[Anesthetic management of a patient with renal cell carcinoma extending into the right atrium]

Renal cell carcinoma (RCC) is characterized by a propensity to invade the inferior vena cava (IVC) via the renal vein. It is estimated that such tumor thrombus extension is observed in 4-10% of cases. As the presence of tumor thrombus has not been shown to be a determinant of survival, surgical resection remains the mainstay for treatment. A 57-year-old woman with renal cell carcinoma extending into the right atrium was scheduled for radical nephrectomy and thrombectomy under cardiopulmonary bypass. There was a high possibility of massive bleeding and pulmonary embolism resulting in sudden death during surgical manipulation. Preparing for pulmonary embolism, at the beginning of the operation, a median sternotomy was perfomed to enable us to initiate the CPB immediately. Moreover transesophageal echocardiography (TEE) was perfomed during the operation to detect pulmonary embolism and to recognize the position of the thrombus. In this case, we can detect the cephalad extent of the thrombus during surgical manipulation by continuous TEE monitoring, and notify the information to the surgeons. The use of TEE allowed rapid initiation of CPB before the onset of pulmonary embolism. The monitor showed no signs of pulmonary embolism, and the operation proceeded uneventfully. We recognized the diagnostic power of TEE and its crucial role in a patient having tumor thrombus extending to the IVC.