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Ann Thorac Surg 1996;61:708-710
© 1996 The Society of Thoracic Surgeons

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Case Report

Successful Management of Massive Pulmonary Tumor Embolism From Renal Cell Carcinoma

Department of Cardiothoracic Surgery, University of Tokyo, Tokyo, Japan

Accepted for publication July 31, 1995.

	Abstract

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Renal cell carcinoma occasionally invades the inferior vena cava and rarely extends to the right atrium. However, despite the frequency of venous extension, it is unusual to recognize patients with massive pulmonary tumor embolus clinically. We describe a 60-year-old man who underwent pulmonary tumor embolectomy using cardiopulmonary bypass combined with profound hypothermia and intermittent low-flow perfusion. The patient is currently alive and well without implantation metastasis 6 months after the operation.

	Introduction

Top Footnotes Abstract Introduction Comment References

 
We describe successful management of a massive pulmonary tumor embolus from renal cell carcinoma. The patient survived severe acute respiratory distress after emergency intubation and intensive respiratory care. After radical nephrectomy, elective tumor embolectomy using cardiopulmonary bypass was performed. Profound hypothermia and low-flow perfusion were useful for obtaining a bloodless operative field.

A 60-year-old man presented at a local hospital with a 2-month history of flank pain and a progressively enlarging abdominal mass. Computed tomographic scan revealed a large enhanced mass in the left kidney and local extension to the infrahepatic inferior vena cava without implantation metastasis to the liver, lung or brain.

While the patient was awaiting admission to our institute, sudden chest pain and severe shortness of breath developed when he was washing his face at home. He was admitted as an emergency patient to the local hospital and intubated. Blood gas analysis on admission revealed severe respiratory distress (arterial oxygen tension, 46 mm Hg; arterial carbon dioxide tension, 34 mm Hg). The blood pressure was 70/50 mm Hg. Computed tomographic scan on admission showed massive pulmonary emboli in the bilateral pulmonary artery, while part of the local extension to the inferior vena cava had disappeared (Fig 1). Lung-perfusion imaging showed multiple perfusion defects in the bilateral lungs. The functional perfusion ratio was 33% in the right and 67% in the left lung.

View larger version (90K): [in this window] [in a new window]   Fig 1. . (A) Computed tomographic scan reveals a large enhanced mass in the left kidney and local extension to the infrahepatic inferior vena cava without implantation metastasis to the liver, lung, or brain. (B) Computed tomographic scan obtained on admission shows massive pulmonary emboli in the bilateral pulmonary artery, while part of the local extension to the inferior vena cava has disappeared.

The patient was discharged from the hospital 4 weeks after the operation. He is currently alive and well with no evidence of recurrent disease at 6 months of follow-up.

	Comment

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Renal cell carcinoma has a propensity to extend into the local venous system. Renal vein and inferior vena cava involvement occurs in approximately 33% and 6% of cases, respectively [1]. However, its extension to the right side of the heart is rare. Although massive pulmonary embolism occurs relatively rarely, it can be a major hazard and has resulted in numerous deaths. Especially at the induction of anesthesia and during resection, the risk of massive pulmonary embolism is high because the hemodynamics are unstable and the inferior vena cava is compressed and deformed intraoperatively.

Several authors have reported successful removal of tumor thrombi that have extended to the inferior vena cava, right atrium, and right ventricle using cardiopulmonary bypass. However, the mortality due to massive pulmonary tumor embolism is high, and few reports of successful management have appeared. The first successful removal of a pulmonary embolus secondary to renal cell carcinoma was reported by Daughtry and associates in 1977 [2]. Since this case, 5 cases in which pulmonary emboli of clear cell carcinoma were removed successfully have been reported [3–7]. In 4 cases, emergency pulmonary embolectomy and radical nephrectomy were performed at the same time.

In the present patient, who was admitted to our hospital after recovery from severe respiratory distress, elective embolectomy was performed 4 days after radical nephrectomy because we thought that the patient could tolerate the nephrectomy without simultaneous pulmonary embolectomy, which might cause difficulty in control of bleeding due to heparinization. A separate incision on each pulmonary artery was useful both for removing the tumor embolus and for confirming any remaining embolus. A Fogarty catheter was useful for removing the remaining tumors. For creating a bloodless operative field, profound hypothermia and low-flow perfusion were adequate and total circulatory arrest was not necessary, in contrast to a patient with chronic pulmonary embolism and many collaterals.

Pulmonary embolism secondary to renal cell carcinoma does not always cause pulmonary metastasis. Masumori and associates [8] reported 2 patients with renal cell carcinoma in whom positive findings on lung-perfusion imaging disappeared during follow-up. This suggests that the establishment of pulmonary metastasis requires not only mechanical trapping of carcinoma cells in the pulmonary microvasculature, but an invasive potential of the cells themselves (``seed'') and appropriate microenvironment (``soil'') for enhancing the local growth of cells [8].

This report will encourage the cardiovascular surgeon because removal of the thrombus improves not only respiratory distress and right heart failure but also the prognosis of patients with renal cell carcinoma. Histologically, in the present case, viable clear cells were present only on the surface of the thrombus and the others had become necrotic. This suggests that the embolus is fed by pulmonary arterial blood flow.

	Footnotes

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Address reprint requests to Dr Kubota, Department of Cardiothoracic Surgery, University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo 113, Japan.

	References

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1. Marshall VF, Middleton RG, Holswade GR, Goldsmith EI. Surgery for renal cell carcinoma in the vena cava. J Urol 1970;103:414–20.[Medline]
2. Daughtry JD, Stewart BH, Golding LAR, Groves LK. Pulmonary embolus presenting as the initial manifestation of renal cell carcinoma. Ann Thorac Surg 1977;24:178–81.[Abstract]
3. Wilkinson CJ, Kimovec MA, Uejima T. Cardiopulmonary bypass in patients with malignant renal neoplasms. Br J Anesth 1986;58:461–65.[Abstract/Free Full Text]
4. Milne B, Cervenko FW, Morales A, Salerno TA. Massive intraoperative pulmonary tumor embolus from renal cell carcinoma. Anesthesiology 1981;54:253–5.[Medline]
5. Heaton BW, Sorenson CW Jr, Middleton RG. Renal cell cancer tumor thrombi causing a massive pulmonary embolus in a 34-year-old man. J Urol 1993;150:1225–6.[Medline]
6. Hedderich GS, O'Connor RJ, Reid EC, Mulder DS. Caval tumor thrombus complicating renal cell carcinoma: a surgical challenge. Surgery 1987;102:614–21.[Medline]
7. Fukui Y, Koie K, Takashima T, et al. A case report of a massive pulmonary tumor embolism that occurred during surgery for renal cell carcinoma. Kyobu Geka 1992;45:529–32.[Medline]
8. Masumori N, Iwabe H, Kumamoto E. Studies on pulmonary metastasis of renal cell carcinoma-pulmonary embolism revealed by lung perfusion imaging and the metastasis. Nippon Hinyokika Gakkai Zasshi 1991;82:769–75.[Medline]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Hiroshi Kubota Akira Furuse Yutaka Kotsuka Kuniyoshi Yagyu Motohiro Kawauchi Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kubota, H. Articles by Saito, H. Search for Related Content PubMed PubMed Citation Articles by Kubota, H. Articles by Saito, H.