Anesthetic Challenges in Renal Cell CarcinomaAnesthetic Challenges in Renal Cell Carcinoma with Metastases to the Lungs and Craniocervical Junction with Metastases to the Lungs and Craniocervical Junction

R. F. Ghaly, MD, FACS, A. Germanovich, DO, A. Khorasani, MD, N. N. Knezevic, MD, PhD, K. D. Candido, MD

Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL 60657 USA

Discussion

Abstract

References

Introduction

Renal Cell Carcinoma (RCC):• rises from renal tubular epithelium• 3% of adult cancers; peak incidence 40-60 years• 5 yr survival same since 1960’s; <10% once metastasized• Current Chemo Rx and radiation treatments ineffective• Mets to lung, bone, soft tissue and liver

Craniocervical junction (CCJ):• Complex biomechanical unit• From base of skull to C-2• Greatest mobility, brainstem & CNs

Compression of CCJ: • Respiratory distress, airway obstruction, CN palsies, diaphragmatic paralysisWe report a rare complex case of metastatic RCC and our approach to anesthetic management

A 28-year old male with renal cell carcinoma and multiple metastatic lesions of craniocervical junction, which is crucial for head and neck rotations, presented for tumor debulking and fusion of occiput to C5 in prone position. Due to airway deformity and torticollis we performed a fiberoptic intubation, followed with total IV anesthesia to allow for use of motor and sensory evoked potentials for intraoperative neurologic monitoring in absence of muscle relaxation. Other challenges in the case included prone one lung ventilation with high peak airway pressures and significant hemodynamic instability due to extensive blood loss from hypervascular tumor resection.

• 28 year old man with PMH of left RCC, s/p L nephrectomy in 2007 presented to ED with 10/10 neck pain

1.Motzer RJ, Bander NH, Nanus D. N. Engl. J. Med. 1996;335:8652. Cotran, Kumar, Fausto, Nelson, Robbins, Abbas. (2005). Robbins and Cotran pathologic basis of disease. St. Louis, Mo: Elsevier Saunders. pp. 10163. Haher TR, Merola AA. Surgical Techniques of the Spine. Thieme Publishers, New York. 2003

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Recommendations

• Many challenges are posed by the biomechanical disruption of CCJ and pulmonary implications due to metastatic RCC• A thorough preoperative assessment and planning is essential for optimal airway management and anesthesia• Diligent awake fiberoptic intubation• Use of total or partial IV anesthesia• Monitoring of evoked potentials• Early total blood resuscitation to maintain spinal cord perfusion pressures

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Case Description

• IMAGING: multiple infiltrative, highly vascular lesions to CCJ, right lung, and iliac crest; Right lung collapse, C1 and C2 destruction (Figures 1 and 2)

• SURGICAL PLAN: tumor debulking & fusion of occiput to C5 via posterior cervical approach in prone position

• ANESTHETIC PLAN: awake FOI, 0.25 MAC isoflurane with propofol and remifentanil to allow for use of MEP and SSEP intraoperative monitoring in absence of NMB• Airway: cervical collar, challenging awake FOB intubation; acute θ• Mild cervical radiculo-myelopathy; Mayfield pins• Pulm: High PAP’s, gas exchange adequate (Graph 1)• CV: BP, HR – stable initially, but required increased pressor, multiple pRBC and IVF support (9u and 7L) (Graph 2)• Neuro: no deficits reported after intubation, surgery, and pt mobilization

Figure 1. CT scan chest Figure 2. MRI cervical spine

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• CCJ is an area of greatest neck mobility. Most flexion and extension of the head occurs due to the motion of biconvex occipital condyles on biconcave articulating surface of C1• Greatest rotation occurs at anterior arch of C1 on odontoid peg of C2. This area also contains the lower brain stem and lower CN• Compression of CCJ can → respiratory distress 2° brainstem compression, airway obstruction due to CN palsies and diaphragmatic paralysis.• One lung ventilation can be successful in younger, healthier pts.• The risk of barotrauma must be weighed against the potential benefit or nature of surgical emergency.