Spread of primary lung carcinoma to the heart by direct extension of metastasis is rare. Disruption of normal organ anatomy and physiology in this area requires extreme care during diagnostic and therapeutic interventions. We report a case of invasion of left atrium in primary lung cancer.
This patient is 60 years old AAM smoker with PMHx of rheumatoid arthritis and COPD presented for evaluation of a lung mass. His presenting complaints were dyspnea on exertion, NYHA class II progressing to class III and increasing sputum production over 6 months. He also c/o anorexia and weight loss of 70 lbs over last one year. He had CXR and CT scan, which showed a left hilar mass with possible extension into left atrium. Echocardiogram confirmed the invasion of left atrium. He underwent flexible bronchoscopy, which revealed a large fungating mass in left main bronchus within 1 1/2 cm of the carina. An electrocautery snare was used to remove part of the endobronchial mass, histopathologic review was consistent with non-small cell cancer. The patient was treated with carboplatin and taxol. At the time of this abstract he is doing well.
Direct extension of primary lung cancers to heart is a rare feature. There are about 30 case reports of extension of cancer into left atrium. The types of cancer that invaded the left atrium included non-small and small cell cancer, fibrosarcoma and carcinoid tumor. The studies helpful to make diagnosis include transthoracic and transesophageal echocardiogram; CT scan; and MR imaging and angiography. The presenting features include systemic embolism, stroke, multiple metastasis, congestive heart failure. Prognosis is poor, if the patient does not respond to chemotherapy. There are published case reports of aggressive surgery including pneumonectomy with en bloc or partial removal of left atrium. Four patients are reported in case report by Kodama. Two of them underwent pneumonectomy and left atrial resection and cardiopulmonary bypass, one died seven months after surgery, the other one had longer survival but had recurrence. Two patients underwent ordinary lobectomy as there were no abnormal findings on hilar examination. However, lumen of pulmonary veins were filled with tumor tissue. One patient died next day because of massive embolism and second patient was discharged without complications but later developed distant metastasis because of dislodgement of tumor into aorta. Other case report by Olearchyk had 3 patients who underwent surgery, two of them underwent adjuvant chemotherapy. One of them died after nine months because of ruptured abdominal aneurysm, the second patient died three months later from complications of chemotherapy. One of them was alive after 2 years of surgery at the time of publishing the article.
The involvement of heart by direct extension in primary lung cancer is rare and presents as challenge for diagnosis and treatment. Radical surgery with pneumonectomy and atrial resection is an option but has a high morbidity and mortality. Further studies comparing chemotherapy and or radiation therapy alone or as an adjuvant to surgery are needed.
A.S. Qureshi, None.