Cancer Surgery and Anaesthesia

Quick Answer

What is it? Anaesthesia for cancer surgery requires specialized knowledge of cancer biology, immunosuppression effects, optimal surgical timing, and perioperative considerations that differ significantly from non-oncological procedures.

Why does it matter? Surgical resection remains the primary curative treatment for solid tumours. Perioperative decisions significantly impact cancer recurrence, metastasis, and long-term survival. Anaesthetic technique may influence immunological responses and cancer outcomes.

Key points:

• Surgery induces immunosuppression, potentially promoting tumour spread [1]
• Regional anaesthesia may reduce cancer recurrence compared to general anaesthesia alone [2]
• Optimal timing depends on neoadjuvant therapy completion, patient nutritional status, and immune function recovery
• Thrombocytopenia and neutropenia from chemotherapy contraindicate neuraxial techniques
• Blood transfusion is associated with worse cancer outcomes—avoid when possible [3]

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Indigenous Health Considerations

Aboriginal and Torres Strait Islander Health

Cancer remains the leading cause of death among Aboriginal and Torres Strait Islander peoples, with age-standardised mortality rates 45% higher than non-Indigenous Australians [4]. This disparity reflects complex intergenerational factors including higher smoking rates (37.3% vs 13.8%), delayed presentation due to geographical barriers, and systemic inequities in screening access [5].

Cultural safety profoundly influences perioperative outcomes. Many Aboriginal patients experience significant distress when separated from Country and family during tertiary care transfers [6]. Traditional healing practices often complement Western medicine, requiring respectful integration. Anaesthetists should acknowledge the ongoing impacts of colonisation on health outcomes and demonstrate cultural humility.

Communication barriers extend beyond language. Conceptual differences regarding time, causation, and consent necessitate adapted approaches [7]. Visual aids and translated materials improve understanding. Family involvement in decision-making reflects collective cultural values—excluding relatives may breach cultural protocols and reduce compliance.

Smoking cessation programs must address nicotine dependence within contexts of intergenerational trauma and stress. Preoperative optimisation periods present opportunities for culturally tailored interventions [8].

Māori Health (Aotearoa New Zealand)

Māori experience disproportionate cancer burden with incidence rates 20-30% higher and mortality 1.5 times non-Māori rates for most cancer types [9]. Whānau-centred care models align with Māori worldviews where health encompasses whānau (family), hapū (sub-tribe), and iwi (tribe) wellbeing.

Māori patients may prefer whānau involvement in all clinical discussions, including anaesthetic consent [10]. Karakia (prayers) and blessing ceremonies before surgery support spiritual wellbeing. Acknowledging tapu (sacred) and noa (profane) concepts informs respectful care delivery.

Geographical disparities particularly affect rural Māori communities. Extended preoperative stays in unfamiliar urban environments generate significant whānau stress. Telehealth consultations and coordinated care pathways reduce these barriers [11].

Genetic predispositions to certain cancers (e.g., stomach cancer in some iwi) necessitate heightened surveillance and family cascade screening discussions. Anaesthetists should facilitate referrals to genetic services when appropriate.

Shared Indigenous Considerations

Both populations demonstrate elevated rates of comorbidities complicating cancer surgery:

• Diabetes mellitus (2-3× higher prevalence)
• Chronic kidney disease
• Cardiovascular disease
• Obesity-related surgical complexity

These comorbidities increase perioperative risk and require modified anaesthetic approaches. Higher rates of opioid tolerance from chronic pain conditions necessitate multimodal analgesia strategies [12].

Institutional racism within healthcare systems contributes to delayed cancer diagnosis and treatment. Implicit bias training for all perioperative staff improves care quality. Patient advocates and Indigenous liaison officers facilitate culturally safe navigation through complex cancer pathways.

Research representation remains inadequate—clinical trials historically excluded Indigenous participants, limiting evidence-based guidance for these populations [13]. Anaesthetists should support recruitment initiatives and advocate for inclusive research design.

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Clinical Overview

Cancer Biology and Surgical Implications

Cancer encompasses uncontrolled cellular proliferation with capacity for local invasion and distant metastasis. The perioperative period represents a vulnerable window where surgical stress may promote tumour cell dissemination and establishment of metastatic deposits [14].

Key biological mechanisms relevant to anaesthesia:

Immune Surveillance Dysfunction Normal immune function detects and eliminates circulating tumour cells. Surgery-induced immunosuppression, characterised by decreased natural killer (NK) cell activity, impaired T-cell function, and elevated immunosuppressive cytokines, compromises this surveillance [15].

Angiogenesis and Metastasis Surgical trauma upregulates pro-angiogenic factors (VEGF, bFGF) and growth factors that may facilitate tumour cell survival in distant sites [16].

Cellular Adhesion and Migration Inflammatory mediators released during surgery alter endothelial adhesion molecule expression, potentially enhancing circulating tumour cell adhesion and extravasation.

Surgery Timing Considerations

Optimal surgical timing balances tumour control against patient physiological readiness:

Neoadjuvant Therapy Completion

• Chemotherapy: typically 2-4 weeks washout required for bone marrow recovery
• Radiotherapy: acute effects resolve within 4-6 weeks; late effects persist indefinitely
• Immunotherapy: immune-related adverse events must be resolved [17]

Nutritional Status

• Serum albumin <30 g/L associated with increased complications
• Prehabilitation programs demonstrate improved outcomes [18]

Immune Function Recovery

• Neutrophil count >1.5 × 10⁹/L
• Platelet count >100 × 10⁹/L for neuraxial techniques

Anaesthetic Technique and Cancer Outcomes

Growing evidence suggests anaesthetic technique influences cancer recurrence:

Proposed mechanisms include:

• Preservation of NK cell function with regional techniques
• Reduced opioid-induced immunosuppression
• Direct anti-inflammatory effects of local anaesthetics
• Modulation of cancer cell signalling pathways

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Preoperative Assessment

Cancer-Specific Considerations

Primary Tumour Effects

• Airway obstruction (head and neck cancers)
• Mediastinal compression (lung cancer, lymphoma)
• Superior vena cava syndrome
• Paraneoplastic syndromes
• Hypercalcaemia of malignancy

Metastatic Disease

• Brain metastases (altered consciousness, raised ICP)
• Bone metastases (hypercalcaemia, pathological fractures)
• Liver metastases (coagulopathy, drug metabolism alterations)
• Lung metastases (respiratory compromise)

Treatment-Related Effects

Haematological Parameters

Cytotoxic chemotherapy frequently causes cytopenias:

Neutropenia

• ANC <1.0 × 10⁹/L: contraindication to neuraxial block
• ANC <0.5 × 10⁹/L: increased infection risk with any invasive procedure
• Febrile neutropenia requires postponement of elective surgery [26]

Thrombocytopenia

• Platelets <50 × 10⁹/L: avoid neuraxial techniques
• Platelets 50-100 × 10⁹/L: individual risk-benefit assessment
• Platelets >100 × 10⁹/L: generally safe for neuraxial block [27]

Anaemia

• Liberal vs restrictive transfusion strategies debated
• Cancer-specific concerns about allogeneic blood and recurrence [28]

Cardiopulmonary Assessment

Cardiotoxic chemotherapy requires preoperative evaluation:

• Baseline and preoperative echocardiography for anthracycline exposure >250 mg/m² doxorubicin equivalent
• BNP/NT-proBNP elevation indicates cardiotoxicity
• Multigated acquisition (MUGA) scan alternative for accurate EF measurement

Radiation-induced cardiac disease:

• Accelerated coronary atherosclerosis (left-sided breast, mediastinal radiation)
• Valvular dysfunction
• Constrictive pericarditis
• Ventricular dysfunction [29]

Pulmonary evaluation for thoracic malignancies:

• Spirometry and diffusion capacity
• Exercise tolerance assessment
• Arterial blood gas analysis
• Split lung function testing if pneumonectomy considered

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Intraoperative Management

Monitoring Considerations

Standard Monitoring

• ECG with ST-segment analysis (cardiotoxic chemotherapy)
• Invasive arterial pressure (major resections, haemodynamic instability risk)
• Central venous access (major surgery, vena cava involvement, superior vena cava syndrome)
• Cardiac output monitoring (goal-directed therapy for major abdominal surgery) [30]

Specialised Monitoring

• Neuromonitoring for spinal/paraspinal tumour resection
• TEE for cardiac tumour surgery
• Cerebral oximetry (prone positioning, prolonged surgery)
• Neuromuscular monitoring (neurotoxic chemotherapy)

Airway Management

Head and Neck Cancer

• Difficult airway secondary to tumour mass, previous surgery, or radiation fibrosis
• Fibreoptic intubation often required
• Tracheostomy may be present or required
• Shared airway with surgical team necessitates planning

Mediastinal Mass

• Position-dependent airway obstruction
• Cardiac compression (tamponade physiology)
• Avoid supine induction if symptomatic
• Rigid bronchoscopy standby for central airway obstruction [31]

Fluid Management

Goal-directed fluid therapy reduces complications:

• Stroke volume optimisation
• Oesophageal Doppler or arterial waveform analysis
• Restrictive crystalloid strategy with targeted colloid/blood administration
• Hydroxyethyl starch solutions avoided (renal toxicity, coagulopathy)

Blood product management:

• Cell salvage appropriate for most cancer surgery (oncological safety established) [32]
• Leucodepletion filters may reduce immunomodulatory effects
• Restrictive transfusion strategy (Hb 70-80 g/L) unless symptomatic [33]

Pharmacological Considerations

Chemotherapy Drug Interactions

• Cisplatin: nephrotoxicity enhanced by hypovolaemia, NSAIDs, aminoglycosides
• Bleomycin: oxygen toxicity at FiO₂ >0.3; avoid hyperoxia [34]
• Anthracyclines: additive cardiotoxicity with other myocardial depressants
• Methotrexate: excretion altered by drugs affecting urinary pH

Anaesthetic Agents

• Propofol: anti-emetic properties beneficial; immunomodulatory effects unclear
• Volatile agents: cardioprotection vs. potential cancer-promoting effects debated
• Ketamine: potential anti-tumour properties via inhibition of NMDA receptors on cancer cells
• Dexmedetomidine: sympathetic modulation may reduce metastasis; analgesic and anti-inflammatory properties [35]

Regional Anaesthesia

• Thoracic epidural for thoracotomy: improved analgesia, reduced pulmonary complications
• Paravertebral blocks for breast surgery: reduced chronic pain, possible recurrence benefit
• TAP blocks for abdominal surgery: multimodal analgesia component
• Continuous wound infiltration: opioid-sparing, early mobilisation

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Postoperative Care

Analgesia Strategies

Multimodal opioid-sparing approaches:

Thromboprophylaxis

Cancer patients have 4-7× increased venous thromboembolism (VTE) risk:

• Active malignancy (particularly pancreatic, gastric, brain tumours)
• Surgery (major abdominal/pelvic >30 minutes)
• Chemotherapy (angiogenesis inhibitors, hormonal therapy)
• Central venous catheters

Pharmacological prophylaxis:

• Low molecular weight heparin preferred over unfractionated heparin
• Extended prophylaxis (4 weeks post-surgery) for high-risk abdominal/pelvic cancer surgery [40]
• Direct oral anticoagulants increasingly used (apixaban, rivaroxaban)
• Timing: balance VTE prevention against neuraxial haematoma risk [41]

Mechanical prophylaxis:

• Intermittent pneumatic compression
• Graduated compression stockings (unless peripheral arterial disease)
• Early mobilisation

Nutritional Support

Enhanced Recovery After Surgery (ERAS) protocols:

• Preoperative carbohydrate loading (evening before + 2 hours pre-induction)
• Early enteral feeding (postoperative day 0-1)
• Avoidance of routine nasogastric decompression
• Glycaemic control (target 6-10 mmol/L) [42]

Parenteral nutrition:

• Reserved for prolonged ileus or intolerance to enteral feeding
• High metabolic demands of cancer may increase requirements
• Refeeding syndrome risk in severely malnourished patients

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Special Considerations

Hyperthermic Intraperitoneal Chemotherapy (HIPEC)

Combined cytoreductive surgery with heated intraperitoneal chemotherapy:

• Temperatures 40-43°C for 60-120 minutes
• Significant physiological challenges:
  • Hyperthermia-induced vasodilation
  • Third-space fluid losses
  • Coagulopathy
  • Cardiac stress
  • Electrolyte disturbances

Anaesthetic management:

• Invasive monitoring mandatory (arterial line, CVC, cardiac output)
• Active cooling post-procedure to prevent malignant hyperthermia-like responses
• Aggressive fluid resuscitation (often >10 L crystalloid)
• Blood product availability (DIC risk)
• Postoperative ICU admission [43]

Cytoreductive Surgery for Advanced Ovarian Cancer

Extensive debulking procedures:

• Diaphragm resection, liver mobilisation, splenectomy, bowel resection
• Massive blood loss potential
• Prolonged operative time (8-12 hours common)
• Postoperative complications: 30-50%
• Optimal debulking (<1 cm residual) improves survival [44]

Oncological Emergencies

Spinal Cord Compression

• Surgical decompression within 24-48 hours
• High-dose dexamethasone (10 mg IV then 16 mg/day)
• Maintain spinal cord perfusion pressure
• Positioning for decompression (prone, lateral)

Superior Vena Cava Syndrome

• Semi-upright positioning
• Avoid upper limb IV access if possible
• Invasive monitoring from lower body
• Stenting or radiation may precede surgery

Tumour Lysis Syndrome

• Preventive strategies: aggressive hydration, rasburicase, allopurinol
• Avoid potassium-containing fluids
• Monitor: uric acid, potassium, phosphate, calcium
• Postoperative renal replacement therapy may be required [45]

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Anaesthesia and Cancer Recurrence

Evidence Summary

Current evidence remains conflicting with significant heterogeneity across studies. Mechanistic plausibility exists but definitive clinical trials are lacking.

Proposed Mechanisms

Immunomodulation

• Preservation of NK cell cytotoxicity
• Reduced pro-inflammatory cytokine release
• Attenuated stress response

Opioid Effects

• Morphine and fentanyl may promote angiogenesis and tumour growth in preclinical models
• Mu-opioid receptor expression on cancer cells
• Clinical significance uncertain

Local Anaesthetics

• Direct cytotoxic effects on cancer cells (in vitro)
• Inhibition of cancer cell migration and proliferation
• Anti-inflammatory properties [51]

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Indigenous Health in Cancer Surgery

Addressing Disparities

Australia and Aotearoa New Zealand demonstrate persistent Indigenous cancer disparities requiring targeted perioperative approaches:

Aboriginal and Torres Strait Islander Peoples

• Age-adjusted cancer mortality 45% higher than non-Indigenous Australians [52]
• Lower 5-year survival rates for most cancer types
• Higher rates of comorbidities complicating surgery
• Geographic barriers to tertiary care access

Māori

• Cancer incidence rates 20-30% higher than non-Māori
• Mortality rates 1.5× higher
• Later stage at diagnosis for many cancers
• Lower rates of curative-intent treatment [53]

Cultural Safety Strategies

Preoperative Phase

• Cultural liaison officers facilitate communication
• Family/whānau involvement in consent discussions
• Acknowledgment of traditional healing practices
• Flexible scheduling accommodating cultural obligations
• Provision of bush tucker/kai Māori options

Perioperative Phase

• Welcome to Country/Mihi whakatau ceremonies where requested
• Maintaining connection to family and community
• Culturally appropriate pain assessment (verbal descriptors may differ)
• Recognition of stoicism masking pain severity

Postoperative Phase

• Discharge planning incorporating family support structures
• Follow-up in community settings where possible
• Telehealth consultations reducing travel burden
• Culturally tailored survivorship programs

Institutional Responsibilities

Healthcare institutions must address systemic racism:

• Indigenous workforce development and retention
• Cultural safety training mandatory for all staff
• Data collection enabling disparity monitoring
• Co-designed service models with Indigenous communities
• Trauma-informed care recognizing intergenerational impacts [54]

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SAQ Practice Questions

SAQ 1: Perioperative Management (25 marks)

A 58-year-old woman is scheduled for radical cystectomy with ileal conduit for muscle-invasive bladder cancer. She completed neoadjuvant cisplatin-gemcitabine chemotherapy 3 weeks ago. Her current haemoglobin is 92 g/L, platelets 85 × 10⁹/L, and neutrophils 0.8 × 10⁹/L.

a) Outline your preoperative optimisation strategy (10 marks)

b) Discuss your intraoperative anaesthetic technique and monitoring (8 marks)

c) What postoperative analgesia strategy would you employ? (7 marks)

Model Answer

a) Preoperative Optimisation (10 marks)

Haematological issues (4 marks):

• Neutropenia (0.8 × 10⁹/L) contraindicates neuraxial blockade—risk of epidural abscess and haematoma [55]
• Thrombocytopenia (85 × 10⁹/L) also contraindicates neuraxial techniques (platelets <100 × 10⁹/L) [56]
• Anaemia (Hb 92 g/L): consider iron supplementation, EPO if time permits; avoid transfusion unless symptomatic as allogeneic blood associated with worse cancer outcomes [57]
• Consider delaying surgery 1-2 weeks for count recovery if clinically appropriate

Cisplatin nephrotoxicity (2 marks):

• Assess renal function: creatinine, eGFR, electrolytes (magnesium, potassium)
• Hydration protocol preoperatively
• Avoid nephrotoxins: NSAIDs, aminoglycosides, contrast

Cardiovascular assessment (2 marks):

• ECG and baseline troponin
• Echocardiography if anthracycline exposure or cardiac symptoms
• Functional capacity assessment

Nutritional optimisation (2 marks):

• Albumin level; dietician referral if <30 g/L
• Prehabilitation program if time permits
• Smoking cessation if applicable

b) Intraoperative Technique and Monitoring (8 marks)

Monitoring (3 marks):

• Standard monitoring plus invasive arterial pressure (major surgery, blood loss)
• Central venous access (fluid management, drug administration)
• Cardiac output monitoring (goal-directed therapy for major abdominal surgery)
• Temperature monitoring and active warming

Anaesthetic technique (3 marks):

• General anaesthesia with muscle relaxation
• No neuraxial component given cytopenias
• Opioid-sparing multimodal approach: paracetamol, NSAIDs (if renal function acceptable), magnesium, ketamine infusion
• Maintenance with either volatile or TIVA—no definitive evidence for cancer outcomes difference

Fluid management (2 marks):

• Goal-directed fluid therapy (stroke volume optimisation)
• Restrictive crystalloid with targeted colloid/blood administration
• Cell salvage appropriate for this surgery (no increased recurrence risk demonstrated)

c) Postoperative Analgesia (7 marks)

Multimodal approach without neuraxial block (4 marks):

• IV paracetamol regularly
• NSAIDs if renal function permits (avoid with cisplatin nephrotoxicity)
• Ketamine infusion 0.1-0.3 mg/kg/hr for 24-48 hours
• Magnesium infusion
• Lidocaine infusion (evidence for reduced opioid consumption in abdominal surgery)

Regional alternatives (2 marks):

• Transversus abdominis plane (TAP) blocks or catheter
• Rectus sheath blocks
• Wound catheter infiltration

Opioid management (1 mark):

• PCA morphine or fentanyl as rescue
• Regular bowel regimen to prevent constipation
• Monitor for opioid-induced respiratory depression, especially with sleep apnoea risk

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SAQ 2: Cancer Recurrence and Anaesthesia (20 marks)

A 45-year-old woman with node-positive breast cancer is scheduled for mastectomy with axillary clearance. She asks whether her choice of anaesthetic will affect her cancer recurrence risk.

a) What is the current evidence regarding anaesthetic technique and cancer recurrence? (10 marks)

b) What multimodal analgesia strategy would you recommend for this patient and why? (6 marks)

c) Discuss the potential mechanisms by which anaesthetic technique might influence cancer outcomes (4 marks)

Model Answer

a) Evidence on Anaesthesia and Cancer Recurrence (10 marks)

Observational studies (4 marks):

• Exadaktylos et al. (2006): Retrospective study of 129 breast cancer patients; paravertebral block associated with 57% reduction in recurrence over 3 years [58]
• Biki et al. (2008): 225 prostatectomy patients; epidural associated with 57% improvement in biochemical recurrence-free survival [59]
• Multiple retrospective studies show associations but cannot establish causation

Randomised controlled trials (4 marks):

• Sessler et al. (2018) - CANVAS trial: 2,132 breast cancer patients randomised to paravertebral + GA vs GA + opioid; no difference in locoregional recurrence, distant metastasis, or mortality at median 36 months [60]
• Provides highest quality evidence contradicting earlier observational studies
• Trial may be underpowered for small effect sizes; follow-up possibly too short

Meta-analyses (2 marks):

• Du et al. (2021): Meta-analysis of 27 studies; regional anaesthesia associated with reduced recurrence (OR 0.88, 95% CI 0.80-0.97) [61]
• Significant heterogeneity between studies; high risk of bias in observational data
• Overall: plausible biological mechanisms exist but definitive clinical evidence lacking

b) Multimodal Analgesia Strategy (6 marks)

Recommended approach (4 marks):

• Paravertebral block (single shot or catheter) for mastectomy: superior analgesia, reduced opioid consumption, possible recurrence benefit, reduced chronic pain syndrome [62]
• Adduct to general anaesthesia
• Regular paracetamol
• NSAIDs if not contraindicated (cardiac, renal, anticoagulation considerations)
• Magnesium infusion
• Dexamethasone (anti-emetic, anti-inflammatory, possible analgesic benefit)

Justification (2 marks):

• Paravertebral block provides excellent analgesia for breast surgery with fewer complications than epidural
• Reduced opioid consumption aligns with possible immunomodulatory benefits
• Prevention of chronic post-surgical pain (15-50% after breast surgery)
• ERAS protocol alignment

c) Proposed Mechanisms (4 marks)

Immunomodulation (2 marks):

• Surgery induces immunosuppression (decreased NK cell activity, T-cell dysfunction, elevated immunosuppressive cytokines)
• Regional anaesthesia attenuates this response, preserving immune surveillance against circulating tumour cells
• Reduced stress hormone response (cortisol, catecholamines) may preserve immune function

Direct drug effects (2 marks):

• Local anaesthetics demonstrate direct cytotoxic effects on cancer cells in vitro (inhibit migration, proliferation, induce apoptosis)
• Opioids may promote tumour growth and angiogenesis through mu-opioid receptors on cancer cells
• Ketamine and other agents may have anti-tumour properties through various pathways

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SAQ 3: Chemotherapy Toxicity and Surgery (25 marks)

A 62-year-old man is scheduled for oesophagectomy. He received neoadjuvant carboplatin-paclitaxel chemotherapy 4 weeks ago. He complains of progressive dyspnoea on exertion and peripheral oedema.

a) What chemotherapy-related complications should you consider? (8 marks)

b) How would you investigate and optimise this patient preoperatively? (10 marks)

c) Discuss specific intraoperative considerations for this patient (7 marks)

Model Answer

a) Chemotherapy-Related Complications (8 marks)

Carboplatin (3 marks):

• Delayed-onset hypersensitivity reactions (can occur months after exposure)
• Myelosuppression (thrombocytopenia typically most significant with carboplatin)
• Electrolyte disturbances: hypomagnesaemia, hypokalaemia, hypocalcaemia
• Nephrotoxicity (less than cisplatin but still significant)

Paclitaxel (3 marks):

• Cardiac toxicity: arrhythmias (bradycardia, heart block), myocardial ischaemia
• Cardiomyopathy (rare but reported)
• Peripheral neuropathy (may affect respiratory muscle function)
• Hypersensitivity reactions (premedication with steroids/H1/H2 blockers required)

Combined effects (2 marks):

• Symptom constellation suggests possible cardiac involvement (dyspnoea, oedema)
• Could represent congestive cardiac failure from chemotherapy-induced cardiomyopathy
• Alternatively: pulmonary toxicity, pericardial effusion, SVC obstruction from tumour

b) Investigation and Optimisation (10 marks)

Cardiac assessment (4 marks):

• 12-lead ECG: arrhythmias, conduction abnormalities, ischaemia
• Transthoracic echocardiogram: LV function, pericardial effusion, valvular function
• BNP/NT-proBNP: sensitive markers of cardiac dysfunction
• Troponin: myocardial injury
• If cardiomyopathy confirmed: cardiology referral, ACE inhibitor, beta-blocker initiation; may require delay of surgery for optimisation

Pulmonary assessment (2 marks):

• Chest X-ray: pulmonary oedema, effusion, metastases
• CT chest if concern for pulmonary embolism or tumour progression
• Arterial blood gas
• Spirometry if baseline available

Haematological assessment (2 marks):

• FBC: recovery from myelosuppression (Hb >100 g/L, platelets >100 × 10⁹/L ideally)
• Coagulation studies
• Electrolytes including magnesium (often depleted by platinum agents)

Other investigations (2 marks):

• Renal function: creatinine, eGFR
• Albumin: nutritional status
• Consider cardiac MRI if echo inconclusive
• Consider coronary angiography if significant risk factors or symptoms

c) Intraoperative Considerations (7 marks)

Monitoring (2 marks):

• Invasive arterial pressure monitoring
• Central venous access (for vasoactive drugs, fluid management)
• Cardiac output monitoring (goal-directed therapy)
• Consider arterial line for frequent ABG analysis

Anaesthetic technique (3 marks):

• General anaesthesia with lung isolation (double-lumen tube or bronchial blocker) for thoracotomy
• Epidural or paravertebral catheter for postoperative analgesia (if no contraindication)
• Avoid myocardial depressants if LV dysfunction present
• Maintain normothermia

Specific precautions (2 marks):

• If cardiomyopathy present: avoid fluid overload, use vasoactive support if needed
• Consider TEE if significant cardiac dysfunction to guide fluid management
• Have cardiac drugs available: adrenaline, noradrenaline, milrinone
• Postoperative ICU/HDU admission likely required

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Viva Voce Scenarios

Viva Scenario 1: Breast Cancer and Paravertebral Block

Examiner: "A 55-year-old woman presents for mastectomy and axillary clearance for breast cancer. She asks about the anaesthetic and whether it might affect her cancer recurrence. How would you approach this?"

Model Answer:

"I would approach this by discussing the available evidence regarding anaesthetic technique and cancer outcomes. The patient presents an opportunity to optimise both her immediate perioperative experience and potentially her long-term cancer prognosis.

Firstly, regarding the evidence base: retrospective studies, including the influential work by Exadaktylos et al. in 2006, suggested that paravertebral block combined with general anaesthesia was associated with a significant reduction in breast cancer recurrence compared to general anaesthesia with opioids alone. Similarly, studies in prostate and ovarian cancer showed associations between regional anaesthesia and improved cancer-free survival.

However, the CANVAS randomised controlled trial by Sessler et al. in 2018, which included over 2,000 breast cancer patients, showed no difference in recurrence rates between paravertebral block plus general anaesthesia versus general anaesthesia with opioid analgesia, at a median follow-up of 36 months. This high-quality randomised evidence contradicts the earlier observational studies.

That said, I would still recommend paravertebral block for this patient for several reasons: it provides excellent analgesia, significantly reduces opioid consumption, decreases the incidence of chronic post-surgical pain—which affects up to 50% of women after breast surgery—and is associated with fewer side effects compared to systemic opioid analgesia. While the recurrence benefit remains uncertain, the immediate perioperative benefits are well-established.

I would explain to the patient that while the direct effect on cancer recurrence is unclear, the regional technique offers clear benefits for her comfort and recovery, aligns with enhanced recovery principles, and is my recommended approach for this surgery."

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Viva Scenario 2: Bleomycin and Oxygen Toxicity

Examiner: "A 28-year-old man with testicular cancer is listed for retroperitoneal lymph node dissection. He received bleomycin as part of BEP chemotherapy. What are your specific concerns and how would you manage this case?"

Model Answer:**

"This case presents significant respiratory concerns due to bleomycin-induced pulmonary toxicity. Bleomycin is a cytotoxic antibiotic that causes dose-dependent pulmonary fibrosis through direct endothelial and epithelial cell injury, with subsequent inflammatory cascade and collagen deposition.

The key concern is that patients who have received bleomycin are at risk of life-threatening oxygen toxicity. The mechanism involves oxygen-free radical generation causing acute respiratory distress syndrome, often with delayed onset 24-72 hours postoperatively. The risk appears to increase with cumulative bleomycin dose >400 units, age >40, renal dysfunction, and concurrent radiation.

My management strategy would include:

Preoperative assessment: detailed respiratory history, chest X-ray looking for interstitial changes, pulmonary function tests if available. I would specifically avoid supplemental oxygen unless hypoxaemia is present.

Intraoperative management: this is critical. I would maintain the lowest FiO₂ compatible with adequate oxygenation—ideally keeping FiO₂ ≤0.3 or the minimum necessary to maintain SpO₂ >90%. This may mean accepting lower saturation targets than usual. I would use air-oxygen mixtures rather than high-flow oxygen. Positive end-expiratory pressure (PEEP) should be minimised or avoided as it may exacerbate injury.

Monitoring: continuous SpO₂ monitoring with low threshold for arterial blood gas analysis if concerns. I would be particularly vigilant in the postoperative period for delayed presentation of ARDS.

Fluid management: conservative approach to avoid pulmonary oedema compounding any lung injury.

Postoperative care: continued minimisation of supplemental oxygen, early chest physiotherapy, and a low threshold for respiratory physician involvement if deterioration occurs.

I would document these concerns clearly and ensure the surgical and recovery teams are aware of the oxygen restriction."

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ANZCA Syllabus Mapping

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