Journal of Marine Medical Society

LETTER TO EDITOR
Year
: 2017  |  Volume : 19  |  Issue : 1  |  Page : 70--71

Renal cell carcinoma with inferior vena cava extension: An anesthetic challenge


MK John1, Nihar Ameta1, Jacob Mathews2, Sarvesh Shrivastava3,  
1 Clinical Tutor, Department of Anaesthesiology and Critical Care, Armed Forces Medical College, Pune, Maharashtra, India
2 Associate Professor, Department of Anaesthesiology and Critical Care, Armed Forces Medical College, Pune, Maharashtra, India
3 Resident, Department of Anaesthesiology and Critical Care, Armed Forces Medical College, Pune, Maharashtra, India

Correspondence Address:
Maj Nihar Ameta
Department of Anaesthesiology and Critical Care, Armed Forces Medical College, Pune - 411 040, Maharashtra
India




How to cite this article:
John M K, Ameta N, Mathews J, Shrivastava S. Renal cell carcinoma with inferior vena cava extension: An anesthetic challenge.J Mar Med Soc 2017;19:70-71


How to cite this URL:
John M K, Ameta N, Mathews J, Shrivastava S. Renal cell carcinoma with inferior vena cava extension: An anesthetic challenge. J Mar Med Soc [serial online] 2017 [cited 2021 Jan 25 ];19:70-71
Available from: https://www.marinemedicalsociety.in/text.asp?2017/19/1/70/213102


Full Text



Sir,

Renal cell carcinoma (RCC) represents 2%–3% of all cancers.[1] Surgical management is preferred in these patients.[2] These cases present with unique anesthetic challenges and complications. However, with appropriate workup and intraoperative anesthetic management, the surgery can be successfully contemplated without any complications.

A 55-year-old male patient presented with a history of pain in the right lower back of 3 months' duration followed by hematuria of about a month's duration. There were no associated comorbidities. He was evaluated with abdominal ultrasound, computed tomography scan, followed by magnetic resonance imaging and whole-body positron emission tomography scan confirming the diagnosis of right RCC with tumor thrombus extending into right renal vein and infradiaphragmatic inferior vena cava (IVC).

The patient was planned for right radical nephrectomy with thrombectomy. A high-risk consent for the surgery was taken and cardiopulmonary bypass was also kept standby. All the hematological investigations except serum urea (68 mg/dL) and creatinine (2 mg/dL) were within normal range. The surgical plan was laparotomy, and hence, the anesthetic plan was endotracheal intubation with invasive monitoring and epidural analgesia.

All the baseline parameters were within normal limits. Epidural catheter was inserted at T7–T8 level using an 18-gauge Tuohy needle. The patient was intubated using injection propofol and injection pancuronium. Left femoral artery and right internal jugular vein were cannulated. Balanced anesthesia was maintained using opioids and inhalational agents.

The intraoperative course was hemodynamically stable, except when the IVC was clamped during thrombectomy. This hypotension was anticipated and managed with injection noradrenaline 0.03–0.05 mcg/kg/min.

The surgery lasted for 8 h; the patient was not extubated and placed on postoperative mechanical ventilation. As the patient remained hemodynamically stable, he was extubated next morning after appropriate weaning trials.

Intraluminal extension of RCC into IVC occurs in 4%–10% of all the patients.[3] For removal of a large thrombus in the supradiaphragmatic IVC or atrium, cardiopulmonary bypass either with or without deep hypothermic circulatory arrest is appropriate.[4] Cardiopulmonary bypass can be avoided by using transesophageal echocardiography imaging to guide the manipulation of a vena caval balloon.

In this patient, the tumor thrombus extraction was done using balloon extraction technique. Cardiopulmonary bypass, though kept ready, was not required during the surgery.

Another anesthetic consideration is the intraoperative blood loss. Blood loss in RCC with level III IVC thrombus may be of the range 100–5000 mL (mean 500 mL).[5] In our case, the loss was approximately 1.5 L and was appropriately managed using crystalloids (3500 mL) and blood products (1000 mL).

Intraoperative hypotension which commonly appears as a result of blood loss should be tackled using intravenous fluids and vasopressors. Central venous pressure and hourly urine output monitoring can be used to achieve desired hemodynamic goals, as was done in this case.

Successful anesthetic management of RCC with IVC thrombus requires meticulous monitoring, anticipating, and appropriately managing the possible complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Cohen HT, McGovern FJ. Renal-cell carcinoma. N Engl J Med 2005;353:2477-90.
2Kaplan S, Ekici S, Dogan R, Demircin M, Ozen H, Pasaoglu I. Surgical management of renal cell carcinoma with inferior vena cava tumor thrombus. Am J Surg 2002;183:292-9.
3Campbell SC NA, Bukowski RM. Renal tumors. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, editors. Campbell-Walsh Urology. 9th ed. Philadelphia: Saunders - Elsevier; 2007. p. 1567-637.
4Montie JE, Pontes JE, Novick AC, Vanderburg Mendendorp S, Streem SB, Montague DK, et al. Resection of inferior vena cava tumor thrombi from renal cell carcinoma. Am Surg 1991;57:56-61.
5Ciancio G, Vaidya A, Savoie M, Soloway M. Management of renal cell carcinoma with level III thrombus in the inferior vena cava. J Urol 2002;168(4 Pt 1):1374-7.