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Ann Thorac Surg 2004;77:260-265
© 2004 The Society of Thoracic Surgeons

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Original article: general thoracic

Respiratory function changes after chemotherapy: an additional risk for postoperative respiratory complications?

^a Department of Thoracic Surgery, Milan, Italy
^b Department of Oncology, Milan, Italy
^c Division of Epidemiology and Biostatistics, European Institute of Oncology, Milan, Italy

Accepted for publication July 30, 2003.

^* Address reprint requests to Dr Leo, Service de Chirurgie Thoracique, Hopital Pasteur–Pavillon H, 30 Ave de la Voie, Romaine 06002 Nice, France
e-mail: francescoleo{at}interfree.it

	Abstract

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BACKGROUND: Patients receiving chemotherapy for lung cancer usually modify their lung function during treatment with increases in forced expiratory volume in 1 second (FEV₁) and forced vital capacity (FVC) and decreases in lung diffusion for carbon monoxide (DLCO). This prospective study was designed to evaluate functional changes in forced expiratory volume in 1 second, forced vital capacity, and DLCO after three courses of induction chemotherapy with cisplatinum and gemcitabine in stage IIIa lung cancer patients and to assess their impact on respiratory complications after lung resection.

METHODS: From March 1998 to January 2001, 30 consecutive patients with N2 nonsmall cell lung cancer had surgical resection after neoadjuvant treatment. Pre-chemotherapy and postchemotherapy results of standard respiratory function tests and DLCO were compared in patients with and without postoperative respiratory complications.

RESULTS: All 30 patients completed the chemotherapy protocol without respiratory complications. Significant improvements (p < 0.05) were recorded after chemotherapy in transition dyspnea score, PaO₂ (mean value from 79.8 to 86.4 mm Hg), forced expiratory volume in 1 second % (from 78.1% to 87.5%) and forced vital capacity % (from 88.1% to 103.3%). Lung diffusion for carbon monoxide was significantly impaired after chemotherapy (from 74.1% to 65.7%; p = 0.0006), as well as DLCO adjusted for alveolar volume (from 92.8% to 77.4%; p < 0.0001). One patient died after surgery and 4 patients (13.3%) experienced postoperative respiratory complications. Compared with patients without complications, these 4 patients had higher mean increase in FEV₁ after chemotherapy (+26.8% vs + 6.7%; p = 0.025), but greater mean decrease in DLCO/Va (-27.8% vs -13.6%; p = 0.03). Impact of change in DLCO on postoperative respiratory complications was not confirmed by multiple logistic regression analysis (p = 0.16).

CONCLUSIONS: In lung cancer patients, forced expiratory volume in 1 second and forced vital capacity assessed after neoadjuvant chemotherapy are not reliable indicators of the likelihood of respiratory complications after surgery. The risk of respiratory complication may be directly linked to loss of DLCO/Va. Lung diffusion for carbon monoxide assessed after neoadjuvant chemotherapy is probably the most sensitive risk indicator of respiratory complications after surgery. We recommend that DLCO studies be performed before and after chemotherapy in lung cancer patients undergoing induction therapy.

	Introduction

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Induction chemotherapy can improve both resectability and long-term survival in patients who have lung cancer with ipsilateral mediastinal lymph-node involvement (stage IIIa) [1]. It is known that chemotherapy affects lung function, but it is still unclear to what extent induction chemotherapy may raise the risk of postoperative complications. Bleomycin-induced lung toxicity is a well-known complication occurring in 5% to 10% of patients with a subsequent mortality of 1% [2, 3]. An adverse effect on lung function has been documented for many other cytotoxic drugs, but the chemotherapy-induced pathologic mechanisms, duration, and severity of pulmonary impairment remain unknown [4].

Patients receiving chemotherapy for lung cancer (mainly cisplatinum-based regimens) usually show improvements in spirometric performance [5] and reductions in diffusing capacity. Despite increases in forced expiratory volume in 1 second (FEV₁) and forced vital capacity (FVC) after neoadjuvant chemotherapy, the rate of postoperative complications is not reduced in patients receiving chemotherapy. Whether these improvements are only apparent and therefore misleading, or if they are real but counterbalanced by an interstitial diffuse damage to the lung, remain unclear.

The lung diffusion for carbon monoxide (DLCO) is regarded as being as important as FEV₁ and FVC in predicting postoperative complications [6, 7]. Lung diffusion for carbon monoxide reduction after chemotherapy is often subclinical, but could be a sensitive indicator of lung damage due to toxic agents, possibly exposing patients to a greater risk of lung injury after surgery. The heterogeneity of chemotherapy regimens, their different schedules, and the paucity of data on concomitant lung toxicity make it difficult to assess the potential for postoperative complications after lung resection in subjects receiving induction chemotherapy.

The aim of this study was to prospectively evaluate pulmonary effects of neoadjuvant chemotherapy (three courses of cisplatinum and gemcitabine) on N2 nonsmall cell lung cancer patients scheduled for surgical resection and mediastinal hyperfractionated radiotherapy after chemotherapy. The primary focus was to identify changes in lung function after treatment and any potential association with postoperative respiratory complications.

	Patients and methods

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Study participants
The study population consisted of a subset of patients with stage IIIa lung cancer who were enrolled in a prospective trial for stage IIIa (N2) and IIIb (N3) nonsmall cell lung cancer proven by mediastinoscopy or mediastinotomy that was initiated at the European Institute of Oncology in 1998. Between December 1998 and January 2001, 52 consecutive patients were enrolled in this study. After three courses of chemotherapy (cisplatinum 80 mg/m² on days 1 and 21 and gemcitabine 1.250 mg/m² on days 1, 8, and 21), patients with stage IIIa disease were re-evaluated for surgical resection. For patients who underwent surgical resection, mediastinal hyperfractionated radiotherapy (54.4 Gy, 1.2 + 1 + 1.2, 5 days per week) was started 4 weeks after resection. Patients with pathologic stage N2 lung cancer at the time of mediastinoscopy and mediastinotomy who underwent lung resection after chemotherapy comprise the population of the study reported here.

Lung function
In order to quantify clinical, functional, and radiologic changes after chemotherapy, stage IIIa patients were functionally evaluated before starting chemotherapy by baseline dyspnea index evaluation, spirometry, DLCO, blood gas analysis, chest roentgenogram, and spiral computed tomographic scan. Evaluations were repeated 4 weeks after the end of chemotherapy, before surgery, and before initiation of radiotherapy.

Dyspnea index was calculated using Mahler's method [8] evaluating 3 categories: (1) functional impairment, (2) magnitude of the task needed to evoke dyspnea, and (3) magnitude of effort needed to evoke dyspnea. At baseline evaluation, the patient's condition was rated from 0 (severe) to 4 (unimpaired) for each category; ratings were added together to form a baseline score (range, 0 to 12). Changes from baseline to the end of chemotherapy were rated in seven grades from –3 (major deterioration) to + 3 (major improvement). The ratings from the three categories were added to give a transitional focal score (range, –9/+9).

Spirometry was performed with a Ra-Med Spirometer System using a Jaeger MasterScreen diffusion system (Jaeger, Wuerzburg, Germany) using the American Thoracic Society guidelines [9]. Forced vital capacity (expressed in liters), FEV₁ (expressed in liters per second), total lung capacity (expressed in liters), DLCO (expressed in mmoL/min/kPa), and DLCO adjusted for alveolar volume (DLCO/Va) (expressed in mmoL/min/kPa) were expressed both as absolute values and as percentages of predicted values calculated for every patient on the basis of age, gender, and height. Total lung capacity was assessed by the helium dilution method. Lung diffusion for carbon monoxide was determined by the single-breath technique according to the Gaensler and Wright method [10] and by adjusting for hemoglobin.

Response to chemotherapy
Chest roentgenograms and computed tomographic scans were reviewed by a senior radiologist blinded to the clinical and functional condition of the patients for analysis of tumor response to chemotherapy and interstitial changes in the lung parenchyma. Information on tumor response to chemotherapy was prospectively recorded following WHO guidelines and was classified in March 2001 according to the guidelines for response evaluation in solid tumors [11]. Patients were divided by disease response into the following four categories: (1) stable disease, (2) partial response, (3) complete response, and (4) progressive disease. Presence and extent of any interstitial change in the lung were noted.

Postoperative complications
Respiratory postoperative complications were classified as follows: (1) acute respiratory failure, defined as postoperative ventilator dependence more than 12 hours or reintubation for controlled ventilation; (2) adult respiratory distress syndrome (ARDS), defined as respiratory failure with acute onset (PaO₂ fraction of inspired O₂ less than 200 mm Hg and bilateral infiltrates seen on chest roentgenogram, and pulmonary wedge pressure less than 20 [12]; (3) acute lung injury, defined with the same criteria as adult respiratory distress syndrome, but with PaO₂ fraction of inspired oxygen less than 300 mm Hg; (4) pneumonia, defined by the presence of at least three of the following criteria: persistent lung infiltrate on chest roentgenogram, fever more than 38°C, white cell blood count more than 10,000/mm³ or less than 3,000/mm³, purulent secretions, documented presence of microorganisms on sputum or bronchoaspirate; (5) sputum retention, defined as lobar or whole-lung atelectasis requiring bronchoscopy; (6) pulmonary embolism documented by lung ventilation and perfusion scintigraphy or angioscan; and (7) pulmonary edema. All other complications (such as prolonged air leak, atrial fibrillation, and hemothorax) were recorded but not included in this analysis.

Data analysis
Pre-chemotherapy and postchemotherapy comparisons of lung function were performed using the Student's t test (paired values) for continuous variables and Fischer's exact test for categorical variables. In order to identify respiratory function, clinical, demographic, and surgery variables associated with postsurgery respiratory complications, multiple logistic regression models were run including variables with a p value less than or equal to 0.1 in univariate logistic regression. An association or a difference was considered statistically significant if the associated p value was less than or equal to 0.05. All statistical analysis was done using the SAS program (SAS Institute, Inc, Cary, NC).

	Results

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Patients
Thirty-four patients with stage IIIa nonsmall cell lung cancer were considered surgical candidates before chemotherapy. After chemotherapy, 4 patients were no longer candidates for surgery. Two patients were excluded because calculations based on lung perfusion scans after chemotherapy predicted postoperative FEV₁ values less than 40%. The third patient excluded from surgery, initially a candidate for a right pneumonectomy, had postoperative predicted FEV₁ and FVC values of 45%, but a DLCO Va loss of 55% after chemotherapy. The fourth patient was ineligible for surgery due to disease progression with a supraclavicular lymph node appearing during the third course of chemotherapy. Consequently, 30 patients who underwent surgical resection after chemotherapy comprise the study population (Table 1).

Twenty-five patients had impaired DLCO after chemotherapy. The mean DLCO in the study population decreased from 6.5 ± 1.6 to 5.8 ± 1.2 (p = 0.002) and percentage decreased from 74.1% ± 14.3 to 65.8% ± 12.2 of predicted value (p = 0.0006). The DLCO/Va decreased from a mean of 1.3 ± 0.3 to 1.08 ± 0.2 (p < 0.0001), and the DLCO/Va decreased from 92.9% ± 17.4% to 77.4% ± 11.8 of predicted value (p < 0.0001). Radiologic evaluation of the study population after three courses of chemotherapy did not reveal any significant interstitial disease or infiltrates other than tumor. After chemotherapy 19 patients were considered to have a partial response and 11 patients were considered to have stable disease.

Postoperative complications
Two pneumonectomies, 25 lobectomies (10 with bronchoplasty procedure, 2 with chest-wall resection), 1 bilobectomy and 1 segmentectomy were performed. In 1 patient, an exploratory thoracotomy was performed due to the presence of pleural metastases.

Four patients experienced postoperative respiratory complications. One patient (3.3%) had adult respiratory distress syndrome develop on postoperative day 7 and subsequently died. Another patient developed staphylococcal pneumonia. A 48-year-old woman with a right upper lobe squamous cell carcinoma had an acute lung injury develop 24 hours after a right upper sleeve lobectomy, which required 48 hours of mechanical ventilation. The fourth respiratory complication occurred in a 66-year-old woman who was discharged 7 days after a right upper lobectomy and was then admitted to another hospital 2 days later for respiratory failure due to right atelectasis.

Two patients had a prolonged air leak for more than 7 days. One patient experienced additional complications of atrial fibrillation, another had a thoracotomy for hemothorax, and a cerebral transient ischemic attack.

There were no significant differences between patients who had respiratory complications (n = 4; group A) and those who did not (n = 26; group B) in terms of age, gender, smoking status, dyspnea score, PaO₂, tumor response to chemotherapy, extent of lung resection and associated procedures, and anesthesia time (Table 2). The two groups did not differ in functional measurements assessed before and after chemotherapy, except for postchemotherapy DLCO/Va, in which group A had a significantly lower mean value (0.79 in group A vs 1.12 in group B; p = 0.008).

In univariate logistic regression, the risk of a respiratory complication was increased by approximately 7% with a unit increase in postchemotherapy change in predicted by FEV₁ (odds ratio [OR] = 1.07; 95% confidence limits [CL] = 1–1.14). An approximate 13% decrease in respiratory complication risk was observed with a unit increase in DLCO/Va (OR = 0.87; 95% CL = 0.76–1.0). The risk of respiratory complications was not affected by age (associated p value with the age coefficient in univariate logistic regression; p = 0.89). With simultaneous modeling of mean change in predicted FEV₁ and DLCO/Va, both variables lost their statistical significance (OR = 1.04; 95% CL = 0.97–1.12; p = 0.3 and OR = 0.9; CL = 0.77–1.04; p = 0.16, respectively) (Fig 1).

View larger version (12K): [in this window] [in a new window]   Fig 1. Changes in forced expiratory volume in 1 second (FEV1) and lung diffusion for carbon monoxide adjusted for alveolar volume (DLCO/Va) after neoadjuvant chemotherapy by postoperative complications. • = no complications (n= 26); = complications (n = 4).

	Comment

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Some studies have reported that the risk of postoperative complications is higher after chemotherapy [14], mainly after right pneumonectomy [15]. Do functional changes have an impact on postoperative complications? This study was designed to test pulmonary toxicity of a standard regimen (cisplatinum and gemcitabine) to assess modification in respiratory function after treatment and to correlate these findings to postoperative pulmonary complications. Cisplatinum can cause a decline in alveolo-capillary membrane diffusing capacity, which is usually subclinical [16]. Experience with gemcitabine is increasing and a few cases of pulmonary toxicity related to its use have been reported [17, 18], possibly due to induction of a capillary-leak syndrome [19]. Even if the combination of these two drugs during treatment did not cause any episode of clinically evident lung effect, recorded modifications of FEV₁, FVC, and DLCO were significant. The first consequence in functional evaluation of patients after neoadjuvant treatment is that postchemotherapy FEV₁ and FVC can be misleading. If we assume that chemotherapy may increase surgical risk, postchemotherapy FEV₁ and FVC values are poor indicators of the risk of postoperative respiratory complications. For example, the patient in the study who had ALI also had both FEV₁ and FVC less than 50% before chemotherapy, but both values increased to 79% after induction treatment. It is probably safer and more appropriate to evaluate postoperative predicted FEV₁ on the basis of pre-chemotherapy spirometry.

Decrease of DLCO after 3 courses of chemotherapy was about 10%. However, all the patients maintained a DLCO greater than 50% of predicted value. If we assume that modifications of DLCO represent subclinical damage to the alveolo-capillary membrane, the degree of such damage may be proportional to DLCO loss and subsequent to the risk of respiratory complications. Multiple regression analysis did not confirm this hypothesis, probably due to the small population (n = 30) and the limited number of observed complications (n = 4).

The study was not designed to assess the relationship between response to chemotherapy and DLCO modifications, but results showed that partial responders had a lower postchemotherapy DLCO compared with nonresponders (62% vs 71.9%; p = 0.03). The type of damage of the alveolo-capillary membrane should need histologic confirmation by additional biopsy of healthy lung tissue at thoracotomy. Unfortunately, additional biopsy was not justified by data available at the time of the study design and therefore was not performed.

When do DLCO modifications occur and how long do they last? Anecdotal information on patients not included in the study, but receiving the same chemotherapy regimen, suggests that DLCO modifications probably occur early and are at least partially reversible several weeks after the end of treatment. This recovery could explain the absence of pulmonary complications during hyperfractionated radiotherapy [20]. However, these observations on reversibility are not sufficient to justify proposing a longer delay between chemotherapy and surgery.

In conclusion, functional evaluation before lung resection in patients receiving neoadjuvant treatment can be problematic. Using the standard definition of the high-risk patient for lung resection (postoperative predicted FEV₁ and DLCO < 40%) [21], is the pre-chemotherapy or the postchemotherapy evaluation more precise? Considering results from this study, evaluation of postoperative predicted FEV₁ should probably be performed on the prechemotherapy spirometry. Moreover, these results support the hypothesis that a decrease in DLCO/Va after chemotherapy can affect the risk of respiratory complications. For this reason, a decrease in DLCO/Va greater than 15% after chemotherapy probably should be considered an additional risk factor for postoperative complications in stage IIIa lung cancer patients undergoing lung resection.

	Acknowledgments

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The authors thank Raffaella Ballestrieri, Paola Lasagna, Antonietta Scopigno, and Arnaldo Zanelotti of the Cardiology Department for their helpful cooperation in the realization of data collection.

	References

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1. Ginsberg R.J., Vokes E.E., Raben A. Non-small cell lung cancer. In: DeVita V.T., Hellman S., Rosenberg S.A., eds. Cancer: Principles & Practice in Oncology, 1997. Philadelphia: Lippincott-Raven, 1997:887-899.
2. Blum R.H., Carter S.K., Agre K. A clinical review of bleomycin: a new antineoplastic agent. Cancer 1973;31:903-914.[Medline]
3. Rabinowits M., Souhami L., Gil R.A., et al. Increased pulmonary toxicity with bleomycin and cisplatin chemotherapy combinations. Am J Clin Oncol 1990;13:132-138.[Medline]
4. McDonald S., Rubin P., Phillips T.L., et al. Injury to the lung from cancer therapy: clinical syndromes, measurable endpoints and potential scoring systems. Int J Rad Oncol 1995;31:1187-1203.
5. Pinson P., Klastersky J. The value of lung function measurements for the assessment of chemotherapy in lung cancer patients. Lung Cancer 1998;19:179-184.[Medline]
6. Wang J., Olak J., Ferguson M.K. Diffusing capacity predicts operative mortality but not long-term survival after resection for lung cancer. J Thorac Cardiovasc Surg 1999;117:581-587.[Abstract/Free Full Text]
7. Cerfolio R.J., Allen M.S., Trastek V.F., et al. Lung resection in patients with compromised pulmonary function. Ann Thorac Surg 1996;62:348-351.[Abstract/Free Full Text]
8. Mahler D.A., Weinberg D.H., Wells C.K., et al. The measurement of dyspnoea. Contents, interobserver agreement and physiologic correlates of two new clinical indexes. Chest 1984;85:751-758.[Abstract/Free Full Text]
9. American Thoracic Society. Standardization of spirometry, 1994 update. Am J Respir Crit Care Med 1995;152:1107-1136.[Medline]
10. Gaensler E.A., Wright G.W. Evaluation of respiratory impairment. Arch Environ Health 1966;12:146-189.[Medline]
11. Therasse P., Arbuck S.G., Eisenhauer E.A., et al. New guidelines to evaluate the response to treatment in solid tumors. J Natl Cancer Inst 2000;92:205-216.[Abstract/Free Full Text]
12. Bernard G.R., Artigas A., Brigham K.L., et al. The American European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med 1994;149:818-824.[Abstract]
13. Dimopoulou I., Galani H., Dafni U., Samakovli A., Roussos C., Dimopoulos M. A prospective study of pulmonary function in patients treated with Paclitaxel and Carboplatin. Cancer 2002;94:452-458.[Medline]
14. Roberts J.R., Eustis C., Devore R., et al. Induction chemotherapy increases perioperative complications in patients undergoing resection for non-small cell lung cancer. Ann Thorac Surg 2001;72:885-888.[Abstract/Free Full Text]
15. Martin J.M., Ginsberg R.J., Abolhoda A., et al. Morbidity and mortality after neoadjuvant therapy for lung cancer: the risk of right pneumonectomy. Ann Thorac Surg 2001;72:1149-1154.[Abstract/Free Full Text]
16. Sleijfer S., van der Mark T.W., Schraffordt Koops, et al. Decrease in pulmonary function during bleomycin-containing combination chemotherapy for testiculal cancer: not only a bleomycin effect. Brit J Cancer 1995;71:120-123.[Medline]
17. Vander Els N., Miller V. Successful treatment of Gemcitabine toxicity with a brief course of oral corticosteroid therapy. Chest 1998;114:1779-1881.[Abstract/Free Full Text]
18. Pavlakis N., Bell D.R. Fatal pulmonary toxicity resulting from treatment with gemcitabine. Cancer 1997;80:286-291.[Medline]
19. De Pas T., Curigliano G., Franceschelli L., et al. Gemcitabine-induced systemic capillary leak syndrome. Ann Oncol 2001;12:1651-1652.[Abstract/Free Full Text]
20. De Pas T., Catalano G., Pastorino U., et al. Very low acute toxicity of three fractions per day accelerated radiotherapy given after induction chemotherapy and surgery in stage III non-small cell lung cancer. Lung Cancer 2000;30:149-150.[Medline]
21. British Thoracic Society, Society of Cardiothoracic Surgeons of Great Britain, and Ireland Working Party. Guidelines on the selection of patients with lung cancer for surgery. Thorax 2001;56:89-108.[Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Francesco Leo Lorenzo Spaggiari Ugo Pastorino Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Leo, F. Articles by Pastorino, U. Search for Related Content PubMed PubMed Citation Articles by Leo, F. Articles by Pastorino, U. Related Collections Lung - cancer