CPET before oesophageal cancer

Gabrielle Morris

61-year-old man Oesophageal cancer for consideration of Oesophagectomy

Background:

  • Morbid obesity – BMI 35
  • Asthma – no admissions, daily salbutamol
  • Distant ex-smoker
  • NIDDM – single agent
  • Hypertension and hypercholesterolaemia
  • Main carer for wife (chronic back pain)

Issues:

  • Distal Oesophageal adenocarcinoma. T3N0
  • Currently undergoing NAC with a view to trimodal therapy
  • Multiple recent admissions – NG feeding, pancytopenia, and tachycardia
  • CPET:
    • Max test: HR =94% predicted RER=1.3 HRR = 7bpm
    • peak vo2 = 9.8, AT = 5.1ml/kg/min, VE/VCO2 = 38
    • High-risk category for major surgery – see departmental guideline below
  • HR trajectory high, normal slope. Frequent finding in upper GI cancers
  • Spirometry – mild obstructive defect
  • Decreased fitness and deconditioning thought to be causative factors for poor CPET result
  • VO2 and AT impacted by obesity as measured in ml/kg/min
  • Perioperative clinic:
    • wheelchair bound due to gout, normally walks with 4WW.
    • 3.6 METs on DASI
    • Normal Hb 125, Albumin 35, Troponin 4, HbA1c 5.4.
    • Sinus tachycardia – 100bpm
    • Extensive discussion with patient and wife regarding potential complications and high-risk nature of this surgery for him. Understands and is motivated to proceed, wants to continue to care for wife for as long as possible.

Discussion

  • Extremely high-risk surgical candidate, warrants further discussion after NAC and prehab
  • Decompensating with NAC – unlikely that we will improve fitness during this period. Aim is to to maintain current level of fitness with light exercise. Attempt to improve fitness post-chemo and pre-surgery, usually with HITT-training.
  • Young patient
  • Sestamibi organised – DASI < 4 METs and multiple cardiac risk factors. Abnormal test may add to the discussion in future.

Plan:

  • Sestamibi
  • Prehabilitation and physio during NAC
  • Re-test CPET post-NAC
  • Surgical review in interim