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Ann Thorac Surg 1996;62:891-892
© 1996 The Society of Thoracic Surgeons

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Case Report

Surgical Approach for Renal Cell Carcinoma Metastatic to the Left Atrium

Division of Cardiothoracic Surgery, Department of Surgery, St Vincents Hospital and Medical Center, New York, New York

Accepted for publication April 9, 1996.

	Abstract

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Metastatic tumor involvement of the left atrium via the pu lmonary veins has been reported rarely. We report a 58-year-old patient with renal cell carcinoma metastatic to the left atrium via the pulmonary veins and the lower lobe of the left lung. An unusual surgical approach combining median sternotomy and videoscope-assisted thoracic surgery was used in resecting the atrial mass and performing a lower lobe resection.

	Introduction

Top Footnotes Abstract Introduction Comment Acknowledgments References

 
Metastatic tumor involvement of the heart may occur with all types of primary neoplasms. Tumor invasion may be seen along the pericardium, myocardium, or the valvular structures. Our literature search found 4 reported instances of surgical resection of metastatic tumor extending into the left atrium via the pulmonary veins [1–3]. We report an unusual surgical approach to the treatment of metastatic renal carcinoma originating from within the inferior pulmonary vein and extending into the left atrial cavity.

A 58-year-old woman with a past medical history of hypertension was evaluated for exertional angina. Five years before this admission the patient had undergone a left nephrectomy for renal cell carcinoma. Cardiac catheterization revealed no evidence of coronary artery disease but was remarkable for the finding of a left atrial tumor. Transthoracic echocardiography was suggestive of a left atrial myxoma.

Physical examination revealed normal heart tones. She was taken to the operating room for planned excision of an atrial myxoma. Intraoperative transesophageal echocardiography suggested that the pedunculated portion of the tumor actually originated in the left inferior pulmonary vein. A median sternotomy was performed, and the patient was placed on cardiopulmonary bypass. A left atriotomy was made and a 2.5-cm friable mass was discovered within the left atrium adjacent to and extending into the lumen of the left inferior pulmonary vein. The tumor was excised as far back as possible and the lumen of the pulmonary vein was oversewn with a 2-0 Prolene (Ethicon, Somerville, NJ) suture. Residual tumor was left within the pulmonary vein. The atriotomy and the sternotomy were closed, and the patient was positioned on her right side. Video-assisted thoracoscopic lobectomy of the left lower lobe of the lung and included pulmonary vein was carried out in the standard fashion through three ports.

Pathologic diagnosis of the intraatrial portion of the tumor as well as the left lower lobe was consistent with metastatic renal cell carcinoma of the lung with extension into the left inferior pulmonary vein. A postoperative computed tomographic scan revealed no further evidence of metastasis, which was consistent with the pathologic finding of a solitary metastasis. The postoperative course was uneventful, and the patient was discharged on postoperative day 7. The patient is currently undergoing a second course of chemotherapy at 13 months of follow-up.

	Comment

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Tumors of the heart and pericardium are rare. Primary tumors occur with a frequency of 1:4,000 in autopsy studies, with atrial myxomas comprising approximately 50% of these lesions. Secondary tumors arising from a distant origin occur 20 to 40 times more frequently. Their presence is often suggested by the onset of unexplained cardiac symptoms in the face of an existing malignancy [4].

Metastatic tumors may reach the heart by hematogenous spread, lymphatic spread, or direct invasion. Intracavitary tumors may also arise from tumor thrombus implanted in the great veins. Tumor cells that infiltrate the lumen of the vein may induce the deposition of fibrin, which then serves as a framework to support continued cancer growth [1]. Tumor involvement of the right atrium, extending from a vena cava, is not uncommon and has been reported with a variety of neoplasms. However, extension of tumor thrombus from the pulmonary veins into the left atrium is rare.

In 1970, Schiller and Madge [5] noted the rarity of this type of metastasis, collecting only 15 prior cases in the literature in addition to their own presentation. In 1972, Onuigbo [6] reported 3 additional cases discovered in autopsies. In 1977, Boland and associates [7] reported a metastatic chondrosarcoma involving the left atrium that presented clinically as an atrial myxoma. Upon exploration via a median sternotomy, they discovered that the tumor had originated from within the pulmonary vein. The atrial portion of the tumor was resected through the median sternotomy. However, the patient was brought back to the operating room at a later date for the lobectomy [7].

In 1984, Schuman [3] reported the first case in which extension of tumor from the pulmonary veins into the left atrium was suspected preoperatively and successfully removed. Before this, all other reports of this type of tumor extension were either noted at autopsy or discovered incidentally at exploratory thoracotomy.

In 1990, Fogel and associates [2] published a case report of a metastatic renal cell carcinoma of the left lung that extended into the left atrium. This represented the first reported instance of a renal cell carcinoma metastasizing in such a fashion.

Kodoma and colleagues [1] reported 4 additional cases of left atrial tumor extension via the pulmonary veins. Two of the patients underwent successful operation through combined left atrial resection and left pneumonectomy. The other 2 patients, however, underwent lobectomy alone due to the lack of suspicion of intraatrial involvement. In these cases, tumor thrombus was discovered in the lumens of the resected pulmonary veins. One patient had a massive embolism and died postoperatively. The other was discharged uneventfully, although the intraatrial portion of the tumor was believed to have dislodged intraoperatively. As a result, multiple brain metastases developed 4 months after the operation.

The case discussed in this report demonstrates a highly unusual metastatic site for renal cell carcinoma, with only one prior incident reported. Metastatic neoplasms extending into the left atrium via the pulmonary veins are most often discovered incidentally. Our literature search found only 4 prior reports of successful resection of these tumors [1–3]. One of the most crucial aspects in the management of these tumors is preoperative recognition of pulmonary vein involvement. This is important because manipulation or division of the pulmonary vein can lead to systemic embolization of tumor thrombus. The potential adverse effects of this include stroke, myocardial infarction, and tumor metastasis [1]. Transesophageal echocardiography has been shown to be superior in the evaluation of hilar masses with pulmonary vein involvement. Because of the close anatomic relationship of the esophagus and left atrium, transesophageal echocardiography is the method of choice in evaluating intracavitary tumors [8].

Because there have been so few reports of successful surgical removal of intracardiac tumors emerging from the pulmonary veins, no standard operative approach has been established. Schuman [3] was able to perform a left atrial resection and pericardiopneumonectomy via a median sternotomy. However, other authors [7] have noted the difficulty encountered in this approach due to limited exposure and access to the left lower lobe. Kodoma and colleagues [1] employed a combination median sternotomy and anterolateral thoracotomy to successfully perform a pneumonectomy and left atrial resection. Fogel and associates [2] used a left thoracotomy and cardiopulmonary bypass to resect an atrial intracavitary metastatic renal cell carcinoma.

The use of video-assisted thoracic surgery in conjunction with a median sternotomy provides an alternative in instances where tumor thrombus involves both the pulmonary veins and the atrial cavity. Thoracoscopic assistance avoids the morbidity associated with an open thoracotomy, yet provides exposure for a wedge resection or lobectomy in instances of pulmonary metastasis. In the case presented here, a second major chest incision was avoided and complete excision of a complicated metastatic deposit was made possible by using thoracoscopy in conjunction with a median sternotomy.

	Acknowledgments

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We thank Marie Boyle for her expert assistance in manuscript preparation.

	Footnotes

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Address reprint requests to Dr McGinn, 153 W 11th St, Smith 525, New York, NY 10011.

	References

Top Footnotes Abstract Introduction Comment Acknowledgments References

 

1. Kodoma K, Doi O, Tatsuta M. Unusual extension of lung cancer into the left atrium via the pulmonary vein. Int Surg 1990;75:22–6.[Medline]
2. Fogel RI, Balady G, Klein MD, Rajaii-Khorasani A. Metastatic renal cell carcinoma: an unusual cause of syncope. Chest 1990;98:481–2.[Abstract/Free Full Text]
3. Schuman R. Primary pulmonary sarcoma with left atrial extension via the left superior pulmonary veins. J Cardiovasc Surg 1984;88:189–92.
4. Hall R, Cooley DA, McAllister H, Frazier OH. Neoplastic heart disease. In: Schlant RC, Alexander RW, O'Rourke RA, Roberts R, Sonnenblick EH, eds. Hurst's the heart. New York: McGraw Hill, 1994:2007–23.
5. Schiller H, Madge G. Neoplasms within the pulmonary veins. Chest 1970;58:535–7.[Abstract/Free Full Text]
6. Onuigbo W. Direct extension of cancer between pulmonary veins and left atrium. Chest 1972;62:444–5.[Abstract/Free Full Text]
7. Boland T, Winga E, Kalfayan B. Chondrosarcoma: a case report with left atrial involvement and systemic embolization. J Thorac Cardiovasc Surg 1977;74:268–72.[Abstract]
8. Suriani R, Konstadt S, Camunas J, Goldman M. Transesophageal echocardiographic detection of left atrial involvement of a lung tumor. J Thorac Cardiovasc Surg 1993;7:73–5.

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Joseph T. McGinn, Jr Denis H. Tyras Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Patane, J. Articles by Tyras, D. H. Search for Related Content PubMed PubMed Citation Articles by Patane, J. Articles by Tyras, D. H.