Asian Cardiovasc Thorac Ann 2006;14:e99-e101
© 2006 Asia Publishing EXchange Ltd
Extension of Pulmonary Adenocarcinoma into the Left Atrium
Jan Vojá
ek, MD,
Jan Burkert, MD1,
Pavel Pafko, MD1,
Martin Mates, MD2,
Jaroslav 
patenka, MD,
Petr Pavel, MD
Division of Cardiac Surgery
1 Division of Thoracic Surgery
2 Division of Cardiology, University Hospital Motol Prague, Czech Republic
For reprint information contact: Jan Vojáek, MD Tel: 420 7 7709 5921 Fax: 420 2 2443 5220 Email: j.vojacek{at}fnmotol.cz, Division of Cardiac Surgery, University Hospital Motol, Prague 5, 155 00, Czech Republic.
 |
ABSTRACT
|
|---|
A 62-year-old man presented with pulmonary adenocarcinoma that penetrated through the pulmonary vein into the left atrium. The tumor in the left atrium was removed via a right lower lobectomy under cardiopulmonary bypass. In selected cases, radical removal of a tumor in patients without mediastinal lymph node involvement may improve the prognosis. The use of cardiopulmonary bypass extends the possibilities of radical tumor removal.
|
Introduction
|
|---|
Intrathoracic tumors penetrating the mediastinum or extrathoracic tumors metastasizing into the mediastinal organs are 20 to 40 times more frequent than primary cardiac tumors. Despite this, direct infiltration of non-small cell lung cancer (NSCLC) into the mediastinum (stage T4) is rare. Pitz and colleagues1 report a 4.4% incidence of T4. Involvement of the mediastinum in lung cancer is associated with an extremely poor prognosis and many thoracic surgeons consider such tumors inoperable. We report a successful radical removal of NSCLC penetrating through the pulmonary vein into the left atrium (LA). Due to extensive involvement of the LA, it was necessary to remove the tumor under cardiopulmonary bypass (CPB).
|
Case Report
|
|---|
A 62-year-old man, a long-time smoker, was investigated for hemoptysis, chronic fatigue, and dysorexia. Chest radiography showed an opacity in the right lower lung field. Computed tomography (CT) of the thorax confirmed a tumor in the right lower lobe, measuring 2 x 2 cm. The tumor penetrated the lower right pulmonary vein into the LA (Figure 1
). No involvement of hilar or mediastinal nodes was found. Magnetic resonance imaging confirmed a 65 x 50 x 40 mm tumor in the LA. A lung biopsy was performed under CT guidance, and primary pulmonary adenocarcinoma was verified histologically. Whole-body positron emission tomography identified 2 tumors with glucose hypermetabolism, in the lower right pulmonary lobe and the LA, with no involvement of mediastinal nodes or distant metastases. The TNM classification was T4N0M0. A coronary angiogram showed only nonsignificant stenoses, and there was pathological vascularization of the tumor from the circumflex and right coronary arteries (Figure 2).
View larger version (78K):
[in this window]
[in a new window]
|
Figure 1. Computed tomography scan clearly showing a left atrial tumor (black arrow) that penetrates into the left atrium through the lower right pulmonary vein (white arrow).
|
|
View larger version (161K):
[in this window]
[in a new window]
|
Figure 2. A Right coronary artery angiogram showing pathological vascularization of the left atrial tumor (white arrow).
|
|
The patient was considered to be a candidate for en bloc right lower lobectomy and LA resection. A radical right lower lobectomy was performed via a right anterolateral thoracotomy. Cardiopulmonary bypass was instituted using bicaval cannulation from this exposure, and femoral artery cannulation from the groin. The LA was opened on the beating heart. The tumor, measuring 6 x 5 x 4 cm, was seen to fill approximately two thirds of the LA, it was immobile and fixed to the wall at the ostium of the right lower pulmonary vein (Figure 3). The tumor was easily removed, the ostium of the pulmonary vein was widely excised, and the defect was closed with a continuous 4/0 polypropylene suture. Cardiopulmonary bypass was discontinued uneventfully after 90 minutes, and the patient was discharged on the 7th postoperative day. Histologically, a poorly differentiated adenocarcinoma with focal intracellular mucin production was confirmed in the lung tissue. The tumor in the LA was formed by necrotic adenocarcinoma. The patient underwent a course of chemotherapy postoperatively. After 15 months, he was well, without any signs of tumor progression or metastatic involvement.
View larger version (110K):
[in this window]
[in a new window]
|
Figure 3. View from the right thoracotomy; the left atrium is opened demonstrating a solid tumor within the lumen of the left atrial cavity (white arrow) and involving a portion of the wall.
|
|
|
DISCUSSION
|
|---|
Non-small cell lung cancer infiltration of the wall of the LA or intrapericardial pulmonary veins is a relatively rare presentation. This condition is usually discovered at autopsy. With improvements in diagnostic imaging techniques including CT, magnetic resonance imaging, positron emission tomography, and echocardiography, isolated T4 lung cancers can be identified earlier. There may be either direct penetration of the tumor into the LA wall or expansion into the LA cavity through the pulmonary veins.
Although the lower pulmonary vein was completely closed by the penetrating tumor in our patient, there was no pulmonary infarct. This may be explained by gradual venous obstruction that allowed the development of collateral circulation. The coronary angiogram showed pathological vascularization of the carcinoma from the coronary arteries. Similar vascularization occurs in primary cardiac tumors, such as myxoma. The histology confirmed an adenocarcinoma that was clearly an extension of the primary pulmonary carcinoma. The vascularization probably developed as part of tumor erosion of the coronary arteries in the LA wall. This pathological tumor vascularization has not been demonstrated previously. Most reports describe partial LA resection without CPB, using vascular clips or staples.2,3 However, this is possible only when the tumor does not penetrate extensively into the cardiac cavity, but infiltrates the LA wall locally. Otherwise, most surgeons consider it inoperable and apply conservative treatment. Use of CPB extends the possibility of a radical resection, but also increases the surgical risk. Its use is indicated if an atriotomy is necessary to remove an intra-atrial tumor. Rare case reports have described this type of procedure.4,5
A lung tumor involving the intrapericardial part of the pulmonary veins or the LA is classified as T4, regardless of the degree and extent of infiltration. There are few such reports and they include patients with various degrees of LA infiltration. The perioperative mortality for this procedure is 5%–18%.6 It is not clear whether the use of CPB contributes to a higher mortality rate. The 5-year survival in cases of NSCLC penetrating the LA is 0% to 22%. Factors that have adverse effects on survival are mediastinal node involvement (stage N2), location of the primary tumor in the lower lobe, and incomplete radical surgery.3 Tumors of the lower lobe most often penetrate the LA. The prognosis deteriorates considerably when mediastinal nodes are affected, even in the case of radical removal of a tumor in the LA. Fukuse and colleagues6 reported mean survival of only 9 months in these patients.
A poor prognosis in patients with NSCLC at T4 stage infiltrating the LA persists even after surgical treatment. In spite of this, it appears that in selected cases, radical tumor removal may improve the prognosis. This applies to patients at T4 stage without mediastinal node involvement and without remote metastases. These patients should be offered surgical treatment. If the tumor is in an intra-atrial position or extensively infiltrates the LA wall, radical removal of the tumor under CPB is possible. If mediastinal nodes are affected, surgery does not improve the prognosis and conservative treatment should be applied.
|
References
|
|---|
- Pitz CC, Brutel de la Riviere A, van Swieten HA, Westermann CJ, Lammers JW, van den Bosch JM. Results of surgical treatment of T4 non-small cell lung cancer. Eur J Cardiothorac Surg 2003;24:1013–8.[Abstract/Free Full Text]
- Shimizu J, Hirano Y, Ishida Y, Kinoshita S, Tatsuzawa Y, Kawaura Y, et al. Advanced lung cancer invading the left atrium wall treated with pneumectomy and combined resection of the left atrium using stapling devices: report of two cases. Ann Thorac Cardiovasc Surg 2004;10:113–7.[Medline]
- Ratto GB, Costa R, Vassallo G, Alloisio A, Maineri P, Bruzzi P. Twelve-year experience with left atrial resection in the treatment of non-small cell lung cancer. Ann Thorac Surg 2004;78:234–7.[Abstract/Free Full Text]
- Baron O, Jouan J, Sagan C, Despins P, Michaud JL, Duveau D. Resection of bronchopulmonary cancer invading the left atrium-benefit of cardiopulmonary bypass. Thorac Cardiovasc Surg 2003;51:159–61.[Medline]
- Byrne JG, Leacche M, Agnihotri AK, Paul S, Bueno R, Mathisen DJ, et al. The use of cardiopulmonary bypass during resection of locally advanced thoracic malignancies: a 10-year two-center experience. Chest 2004;125:1581–6.[Abstract/Free Full Text]
- Fukuse T, Wada H, Hitomi S. Extended operation for non-small cell lung cancer invading great vessels and left atrium. Eur J Cardiothorac Surg 1997;11:664–9.[Abstract]
TOP
ABSTRACT
Introduction
