Performance in the shuttle walk test is associated with cardiopulmonary complications after lung resections

Increased minute ventilation-to-carbon dioxide slope during cardiopulmonary exercise test is associated with poor postoperative outcome following lung cancer resection

OBJECTIVES

Ventilatory efficiency [minute ventilation-to-carbon dioxide output slope (VE/VCO2 slope)] can be measured at sub-maximal workload during cardiopulmonary exercise test. The aim of this study is to assess the association between VE/VCO2 slope and outcome after lung cancer resections.

METHODS

Retrospective, single-centre analysis on all patients undergoing lung resection for cancer (April 2014-August 2022) and with a preoperative cardiopulmonary exercise test. VE/VCO2 slope >40 was chosen as high-risk threshold. Logistic regression analysis was used to test the association of VE/VCO2 slope and several patient- and surgery-related factors with 90-day mortality.

RESULTS

A total of 552 patients were included (374 lobectomies, 81 segmentectomies, 55 pneumonectomies and 42 wedge resections). Seventy-four percent were minimally invasive procedures. Cardiopulmonary morbidity was 32%, in-hospital/30-day mortality 6.9% and 90-day mortality 8.9%. A total of 137 patients (25%) had a slope of >40. These patients were older (72 vs 70 years, P = 0.012), had more frequently coronary artery disease (17% vs 10%, P = 0.028), lower carbon monoxide lung diffusion capacity (57% vs 68%, P < 0.001), lower body mass index (25.4 vs 27.0 kg/m2, P = 0.001) and lower peak VO2 (14.9 vs 17.0 ml/kg/min, P < 0.001) than those with a lower slope. The cardiopulmonary morbidity among patients with a slope of >40 was 40% vs 29% in those with lower slope (P = 0.019). Ninety-day mortality was 15% vs 6.7% (P = 0.002). The 90-day mortality of elderly patients with slope >40 was 21% vs 7.8% (P = 0.001). After adjusting for peak VO2 value, extent of operation and other patient-related variables in a logistic regression analysis, VE/VCO2 slope retained a significant association with 90-day mortality.

CONCLUSIONS

VE/VCO2 slope was strongly associated with morbidity and mortality following lung resection and should be included in the functional algorithm to assess fitness for surgery.

Beyond the Frontline: A Triple-Line Approach of Thoracic Surgeons in Lung Cancer Management-State of the Art

Non-small cell lung cancer (NSCLC) is now described as an extremely heterogeneous disease in its clinical presentation, histology, molecular characteristics, and patient conditions. Over the past 20 years, the management of lung cancer has evolved with positive results. Immune checkpoint inhibitors have revolutionized the treatment landscape for NSCLC in both metastatic and locally advanced stages. The identification of molecular alterations in NSCLC has also allowed the development of targeted therapies, which provide better outcomes than chemotherapy in selected patients. However, patients usually develop acquired resistance to these treatments. On the other hand, thoracic surgery has progressed thanks to minimally invasive procedures, pre-habilitation and enhanced recovery after surgery. Moreover, within thoracic surgery, precision surgery considers the patient and his/her disease in their entirety to offer the best oncologic strategy. Surgeons support patients from pre-operative rehabilitation to surgery and beyond. They are involved in post-treatment follow-up and lung cancer recurrence. When conventional therapies are no longer effective, salvage surgery can be performed on selected patients.

Feasibility and outcomes of a real-world regional lung cancer prehabilitation programme in the UK

BACKGROUND

Prehabilitation, or multimodality patient optimisation before major treatment, has demonstrated meaningful improvements in patients' outcomes. In the setting of lung cancer surgery, postoperative complications and length of hospital stay are reduced, but there is currently limited access to prehabilitation. Prehab4Cancer (P4C) is an innovative regional programme serving all areas of Greater Manchester (GM).

METHODS

The lung cancer P4C service commenced in 2019 as a collaboration between the GM Cancer alliance and 12 leisure and community organisations. Patients planning surgical resection could be referred to receive exercise, nutrition, and well-being assessment and interventions before surgery. We evaluated the programme's feasibility, uptake, and outcomes during the 11 months before COVID-19 restrictions.

RESULTS

In total, 377 patients were referred to the lung cancer P4C service from all 11 hospitals in GM. Of the patients reached by telephone, 80.0% (n=280/348) attended initial P4C assessment, which occurred a median of 8 days (inter-quartile range [IQR]: 4-14) after referral. In addition, 74.3% (n=280/377) attended for baseline assessment and 47.7% (n=180/377) completed prehabilitation, attending a median of six sessions (IQR: 4-9). Statistically significant improvements in all objective physiological and subjective functional assessments were observed preoperatively, including a mean increase in the incremental shuttle walk test of 50 m (95% confidence interval: 25-74; P<0.001).

CONCLUSIONS

The P4C programme demonstrated feasibility at scale, high uptake, and promising impact on the status of patients with lung cancer before surgery. P4C is the first regional prehabilitation service internationally, and this evaluation provides a framework for implementing similar services in other regions.

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

Background

The Master’s double two-step test (MDT), which is used to screen for coronary heart disease, is difficult for physically impaired patients to complete. The purpose of this study was to clarify the relationship between the results of the MDT and prognosis after lung cancer surgery.

Methods

Between May 2004 and September 2019, 1,434 patients underwent complete resection for lung cancer at our hospital. Among them, 418 with pathological stage I disease who underwent lobectomy were evaluated. We defined patients who could accomplish the MDT as the complete MDT group and those who could not as the incomplete MDT group. Patients who could not perform the MDT due to physical problems were included in the incomplete MDT group. We explored the prognostic impact of the MDT results in these patients.

Results

Fifty-three patients (12.7%) were in the incomplete MDT group; compared with the complete MDT group, they were older and had poorer performance status and respiratory function. However, the incidence of postoperative complications and 90-day mortality did not differ significantly between groups. Multivariate analyses revealed that age (p < 0.001), Charlson comorbidity index (p = 0.013), incomplete MDT (p = 0.049) and carcinoembryonic antigen (CEA) level (p = 0.003) were prognostic factors for worse overall survival; age (p < 0.001) and incomplete MDT (p = 0.022) were prognostic factors for worse non-cancer-specific survival.

Conclusions

Although incomplete MDT was not associated with postoperative complications, 90-day mortality or cancer-specific survival, MDT results may be significantly associated with non-cancer-specific survival.

The 6-minute stepper test and the sit-to-stand test predict complications after major pulmonary resection via minimally invasive surgery: a prospective inception cohort study

QUESTIONS

How well do the 6-minute stepper test (6MST) and sit-to-stand test (STST) predict complications after minimally invasive lung cancer resection? Do the 6MST and STST provide supplementary information on the risk of postoperative complications in addition to the prognostic variables that are currently used, such as age and the American Society of Anesthesiology (ASA) score?

DESIGN

Prospective inception cohort study with follow-up for 90 days.

PARTICIPANTS

Consecutive sample of adults undergoing major lung resection with video-assisted thoracic surgery (VATS) or robot-assisted thoracic surgery (RATS).

OUTCOME MEASURES

Patients had a preoperative functional evaluation with the 6MST and STST. The number of steps, heart rate change, saturation and dyspnoea during the 6MST and the number of lifts during the STST were recorded. Complications graded ≥ 2 on the Clavien-Dindo classification were recorded for 90 days after surgery.

RESULTS

Between November 2018 and November 2019, 118 patients with a mean age of 65 years (SD 9) were included and analysed. Their surgeries were via VATS in 88 (75%) and via RATS in 30 (25%). For predicting a postoperative complication graded ≥ 2 on the Clavien-Dindo classification, the area under the Receiver Operating Characteristic curve was: 0.82 (95% CI 0.75 to 0.90) for the number of steps during the 6MST, with an optimum cut-off of 140 steps; and 0.85 (95% CI 0.77 to 0.93) for the number of lifts during the STST, with an optimum cut-off of 20 lifts.

CONCLUSION

The 6MST and STST predicted morbidity and mortality after lung cancer resection via minimally invasive surgery. The preoperative use of these exercise tests in clinical practice may be useful for risk stratification.

REGISTRATION

NCT03824977.

Exercise prehabilitation in lung cancer: Getting stronger to recover faster

Despite several recent advances, lung cancer surgery is still associated with potentially severe postoperative complications. It has been suggested that preoperative exercise training could render patients with borderline functional parameters eligible for surgery, improve perioperative outcomes and that these benefits might reduce healthcare costs. Nevertheless, given the substantial heterogeneity of the available studies, no specific guidelines for preoperative exercise training have been released so far. This narrative review aims to provide an overview of the potential benefits of exercise training in the preoperative period as a central intervention for lung cancer patients. In detail, the effects of exercise (with different regimens) were evaluated in terms of physical functions, patients' eligibility for curative surgery, postoperative complications and length of stay, with an exploratory focus on healthcare costs and long-term outcomes. Furthermore, a feasible approach for every-day clinical practice is proposed in order to increase the expected benefit deriving from a more extensive and methodical application of prehabilitation exercise, ideally in the context of a comprehensive approach to lung cancer patients, including nutritional and psychological support.

Associations between pretreatment physical performance tests and treatment complications in patients with non-small cell lung cancer: A systematic review

This systematic review evaluated which outcome variables and cut-off values of pretreatment exercise tests are associated with treatment complications in patients with stage I-III non-small cell lung cancer (NSCLC). PRISMA and Cochrane guidelines were followed. A total of 38 studies with adult patients undergoing treatment for stage I-III NSCLC who completed pretreatment exercise tests, and of whom treatment-related complications were recorded were included. A lower oxygen uptake at peak exercise amongst several other variables on the cardiopulmonary exercise test and a lower performance on field tests, such as the incremental shuttle walk test, stair-climb test, and 6-minute walk test, were associated with a higher risk for postoperative complications and/or postoperative mortality. Cut-off values were reported in a limited number of studies and were inconsistent. Due to the variety in outcomes, further research is needed to evaluate which outcomes and cut-off values of physical exercise tests are most clinically relevant.

"Fit for Surgery? What's New in Preoperative Assessment of the High-Risk Patient Undergoing Pulmonary Resection"

Advances in perioperative assessment and diagnostics, together with developments in anesthetic and surgical techniques, have considerably expanded the pool of patients who may be suitable for pulmonary resection. Thoracic surgical patients frequently are perceived to be at high perioperative risk due to advanced age, level of comorbidity, and the risks associated with pulmonary resection, which predispose them to a significantly increased risk of perioperative complications, increased healthcare resource use, and costs. The definition of what is considered "fit for surgery" in thoracic surgery continually is being challenged. However, no internationally standardized definition of prohibitive risk exists. Perioperative assessment traditionally concentrates on the "three-legged stool" of pulmonary mechanical function, parenchymal function, and cardiopulmonary reserve. However, no single criterion should exclude a patient from surgery, and there are other perioperative factors in addition to the tripartite assessment that need to be considered in order to more accurately assess functional capacity and predict individual perioperative risk. In this review, the authors aim to address some of the more erudite concepts that are important in preoperative risk assessment of the patient at potentially prohibitive risk undergoing pulmonary resection for malignancy.

Evaluation of Risk for Thoracic Surgery

Modern surgical practice places increased emphasis on treatment outcomes. There has been a paradigm shift from paternalistic ways of practicing medicine to patients having a major involvement in decision making and treatment planning. The combination of these two factors undoubtedly leaves the surgeon open to greater scrutiny in respect of results and outcomes. In dealing with this it is important that the surgeon, wider multidisciplinary team, and patient appreciate the idea of surgical risk. This article reviews the latest evidence relating to risk assessment in thoracic surgery and suggests how this should be incorporated into clinical practice.

Minute ventilation-to-carbon dioxide slope is associated with postoperative survival after anatomical lung resection

OBJECTIVES

The aim of the study was to identify whether ventilation-to-carbon dioxide output (V_E/V _CO2) slope obtained from cardiopulmonary exercise test (CPET) as part of the preoperative functional workup was an independent prognostic factor for short and long-term survival after major lung resection.

PATIENTS AND METHODS

974 consecutive patients undergoing lobectomy (n = 887) or segmentectomy (n = 87) between April 2014 to March 2018 were included. 209 (22%) underwent CPET, and pulmonary function tests and several clinical factors including age, sex, performance status and comorbidities were retrospectively investigated to identify the prognostic factors with a multivariable Cox regression analysis.

RESULTS

Among the patients with measured V_E/V _CO2, the incidence of cardiopulmonary complications in patients with high V_E/V _CO2 slope (>40) was 37% (19 of 51) vs. 27% (33 of 121) in those with lower slope values (p = 0.19). The 90-day mortality in patients with high V_E/V _CO2 slope (n = 8) was 16% vs. 5% (n = 6) in those with lower slope values (p = 0.03). No overall difference in 2-year mortality was identified between the two groups (VE/VCO2 > 40: 70% (54-80) vs. VE/VCO2 ≤ 40: 72% (63-80), log-rank test, p = 0.39). In a Cox regression analysis V_E/V_CO2 values were associated with poorer 2-year survival (HR 1.05, 95% CI 1.01-1.10, p = 0.030).

CONCLUSIONS

We found that V_E/V _CO2 slope was an independent prognostic factor for the 90-day mortality and 2-year survival after anatomic pulmonary resection. This finding may assist during the multidisciplinary treatment decision-making process in high-risk patients with lung cancer.