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Perioperative management of patients with renal cell carcinoma with high level of IVC tumor thrombus invasion revisited
Journal of Clinical Anesthesia 39 (2017) 23–24
Contents lists available at ScienceDirect
Journal of Clinical Anesthesia
Correspondence Perioperative management of patients with renal cell carcinoma with high level of IVC tumor thrombus invasion revisited
We have read with great interest the recent report regarding the perioperative management and outcomes of 8 patients with renal cell carcinoma with level IV inferior vena cava (IVC) tumor thrombus extension [1]. The authors should be commended for their clinical skills in addressing this challenging and complex problem. However, we would like to draw the authors' and readers' attention to several points of great importance, both clinical and academic. We disagree with the authors' contention that “… aside from sporadic case reports, a comprehensive review of the anesthetic approach in these cases has not been suggested” [1]. To the contrary, we have done exactly that, and in addition to various case reports, we have shared our experience in intraoperative anesthetic management of 70 patients with renal cell carcinoma with level III and IV IVC tumor thrombus spread [2]. We believe that the authors' familiarity with our results may have significantly enhanced the value of their communication. The outcomes reported by Morita et al. further confirm our strong preference for the avoidance of extracorporeal circulatory support whenever possible. Utilization of trans-abdominal exposure to infra- and supra-hepatic IVC in combination with “piggy-back” technique of mobilization of liver off IVC, an approach borrowed from the liver transplantation surgical repertoire, made access to intrathoracic portions of IVC and radical resection of level III and IV tumor thrombus extension possible without the extracorporeal support in the great majority of patients. In contrast to Morita et al.'s use of sternotomy in all 8 patients and cardiopulmonary bypass CPB in 6 out of 8 patients (75%), in our series CPB was required in only 5 out of 70 patients (7.1%): in two patients with level III thrombus who required CPB for pulmonary embolectomy (but not for the removal of the IVC tumor thrombus), and in three patients with level IV thrombus (out of 12; 25%) who did require CPB for tumor thrombus removal. This trans-abdominal technique for thoracic IVC exposure is described in detail elsewhere [2–4]. Unfortunately, this approach was neither discussed nor mentioned by Morita et al. Additionally, a more detailed description of intraoperative CPB management may be important for greater understanding of the etiology of intractable post-bypass right ventricular (RV) failure. The authors' differential diagnosis (coronary embolism from thrombus or RV pressure overload from tumor thrombus pulmonary embolism) should also include the more likely possibility of ineffective RV myocardial protection during CPB. Details regarding myocardial perfusion, such as its composition (with or without cardioplegia in case of a beating heart technique), its mode (antegrade or retrograde), and its monitoring may be important. When the extracorporeal support is required, we see the beating heart technique during CPB with continuous myocardial perfusion without cardioplegia [5]
http://dx.doi.org/10.1016/j.jclinane.2017.03.014 0952-8180/© 2017 Elsevier Inc. All rights reserved.
as an important means of mitigating post-bypass RV dysfunction. Concomitant pulmonary perfusion and ventilation may lessen pulmonary ischemia reperfusion injury and decrease RV afterload [6]. Finally, additional details regarding preoperative cardiac functional assessment and coronary flow would seem relevant in patients at risk of exposure to CPB. In conclusion, we believe that our approach of circumventing the need for CPB, adopting the trans-abdominal approach in patients with high level of IVC tumor thrombus, and utilizing the beating heart/pulmonary perfusion and ventilation technique when CPB is required may explain the differences in the immediate and short-term patients' outcomes. Nonetheless, these considerations may be irrelevant for long term survival, which is largely determined by the tumor anatomy and the completeness of the surgical resection [7,8]. References [1] Morita Y, Ayabe K, Nurok M, Young J. Perioperative anesthetic management for renal cell carcinoma with vena caval thrombus extending into the right atrium: case series. J Clin Anesth 2017;36:39–46. [2] Fukazawa K, Gologorsky E, Naguit K, Pretto Jr EA, Salerno TA, Arianayagam M, et al. Invasive renal cell carcinoma with inferior vena cava tumor thrombus: cardiac anesthesia in liver transplant settings. J Cardiothorac Vasc Anesth 2014;28:640–6. [3] Ciancio G, Shirodkar SP, Soloway MS, Livingstone AS, Barron M, Salerno TA. Renal carcinoma with supradiaphragmatic tumor thrombus: avoiding sternotomy and cardiopulmonary bypass. Ann Thorac Surg 2010;89(2):505–10. [4] Ciancio G, Shirodkar SP, Soloway MS, Salerno TA. Techniques for avoidance of sternotomy and cardiopulmonary bypass during resection of extensive renal cell carcinoma with vena caval tumor thrombus extension above the diaphragm. J Card Surg Nov-Dec 2009;24(6):657–60. [5] Macedo FIB, Carvalho EM, Hassan M, Ricci M, Gologorsky E, Salerno TA. Beating heart valve surgery in patients with low left ventricular ejection fraction. J Card Surg 2010; 25:267–71. [6] Gologorsky E, Gologorsky A, Salerno TA. Lung-centered open heart surgery: a call for a paradigm change. Front Cardiovasc Med 2016;3:1. [7] Martínez-Salamanca JI, Linares E, González J, Bertini R, Carballido JA, Chromecki T, et al. Lessons learned from the International Renal Cell Carcinoma-Venous Thrombus Consortium (IRCC-VTC). Curr Urol Rep 2014;15:404–13. [8] Nguyen HG, Tilki D, Dall'Era MA, Durbin-Johnson B, Carballido JA, Chandrasekar T, et al. Cardiopulmonary bypass has no significant impact on survival in patients undergoing nephrectomy and level III–IV inferior vena cava thrombectomy: multi-institutional analysis. J Urol 2015;194(2):304–8.
Edward Gologorsky MD, FASE Temple University School of Medicine, Department of Anesthesiology, CVT and Liver Transplant Divisions, Allegheny General Hospital, Pittsburgh, PA, United States Corresponding author at: Temple University School of Medicine, Department of Anesthesiology, CVT and Liver Transplant Divisions, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212, United States. E-mail address: [email protected]. Kyota Fukazawa MD Dept. of Anesthesiology and Pain Medicine, Univ. of Washington School of Medicine, Seattle, WA, United States
24
Correspondence
Gaetano Ciancio MD, MBA, FACS Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States 6 March 2017 Available online xxxx
Contents lists available at ScienceDirect
Journal of Clinical Anesthesia
Correspondence Perioperative management of patients with renal cell carcinoma with high level of IVC tumor thrombus invasion revisited
We have read with great interest the recent report regarding the perioperative management and outcomes of 8 patients with renal cell carcinoma with level IV inferior vena cava (IVC) tumor thrombus extension [1]. The authors should be commended for their clinical skills in addressing this challenging and complex problem. However, we would like to draw the authors' and readers' attention to several points of great importance, both clinical and academic. We disagree with the authors' contention that “… aside from sporadic case reports, a comprehensive review of the anesthetic approach in these cases has not been suggested” [1]. To the contrary, we have done exactly that, and in addition to various case reports, we have shared our experience in intraoperative anesthetic management of 70 patients with renal cell carcinoma with level III and IV IVC tumor thrombus spread [2]. We believe that the authors' familiarity with our results may have significantly enhanced the value of their communication. The outcomes reported by Morita et al. further confirm our strong preference for the avoidance of extracorporeal circulatory support whenever possible. Utilization of trans-abdominal exposure to infra- and supra-hepatic IVC in combination with “piggy-back” technique of mobilization of liver off IVC, an approach borrowed from the liver transplantation surgical repertoire, made access to intrathoracic portions of IVC and radical resection of level III and IV tumor thrombus extension possible without the extracorporeal support in the great majority of patients. In contrast to Morita et al.'s use of sternotomy in all 8 patients and cardiopulmonary bypass CPB in 6 out of 8 patients (75%), in our series CPB was required in only 5 out of 70 patients (7.1%): in two patients with level III thrombus who required CPB for pulmonary embolectomy (but not for the removal of the IVC tumor thrombus), and in three patients with level IV thrombus (out of 12; 25%) who did require CPB for tumor thrombus removal. This trans-abdominal technique for thoracic IVC exposure is described in detail elsewhere [2–4]. Unfortunately, this approach was neither discussed nor mentioned by Morita et al. Additionally, a more detailed description of intraoperative CPB management may be important for greater understanding of the etiology of intractable post-bypass right ventricular (RV) failure. The authors' differential diagnosis (coronary embolism from thrombus or RV pressure overload from tumor thrombus pulmonary embolism) should also include the more likely possibility of ineffective RV myocardial protection during CPB. Details regarding myocardial perfusion, such as its composition (with or without cardioplegia in case of a beating heart technique), its mode (antegrade or retrograde), and its monitoring may be important. When the extracorporeal support is required, we see the beating heart technique during CPB with continuous myocardial perfusion without cardioplegia [5]
http://dx.doi.org/10.1016/j.jclinane.2017.03.014 0952-8180/© 2017 Elsevier Inc. All rights reserved.
as an important means of mitigating post-bypass RV dysfunction. Concomitant pulmonary perfusion and ventilation may lessen pulmonary ischemia reperfusion injury and decrease RV afterload [6]. Finally, additional details regarding preoperative cardiac functional assessment and coronary flow would seem relevant in patients at risk of exposure to CPB. In conclusion, we believe that our approach of circumventing the need for CPB, adopting the trans-abdominal approach in patients with high level of IVC tumor thrombus, and utilizing the beating heart/pulmonary perfusion and ventilation technique when CPB is required may explain the differences in the immediate and short-term patients' outcomes. Nonetheless, these considerations may be irrelevant for long term survival, which is largely determined by the tumor anatomy and the completeness of the surgical resection [7,8]. References [1] Morita Y, Ayabe K, Nurok M, Young J. Perioperative anesthetic management for renal cell carcinoma with vena caval thrombus extending into the right atrium: case series. J Clin Anesth 2017;36:39–46. [2] Fukazawa K, Gologorsky E, Naguit K, Pretto Jr EA, Salerno TA, Arianayagam M, et al. Invasive renal cell carcinoma with inferior vena cava tumor thrombus: cardiac anesthesia in liver transplant settings. J Cardiothorac Vasc Anesth 2014;28:640–6. [3] Ciancio G, Shirodkar SP, Soloway MS, Livingstone AS, Barron M, Salerno TA. Renal carcinoma with supradiaphragmatic tumor thrombus: avoiding sternotomy and cardiopulmonary bypass. Ann Thorac Surg 2010;89(2):505–10. [4] Ciancio G, Shirodkar SP, Soloway MS, Salerno TA. Techniques for avoidance of sternotomy and cardiopulmonary bypass during resection of extensive renal cell carcinoma with vena caval tumor thrombus extension above the diaphragm. J Card Surg Nov-Dec 2009;24(6):657–60. [5] Macedo FIB, Carvalho EM, Hassan M, Ricci M, Gologorsky E, Salerno TA. Beating heart valve surgery in patients with low left ventricular ejection fraction. J Card Surg 2010; 25:267–71. [6] Gologorsky E, Gologorsky A, Salerno TA. Lung-centered open heart surgery: a call for a paradigm change. Front Cardiovasc Med 2016;3:1. [7] Martínez-Salamanca JI, Linares E, González J, Bertini R, Carballido JA, Chromecki T, et al. Lessons learned from the International Renal Cell Carcinoma-Venous Thrombus Consortium (IRCC-VTC). Curr Urol Rep 2014;15:404–13. [8] Nguyen HG, Tilki D, Dall'Era MA, Durbin-Johnson B, Carballido JA, Chandrasekar T, et al. Cardiopulmonary bypass has no significant impact on survival in patients undergoing nephrectomy and level III–IV inferior vena cava thrombectomy: multi-institutional analysis. J Urol 2015;194(2):304–8.
Edward Gologorsky MD, FASE Temple University School of Medicine, Department of Anesthesiology, CVT and Liver Transplant Divisions, Allegheny General Hospital, Pittsburgh, PA, United States Corresponding author at: Temple University School of Medicine, Department of Anesthesiology, CVT and Liver Transplant Divisions, Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212, United States. E-mail address: [email protected]. Kyota Fukazawa MD Dept. of Anesthesiology and Pain Medicine, Univ. of Washington School of Medicine, Seattle, WA, United States
24
Correspondence
Gaetano Ciancio MD, MBA, FACS Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States 6 March 2017 Available online xxxx