Lobar volume reduction surgery: a method of increasing the lung cancer resection rate in patients with emphysema

BACKGROUND—Guidelines on patient selection for lung cancer resection identify a predicted postoperative forced expiratory volume in 1second (ppoFEV1) of <40% as a predictor of high risk. Experience with lung volume reduction surgery suggests that ppoFEV1 may be underestimated in those with concomitant emphysema. METHODS—Anatomical lobectomy was performed in 29 patients with a resectable lung cancer within a poorly perfused, hyperinflated emphysematous lobe identified by radionuclide perfusion scintigraphy and computed tomographic scanning. Perioperative changes in spirometric parameters at 3 months were compared in 14 patients (group A) of mean age 69 years (range 48-78) with ppoFEV1 40% (mean (SD) 47 (5)%). The correlation between predicted and actual postoperative FEV1 was also assessed. RESULTS—In group B there was a significant perioperative reduction in FEV1 (p=0.01) but in group A FEV1 did not change significantly after lobectomy (p=0.87); mean difference in perioperative change between groups A and B 331 ml (95% CI 150 to 510). Despite the difference in ppoFEV1 between the groups, there was no difference in actual FEV1 at 3 months. In-hospital mortality was 14% in group A and zero in group B, but at a median follow up of 12 (range 6-40) months there was no difference in survival between the groups. CONCLUSIONS—Selection for lung cancer resection in patients with emphysema using standard calculations of ppoFEV1 may be misleading. The effect of lobar volume reduction allows for an extension of the selection criteria.