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A. Brunelli

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    SC08 - IASLC- ESTS Joint Symposium: The Borderline Patient (ID 332)

    • Event: WCLC 2016
    • Type: Science Session
    • Track: Pulmonology
    • Presentations: 1
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      SC08.01 - Impact and Management of Co-Morbidities (ID 6628)

      16:00 - 17:30  |  Author(s): A. Brunelli

      • Abstract
      • Presentation
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      Introduction Due to general ageing population, many patients with lung cancer are elderly and with frequent underlying co-morbidities. The most frequent co-morbidities associated with lung cancer are cardiac (i.e. coronary artery disease) and pulmonary diseases (i.e. COPD). Cardiac co-morbidity Coronary artery disease (CAD) is present in approximately 10-15% of lung resection candidates. The risk of major adverse cardiac events (MACE) and cardiac mortality is 4-fold higher in patients with previous history of CAD1 and patients with a previous coronary stent procedure within 1 year from lung resection had MACE and mortality rates of 9.3% and 7.7% after surgery, respectively2. Cardiac evaluation is therefore particularly important in this population to optimize their treatment and reduce surgical risk. A specific cardiac risk score was recently developed and is named Thoracic RCRI (ThRCRI). Patients in the highest class of risk had a incidence of MACE of 23% versus only 1.5% in those in the lowest class of risk1. These findings were subsequently validated by a number of independent studies. Detailed evaluation for coronary heart disease is not recommended in patients who have an acceptable exercise tolerance and with low cardiac risk score. For patients whose exercise capacity is limited, those with a ThRCRI > 1.5 or those with known or newly suspected cardiac condition, non-invasive cardiac evaluation is recommended as per AHA/ACC guidelines3 to identify patients needing more invasive interventions. Appropriately aggressive cardiac interventions should be instituted prior to surgery only in patients who would need them irrespective of the planned surgery. However, prophylactic coronary revascularization prior to surgery in patients who otherwise do not need such a procedure does not appear to reduce perioperative risk4. Pulmonary co-morbidity Approximately 20-25% of patients with early stage lung cancer have a concomitant moderate to severe COPD (FEV1<80% and FEV1/FVC ratio < 70%). Many studies have shown the association between FEV1 or predicted postoperative FEV1 (ppoFEV1), and surgical risk. In particular the risk of pulmonary morbidity and mortality has been shown to increase when FEV1 is below 50-60% or ppoFEV1< 30-40%. However, recent evidence has shown that even patients with moderate to severe COPD and lung cancer can undergo safely to lung resection. In these patients, the resection of the most affected parenchyma containing the tumor may determine a minimal loss or even an improvement in respiratory mechanics and elastic recoil, similar to what happens in typical end-staged emphysema patients candidates to lung volume reduction surgery. Nearly one third of COPD patients may actually improve their FEV1 3 months after pulmonary lobectomy for cancer. Therefore, although a reduced FEV1 or ppoFEV1 is associated with increased morbidity and mortality, most recent guidelines recommended against using this parameter alone to exclude patients from surgery even in case of very low values5,6. Patients with idiopathic pulmonary fibrosis (IPF) and lung cancer are a more challenging population to manage. Surgical treatment of these patients is high risk for postoperative acute exacerbations of IPF, which is associated with 80-100% mortality rate. The postoperative mortality rate of these patients has been reported to range between 7 and 18%. Moreover, long-term prognosis of IPF itself affects long term survival following surgery for cancer. Additional fitness tests Carbon monoxide lung diffusion capacity (DLCO) appears to be a more sensitive indicator of poor pulmonary function and more reliably associated with postoperative respiratory complications and mortality. Until recently, DLCO measurement has been mainly reserved to patients with abnormal FEV1. However, recent studies have shown that FEV1 and DLCO are poorly correlated and that more than 40% of patients with normal FEV1 (>80%) may have reduced DLCO. A low DLCO or ppoDLCO is a reliable predictor of cardiopulmonary morbidity and mortality not only in patients with COPD but also in those with normal respiratory function. This is the rationale behind the most recent recommendations to measure DLCO systematically in all lung resection candidates. Cardiopulmonary exercise test: Cardiopulmonary exercise test is the gold standard in preoperative evaluation of lung resection candidates. In addition to the most frequently used parameter, VO2max, it provides several other direct and derived measures that permit, in case of a limited aerobic reserve, to precisely identify possible deficits in the oxygen transport system. Several series have shown that a VO2max>20 mL/kg/min is safe for every extent of resection, whilst values < 10 mL/kg/min are associated with a high risk of potoperative mortality. We recently found that VO2max<12 mL/kg/min was associated with 13% in-hospital mortality rate following open major anatomic lung resections7. A parameter, which has gained recent interest in our specialty is the minute ventilation to carbon dioxide output (VE/VCO2) slope, also named as ventilatory efficiency slope. VE/VCO2 slope can be increased due to either pulmonary or cardiac diseases. Several studies have shown that a value greater than 35 is associated with increased respiratory complications and mortality after lung resection. We found that the mortality rate of patients with VE/VCO2>35 was 7% versus only 0.6% of those with lower values. The association between this parameter and respiratory complications remained the same for patients with and without COPD and for those with VO2max greater or lower than 15 mL/kg/min. VATS and sublobar resections Videoassisted thoracoscopic surgery (VATS) has been recommended as the approach of choice for stage I lung cancer patients. Several studies showed that this approach is associated with lower incidence of complications, shorter hospital stay and in some cases lower mortality rates compared to thoracotomy. The benefits of VATS are particularly evident in patients with poor pulmonary function. Large series found that the difference in pulmonary complication rates after lobectomy by VATS versus thoracotomy was present only in patients with a FEV1<60%. Burt and coll.8 found that patients with ppoFEV1<40% or ppoDLCO<40% and submitted to VATS lobectomy had a markedly reduced incidence of mortality compared to those operated on through thoracotomy (ppoFEV1<40%: 0.7% vs. 4.8%, p=0.003; ppoDLCO<40%: 2% vs. 5.2%, p=0.003). Recent evidences have shown that anatomic segmentectomies provide equivalent oncologic results compared to lobectomy for tumours smaller than 2 cm, whilst preserving much more respiratory function and being associated with lower incidence of postoperative complications9,10. This extent of resection appears therefore ideal for patients with a limited baseline pulmonary function. Selected references 1. Brunelli A, et al. Recalibration of the revised cardiac risk index in lung resection candidates. Ann Thorac Surg. 2010;90(1):199-203. 2. Fernandez FG, et al. Incremental risk of prior coronary arterial stents for pulmonary resection. Ann Thorac Surg. 2013 Apr;95(4):1212-8 3. Fleisher LA, et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. Circulation 2007: 116(17): 418-499. 4. McFalls EO, et al. Coronary-artery revascularization before elective major vascular surgery. N Eng J Med 2004; 351(27): 2795-2804 5. Brunelli A, et al. ERS/ESTS clinical guidelines on fitness for radical therapy in lung cancer patients (surgery and chemo-radiotherapy). Eur Respir J 2009; 34:17-41. 6. Brunelli A, et al. Physiologic Evaluation of the Patient With Lung Cancer Being Considered for Resectional Surgery: Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2013 May;143(5 Suppl):e166S-90S 7. Brunelli A, et al. Peak Oxygen Consumption During Cardiopulmonary Exercise Test Improves Risk Stratification in Candidates to Major Lung Resection. Chest 2009; 135:1260-1267. 8. Burt BM, et al. Thoracoscopic lobectomy is associated with acceptable morbidity and mortality in patients with predicted postoperative forced expiratory volume in 1 second or diffusing capacity for carbon monoxide less than 40% of normal. J Thorac Cardiovasc Surg. 2014 Jul;148(1):19-28 9. Okada M, et al. Radical sublobar resection for small-sized non-small cell lung cancer: a multicenter study. J Thorac Cardiovasc Surg. 2006 Oct;132(4):769-75 10. Yano M, et al. Survival of 1737 lobectomy-tolerable patients who underwent limited resection for cStage IA non-small-cell lung cancer. Eur J Cardiothorac Surg. 2015 Jan;47(1):135-42

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