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. 2018 Apr 16;5(1):e000273. doi: 10.1136/bmjresp-2017-000273
Quality statement 5 People with pulmonary nodules considered for definitive treatment and suitable for surgical intervention are offered lobectomy with pathological confirmation of malignancy by frozen section, if not previously confirmed, or anatomical segmentectomy if unfit for lobectomy.
Rationale To maximise the surgical resection rate for early stage lung cancer and to allow geographical and temporal comparison of resection rates to instruct service development.
To ensure an appropriate surgical strategy for resection that minimises lobectomy for benign disease, ensures anatomical resection for all pulmonary nodules confirmed as lung cancer and that, where appropriate, a completion lobectomy occurs during the same anaesthetic.
Quality measure Structure:

  • Evidence of local arrangements and written clinical protocols that ensure people with pulmonary nodules considered for definitive treatment and suitable for surgical intervention are offered lobectomy with pathological confirmation of malignancy by frozen section, if not previously confirmed, or anatomical segmentectomy if unfit for lobectomy.

Process:

  • Overall proportion of patients who have pulmonary nodules with pathological confirmation of malignancy that undergo surgical resection.

  • Proportion of patients undergoing lobar or segmental resection of malignant pulmonary nodules as one definitive procedure.

  • Proportion of patients undergoing wedge or segmental resection of pulmonary nodules with eventual benign diagnosis.
Numerator 1:

  • Number of patients who have pulmonary nodules with pathological confirmation of malignancy that undergo surgical resection.
Denominator 1:

  • Total number of patients who have pulmonary nodules with pathological confirmation of malignancy.

Numerator 2:

  • Number of patients undergoing lobectomy with intraoperative frozen section analysis, or undergoing anatomic segmentectomy where not fit for lobectomy.

Denominator 2:

  • Number of patients undergoing resection of pulmonary nodules without a preoperative diagnosis who are subsequently confirmed malignant.


Numerator 3:

  • Number of patients undergoing resection of pulmonary nodules with an eventual benign diagnosis who undergo lobectomy.
Denominator 3:

  • Number of patients undergoing surgical resection of pulmonary nodules by lobectomy.

(This fraction should be equivalent to 10% or less)
Description of what the quality statement means for each audience Service providers:

  • Ensure services are provided that ensure people with pulmonary nodules considered for definitive treatment and suitable for surgical intervention are offered lobectomy with pathological confirmation of malignancy by frozen section, if not previously confirmed, or anatomical segmentectomy, if unfit for lobectomy.
Healthcare professionals

  • Ensure surgical involvement in MDT discussion of pulmonary nodules, and ensure that surgical strategy is appropriate for the clinical situation.

Commissioners:

  • Commission specialist thoracic surgical services that offer lobectomy with pathological confirmation of malignancy by frozen section, if not previously confirmed, or anatomical segmentectomy, if unfit for lobectomy. Services will be supported by an expert lung cancer MDT.

People with pulmonary nodules considered for definitive treatment and suitable for surgical intervention

  • Should be treated at specialist centres with adequate provision for preoperative assessment, and intraoperative management for both diagnosis and resection.
Relevant existing indicators Local MDT minutes/database/audit
National data sources National Lung Cancer Audit, Society for Cardiothoracic Surgery Thoracic Registry
Source references BTS Guidelines for the Investigation and Management of Pulmonary Nodules, 20153; NICE Lung Cancer: Diagnosis and Management Guideline, 20114; BTS Guidelines on the Radical Management of Patients with Lung Cancer, 20107
Other information