Management of Synchronous Renal Cell Carcinoma and Abdominal Aortic Aneurysm as a Single Staged Operation

Abstract

Simultaneous occurrence of abdominal aortic aneurysm and renal cell carcinoma is a rare entity. Benefits of single stage operations have to be weighed against staged operations. There is no consensus on the best management approach for patients with simultaneous aortic aneurysm and malignancy. Various possibilities have been considered, namely, to repair the aneurysm and treat the malignancy later, to resect the malignancy and repair the aneurysm later, to undertake both procedures simultaneously, and in some cases to treat the malignancy and manage the aneurysm conservatively. Aortic aneurysm repair is a prophylactic procedure and is worthwhile where the lifetime risk of rupture exceeds the risk from treatment. The prognosis of cancer is therefore central to the decision making process. The perceived increase risk of aortic aneurysm rupture following cancer surgery, the significant delay in the treatment of cancer if aneurysm is treated first, and the risk of graft infection are the other important considerations in the management of concomitant aortic aneurysm and cancer. In staged operations, malignancy or abdominal aortic aneurysm (AAA) first have to be decided depending on stage of cancer, risk of aneurysm rupture, graft infection and other comorbid features. We rarely encounter a situation where abdominal aortic aneurysm and abdominal malignancy, in particular renal cell carcinoma (RCC) occurs concomitantly and treated as single staged operation. Patient underwent bypass graft followed by partial nephrectomy through a midline laparotomy. Patient had uneventful post operative recovery except for chylous leak, not subsiding with conservative treatment followed by blockage of lymphatic fistula with computerized tomography (CT) guided fibrin glue application. Chylous ascites has to be treated as early as possible since it increases the possibility of graft infection. In this case, we discuss various possibility to approach a case of synchronous malignancy, and chylous ascites management through ‘CT guided fibrin glue application’ for a favourable outcome.