Perioperative management of non-small cell lung cancer (NSCLC)
Medically reviewed by Christophe Marois.
Answer
The perioperative management of non-small cell lung cancer (NSCLC) involves several key components, including preoperative cardiorespiratory assessment, surgical intervention, perioperative thromboprophylaxis, and symptomatic management.
Preoperative cardiorespiratory assessment
- The European Society for Medical Oncology (ESMO) 2017 guidelines recommend assessing the cardiopulmonary fitness of the patient with non-metastatic NSCLC for treatment decision-making. This includes obtaining a precise assessment of cardiac and pulmonary function to estimate the risk of operative morbidity before surgical resection
- The American College of Chest Physicians (ACCP) 2013 guidelines recommend offering tobacco dependence treatment in all actively smoking patients with lung cancer planned for surgery
- Patients with a VO2 MAX < 10 mL/kg/min or < 35% of predicted should be counseled about minimally invasive surgery, sublobar resections, or nonoperative treatment options
Surgical intervention
- For early-stage disease, the ACCP 2013 guidelines suggest performing anatomic sublobar resection (segmentectomy) over lobectomy in patients with a significantly increased risk of perioperative mortality or competing causes of death
- For locally advanced disease, the ACCP 2013 guidelines recommend offering induction therapy followed by surgery or definitive chemoradiotherapy rather than surgery or radiotherapy alone in patients with discrete N2 involvement by NSCLC identified preoperatively (IIIA)
Perioperative thromboprophylaxis
- For patients undergoing lobectomy or segmentectomy, the AATS/EACTAIC/EACTS/EAU/EBCOG/EHS/EKS/ESAIC/ESTS/EURAPS/ISTH/NATA/SRLF 2024 guidelines recommend administering in-hospital prophylaxis only in patients at low risk of thrombosis. Extended prophylaxis for 28-35 days is considered for patients at moderate or high risk of thrombosis
- For patients undergoing pneumonectomy or extended resections, the same guidelines suggest administering parenteral anticoagulation with LMWH or UFH for VTE prophylaxis, with a preference for LMWH over UFH
Symptomatic management
- For pain control, the ACCP 2013 guidelines recommend offering codeine or dihydrocodeine, in addition to acetaminophen and/or NSAIDs, in patients with mild-to-moderate chronic pain
- For severe chronic pain, oral morphine is recommended as first-line therapy, with oxycodone or hydromorphone as alternatives when there are significant side effects or lack of efficacy with oral morphine