Multidisciplinary approach and anesthetic management of a surgical cancer patient with methylene tetrahydrofolate reductase deficiency: a case report and review of the literature.
BACKGROUND
Hyperhomocysteinemia is a known risk factor for myocardial infarction, stroke, peripheral vascular disease, and thrombosis. Elevated plasma homocysteine levels have been demonstrated in patients with recurrent episodes or a single episode of thrombosis. Here we describe the development of cardiovascular disease as a complication of a surgical intervention in a patient with colorectal cancer and hyperhomocysteinemia.


METHODS
A 65-year-old Caucasian man complained of pain and constipation, attributed to previously diagnosed adenocarcinoma (stage IIB) of the hepatic flexure. An anamnestic investigation showed that he had undergone two surgical interventions. During both, he suffered thrombotic postoperative complications, a deep vein thrombosis of the upper extremity after the first operation and retinal vein occlusion after the second. He was diagnosed with hyperhomocysteinemia associated with a homozygous C677T mutation of the gene encoding the enzyme methylenetetrahydrofolate reductase. Our patient was initially treated with folic acid and high-dose B vitamins. On day 7 he underwent a right hemicolectomy. Anesthesia was performed with sevoflurane in 40% O2 and without the use of nitrous oxide. Postoperatively, our patient remained on folic acid and B vitamins and was without immediate or subsequent complications.


CONCLUSIONS
Neoplastic disease and related surgery followed by the administration of chemotherapeutic drugs alter the hemostatic balance in cancer patients. Those suspected of also having a thrombophilic disease require a thorough laboratory diagnostic workup, including a molecular analysis aimed at identifying the genetic mutation responsible for the hyperhomocysteinemia, as indicated. The case described in this report highlights the importance of a multidisciplinary approach that includes expertise in peri-operative anesthesia, surgery, oncology, and hematology.
Division of Anesthesia, Department of Anesthesia, Endoscopy and Cardiology, Istituto Nazionale Tumori "Fondazione G. Pascale" - IRCSS, Naples, Italy. m.cascella@istitutotumori.na.it.
Marco
M
Cascella
Marco Mc
MM
Cascella
Division of Haematology-Oncology and Stem Cell Transplantation Unit, Istituto Nazionale Tumori "Fondazione G. Pascale" - IRCSS, Naples, Italy. m.arcamone@istitutotumori.na.it.
Manuela
M
Arcamone
Manuela Ma
MM
Arcamone
Division of Haematology-Oncology and Stem Cell Transplantation Unit, Istituto Nazionale Tumori "Fondazione G. Pascale" - IRCSS, Naples, Italy. manucobain@yahoo.com.
Emanuela
E
Morelli
Emanuela Em
EE
Morelli
Department of Surgery, Anesthesia, Emergency and Intensive Care, University of Naples "Federico II", Naples, Italy. nicedy84@hotmail.it.
Daniela
D
Viscardi
Daniela Dv
DD
Viscardi
Department of Surgery, Anesthesia, Emergency and Intensive Care, University of Naples "Federico II", Naples, Italy. fedinavr@yahoo.it.
Viera
V
Russo
Viera Vr
VV
Russo
Department of Abdominal Oncology Surgery, Istituto Nazionale Tumori "Fondazione G. Pascale"- IRCSS, Naples, Italy. silviadefra18@gmail.com.
Silvia
S
De Franciscis
Silvia Sdf
SS
De Franciscis
Department of Abdominal Oncology Surgery, Istituto Nazionale Tumori "Fondazione G. Pascale"- IRCSS, Naples, Italy. a.belli@istitutotumori.na.it.
Andrea
A
Belli
Andrea Ab
AA
Belli
Division of Anesthesia, Department of Anesthesia, Endoscopy and Cardiology, Istituto Nazionale Tumori "Fondazione G. Pascale" - IRCSS, Naples, Italy. r.accardo@istitutotumori.na.it.
Rosanna
R
Accardo
Rosanna Ra
RR
Accardo
Division of Anesthesia, Department of Anesthesia, Endoscopy and Cardiology, Istituto Nazionale Tumori "Fondazione G. Pascale" - IRCSS, Naples, Italy. d.caliendo@istitutotumori.na.it.
Domenico
D
Caliendo
Domenico Dc
DD
Caliendo
Division of Anesthesia, Department of Anesthesia, Endoscopy and Cardiology, Istituto Nazionale Tumori "Fondazione G. Pascale" - IRCSS, Naples, Italy. e.deluca@istitutotumori.na.it.
Elena
E
De Luca
Elena Edl
EE
De Luca
Division of Anesthesia, Department of Anesthesia, Endoscopy and Cardiology, Istituto Nazionale Tumori "Fondazione G. Pascale" - IRCSS, Naples, Italy. b.dicaprio@istitutotumori.na.it.
Barbara
B
Di Caprio
Barbara Bdc
BB
Di Caprio
Division of Anesthesia, Department of Anesthesia, Endoscopy and Cardiology, Istituto Nazionale Tumori "Fondazione G. Pascale" - IRCSS, Naples, Italy. f.disauro@istitutotumori.na.it.
Francesco
F
Di Sauro
Francesco Fds
FF
Di Sauro
Division of Anesthesia, Department of Anesthesia, Endoscopy and Cardiology, Istituto Nazionale Tumori "Fondazione G. Pascale" - IRCSS, Naples, Italy. g.giannoni@istitutotumori.na.it.
Giovanni
G
Giannoni
Giovanni Gg
GG
Giannoni
Division of Anesthesia, Department of Anesthesia, Endoscopy and Cardiology, Istituto Nazionale Tumori "Fondazione G. Pascale" - IRCSS, Naples, Italy. c.iermano@istitutotumori.na.it.
Carmine
C
Iermano
Carmine Ci
CC
Iermano
Division of Anesthesia, Department of Anesthesia, Endoscopy and Cardiology, Istituto Nazionale Tumori "Fondazione G. Pascale" - IRCSS, Naples, Italy. m.maciariello@istitutotumori.na.it.
Maria
M
Maciariello
Maria Mm
MM
Maciariello
Division of Anesthesia, Department of Anesthesia, Endoscopy and Cardiology, Istituto Nazionale Tumori "Fondazione G. Pascale" - IRCSS, Naples, Italy. m.marracino@istitutotumori.na.it.
Marcella
M
Marracino
Marcella Mm
MM
Marracino
Division of Anesthesia, Department of Anesthesia, Endoscopy and Cardiology, Istituto Nazionale Tumori "Fondazione G. Pascale" - IRCSS, Naples, Italy. arturo.cuomo@alice.it.
Arturo
A
Cuomo
Arturo Ac
AA
Cuomo
D000368:Aged; D000758:Anesthesia / Q000379:methods*; D000769:Anesthesia, Inhalation; D015179:Colorectal Neoplasms / Q000601:surgery*; D006712:Homocystinuria / Q000150:complications* / Q000601:surgery; D006801:Humans; D008297:Male; D008738:Methyl Ethers; D042965:Methylenetetrahydrofolate Reductase (NADPH2) / Q000172:deficiency*; D009128:Muscle Spasticity / Q000150:complications* / Q000601:surgery; D009609:Nitrous Oxide; D011618:Psychotic Disorders / Q000150:complications / Q000601:surgery; D000077149:Sevoflurane
D008738:Methyl Ethers; D000077149:Sevoflurane; D042965:Methylenetetrahydrofolate Reductase (NADPH2); D009609:Nitrous Oxide