmen dieser Evaluation ergeben sich demnach 3 verschiedene Risikogruppen: Patienten mit einem geringen Risiko für intra- und postoperative Komplikationen und Letalität; Patienten mit einem entsprechend erhöhten Risiko; Patienten, die als inoperabel eingeschätzt werden.

Um eine autonome Entscheidung des Patienten über die optimale Therapie auf dem Hintergrund definierter Risiken zu ermöglichen, ist zudem auch die Kenntnis des Patienten, seiner Präferenzen und Wertmaßstäbe sowie seiner familiären und sozialen Einbindung unverzichtbar.

Abstract

Surgical resection continues to be a mainstay of curative treatment of patients with non-small cell lung cancers stages I – III and some small cell lung cancers.

Reported rates of complications and mortality vary considerably. Therefore, a thorough and comprehensive preoperative evaluation of lung cancer patients is crucial in order to select appropriate surgical candidates and to determine their individual risk, including the extent of resection possible.

Following available data and guidelines, such evaluation should include: ECOG-scoring, cardiac risk assessment, cerebrovascular assessment, pulmonary risk assessment, including split function analysis, and additional initiation or adjustment of treatment where appropriate; in patients aged ≥ 70 years: functional scoring (IADL).

Risk stratification results in three groups: patients at low risk for complications and mortality, patients at increased risk, and patients who usually are not candidates for surgical resection.

Finally, in order to support autonomous decisions of patients on optimal treatment based on defined risks, physicians must be familiar with values and preferences of patients as well as their familial and social situation.

 
  • Literatur

  • 1 Brunelli A, Charloux A, Bolliger CT. et al.; European Respiratory Society. ERS/ESTS clinical guidelines on fitness for radical therapy in lung cancer patients (surgery and chemo-radiotherapy). Eur Respir J 2009; 34: 17-41
  • 2 Lim E, Baldwin D, Beckles M. et al.; British Thoracic Society. Guidelines on the radical management of patients with lung cancer. Thorax 2010; 65 (Suppl. 03) iii1-27
  • 3 Fleisher LA, Beckman JA, Brown KA. et al.; American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2007; 116: e418-e499
  • 4 https://www.awmf.org/uploads/tx_szleitlinien/020-007OL_l_S3_Lungenkarzinom_2018-03.pdf letzter Zugriff: 1. 5. 2019
  • 5 Brunelli A, Kim AW, Berger KI. et al. Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013; 143 (Suppl. 05) e166S-e190S
  • 6 Ferguson MK, Saha-Chaudhuri P, Mitchell JD. et al. Prediction of major cardiovascular events after lung resection using a modified scoring system. Ann Thorac Surg 2014; 97: 1135-1140
  • 7 Bateman BT, Schumacher HC, Wang S. et al. Perioperative acute ischemic stroke in noncardiac and nonvascular surgery: incidence, risk factors, and outcomes. Anesthesiology 2009; 110: 231-238
  • 8 Berrisford R, Brunelli A, Rocco G. et al. The European Thoracic Surgery Database project: modelling the risk of in-hospital death following lung resection. Eur J Cardiothorac Surg 2005; 28: 306-311
  • 9 Falcoz PE, Conti M, Brouchet L. et al. The Thoracic Surgery Scoring System (Thoracoscore): risk model for in-hospital death in 15,183 patients requiring thoracic surgery. J Thorac Cardiovasc Surg 2007; 133: 325-332
  • 10 Chamogeorgakis TP, Connery CP, Bhora F. et al. Thoracoscore predicts midterm mortality in patients undergoing thoracic surgery. J Thorac Cardiovasc Surg 2007; 134: 883-887
  • 11 Chamogeorgakis T, Toumpoulis I, Tomos P. et al. External validation of the modified Thoracoscore in a new thoracic surgery program: prediction of in-hospital mortality. Interact Cardiovasc Thorac Surg 2009; 9: 463-466
  • 12 Bradley A, Marshall A, Abdelaziz M. et al. Thoracoscore fails to predict complications following elective lung resection. Eur Respir J 2012; 40: 1496-1501
  • 13 Qadri SS, Jarvis M, Ariyaratnam P. et al. Could Thoracoscore predict postoperative mortality in patients undergoing pneumonectomy?. Eur J Cardiothorac Surg 2014; 45: 864-869
  • 14 Sharkey A, Ariyaratnam P, Anikin V. et al. Thoracoscore and European Society Objective Score Fail to Predict Mortality in the UK. World J Oncol 2015; 6: 270-275
  • 15 Chesterfield-Thomas G, Goldsmith I. Impact of preoperative pulmonary rehabilitation on the Thoracoscore of patients undergoing lung resection. Interact Cardiovasc Thorac Surg 2016; 23: 729-732
  • 16 Bolliger CT, Jordan P, Solèr M. et al. Pulmonary function and exercise capacity after lung resection. Eur Respir J 1996; 9: 415-421
  • 17 Criée CP, Baur X, Berdel D. et al. Standardization of spirometry: 2015 update. Published by German Atemwegsliga, German Respiratory Society and German Society of Occupational and Environmental Medicine. Pneumologie 2015; 69: 147-164
  • 18 Brunelli A, Refai M, Xiumé F. et al. Oxygen desaturation during maximal stair-climbing test and postoperative complications after major lung resections. Eur J Cardiothorac Surg 2008; 33: 77-82
  • 19 Meyer FJ, Borst MM, Buschmann HC. et al. Belastungsuntersuchungen in der Pneumologie – Empfehlungen der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin. Pneumologie 2018; 72: 687-731
  • 20 Miller Jr JI. Physiologic evaluation of pulmonary function in the candidate for lung resection. J Thorac Cardiovasc Surg 1993; 105: 347-351
  • 21 Linden PA, Bueno R, Colson YL. et al. Lung resection in patients with preoperative FEV1 < 35 % predicted. Chest 2005; 127: 1984-1990
  • 22 Ferguson MK, Reeder LB, Mick R. Optimizing selection of patients for major lung resection. J Thorac Cardiovasc Surg 1995; 109: 275-281
  • 23 Kearney DJ, Lee TH, Reilly JJ. et al. Assessment of operative risk in patients undergoing lung resection. Importance of predicted pulmonary function. Chest 1994; 105: 753-759
  • 24 Pierce RJ, Copland JM, Sharpe K. et al. Preoperative risk evaluation for lung cancer resection: predicted postoperative product as a predictor of surgical mortality. Am J Respir Crit Care Med 1994; 150: 947-955
  • 25 Baldi S, Ruffini E, Harari S. et al. Does lobectomy for lung cancer in patients with chronic obstructive pulmonary disease affect lung function? A multicenter national study. J Thorac Cardiovasc Surg 2005; 130: 1616-1622
  • 26 Varela G, Brunelli A, Rocco G. et al. Measured FEV1 in the first postoperative day, and not ppoFEV1, is the best predictor of cardio-respiratory morbidity after lung resection. Eur J Cardiothorac Surg 2007; 31: 518-521
  • 27 Ferguson MK, Vigneswaran WT. Diffusing capacity predicts morbidity after lung resection in patients without obstructive lung disease. Ann Thorac Surg 2008; 85: 1158-1164
  • 28 Bolliger CT, Jordan P, Solèr M. et al. Exercise capacity as a predictor of postoperative complications in lung resection candidates. Am J Respir Crit Care Med 1995; 151: 1472-1480
  • 29 Benzo R, Kelley GA, Recchi L. et al. Complications of lung resection and exercise capacity: a meta-analysis. Respir Med 2007; 101: 1790-1797
  • 30 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: 1450-1456
  • 31 Loughney L, West M, Pintus S. et al. Comparison of oxygen uptake during arm or leg cardiopulmonary exercise testing in vascular surgery patients and control subjects. Br J Anaesth 2014; 112: 57-65
  • 32 American Thoracic Society; American College of Chest Physicians. ATS/ACCP Statement on cardiopulmonary exercise testing. Am J Respir Crit Care Med 2003; 167: 211-277
  • 33 Begum SS, Papagiannopoulos K, Falcoz PE. et al. Outcome after video-assisted thoracoscopic surgery and open pulmonary lobectomy in patients with low VO2 max: a case-matched analysis from the ESTS database. Eur J Cardiothorac Surg 2016; 49: 1054-1058
  • 34 Loran DB, Zwischenberger JB. Thoracic surgery in the elderly. J Am Coll Surg 2004; 199: 773-784
  • 35 Fulop T, Larbi A, Dupuis G. et al. Immunosenescence and Inflamm-Aging As Two Sides of the Same Coin: Friends or Foes?. Front Immunol 2018; 8: 1960
  • 36 Tsiouris A, Horst HM, Paone G. et al. Preoperative risk stratification for thoracic surgery using the American College of Surgeons National Surgical Quality Improvement Program data set: functional status predicts morbidity and mortality. J Surg Res 2012; 177: 1-6
  • 37 Tsiouris A, Hammoud ZT, Velanovich V. et al. A modified frailty index to assess morbidity and mortality after lobectomy. J Surg Res 2013; 183: 40-46
  • 38 https://www.onkopedia.com/de/wissensdatenbank/wissensdatenbank/wissensdatenbank/geriatrische-onkologie/InstrumentelleAktivittendestglichenLebensIADLnachLawtonundBrody.pdf zuletzt abgerufen 2. 5. 2019
  • 39 Silvestri GA, Handy J, Lackland D. et al. Specialists achieve better outcomes than generalists for lung cancer surgery. Chest 1998; 114: 675-806
  • 40 Hoffmann H, Passlick B, Ukena D. et al. Surgical therapy for lung cancer: why it should be performed in high volume centres. Zentralbl Chir 2019; 144: 62-70