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

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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 Pre-OP Evaluation of A 74 y/o Male with Lung Cancer Lung Cancer

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Patient DataPatient 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

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Present IllnessPresent 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.

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Present IllnessPresent 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.

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Physical ExaminationPhysical 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

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Lab Lab 項目 : WBC RBC HB HCT MCV MCH MCHC PLT日期 K/μL M/μL g/dL % fL pg g/dL K/μL0930 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/l0930 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/dl0930 6.6 5.1 4.12 12 21 146 0.56

項目 : PT PT INR PTT日期 sec0930 12.2 1.08 36.9

項目 : RIA:CEA (Serum)日期 ( 時間 ) ng/ml1001 5.16

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StagingStaging

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)

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Course and treatmentCourse and treatment

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Course and TreatmentCourse 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

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Course and TreatmentCourse and Treatment

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DiscussionDiscussion

Pre-operation evaluation of the patients with lung cancer

Lung function test Back to our patient

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Preoperative EvaluationPreoperative 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

Miller: Miller's Anesthesia, 6th ed., ch.49

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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.


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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



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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



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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


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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



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Measurements of PVRMeasurements 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


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Measurements of PVRMeasurements 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)

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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.



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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…

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

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