Multicentric Italian early Lung cancer Detection project Functional evaluation and Risk in COPD Patients Elisa Calabrò U.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 FEV 1 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) FEV birth Peak Decline Plateau Smoke and decline of respiratory function Non smokers Smokers

COPD results from an interaction between host and environmental factors Host factors   genetic susceptibility  AAT deficiency  other possible genetic factors  phenotypic susceptibility Environmental exposures  tobacco smoke (active and passive)  occupational dusts and chemicals  air pollution (indoor and outdoor)

 Genetic susceptibility influences occurrence of COPD COPD  Not every active smokers get clinical COPD  But Smoking 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 lung cancer, 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: riduzione della CV ( o della CVF), e proporzionalmente, di tutti i volumi e di tutte le capacità polmonari; il rapporto VEMS/CVF pertanto rimane normale. Deficit ostruttivo: riduzione del VEMS e dei flussi espiratori, con diminuzione anche del rapporto VEMS/CVF.

0 AT RISK Normal Spirometry I MILD I MILD FEV/FVC <70% and FEV1 80% predicted FEV 1 /FVC <70% and FEV1 80% predicted II MODERATE II MODERATE III SEVERE FEV/FVC <70% and FEV1 50–80% predicted FEV 1 /FVC <70% and FEV1 50–80% predicted FEV/FVC <70% and FEV1 30–50% predicted FEV 1 /FVC <70% and FEV1 30–50% predicted IV IV VERY SEVERE FEV/FVC <70% and FEV1 <30% predicted FEV 1 /FVC <70% and FEV1 <30% predicted Global Initiative for Chronic Obstructive Lung Disease Classification of Severity of COPD STAGE

Guidelines to estimate the risk in resective pulmonary procedure R. E. Hyatt et al, 1997 ParametersIncreased riskHigh risk Spirometry FVC FEV 1 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 PaCO 2 > 45 mmHg

Post-operating risk based on the maximum oxygen consumption (VO 2 max) Morbidity % VOmax < 15 ml/Kg/min VO 2 max < 15 ml/Kg/min Mortality 15-75% Mortality 15-75% Post-operative Morbidity < 10% Post-operative Morbidity < 10% VOmax > 20 ml/Kg/min VO 2 max > 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 Nov-Dec;29(6): 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 HU, the white areas of emphysema were clearly depicted.

AIMS   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