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Presented by Ri 李佩蓉 Supervisor: CR 顏郁軒 Oct 27, 2005

Pre-OP Evaluation of A 74 y/o Male with Lung Cancer . Presented by Ri 李佩蓉 Supervisor: CR 顏郁軒 Oct 27, 2005. Patient Data. 74 y/o male Occupation: 漁業 Smoking(+) 2-3 PPD for more than 60 years Betel nut chewer for decades: 30 顆/ day

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Presented by Ri 李佩蓉 Supervisor: CR 顏郁軒 Oct 27, 2005

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  1. Pre-OP Evaluation of A 74 y/o Male with Lung Cancer Presented by Ri 李佩蓉 Supervisor: CR 顏郁軒 Oct 27, 2005

  2. Patient Data • 74 y/o male • Occupation: 漁業 • Smoking(+) 2-3 PPD for more than 60 years • Betel nut chewer for decades: 30顆/ day • Denied major systemic diseases such as DM, HTN, liver or kidney diseases • BPH for more than 6 years under medical control • OP history: 1) Appendectomy more than 10 years ago 2) Hernia s/p OP • Allergy: denied

  3. Present Illness • Chief complaint • Intermittent fever up to 38-40°C since about 6 months ago • Associated symptoms • Short of breath sensation, easy fatigue, general malaise, exertional dyspnea, and exercise intolerance have been noted since early this year.

  4. Present Illness • Refer to 嘉義長庚 from local clinic • Chest CT revealed fibrotic change over RUL and mediastinal LAPs. • Bronchoscopy with biopsy yielded poor differentiated squamous cell carcinoma arising from carcinoma in situ with focal tumor necrosis. • Bone scan revealed no bone metastasis.

  5. Physical Examination • Consciousness: clear; Appearance: fair • HEENT: Eyes: pupil: isocoric, light reflex:(+/+), conjunctiva: not pale, sclera: anicteric Throat: not injected, no ulcer, no gum bleeding Neck: supple, no LAPs, JVE(-), goiter(-) • Chest: symmetric expansion; breath sound: wheezing (+) over bilateral upper lung fields, especially right side • Heart: regular hearty beat without audible murmur • Abdomen: soft and flat, tenderness(-), mass(-) Liver: 1fb below RMCL, spleen: impalpable • Extremity: no pitting edema, no skin rash

  6. Lab 項 目: WBC RBC HB HCT MCV MCH MCHC PLT 日期 K/μL M/μL g/dL % fL pg g/dL K/μL 0930 4.99 3.98 12.2 37.8 95.0 30.7 32.3 167.0 項 目: GLU UN CRE Na K Cl Ca 日期 mg/dl mg/dl mg/dl mmol/l mmol/l mmol/l mmol/l 0930 90 21.4 0.8 137 3.9 107 2.10 項 目: TP UA(B) ALB ALT AST ALP T-BIL 日期 g/dL mg/dl g/dL U/l U/l U/l mg/dl 0930 6.6 5.1 4.12 12 21 146 0.56 項 目: PT PT INR PTT 日期 sec 0930 12.2 1.08 36.9 項 目: RIA:CEA (Serum) 日期 (時間) ng/ml 1001 5.16

  7. Staging • Chest CT: 1.4cm nodule at ant. segment of RUL adjacent to RUL bronchus and multiple non-specific small mediastinal LNs. • Bronchoscopy: no obvious endobronchial lesion. • The bronchoscopic washing for RUL: no malignant cells. • PET: a 1.5cm FDG hypermetabolic nodule adjacent to RUL bronchus with suspicion of a malignant tumor, but no abnormal FDG uptake in other part of the body. • Brain CT: no abnormal density or enhancement. • Tentative diagnosis: • Lung cancer, right upper lobe, squamous cell carcinoma, stage IA (cT1N0M0)

  8. Course and treatment

  9. Course and Treatment • VATs RUL lobectomy and LND were performed on 10/13 • OP finding: • One 1.5*1 cm whitish, hypercellular, firm tumor at RUL, near RUL bronchus, no obvious pleura retraction • LN enlargement: Gr 2,3,4,7,10,11 • LN dissection of Gr 5,7

  10. Course and Treatment

  11. Discussion • Pre-operation evaluation of the patients with lung cancer • Lung function test • Back to our patient

  12. Miller: Miller's Anesthesia, 6th ed., ch.49 Preoperative Evaluation • Determination of Pathology • Small cell lung cancers are rarely operable lesions • Early stage (T1-2N0M0) with postoperative C/T • Endocrinologic and neurologic paraneoplastic syndromes • SIADH • Induction of general anesthesia • Eaton-Lambert myasthenic syndrome • Increased risk for prolonged neuromuscular blockade

  13. Miller: Miller's Anesthesia, 6th ed., ch.49 Preoperative Evaluation • Staging • Resection is indicated at NSCLC with stage < T4N3M0 (for stages I to IIIa) • T4: malignant pleural effusion or invasion of generally unresectable structures such as the heart, great vessels, trachea, vertebral body, carina, or esophagus • N3: contralateral mediastinal or hilar, supraclavicular, or interscalene nodes.

  14. Miller: Miller's Anesthesia, 6th ed., ch.49 Preoperative Evaluation • Determining Fitness for Surgery • Pulmonary history • Bronchopulmonary • Extrapulmonary intrathoracic • Extrathoracic metastatic: brain, skeleton, liver, adrenal • Extrathoracic nonmetastatic • SCLC: Cushing’s syndrome, SIADH • SCC: parathormone -> hypercalcemia • Bronchial carcinoids: carcinoid syndromes • Nonspecific symptoms

  15. Miller: Miller's Anesthesia, 6th ed., ch.49 Preoperative Evaluation • Several radiographic findings have specific anesthetic implications • Tracheal deviation or obstruction • Mediastinal mass • Pleural effusions • Cardiac enlargement • Bullous cyst • Air-fluid levels • Parenchymal reticulation, consolidation, atelectasis, or edema

  16. Miller: Miller's Anesthesia, 6th ed., ch.49 Preoperative Evaluation • Preoperative bronchoscopic examination • Critical for staging, planning and deciding on the method of lung separation • Deferring fiberoptic bronchoscopic examination • Lung function test • Operability? • Safely remove without rendering the patient a pulmonary cripple

  17. Miller: Miller's Anesthesia, 6th ed., ch.49 Preoperative Evaluation • Evaluation of the Cardiovascular System • Pulmonary vascular and RV function • The cardiovascular response in COPD • Pulmonary hypertension, increased PVR • RV hypertrophy and dilation • Unable to accommodate even small increases in pulmonary blood flow without concomitant increases in PVR • Contributing to post-pneumonectomy pulmonary edema

  18. Miller: Miller's Anesthesia, 6th ed., ch.49 Measurements of PVR • Determining mean PA and PAWP • At various levels of CO produced by varying treadmill exercises. • Good indicators of the risk associated with pneumonectomy. • Operative risk increases if PVR > 190 dyne/sec/cm • Temporary unilateral PA balloon occlusion at rest and exercise • Specifically test the compliance of the pulmonary vascular bed after pneumonectomy. • Most realistic preoperative approximation in an ambulatory postpneumonectomy patient

  19. Measurements of PVR • Temporary unilateral PA balloon occlusion at rest and exercise • Specifically test the compliance of the pulmonary vascular bed after pneumonectomy. • Most realistic preoperative approximation in an ambulatory postpneumonectomy patient TPVRI=meanPAP(mmHg)/CI(l*min-1m2)

  20. Miller: Miller's Anesthesia, 6th ed., ch.49 Preoperative Evaluation • Testing of left ventricular function • CAD, MI • Perioperative cardiac morbidity • Only 2 preoperative predictors: recent (<6 months) MI and current CHF. • Intraoperative predictors: emergency, prolonged (>3 hours) operations, and thoracic or upper abdominal surgery • Whereas the choice of anesthetic is not. • Intraoperative hypotension and tachycardia.

  21. Miller: Miller's Anesthesia, 6th ed., ch.49 Preoperative Evaluation • If a history of angina is present or the ECG is suggestive • Exercise ECG • Thallium exercise scan • Coronary angiography • If strongly suspected, even though exercise testing is negative or equivocal, coronary angiography is indicated • CABG before or at the time of pulmonary resection • In large resections of compromised patients, pulmonary resection should be delayed (usually 4 to 6 weeks) To be continued…

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