Anaesthesia considerations and Implications during Oncologic and Non-Oncologic surgery in Cancer patients

Anaesthesia considerations and Implications during
Oncologic and Non-Oncologic surgery in Cancer patients

a p o l l o m e d i c i n e x x x ( 2 0 1 3 ) 1 e6

Available online at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/apme

Theme Symposium

Anaesthesia considerations and implications during
oncologic and non-oncologic surgery in cancer patients
Sukhminder Jit Singh Bajwa a,*, Ashish Kulshrestha b
a

Associate Professor, Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Ram Nagar, Banur,
Punjab, India
b
Assistant Professor, Gian Sagar Medical College and Hospital, Banur, Patiala, Punjab, India

article info

abstract

Article history:

Cancer has been the leading cause of mortality in both developed and developing coun-

Received 24 June 2012

tries. With the advancement in chemotherapeutic agents, the quality and lifespan of pa-

Accepted 13 February 2013

tients with advanced malignancies has improved. These patients often come to hospitals

Available online xxx

for various types of elective and emergency surgeries. The attending anaesthesiologist
faces a daunting task while managing these patients as there can be gross physiological

Keywords:

derangements in most of the organ systems. A careful and thorough preoperative

Malignancy

assessment, optimisation of physiological milieu, vigilant intraoperative monitoring,

Chemotherapeutic agents

anticipation of potential complications and postoperative pain control is essential for

Anaesthesia

reducing perioperative mortality and morbidity in these patients. The toxicity of chemo-

Surgery

therapeutic agents and potential drug interactions with selected anaesthetic drugs are of
prime concern while anaesthetizing such patients. The build-up of nutrition in these
patients is essential during preoperative period and should be continued during postoperative period also.
Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved.

1.

Introduction

Malignancy has become one of the leading causes of death
especially in developed world and even in developing countries; its incidence has increased tremendously over the last
few decades. In 2008, it was found that about 12.7 million patients were diagnosed of some form of malignancies worldwide
out of which about 7.6 million died of the malignancy itself or
its associated complications.1 Malignancy as a group accounts
for about 13% of all deaths per year with the most common sites
being lung/bronchus, colorectal, breast and prostate.2 The

most common types of malignancies found in children are
leukaemia (34%), brain tumours (23%) and lymphoma (12%).3
With the advent of newer and advanced chemotherapeutic
agents, survival and lifespan of these patients has witnessed a
tremendous increase. As a result, large number of these cancer
patients during post cancer treatment presents either for surgical intervention for the primary tumour excision or emergency intervention for their various ill effects. Due to multitude
of effects of malignancy on various systems in the body and
effects of chemotherapeutic agents, these patients pose a great
challenge to the attending anaesthesiologist.4

* Corresponding author. House No-27-A, Ratan Nagar, Tripuri, Patiala, Punjab 147001, India. Tel.: þ91 (0) 9915025828, þ91 1752352182.
E-mail addresses: sukhminder_bajwa2001@yahoo.com, sukhminderbajwa@gmail.com (S.J.S. Bajwa).
0976-0016/$ e see front matter Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.apme.2013.02.004

Please cite this article in press as: Bajwa SJS, Kulshrestha A, Anaesthesia considerations and implications during oncologic and
non-oncologic surgery in cancer patients, Apollo Medicine (2013), http://dx.doi.org/10.1016/j.apme.2013.02.004

2


2.

Effects of tumour on the body

2.1.

Local effects of tumours

Tumours of head, neck and pose significant problems in
maintenance of airway especially after induction of anaesthesia due to their extrinsic compressive effects or may be due
to presence of intrinsic tumour.5 Preoperatively, radiographic
examination of soft tissues of neck and computed tomography of neck is mandatory in these patients for careful preoperative planning for securing an unobstructed airway.
Planned awake fibreoptic guided intubation may be required
in tumours with extrinsic compression on airway and a preoperative tracheostomy may be required in patients with an
anticipated difficult fibreoptic intubation due to presence of
large vascular tumour inside the airways. Postoperatively
these patients can be at risk of airway compromise due to
oedema of larynx and neck structures which may warrant
continuing the mechanical ventilation in these patients till
the airway oedema subsides.
Superior vena cava syndrome may develop in primary lung
malignancy due to obstruction of venous return from the head
and neck by the tumours. It may be an acute or subacute
process and results in facial oedema, plethora, dilatation of
veins of chest wall and neck, headache, conjunctival oedema,
respiratory difficulty, visual disturbances and altered level of
consciousness. Diagnosis is usually clinical or by non-invasive
venous studies. Therapy includes administration of thrombolytic agents and/or emergent radiotherapy in patients with
airway compromise.6
Pericardial effusion and cardiac tamponade are rare due
to the primary tumours of pericardium but are usually due to
metastasis to the pericardium. Acute accumulation of as
little as 100 ml of fluid in pericardial cavity can lead to
tamponade and cardiovascular collapse while chronic accumulation of large volumes of fluid can be accommodated
inside the pericardial cavity due to the stretching of the
pericardium. Echocardiography is the investigation of choice
and can detect as little as 15 ml of pericardial fluid.7 Treatment depends on the degree of haemodynamic compromise
and can involve pericardiocentesis or pericardiectomy
depending on the aetiology of diffusion and its likely
recurrence.

2.2.

Systemic effects of tumour

Pain is a common symptom in patients with malignant tumours with an incidence of 25% in newly diagnosed malignancies and upto 75% in advanced disease.8 It may be due to
involvement of somatic nerves by tumour itself or by the
systemic metastasis. These patients can present for various
procedures for relief of chronic pain like nerve blocks, ganglion blocks etc.
Majority of patients with advanced malignancy present
with cachexia which is characterised by significant weight
loss, anorexia, weakness, poor performance and impaired
immune function.9 These cachectic patients pose significant challenges to the attending anaesthesiologist due to
their disturbed homoeostasis

Renal failure can develop in cancer patients by both prerenal as well as intrinsic renal mechanisms. However, preexisting renal and renal endocrine disorders can be more
challenging in such patients.10 Pre-renal causes include
dehydration due to cachexia or poor oral intake and
intrinsic renal causes includes sepsis syndrome or use of
nephrotoxic chemotherapeutic agents. Post-renal failure
also is likely in obstruction of renal outflow tract by pelvic
tumours, prostate or cervical malignancies.11
Infection is a common and unfavourable effect of malignancy which is mainly contributed by depressed immunologic function due to neutropenia. It may occur due to
malignancy interfering with bone marrow functions or may
be due to drug induced myelosuppression. These nosocomial infections increase hospital stay and the cost to
patient.12
A characteristic constellation of systemic symptoms termed
as ‘paraneoplastic syndrome’ can occur due to secretion of
various hormones from the primary tumour into the circulation which causes various metabolic abnormalities like
myasthenic syndrome in thymoma, syndrome of inadequate secretion of antidiuretic hormone (SIADH) seen in
small cell carcinoma bronchus and so on.13
Electrolyte abnormalities usually develop in malignancy,
the commonest being hypercalcaemia which develops in
about 10% of all malignancies and is due to bony metastasis
causing bone resorption. Other abnormality seen is hyponatremia which may develop due to SIADH or due to
impaired ability to produce dilute urine.
Tumour lysis syndrome is a constellation of symptoms that
is associated with cytotoxic therapy of malignancy resulting
in various metabolic derangements like hyperuricemia,
hypocalcemia, hyperkalemia, hyperphosphatemia and
uraemia leading to acute renal failure. It is associated with
leukaemia, small cell carcinoma lung, testicular and breast
cancer.14

2.3.

Haematological effects

The haematologic effects of malignancy are due to a primary
malignancy of bone marrow (leukaemia), metastasis or myelosuppression due to chemotherapeutic agents. The major
haematologic effects seen are:
Anaemia is a common finding and suggests chronicity of the
disease with significantly low erythropoietin levels due to
direct suppression of erythropoietin secreting cells by the
malignancy or due to suppressive effects of radiotherapy
and chemotherapy.15
Leukopenia is most often associated with the chemotherapeutic treatment of solid tumours and is directly related to
the incidence of systemic infections.16
Thrombocytopenia occurring in malignancy is usually
due to effects of chemotherapy and radiotherapy on bone
marrow function and may also be due to splenic
sequestration of platelets because of enlarged spleen.
Thrombosis can also occur in about 2e10% of cases of
cancer and may be the first indication of an occult
malignancy.17


3


2.4.

Effects of anticancer treatment

The treatment of cancer involves selective destruction of
malignant cells by both radiation therapy and by chemotherapeutic agents directed against malignant cells. This
anticancer therapy has various negative effects on body which
may cause debilitating effects on normal body homoeostasis.
1. Effects of radiation therapy: Radiations are used in specific
tumours to achieve complete cure and in some tumours to
achieve palliation. The ill effects of radiation therapy
depend upon the intensity of radiation used.16 The various
effects of radiation therapy are18,19:
Direct effect of radiation can cause epidermal desquamation and pigmentation which can lead to contractures
of irradiated area.
Acute radiation enteritis can result due to radiation
induced mucositis and is often self-limiting but long term
effects can result in strictures, obstruction, perforation
and fistula formation, which may require emergency
intervention.
Acute radiation pneumonitis can develop in lungs
resulting in reduced pulmonary compliance and dyspnoea which can lead to pulmonary fibrosis in long term.
The nervous system is usually least affected and radiation induced peripheral neuropathy is seen with mixed
sensory and motor deficits.
Radiation nephropathy can result in proteinuria and hypertension and treatment with angiotensin converting
enzyme inhibitors (ACEI) can reduce its severity.
The radiation induced cardiac injury usually manifest as
mild pericarditis and pericardial effusion after 6 months
of therapy.
The hepatic injury can occur as an acute reaction within
2e6 weeks of initiation of therapy with hepatic enlargement and portal hypertension and abnormal liver function tests whereas a chronic form occurring after 6
months usually results in progressive cirrhosis.
Radiation therapy causes swelling and oedema of soft
tissues of head and neck which can later result in fibrosis
posing difficulties in intubation of these patients.
2. Effects of chemotherapy: With recent advancement in
chemotherapeutic agents, more number of cancer patients
are being treated with these agents. Apart from their
cytotoxic effects on malignant cells, they also have toxic

effects on normal body cells which cause their sideeffects.20,21 The various chemotherapeutic agents with
their side-effects are summarised in Table 122:

3.
Anaesthetic considerations in patients
with cancer
The patients with malignancy can present with myriad of
physiological alterations in body systems which place these
patients at an extra risk during the perioperative period as
compared to the normal population. These patients can present for various surgeries for resection of primary tumour,
diagnostic procedures for unknown primary or emergency
surgery for complication of malignancy. The risks increase to
a greater extent if such patients present with untreated comorbid diseases.23 The anaesthetic management of these
patients require a sound knowledge of the various physiological alterations and should involve:

3.1.

Preoperative assessment

A thorough preoperative assessment is mandatory to know
the physical status of the patient, the stage of malignancy and
the risk involved with the surgery.
The assessment of the nutritional status of the patient is
essential as these patients are often poorly nourished
because of the malignancy. The build-up of nutritional state
is mandatory for a positive postoperative outcome and can
be achieved with hyperalimentation or parenteral nutrition.
Due to the physiological alterations in patients with malignancy, these often have electrolyte abnormalities which
should be corrected preoperatively for better intra and
postoperative haemodynamic stability.
Assessment of cardiopulmonary reserve is very essential as
the cardiovascular system is often involved by the primary
malignancy, metastatic disease or by the radiotherapy or
chemotherapeutic agents. Any involvement of cardiovascular system should prompt to undergo echocardiography
and exercise stress testing and further invasive testing with
angiography should be considered in specific conditions.24
Several endocrine abnormalities exist in these patients
including diabetes mellitus, diabetes insipidus, hypopituitarism, thyroid dysfunction, adrenal cortical and medullary

Table 1 e Showing various chemotherapeutic agents and their associated side-effects.
Class

Drugs

Side-effects

Vinca alkaloids

Busulfan, Chlorambucil, Cyclophosphamide, Melphalan,
Isofosfamide
Methotrexate, Fluorouracil, Gemcitabine,
Mercaptopurine
Vincristine, Vinblastine, Paclitaxel, Etoposide, Docetaxel

Antibiotics

Bleomycin, Doxorubicin, Daunorubicin, Mitoxantrone

Hormones

Tamoxifen, Letrozole, Flutamide, Oestrogen

Myelosuppression, uric acid nephropathy, nausea
vomiting, hemorrhagic cystitis, carcinogenic, SIADH
Myelosuppression, dermatitis, alopecia, pulmonary
fibrosis, nephrotoxicity,
Autonomic peripheral neuropathy, myelosuppression,
dermatitis, cardiotoxicity
Pulmonary fibrosis, cardiotoxicity, myelosuppression,
dermatitis
Myelosuppression, coagulation abnormalities,
hemorrhagic cystitis

Alkylating agents
Antimetabolites


4


dysfunction, calcium disorders etc.25e28 Preoperative review
and management of all these condition is essential for
preventing intra and postoperative complications. Such
patients may require intensive care monitoring during
postop period.
Patients having co-morbid psychiatric and psychologic disorders are difficult to treat. The preoperative evaluation is
extremely challenging in such patients as the elicitation of
proper history and relevant clinical examination is difficult
as these patients exhibit a different degree of co-operation
during such evaluation.29
A deranged haemogram is often encountered in these patients and any correctable causes of such abnormalities
should be identified and appropriately treated for a better
postoperative outcome like stem cell stimulation therapy
and correcting the coagulation defects.30
As a rule, all patients with malignancy should have extensive preoperative testing which should include complete
haemogram, coagulation profile, liver function test, renal
function test, electrolytes, 12 lead electrocardiogram and
chest radiograph.
Airway assessment is of utmost importance to an anaesthesiologist especially in head and neck malignancies to
anticipate any intubation difficulties and to develop a plan
to overcome such difficulties.

3.2.

Intraoperative management

Intraoperative management of these patients is as important
as the preoperative assessment as these patients are prone to
develop serious intraoperative cardiovascular complications
due to their disturbed homoeostasis:
These patients should be monitored with the standard
intraoperative monitors including non-invasive blood
pressure, electrocardiogram, pulse oximeter, end-tidal carbon dioxide monitor, temperature probe and urine output.
Invasive monitoring should be used wherever the clinical
condition of the patient mandates.
Intraoperative temperature monitoring is essential to
maintain the temperature as these patients are prone to
develop hypothermia. Forced convective air warming devices are beneficial in maintaining normothermia to prevent
ill effects of hypothermia in the postoperative period.31
Shivering is a very unpleasant phenomenon in postoperative patients. Numerous drugs have been used to
control the incidence of postoperative shivering with a
varying level of success. Dexmedetomidine is the newer
addition to the anaesthesiologist’s armamentarium for
control of this postoperative menace.32
As mentioned earlier, airway maintenance in patients with
head and neck malignancies is essential and should be
planned preoperatively. The decision of awake fibreoptic
guided intubation or elective tracheostomy should be based
on clinical judgement of the anaesthesiologist.
Positioning of the patient is a very important but often
neglected part in the intraoperative management of these
patients. There are different types of positions which are
employed by the surgeons depending upon type of surgery

like supine, lateral decubitus, prone etc. The common precautions which should be taken in each of these positions are:
- proper padding of all the pressure points,
- avoidance of excessive stretching of the nerve plexuses
especially in upper limbs,
- proper positioning of eyes in prone position to prevent
postoperative blindness and
- avoidance of compression on abdomen in prone position to facilitate proper ventilation.
Blood component therapy in these patients should be
guided by clinical judgement. Risk of transmission of
infection in these immunocompromised patients should be
weighed with the benefits of blood transfusion. A value of
6e8 g/dl for haemoglobin is considered a threshold for patients without any preoperative risk factors and 10e11 g/dl
for those with significant risk factors.33
Blood conservation strategies may be employed to prevent
excessive intraoperative blood loss like preoperative embolisation of highly vascular tumours and metastases.
Intraoperative cell salvage have been controversial as it can
increase the risk of spreading the cancerous cells systemically, however use of filtration and irradiation have found
some use in reducing tumour load of the salvaged blood.34
Use of antifibrinolytics have been studied recently and
have been found to significantly reduce the intraoperative
blood loss with reduced need for allogenic blood transfusions and also no significant increased incidence of
venous thrombosis have been found.35
Benzodiazepines have been shown to alter the immunological response to stress of surgery by reduction in cytokines release and thus may be beneficial in these patients.36
General anaesthesia have been found to be immunomodulatory in these patients by interfering with functions of immunological cells like natural killer cells (NK), macrophages and
can increase the mortality associated with postoperative
wound healing.37 However, wherever general anaesthesia is
necessary, efforts should be done to administer minimal dose
of anaesthetics by addition of adjuvants like dexmedetomidine which definitely decreases the dose of analgesics and
anaesthetics.38 Total intravenous anaesthesia is better alternative for a rapid and smooth recovery from anaesthesia.39
Regional anaesthesia alone or combined with general
anaesthesia have been found to not only cause reduction of
stress response to surgical stress but also to reduce the
occurrence of metastasis in advanced malignancies.40e42
Administration of regional anaesthesia should aim at
administering minimal dose of local anaesthetics and this
can be achieved with addition of adjuvants like dexmedetomidine, fentanyl, clonidine and so on wherever
feasible.43e45 However, regional anaesthesia becomes challenging in patients with suspected metastasis to the spine.
Elicitation of paraesthesia during administration of epidural
regional anaesthesia should prompt one to discard this
technique and should resort to general anaesthesia.46

3.3.

Postoperative management

A careful postoperative monitoring of these patients in a high
dependency unit is desirable especially in patients with



significant risk factors. In few patients, the postoperative
intensive care becomes essential and such patients have to be
shifted to ICU for further management. Prognosis and costs
involved in the treatment of such patients should be thoroughly explained to the patient’s relative in their own
vernacular.47 Alleviation of acute surgical pain is of utmost
importance in the postoperative period with advanced malignancies to reduce the stress response and to aid in proper
wound healing. These patients are often on long term oral
opioids which should be replaced with parenteral formulations and the dose carefully titrated to the desired effect with
an additional 30% of the dose added for the acute postoperative pain over and above the usual dose of opioids.48 The
nutritional aspects cannot be ignored at all in these patients
especially in preoperative malnourished and aged patients.
The nutritional supplements should be continued during the
postoperative period whether they are in ward, high dependency units or intensive care units.49

3.4.

Thromboprophylaxis

Venous thromboembolism is a serious postoperative complication especially in patients with malignancy with an incidence
of 45e69% without any prophylaxis. Various mechanical and
pharmacological methods can be employed and the incidence
of deep vein thrombosis can be reduced to 4%.50,51 The various
pharmacological methods are use of warfarin, low-dose heparin, low molecular weight heparin and aspirin. An important
implication of use of thromboprophylaxis for anaesthesiologist
is when epidural catheter is in place, so that the removal of the
catheter should take place at an appropriate time period to
prevent development of any epidural haematoma.

4.

Conclusion

In conclusion, anaesthesia for patients with cancer pose significant challenges due to physiological alterations caused by
malignancy itself, due to distant metastasis and also due to
endocrine changes brought about by the tumour. A thorough
preoperative assessment with correction of nutritional status
and electrolyte abnormalities, careful intraoperative planning
and monitoring and intensive postoperative monitoring and
relief of acute postoperative pain, is essential for a positive
outcome of the patient. The effect of anaesthesia on malignancy is a matter of debate and should be consolidated by
further randomised controlled studies.

Conflicts of interest
All authors have none to declare.

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