85 yo man for excision of large fungating SCC from face

Background

Nursing home resident – lived alone on a farm until recently. Entered nursing home post-cataract surgery as found to be not coping at home

Dementia

Prostate cancer

CABG 1997. No follow-up. Asymptomatic but doesn’t exercise much

DASI 3.9

Issues

• Very frail
• Large resection – PET scan shows invasion into skull bone and numerous surrounding structures. Lymph node involvement, no distant mets 
• Systolic Murmur
• Functional capacity very difficult to ascertain

Discussion:

• Surgical plan – palliative vs curative surgery and radiotherapy. 
• Curative surgery – Resectable but involves all inferotemporal fossa and teeth, will need neck dissection and free flap. May require exenteration of eye especially for curative intent. Long operation 8+ hours
• Palliative – will still require significant surgery and skin graft
• Surgeons feel curative us preferable for this patient. Likely die from maxillary artery bleed if cancer erodes into artery. 
• Has a mediastinal node – awaiting Endobronchial US guided biopsy in 4-6 weeks to determine if metastatic disease. IF metastatic, then not for surgery. 
• Family – further discussion required. Family discussion in clinic highlighted that patient will unlikely return to baseline. Patient and family were hoping that current nursing home admission was temporary.
• Stress imaging – unlikely to change management
• Echocardiogram – no evidence of heart failure but has a murmur. Could consider a BNP to give an indication of the contribution of valvopathy as has been recommended by cardiolgy in the past. 
• Post-operative delirium – very high risk given dementia.
• No baseline cognitive assessment. No regular GP