Assos Prof Dr Sevin Başer Öncel University of Pamukkale Department of Pulmonary Medicine

1. Assos Prof Dr Sevin Başer Öncel University of Pamukkale Department of Pulmonary Medicine

2. CASE • 66 year-old, male, retired technician • No respiratory symptoms • At his check-up erythrocyte sedimentation rate (ESR) was found high • Due to complain of abdominal pain abdominal CT ordered by another hospital

3. Abdominal CT What is the abnormality at abdominal CT?

4. What is the lesion at abdominal CT? • A. Abdominal abcess • B. Hydatidcyst • C. Abdominal aorta aneurysm • D. Peritoneal mesothelioma • E. LAM due to lymphoma

5. Abdominal CT ANSWER: Abdominal aorta aneurysm

6. Referred to Cardiac Surgery Department for aneurysm surgery • Pulmonary consultation ordered before surgery

7. Symptoms and History • No respiratory symptoms • When questioned detailed Cough Dyspnea during exercise (after second floor) • ESR was high at his check-up

8. Past Medical History • No disease • No medications • New diagnosed abdominal aorta aneurysm • No exposure to asbestos or gases • Smoking: Current smoker, 46 years x 1.5 pack/day

9. Family history • MotherLiver Cancer • Father Renal Cancer

10. Physical Examination • General status: good • No syanosis, No clubbing, No wheese • Temperature: 36.8°C,pulse: 92 /min, respiratory rate:24/min • Barrel chest • Hypersonarity at chest percussion • Decreased breathe sounds at both lungs • No rales, no rhoncus, lungs were clear

11. Chest Radiograph Any pathology at chest radiograph?

12. Any pathology at chest radiograph? • A. Normal chest radiograph • B. Left hiler opacity • C. Right hiler opacity • D. Cavity at right upper zone • E. Cavity at left upper zone

13. Chest Radiograph ANSWER: C. Right hiler opacity

14. What would be your next step? • A. Allow operation without any additional test • B. Pulmonary function tests • C. Arterial blood gases • D. Thorax CT • E. Bronchoscopy

15. Thorax CT

16. Right main bronchus open RUL bronchus open Tumoral lesion in the RUL anterior segment, biopsied and brushed RMB open RLL bronchus open Left main bronchus open LUL bronchus open Lingula open LLL bronchus open Bronchoscopy • Normal vocal cords • Normal trachea • Normal main carina

17. Result of Broncoscopy • Squamous cell lung cancer

18. PFT

20. PET

21. 32x28 mmhypermetabolic (SUV:10.6)malign tumor at RUL ant segment • Low glycolytic activity (SUV<2.5)at right lower paratracheal lymph node which is 17 mmand had faty changesat the centre What is the radiologic stage?

22. What is the radiologic stage? • A. T1N0M0 • B. T1N1M0 • C. T2N0M0 • D. T2N1M0 • E. T3N0M0

23. Radiologic stage • 32x28 mm T2 • Hypometabolic lymph node N0 • No distant metastasis M0 • ANSWER: C. T2N0M0

24. Early stage T2 tumor + Low PFTs FEV1 1.61 L 48% pred DLCO 41% pred + Radiologic diffuse emphysema + 8 cm abdominal aorta aneurysm

25. What would be your next step? • A. Low PFTs,diffuse emphysema, never think about lung resection surgery • B. Already had a major comorbidity (abdominal aorta aneurysm), can not be operated, he even did not need these tests • C. Early stage tumor, can tolerate lobectomy, no need further tests, I would refer him to chest surgeon • D. I would count post op FEV1andpost op DLCO, if they are OK I would refer to chest surgeon

26. ACCP Guideline (2nd edition)Chest 2007; 132: 161-177 FEV1 > 1.5L Lobectomy FEV1 > 2L pneumonectomy FEV1 > 80% predicted Perform Spirometry FEV1 < 1.5L Lobectomy FEV1 < 2L pneumonectomy FEV1 < 80% predicted Unexplained dyspnea or diffuse parenchymal Disease on CXR/CT No Yes Estimate %ppo FEV1 and %ppo DLCO DLCO<80% predicted Measure DLCO DLCO>80% predicted %ppo FEV1 <30 or %ppoFEV1x %ppo DLCO <1650 %ppo FEV1 and %ppo DLCO >40 %ppo FEV1 and %ppo DLCO <40 Perform CPET VO2max > 15 ml/kg/min VO2max 10-15 ml/kg/min VO2max < 10 ml/kg/min Average Risk Increased Risk Increased Risk

27. Post op FEV1= pre op FEV1x Remaining segment number Total segment number • Post op FEV1= 40.2 % • Post op DLCO = 34.5 %

28. ACCP Guideline (2nd edition)Chest 2007; 132: 161-177 FEV1 > 1.5L Lobectomy FEV1 > 2L pneumonectomy FEV1 > 80% predicted Perform Spirometry FEV1 < 1.5L Lobectomy FEV1 < 2L pneumonectomy FEV1 < 80% predicted Unexplained dyspnea or diffuse parenchymal Disease on CXR/CT No Yes Estimate %ppo FEV1 and %ppo DLCO DLCO<80% predicted Measure DLCO DLCO>80% predicted %ppo FEV1 <30 or %ppoFEV1x %ppo DLCO <1650 %ppo FEV1 and %ppo DLCO >40 %ppo FEV1 and %ppo DLCO <40 Perform CPET VO2max > 15 ml/kg/min VO2max 10-15 ml/kg/min VO2max < 10 ml/kg/min Average Risk Increased Risk Increased Risk

29. Preop Postop

30. PFT follow-up

31. Abdominal aorta stent indwelling

32. Take home messages • Surgery is the best option for achieving a cure in patients with NSCLC • All patients should undergo preoperative physiologic assessment and staging for operability • Most of lung cancer patients are current smokers or quit smoking after smoking it for a long time. A substantial number of patients (37%) with anatomically resectable NSCLC are deemed surgically ineligable based on poor PFTs. Baser et al. Clinical Lung Cancer 2006; 7: 344-349 • Altough accompanying emphysema might be frightening, a selected group of patients might benefit from surgery by additional volume reduction surgery effect

33. We would like to thank Assoc Prof Gokhan Yuncu, who did the surgery of the case