Ann Thorac Surg 1998;65:544
© 1998 The Society of Thoracic Surgeons
Case Reports
Preoperative Identification and Operative Management of Intraatrial Extension of Lung Tumors
Martin J. Heslin, MD,
Ephraim S. Casper, MD,
Patrick Boland, MD,
Jeffrey P. Gold, MD,
Michael E. Burt , MD, PhD
Department of Surgery, Memorial Sloan-Kettering-Cancer Center, New York, New York, USA
Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
Accepted for publication September 16, 1997.
Dr Heslin, The University of Alabama at Birmingham, 321 Kracke Bldg, 1922 Seventh Ave S, Birmingham, AL 35294-0007.
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Abstract
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Preoperative identification of intraatrial tumor is uncommon. A 23-year-old woman presented with local recurrence and pulmonary metastases after previous resection of a clavicular sarcoma. Evaluation by computed tomography revealed bilateral pulmonary masses. Due to the size and proximal location, magnetic resonance imaging and transesophageal echocardiography were performed, revealing a large intraatrial mass. She then underwent staged surgical excision without intraoperative complications. We summarize this case and review risk factors for intracardiac extension and prevention of tumor emboli.
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Introduction
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Soft tissue sarcomas are rare tumors constituting approximately 0.1% of all malignancies in the United States [1]. Ninety percent of extremity soft tissue sarcomas that metastasize localize in the lungs, and this usually occurs in the first 2 years after initial resection [2]. The only treatment proven effective for pulmonary metastasis from soft tissue sarcoma is complete resection of all disease, with approximately 25% of patients surviving 5 years [3]. Systemic arterial tumor embolization during pulmonary resection is a relatively rare complication; however, when it occurs the outcome is often devastating. Here we report on preoperative identification of intraatrial tumor extension, one possible management strategy, and a review of the literature to identify high-risk patients.
This 23-year-old woman underwent primary excision of a right clavicular small cell sarcoma in Russia. No adjuvant therapy was given at that time. Eight years later, right shoulder pain developed, and examination revealed a right axillary mass. Further work-up with open biopsy and computed tomographic scan of the chest revealed recurrent sarcoma, most likely synovial sarcoma, and multiple bilateral pulmonary metastases. Initial treatment was with three cycles of ifosfamide, carboplatin, and etoposide chemotherapy with moderate response. She then underwent two cycles of high-dose ifosfamide chemotherapy over the next 2 months with minimal response; the treatment was changed to doxorubicin for three additional cycles without significant regression of the pulmonary nodules. Eight months from the time of initial presentation, she underwent an uncomplicated radical resection of the right clavicular local recurrence. Pathologic examination revealed a 4.5-cm, high-grade, biphasic synovial sarcoma with negative margins.
Work-up for her pulmonary metastatic disease involved bronchoscopy, pulmonary function tests, plain roentgenograms, and computed tomographic scan of the chest (Fig 1). These studies only revealed intrapulmonary disease. Because of the close proximity of the left lower lobe mass to the left inferior pulmonary vein and left atrium as well as our inability to visualize the cardiac chambers well on computed tomography, magnetic resonance imaging was performed, which revealed substantial intraatrial extension (Fig 2). This was confirmed with transesophageal echocardiography.
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Chest computed tomographic cut demonstrating inability to adequately view the intracardiac chambers and proximity of pulmonary mass to pulmonary vein and left atrium.
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Coronal magnetic resonance image demonstrating extension of tumor from the mass along the pulmonary vein into the left atrium.
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Based on these findings the patient underwent a two-stage procedure to ensure control of tumor emboli, complete resection, and minimal risk of bleeding. One month after right shoulder resection, she was placed on cardiopulmonary bypass via median sternotomy and underwent resection of a highly mobile, pedunculated, left atrial tumor measuring 2.5 x 2.0 x 1.5 cm. At the same operation, extrapericardial stapling of the left inferior pulmonary vein and wedge resection of two metastatic nodules in the right lung (measuring 1.5 and 1.4 cm) was performed. Four days later, via left posterolateral thoracotomy, a 6 x 5 x 5-cm mass and a 1.5-cm nodule were resected by a left lower lobectomy. Wedge resection of the left upper lobe revealed a 0.8-cm metastatic nodule. All resection margins were negative for tumor. Histopathologic examination of all resected tissue revealed metastatic biphasic synovial sarcoma. She recovered uneventfully and was discharged home on postoperative day 5 after posterolateral thoracotomy.
Routine follow-up with physical examination and chest roentgenogram 16 months after the last operation revealed no evidence of disease.
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Comment
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Preoperative identification of patients at risk for tumor embolization is important, even though this represents a relatively uncommon scenario. This case is exemplary. A large, centrally located focus of metastatic synovial sarcoma was visualized on computed tomographic scan, abutting the inferior pulmonary vein without adequate visualization of the cardiac chambers. Preoperative magnetic resonance imaging and transesophageal echocardiography demonstrated a large intraatrial mass protruding into the left atrial chamber. Clearly, without prior imaging, division of the inferior pulmonary vein at any time during lobectomy would have resulted in a catastrophic outcome. Preoperative imaging allowed safe and complete intracardiac excision, with subsequent formal lobectomy.
Tumor embolization during pulmonary resection is a relatively rare complication, with approximately 27 cases reported since 1950 [4] [5]. In nearly all of these cases the presence of emboli was diagnosed in the early postoperative period, with a high associated mortality. Non–small cell lung cancer was the primary tumor type, seen in 81% of the cases. Only 19% of the cases involved resection of metastatic disease, of which all were sarcomas, with 2 of the 5 being synovial sarcoma. Pneumonectomy was the procedure in 52% and lobectomy in 41%, with a single case each of wedge resection and exploration only.
Whyte and associates [5] recently reported 2 cases involving systemic embolization from non–small cell lung cancer during pulmonary resection, with a review of the literature. Both of these cases had extension of the tumor into the pulmonary vein, which was identified at the time of resection with attempt at inclusion during the operative procedure. The majority of the cases reviewed had either intraoperative or postoperative identification due to symptoms of the embolus. High-risk tumors were large and centrally located, especially those that abutted the pulmonary veins. Whyte and associates presented an algorithm that starts with "palpable tumor within the pulmonary vein." We would agree that factors associated with "high-risk" tumors would be the same as was outlined. There is also a suggestion that in the subset of patients with metastatic sarcomas the histologic subtype of synovial sarcoma may have a particular predilection for embolization. Other patients have been reported with intravascular involvement by synovial sarcoma in locations other than the lung, of whom 1 died of massive embolization [6]. We would argue, however, that noninvasive preoperative identification of intraatrial tumor in these high-risk patients is possible and might afford avoidance of the significant sequelae of embolization. In our patient, magnetic resonance imaging and transesophageal echocardiography provided excellent imaging of the tumor extension [7] [8].
In many of the cases reported, early ligation of the pulmonary vein was recommended to decrease the occurrence of this tragic complication. This certainly may reduce the prevalence in patients with tumor contained in the vein itself; however, it is very likely that regardless of the timing of the ligation, tumor embolization may have occurred in this patient had the vein been clamped or manipulated before intraatrial tumor removal. Similarly, in some of the reported cases of tumor embolization the vein was clamped early in the procedure and systemic embolization still occurred. This is likely due to tumor extending past palpation (a crude measure of tumor location) and subsequently the clamp.
This case demonstrates the value of preoperative imaging and a possible treatment strategy in the patient at high risk for tumor embolization. High-risk patients are those with large, centrally placed tumors abutting the pulmonary veins. The majority of cases will be non–small cell lung cancer; however, synovial sarcoma may represent a form of metastatic sarcoma with a predilection for intravascular growth. Our preoperative algorithm in these patients includes imaging via either magnetic resonance imaging or transesophageal echocardiography, which provides adequate noninvasive imaging of the cardiac chambers. After identification, our treatment plan using cardiopulmonary bypass and staged surgical procedures can safely accomplish complete tumor resection. In the absence of intraatrial extension, but in the presence of suspected involvement of the main pulmonary vein, a possible one-stage procedure by clamshell or median sternotomy could be employed.
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Acknowledgments
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Doctor Heslin is a Kristen Ann Carr Fellow in Surgical Oncology.
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Footnotes
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Doctor Burt passed away on October 4, 1997. 
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References
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- Parker SL, Tong T, Bolden S, Wingo PA Cancer statistics, 1996. CA Cancer J Clin 1996;46:5-27.[Abstract]
- Brennan MF Current management of soft tissue sarcoma. Ann Surg 1993;217:ii-iv.
- McCormack PM Surgical resection of pulmonary metastases. Semin Surg Oncol 1990;6:297-302.[Medline]
- Mansour KA, Malone CE, Craver JM Left atrial tumor embolization during pulmonary resection: review of the literature and report of two cases. Ann Thorac Surg 1988;46:455-456.[Abstract]
- Whyte RI, Starkey TD, Orringer MB Tumor emboli from lung neoplasms involving the pulmonary vein [Review]. J Thorac Cardiovasc Surg 1992;104:421-425.[Abstract]
- Shaw GR, Lais CJ Fatal intravascular synovial sarcoma in a 31-year-old woman. Hum Pathol 1993;24:809-810.[Medline]
- Esakof DD, Schneider AT, Pandian NG, et al. Delineation of pulmonary artery sarcoma with multiplane and panoramic transesophageal echocardiography. J Am Soc Echocardiogr 1993;6:619-623.[Medline]
- Shechter M, Glikson M, Agranat O, Motro M Echocardiographic demonstration of mitral block caused by left atrial spindle cell sarcoma. Am Heart J 1992;123:232-234.[Medline]
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Abstract
Introduction
