Anesthetic management for renal tumor extending to the inferior vena cava

A 58 year-old woman underwent radical nephrectomy, thrombectomy and ileo-cecal resection for renal tumor with thrombus involving the inferior vena cava and ascending colon cancer. In a patient having tumor thrombus extending to the vena cava, recognition of the position of the thrombus is important for surgical and anesthetic management in pre- and intra-operative periods. Transesophageal echocardiography (TEE) enabled us to visualize the real-time movement and deformity of thrombus by surgical manipulation and compression during operation. TEE seemed also very useful not only in understanding the hemodynamics during operation but also in detecting the residual tumor and the blood flow in liver and the inferior vena cava after operation.     

Progressive angiomyolipoma with inferior vena cava tumor thrombus

A 45-year-old man presented with an incidentally discovered benign renal angiomyolipoma. This lesion initially demonstrated renal vein involvement. On referral to our institution 3 years later, there was interval progression of tumor thrombus to the intrahepatic inferior vena cava. Intravascular extension of benign angiomyolipoma, though rare, has been reported. We present a new example and review the literature concerning this unusual complication of a common renal neoplasm.     

Rational diagnosis and surgical therapy of renal cell carcinoma with tumor thrombosis in the vena cava

Cerebral blood flow (CBF) rises when the glucose supply to the brain is limited by hypoglycemia or glucose metabolism is inhibited by pharmacological doses of 2-deoxyglucose (DG). The present studies in unanesthetized rats with insulin-induced hypoglycemia show that the increases in CBF, measured with the [14C]iodoantipyrine method, are relatively small until arterial plasma glucose levels fall to 2.5 to 3.0 mM, at which point CBF rises sharply. A direct effect of insulin on CBF was excluded; insulin administered under euglycemic conditions maintained by glucose injections had no effects on CBF. Insulin administration raised plasma lactate levels and decreased plasma K+ and HCO3- concentrations and arterial pH. These could not, however, be related to the increased CBF because insulin under euglycemic conditions had similar effects without affecting CBF; furthermore, the inhibition of brain glucose metabolism with pharmacological doses (200 mg/kg intravenously) of DG increased CBF, just like insulin hypoglycemia, without altering plasma lactate and K+ levels and arterial blood gas tensions and pH. Nitric oxide also does not appear to mediate the increases in CBF. Chronic blockade of nitric oxide synthase activity by twice daily i.p. injections of NG-nitro-L-arginine methyl ester for 4 days or acutely by a single i.v. injection raised arterial blood pressure and lowered CBF in normoglycemic, hypoglycemic, and DG-treated rats but did not significantly reduce the increases in CBF due to insulin-induced hypoglycemia (arterial plasma glucose levels, 2.5-3 mM) or pharmacological doses of deoxyglucose.     

Tumor thrombosis of the inferior vena cava in renal carcinoma extending to the upper hepatic margin--surgical technique

The authors divide the invasion of a tumourous thrombus of renal cell carcinoma into the IVC, consistent with the surgical approach of this problem into three levels. They describe in detail the approach and solution of the thrombus which reached as far as the upper hepatic margin or as far as the passage of the IVC through the diaphragm. Separation of the IVC between the liver and the path of the IVC into the right atrium from the median upper section from the xiphoid two fingers beneath the umbilicus seems the optimal and safe approach to tumourous thrombosis reaching that far. Using this approach at the Urological Clinic in Hradec four patients were operated. At present the authors consider other approaches to tumourous thrombosis of the IVC of renal cell carcinoma reaching up to the upper hepatic margin less suitable and associated with a higher risk of possible tumourous embolism of the pulmonary artery.     

Anesthetic management of a patient with renal cell carcinoma extending into the right atrium

A 60-year-old man with renal cell carcinoma extending through inferior vena cava into the right atrium was scheduled for the removal of the right kidney under general anesthesia and the cardiopulmonary bypass technique. In order to obtain a clear operative field and to minimize the risk for pulmonary embolism of necrotizing tumor, total circulatory arrest under profound hypothermia (20 degrees C) was performed. Anesthesia was maintained with high doses of fentanyl (62 micrograms.kg-1), midazolam and supplemented with enflurane. We attempted to prevent circulatory collapse due to acute pulmonary embolism by tumor fragments during operation. The body temperature of the patient was decreased down to 20 degrees C for protecting central nervous system with the minimal damage. No complications occurred during anesthesia and the post-operative period. For the safe anesthetic management of the patient such as our case, adequate monitoring of circulation and protection of central nervous system are essential.     

Inferior vena cava filter used for unresectable renal cell carcinoma with tumor thrombi

A titanium Greenfield inferior vena cava filter was used for the treatment of 2 patients with unresectable renal cell carcinomas with tumor thrombi to prevent a fatal pulmonary embolism induced by tumor clots released during systemic interferon therapy and embolization of the primary tumor. After treatment, the size of the renal cell carcinomas at the primary site and the tumor thrombi decreased by 50%. There were no fatal pulmonary embolisms or complications related to the filter during the observation period (24 and 25 months) after therapy. This method may be useful in the prevention of a fatal pulmonary embolism induced by embolization and systemic interferon therapy in these patients.     

Use of dynamic two-dimensional transesophageal echocardiography for renal cell carcinoma with cavoatrial tumor thrombus

Previous investigations involving continuous blood pressure (BP) monitoring have shown an important alteration of the 24-hour BP profile in patients with obstructive sleep apnea syndrome (OSAS). We investigated the impact of REM sleep on the 24-hour BP cycle in 16 severe OSAS male patients (mean respiratory disturbance index = 66 +/- 16 events/hour of sleep), with hypertension (mean BP 162 +/- 21/105 +/- 11 mmHg World Health Organization (WHO) protocol). Two successive nights of polysomnography were performed, and arterial BP was monitored continuously during the second 24-hour period after brachial artery cannulation. During the daytime, subjects were kept awake and supine. At 3 p.m. BP was continuously monitored during quiet supine wakefulness for 20 minutes. Systolic, diastolic and mean BP and heart rate (HR) were analyzed and tabulated in mean values of 5 minute segments. Sleep/wake information were correlated with cardiovascular variables. Each uninterrupted REM sleep period was identified and comparison between the period of quiet supine wakefulness and REM sleep HR and BP values was performed. 8 OSAS patients presented a normal drop of the mean arterial BP during the nocturnal REM sleep periods compared to quiet supine wakefulness (mean value = -10.8 +/- 7.3 mmHg) ("dippers") while the other 8 subjects ("REM sleep non dippers"), revealed an elevated mean arterial BP during REM sleep (mean value = 18.9 +/- 10.9 mm Hg). The absence of the normal circadian BP dip seen during the nocturnal sleep period is considered as an indication of vascular risk. The REM sleep non dipping may play a role in this risk.     

Application of the flexible cystoscope to the excision of renal cell carcinoma with intracaval tumor thrombus

Cardiopulmonary bypass, temporary cardiac arrest, and exsanguination have facilitated the surgical resection of renal tumors with intracaval thrombi that extend above the hepatic veins or into the atrium. The bloodless field provided by this approach enables the surgeon to utilize a flexible cystoscope to ensure that the caval thrombus has been removed entirely from the hepatic veins.     

Postpartum ultrasonographic diagnosis of inferior vena cava thrombus associated with ovarian vein thrombosis

Postoperative ultrasonographic assessment as a result of unremitting fever after cesarean section depicted a large pedunculated thrombus within the inferior vena cava at the level of the right renal vein. Subsequent imaging studies revealed that this thrombus was the distal extension of right ovarian vein thrombosis into the inferior vena cava.     

Combination therapy of daily intramuscular injection of interferon-alpha and oral administration of fluorouracil for advanced renal cell carcinoma]

The present study, using proton nuclear magnetic resonance relaxation (H1 NMR) measurements, was undertaken to quantitate water fractions with different mobility in the brain tissue obtained form New Zealand White rabbit pups. Serial studies were carried out at the postnatal age of 0-1, 24, 48, 72, and 96 h in pups nursed with their mothers and suckling ad libitum (group I) and in those pups separated from their mothers and completely withheld from suckling (group II). Tissue water content (desiccation method) and T1 and T2 relaxation times (H1 NMR method) were measured. Free, loosely bound, and tightly bound water fractions were calculated by applying multicomponent fits of the T2 relaxation curves. It was demonstrated that brain water content and T1 and T2 relaxation times did not change with age in the suckling pups. In pups withheld from suckling brain water decreased from 89.4 +/- 0.5% at birth to 87.7 +/- 0.1% at the age of 96 h (p < 0.05), T1 remained unchanged, and there was a significant fall in T2 by the age of 72 h (188 +/- 12 versus 178 +/- 4 ms, p < 0.05) and 96 h (171 +/- 6 ms, p < 0.01). Partition of brain water into bound and free fractions as derived from biexponential fits of T2 decay curve showed that the percent contribution of bound water fraction in pups of group I fell progressively from 61% at birth to 3% at the age of 72-96 h (p < 0.05). This fall was accelerated by the complete deprival of fluid intake, and the level of about 4% could be attained as early as the age of 24 h. Triexponential analysis of T2 relaxation curves revealed that the loosely bound fraction (middle component) predominated over the free (slow component) and the tightly bound (fast component) water fractions. In response to withholding fluid intake, the free water fraction increased 4-fold at the expense of tightly bound brain water. It is concluded that the majority of neonatal brain water is motion-constrained. The free, the loosely bound, and the tightly bound water fractions appear to be interrelated; from the brain water store water can be released to supply free water for volume regulation.     

Surgery for hepatocellular carcinoma with tumor thrombus in the right atrium

Three cases of tumor thrombus that originated from a hepatocellular carcinoma in the liver and extended into the right atrium are described. All patients had received both resection of the tumor thrombus and lobectomy of the liver either simultaneously or independently within a short interval. Surgical order and extracorporeal circulation system were varied depending on the thrombus extension. Two of the patients died within 4 months of surgery due to different reasons and the other is doing well at 24 months after surgery.     

Perioperative management of a patient with bilateral renal cell cancer and large vena caval tumor thrombosis

Von Hippel-Lindau disease is a kind of rare autosomal dominant hereditary disease characterized with many kinds of tumor or cystic lesion. In this 30 year old woman, vena caval tumor thrombi from retroperitoneal malignancies caused by renal cell cancer extended into the right atrium. She was scheduled to undergo bilateral radical nephrectomy and removal of vena caval thrombi under continuous hemodiafiltration (CHDF) and extracorporeal circulation. CHDF and Biomedics Pump were on stand-by during the operation. Radical left nephrectomy was performed. In the right kidney, however only the tumor could be removed and other part of the right kidney remained untouched. Therefore, CHDF was not used because urine volume and electrolyte balance were maintained with furosemide administration. The change of blood pressure caused by inferior vena caval clamping at just below the renal vein was not so great that the operation was performed without extracorporeal circulation. Total blood loss was 12,000 ml and careful management of water balance was necessary. She did not need any hemodialysis after the surgery.     

Study on the combined therapy of DNA-methyltransferase inhibitor and interferon-alpha/beta for mouse spontaneously arose renal cell carcinoma, and immunological mechanism induced by the therapy

BACKGROUND: In order to change the immunological environment of T-helper2 (Th2) predominance, namely humoural immunity, in renal cell carcinoma, we tried to examine the efficacy of combined treatment with DNA-methyltransferase inhibitor (Procainamide) and interferon (IFN)-alpha/beta in basic experiments, and also examined the immunological mechanism induced by this treatment modality. MATERIALS AND METHODS: The monotherapy of Procainamide (10 mg/kg, 20 mg/kg, 30 mg/kg, everyday for 3 weeks, i.p.) and of natural murine IFN-alpha/beta (1 x 10(4) I.U./mouse, 3 times for a week, total 9 times, s.c.), and combined treatment with these 2 drugs for mouse spontaneously arose renal cell carcinoma (RC-2) were undertaken. Furthermore, we examined the expression of cytokine mRNA related to the Th-subset in murine spleen under the tumour burden by the RT-PCR methods. RESULTS: 1) Regarding the anti-tumour efficacy of two kinds of monotherapy (Procainamide and IFN-alpha/beta), no effective result was obtained. On the other hand, the combined treatment with these two drugs induced effective anti-tumour efficacy in the relative mean tumour weight ratio (TRW/CRW), mean tumour weight and the survival rate compared with the control and each monotherapy, especially in the administration of Procainamide dosed at 30 mg/kg. As to the histological degeneration induced by the combined therapy, there still remained the viable tumour cells (grade IIb). 2) In an effort to analyse the immunological changes induced by the administration of Procainamide, there observed the expression of Th1-derived cytokines mRNA such as IFN-gamma, IL-2 and tumour necrosis factor-beta, and except for interleukin (IL)-10, there also observed the disappearance of Th2-derived cytokines mRNA such as IL-4, IL-5 and IL-6 in the murine spleen. CONCLUSION: We draw the conclusion that the treatment with DNA-methyltransferase inhibitor may change the humoural immunological environment into the cellular immunological environment enabling the effective anti-tumour efficacy combined with IFN-alpha/beta in renal cell carcinoma.