The Role of Transesophageal Echocardiography in Rapid Diagnosis and Treatment of Migratory Tumor Embolus

Abstract

Transesophageal echocardiography (TEE) is sometimes used in renal cell carcinoma excision for evaluating the extension of tumor in the inferior vena cava (IVC), characterizing the tumor anatomy, monitoring the tumor during surgical mobilization, and assessing cardiac function. Although the risk for embolization is small, when embolization does occur, its consequences can be catastrophic. In this case report, we describe the crucial role of TEE in diagnosing an intraoperative migratory embolus from the IVC to the pulmonary artery and also provide both single-frame photographs and Internet-accessible videos of the event. Our case illustrates the key role that TEE played in the intraoperative management of a patient with renal cell carcinoma undergoing surgical excision of tumor. TEE aided in accurately defining the cephalad extent of the thrombus, provided continuous monitoring of the thrombus during surgical manipulation, and allowed immediate identification of its embolization and proper notification of the surgeons. This case illustrates the crucial role TEE played in the management of a migratory tumor embolus and argues for its routine use during excision of renal cell carcinomas invading the IVC.

The role of transesophageal echocardiography in the management of renal cell carcinoma with venous tumor thrombus

“…One institution recommended TEE only be available for all higher staged tumors, even if thought to be organ‐confined, to help prevent risk of tumor embolization if incidentally present in the venous system. This same group also routinely used intraoperative TEE for all tumors with known IVC involvement irrespective of level . No matter the preoperative plan, it is our recommendation that any institution attempting resection of RCC with tumor thrombus have the capability to obtain an intraoperative TEE assessment quickly should the clinical need arise.…”

“…Most studies reported preoperative imaging within 4 weeks of surgery, but many are now recommending reimaging within seven to 14 days of surgical extirpation . The reason for this is that tumor thrombi can grow and propagate quickly, and there are many examples throughout the literature where preoperative imaging did not well‐represent the degree of tumor thrombus compared to the surgical resection specimen . For example, it has been reported that intraoperative TEE revealed findings not seen on a TTE from just 2 days prior to surgery.…”

“…Another paper described an example in which intraoperative TEE was not used and a missed embolism led to delay in diagnosis and treatment . In addition to its diagnostic use, TEE can also aid in the removal of emboli . Further, TEE may also aid in preventing embolism by providing the surgeon real‐time feedback to assess the mobility and fragility of thrombus, and thus its propensity to embolize, which can alter surgical technique .…”

Early Detection of a Cavopulmonary Tumor Embolus with the Use of Transesophageal Echocardiography

“…13 Other similarly favorable outcomes were subsequently reported. [14][15][16] Investigators have found TEE to be accurate in monitoring intraoperative embolic phenomena during tumor manipulation, 17 evaluating IVC tumor extension, 18 recognizing residual tumor after attempted resection, 19 and evaluating preload and cardiac function during IVC clamping. Oikawa and colleagues 20 described the additional use of intraoperative TEE to position an intracaval balloon above the tumor thrombus, thus enabling resection without the need to mobilize the liver.…”

Echocardiography images of inferior vena cava tumour thrombus in patient with renal cell carcinoma

“…Clinical reports have highlighted the role of the TEE in patients undergoing renal cell carcinoma excision utilizing cardiopulmonary bypass. 1,2 In this case, TEE imaging provided real-time guidance to surgical excision of a large renal cell carcinoma.…”