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Ann Thorac Surg 2004;78:1215-1218
© 2004 The Society of Thoracic Surgeons

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Original article: general thoracic

Use of Quantitative Lung Scintigraphy to Predict Postoperative Pulmonary Function in Lung Cancer Patients Undergoing Lobectomy

^a Departments of Thoracic Oncology, Papworth, United Kingdom
^b Department of Radiology, Papworth, United Kingdom
^c Department of Cardiothoracic Surgery, Papworth Hospital, Papworth, United Kingdom
^d Department of Radiology and Nuclear Medicine, Addenbrooke's Hospital, Cambridge, United Kingdom

Accepted for publication April 1, 2004.

^* Address reprint requests to Dr Win, Thoracic Oncology Unit, Papworth Hospital, Papworth Everard, Cambridge CB3 8RE, UK
thida.win{at}papworth.nhs.uk

	Abstract

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
BACKGROUND: In patients with non-small cell lung cancer, the only realistic chance of cure is surgical resection. However, in some of these patients there is such poor respiratory reserve that surgery can result in an unacceptable quality of life. In order to identify these patients, various pulmonary function tests and scintigraphic techniques have been used. The current American College of Physicians and British Thoracic Society guidelines do not recommend the use of quantitative ventilation-perfusion scintigraphy to predict postoperative function in lung cancer patients undergoing lobectomy. These guidelines may have been influenced by previous scintigraphic studies performed over a decade ago. Since then there have been advances in both surgical techniques and scintigraphic techniques, and the surgical population has become older and more female represented.

METHODS: We prospectively performed spirometry and quantitative ventilation-perfusion scintigraphy on 61 consecutive patients undergoing lobectomy for lung cancer. Spirometry was repeated one-month postsurgery. Both a simple segment counting technique alone and scintigraphy were used to predict the postoperative lung function.

RESULTS: There was statistically significant correlation (p < 0.01) between the predicted postoperative lung function using both the simple segment counting technique and the scintigraphic techniques. However, the correlation using simple segment counting was of negligible difference compared to scintigraphy.

CONCLUSIONS: In keeping with current American Chest Physician and British Thoracic Society guidelines, our results suggest that quantitative ventilation-perfusion scintigraphy is not necessary in the preoperative assessment of lung cancer patients undergoing lobectomy. The simple segmenting technique can be used to predict postoperative lung function in lobectomy patients.

	Introduction

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Lung cancer continues to be the most common fatal malignancy [1]. In patients with non-small cell lung cancer, surgical resection offers the only realistic chance of cure. However, some of these patients have such poor respiratory reserve that surgery results in an unacceptable quality of life. Different techniques have therefore been used to predict postoperative lung function. These have included various pulmonary function tests and quantitative ventilation (V)-perfusion (Q) scintigraphy [2–5]. In practice, scintigraphy is not widely employed in assessing patients for lobectomy, because of difficulty interpreting the contribution of individual lobes to the overall ventilation or perfusion.

At present, the American College of Physicians (ACP) and British Thoracic Society (BTS) do not recommend the use of scintigraphy as part of the prelobectomy assessment of lung cancer patients [6, 7]. This may reflect that several investigators have reported that the use of a simple calculation using lung segment counting can predict postoperative forced expiratory volume in one second (FEV1) as accurately as V/Q scintigraphy [8–11]. However, previous scintigraphic data were obtained over a decade ago, using limited size populations (less than 50 patients), and tended to underestimate the postsurgical FEV1 values [2–5, 10, 11]. Moreover, the cohorts that were used were male dominant and of younger age than the typical patient presenting for lung cancer surgery today. In addition, the last ten years have seen refinement in both surgical and scintigraphic techniques as well as a fall in postsurgical mortality. We therefore prospectively investigated the use of V/Q scintigraphy in predicting lung function postlobectomy in a representative population, in order to ascertain the appropriateness of present clinical guidelines.

	Patients and Methods

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Patients
For more than 18 months, we prospectively performed full pulmonary function tests and quantitative planar V/Q scintigraphy on 61 (35 male and 26 female) consecutive patients undergoing lobectomy for non-small cell lung cancer. Their mean age was 69.2 years (range, 54 to 85). The mean body mass index was 26.5 (range, 17 to 38). All except 2 were ex or current smokers. Fifteen patients had borderline preoperative lung function (FEV₁ less than 1.5 L). Lobectomy was performed by our institution's standard thoracotomy by one of the three designated cardiothoracic surgeons (see Table 1 for summary of lobectomy sites). The local Research Ethics Committee approval was obtained and all patients gave written consent.

Scintigraphy
All studies were performed using an Elscint Apex SP4 (Elscint Ltd, Tel Aviv, Israel) single headed camera and a multipurpose collimator. Patients were imaged in the erect position. All examinations were supervised by qualified nuclear medicine technicians and then reported by one of three specialist cardiothoracic radiologists.

Ventilation images were acquired before perfusion imaging. The ventilation study was performed with 40 MBq of technetium 99 (Tc99) m –diethylene-triamine-penta-acetic acid, nebulized through a Venticis II aerosol delivery system (Cis Diagnostici, Vercelli, Italy). Seventy-five MBq of intravenous Tc99 m macroaggregated albumin was used for the perfusion studies. Four routine views were taken (anterior, posterior, right, and left posterior oblique).

Using the four views, regions of interest were obtained of the upper, middle, and lower zones. Counts from each zone were obtained and thus the relative ventilation-perfusion for each lobe was approximated. In this manner the predicted loss of pulmonary function was estimated.

Analysis
The following equations were used to estimate the predicted postoperative FEV₁.

Simple Segment Counting
Predicted postoperative FEV₁ = preoperative FEV₁ x (1 – segment of lung to be resected/19) as described by Bolliger and colleagues [13]; 19 being the total number of lung functional segments in both lungs as described by Olsen and colleagues [14].

V/Q Scintigraphy Using Region of Interest
Predicted postoperative FEV₁ = preoperative FEV₁ x (1 – functional contribution of ventilation or perfusion of the region to be resected) as described by Bolliger and colleagues [13].

The patient's preoperative and postoperative lung function results were compared to the predicted outcome as calculated by the segmental counting method and the scintigraphic techniques (Table 2) . The baseline characteristics were quoted as mean (range) values. Pearson's correlation coefficient and Bland-Altman analysis were used to compare the three different methodologies.

	Results

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	Comment

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
For most patients with non-small cell lung cancer, surgery remains the best prospect for cure. The preoperative evaluation of patients with lung cancer is a challenging problem. The presence of carcinoma causes a decrease in both ventilation and perfusion of the involved lung, especially in hilar lesions. In order to define those patients with borderline pulmonary function who will benefit from lobectomy, many studies have tried to predict postoperative pulmonary function. Radionuclide lung scintigraphy offers a simple method of predicting this outcome by combining spirometry with quantitative measurement of differential ventilation or perfusion. In the current study, we analyzed the accuracy of the quantitative V/Q scintigraphy to predict postlobectomy lung function and compared the prediction against a simple segment counting prediction in a reasonably large cohort of representative lung cancer patients.

As previously reported [2, 14, 15] we found the correlation between actual and predicted values (using scintigraphic as well as segment counting) significantly correlated in terms of both FEV₁ in liter and FEV₁ in percentage of predicted. However, the correlation values using the simple segment counting method alone was almost identical to that obtained by quantitative scintigraphy. Bland-Altman analysis also shows that the agreements between all three methods of segment counting, using V and Q scintigraphy, were not different. There was no systematic association between size of measurement and measurement error. Although our results (using both segment counting and scintigraphic techniques) exhibited a tendency to underestimate the true postoperative function, this tendency was much smaller than reported in pneumonectomy patients [8, 14, 16]. Bolliger and colleagues [13] showed that computed tomography (CT) and/or perfusion prediction was better than segment counting in pneumonectomy patients; however, segment counting was equally effective in lobectomy patients. They also suggested that anatomically based calculations for resection should be reserved for resection not exceeding lobectomy.

It should be noted that Bolliger and colleagues [13] employed three different segment counting techniques and correlated them all with the actual postoperative value. These techniques included functional segment counting (correcting for unobstructed segments), subsegmental, and simple segment counting. Despite attempting to correct the functioning lung volume by counting the obstructed segments, this did not improve the correlation. Subsegment counting correlated slightly less than simple counting. It is often impossible to predict which segments are blocked, especially in lobectomy patients.

Although the correlation values we obtained were generally in keeping with other studies, it could be argued that refinements to our technique might have yielded better postoperative predictions. Some authors claim single photon emission computed tomography is more appropriate than performing planar images [17, 18], but our results were only marginally inferior. We could also have used better ventilation agents such as technetium gas or 81 m-krypton, but there is both local lack of availability and lack of experience with these radionuclides. In the future it may be possible to combine radionuclide techniques with the use of CT. This technique has been successfully used and examines the lobar lung density to estimate the function of the individual lung lobes [13, 19].

In conclusion, since there was no significant additional benefit using V/Q scintigraphy over simple segment counting, we confirm present ACP and BTS guidelines [6, 7] and do not recommend the routine use of quantitative planar V/Q scintigraphy in the assessment of lung cancer patients for lobectomy.

	Acknowledgments

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Dr Win received a National Health Service Eastern Region Research and Development Grant. We would like to thank Dr Linda Sharples (Medical Research Council, Biostatistician, Research and Development Unit, Papworth Hospital) for her statistical advice regarding this manuscript.

	References

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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): Francis C. Wells Andrew J. Ritchie Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Win, T. Articles by Tasker, A. D. Search for Related Content PubMed PubMed Citation Articles by Win, T. Articles by Tasker, A. D. Related Collections Lung - other