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

Abstract

We reviewed the role of transesophageal echocardiography (TEE) in the management of renal cell carcinoma (RCC) with associated tumor thrombus. Many consider intraoperative TEE as imperative in cases of Level 4 thrombi with atrial involvement, as well as in cases that require the use of cardiopulmonary bypass (CPB). However, the role of TEE in the surgical management of RCC with associated inferior vena cava (IVC) thrombus may expand beyond this subset. When performed after induction, TEE provides updated information regarding tumor thrombus staging, which is essential for optimal surgical planning. Furthermore, TEE provides feedback regarding properties of the thrombus, such as fragility and adherence, which may alter surgical technique. TEE can also be used intraoperatively for central venous line placement, to monitor cardiovascular and fluid status, to guide vascular clamp placement, and to ensure complete removal of the tumor thrombus. In some cases, the use of TEE allows for less morbid procedures and safe avoidance of CPB. We therefore recommend the use of preoperative TEE in all cases with a known tumor thrombus with discretion as to what extent TEE is used throughout the remainder of the case. Further investigation is necessary to elucidate the effect of TEE on patient outcomes, including surgical complication rates, morbidity and mortality of procedures, and cancer control.

The role of intraoperative transesophageal echocardiography in the management of renal cell carcinoma with atrial thrombus – case report

“…In preoperative imaging, CT is the most common imaging modality used in the preoperative setting, whereas three-dimensional breath-hold T1-weighted MRI performed after intravenous gadolinium contrast administration is the most sensitive method ( 6 ) . Nevertheless, TEE can accurately define the cranial extent of tumor thrombus, and its diagnostic utility increases with the level of tumor thrombus extension ( 7 ) .…”

“…Based on TEE imaging, one can choose or modify the surgical approach depending on the situation: transabdominal approach with the milking maneuver of the tumor thrombus (case 1) or transabdominal approach with CBP and DHCA (case 2). It provides continuous monitoring of cardiac function, and helps with central line placement ( 6 ) . In the transabdominal approach, it guides the surgeon and prevents applying the vascular clamp to a portion of the IVC with the thrombus, which can result in embolization.…”

Renal cell carcinoma with inferior vena cava tumor thrombus initially misdiagnosed as bland thrombus due to hypercoagulable state

“…Intra-operative transesophageal echocardiogram (TEE) 13 was used to delineate the cranial extent and mobility of the TT during the dissection of the retro-hepatic IVC, supradiaphragmatic IVC, and RA. Its use ensured that there were no pulmonary artery emboli or TT in the RA.…”

Transgastric Abdominal Ultrasonography in Anesthesia and Critical Care: Review and Proposed Approach

“…Some authors have suggested that TGAUS can provide real-time assessment of the mobility, fragility, and degree of IVC invasion by the tumor or risk of embolization into the right atrium using the Neves and Zincke classification of renal cell carcinoma. 43,45,50,51,66,123,124 Tumors can evolve between the time of preoperative testing and the day of surgery; TGAUS is, therefore, considered an important tool to accurately locate the tumor intraoperatively, which will improve surgical planning, 50,52,67,68 as well as guide and direct 69 catheter-guided 49 or robot-assisted thrombectomy. 70 Tumor resection may require clamping of the IVC, which dramatically affects preload.…”