|Year : 2017 | Volume
| Issue : 2 | Page : 78-81
Clinical pearls in anesthesia for excision and reconstructive surgery for cauliflower carcinoma on psoriatic plaques
Shagun Bhatia Shah, Anita Kulkarni
Department of Anaesthesia, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
|Date of Submission||20-Jun-2017|
|Date of Acceptance||24-Aug-2017|
|Date of Web Publication||12-Dec-2017|
Dr. Shagun Bhatia Shah
H. No: 174 – 175, Ground Floor, Pocket-17, Sector-24, Rohini, New Delhi - 110 085
Source of Support: None, Conflict of Interest: None
Meticulous preoperative evaluation and planning is essential in psoriasis patients presenting for surgery as the airway and axial skeleton may both be involved in addition to extensive integumentary involvement. Difficult airway as well as difficult neuraxial block may be encountered due to psoriatic arthropathy. Widespread skin lesions may not spare free space for intravenous cannulation, invasive arterial/central venous lines, spinal/epidural block, and electrode placement for electrocardiogram, bispectral index, or peripheral nerve stimulator. Noninvasive techniques such as pleth variability index for guiding fluid therapy are encouraged to avoid instrumentation induced fresh psoriatic lesions. Psoriasis therapy (steroids, methotrexate, psoralens, and antidepressants) has side effects including malignant transformation of multiple psoriatic plaques which merit consideration. Drugs known to aggravate psoriasis (benzodiazepines, clonidine, beta blockers, and nonsteroidal anti-inflammatory drugs) and slightest trauma to skin need to be avoided. Anesthetic challenges in a psoriatic patient and their successful management have been described here.
Keywords: General anesthesia, psoriasis, psoriatic arthropathy, regional anesthesia, squamous cell carcinoma
|How to cite this article:|
Shah SB, Kulkarni A. Clinical pearls in anesthesia for excision and reconstructive surgery for cauliflower carcinoma on psoriatic plaques. Indian Anaesth Forum 2017;18:78-81
|How to cite this URL:|
Shah SB, Kulkarni A. Clinical pearls in anesthesia for excision and reconstructive surgery for cauliflower carcinoma on psoriatic plaques. Indian Anaesth Forum [serial online] 2017 [cited 2019 Aug 25];18:78-81. Available from: http://www.theiaforum.org/text.asp?2017/18/2/78/220545
| Introduction|| |
Psoriasis is a chronic inflammation of the skin with well circumscribed erythematous papules and silver scaled plaques on extensor surface of elbows, knees, sacral area, nails, and scalp affecting 2%–3% of population. Interdigital joints are commonly involved while temporomandibular and hip joints may rarely be involved in psoriatic arthritis.
The anaesthetic management of a psoriasis patient with multicentric cauliflower psoriatic lesions showing carcinomatous transformation is detailed below.
| Case Report|| |
A 54-year-old male patient weighing 90 kg, with long-standing (20 years) psoriasis [Figure 1] presented with 6 months old rapidly growing, foul smelling, fungating, nonhealing ulcers on buttocks, calf, and shin area. He was a chronic smoker and alcoholic with no family history of psoriasis or malignancy. His hematological and biochemical investigations were normal. Positron emission tomography – computed tomography revealed multiple metabolically active cutaneous lesions with bilateral external iliac and inguinal lymph node involvement. The largest lesions measured 10 cm × 8 cm (Standardized Uptake Value (SUV) maximum 21.6) on the right buttock and 5.4 cm × 1.3 cm on right shin confirmed to be malignant by triangular biopsy.
|Figure 1: Multiple psoriatic lesions with exophytic carcinoma complicating the psoriatic plaque on the right buttock|
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The patient could not lie down supine due to the painful lesion on his right buttock and was preooxygenated and mask ventilated in Right semilateral position on the trolley juxtaposed with the OT table. Propofol 100 mg, fentanyl 140 μg, and vecuronium 8 mg were injected intravenously, and a C Mac D Blade videolaryngoscope along with backward, upward, rightward pressure (BURP maneuver) were utilized for intubating the trachea with a 7.5 mm ID flexo metallic cuffed endotracheal tube (FMCETT). After auscultatory and capnographic confirmation of FMETT placement and nasogastric tube insertion, the oral cavity was packed with ribbon gauze. As an institutional protocol a Guedels airway was placed to prevent FMCETT displacement and obstruction due to tube bite [Figure 2]. The eyes were taped shut and protected with eyepads. The patient was now carefully log rolled into prone position onto the adjacent OT table which had been prepared with foam head rest gelfoampadding and bolsters beforehand [Figure 2].
|Figure 2: Airway management and prone positioning in the psoriasis patient|
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Besides routine monitoringspirometery, bispectral index (BIS) and peripheral nerve stimulator (PNS) were used. Maintenance of anesthesia included BIS-guided dexmedetomidineinfusion, PNS-guided vecuronium infusion, and 40% oxygen in medical air along with 1%–2% sevoflurane. Intravenous (IV) hydrocortisone 100 mg bolus followed by infusion at 5 mg/kg/h was given. Excision and rotational flap reconstruction in prone position was followed by logrolling the patient into the supine position onto the adjacent trolley. Then shifting the supine patient back onto the OT table for wide local excision of the squamous cell cancer lesions on the right shin (repaired with gastrocnemius flap and split skin graft). A cooximeter (pleth variability index [PVI] was kept below 10) was used to noninvasively guide IV fluid therapy. Surgery lasted eight hours, and patient was conscious and oriented before tracheal extubation. Postoperative analgesia comprised patient controlled IV morphine infusion.
| Discussion|| |
The most common cancers in psoriasis patients are lymphohematopoietic and pancreatic., A squamous cell carcinoma (SCC) rarely arises from psoriatic plaques in the absence of predisposing factors such psoralen AQ4 ultraviolet A (PUVA), cyclosporine, methotrexate, topical tar, rituximab or etanercept (within 11 months) therapy for psoriasis.,, Since exaggerated immune response is fundamental to psoriasis progression, most patients receive chronic corticosteroid therapy.
An above average risk of nonmelanoma skin cancers, particularly SCC exists in psoriasis patients exposed to therapeutic 8 methoxypsoralen ultraviolet A (PUVA), cyclosporin, and perhaps methotrexate. In both psoriasis and SCC patients, there is augmented expression of proliferation regulators such as Keratin 16, WNT 5A, defensin B4, SERPIN B3, and STAT-1. Psoriasis entails overexpression of tumor necrosis factor α (TNFα)., Anti TNF, anti psoriasis drugs such as etanercept may cause SCC within 11 months of beginning therapy. Our patient developed SCC at multiple sites atop his psoriatic plaques despite never having undergone any of the above therapies for psoriasis. Periodic biopsy of long standing lesions facilitates early detection of malignant change. Gentle scraping of psoriatic lesions accentuates scaling whereas vigorous scraping causes pin point bleeding (Auspitz sign). We avoided placing the 18 gauge IV catheter over psoriatic lesions and used Tegaderm™ to secure it (less abrasive so less traumatic peel off amounting to reduced scaling). We encountered a positioning difficulty during sequential right semilateral (for intubation), prone(surgery on buttocks) and then finally supine (surgery on skin lesions) position changes because of psoriatic arthropathy involving the knees and a large painful cauliflower mass on the right buttock of our patient. The pros and cons of general as well as regional anesthesia which we took into account to formulate a tailor made anesthesia plan for this patient, are detailed in [Table 1].,,, These can prove useful in providing tailormade anesthesia to other psoriasis patients as well. Psoriasis undermines the physical, mental, and social status of the victims. Our patient was on tricyclic antidepressants due to loss of self esteem and social phobia because of his ailment. The dose of anesthetic agents was adjusted accordingly. We avoided midazolam and NSAIDs as these are known to trigger psoriasis. Opioids for analgesia and dexmedetomidine infusion were utilized instead. Nitrous oxide was avoided in accordance with the green OT concept and also since it aggravates side effects of methotrexate(used for psoriasis therapy). Ceftriaxone 1.5 g IV was used to provide antibiotic cover since most common triggers for psoriasis are infections (upper respiratory tract infection and gingivitis)., Paradoxically, some antibiotics (tetracycline, penicillin, and clindamycin), are known to aggravate psoriasis. Exaggerated immune response is a key factor in the progression of the disease and hence most of the patients, including our patient, receive chronic corticosteroid therapy. Our patient developed SCC despite having taken only high dose corticosteroids (no psoralens) as psoriasis therapy. Stress dose corticosteroid is usually required during the perioperative period in such patients on chronic corticosteroid therapy. We followed the traditional time-tested supraphysiological stress dosing technique for corticosteroids because preoperative biochemical testing of hypothalamo –pituitary axis was not feasible in our patient. Recent reports in literature claim that even 25mg hydrocortisone followed by 100-150 mg over next 24 hours also suffice to prevent hypotension and Addisonian crisis in patients on long term steroid therapy undergoing major surgery., In patients receiving more than 20-30mg prednisolone per day preoperative biochemical testing of HPA maybe indicated. Renal and liver function tests are important in a patient on methotrexate therapy. We employed noninvasive monitoring (co-oximetric PVI guided intravenous fluid therapy) instead of invasive monitoring like central venous pressure (CVP) as the latter may initiate fresh psoriatic patches at the site of instrumentation (Koebner's phenomenon). A cooximeter has the additional advantage of providing accurate pulse oximeter readings where an ordinary pulse oximeter may fail (as in presence of psoriatic nails).
| Conclusion|| |
The blueprint of pros and cons of general versus regional anesthesia to provide tailormade anaesthesia for each psoriatic patient is unique. Using a co oximeter (for SpO2 and PlethVariability Index) to first, overcome the loss of SPO2 signals by psoriatic nails and second, to reduce instrumentation (arterial and CVP line) induced fresh psoriatic patches has not been mentioned in any other case report on psoriatic patients.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kuchekar AB, Pujari RR, Kuchekar SB, Dhole SN, Mule PM. Psoriasis: A comprehensive review. Int J Pharm Life Sci 2011;2:857-77.
Farronato G, Garagiola U, Carletti V, Cressoni P, Bellintani C. Psoriatic arthritis: Temporomandibular joint involvement as the first articular phenomenon. Quintessence Int 2010;41:395-8.
Brauchli YB, Jick SS, Miret M, Meier CR. Psoriasis and risk of incident cancer: An inception cohort study with a nested case-control analysis. J Invest Dermatol 2009;129:2604-12.
Pouplard C, Brenaut E, Horreau C, Barnetche T, Misery L, Richard MA, et al.
Risk of cancer in psoriasis: A systematic review and meta-analysis of epidemiological studies. J Eur Acad Dermatol Venereol 2013;27 Suppl 3:36-46.
Takeda A, Higuchi D, Takahashi T, Ogo M, Baciu P, Goetinck PF, et al.
Overexpression of serpin squamous cell carcinoma antigens in psoriatic skin. J Invest Dermatol 2002;118:147-54.
Gupta M, Das JK, Gangopadhyay A. Multicentric squamous cell carcinoma arising on psoriatic plaque. Indian J Dermatol 2013;58:151-3.
] [Full text]
Brewer JD, Hoverson Schott AR, Roenigk RK. Multiple squamous cell carcinomas in the setting of psoriasis treated with etanercept: A report of four cases and review of the literature. Int J Dermatol 2011;50:1555-9.
Kim GK, Del Rosso JQ. Drug-provoked psoriasis: Is it drug induced or drug aggravated? Understanding pathophysiology and clinical relevance. J Clin Aesthet Dermatol 2010;3:32-8.
Samanta S, Samanta S, Chatterjee D, Gupta V. Anesthesia and psoriatic arthropathy: Challenges and literature review. Anaesth Pain Intensive Care 2015;19:402-4.
Milavec-Puretić V, Mance M, Ceović R, Lipozenčić J. Drug induced psoriasis. Acta Dermatovenerol Croat 2011;19:39-42.
Katz HI, Hien NT, Prawer SE, Mastbaum LI, Mooney JJ, Samson CR, et al.
Superpotent topical steroid treatment of psoriasis vulgaris – Clinical efficacy and adrenal function. J Am Acad Dermatol 1987;16:804-11.
Coursin DB, Wood KE. Corticosteroid supplementation for adrenal insufficiency. JAMA 2002;287:236-40.
Fraser CG, Preuss FS, Bigford WD. Adrenal atrophy and irreversible shock associated with cortisone therapy. J Am Med Assoc 1952;149:1542-3.
Shah SB, Hariharan U, Bhargava AK. Novel perioperative utilities of the newer co oximetery parameters: A practical review. EC Anaesth 2016;2:205-11.
Thappa DM. The isomorphic phenomenon of Koebner. Indian J Dermatol Venereol Leprol 2004;70:187-9.
] [Full text]
[Figure 1], [Figure 2]