Preoperative Master's double two-step test may predict survival after lobectomy in patients with lung cancer

Prognostic significance of preoperative exercise tolerance in patients with early-stage lung cancer

OBJECTIVE

To investigate the influence of simple preoperative exercise tests as prognostic factors for early-stage lung cancer.

METHODS

This single-institution retrospective study included consecutive patients who underwent pulmonary resection for stage 0 to I lung cancer between April 2017 and December 2019. Before surgery, 7 metabolic equivalents of task in the double Master 2-step test were loaded into the exercise echocardiogram. The relationship between prognosis and exercise stress test results in terms of availability, symptoms, and saturation of percutaneous oxygen was investigated.

RESULTS

This study included 862 patients with pathological stage 0 to I lung cancer. Among the 862 patients, 673 patients (78.1%) who were able to complete 7 metabolic equivalents of task exercise for 3 minutes without assistance were classified into the complete group. The 5-year survival of the complete group was significantly better than that of the incomplete group. Multivariable analysis revealed that age (hazard ratio, 1.06; P = .008), male sex (hazard ratio, 2.23; P = .011), carcinoembryonic antigen level >5 ng/mL (hazard ratio, 2.33; P = .011), and inability to complete 7 metabolic equivalents of task exercise (hazard ratio, 3.90; P < .001) were the prognostic factors. Patients in the older group who had the ability to complete exercise had a better prognosis than those in the younger group without the ability (P = .003).

CONCLUSIONS

Preoperative exercise ability is a prognostic factor for early-stage lung cancer. Patients who can tolerate an exercise load of 7 metabolic equivalents of task, even if they are aged 70 years or older, have a better prognosis than patients younger than age 70 years without exercise tolerance.

Identification of the Vessels Causing Myocardial Ischemia by a Synthesized 18-Lead Electrocardiogram Obtained After the Master Two-Step Exercise Test in a Patient With Effort Angina

A synthesized 18-lead electrocardiograph is a specialized technology that mathematically computes the virtual electrocardiographic waveforms of the right chest leads (V3R, V4R, and V5R) and posterior leads (V7, V8, and V9) based on a standard 12-lead electrocardiograph input without additional lead placement or techniques. Synthesized 18-lead electrocardiography is a useful test for the identification of the culprit coronary arteries in patients with ST-segment elevation myocardial infarction of the right ventricular wall or the posterior/lateral left ventricular wall, which are often missed on standard 12-lead electrocardiography. However, few studies have examined the usefulness of this modality during exercise stress testing. We present a case of a 78-year-old man with a two-month history of typical angina. The synthesized 18-lead electrocardiogram obtained just after the Master two-step exercise test revealed ST-segment shifts in multiple leads, including synthesized V4R, V5R, and V7-9 leads, and U-wave changes in some leads, including the synthesized V9 lead. The diagnosis of the culprit coronary arteries causing exercise-induced myocardial ischemia is discussed with reference to coronary angiographic findings. This modality could potentially increase the sensitivity and specificity for the detection of coronary artery disease and accurately pinpoint the site of the lesion. If an electrocardiograph can display a synthesized 18-lead electrocardiogram, it should be used when evaluating the waveform due to myocardial ischemia.

Exercise oxygen desaturation is a predictor of cardiopulmonary complications after lung resection

BACKGROUND

To investigate whether oxygen desaturation during low technology tests was associated with complications after lung resection.

METHODS

A retrospective cohort study was conducted on 1097 candidates for pulmonary resection; seven metabolic equivalents in the Master's double two-step test were loaded. The predicted postoperative (PPO) forced expiratory volume in 1 s and PPO diffusing capacity of the lung for carbon monoxide were estimated. The patients were divided into three groups: those with both values ≥60% (≥60% group (n=298)), either value <30% (<30% group (n=112)) and others (30%-60% group (n=687)). The relationships between postoperative cardiopulmonary complications and exercise stress test based on availability, symptoms and percutaneous oxygen saturation values were investigated in each group.

RESULTS

Τhe cardiopulmonary morbidity rates in the ≥60%, 30%-60%, and <30% groups were 7.7%, 14.6%, and 47.3%, respectively. Multivariate analyses revealed that predictors of complications were age (OR 0.96; p<0.001), male sex (OR 1.74; p=0.016) and exercise oxygen desaturation (EOD) >4% (OR 2.39; p=0.001) in the 30%-60% group, and male sex (OR 3.76; p=0.042) and EOD >4% (OR 2.28; p=0.030) in the <30% group.The two-flight test (TFT) was performed in 181 patients (22.8%); desaturation >4% in the TFT was also a predictor of complications.

CONCLUSIONS

A low technology test is also valuable for high-risk patients. EOD >4% is a predictor of postoperative complications.

CLINICAL REGISTRATION

This study is a non-interventional observational study and has not been registered in a public database. The study followed the Strengthening the Reporting of Observational Studies in Epidemiology reporting guidelines.This study was approved by the Ethics Committee of the Juntendo University School of Medicine (no. 2016085).