Age is not an obstacle: Tumor excisions under local anesthesia even in very old people

Skin cancer is common and its prevalence in the population is steadily increasing.1 Surgical excision is the treatment of choice for many skin cancers, even in older patients.2 Patients over 80 years of age are defined as “very old”. Advanced age and large tumors can make surgery a challenge. General anesthesia in patients over 80 years of age is associated with increased risks of postoperative complications.3 We present three very old patients from our specialist center for dermatology and dermatosurgery, in whom large facial tumors were surgically removed exclusively under local infiltration anesthesia. Three very old people were operated on under infiltration local anesthesia, using lidocaine with adrenaline (buffered with bicarbonate as an off-label application). The local anesthesia is prepared from 0.2 mL epinephrine 1 mg/mL and 5 mL sodium hydrogen carbonate 8.4% in 45 mL lidocaine hydrochloride 10 mg/mL. Sodium bicarbonate reduces the pain of infiltration.4 The time required for the local anesthesia to take full effect should be noted.4 No additional sedation was used. Large facial tumors were removed and the defects subsequently covered by plastic surgery. A 98-year-old female patient with a large squamous cell carcinoma on her left cheek had initially undergone therapy attempts with cryosurgery and topical imiquimod at an external clinic. This was followed by daylight PDT therapy. Initially, the tumor shrank after PDT therapy but progressed again in size over time. The indication for tumor excision under local anesthesia was given, whereupon the tumor was excised and the defect covered by means of a trilobed flap plasty starting from the left side of the neck. The follow-up shows the result two months after surgery (Figure 1). An 87-year-old patient underwent excision of an extensive sarcoma of the right cheek under local anesthesia. For plastic reconstruction, a double transposition flap plasty was performed starting from the upper right temple, including rotation and retroauricular to preauricular full-thickness skin grafting (Figure 2). The most common skin tumors in the elderly are basal cell carcinoma and squamous cell carcinoma.5 In the current S3 guideline, surgical removal is recommended as the primary treatment method for squamous cell carcinoma. Radiotherapy is recommended for inoperable findings. In advanced disease, for example with metastases, systemic therapy with a cemiplimab or pembrolizumab PD1 antibody should be evaluated. Administration of chemotherapeutic agents and EGFR blockers is an option currently being discussed.6 Surgical removal of the carcinoma, described as the “method of choice”, can pose a particular challenge in very old patients and in the case of extensive tumors. The use of general anesthesia for tumor excision carries fundamental risks, such as the risk of aspiration.3 In addition, the risk of postoperative delirium and cognitive dysfunction is increased in very old people, which can lead to significant morbidity and mortality.7, 8 Furthermore, the use of general anesthesia increases the risk of postoperative pulmonary complications in older patients.3 Another aspect to be considered is that older people more frequently display limited mobility of the cervical spine, which can make intubation more difficult. Additionally, the literature indicates that dental injuries are more common in older age groups when general anesthesia is used.8 To avoid these risks, there is the option of performing surgery under local anesthesia only. The risk associated with local anesthesia is considered low. In rare cases, allergic reactions may occur, ranging from a mild allergy with a skin rash to anaphylactic shock. In the event of an anaphylactic reaction, administration of the local anesthetic must be stopped, the application of epinephrine is indicated, and care must be taken to secure the airway and provide ventilation.9 In addition, the administration of antihistamines and glucocorticoids may be considered. In theory, systemic toxic effects, most likely to be triggered by an accidental intravascular injection of the local anesthetic, are possible. This phenomenon manifests itself only rarely when using local anesthetics and correlates with the plasma concentration. The kinetics of systemic absorption at the injection site depends on blood flow and capillary density at the injection site. For example, it is high for peritonsillar application and very low for subcutaneous application. In the unlikely event of a systemic toxic reaction occurring in dermatosurgery, further administration of the local anesthetic (for example in tumescent local anesthesia) should be stopped, attention should be paid to maintaining vital bodily functions, and infusion of a lipid solution is recommended.10, 11 The experience of our center suggests that, in the case of old, multimorbid patients, a willingness to cooperate must be achieved to a certain extent, particularly with regard to avoiding intraoperative injuries. A lack of cooperation could result in a need to interrupt surgery, or alternative procedures (general anesthesia, radiotherapy, drug-based tumor therapy) would need to be considered in advance. Apart from the primary medical indication for surgery, the psychological strain due to visually prominent tumors, especially on the face, can be considerable for those affected, even at an advanced age. Excision and defect coverage through plasty under local anesthesia is a treatment option with comparatively low risk that offers the possibility of healing or palliation and a significant improvement in quality of life. In addition, compared to surgery under general anesthesia, surgery under local anesthesia can save costs, as personnel and material requirements are reduced.12-14 Our cases show that excision of larger skin tumors under local anesthesia can be a good treatment option. A particular challenge of surgery under local anesthesia is empathic patient management. Surgery under tumescent local anesthesia is also conceivable.12 A conscious patient can move, may feel anxiety, or becomes impatient over time. For all surgeries on conscious patients, appropriate communication with the team is important, as the patient hears everything. Empathetic support throughout the procedure can minimize anxiety and concerns. In a specialized center like ours, the surgical team is also specially trained in dealing with very old (but also very young) patients. In summary, excision under local anesthesia is a proven option for the treatment of epithelial carcinomas, even in very old people, as a sole or complementary method to radiotherapy or drug therapy. Avoiding general anesthesia helps prevent potential risks and reduces costs and effort. None.