Major orthopaedic surgery with metastatic melanoma

garychleung

PIG Meeting: 13th May 2021

74yo male for THR with multiple comorbidites including metastatic melanoma

Background

  • Melanoma – metastatic
  • Acromegaly – transphenoidal resection, low level biochemical persistence, no further tx planned
  • Cardiac disease – due to acromegaly, HCM and mild PHTN
  • OSA – improved post adenoma resection, daytime somnolence and apnoeas resolved.
  • Obesity BMI 50
  • DASI 4.6 METS, limited by hip pain/function and fatigue
  • Previous difficult spinal (failed attempts), difficult BMV but grade I ETT.

Issues

  • Cardiac disease
    • TTE arranged, very reassuring with nil significant abnormalities.
    • ECG consistent with changes due to HTN/BMI/acromegaly
    • Reviewed at cardiology-anaesthetics meeting. Ok to proceed with nil further imaging/review
  • Melanoma/life expectancy
    • Oncologist says pt a candidate for last-line immunomodulatory melanoma tx but will commence this after THR.
    • If tx successful, patient may have years to live, if not then possibly only months.

Discussion

  • Should surgery proceed?
    • Severe hip dx, affecting QoL ++
    • Life expectancy may be dramatically improved by new therapy.
    • Nil specific medical contraindications to surgery.
    • Nil imminently life-threatening conditions, so if this man presented with a hip fracture, surgery would proceed. Given the severe pain/disability at present, perhaps could consider in the same way, as “palliative surgery”.
    • Patient has had a previous THR (other side) in 2017, so is understanding of the rehab requirements and time spent away from family.
    • Group consensus was to proceed with surgery