Asian Cardiovasc Thorac Ann 2007;15:e20-e22
© 2007 Asia Publishing EXchange Ltd
Resection of Right Atrial Metastatic Large-Cell Neuroendocrine Carcinoma
Cheng-Hon Yap, MBBS,
Christopher Hair, MBBS1,
Stephan Foy, FRACP2,
Sanjeev Sewak, FRACP3,
Michael Francis, FRACR3,
James F Kenny, FRACS
Department of Cardiothoracic Surgery, Geelong Hospital
1 Department of Anatomical Pathology, Pathcare Consulting Pathologists
2 Department of Cardiology, St. John of God Healthcare
3 Andrew Love Cancer Center, Geelong Hospital, Geelong, Australia
For reprint information contact: Cheng-Hon Yap, MBBS Tel: 61 40 201 5001 Fax: 61 3 9288 2211 Email: yapch{at}svhm.org.au, St. Vincent’s Hospital, Melbourne, PO Box 2900, Fitzroy, Victoria 3065, Australia.
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ABSTRACT
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The incidence of cardiac metastases is rising due to increasingly sensitive diagnostic investigations and longer patient survival as a result of improved treatment for malignancies. We report a rare case of right atrial metastasis from a large cell neuroendocrine carcinoma successfully resected with cardiopulmonary bypass. The surgical management of advanced cardiac malignancy is discussed. In appropriately selected cases surgical resection of cardiac metastases can be beneficial, allowing improvement in quality of life, and prolongation of life.
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INTRODUCTION
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Clinical involvement of the heart by metastatic malignancies is uncommon. However, in patients with malignant neoplasms autopsy studies have shown 1 in 10 patients to have metastatic cardiac involvement.1,2 Thoracic surgery is usually directed at providing palliative symptomatic relief of pericardial effusion or tamponade, as most patients have widespread disease and limited life expectancies. We report a rare case of right atrial metastatic large cell neuroendocrine carcinoma, successfully resected with cardiopulmonary bypass.
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CASE REPORT
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A 57-year-old woman was referred to the cardiothoracic unit with a large right atrial mass. She had a past history of metastatic large cell neuroendocrine carcinoma. She presented 3 years ago with a painful groin lump. Investigations revealed a left lung cancer with mediastinal involvement. She underwent excisional biopsy of the lung primary followed by adjuvant concurrent chemo-radiation and prophylactic cranial irradiation. The metastasis in the left anterior pelvic wall was excised.
She remained in remission for 20 months until she relapsed with a metastasis in the left adductor canal which was resected and followed by adjuvant radiotherapy. Six months later she presented with symptomatic pericardial effusion and a 4 cm right atrial mass which showed avid uptake on positron emission tomography. The pericardial effusion (bloodstained) was drained percutaneously with symptomatic relief. However, the right atrial mass failed to respond to chemotherapy and increased in size to 8 cm on echocardiography (Figure 1
). Although asymptomatic at time of surgery, she was referred for palliative resection on the basis of impending critical obstruction of the cardiac blood flow.
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Figure 1. Transthoracic echocardiography showing the right atrial tumor. Right atrial tumor (T); right ventricle (RV); tricuspid valve (arrow).
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At surgery the tumor was found to occupy the entire free wall of the right atrium with the exception of about 1 cm of normal atrial tissue adjacent to the anterior atrio-ventricular groove and appendage. It involved 75% of the circumference of the superior vena cava and 30% of the distal inferior vena cava. Under cardiopulmonary bypass and a brief period of circulatory arrest the tumor was resected with reconstruction of the atrium using a large bovine pericardial patch. The patient’s postoperative course was uncomplicated.
The tumor measured 70 x 60 x 40 mm (Figure 2). The cellular morphology and immunohistochemical staining characteristics were those of large cell neuroendocrine carcinoma. Surgical margins were focally incomplete. At latest follow-up, 14 months postoperatively, the patient has a 2 cm right atrial tumor recurrence, and recurrent mediastinal disease on chest computed tomography. She remains asymptomatic and is undergoing palliative chemotherapy.
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DISCUSSION
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The heart is a relatively common site for metastatic tumors in autopsy series. Metastatic tumors of the heart are at least 100 times more common than primary malignant cardiac tumors.1,3 The incidence of cardiac metastases is rising due to longer patient survival as a result of improved chemotherapy and radiotherapy, coupled with increasingly sensitive diagnostic investigations. Although difficult to define, the incidence of cardiac involvement in patients with malignant neoplasms is probably above 10%.2 The most common primary neoplasms include leukemia, lymphoma, melanoma, lung, and breast.3 Metastases reach the heart and pericardium by retrograde lymphatic spread, the bloodstream, direct extension, or by direct venous extension.
Surgical intervention is usually limited to providing palliative symptomatic relief of pericardial effusion or tamponade, as most patients have widespread disease and limited life expectancies. In such cases, pericardial drainage can be achieved by subxiphoid pericardiotomy or alternatively, thoracoscopic creation of left pleuropericardial window. Refinements in imaging techniques of conventional computed tomography, magnetic resonance imaging, and echocardiography, in addition to newer nuclear imaging modalities such as positron emission tomography have improved the diagnostic capabilities of detecting cardiac metastases, thus contributing to its rising incidence. Additionally, in providing important anatomic information about the tumor’s local extension they have facilitated the potential for successful surgical resection.
In appropriately selected cases surgical resection of cardiac metastases can be beneficial. The goal should be complete resection and accurate anatomic reconstruction allowing for improvement in quality of life,4 and prolongation of life.5 The surgical procedure will be dependent on the anatomic site and the extent of tumor growth into adjacent structures. Surgical excision is indicated in patients with good preoperative performance status, absent or limited extracardiac disease, long disease-free interval, those with more indolent tumor biology, and clinical deterioration as a result of cardiac involvement. Indications for urgent surgery include prior embolic events, syncopal attacks, or echocardiographic evidence of a mass causing critical obstruction of cardiac blood flow or severe valvular dysfunction. Surgical resection in the literature has been described for various tumor types including melanoma, carcinoid tumors, sarcomas, and renal-cell carcinoma. To our knowledge surgical resection of a metastatic neuroendocrine tumor of the heart has not been previously reported.
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CONCLUSION
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In conclusion, we describe a rare case of metastatic neuroendocrine tumor which was successfully resected from the right atrium. This case demonstrates that successful palliation can be obtained by resection of cardiac metastases in selected patients.
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REFERENCES
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- Hanfling SM. Metastatic cancer to the heart. Review of the literature and report of 127 cases. Circulation 1960;22:474–83.[Abstract/Free Full Text]
- Klatt EC, Heitz DR. Cardiac metastases. Cancer 1990;65:1456–9.[Medline]
- Schoen FJ, Berger BM, Guerina NG. Cardiac effects of noncardiac neoplasms. Cardiol Clin 1984;2:657–70.[Medline]
- Manner G, Harting MT, Russo P, Gregoric ID, Mukhopadhyay M, Flamm SD, et al. Surgical management of metastatic melanoma to the ventricle. Tex Heart Inst J 2003;30:218–20.[Medline]
- Leung CY, Cummings RG, Reimer KA, Lowe JE. Chondrosarcoma metastatic to the heart. Ann Thorac Surg 1988;45:291–5.[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
