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Highlights • Pulmonary function test is essential for the surgery of lung cancer patients. • Cardiopulmonary exercise test should be performed if pulmonary function is poor. • Maximal oxygen consumption and minute ventilation-to-carbon dioxide is measured. • Higher VE/VCO2 slope represents a poor postoperative prognostic factor. • VE/VCO2 slope should be part of the functional algorithm of lung resection candidates. Abstract Objectives The aim of the study was to identify whether ventilation-to-carbon dioxide output (V E /V CO2) slope obtained from cardiopulmonary exercise test (CPET) as part of the preoperative functional workup was an independent prognostic factor for short and long-term survival after major lung resection. Patients and methods 974 consecutive patients undergoing lobectomy (n = 887) or segmentectomy (n = 87) between April 2014 to March 2018 were included. 209 (22%) underwent CPET, and pulmonary function tests and several clinical factors including age, sex, performance status and comorbidities were retrospectively investigated to identify the prognostic factors with a multivariable Cox regression analysis. Results Among the patients with measured V E /V CO2 , the incidence of cardiopulmonary complications in patients with high V E /V CO2 slope (>40) was 37% (19 of 51) vs. 27% (33 of 121) in those with lower slope values (p = 0.19). The 90-day mortality in patients with high V E /V CO2 slope (n = 8) was 16% vs. 5% (n = 6) in those with lower slope values (p = 0.03). No overall difference in 2-year mortality was identified between the two groups (VE/VCO2 > 40: 70% (54–80) vs. VE/VCO2 ≤ 40: 72% (63–80), log-rank test, p = 0.39). In a Cox regression analysis V E /V CO2 values were associated with poorer 2-year survival (HR 1.05, 95% CI 1.01–1.10, p = 0.030). Conclusions We found that V E /V CO2 slope was an independent prognostic factor for the 90-day mortality and 2-year survival after anatomic pulmonary resection. This finding may assist during the multidisciplinary treatment decision-making process in high-risk patients with lung cancer. [ABSTRACT FROM AUTHOR]

Pulmonary nodules are a common incidental finding on CT and the inexorable rise in the use of CT (10% increase per year in the UK over the last decade) means that the frequency of their detection is likely to increase over coming years. This may be augmented further if CT screening is implemented. Management has previously been influenced by North American guidelines, with the most widely used resource to date being the Fleischner Society guidelines published in 2005. These predominantly focus on the timing of CT scans arranged to survey small pulmonary nodules (≤8 mm), and the guideline authors chose not to offer specific recommendations regarding larger nodules. More recently, the society published specific guidelines for sub-solid nodules, reflecting the different prognosis that this subtype of nodules confers. The American College of Chest Physicians have published two guidelines on pulmonary nodules—the latest was completed in 2012 and published in Chest the following year. However, the investigation and management of pulmonary nodules is a rapidly evolving subject largely driven by evidence from the large CT screening studies. In 2012, The British Thoracic Society (BTS) convened a guideline development group to address the topic of pulmonary nodule investigation and management, with publication of the guideline in July 2015. One third of the 359 references included in the guideline date from 2012 onwards, and many of the differences between the recommendations made and previous guideline recommendations reflect this recent evidence. This article reviews specific evidence considered in formulating the BTS guidelines, and summarises the main guideline recommendations. [ABSTRACT FROM AUTHOR]

Introduction Rising healthcare costs and financial constraints are increasing pressure on healthcare budgets. There is little published data on the healthcare costs of lung cancer in the UK, with international studies mostly small and limited by data collection methods. Accurate assessment of healthcare costs is essential for effective service planning. Methods We conducted a retrospective, descriptive cohort study linking clinical data from a local electronic database of lung cancer patients at a large UK teaching hospital with recorded hospital income. Costs were adjusted to 2013–2014 prices. Results The study analysed secondary care costs of 3274 patients. Mean cumulative costs were £5852 (95% CI, £5694 to £6027) at 90 days and £10,009 (95% CI, £9717 to £10,278) at one year. The majority of costs (58.5%) were accumulated within the first 90 days, with acute inpatient costs the largest contributor at one year (42.1%). The strongest predictor of costs was active treatment, especially surgery. Costs were also affected by age, route to diagnosis, clinical stage and cell type. Discussion Successful early diagnosis initiatives that increase radical treatment rates and improve outcomes may significantly increase the secondary care costs of lung cancer management. The use of routine NHS clinical and financial data can enable efficient and effective analyses of large cohort health economic data. [ABSTRACT FROM AUTHOR]

Objectives Clinical prediction models assess the likelihood of malignancy in pulmonary nodules detected by computed tomography (CT). This study aimed to validate four such models in a UK population of patients with pulmonary nodules. Three models used clinical and CT characteristics to predict risk (Mayo Clinic, Veterans Association, Brock University) with a fourth model (Herder et al. [4] ) additionally incorporating 18 Fluorine-Fluorodeoxyglucose (FDG) avidity on positron emission tomography–computed tomography (PET–CT). Materials and methods The likelihood of malignancy was calculated for patients with pulmonary nodules (4–30 mm diameter) and data used to calculate the area under the receiver operating characteristic curve (AUC) for each model. The models were used in a restricted cohort of patients based on each model's exclusion criteria and in the total cohort of all patients. Results Two hundred and forty-four patients were studied, of whom 139 underwent FDG PET–CT. Ninety-nine (40.6%) patients were subsequently confirmed to have malignant nodules (33.2% primary lung cancer, 7.4% metastatic disease). The Mayo and Brock models performed similarly (AUC 0.895 and 0.902 respectively) and both were significantly better than the Veterans Association model (AUC 0.735, p < 0.001 and p = 0.002 respectively). In patients undergoing FDG PET–CT, the Herder model had significantly higher accuracy than the other three models (AUC 0.924). When the models were tested on all patients in the cohort (i.e. including those outside the original model inclusion criteria) AUC values were reduced, yet remained high especially for the Herder model (AUC 0.916). For sub-centimetre nodules, AUC values for the Mayo and Brock models were 0.788 and 0.852 respectively. Conclusions The Mayo and Brock models showed good accuracy for determining likelihood of malignancy in nodules detected on CT scan. In patients undergoing FDG PET–CT for nodule evaluation, the highest accuracy was seen for the model described by Herder et al. incorporating FDG avidity. [ABSTRACT FROM AUTHOR]