Transesophageal Echocardiography in Renal Cell Carcinoma: An Accurate Diagnostic Technique for Intracaval Neoplastic Extension

Abstract

Between 4 and 10% of patients with renal cell carcinoma have tumor involving the inferior vena cava and many of these patients have suprahepatic extension. In patients with intracaval neoplastic extension precise definition of the superior aspect of the tumor thrombus is critical. Transabdominal ultrasonography, computerized tomography (CT), magnetic resonance imaging (MRI) and inferior venacavography are all currently used to evaluate the inferior vena cava in these patients. Intraoperative transesophageal echocardiography was used to image the inferior vena cava in 5 patients with renal cell carcinoma and intracaval neoplastic extension. In each patient transesophageal echocardiography correctly revealed the superior extent of tumor thrombus. In 3 patients tumor thrombus was found at a higher level by transesophageal echocardiography than by CT, MRI and inferior venacavography. In all patients tumor imaging by transesophageal echocardiography correlated well with the gross appearance and extent of tumor found at operation. Echocardiography also documented the absence of residual gross tumor after resection. Transesophageal echocardiography was also useful to assess left ventricular function. Although each of these patients had a pulmonary artery catheter as well transesophageal echocardiography can be useful in situations when right atrial tumor thrombus prevents right heart catheterization. This small series demonstrates that intraoperative transesophageal echocardiography can accurately evaluate the extent of tumor thrombus and provides a means to assess myocardial function complementary to the pulmonary artery catheter.

Surgical management of large adrenal tumours: the University of Miami experience using liver transplantation techniques

“…We suggest that CPB should be a backup technique in cases of extensive level IV thrombus, especially when it is adherent to the IVC wall or atrium. It should be mentioned that TEE is a valuable tool in such cases, to determine the extent of thrombus and whether it is freely movable [6]. Rarely adrenal malignancy can cause Budd-Chiari syndrome, as in one case in the present series.…”

“…The median (range) intraoperative blood loss, except in the patient who required CPB, was 500 (250-1500) mL (Table 1), and the median operative time was 320 (260-475min) min. The median tumour size was 11 (5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20) cm (Fig. 3).…”

“…Preoperative fine-needle aspiration biopsy or cytology was not required, as they would not have changed the treatment plan and would have increased the risk of dissemination or haemorrhage. Transoesophageal echocardiography (TEE) was performed intraoperatively to assess thrombus mobility when it extended above the hepatic veins [6]. To determine the surgical approach, we used the classification of tumour thrombus for adrenal tumours, proposed by Ekici and Ciancio [7] in 2004 (Table 2).…”

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.…”

Use of Dynamic Two-Dimensional Transesophageal Echocardiography for Renal Cell Carcinoma with Cavoatrial Tumor Thrombus

“…In the absence of distant metastases, positive lymph nodes, or perinephric fat inva sion, surgical excision of the renal tumor and its thrombus is associated with a 5-year survival of 20-50% [4][5][6][7], Precise preoperative determination of the cephalad extent of the tumor thrombus is essential for planning sur gical excision. Transesophageal echocardiography (TEE) has recently been reported to provide this information with an accuracy that equals or exceeds that of other methods commonly used to stage tumors [8], The useful ness of TEE is not limited to preoperative staging, how ever, and when used intraoperatively in addition to other monitoring devices, it can provide data to facilitate the surgical and anesthetic management of these challenging patients. …”