Commentary: Dum spiro spero

Abstract

Central MessageRepeat pulmonary function testing after induction chemo- or immunotherapy may offer the opportunity to recognize a subset of patients whose pulmonary function decreased.See Article page 389. Repeat pulmonary function testing after induction chemo- or immunotherapy may offer the opportunity to recognize a subset of patients whose pulmonary function decreased. See Article page 389. Dum spiro spero is a Latin phrase that translates to, “while I breathe, I hope,” as the verb spiro means both “to breathe” and “to live.” Similarly, the Sanskrit and Hindi word prana, the Hebrew word ruach, and the Chinese word qi all represent a duality of breath and life. Despite clearly different etymological origins, these words communicate the idea of the literal and figurative association between breathing, hope, and life. However, the association between breathing, hope, and life are not just a theoretical concept. As thoracic surgeons, we are frequently forced to make the difficult judgment of whether to recommend lung resection in a patient with marginal pulmonary reserve. Hence, the Latin phrase aegrescit medendo, “the disease worsens with the cure,” comes to mind. In their investigation, Connolly and colleagues1Connolly J.G. Fiasconaro M. Tan K.S. Cirelli M.A. Jones G.J. Caso R. et al.Postinduction therapy pulmonary function retesting is necessary before surgical resection for non–small cell lung cancer.J Thorac Cardiovasc Surg. 2022; 164: 389-397.e7Abstract Full Text Full Text PDF Scopus (1) Google Scholar sought to advance our understanding of the effects of neoadjuvant chemotherapy and immunotherapy on lung function to prevent the cure for lung cancer being worse than the disease and, potentially impacting a patient's breath, hope, and life. Their retrospective cohort analysis found there was a subset of patients who experienced a worsening of their forced expiratory volume at 1 second and diffusing capacity of carbon monoxide after induction chemo/immunotherapy from normal to impaired parameters. The reduction in this patient cohort was associated with a significant increased risk of perioperative morbidity and mortality. The association discovered by Connolly and colleagues1Connolly J.G. Fiasconaro M. Tan K.S. Cirelli M.A. Jones G.J. Caso R. et al.Postinduction therapy pulmonary function retesting is necessary before surgical resection for non–small cell lung cancer.J Thorac Cardiovasc Surg. 2022; 164: 389-397.e7Abstract Full Text Full Text PDF Scopus (1) Google Scholar offers the opportunity for another point of assessment for the appropriateness of surgical therapy for patients with non–small cell lung cancer. Although one could argue about the cost–benefit ratio of the recommendation to repeat pulmonary function testing on all patients after preoperative chemotherapy, it seems a reasonable consideration, given the significant increase in respiratory and postoperative complications identified. At a minimum, this would allow a comprehensive evaluation of the patient's respiratory status. A change in the treatment plan to include consideration for pulmonary rehabilitation, parenchymal-sparing resection, or nonsurgical control of the primary tumor would also be possible. Left for further investigation is whether these results are substantiated if the postinduction chemotherapy is adjusted for hemoglobin, given the significant rate of anemia in these patients. Also worth further study is whether the significant decline in pulmonary function after chemo- or immunotherapy experienced by some patients is transient. If so, optimization of hemoglobin and a brief delay to allow recovery before surgical resection may be warranted. Connolly and colleagues1Connolly J.G. Fiasconaro M. Tan K.S. Cirelli M.A. Jones G.J. Caso R. et al.Postinduction therapy pulmonary function retesting is necessary before surgical resection for non–small cell lung cancer.J Thorac Cardiovasc Surg. 2022; 164: 389-397.e7Abstract Full Text Full Text PDF Scopus (1) Google Scholar’ investigation certainly provides another point of consideration in evaluating patients for lung resection after chemo- or immunotherapy. It remains to be seen if their work will form the foundation of further investigations that could change our treatment algorithms to include mandatory reassessment of pulmonary function tests, an optional waiting period after neoadjuvant therapy, and optimization of hemoglobin before surgery. In any event, si non respicimus, non videbimus, “if we do not look, we will not see.” Postinduction therapy pulmonary function retesting is necessary before surgical resection for non–small cell lung cancerThe Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 2PreviewPretreatment-predicted postoperative diffusing capacity of the lung for carbon monoxide (DLCO) has been associated with operative mortality in patients who receive induction therapy for resectable non–small cell lung cancer (NSCLC). It is unknown whether a reduction in pulmonary function after induction therapy and before surgery affects the risk of morbidity or mortality. We sought to determine the relationship between induction therapy and perioperative outcomes as a function of postinduction pulmonary status in patients who underwent surgical resection for NSCLC. Full-Text PDF