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Renal
Cell Carcinoma (RCC) is the most common malignancy affecting Kidney with an
incidence of 85%. It is usually asymptomatic, may present with metastases.
Inferior Vena Cava (IVC) involvement occurs in 5-10% of patients. The mainstay
of management of RCC remains surgical and chemotherapy is of limited value. IVC
extension requires meticulous preoperative preparation, coordination amongst
Urology and Cardiothoracic team for safe outcome. In this present case report,
we encountered RCC with IVC extension up to the junction of Right atrium and
IVC, which was managed using Cardiopulmonary bypass and was successful
multidisciplinary team management.
Keywords: IVC, Cardiopulmonary bypass, RCC, Thrombus, TEE
INTRODUCTION
Surgical resection of renal cell carcinoma
with tumor invasion into inferior vena cava (IVC) or right atrium (RA) will be
a life-threatening procedure as the tumor can embolise or it can lead to
massive blood loss. The tumor or thrombus migration can occur into the IVC in
4-10% of the patients and into RA 1% of patients with RCC, respectively [1,2].
CASE SCENARIO
A 52 year asymptomatic male was detected to
have a left renal mass on routine medical checkup. Investigations revealed
hemoglobin 10 g%, creatinine 1.61 mg/dl, ECG and echocardiography found to be
normal except for an IVC mass extending up to the right atrium with a normal LV
and RV function. CT abdomen showed T1/T2 heterogeneous diffuse mass almost
replacing the entire renal parenchyma, with left renal vein and IVC extension
reaching up to the right atrium (level IV tumor as per Mayo classification).
As per the ASA, standards monitors were
connected to the patient, patient was given general anesthesia intubated and a
trans-esophageal echocardiography probe was inserted. Preoperative TEE showed a
mass in the inferior vena cava extending till the junction of IVC and the right
atrium (Figure 1). The surgical plan
was to do left radical nephrectomy along with IVC mass excision. Following
Laparotomy incision, left renal mass was exposed and IVC was mobilised and
cardiothoracic surgical team was called in. Median sternotomy was performed; after
systemic heparinization, superior venacava and right femoral vein were
cannulated. Aortic cannulation was done and cardioplumonary bypass was
instituted after confirming ACT >480 s. Aorta was cross clamped
intermittently in the supra coeliac part and IVC opened after snaring the
intracardiac part of it. IVC mass was removed enbloc along with the left renal
mass. Patient was gradually weaned off bypass with inotropic support. The total
CPB time was 77 minutes. Protamine administered to reverse Heparin in the ratio
of 1:1. Post-operative TEE showed no mass in the IVC or any evidence of
embolism into RV or pulmonary artery (Figure
2). Patient’s LV and RV systolic function was found to be normal. This
patient had extensive blood loss (4-5 L) in the intraoperative period. Blood
volume was replaced with 4U of fresh blood, 4U of packed cells and coagulopathy
was managed with 6U Fresh frozen plasma. Patient abdomen and chest was packed
in view of extensive blood oozing and it was closed in layers on the first
post-operative day. Acidosis and volume loss
were corrected and Patient
was
DISCUSSION
Renal cell carcinoma constitutes <5% of
all malignancies and it is the commonest malignancy of kidney with 85%
incidence. Usually asymptomatic in its early stage, 30-40% patients present
with metastasis [3,4], IVC invasion occurs in 5-10% of RCC patients [5-9].
Surgical resection remains gold standard in treatment of RCC and chemotherapy
has a limited efficacy [5-10]. Despite a 5 year survival rate of 40-70% after
surgical resection [10], advanced or metastatic tumors carry perioperative
morbidity and mortality with rates of 30-40% and 2-8%, respectively [11-13]. Several
classification systems have been proposed to describe extension of tumor
thrombus based on anatomic landmarks. One of the most popular classification
schemes is the Novick staging system (Figure
3) in which level I thrombi are limited to the renal vein or extend >2
cm within the IVC. Level II thrombi extend >2 cm cephalad within the IVC but
do not reach the level of the liver. Level III thrombi extend into the
intrahepatic IVC and level IV thrombi extend above the diaphragm [14].
Preoperative anticoagulation is given usually
for some patients to prevent the further spread of the tumor thrombus and in
this case, patient received LMWH till the night before surgery as a
prophylactic measure. Woodruff et al. [13] suggested that patients with caval
tumor thrombus should receive low molecular-weight heparin preoperatively
unless contraindicated, such as in the setting of renal dysfunction.
The use of TEE intra-operatively allows us to
localize tumor, compute its size and extension, analyse its spread in long and
short axes and will allow us to compare preoperative and post-operative cardiac
function and embolic events like pulmonary embolism or presence of intra
cardiac air. In this case, there was no post-operative LV or RV dysfunction and
there were no embolic events. A similar case report was published by Spelde and
Steinberg [14] wherein there was RV dysfunction and pulmonary embolism in their
case.
Cardioplumonary bypass has remained a mainstay
strategy for those tumors extending above the diaphragm for the main advantage
that it offers a bloodless surgical field. Deep Hypothermic circulatory arrest
has also been adopted by few authors to minimise the blood in the surgical
field. First described by Morita et al. [15], CPB with deep hypothermic cardiac
arrest (DHCA) has become a common surgical technique for patients with tumor
thrombus that extends above the level of the diaphragm. A normothermic CPB is
considered superior to DHCA due to associated coagulopathy, prolonged surgical
time and delayed recovery associated with the latter. Vogt et al. [16] also
reported no perioperative deaths and no cases of renal failure, pulmonary
embolism or neurologic complications for 11 patients managed with normothermic
CPB. Radak et al. [17] reported on 5 patients managed with normothermic CPB
with no perioperative deaths or pulmonary emboli. This case was managed at a
temperature of 31℃ during the time of cardiopulmonary bypass.
In the management of such cases, meticulous
preoperative work up of the patient and patient’s co morbidities, careful
intraoperative anesthetic management, a good surgical team minimising the blood
loss, intraoperative TEE to evaluate any embolic events and heart failure and a
good post-operative management of complications, if any, will improve the
patient’s outcome and reduce the morbidity and mortality. Multidisciplinary
approach is the need of hour for such cases.
Intraoperative TEE guides the surgeons to
remove the tumor enbloc and to record any evidence of RV dysfunction or embolism
into the pulmonary artery.
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