83yo male with a very large renal cancer for hand-assisted laparoscopic nephrectomy. Urologists had arranged a CPET to help the decision-making process.
- Subcortical stroke 2017
- RCC – large mass, visible externally and with a contralateral adrenal mass (likely metastasis).
- 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.
- 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.
- Family discussion ongoing but likely patient will decline surgery