Severe asthma and forehead SCC for free flap surgery

garychleung

PIG Meeting: 1st April 2021

74yo male with a positive margin from a previous forehead SCC resection performed under LA. Consultation for suitability for general anaesthesia.

Background

  • Severe asthma secondary to ANCA-negative vasculitis(Chrurg Straus disease)
    • FEV1 1.1L (38%), DLCO 53%
    • Gardens, uses mobility scooter outside the home
    • Maximal medical therapy trialled including monoclonal antibody tx. Now on mycophenylate and prednisone.
  • OSA on CPAP – non-adherent at present due to forehead lesion interfering with mask
  • Obesity with 30kg weight gain over 3yrs in setting of chronic steroids

Discussion

  • Are there non-surgical options for his SCC?
    • Concern about asthma exacerbation due to pneumonitis risk with immune cancer therapy.
    • Does not qualify for trials of novel agents due to lack of nodal or distant mets. Qualification on compassionate grounds thought ++ unlikely.
    • Has already trialled radiation therapy – complicated by wound breakdown. Deemed not suitable for further radiotherapy.
  • Is his SOB fully accounted for?
    • TTE arranged due to orthopnoea but nil major abnormalities found
  • Can he be optimised?
    • Short course high dose steroids unhelpful due to known steroid insensitivity of his asthma.
    • Resp physician feels no further optimisation possible.
  • Should surgery proceed? What are the risks?
    • Respiratory physician believes patient likely to live 2+ years with lung disease
    • There is no documented lower limit of mechanical respiratory function at which general anaesthesia is contra-indicated.
    • Wound breakdown felt to be biggest risk given immunosuppression and chronic steroid use for vasculitis
    • NSQIP suggests 2.2% risk of death and 20% risk of morbidity for free flap surgery
    • Low risk of post operative respiratory complications as per ARISCAT scoring but is the unique risk of severe, life threatening intraoperative bronchospasm accounted for in these scoring systems?

Plan:

  • Further discussion with surgeons about options for surgery – they report that there will need to be consultation with plastic surgery to minimize risk of wound breakdown. Will likely need 6 hour procedure.
  • ICU level 2 booking if surgery does proceed
  • Consideration of nasal CPAP
  • Return to GP for assistance (e.g. dietician review) for weight loss preop