Multicentric Italian early Lung cancer Detection project

Functional evaluation andRisk in COPD Patients

Elisa CalabròU.O. di Chirurgia Toracica – INT Milano

Clinica Pneumologica Università di Parma

Istituto Nazionale Tumori 24 Marzo, Milano

Relationship between lung cancer and airflow obstruction is well recognized

COPD and lung cancer are caused primarily by smoking

Patients who stopped smoking had a slight improvement in FEV1 followed by a mild decline. Those who continued smoking had a much more rapid decline, indicating a poor prognosis in years to come

Introduction

age (year)

FE

V1

20 40birth

Peak

Decline

Plateau

Smoke and decline of respiratory function

Non smokersSmokers

COPD results from an interaction between host and environmental factors

Host factors

genetic susceptibility AAT deficiencyAAT deficiency other possible genetic factorsother possible genetic factors phenotypic susceptibilityphenotypic susceptibility

Environmental exposuresEnvironmental exposures

tobacco smoke (active and passive)tobacco smoke (active and passive) occupational dusts and chemicalsoccupational dusts and chemicals air pollution (indoor and outdoor)air pollution (indoor and outdoor)

Genetic susceptibilityGenetic susceptibility influences occurrence of influences occurrence of

COPDCOPD

Not every active smokers get clinical Not every active smokers get clinical COPDCOPD

But But Smoking is responsible for 90% of cancerSmoking is responsible for 90% of cancer

deaths deaths

Genetic (host) risk factors in COPD 

Because smoking and airflow obstruction are such powerful risk factors for lungcancer, their assessment is useful in patient evaluation. Risk can be stratified on the basis of the age (49-75), of the presence or absence of smoking (20 packs/year) and the presence or absence of symptoms. Patients at highest risk are those who smoke heavily, have spirometric abnormalities, and have symptoms.

            

Deficit restrittivo: Deficit restrittivo: riduzione della CV ( o riduzione della CV ( o della CVF), e della CVF), e proporzionalmente, di proporzionalmente, di tutti i volumi e di tutte tutti i volumi e di tutte le capacità polmonari; il le capacità polmonari; il rapporto VEMS/CVF rapporto VEMS/CVF pertanto rimane pertanto rimane normale. normale. Deficit ostruttivo: Deficit ostruttivo: riduzione del VEMS e riduzione del VEMS e dei flussi espiratori, con dei flussi espiratori, con diminuzione anche del diminuzione anche del rapporto VEMS/CVF. rapporto VEMS/CVF.

0 AT RISK Normal Spirometry

I MILDI MILD FEVFEV1/FVC <70% and FEV1 80% predicted/FVC <70% and FEV1 80% predicted

II MODERATEII MODERATE

III SEVEREIII SEVERE

FEVFEV1/FVC <70% and FEV1 50–80% predicted/FVC <70% and FEV1 50–80% predicted

FEVFEV1/FVC <70% and FEV1 30–50% predicted/FVC <70% and FEV1 30–50% predicted

IV IV VERY SEVERE FEVFEV1/FVC <70% and FEV1 <30% predicted/FVC <70% and FEV1 <30% predicted

Global Initiative for ChronicObstructiveLungDisease

Classification of Severity of COPD

STAGE

Guidelines to estimate the risk in resective pulmonary procedure

R. E. Hyatt et al, 1997R. E. Hyatt et al, 1997

Parameters Increased risk High risk

Spirometry FVCFEV1

MVV

< 50% of pred < 2 liter o 60% of pred

< 1.5 liter < 1 liter< 50% of pred

Diffusion capacity

DLCO < 60% of pred

Blood gas PaCO2 > 45 mmHg

Post-operating risk based on the maximum oxygen consumption (VO2max)

Morbidity 75-100%Morbidity 75-100%VOVO2max < 15 ml/Kg/minmax < 15 ml/Kg/min

Mortality 15-75%Mortality 15-75%

Post-operative Morbidity < 10%Post-operative Morbidity < 10%

VOVO2max > 20 ml/Kg/minmax > 20 ml/Kg/min Post-operative Mortality 0 Post-operative Mortality 0

Quantitative CT: predict post op lung function

“One stop shop”

Reliability of quantitative computed tomography to predict postoperative lung function in patients with chronic obstructive pulmonary disease having a lobectomy

J Comput Assist Tomogr. 2005 Nov-Dec;29(6):819-24.

Virtual upper right lobectomy

On the quantitative CT map, the white areas denote the “functional lung parenchyma.” By applying the range of density from -910 to -1024 HU, the white areas of emphysema were clearly depicted.

AIMSAIMS

Correlation between GOLD stage and long-term survival

Correlation between GOLD stage and pathological stage

Correlation between COPD and histological subtype

Correlation between GOLD stage and surgery risk

Correlation between GOLD stage and post-operative mortality

Correlation between COPD and post-operative

complication

Correlation between COPD and lung cancer