Elderly, severe comorbidities, ? nephrectomy

Gabrielle Morris

84-year-old lady with localised small central renal tumour

Background

  • HTN
  • COPD
  • CKD

Issues

  • Congestive cardiac failure
    • Recent hospital admissions with dyspnoea and significant decompemsation
    • NYHA class 4. Housebound, walks 20m on flat
    • Echo 2020: Mild pulmonary hypertension and mod-severe AR
  • Recent echo – significant deterioration. Severe pulmonary hypertension; PASP = 66mmHg, dilated RV, Moderate MR, Moderate-Severe AR, Mod TR
  • Respiratory component?
    • No formally diagnosed lung disease
    • Respiratory physician and spirometry organised and pending

Discussion

  • Renal cell carcinoma
    • Very small cancer: 3cm, central so not appropriate for ablation currently.
    • Issues are local growth and bleeding.
    • Tumour progression and Metastatic disease usually occur very slowly.
    • There may be less invasive procedures available to address local symptoms/tumour may become amenable to ablation as it increases in size
  • Significant risk of perioperative M&M
    • Patient states quality of life more important than quantity, happy to continue the way she is for the next year or longer
    • High risk of death from current cardiac disease and pulmonary hypertension
    • RCRI 2-3

Plan

  • Surgeon has organised meeting with patient and family to discuss options for non-surgical management
  • To continue with respiratory review – options for symptomatic improvement and optimisation for further, less invasive procedures