P045: ANESTHETIC MANAGEMENT OF HYPERTHERMIC INTRATHORACIC CHEMOTHERAPY (HITHOC) FOR THORACIC INVASION OF RECURRING METASTATIC WILMS TUMOR AFTER CYTOREDUCTIVE SURGERY IN A PEDIATRIC PATIENT
Michele Hendrickson, MD, Karen Ashley Jackson, MD, Alecia L Sabartinelli Stein, MD; University of Miami Miller School of Medicine
Introduction: Cytoreductive surgery with heated intraperitoneal chemotherapy (HIPEC) for abdominal carcinomatosis is well described in the adult literature and is standard of care for several cancers. More recently, use of hyperthermic intrathoracic chemotherapy (HITHOC) for treatment of adult malignant tumors of the thoracic cavity and malignant pleural effusions has been reported.
In pediatric patients, the incidence of peritoneal sarcomatosis is not known, and when present, carries a poor prognosis. Due to the success in the adult cohort, the first clinical trial of HIPEC treatment efficacy in pediatric abdominal malignancies was undertaken and resulted in increased survival. Only few centers, one being our institution, are utilizing this therapy for rare pediatric tumors with abdominal seeding (i.e. Wilm’s tumor, small round cell tumor, etc.). There is limited data on use of HIPEC and its perioperative anesthetic management in this population. To date, there are no reported cases of HITHOC for thoracic tumor dissemination in the pediatric population.
Case summary: We present a rare case of intrathoracic cytoreductive surgery with HITHOC in a pediatric patient with recurrent metastatic Wilm’s tumor with thoracic invasion. This 13-year-old female failed multiple cycles of traditional chemotherapy following nephrectomy for primary tumor removal and two prior resections of diaphragm and pulmonary seeding. She was to undergo cytoreductive removal of lesions on the left lung, pleura, posterior diaphragm and pericardium prior to heated chemotherapy infusion.
Anesthetic management consisted of the following: thoracic epidural placement prior to induction of general anesthesia with placement of a 35 french left-sided double lumen endotracheal tube for lung isolation; vascular access consisting of large-bore IVs and central venous access; invasive blood pressure monitoring via radial artery cannulation for goal-directed fluid resuscitation and arterial blood-gas sampling; thromboelastography-guided intraoperative blood product management; and multi-modal systemic analgesia therapy including continuous epidural infusion intra- and postoperatively.
During the heated chemotherapy infusion, urine output was measured every 15 minutes with a goal of 3cc/kg/hour of urine output to minimize cisplatin-related acute kidney injury; and careful attention was paid to the patient’s core temperature.
At surgery end, the double-lumen tube was exchanged for a single-lumen tube, and the patient was transported to the ICU intubated and sedated.
Discussion/Conclusion: This case represents the first known report of a pediatric HITHOC and will highlight the unique challenges in anesthetic management. HITHOC may be characterized by significant fluctuations in peak airway pressures, fluid compartment shifts, severe blood loss and alterations in hemodynamics, systemic hypo- or hyperthermia, and a high degree of post-operative pain, as has been described in adult literature. Intraoperative fluid management is also challenging, being a balance between reducing risk of chemo-related acute kidney injury and use liberal fluid administration associated with acute lung injury. We were able to achieve this goal without diuretic use or pulmonary complications. Because there is a paucity in the literature regarding the anesthetic management of pediatric patients undergoing these procedures, we extrapolated whenever possible from the adult literature. Careful planning and attention of safe anesthetic care contributed to a successful outcome for this young girl.