Case presentation: A 56-year-old lady presented to us with progressive abdominal distension and right hypochondriac pain for two months. She was anemic with elevated liver enzymes. Urgent computed tomography (CT) of the abdomen and pelvis showed a huge right supra renal mass. She subsequently developed respiratory failure due to splinting of diaphragm, of which successfully underwent an emergency exploratory laparotomy. Subsequent endocrine and histopathological work up showed an adrenocortical carcinoma (ACC).

Discussion: Suprarenal masses usually originate from the adrenal glands. They should be investigated to rule out phaeochromocytoma, which originate from the inner adrenal medulla or outer cortex to form ACC. The latter usually occur in women and of poor prognosis. Huge ACC may cause acute respiratory failure by way of splinting of diaphragm. Both anaesthetic and surgical teams should be well trained in handling patients who undergo adrenal surgeries.

Case presentation: A young morbidly obese man with a body mass index (BMI) of 43.3 kg/m2 presented to us with acute symptoms of heart failure. An urgent transthoracic echocardiogram showed a huge pedunculated mass which arise from the left atrium, which occasionally completely occludes the mitral valve during each diastole. He underwent a resection of cardiac myxoma, which was complicated with intraoperative hypotension. Fortunately, it was successfully managed by placing the patient in Trendelenburg position for optimum blood pressure control.

Discussion: Tumours of the heart are very rare. Common histopathological findings are myxomas, followed by uncommon types of rhabdomyosarcomas and angiosarcomas. Pedunculated cardiac tumours can cause partial to complete obstructions which may lead to devastating conditions. Anaesthesia for morbidly obese patients with pedunculated cardiac myxoma are extremely challenging. Cardiac anaesthetists should be vigilant in managing these patients as they posed many life-threatening complications.

Case presentation: An elderly man presented to us with progressive onset of bilateral lower limb weakness which was associated with thoracic radiculopathy and urinary incontinence. An urgent magnetic resonance imaging (MRI) of the spine showed severe cord compression with enlarged prostate and superior mediastinal mass. A computed tomography (CT) guided biopsy of the mediastinal mass was suggestive of prostatic malignancy. An emergency posterior instrumentation and fusion (PSIF) in prone position was successfully done. Histopathological examination of the spine showed malignant glandular tissues, suggestive of prostate.

Discussion: A huge mediastinal mass can compromise the cardiorespiratory system and is very challenging for the anaesthetist to safely secure the airway for surgical procedures. Androgen deprivation therapy (ADT) for patients with metastatic prostatic carcinoma can be achieved either by medical castration or with bilateral orchidectomy.

Case presentation: A 50-years-old Asian man, with a one-year history of surgically resected UC, presented to us with a complaint of worsening upper back pain for three months. Magnetic resonance imaging (MRI) showed a destructed second thoracic (T2) vertebra with lytic lesion. A thoracic vertebrectomy was performed and histopathological examination (HPE) showed high-grade infiltrating metastatic malignant UC. Postoperatively, he was well and did not have any back pain. He was followed up under combined spine and oncology clinic regularly and was planned for chemoradiotherapy.

Discussion: UC commonly metastasizes to the lungs, liver, and lymph nodes. In young Asians, thoracic spinal metastases are rare. Urgent palliative spinal surgery is indicated to prevent further deterioration of function. Intraoperative usage of targeted controlled infusion (TCI) of remifentanil and propofol as maintenance of anaesthesia are gold standard in assisting spine surgeons who are guided by neuromuscular monitoring.