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Ann Thorac Surg 2000;69:972-973
© 2000 The Society of Thoracic Surgeons

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Correspondence

Successful treatment of massive pulmonary tumor embolism from renal cell carcinoma

^a Department of Surgery, Tokyo Metropolitan Police Hospital, 2-10-41, Fujimi, Chiyodaku, 102-8161 Tokyo, Japan
^b Department of Cardiothoracic Surgery, University of Tokyo, 113-8655 Tokyo, Japan
^c Department of Cardiothoracic Surgery, JR Tokyo General Hospital, 151-8528 Tokyo, Japan

To the Editor

Renal cell carcinoma has a propensity to extend into the local venous system. Renal vein and inferior vena cava involvement occur 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. In 1996 we reported a 60-year-old man as a case of successful management of massive pulmonary tumor embolism from renal cell carcinoma in The Annals of Thoracic Surgery [2]. Five years after the operation the patient is doing well without any sign of metastasis or local recurrence.

The patient presented at a local hospital with flank pain and a progressively enlarging abdominal mass. Computed tomographic scan revealed a large enhanced mass, which was diagnosed as renal cell carcinoma in the left kidney and local extension to the infrahepatic inferior vena cava. Awaiting admission to our institute, the patient experienced sudden chest pain and severe shortness of breath at his home. He was admitted as an emergency patient to the local hospital and intubated. Computed tomographic scan on admission showed massive pulmonary emboli in the bilateral pulmonary artery, whereas part of the local extension to the inferior vena cava had disappeared. Radical nephrectomy and resection of the extended tumor in the inferior vena cava were performed in our institute in October 1994. Four days after the nephrectomy, tumor embolectomy of the bilateral pulmonary artery was performed through a median sternotomy using cardiopulmonary bypass with deep hypothermia and intermittent circulatory arrest. According to the TNM classification of renal call carcinoma UICC (International Union Against Cancer) 1997 [3], this case is classified as stage III (T3b, N0, M0). The histopathologic diagnosis was infiltrating type, papillary–alveolar type, granular cell subtype, G2>>G1, inf beta, pT3c (9.5 x 5 x 5 cm), pN0 (0/17), pV2c, ly (+). The cut end of the ureter was negative for cancer, and there was a tumor thrombus in the left testicular vein. The postoperative course was uneventful and the patient was discharged from the hospital 4 weeks after the operation. The patient was followed at our outpatient unit. At 5 years after the operation, although some scarring from the pulmonary infarcts was detected, no metastatic lesion was found on computed tomographic scan.

As Javidan and associates [4] describe, the 5-year survival rates of renal cell carcinoma are 95% (stage I), 88% (stage II), 59% (stage III), and 20% (stage IV). Compared with other malignant tumors, the survival rate of renal cell carcinoma is relatively high. Our report described a patient who was rescued from the shock and survived long after the surgical management of massive pulmonary tumor embolism due to renal cell carcinoma. The pulmonary emboli should not be considered distant metastases as pulmonary embolism secondary to renal cell carcinoma does not always cause pulmonary metastasis. Masumori and associates [5] reported 2 patients with renal cell carcinoma in whom positive findings on lung perfusion imaging disappeared during follow-up. They suggest 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 [5]. Wagner and associates [6] also describe that pulmonary infarcts can "mimic" pulmonary metastases from renal cancer for the same reason. When there is a distant metastasis, it is classified as stage IV, so it is important not to diagnose pulmonary infarcts as pulmonary metastases. As renal cell carcinoma is not very sensitive to radiation therapy and anticancer agents, treatment of the original lesion and immediate removal of the pulmonary tumor thrombus should improve the long-term results of patients with renal cell carcinoma.

References

1. Marshall V.F., Middleton R.G., Holswade G.R., Goldsmith E.I. Surgery for renal cell carcinoma in the vena cava. J Urol 1970;103:414-420.[Medline]
2. Kubota H., Furuse A., Kotsuka Y., Yagyu K., Kawauchi M., Saito H. Successful management of massive pulmonary tumor embolism from renal cell carcinoma. Ann Thorac Surg 1996;61:708-710.[Abstract/Free Full Text]
3. Sobin L.H., Wittekind Ch. International Union Against Cancer (UICC), 5th ed. New York: Wiley-Liss, 1997:180-182.
4. Javidan J., Stricker H.J., Tamboli P., et al. Prognostic significance of the 1997 TNM classification of renal cell carcinoma. J Urol 1999;162:1277-1281.[Medline]
5. 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;82:769-775.[Medline]
6. Wagner J.R., Merino M.J., Pass H.I., Linehan W.M., Walther M.M. Pulmonary infarcts can mimic pulmonary metastases from renal cancer. J Urol 1997;158:1688-1690.[Medline]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted 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): Shinichi Takamoto Yutaka Kotsuka Akira Furuse Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Kubota, H. Articles by Furuse, A. Search for Related Content PubMed PubMed Citation Articles by Kubota, H. Articles by Furuse, A.