Case Study

Tumor thrombus in left atrium from pulmonary adenosquamous carcinoma

Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(1) 75–77 ß The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492313515896 aan.sagepub.com

Dong Xie, Jiaan Ding, Xiao Zhou, Chang Chen, Deping Zhao and Gening Jiang

Abstract We report a case of pulmonary adenosquamous carcinoma with a tumor thrombus in the left atrium. The left atrial tumor thrombus and lung cancer were removed via a right pneumonectomy and atriotomy under cardiopulmonary bypass. Simultaneous resection of a left atrial tumor thrombus and lung cancer can prevent systemic embolization, mitral obstruction, and sudden death, and improve the prognosis in selected patients.

Keywords Cardiac surgical procedures, cardiopulmonary bypass, heart atria, lung neoplasms, pneumonectomy, thrombosis

Introduction In patients with advanced non-small-cell lung cancer, left atrial tumor thrombus is an uncommon finding.1–5 Tumor thrombus shedding may cause systemic embolization, mitral obstruction, or sudden death. Surgical interventions in these tumors are still controversial and challenging.3 In selected cases, simultaneous removal of a left atrial tumor thrombus and lung cancer may improve the prognosis. We present a case of pulmonary adenosquamous carcinoma with left atrial tumor thrombus, which was successfully treated with simultaneous atrial thrombectomy and pneumonectomy.

Case report A 61-year-old man presented with bloody sputum. Thoracic computed tomography and magnetic resonance imaging showed a huge mass in the right upper lobe, with a tumor thrombus, extending from the right superior pulmonary vein to the left atrium (Figures 1 and 2). There was no evidence of distant metastasis or involvement of mediastinal nodes. Considering the risk of sudden death due to cardiac failure or emboli, we decided to perform a pneumonectomy and atrial thrombectomy. Via a right lateral thoracotomy, cardiopulmonary bypass was established. The aorta was crossclamped, and cardiac arrest was obtained by

antegrade cold blood cardioplegia. After a longitudinal left atriotomy, a yellowish fragile tumor mass, approximately 4.0  4.0 cm in size, was noted. The left atrial wall was free from invasion. The tumor thrombus was removed. The defect in the left atrium was closed using a running 3/0 polypropylene suture. Wide excision of the orifice of the pulmonary vein and subsequent right pneumonectomy were performed. Systemic mediastinal lymph node dissection was carried out. Pathological examination revealed adenosquamous carcinoma of the right upper lobe with cancerous thrombus formation in the left atrium. The resection margins were found to be free of tumor. Mediastinal lymph nodes were all negative. The patient was diagnosed as pT4N0M0 stage IIIA. His postoperative course was uneventful, and he was discharged on the 7th postoperative day. He received 4 cycles of adjuvant chemotherapy. He is still alive 27 months after the operation, with multiple brain metastases.

Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China Corresponding author: Gening Jiang, Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University, 507 Zheng Min Rd, Shanghai 200433, China. Email: [email protected]

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Figure 1. Thoracic computed tomographic scan showing a mass in the left atrium.

Figure 2. Thoracic magnetic resonance imaging revealing a giant mass in the right upper lobe and a left atrial mass.

A simultaneous cardiac operation with a lung cancer operation can be safely undertaken in selected patients.6 In most reports, the cardiac operations were coronary artery bypass grafting or valve replacement. The use of cardiopulmonary bypass may result in a higher mortality rate and a negative prognostic impact on patients with advanced lung cancer. Thus the indications for cardiopulmonary bypass require careful consideration. Surgical intervention in tumor thrombus is still controversial and challenging. Tumor thrombus shedding may cause systemic embolization, mitral obstruction, or sudden death. Complete resection of these tumors may improve long-term survival and reduce the risk of sudden death. A tumor thrombus in the left atrium can be derived from various histological types including sarcoma, adenocarcinoma, squamous cell carcinoma, large cell carcinoma, blastoma, and metastatic lung tumors.1–5 To our knowledge, there has been no previous report of pulmonary adenosquamous carcinoma with tumor thrombus in the left atrium. Adenosquamous carcinoma of the lung is an uncommon entity, and comprises less than 4% of lung carcinomas.7,8 It is an aggressive tumor that grows rapidly. Multidisciplinary treatment is needed to improve the prognosis. In our patient, despite adjuvant chemotherapy, multiple brain metastases developed. Systemic tumor cell seeding from the tumor thrombus might have resulted in multiple brain micrometastases before the operation. Prophylactic wholebrain irradiation may be helpful for controlling brain metastasis and improving the prognosis. Simultaneous surgery for lung cancer and left atrial tumor thrombus may improve survival in selected cases, and reduce the risk of sudden death. Funding This research received no specific grant from any funding agency in the public, commerical, or not-for-profit sectors.

Conflict of interest statement

Discussion

None declared.

Non-small-cell lung cancer involving the left atrium is classified as T4, regardless of the degree and extent of infiltration. There may be either direct penetration of the tumor into the left atrial wall or expansion into the left atrial cavity through the pulmonary veins. Resection of the left atrium because of tumor invasion is an infrequent procedure, and standard surgical feasibility criteria for this disease have not been established. Complete left atrial resection may be possible if there is limited involvement of the left atrium. If no more than one-third of the left atrial volume needs be resected and there is no involvement of the interatrial septum, partial resection can be technically considered.

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7. Shimizu J, Oda M, Hayashi Y, Nonomura A and Watanabe Y. A clinicopathologic study of resected cases of adenosquamous carcinoma of the lung. Chest 1996; 109: 989–994. 8. Gawrychowski J, Brulin´ski K, Malinowski E and Papla B. Prognosis and survival after radical resection of primary adenosquamous lung carcinoma. Eur J Cardiothorac Surg 2005; 27: 686–692.

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Tumor thrombus in left atrium from pulmonary adenosquamous carcinoma.

We report a case of pulmonary adenosquamous carcinoma with a tumor thrombus in the left atrium. The left atrial tumor thrombus and lung cancer were re...
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