Resection of Atriocaval Adrenal Carcinoma Using Hypothermic Circulatory Arrest
David M. Shahian, MD, Peter T. Nieh, MD, and John A. Libertino, MD
Departments of Thoracic and Cardiovascular Surgery and Urology, Lahey Clinic Medical Center, Burlington, Massachusetts, and Division of Thoracic and Cardiovascular Surgery, New England Deaconess Hospital, Boston, Massachusetts
Carcinoma of the adrenal cortex may occasionally extend through the inferior vena cava to the right atrium without actually invading the vascular endothelium. Surgical resection may result in excellent palliation and the po- tential for prolonged survival when no other signs of
advanced disease are present. Extrapolating from our experience with renal cell carcinoma extending to the right atrium, we resected a similar adrenocortical carci- noma using hypothermic circulatory arrest.
(Ann Thorac Surg 1989;48:421-2)
W e recently treated a patient with adrenocortical carcinoma involving the inferior vena cava, he- patic veins, and right atrium using hypothermic total circulatory arrest. To our knowledge, this is the first such case reported in the literature.
A 51-year-old woman was seen with a 3-month history of progressive weakness, fatigue, dyspnea, early satiety, ascites, and peripheral edema. Computed tomography showed a 12-cm right adrenal tumor with central necrosis and extension to the inferior vena cava (Fig 1). Inferior venacavography showed occlusion of the inferior vena cava and hepatic veins and enlarged azygos and hemiazy- gos collateral vessels. Superior venacavography demon- strated extension of tumor or clot to the right atrium. Evaluation for distant metastatic disease was unrevealing. Serum lactate dehydrogenase level was elevated (535 IU/L; normal, 124 to 275 IU/L).
Electroencephalographic leads were applied preopera- tively. Abdominal exploration through a bilateral subcos- tal excision revealed that the adrenal tumor could be mobilized and had not invaded contiguous structures or nodes. Sternotomy was then performed.
Extracorporeal circulation was instituted, and sodium thiopental (Pentothal), 60 mg/kg, was administered. When body temperature reached 28℃ during hypother- mic cardiopulmonary bypass, the ascending aorta was cross-clamped, and cardiac arrest was induced by cold blood cardioplegia. Ice bags were applied to the head. Cardiopulmonary bypass was discontinued when rectal and nasopharyngeal temperature reached 16° to 18℃, and the patient’s blood volume was partially exsanguinated into the cardiotomy reservoir. The right atrium and infe- rior vena cava at the level of the adrenal vein were opened. In a completely bloodless operative field, throm- bus was extracted under direct vision from the right atrium, occluded hepatic veins, and vena cava. No endo-
thelial invasion was noted. The excised tumor showed areas of necrosis, but no viable tumor cells were found in thrombus extracted from the hepatic veins. No tumor cells were found in the abdominal lymph nodes.
The period of total circulatory arrest was 18 minutes. Bypass was restarted after removal of tumor and vascular isolation of the upper inferior vena cava. The atriotomy was closed, and air was evacuated by backbleeding. The caval defect was reconstructed with a Gore-Tex patch while the patient was slowly rewarmed at a rate of no more than 1ºC per three minutes. The aortic clamp was released, and the patient was defibrillated easily at a body temperature of 32°C.
The patient required vascular support with Neo- Synephrine (phenylephrine hydrochloride) and dopa- mine after operation. She awoke nine hours after the 10.5-hour procedure and was extubated on postoperative day 3. An estimated blood loss of 11 L and urinary output
Accepted for publication Feb 7, 1989.
of 5.8 L were replaced with 12 L of a balanced salt solution, 15 units of packed red blood cells, 1.5 L of autologous blood aspirated after tumor removal, 4 units of fresh frozen plasma, and 10 units of platelets. The patient is well with mild dyspnea and a paretic right hemidia- phragm 10 months after operation.
Comment
The use of hypothermic circulatory arrest has not resulted in neurological or other adverse sequelae in the patient described here or in 6 other patients with atriocaval hypernephromas operated on using the same technique. Total circulatory arrest has been used only for that brief but critical interval required for precise tumor removal from the inferior vena cava, hepatic veins, and right atrium. Local caval control proximal and distal to the cavotomy site is then obtained, and bypass is reinstituted during caval reconstruction. Too few patients have under- gone resection of adrenal tumors extending to the inferior vena cava to permit determination of actuarial survival. However, short-term survival of 5 to 22 months has been reported for patients who survived the procedure [1-6]; metastatic disease has developed in some of these pa- tients. Of the 3 patients with tumors resected from the right atrium, 1 patient described by Hugh and colleagues [1] died of pulmonary metastasis 14 months after opera- tion, whereas the second patient, whose tumor was resected using cardiopulmonary bypass, has remained
free of disease at 15 months. The patient of Javadpour and colleagues [6] was reported to be free of disease 12 months after operation.
We advocate radical one-stage resection of adrenal tumors extending to the inferior vena cava and right atrium provided no other evidence of disseminated local or systemic disease is present. Hypothermic circulatory arrest can be performed safely and provides superior visualization and complete removal of intracaval, hepatic vein, and right atrial tumors.
References
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2. Ritchey ML, Kinard R, Novicki DE. Adrenal tumors: involve- ment of the inferior vena cava. J Urol 1987;138:1134-6.
3. Martorana G, Giberti C, Pescatore D, Giuliani L. Preoperative evaluation of adrenal cortical carcinoma extending into the inferior vena cava. J Urol 1982;128:792-3.
4. Dunnick NR, Doppman JL, Geelhoed GW. Intravenous exten- sion of endocrine tumors. AJR 1980;135:471-6.
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