Endoskopische transthorakale Sympathektomie bei paraneoplastischem Raynaud-Syndrom

Abstract

Six months after nephrectomy for renal-cell carcinoma and during treatment with interferon-alpha and vinblastin, a 70-year-old patient developed necrotizing Raynaud's phenomenon in both hands (at first: pain, livid skin and hyperhidrosis; later: painful acral ulcers; finally: trophic changes plus almost complete impairment of mobility and fine movements in both hands). These changes persisted even after the end of chemotherapy and despite several months on aspirin, naftidrofuryl, nitrates and glucocorticoids, so that the patient's general health was seriously affected. Because repeated sympathetic blocks were efficacious for brief periods, bilateral transthoracic endoscopic sympathectomy (TES) was performed. The patient became free of pain at once, the acral ulcers healed within a few weeks and he could again use his hands. Until his death from advanced metastases 10 months later the Raynaud's phenomenon did not recur. This case suggests that sympathetic vasoconstriction is apparently involved in the maintenance and progression of malignant neoplasm-associated Raynaud's phenomenon. TES is recommended as a reasonable palliative measure in patients with limited life expectancy, as long as preceding sympathetic blockage has indicated likely success and the procedure is performed under intraoperative monitoring of acral and facial skin temperature.

Paraneoplastic Raynaud's phenomenon manifesting before the diagnosis of lung cancer

“…Various prior case-reports have demonstrated that treatment of the malignancy also causes improvement with regards to the paraneoplastic Raynaud’s phenomenon 6 15 24…”

Thoracic sympathectomy: a review of current indications

“…One sign of the paraneoplastic syndrome is digital ischaemia. In one such reported case with severe bilateral Raynaud's phenomenon, bilateral sympathectomy permanently relieved ischaemia of the hands until demise of the patients after 10 months [192].…”

Digitale Ischämien bei einer Patientin mit großzelligem Lungenkarzinom

“…Zur symptomatischen Therapie werden neben der Analgesie mit Opiaten Nitrosalbe, Kalziumantagonisten (prä-ferenziell Nifedipin), Acetylsalicylsäu-re, Heparin und die pharmakologische und/oder interventionelle SympathektoAbb. 2 [7] als auch eine CT-gesteuerte Neurolyse unterhalbTh 3 [2] als erfolgreich beschrieben worden. Letztlich sind die verschiedenen Behandlungsansätze, abgesehen von der Therapie des Malignoms, was zur kompletten Remission der Paraneoplasie füh-ren kann [11], meist lediglich palliativ und nur vorübergehend wirksam: Das Auftreten eines paraneoplastischen RaynaudPhänomens ist oftmals ein "signum mali omnis".…”

“…Im Blutbild fanden sich eine normochrome, normozytäre Anämie von 10,5 g/dl (12,[3][4][5][6][7][8][9][10][11][12][13][14][15]8) und eine leichte Leukozytose von 11,5 G/l (3,7-9,6). Der direkte Coombs-Test, Kälteagglutinine, Kryoglobuline, Rheumafaktoren, ANA, ANCA, Komplement C3 und C4, HIV, Hepatitis B-und C-Serologien sowie Blutkulturen waren negativ bzw.…”