RT Book, Section
A1 West, Malcolm A.
A1 Underwood, Timothy J.
A2 Copson, Ellen R
A2 Hall, Peter
A2 Board, Ruth E
A2 Cook, Gordon
A2 Selby, Peter
SR Print(0)
ID 1152361203
T1 A Patient with Advanced Upper Gastrointestinal Cancer and Poor Physical Fitness
T2 Problem Solving Through Precision Oncology
YR 2018
FD 2018
PB Clinical Publishing
PP New York, NY
SN 9781846921117
LK hemonc.mhmedical.com/content.aspx?aid=1152361203
RD 2021/01/27
AB A  64-year-old  man  presented  with  a  short  history  of  progressive  dysphagia  and  weight  loss.  His  medical  history  included  hypertension,  obesity  and  chronic  obstructive  pulmonary  disease.  He  was  a  current  smoker.  Investigations  (endoscopy,  CT,  PET  and  endoscopic  ultrasound)  revealed  a  T3N1M0  adenocarcinoma  of  the  gastro-oesophageal  junction  (GOJ).  He  underwent  a  cardiopulmonary  exercise  test  (CPET)  to  establish  fitness  for  surgery  and  operative  risk.  His  oxygen  uptake  at  estimated  lactate  threshold  (a  well-validated  postoperative  risk  predictive  variable  derived  from  CPET)  was  7.8  ml/kg/min;  his  oxygen  uptake  at  peak  exercise  was  13.0  ml/kg/min.  Due  to  his  high  risk  of  perioperative  mortality  and  morbidity,  the  upper  gastrointestinal  multidisciplinary  team  recommended  neoadjuvant  chemoradiotherapy  (NACRT)  and  a  course  of  prehabilitation,  with  a  delay  of  the  time  to  surgery  of  10  weeks  after  the  end  of  NACRT.At  his  initial  oncology  appointment,  he  was  referred  to  the  smoking  cessation  clinic  and  consented  to  NACRT,  as  described  in  the  Dutch  Chemoradiotherapy  for  Oesophageal  Cancer  Followed  by  Surgery  Study  (CROSS),1  with  a  modified  dose  of  carboplatin  and  paclitaxel  in  light  of  his  poor  baseline  fitness,  which  he  completed  with  no  adverse  events.  He  then  undertook  a  tailored  in-hospital  supervised  exercise  training  programme  aimed  to  rapidly  improve  his  fitness,  and  a  further  course  of  home-based  exercise  until  surgery.  A  repeat  CPET  immediately  prior  to  surgery  showed  a  significant  improvement  in  objectively  measured  fitness:  his  oxygen  uptake  at  estimated  lactate  threshold  was  11.0  ml/kg/min  and  at  peak  exercise  it  was  16.2  ml/kg/min.  End-of-treatment  scans  showed  stable  disease.  He  underwent  a  laparoscopic  two-phase  Ivor  Lewis  oesophagectomy  and  was  cared  for  on  an  enhanced  recovery  pathway.  After  2  days  in  the  surgical  HDU  he  was  transferred  to  the  ward  and  discharged  at  day  9.What  treatment  options  exist  in  the  neoadjuvant  setting  for  locally  advanced  gastro-oesophageal  cancers?What  is  the  evidence  base  for  CPET  as  a  risk  stratification  tool  prior  to  major  cancer  surgery?What  is  the  relationship  between  objectively  measured  fitness  and  neoadjuvant  cancer  treatment?What  is  the  evidence  base  for  prehabilitation  prior  to  major  cancer  surgery?