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A Pragmatic and Successful Approach to Treating Nonsmall-Cell Lung Carcinoma

Posted on: Tuesday, 16 November 2004, 03:00 CST

ABSTRACT

* LUNG CANCER is the single leading cause of cancer deaths for men and women combined. Nonsmall-cell lung carcinoma (NSCLC), which results largely from smoking tobacco, accounts for 87% of all lung cancer cases.

* METHODS OF PATIENT SELECTION, preoperative and intraoperative care, and postoperative outcomes for patients with NSCLC who were treated from 1991 through 2003 at Inova Fairfax Hospital are discussed.

* ALL PATIENTS WERE TREATED with surgery, some selectively and progressively with a combination of preoperative neoadjuvant therapy, to try to downstage the disease to make complete resection feasible. Outcomes from this data collection period match or exceed the best results for treatment of late-stage (ie, III and IV) disease reported anywhere to date. AORN J 80 (November 2004) 840- 857.

Lung cancer is the single leading cause of cancer deaths for men and women combined,1 resulting in 31% of cancer deaths in men and 25% of cancer deaths in women.2 Nonsmall-cell lung carcinoma (NSCLC), which results largely from smoking tobacco, accounts for 87% of all lung cancer cases.3 Were smoking to be reduced significantly, the incidence of lung cancer likely would decrease proportionately.

The survival rates for patients with stage II or IIIA disease (ie, 41% and 36%, respectively) treated at Inova Fairfax Hospital, Falls Church, Va, between 1981 and 1989 match the best results achieved by other health care facilities.4,5 This article details the methods of patient selection, preoperative and intraoperative care, and postoperative outcomes for patients treated for NSCLC from 1991 through 2003 at Inova Fairfax Hospital. Based on the knowledge that incomplete tumor resection precludes long-term survival where late-stage disease (ie, III, IV) was recognized, patients were treated selectively and progressively with preoperative neoadjuvant chemotherapy, radiation therapy, or a combination of both therapies to try to downstage the disease so that complete resection might be feasible. The outcomes from this data collection period are consistent with Inova's results from 1981 through 1989.5,6 The results match or exceed the best results for treatment of late- stage (ie, III and IV) disease reported anywhere to date.7,8

STAGE OF TUMOR

The pioneering work of H. C. Nohl, MD,9 and D. L. Paulson, MD,10 provides near universal agreement on the importance of lung cancer staging, which is a method of estimating the extent of disease and thereby indirectly determining a patient's prognosis to help determine the best treatment plan. The international tumor, node, metastasis (TNM) staging system uses a "T" to describe the size, location, and pulmonary or extrapulmonary spread of the primary tumor. An "N" is used to describe whether the tumor involves or has progressed via metastasis to particular groups of lymph nodes. The "M" describes metastases to distant organ sites (eg, adrenal, bone, brain, liver) (Table I).11,12 This staging system is accepted by the American Joint Committee on Cancer.12,13

Lung tumors then are grouped according to their stage (Table 2). Individuals without nodal spread (ie, stage I) or with intrapleural, regional nodal spread of disease (ie, stage II) may undergo surgical resection, occasionally supplemented with adjuvant therapy (eg, chemotherapy, radiation therapy), in the hope that all disease will be extirpated. Numerous articles attest to the success of surgical resection of NSCLC when the disease is diagnosed before it progresses to extrapleural, mediastinal lymphatic (ie, stage III), or distant metastatic (ie, stage IV) disease.6,14-18 Until recently, however, the treatment of stage III and stage IV cancer has been considered only palliative-the end result of which is a foregone, dismal conclusion:4,5

TABLE 1

International Tumor, Node, Metastasis (TNM) Cancer-Staging System Descriptors1

The microscopically verified TNM staging system

has proved to be the best method ... to determine treatment strategies and ultimate prognosis . . . the involvement of intrapulmonary (N1) or mediastinal (N2, extrapulmonary) lymph nodes remains the most important predictor of outcome after resection of lung cancer.19

TABLE 2

Stage Grouping-Tumor, Nodes, Metastasis (TNM) Subsets*1

Figure 1 Lymph node stations for lung cancer staging. Mediastinal (ie, N2) nodes are depicted by single digits, and intrapulmonary nodes (ie, Nl) are depicted by two digits. Adapted with permission from Chest 111 (June 1997) 1718-1723.

Figure 1 illustrates the anatomic location of various Nl (ie, intrapulmonary) and N2 (ie, extrapulmonary, mediastinal) nodes.12 Figure 2 relates the microscopically proven pathological stage to the likely posttreatment prognosis,12 thus, when microscopically proven pathological disease is described, the letter "P" is used (eg, PNl, PN2) to differentiate from preoperative, clinical estimate of stage, which uses the letter "C" instead (eg, CNl, CN2).

Preoperative clinical attempts to forecast the actual pathological burden (ie, stage) of disease rest on accuracy in an array of anatomic and physiological imaging modalities, including computed tomography (CT) and positron emission tomography (PET). One experienced surgeon admonishes that the clinical appearance of disease may be misleading, noting that in his experience

if all the patients ... with N-2 disease that is detected by preoperative CT scanning were uniformly excluded from operation, 39% of PNO or PN1 patients would have been excluded.20

Figure 2 Posttherapy nonsmall-cell lung carcinoma survival rates based on pathological stage of disease (surgical deaths excluded from study group). Adapted from collected databases of MD Anderson Cancer Center, Houston, and the North American Lung Cancer Study Group.

The selective addition of PET scanning to routine use of CT is considered progress in the direction of less invasive and more efficacious diagnosis and therapy. Experience indicates that PET scanning seems to achieve a high negative predictive value in the evaluation of mediastinal (ie, N2) disease.2123 In other words, a negative result may be 93% to 95% accurate, so in this instance 93 to 95 out of 100 patients with a negative result will not have mediastinal disease. A PET scan also seems to be particularly helpful in evaluating patients in whom bulky nodes persist on CT after neoadjuvant therapy. A PET scan is significantly more costly than a CT scan, so clinicians at Inova Fairfax Hospital use PET scanning when

* dealing with large or central lesions;

* in doubt (ie, after neoadjuvant therapy); or

* questionable adenopathy is not easily approachable by routine staging mediastinoscopy anterior mediastinotomy, or percutaneous needle biopsy.

PREOPERATIVE ASSESSMENT

Health care team members (eg, surgeon, oncologist, radiologist, anesthesia care provider, circulating nurse) perform a thorough assessment of the patient, including data summarizing physiological review of the patient's performance status and the anatomic extent of the patient's tumor burden. Performance status primarily relates to cardiac and pulmonary reserve. Treadmill exercise or adenosine thallium stress testing effectively detect signs or symptoms of existing coronary artery disease. An abnormal cardiac stress test may presage postoperative myocardial insufficiency leading to infarction. Tn a patient with significant coronary disease, diagnostic tests and treatment normally would ensue to properly prepare him or her for surgery. Based on results, some patients might be directed to nonsurgical therapy.

To expeditiously assess lung function, patients are instructed to rapidly ascend two flights of stairs, which allows clinical assessment of respiratory fitness. Patients also undergo spirometric and diffusion pulmonary function tests, such as

* forced expiratory volume during the first second of a forced vital capacity test (FEV-I);

* maximum voluntary ventilation (MVV); and

* diffusion lung capacity (ie, lung diffusion testing used to determine how well oxygen [02] and carbon dioxide [CO2J traverse the pulmonary alveolar-vascular membranes).

In questionable situations, assessments are augmented with resting room air blood gases and quantitative perfusion lung scans. Postoperative respiratory function may be estimated preoperatively by dividing the relative number of lung segments likely to remain after surgery by the number of segments existing preoperatively. Alternatively, quantitative nuclear scanning allows a more precise physiological calculation of estimated postoperative function based on lung segments remaining as opposed to those resected.

The merits of flow measurements (eg, FEV-1, MVV) versus diffusion criteria have been debated; all are considered important. Historically, an FEV-1 equal to or greater than 800 mL has been considered necessary to blow out a candle at a 1-ft distance, which is easy to measure and presumed to be the minimum expiratory flow that a patient requires to

* clear his or her airway,

* avoid secretion retention,

* prevent airway plugging and shunting, and

* avert pneumonia.

Historically, an estimated postoperative FEV-I less than 800 mL, or less than 30% to 40% of pred\icted value, has presaged significant risk of morbidity and mortality.24

Maximum voluntary ventilation, previously referred to as maximum breathing capacity, has been related to postoperative morbidity and mortality. Classically, an MVV of 40% or greater indicates reasonable risk for patients undergoing lobectomy, but an MVV of less than 50% indicates high risk in patients undergoing pneumonectomy. Similarly, symptom-limited testing by stair climbing has proven reliable in stratification of risk with regard to postoperative complications.25 Modern aids (eg, preoperative pulmonary rehabilitation, postoperative pulmonary toilet) in preparation for and recovery from surgery allow flexible interpretation of such testing parameters and serve to lower estimates of morbidity and mortality. These simple tests still describe relative risk, however, as documented in the results section of this article.

Appreciable differences were not identified at Inova Fairfax Hospital with regard to in-hospital recuperation from surgery when comparing musclesparing thoracotomy versus minithoracotomy versus thoracoscopy. Neither minithoracotomy nor thoracoscopy are performed for cancer-related surgery unless pulmonary function does not allow lobectomy.

OR STRATEGY FOR THE DAY OF SURGERY

The entire perioperative team must be familiar with the needs of any patient with a lung cancer diagnosis. Caregivers should consider the patient's physical and psychological needs, as well as the needs of family members or significant others.

Usually, a patient is admitted to the hospital on a same-day admission basis. He or she is brought directly from registration to the preoperative holding area, where the patient changes into a gown and waits on a stretcher for consultation with perioperative team members. A preoperative nurse completes an assessment of vital signs, reviews laboratory work for variation from normal values, and reviews the chart for completion of necessary paperwork, such as informed consent, history and physical, and boarding pass. A boarding pass includes information regarding the surgical site, side, and nature of the procedure to be performed, and is signed by the patient and the preoperative and perioperative nurses.

The circulating nurse greets the patient, performs a brief assessment of factors affecting positioning and intraoperative care, reviews the planned procedure with the patient and the patient's family members, and gives them an opportunity to ask questions. The patient remains in the preoperative area, where the anesthesia care provider completes a preoperative assessment and inserts peripheral IV and arterial lines. For postoperative pain relief, the anesthesia care provider places an epidural catheter that

* allows maximal relief of discomfort postoperatively and

* allows the patient to awaken from the general anesthesia alert, pain free, and ready to ambulate, which minimizes the potential for atelectasis, deep venous thrombosis, pneumonia, and retained secretions.

After the surgeon arrives, surgical team members jointly confirm the planned procedure, appropriate marking of the surgical site, and completeness of

the boarding pass. The circulating nurse then transports the patient to the OR.

SURGICAL INTERVENTION

The circulating nurse and anesthesia care provider assist the patient onto the OR bed. Before the anesthesia care provider induces general anesthesia, the circulating nurse questions the patient about his or her comfort level. The anesthesia care provider may elevate the head of the OR bed to assist with respiratory effort if needed. The circulating nurse places a pillow under the patient's knees to reduce back strain. He or she applies sequential compression devices to the patient's lower legs and places warm blankets on the patient for comfort and to help maintain the patient's body temperature. The anesthesia care provider continuously monitors the patient's vital signs, including pulse rate, blood pressure, electrocardiogram, O2 saturation, and end tidal CO2 level.

In addition to preoperatively checking the patient's identification (eg, verbal confirmation and arm band) against the patient's medical record, surgical team members cooperatively participate in a surgical pause before induction of anesthesia to ensure they have the correct patient, correct procedure, and correct laterality. The anesthesia care provider then anesthetizes and intubates the patient, after which the surgeon performs prethoracotomy bronchoscopy. Single-lumen endotracheal intubation is used most often because of its simplicity. Double-lumen intubation (Figure 3) is used when there is a risk of

* brochopleural fistula,

* dependent lung contamination by lung abscess, or

* excessive or infected secretions accumulating behind significant endobronchial obstruction.

The double-lumen endotracheal tube is positioned so that both the right and left airways are ventilated. When the leftsided balloon is inflated, the right side is separated effectively from the left side. With a patient in the left lateral decubitus position (ie, left side down), right-sided secretions cannot migrate into the dependent (ie, left) airway. Similarly, with the patient in the right lateral decubitus position (ie, right side down), the right airway is protected. Ventilations may be interrupted to either side, preventing loss of effective ventilation when performing open bronchus surgery. When not placed properly, the endotracheal tube may not be situated distally enough to either protect against secretions migrating or to achieve an airless bronchus, or it may be too far distal, obstructing right-sided ventilation. Double-lumen intubation also is used for open bronchotomy, such as is needed for sleeve resection (Figure 4). During a sleeve lobectomy, ventilation may be shut off from the right side as the tumor is resected and the major airway is repaired, but left-sided ventilation continues uninterrupted.

After the circulating nurse places an indwelling urinary catheter, surgical team members properly position the patient to allow ideal access to the surgical site (eg, posterolateral thoracotomy extended posterolateral thoracotomy) (Figure 5). An extended posterolateral incision allows the scapula to be rotated temporarily off the chest wall, allowing high chest wall resections from the posteroapical approach.

The circulating nurse places an electrosurgical unit dispersive pad on the patient's superior lateral thigh, and a temperature- regulating blanket over the patient's lower body. The circulating nurse documents the patient's skin condition and all measures used to prevent intraoperative injury. The anesthesia care provider places a clear adhesive drape over the epidural catheter to prevent it from being saturated by the prep solution. The circulating nurse cleans the patient's thorax, neck to waist, and from just anterior to the epidural dressing in the back, anteriorly to the inframammary fold.

Figure 3 * The left mainstem balloon In double-lumen intubation separates the right and left endobronchial lumena when placed properly (a). Faulty placements are illustrated in (b) and (c).

Figure 4 * In a right-upper sleeve lobectomy, the surgeon resects the entire right upper lobe and involved bronchus. He or she then reconnects the mainstem bronchus and bronchus intermedius.

Figure 6 depicts several anterior incisions, including mediansternotomy, apical-cervical, and anterior thoracotomy, which may allow a hilar approach in massive tumors or easier access to anteroapical chest wall resections. Thoracoscopic approaches are reserved for smaller or peripheral tumors and patients who would not otherwise tolerate lobectomy.

Some situations, such as when trails tracheal ventilation is impossible or ineffective, may call for cross-field ventilation (ie, placing a second, sterile endotracheal tube across the field) depicted in Figure 7, in which a sleeve resection, in this case carinal, is shown. A sterile, second airway is needed in this instance to ventilate the lung.

The circulating nurse and scrub person ensure that vascular clamps, rib and sternal instruments, and the full array of lung and bronchial staplers are ready for immediate use. To be prepared for crossfield ventilation, the circulating nurse should ensure that all supplies and equipment are available (eg, sterile endotracheal tube, sterile anesthesia connecting circuit).

Figure 5 * Posterolateral thoracotomy. Inset shows posterosuperior extension of the shoulder to allow transient rotation of the scapula off the chest wall. This permits high, posterior chest wall resection.

Figure 6 * Anterior chest incisional approaches include median- sternotomy (b to d); cervicothoracic exposure (a to b to c); and anterior thoracotomy (e to f).

The circulating nurse also should be prepared to handle a wide variety of specimens. These include

* serum specimen for electrolyte measurements (eg, potassium);

* hematology specimen for blood gas, hemoglobin, and hematocrit measurement;

* pathology specimens ranging from wedge resection for differentiation of benign versus malignant disease to lymph nodes for the staging of malignant disease; and

* type and cross match for any blood transfusion request.

The scrub person, anesthesia care provider, and circulating nurse should exercise diligence in collecting specimens, labeling them properly, and transporting them to the appropriate laboratory (eg, hematology, pathology, frozen section laboratory). The circulating nurse must clearly identify pathology specimens as to the precise site of origin, type of tissue, and type of test to be performed with the surgeon's guidance. He or she should immerse the specimen in saline for immediate pathological (ie, frozen section) review or fix it in formalin. Formalin allows the specimen to be prepared in paraffin for final-section (ie, permanent) pathology. Given the overwhelming effect of the stage \of the disease on therapeutic decisions, it is critically important that specimens are labeled precisely (ie, differentiating Nl nodes from N2 nodes).

The circulating nurse completes the laboratory paperwork and ensures that labels placed on specimen containers clearly identify specifics about the specimens. He or she rechecks the labels and paperwork for accuracy before sending specimens to their proper destination. The circulating nurse and anesthesia care provider check and document the accuracy of all materials collected. They also work cooperatively regarding documenting

* chest irrigations performed,

* intake and output,

Figure 7 * Sterile crossfield ventilation allows ventilation of the left and/or right lung(s) when carinal resection temporarily prohibits use of a proximal, single-lumen endotracheal tube.

* IV fluids administered,

* medications administered, and

* results of surgical counts.

INOVA FAIRFAX HOSPITAL RESULTS

The senior surgeon of the thoracic surgery section completed follow-up assessments on 96.6% of the 666 patients operated on from Jan 1, 1991, through Oct 31, 2003. For purposes of statistical analysis, where follow-up was incomplete, patients were categorized as expired at date of last contact according to routine, conservative epidemiological and statistical methodology. Survival figures were calculated according to whether the patient was alive or dead, irrespective of whether carcinoma currently was present or if the patient died of cancer or another related or unrelated cause. Consistent with previously published results from Inova Fairfax Hospital6 where 65% of patients expiring in that series died of unknown cause of death (ie, malignancy versus another possible cause), "the therapeutic control of malignancy may be underestimated by such overall mortality rates [as conducted at Inova Fairfax Hospital]."26 In other words, had survival rates been reported on the basis of only the patients who died of cancer-related causes, the survival rate likely would have been even better.

Figure 8 depicts NSCLC survival between Jan 1, 1991, and Oct 31, 2003, at Inova Fairfax Hospital. The graph presents data on one- year through five-year survival rates, including hospital mortalities. Juxtaposing the results depicted in Figure 8 with those in Figure 2 allows comparison of recent results at Inova Fairfax Hospital with historical controls (ie, the latter does not include hospital mortalities).

Table 3 breaks down the risk of postoperative death occurring in the hospital by patient age, extent of resection, and lung function. Note that minor (ie, wedge) lung resection was accompanied by significantly greater risk of death than was lobectomy (ie, 1.8% versus 0.5% respectively), which probably is explained by the fact that lesser resection was undertaken in patients with poorer pulmonary reserve. Supporting this thesis, death was 10 times more likely in patients with a preoperative estimate of postoperative FEV- 1 equal to or less than 1,000 mL versus FEV-1 greater than 1,000 mL (ie, 6.5% versus 0.65% mortality, respectively). Pneumonectomy also carried a higher risk of hospital mortality (ie, 4.6%), as did being 70 years of age or older (ie, 2.3%), yet these numbers are appreciably lower than those published nationally (ie, 7.0%-13.7% and 3.2%-5.9%).27-29

Figure 8 * Nonsmall-cell lung carcinoma survival according to stage of disease at Inova Fairfax Hospital between Jan 1, 1991 and Oct 31, 2003.

Consistent with results from other studies, resection of tumors that were smaller in size and of a lesser stage resulted in better survival rates.1,2,12-15 Although the patient population at Inova Fairfax Hospital and other facilities studied were weighted heavily with relatively early stage I and II disease (ie, 80%),12 Inova Fairfax Hospital's results when dealing with stage III and IV disease were better than that of most institutions. Inova Fairfax Hospital's surgical mortality rates were lower, and longterm survival rates were equal to or higher per stage than the best of other reports in the literature.4,7,8,12

Such results with late-stage disease at Inova Fairfax hospital are attributed to three factors. First, the newer international system for staging^ categorizes tumors simultaneously arising in ipsilateral same versus separate lobes to stage III versus IV, heretofore, respectively classified by incrementally increasing the T factor and IIIB respectively. Not infrequently, however, when resected, these tumors may be without extended lymphatic involvement, which offers the possibility of a more favorable prognosis. second, Inova Fairfax Hospital already has published superior five-year survival rates (ie, 36% to 42%) for patients in whom N2, IIIA disease was resected (Figure 9)5,20 The selected population clearly lies somewhat to the occult end of the spectrum of N2 disease, akin to the experience of another surgeon, who reported similar five-year survival rates in patients (ie, less than 10%) deemed preoperatively to have NO or Nl disease, but when the tumors were resected, demonstrated pathological, N2 disease.4 In contrast, patients resected with bulky stage III disease (ie, greater than 90% of patients) experienced only a 9% three-year survival rate.4 Third, based on the hypothesis that incomplete resection precludes long-term survival, clinicians at Inova Fairfax Hospital long have tried to combine prudent patient selection with aggressive neoadjuvant therapy intended to downstage regional disease, and allowing successful local resection.

TABLE 3

Inova Fairfax Hospital NonsmalL-cell Lung Cancer Hospital Deaths

Figure 9 * Multi-institutional review of nonsmall-cell lung carcinoma survival rates after resection of stage III disease.

There may be advantages to performing surgical resection up front, perhaps followed by adjuvant chemotherapy or a combination of chemotherapy and radiation therapy.30 Application of such adjuvant therapy can be based on the pathological stage of disease, persistent versus recurrent disease, and patient performance status. Resection of the vast bulk of tumors leads to accelerated growth of micrometastatic disease,30 and minimal disease may remain for regional or systemic treatments. Most of the cells that remain are in their growth phase; thus they are substantially more susceptible to adjuvant therapies.31

Between Jan 1, 1991, and Oct 31, 2003, 163 patients have undergone resection of stage III or IV disease at Inova Fairfax Hospital. Thirty-one patients were treated preoperatively with either chemotherapy (ie, 18 patients) or a combination of chemotherapy and radiation therapy (ie, 13 patients). Three patients underwent only radiation therapy. Table 4 delineates these groups with respect to the percentage achieving complete pathological response (ie, no residual disease noted microscopically), the percentage who experienced residual downstaging to stage I or stage II disease, and the percentage who had persistent stage III disease. Figure 10 depicts the relevant one-year to five-year survival rates achieved at Inova Fairfax Hospital with different neoadjuvant therapies followed by surgery. Single-agent, neoadjuvant, radiation therapy alone has been reserved for patients with brain metastasis (ie, Ml or stage IV disease) or, in the past, for patients with superior sulcus tumors, presently staged T3N0, stage UB if without nodal involvement. Even more important, neoadjuvant chemotherapy followed by surgical resection resulted in Kaplan-Meier five-year survival rate of 46% (14%). The latter rate closely approximates a 42% (11%) five-year survival rate achieved in Inova Fairfax Hospital's 1981 to 1989 experience with predominantly occult N2 disease.5 The recent neoadjuvant results have been achieved despite dealing with significantly more bulky, advanced disease.

TABLE 4

Inova Fairfax Hospital Stage III Nonsmall-cell Lung Cancer Results for Patients Treated With Neoadjuvant Therapy*

Figure 10 * Pretherapy for advanced nonsmall-cell lung carcinoma at Inova Fairfax Hospital, 3an 1, 1991, through Ort 31, 2003.

TWELVE YEARS' EXPERIENCE IN TREATING NSCLC

Using the methods described herein, patients were carefully selected, prepared, and treated. Excellent outcomes may have resulted from the use of a simple yet effective strategy for patient selection, complemented with care delivered by a particularly experienced team of professionals.32

Even a superficial review of the literature and the experience at Inova Fairfax Hospital reveals glaring deficiencies, however. Historically, autopsy studies have demonstrated residual disease in up to 35% of patients expiring within 30 days of what had been thought to be curative surgery.33 Performing PET scans undoubtedly is helping to reduce such results. The costs of such scans and even newer modalities, however, needs to be reduced tremendously to allow broader application.

In addition, the five-year failure rate of 54% to 70% in the treatment of selected patients with stage 111 disease at Inova is telling. Although there is evidence for optimism in the use of newer chemotherapeutic agents,31 clearly the therapy of maximum impact is prophylaxis. Significantly reducing tobacco smoking is the only guaranteed, cost-effective way to effectively reduce lung cancer deaths.

Examination

A pragmatic and successful approach to treating nonsmall-cell Lung carcinoma

1. Lung cancer staging is a method of

a. determining a patient's future risk of acquiring lung carcinoma,

b. estimating a patient's prognosis to help determine the best treatment plan.

c. identifying risk-taking behaviors and inherited traits that increase a patient's probability for cancer.

2. Clinicians at Inova Fairfax Hospital use positron emission tomography when

1. dealing with large or central lesions.

2. in doubt (ie, after neoadjuvant therapy).

3. preapproval has been obtained from the patient's insurance company.

4. questionable adeno\pathy is not easily approachable by traditional methods.

a. 1 and 4

b. 2 and 3

c. 1, 2, and 4

d. 2, 3, and 4

3. To assess preoperative lung function, patients may undergo

1. diffusion lung capacity.

2. forced expiratory volume during the first second of a forced vital capacity test.

3. inspiratory reserve volume.

4. maximum voluntary ventilation.

5. pulmonary vascular resistance.

a. 1 and 3

c. 1, 2, and 4

b. 2, 4, and 5

d. 1, 2, 3, 4, and 5

4. A more precise physiological calculation of estimated postoperative function is achieved by

a. dividing the relative number of lung segments likely to remain after surgery by the number existing preoperatively.

b. magnetic resonance imaging.

c. comparing resting room air blood gases.

5. Double-lumen intubation is used when there is a risk of

1. bronchopleural fistula.

2. dependent lung contamination by lung abscess.

3. excessive or infected secretions.

4. multiple tumors.

a. 1 and 2

b. 3 and 4

c. 1, 2, and 3

d. 1, 2, 3, and 4

6. The scapula may be rotated off the chest wall for high chest wall resections from a posteroapical approach.

a. true

b. false

7. Possible anterior incisions include

1. anterior thoracotomy.

2. apical-cervical.

3. modianstornotomy.

4. Phannenstiel.

a. 1 and 4

b. 1, 2, and 3

c. 2, 3, and 4

d. 1, 2, 3, and 4

8. Cross-field ventilation allows selective ventilation of the right or left lung.

a. true

b. false

9. At Inova Fairfax Hospital, minor lung resection was accompanied by significantly greater risk of death than was lobectomy, probably because lesser resection was undertaken in patients with poorer pulmonary reserve.

a. true

b. false

10. The positive outcomes with latestage disease at Inova Fairfax Hospital could be attributed to 1. improved classification with the new international staging system. 2. improved clinician comfort level with the new international staging system.

3. the selected population lying somewhat to the occult end of the N2 disease spectrum.

4. prudent patient selection with aggressive neoadjuvant therapy to downstage regional disease.

5. pulling a markedly younger population from the surrounding area.

a. 1 and 2

b. 1, 3, and 4

c. 2, 3, and 5

d. 1, 2, 3, 4, and 5

A postoperative epidural catheter provides maximal pain relief and allows early ambulation, which minimizes the potential for deep venous thrombosis, atelectasis, retained secretions, and pneumonia.

Although newer chemotherapeutic agents are optimistic, the most effective therapy is prophylaxis-decreasing smoking is the only guaranteed way to significantly reduce lung cancer deaths.

NOTES

1. L A Ries et al, "Cancer statistics review, 1973-1988," National Cancer Institute (NIH) 1991, Pub No. 91-1789.

2. A Jemal et al, "Cancer statistics, 2002," CA A Cancer Journal for Clinicians 52 (January/February 2002) 23-47.

3. N C Page et al, "The epidemiology of small cell lung carcinoma," Proceedings of the American Society of Clinical Oncology, 21 (August 2002) 305A (Abstr 1216).

4. N Martini, B J Flehinger, "The role of surgery in N-2 lung cancer," South Carolina Nurses Association Newsletter 67 (October 1987) 1037-1049.

5. P D Kiernan et al, "Stage Il and III-A nonsmall-cell cancer of the lung-Results of surgical resection at Fairfax Hospital," Virginia Medical Quarterly 121 (Summer 1994) 172-178.

6. P D Kiernan et al, "Stage I nonsmall-cell cancer of the lung- Results of surgical resection at Fairfax Hospital," Virginia Medical Quarterly 120 (Summer 1993) 146-149.

7. M M DeCamp et al, "Value of accelerated multimodality therapy in stage Ill-A and MI-B nonsmall-cell lung cancer," Journal of Thoracic and Cardiovascular Surgery 126 (July 2003) 17-27.

8. D Galetta et al, "Enduring challenge in the treatment of nonsmall-cell lung cancer with clinical stage III-B-Results of a trimodality approach," Annals of Thoracic Surgery 76 (December 2003) 1802-1809.

9. H C Nohl, "An investigation into the lymphatitic and vascular spread of carcinoma of the bronchus," Thorax 11 (September 1956) 172- 185.

10. D L Paulson, "Selection of patients for surgery for bronchogenic carcinoma," American Surgeon 39 (January 1973) 1-5.

11. L P Lindsey, D Thielvoldt, "Non-small cell lung cancer," in Oncology Nursing: Assessment and Clinical Care, C Miaskowski, P Buchsel, ed (St Louis: Mosby 1999) 1331-1350.

12. C F Mountain, "Revisions in the international system for staging lung cancer," Chest 111 (June 1997) 1710-1717.

13. C F Mountain, C M Dresler, "Regional lymph node classification for lung cancer staging," Chest 111 (June 1997) 1718- 1723.

14. R J Jackman et al, "Survival rates in peripheral bronchogenic carcinomas up to four centimeters in diameter, presenting as solitary pulmonary nodules," Journal of Thoracic and Cardiovascular Surgery 57 (June 1969) 1-8.

15. D E Williams et al, "Survival of patients surgically treated for stage I lung cancer," Journal of Thoracic and Cardiovascular Surgery 82 (July 1981) 70-76.

16. T Ishida et al, "Strategy for lymphadenectomy in lung cancer three centimeters or less in diameter," Annals of Thoracic Surgery 50 (November 1990) 708-713.

17. J D Miller, L A Gorenstein, G A Patterson, "Staging: The key to rational management of lung cancer," Annals of Thoracic Surgery 53 (January 1992) 170-178.

18. N Martini et al, "Survival after resection of stage II nonsmall-cell lung cancer," Annals of Thoracic Surgery 54 (September 1992) 460-465.

19. J D Luketich, R J Ginsberg, "Diagnosis and staging of lung cancer," in Lung Cancer, eds B E Johnson, D H Johnson (New York: Wiley-Liss, 1995) 161-173.

20. Y Watanabe et al, "Aggressive surgical intervention in N-2 nonsmall-cell cancer of the lung," Annals of Thoracic Surgery 51 (February 1991) 253-261.

21. P D Kiernan et al, "Mediastinal staging of nonsmall-cell lung carcinoma using computed and positron-emission tomography," Southern Medical Journal 95 (October 2002) 1168-1172.

22. C A Saunders et al, "Evaluation of flouriene-18- fluorodeoxyglucose whole body positron emission tomography imaging in the staging of lung cancer," Annals of Thoracic Surgery 67 (March 1999) 790-797.

23. R M Pieterman et al, "Preoperative staging of nonsmall-cell lung cancer with positron-emission tomography," The New England Journal of Medicine 343 (July 27, 2000) 254-261.

24. K Nakahara et al, "Prediction of postoperative respiratory failure in patients undergoing lung resection for lung cancer," Annals of Thoracic Surgery 46 (November 1988) 549-552.

25. A Brunelli et al, "Stair climbing test as a predictor of cardiopulmonary complications after pulmonary lobectomy in the elderly," Annals of Thoracic Surgery 77 (January 2004) 266-270.

26. P Thomas, L Rubinstein, "Cancer recurrence after resection: T1N0 nonsmall-cell lung cancer," Annals of Thoracic Surgery 49 (February 1990) 242-247.

27. A Bernard et al, "Pneumonectomy for malignant disease: Factors affecting early morbidity," Journal of Thoracic and Cardiovascular Surgery 121 (June 2001) 1076-1082.

28. E V Finlayson, J D Birkmeyer, "Operative mortality with elective surgery in older adults," Effective Clinical Practice 4 (July/August 2001) 172-177.

29. O Birim et al, "Lung resection for non-small-cell lung cancer in patients older than 70: Mortality, morbidity, and late survival compared with the general population," Annals of Thoracic Surgery 76 (December 2003) 1796-1801.

30. L Simpson-Herren, A Sanford, J Holmquist, "Effects of surgery in the cell kinetics of residual tumor," Cancer Treatment Reports 60 (December 1976) 1744-1760.

31. The International Adjuvant Lung Cancer Trial Collaborative Group, "Cisplatin-based adjuvant chemotherapy in patients with completely resected nonsmall-cell lung cancer," The New England Journal of Medicine 350 (Jan 22, 2004) 351-360.

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Paul D. Kiernan, MD; Paula R. Graling, RN; Vivian L. Hetrick, RN; Betty E. Vaughan, RN; Michael J. Sheridan, ScD; Johnny K. Lee

Paul D. Kiernan, MD, FACS, is chief, section of thoracic surgery, Cardiovascular and Thoracic Surgical Associates, Annandale, Va.

Paula R. Graling, RN, MSN, CNOR7 is a clinical nurse specialist, periopcrative services, Inova Fairfax Hospital, Falls Church, Va.

Vivian L. Hetrick, RN, BSN, is a senior nurse specialist, division of main OR, Inova Fairfax Hospital, Falls Church, Va.

Betty E. Vaughan, RN, is a staff nurse, division of main OR nursing, Inova Fairfax Hospital, Falls Church, Va.

Michael J. Sheridan, ScD, is director, epidemiology and biostatistics, department of medicine, Inova Fairfax Hospital, Falls Church, Va.

Johnny K. Lee, BA, MS, is a medical student, Georgetown University School of Medicine, Washington, DC.

Copyright Association of Operating Room Nurses, Inc. Nov 2004

Source: Association of Operating Room Nurses. AORN Journal

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