83yo male with a very large renal cancer for hand-assisted laparoscopic nephrectomy. Urologists had arranged a CPET to help the decision-making process.

Background:

• HTN
• Subcortical stroke 2017
• RCC – large mass, visible externally and with a contralateral adrenal mass (likely metastasis).

Issues

• CPET result
  • AT 8ml/kg/min and peak VO2 11ml/kg/min = elevated perioperative risk
  • Not always used in this context as with cancer requiring urgent surgical curative treatment it may not offer additional risk stratification. Minimal opportunity for cardiorespiratory optimisation.

• Cognitive function
  • Surgeon noted that Patient coped well with wife present, but cognitive deficits were obvious when she was absent.
  • CPET MDT discussion prompted shared-decision making appointment at clinic
  • MMSE in clinic 12-13/30.

Discussion

• Cognitive screening in clinic
  • Very concerning when a patient scores 12-13/30 on MMSE, but what about 19-20/30 (a common score). Trajectory of their cognitive decline is important, speak with GP and look for geriatrician reviews or other MMSE sources.
  • This patient’s MMSE was performed in front of his family which was useful in demonstrating to them clearly how frail he is.
  • Accelerating his cognitive decline postop was seen as the biggest risk for him with this surgery.

• Goals of care/prognosis
  • What is the role of the contralateral met in his decision making?
  • Surgery thought to be at best curative, at worst palliative (bleeding and pain from renal capsular and peritoneal stretch (regardless of malignant v. benign status).
  • PET scans not always helpful in diagnosing malignant vs. benign renal lesions, due to physiologic uptake of FDG in the kidneys. Can be useful for diagnosing metastases.
  • Adrenal lesions, benign and malignant, also have variable PET avidity due to background high metabolic activity.

Plan

• Family discussion ongoing but likely patient will decline surgery