Preoperative Management Guidelines for Patients Undergoing Cancer Treatment
This comprehensive guide outlines various aspects of preoperative care for cancer patients, covering risk assessment, cardiac and respiratory evaluations, treatment options, and considerations for procedures like PCI. It also addresses the importance of evaluating LV function, coronary disease risk factors, and the role of coronary revascularization. Additionally, it discusses the use of bare-metal stents in patients preparing for PCI and highlights the significance of preoperative chemoradiation and nutritional support.
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Presentation Transcript
NCCN ESOPH NCCN ESOPH- -1 1
NCCN ESOPH NCCN ESOPH- -2 2
Risk assessment Age Functional status Cardiac function Respiratory function Nutritional status Socioeconomic status Other treatment options CCRT / RT / Palliation
Grade 0 1 2 3 4 5 Grade ECOG 50% 50% ECOG
Surgeon Cardiologist 12-lead EKG Echocardiography Optimization of medication (HT, HF, arrhythmia) Tx of coronary obstruction (PCI, CABG) Pulmonologist PFT, ABGA Mucolytics, bronchodilators, respiratory therapy
Patients with DOE should undergo evaluation of LV function Patients with 1 risk factor of coronary disease, known CHD, peripheral arterial disease or cerebrovascular disease 12-lead ECG Patients with 3 or more risk factors and poor functional capacity Noninvasive stress test
Stable angina with left main disease, 3-vessel disease, 2-vessel disease with significant proximal LAD stenosis High risk unstable angina Acute ST-elevation angina Coronary revascularization before surgery is recommended
In patients who are undergoing preparation for PCI and who are likely to require invasive or surgical procedures within the next 12 months, consideration should be given to implantation of a baremetal stent or performance of balloon angioplasty with provisional stent implantation instead of the routine use of a DES.
Preopreative chemoradiation Cytotoxic agents (cisplatin, 5-FU) Nausea, vomitting, diarrhea, mucositis, and anorexia Radiation Mouth and thoroat soreness, difficulty swallowing, fatigue, and anorexia Nutritional support Weight gain after completion of chemoradiation Nutrition monitoring and evaluation Nutrition intervention Content, frequency, amount, IV or tube feeding Nutrition education (esp. for the patients with dysphagia)
Oral feeding in case of no dysphagia Nutrition modification in mild dysphagia Severe dysphagia L-tube feeding J-stomy feeding Esophageal stent PEG (usually not recommended for surgical candidates)
Incidentally detected Dysphagia Odynophagia Anorexia Weight loss Hoarseness Chest pain Vomiting, Reflux Supraclavicular or cervical lymphadenopathy
H&P Upper GI endoscopy and biopsy CBC and chemistry Bronchoscopy (above carina) Chest/abdominal CT (contrast) EUS (FNA if indicated) PET-CT
Location Degree of obstruction Longitudinal / Circumferential extent Biopsy
Anatomi c Name Cervical Thoracic Anatomi c Name Location Location Anatomic Anatomic boundaries boundaries Location Location Upper Upper Middle Hypopharynx to sternal notch Sternal notch to azygos vein Lower border of azygos vein to inferior pulmonary vein Lower border of inferior pulmonary vein to esophagogastric junction Esophagogastric junction to 5cm below esophagogastric junction Esophagogastric junction to 5cm below esophagogastric junction 15 to <20cm 20 to <25cm 25 to <30cm Lower 30 to <40cm Abdomi nal Lower 40 to <45cm EG junction /cardia 40 to <45cm
EUS is the best method for the depth of tumor However, 30% of patients has severe stenosis At least a T3 Chest CT Mediastinal or adjacent organ invasion PET-CT Poor sensitivity for small volume tumor Sensitivity for Dx of cancer T1 43%, T2 90%, T3 98%, T4 100%
EUS is the best method for the depth of tumor T staging Accuracy N staging 80% accuracy Better in celiac than mediastinal EUS-FNA 98% sensitive 100% specific 84~89%
Acurracy T1 T2 T3 T4 84% 73% 89% 89% 16% overstaged 17% overstaged 6% overstaged 11% understaged 73% 10% understaged 5% understaged
Malignant Large, round, hypoechoic, nonhomogenous, sharply bordered Benign Samll, oval, hyperechoic, homogenous, indistinct bordered Sensitivity Specificity Accuracy For T3 and T4 cancers, an EUS assessment of N0 does not ensure absence of N1 disease 89% 75% 84%
Evaluation of airway invasion In cervical / upper / mid thoracic esophageal cancer Tracheobronchial invasion Cervical Upper thoracic Trachea: bronchus Findings Bulging, loss of striations, fixation of post wall, tumor invasion, fistula 26/153 82/487 6:4 (16.9%) (16.9%),
T stage Tis, T1, T2 not distinguishable T3 obliteration of paraesophageal fat T4 invading adjacent organs Aorta invasion contact of 90 degree, obliteration of fat plane Tracheobronchial invasion inward bowing of trachea, obliteration of fat plane Pericardial invasion obliteration of fat plane, pericardial thickening, pericardial effusion, inward deformity of heart Diaphragmatic invasion obliteration of fat plane, crural invasion in adenocarcinoma
Size Supraclavicular 5 mm Retrocrural 5 mm Gastrohepatic ligament 8 mm Periesophageal 10 mm Sensitivity Mediastinal Abdomen 34~61% 50~76%
PET-CT Sensitivity Specificity Unexpected distant metastsis by PET 3~37% Chest CT Sensitivity Specificity Reduce unnecessary surgery by PET-CT 21% 69% 93% 46% 74%
Common metastatic sites of esophageal cancer Liver Lung bone kidneys brain 35% 20% 9% 2% 2%
Stage 0 I II III IV Stage (Carcinoma in situ) / / /
Number Number Name Name Location Location 1, 2R, 4R, 2L, 4L, 3p, 5, 6, 7, 9, 10R, 10L 8M Same with lung cancer mapping Middle esophageal Tracheal bifurcation ~ caudal margin of IPV Caudal margin of IPV ~ GEJ 8L Lower esophageal 15 Diraphragmatic Dome of diaphragm, adjacent or behind crura Immediately adjacent to GEJ 16 Paracardial 17 Left gastric Along the course of left gastric artery 18 Common hepatic Along the course of the common hepatic artery Along the course of the splenic artery 19 Splenic 20 Celiac At the base of the celiac artery
Group 0 IA IB T Tis (HGD) T1 T2 T1 T2 T3 T1-2 T1-2 T3 T4a T3 T4a T4b Any Any N N0 N0 N0 N0 N0 N0 N1 N2 N1 N0 N2 N1-2 Any N3 Any M M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M1 Grade 1,X 1,2 1,2 3 3 Any Any Any Any Any Any Any Any Any Any IIA IIB IIIA IIIB IIIC IV
Group T 0 IA IB N N0 N0 N0 N0 N0 N0 N0 N1 N2 N1 N0 N2 N1-2 Any N3 Any M M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M1 Grade 1 1,X 2-3 1,X 1,X 2-3 2-3 Any Any Any Any Any Any Any Any Any Location Any Any Any Lower, X Upper, Middle Lower, X Upper, Middle Tis (HGD) T1 T1 T2-3 T2-3 T2-3 T2-3 T1-2 T1-2 T3 T4a T3 T4a T4b Any Any IIA IIB IIIA IIIB IIIC IV
Type I II Type Location of 1-5cm above GEJ 1cm above and 2cm below GEJ 2-5cm below GEJ Location of center center GEJ invasion Yes or no Yes GEJ invasion Incidnence 25% 50% Incidnence III Yes 25%
