Journal Thoracic Oncology

Abstracts Journal of Thoracic Oncology • Volume 12 Issue S1 January 2017
SC08.01 IMPACT AND MANAGEMENT OF CO-MORBIDITIES
Alessandro Brunelli
St. James’ University Hospital, Leeds/United Kingdom
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 (FEV180%) 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 VO2max35 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