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Malignancy With a Direct Extension From the Lung Into the Heart Involving the Pulmonary Vein Has Been Rarely Reported FREE TO VIEW

Ramy Abusukheila, MD; Sudheer Chauhan, MD; Jagruti Patel, MD; Yadira Manso, MD
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Jamaica Hospital Medical Center, Jamaica, NY

Chest. 2013;144(4_MeetingAbstracts):642A. doi:10.1378/chest.1705090
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SESSION TITLE: Cancer Student/Resident Case Report Posters II

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Malignancy with a direct extension from the lung into the heart involving the pulmonary vein has been rarely reported. Here we report a case of probable lung cancer extending directly into the left atrium involving the pulmonary vein.

CASE PRESENTATION: A 75-year-old male with a history of tobacco use, COPD, presented with severe worsening of shortness of breath, pleuritic chest pain, and cough with white sputum for 3 days. Initial chest X-ray demonstrated left-sided opacity and chest CT scan without contrast revealed a large left-sided pleural effusion resulting in volume loss of the left lower lobe. There was no recent chest CT for comparison. Thoracocentesis with chest tube placement provided improvement. ECG was normal, however transthoracic echo, followed by transesophageal echo revealed an ill-defined, echogenic mass measuring 2 cm x 1.78 cm. The mass originated from the postero-lateral wall where the left pulmonary vein drained into the left atrium and extended into the left lower pulmonary vein.The left atrial size was normal, tricuspid valve, pulmonic valve and mitral valve demonstrated no stenosis or regurgitation. After the patient removed his chest tube, a chest CT with contrast illustrated a significant decrease in the left pleural effusion, revealinga left lower lobe heterogeneously enhancing mass measuring 5.3 x 4.9 x 3.2 cm resulting in narrowing of the left upper lung bronchus. The mass was directly extending into the left atrium and involved the pulmonary vein. Due to patient comorbidities and refusal for further procedures, he was transferred to hospice where he suddenly developed shortness of breath and expired.

DISCUSSION: We present an unusual case of probable lung cancer extending into the left atrium involving the pulmonary vein. Though other differentials could include thrombus or myxoma, they are very unlikely. The radiographic features of left atrial myxomainclude evidence of mitral valve obstructionsuch as left atrial enlargement, pulmonary venous hypertension, and interstitial edema, which were not observed in our case. Transthoracic and transesophageal echo are highly sensitive and specific for diagnosing cardiac myxoma; these willtypically reveal a spherical, mobile tumor that is connected to the interatrial septum by a narrow stalk.Chest CT defines the lesion as aheterogenous mass of low attenuation surrounded by the enhancing intracardiac blood Thrombus is unlikely due to irregularity and normal left atrial size along with the absence of predisposing factors in our patient.

CONCLUSIONS: large lung mass approaching the pulmonary vein and extending to the left atrium makes a malignancy almost certain, despite no tissue diagnosis.

Reference #1: doi: 10.4081/rt.2010.e53 PMCID: PMC2994530 Left atrial extension of metastatic lung tumor via pulmonary

DISCLOSURE: The following authors have nothing to disclose: Ramy Abusukheila, Sudheer Chauhan, Jagruti Patel, Yadira Manso

Chest CT revealing a mass in the lung extending to the left atrium execludes the possiblity of thrombus and makes malignancy most likely




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