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Perioperative Management of the Patient With Cancer^*

^* From the Division of Surgical Oncology, Department of Surgery, Cedars-Sinai Medical Center, the Department of Surgery, University of California at Los Angeles School of Medicine, Los Angeles, CA.

Correspondence to: Alan T. Lefor, MPH, MD, Cedars-Sinai Medical Center, Department of Surgery, 8700 Beverly Blvd, Suite 8215, Los Angeles, CA 90048; e-mail: alan.lefor{at}cshs.org

	Abstract

TOP Abstract Introduction Anatomic Effects of Tumors Physiologic Effects of Tumors Anatomic Effects of Cancer... Physiologic Effects of Cancer... Conclusions References

 
There are a number of conditions that present commonly in patients with cancer that may have a significant effect on the preoperative, intraoperative, and postoperative treatment of these patients. These effects can be broadly categorized into anatomic and physiologic effects and may be examined as direct effects of the tumor or as effects of therapy administered for the tumors. Tumors that cause anatomic effects of importance to perioperative management include head and neck tumors with airway obstruction, mediastinal masses with respiratory compromise, pericardial effusion and cardiac tamponade, and superior vena cava syndrome. Some tumors that cause physiologic effects include pheochromocytomas and carcinoid tumors. Anatomic effects of tumor therapy are important after radiation therapy to the head and neck and after radiation therapy to the abdomen. Tumor therapy has important physiologic effects in such areas as the cardiopulmonary complications of chemotherapy, hematologic effects of chemotherapy, steroid administration, and wound healing. While the list of topics is not exhaustive, this is a useful framework for discussing the effects of tumors and their therapy on the cancer patient, especially in regard to perioperative management. Most importantly, these examples demonstrate the importance of close cooperation among surgeon, anesthesiologist, and referring physician to assure the conduct of surgical procedures on the patient with cancer with maximal safety.

	Introduction

TOP Abstract Introduction Anatomic Effects of Tumors Physiologic Effects of Tumors Anatomic Effects of Cancer... Physiologic Effects of Cancer... Conclusions References

 
The patient with cancer can represent some formidable challenges in perioperative management due to local effects of a tumor, the myriad systemic effects of a tumor, or the subsequent effects of tumor therapy. Tumors can have anatomic effects on the patient (eg, a large head and neck tumor with tracheal compression), physiologic effects on the patient (eg, a pheochromocytoma), or both (eg, metastatic carcinoid to the liver with portal vein obstruction from direct compression), which ultimately affects the treatment of the patient in the perioperative period. The anatomic (eg, radiation fibrosis) and physiologic (eg, cardiac toxicity of doxorubicin or pulmonary toxicity of bleomycin) effects of cancer therapy add another level of complexity to the treatment of the patient with cancer. Furthermore, since cancer is a disease mostly seen in the elderly, many of these patients have the added complications associated with advanced age. Knowledge of these details is important for the surgeon operating on the patient, the anesthesiologist caring for the patient in the operating room, and the internal medicine specialist involved in the perioperative treatment of these patients. This article will highlight some of the anatomic and physiologic changes associated with cancer and cancer therapy that make treatment of these patients a particular challenge.

	Anatomic Effects of Tumors

TOP Abstract Introduction Anatomic Effects of Tumors Physiologic Effects of Tumors Anatomic Effects of Cancer... Physiologic Effects of Cancer... Conclusions References

 
Airway Considerations in the Patient With Advanced Head and Neck Tumors
Airway management in patients with head and neck tumors can be challenging because of the potential for airway distortion. Since maintenance of an airway is a major concern in the perioperative period, the anatomic effects of a large tumor must be assessed preoperatively to minimize adverse effects. Large tumors with extrinsic compression of the trachea often require awake intubation using fiberoptic guidance. Preoperative review of the CT scan of the neck is important because some large tumors may be relatively asymptomatic prior to attempts at intubation, but may make intubation extremely difficult. Another important management tool is the use of tracheostomy in patients with large tumors. Patients in whom a difficult fiberoptic intubation is anticipated should undergo tracheostomy prior to the planned procedure.

Postoperative airway difficulties can occur due to laryngeal edema and swelling of other cervical structures. IV administration of dexamethasone can be used to limit the postoperative edema. It may be helpful to leave the patient intubated longer than one might otherwise think prudent in these patients, to allow resolution of the edema. Elevation of the head of the bed may also be a useful adjunct.

Mediastinal Masses
Anterior and middle mediastinal masses are particularly important to assess preoperatively because of their association with increased risk of intraoperative complications. Anatomically, they are associated with the tracheobronchial tree, the heart, and the great vessels. Most anterior and middle mediastinal masses are lymphomas or metastatic tumors.¹ The induction of general anesthesia can result in complete airway obstruction or cardiopulmonary arrest in these patients. With the patient under general anesthesia, compression of the tracheobronchial tree distal to the endotracheal tube can result from muscle relaxation and positive pressure ventilation. This problem can be avoided by maintenance of spontaneous ventilation that maintains negative intrathoracic pressure.²

A careful history is important to identify episodes of dyspnea, stridor, wheezing, or orthopnea. A history of these problems and/or findings from a physical examination consistent with possible mediastinal compression should warn the surgeon to avoid general anesthesia, and obtain necessary biopsy specimens using local anesthesia.³ Preoperative workup of the asymptomatic patient with an anterior or middle mediastinal mass should include CT scan of the chest, inspiratory and expiratory flow volume loops with pulmonary function tests, and echocardiography to rule out tracheobronchial, pulmonary artery, or cardiac compression.⁴

Patients who require general anesthesia despite tracheobronchial tree compression should undergo the following: (1) awake fiberoptic intubation; (2) spontaneous ventilation throughout the procedure; (3) ability to quickly reposition the patient to a lateral, prone, or sitting position in the event of cardiovascular collapse or airway obstruction; (4) available rigid bronchoscopy to open a collapsed airway; and (5) standby femoral-femoral cardiopulmonary bypass in the operating room in the event of cardiovascular collapse.⁴

Pericardial Effusion and Cardiac Tamponade
The most common cause of pericardial effusions in the patient with cancer is a metastasis to the pericardium. Rarely, tumors such as mesotheliomas and sarcomas can lead to tamponade from encasement of the pericardium. Rapid accumulation of as little as 100 mL of fluid in the pericardium can lead to tamponade, while when the fluid is gradually accumulated, some patients tolerate huge volumes with little adverse physiologic effect due to stretching of the pericardium over time. Symptoms of tamponade include progressive dyspnea, retrosternal chest pain relieved with sitting forward, and abdominal discomfort from hepatic engorgement. Physical findings include jugular venous distention, diminished heart sounds, narrowed pulse pressure, and hepatic engorgement. While pulsus paradoxus may also be appreciated as part of a careful physical examination, its presence is not pathognomonic of the condition, nor does its absence rule out pericardial tamponade. An ECG may show decreased voltage. The simplest and most direct diagnostic technique is echocardiography, which can detect as little as 15 mL of pericardial fluid.⁵ Echocardiography can also identify the effect of the effusion on diastolic filling and serve as a guide to determining the need and location for pericardial drainage.⁶

The decision to intervene therapeutically for a pericardial effusion depends on the degree of hemodynamic compromise as well as the etiology of the effusion and its likelihood of recurrence. The most common acute intervention is to perform a subxyphoid pericardiocentesis under local anesthesia. Although this may result in symptomatic and physiologic relief acutely, some patients require a definitive procedure. Most commonly this is a subxyphoid pericardiectomy. Pericardioperitoneal shunt may be helpful in some cases. Prior to induction of general anesthesia, an arterial line and pulmonary artery catheter should be placed. Venous return is aided by placing the patient in a semi-Fowler’s position.

Superior Vena Cava Syndrome
Superior vena cava syndrome can result from deep venous thrombosis of the great veins or from extrinsic compression of the veins by a tumor mass, such as mediastinal lymphadenopathy. It often presents as massive upper body swelling, particularly noticeable in the head and neck. Diagnosis can be confirmed by noninvasive venous studies. Therapy is dependent on the etiology. Anticoagulation is used in patients with venous thrombosis. Thrombolytic agents may be used when appropriate. Patients with extrinsic compression of the vena cava by a tumor mass are usually treated with emergent radiation therapy.

	Physiologic Effects of Tumors

TOP Abstract Introduction Anatomic Effects of Tumors Physiologic Effects of Tumors Anatomic Effects of Cancer... Physiologic Effects of Cancer... Conclusions References

 
Pheochromocytoma
While pheochromocytomas remain rare, their physiologic effects can be profound, making the preoperative evaluation and preparation of patients with them a critically important component of management. When undiagnosed, these lesions have been responsible for deaths at the time of anesthesia induction.⁷ When properly treated, large series of such patients have reported rare or no mortality.⁸

Common signs and symptoms include headache, diaphoresis, hypertension, and tachycardia. The presence of these symptoms is quite variable, although most patients have one or more of these symptoms. The screening of asymptomatic patients may identify patients with pheochromocytomas who are related to patients already identified with the disease. Definitive diagnosis is made by the measurement of urinary catecholamines.

The critical treatment of the patient is preoperative pharmacologic manipulation with -blockade first, followed by possible β-blockade. This is best accomplished by coordinated treatment of the patient by the surgeon, the anesthesiologist, and the referring physician. -Blockade is suggested at least 10 days preoperatively using phenoxybenzamine orally.⁹ β-Blockade is used only after adequate -blockade. β-blockade is indicated in patients with tachycardia or tachyarrhythmias, and is not necessary in all patients. Intraoperative management requires invasive monitoring, including an arterial line and a central venous catheter. -Blockade is continued, including administration on the morning of surgery. The critical portion of the procedure occurs during tumor manipulation, when up to 10-fold increases in catecholamine levels have been measured.¹⁰ Hypertensive crises at this time may be managed with nitroprusside administration. Intraoperative tachycardia may be managed with esmolol, a rapid-acting β-blocker. At the time of ligation of the adrenal veins, serum catecholamine levels may drop drastically, resulting in hypotension due to hypovolemia from vasodilatation. This is usually managed with fluid administration, but may require the administration of vasopressors.

Carcinoid Tumors
The most common location for carcinoid tumors is the appendix, and since the liver receives the venous outflow from the appendix, patients with appendiceal carcinoid tumors do not present with the carcinoid syndrome. However, when these tumors have access to the systemic circulation, such as patients with bronchial carcinoid tumors or with hepatic metastases, patients may have the carcinoid syndrome. Most patients with carcinoid syndrome already have a tissue diagnosis of carcinoid tumor. Surgery may be used for the palliation of patients with bulky hepatic metastatic disease to provide symptomatic relief. These patients require adequate perioperative management to avoid complications.

Recognition of the carcinoid syndrome may be complicated by the fact that many patients do not present with the classically described syndrome. These tumors may release a myriad of vasoactive substances, with variable clinical presentation. The classic substance is 5-hydroxytryptamine (serotonin) that results in diarrhea with abdominal cramping, respiratory distress, bronchospasm, and hypertension. The mainstay of preoperative preparation is adequate hydration. Right-sided heart failure may result from long-standing carcinoid syndrome and must be evaluated, usually by echocardiography. The remainder of the preoperative regimen includes pharmacologic blockade of released substances. Antihistamines are used to block the effects of histamine, and ketanserin may be used to block serotonin.¹¹ Drugs that result in histamine release are avoided by the anesthesiologist. In some institutions, the somatostatin analog, octreotide, is used to prevent release of hormonal substances.¹²

	Anatomic Effects of Cancer Therapy

TOP Abstract Introduction Anatomic Effects of Tumors Physiologic Effects of Tumors Anatomic Effects of Cancer... Physiologic Effects of Cancer... Conclusions References

 
Effects of Radiation Therapy to the Head and Neck
Prior radiation therapy can result in distortion of airway anatomy. Radiation therapy can also result in edema and swelling of the tissues. This usually resolves soon after the end of radiation therapy. Fibrosis of tissues is also an anatomic effect of radiation therapy that can affect the perioperative treatment of the patient with cancer. Careful preoperative physical examination, particularly of the tissues between the submental region and the hyoid bone, can provide clues about a potentially difficult airway. Prior radiation therapy can also obliterate lymphatics, resulting in increased postoperative edema.

Effects of Radiation Therapy in the Abdomen
Radiation therapy is used in the treatment of a large proportion of cancer patients. The GI effects of radiation can be particularly problematic as the bowel is very susceptible to radiation damage. Acute toxicity is manifest in the mucosal layer, the site of the greatest mitotic activity. Long-term effects of radiation are postulated to be secondary to radiation-induced vascular injury and the resultant progressive ischemia.¹³ The delivery of radiation therapy to a tumor is tempered by the dose-limiting toxicity of the surrounding tissues. The major factors involved are daily dose fraction administered, total dose delivered, and the volume of normal tissue within the radiation field. Most symptoms of acute radiation enteritis are self-limited and resolve spontaneously after the completion of therapy. Long-term effects are seen months after completion of therapy, and may result in strictures, obstruction, perforation, bleeding, and fistula formation. Surgery is required in 2 to 17% of patients receiving radiation therapy to the abdomen, most commonly those with gynecologic, genitourinary, or rectal cancers.¹³ Most patients with symptomatic bowel obstruction following radiation therapy will require surgery to relieve the obstruction. Small intestinal obstructions are among the most common lesions requiring surgical intervention. The development of radiation enteritis is greater in patients who have had prior surgery or the formation of adhesions. Furthermore, the concurrent use of chemotherapeutic agents such as 5-fluorouracil as a radiation sensitizer are known to further predispose the patient to radiation-induced bowel injury.

	Physiologic Effects of Cancer Therapy

TOP Abstract Introduction Anatomic Effects of Tumors Physiologic Effects of Tumors Anatomic Effects of Cancer... Physiologic Effects of Cancer... Conclusions References

 
Effects of Chemotherapy Agents
Patients who have received cytotoxic chemotherapy agents are subject to injury at multiple end-organ sites. A thorough preoperative history and physical examination are necessary. A list of the exact agents administered as well as the timing of their administration is essential. The total amount of agents with cumulative toxicity such as bleomycin, daunorubicin, and doxorubicin is important to determine. Laboratory studies must include a CBC, serum electrolytes, liver function tests, and a coagulation profile. A chest radiograph and 12-lead ECG are also needed.⁴

Bleomycin has significant effects on the lungs, and the history should focus on pulmonary symptoms such as dry nonproductive cough, dyspnea, fever, or tachypnea. The presence of bibasilar rales should raise the possibility of pulmonary fibrosis. Pulmonary function tests including arterial blood gas, spirometry, and carbon monoxide diffusing capacity should be evaluated. Findings compatible with interstitial fibrosis include increased alveolar-arterial gradient, restrictive lung disease, and decreased carbon monoxide diffusing capacity.¹⁴ These findings will help both the surgeon and anesthesiologist anticipate pulmonary complications and the need for possible postoperative mechanical ventilation.

Patients who have received doxorubicin or daunorubicin should be carefully evaluated for the possible cardiac toxicity of these drugs. Physical examination should evaluate for the presence of an S₃ gallop, fine rales on lung auscultation, jugular venous distention, hepatomegaly, and peripheral edema. Careful review of the chest radiograph is performed to identify evidence of cardiomegaly, pulmonary edema, or pleural effusions. If the patient has findings on history or physical examination that are compatible with congestive heart failure, then further evaluation is indicated.¹⁵

Daunorubicin and doxorubicin have two major cardiac toxic reactions: acute ECG changes and a chronic cardiomyopathy that is dose dependent.¹⁶ Common ECG changes include nonspecific ST- and T-wave changes, premature atrial and ventricular contractions, sinus tachycardia, and low voltage of the QRS complex. The cardiomyopathy is cumulative dose dependent, and for doxorubicin, the critical lifetime total dose is 550 mg/m², and for daunorubicin, it is 600 mg/m².¹⁶ Radiation therapy, preexisting heart disease, and concurrent chemotherapy with certain agents lower the total cumulative dose at which cardiomyopathy is likely to occur.

Hematologic Effects of Cancer Therapy
Bone marrow function in cancer patients may be disturbed by primary bone marrow disorders (eg, leukemia), bony metastases (eg, from breast cancer), as well as myelosuppressive chemotherapy. The production of any or all blood elements may be impaired, although often to different degrees depending on the type of malignancy and therapy administered. Similarly, coagulation mechanisms may be dysfunctional as a result of impaired production or abnormally high consumption. Abnormalities in bone marrow function and/or coagulation mechanisms can have a profound effect on the perioperative treatment of the patient with cancer. Close cooperation among the surgeon, anesthesiologist, and hematologist is required for optimal management and maximal safety.¹⁷

The effect of a particular chemotherapeutic agent on bone marrow function depends on its mechanism of action, dose, and schedule of administration. The surgeon must be aware when myelosuppression is likely to be maximal as well as its duration so that elective surgery can be scheduled when bone marrow recovery has occurred. In general, agents that interfere with DNA synthesis and repair (eg, antimetabolites—cytosine arabinoside, methotrexate, topoisiomerase inhibitors, and anthracyclines—doxorubicin, mitoxantrone, and etoposide) and that are given in large pulse doses produce rapidly developing (7 to 14 days) variably severe neutropenia and thrombocytopenia, often resulting in the need for platelet transfusion as well as neutropenic fever requiring empiric antibiotic therapy. These agents are also likely to produce severe mucositis. Myeolosuppression often lasts for 7 to 14 days but can be prolonged in patients who have received prior multiple doses of the same or other chemotherapeutic agents.¹⁷ In many instances, the period of severe neutropenia may be shortened by the administration of recombinant hematopoietic growth factors such as granulocyte colony-stimulating factor, but only if they are given shortly after the completion of chemotherapy.

Patients with thrombocytopenia secondary to bone marrow failure and chemotherapy often require surgical intervention for diagnostic and therapeutic purposes. There are no prospective trials to date that establish the minimal platelet count necessary to prevent bleeding with specific procedures. Some investigators have maintained a minimal level of 50,000 platelets per microliter in the intraoperative and postoperative period.¹⁷ Correction of other coagulation disturbances is important before undertaking surgical intervention in the thrombocytopenic patient. A common coagulation disorder in cancer patients is disseminated intravascular coagulation (DIC). DIC is characterized as a pathologic, often diffuse activation of the coagulation system as a result of widespread endothelial cell or tissue injury. Patients with acute DIC often exhibit hypotension and acidosis related to overwhelming sepsis or trauma. Continuous oozing from surgical wounds, sites of trauma, central venous catheter sites, Foley catheters, and endotracheal tubes reflect hypocoagulability and secondary fibrinolysis. Chronic DIC associated with malignancy is most often manifested clinically by episodes of thrombosis. Bleeding often ensues as a result of surgical intervention when a preexisting coagulopathy has gone unrecognized. Chronic DIC may present as migratory and recurrent superficial and deep vein thrombosis, arterial occlusion, and nonbacterial thrombotic endocarditis involving the aortic and mitral valves. Chronic DIC is most often associated with adenocarcinomas of the stomach, pancreas, colon, breast, lung, and prostate. It is a very common condition in patients with acute promyelocytic leukemia.¹⁷ Laboratory evidence of chronic DIC is often subtle and difficult to interpret. The prothrombin time and activated partial thromboplastin time are often normal or minimally prolonged until prominent hypofibrinogenemia ensues. Patients who do not have clinical evidence of bleeding may be observed. Patients with clinical evidence of thrombosis should undergo immediate anticoagulation with heparin. Platelets and cryoprecipitate are usually given concomitantly.

Steroid Administration
The oncology patient often has a history of exogenous glucocorticoid administration as part of a chemotherapy regimen. The physician at the time of preoperative evaluation has to decide on the use and the amount of stress steroid coverage. The patient who has received 2 weeks of glucocorticoids within the past year is considered at risk for adrenal suppression. However, many of these patients are capable of a normal stress response. The corticotropin (ACTH) stimulation test is the definitive test to identify adrenal suppression. Cosyntropin, 250 mg, is given IV, and plasma cortisol levels are measured at 30 and 60 min after infusion along with a baseline level. A rise of 7 to 20 mg/dL of cortisol is considered normal.¹⁸ The ACTH stimulation test is often impractical to perform the evening before surgery. Thus, all these patients should be assumed to be at risk for perioperative adrenal insufficiency until adrenal response is proved to be normal.

The normal physiologic production of cortisol is 30 mg/d. Kehlet,¹⁹ upon reviewing the literature, estimated that the adrenal cortex excreted between 75 to 150 mg of cortisol in the first 24-h postoperative period, and maximal adrenal cortex production was 200 mg/d of cortisol with constant ACTH stimulation. At present, many physicians administer 300 mg of hydrocortisone as stress steroid coverage over the first 24-h perioperative period and then taper over a 2- to 3-day period. Several authors now believe that 300 mg of hydrocortisone over the first 24-h period is excessive and may have disadvantages such as hyperglycemia, hypertension, and inhibition of wound healing.^1819202122

Chernow et al²⁰ evaluated cortisol response in patients with no prior glucocorticoid use undergoing surgery. Chernow et al²⁰ divided the patients into three groups: (1) minor surgery (inguinal hernia repair or laparoscopy); (2) moderate surgery (cholecystectomy, appendectomy, or hysterectomy); and (3) severe surgery (major abdominal or vascular). Chernow et al²⁰ found negligible cortisol increases with minor surgery but significant increases at 1 h and 24 h after moderate or severe surgery that returned to normal at 5 days. Thus, for minor surgery, only physiologic doses of glucocorticoids are needed for adequate stress coverage. Kehlet¹⁹ recommended for minor surgery giving 25 mg of hydrocortisone with induction of anesthesia and then resuming normal oral glucocorticoid dose when fluid intake begins. If the patient is unable to take fluids by mouth, then Kehlet¹⁹ recommended 100 mg of hydrocortisone over the first perioperative 24-h period.

Based on available data, the previous standard of giving 300 mg of hydrocortisone over the first 24-h perioperative period is excessive. A dosage of 200 mg of hydrocortisone given over two to three divided doses during the first 24-h perioperative period as recommended by Lampe and Roizen¹⁸ may be used for major surgery until a larger prospective randomized study has been done. Smaller doses such as those recommended by Symreng et al²² and Kehlet¹⁹ should be more than adequate for lesser procedures (eg, cholecystectomy or hysterectomy). For minor procedures (eg, inguinal hernia repair), doses above 30 to 50 mg during the first 24-h perioperative period are most likely not needed unless the patient is already receiving higher doses of glucocorticoids.¹⁹²⁰

Salem et al²³ have emphasized that perioperative glucocorticoid administration should be based on the magnitude of the stress and the known endogenous glucocorticoid production rate associated with it. For minor surgical stress (eg, inguinal herniorrhaphy), they recommend 25 mg of hydrocortisone equivalent. Patients with an uncomplicated postoperative course may return to their usual dose of glucocorticoids on postoperative day 1. For moderate surgical stress (eg, open cholecystectomy, lower extremity revascularization, colon resection), they recommend 50 to 75 mg/d of hydrocortisone equivalent. A patient receiving 10 mg of prednisone should receive 10 mg of prednisone preoperatively and 50 mg of hydrocortisone IV intraoperatively. It is recommended that this patient receive hydrocortisone, 60 mg (in three divided IV doses), on postoperative day 1 and return to his or her preoperative dose on day 2. For major surgical stress (esophagectomy, pancreaticoduodenectomy, cardiac surgery), the target dose is 100 to 150 mg of hydrocortisone per day for 2 to 3 days. The provision of perioperative glucocorticoid coverage must account for the patient’s preoperative glucocorticoid dose as well as the duration and severity of surgery or other stress.

One must carefully monitor the patient’s condition and have a low threshold for giving further hydrocortisone if any evidence of adrenal insufficiency such as hypotension occurs. The risks associated with higher doses of corticosteroids aggravating such conditions as diabetes mellitus or hypertension must also be considered when administering perioperative glucocorticoids.

Chemotherapy and Wound Healing
The outcome of surgical procedures may be affected by the wound-healing impairment caused by antineoplastic agents used to treat the underlying tumor. Normal wound healing usually involves three phases: inflammatory phase, the proliferation phase, and the maturation phase. The neutropenia that accompanies some chemotherapy within 7 to 10 days of administration can interfere with the early phases of wound healing. Most patients with WBC count > 500/mm³ have no adverse effects of leukopenia on surgical wound healing. Chronic anemia also has little effect on surgical wound healing.²⁴

The effects of chemotherapy directly on wound healing depend on dose and the timing of drug administration relative to creation of the wound. There are no typical patterns and each class of agent is usually considered separately. Administration of doxorubicin 4 weeks postoperatively has been shown to be safe, while preoperative administration has decreased wound bursting strength in animal studies.²⁵ A high incidence of wound complications has been reported in women undergoing mastectomy after receiving preoperative chemotherapy and radiation. Bleomycin has not been associated with increased wound complications.²⁶ Clinical trials with cisplatinum have not shown increased wound morbidity.²⁷ Controlled clinical trials with fluorouracil have shown increased wound complications when administered 7 to 10 days postoperatively, but not when treatment with it was withheld until after the 14th postoperative day.²⁸ Corticosteroids are commonly used in chemotherapy regimens, and are well known to increase wound complications. In summary, adverse effects of chemotherapeutic agents on wound healing have been difficult to demonstrate clinically, except for corticosteroids in which the effects are well documented.

	Conclusions

TOP Abstract Introduction Anatomic Effects of Tumors Physiologic Effects of Tumors Anatomic Effects of Cancer... Physiologic Effects of Cancer... Conclusions References

 
The framework presented herein examines the effect of tumors and their therapy on the anatomic and physiologic function of the patient with cancer. The preoperative treatment of the cancer patient can be a challenge for both anesthesiologist and surgeon. Clearly, there are considerations in many of these patients that are not usually necessary and call for exceptionally close cooperation in preoperative and intraoperative management. In all of the considerations discussed in this article, an essential element is a complete history of prior cancer therapy (chemotherapy, radiation therapy, and prior surgery) to allow assessment of its impact on patient treatment. Most importantly, a full knowledge of these therapies will allow complete evaluation before the next surgical intervention is undertaken. The above discussion was intended to provide practical guidelines for the preoperative management of a number of problems that are found uniquely, or most commonly, in the cancer patient.

	References

TOP Abstract Introduction Anatomic Effects of Tumors Physiologic Effects of Tumors Anatomic Effects of Cancer... Physiologic Effects of Cancer... Conclusions References

 

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