Ann Thorac Surg 2009;87:e11-e12. doi:10.1016/j.athoracsur.2008.08.013
© 2009 The Society of Thoracic Surgeons
Case Reports
Tumor Thrombus in Right Atrium From Lung Adenocarcinoma
Clara Alexandrescu, MD*,
Fillipo Civaia, MD,
Vincent Dor, MD
Cardio-Thoracic Center Monaco, Monte Carlo, Monaco
Accepted for publication August 4, 2008.
* Address correspondence to Dr Alexandrescu, Cardio-Thoracic Center Monaco, Avenue d'Ostende 11 bis, Monte Carlo, 98000, Monaco (Email: clara1973alex{at}yahoo.fr).
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Abstract
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We report a case referred for elective surgery to remove an intra-atrial extension of a tumor thrombus. The patient underwent surgical excision of the mass because he would have a high risk of sudden death, pulmonary embolism, or tricuspid obstruction. A histologic examination established the diagnosis of lung adenocarcinoma metastases.
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Introduction
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The tumor thrombus extension in the right atrium from lung cancer occurs infrequently. Usually right tumor thrombus is a invasion from thyroid carcinoma by superior vena cava or from renal origin by inferior vena cava. The management of this complication is not standardized.
A 59-year-old, heavy smoking man, complaining of chest pain, nonproductive cough, and shortness of breath sought medical evaluation in September 2006. After examination of the chest radiographic scan, thoracic computed tomographic scan, and biopsy of the flexible fibrobronchoscopy, a diagnosis was made of lung adenocarcinoma of the right lower lobe. The tumor was advanced locally and metastases in carinal and mediastinal lymph nodes were present. Moreover, the bone metastases and mild right pleural effusion had been detected. The patient was considered inoperable (stage T4 N2 M1). A port-a-catheter was inserted in the superior vena cava for the infusion of chemotherapy.
The patient completed only two cycles of chemotherapy because during the third cycle the patient had fever with sepsis develop. Clinical examination disclosed incomplete syndrome of superior vena cava (SVC), dilatation of the veins of the upper torso and neck without blurring of the vision or aggravation of the cough.
The patient was referred to our hospital for complementary investigations. Current thoracic computed tomographic scan visualized a nonhomogeneous mass within the SVC with incomplete obstruction of the lumen (Fig 1). The intracavitary atrial extension of the mass was detected with mild dilation of the right cavity. There were no evidence of pulmonary embolism, and the primary tumor was stable. The transthoracic echocardiographic scan confirmed the presence of the intracavitary mass in the right atrium extending from the SVC. The mass has serpengeneous form, high mobility, and passed through the tricuspid valve with the right ventricle during diastole, as the embolic risk is elevated.
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Fig 1. (A) Thoracic computed tomographic scan with contrast showed a solid mass in the right atrium near the superior vena cava. (B) Transthoracic echocardiographic scan (subcostal four-chamber view) revealed the serpengeneous imagine in the right atrium.
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There was no evidence of other cardiac metastase. At this point our differential diagnosis was either a thrombus in the SVC after implantation of the port-a catheter or an SVC obstruction and extension in the right atrium of a neoplastic thrombus. The port-a catheter was removed without incident during this hospitalization. We initiated the anticoagulant and corticosteroids therapy, but the mass remained unchanged.
Considering the death risk from tumor embolism or obstruction of tricuspid valve we choose the elective surgical treatment. After a median sternotomy and cardiopulmonary bypass, but without cardiac arrest, the SVC was incised near the junction of the right atrium. The SVC wall has limited infiltration (less than 1/3 of the vessel circumference). Partial resection of the vessel is performed with mass excision en bloc and reconstruction of the vessel (Fig 2). No prosthetic replacement was required. Also, the solid mass in the right atrium was removed (ie, the aspect was like the shell of an egg). The histopathologic examination confirmed the presence of SVC invasion by tumor cells identification as adenocarcinoma.
Long-term anticoagulant therapy was prescribed for the prevention of vessel occlusion after reconstruction. The postoperative evolution was uneventful. The patient was discharged on postoperative day 7. Chemotherapy and radiotherapy were reprised after an oncology consult.
The patient died of multiple metastases 6 months after the previously described intervention.
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Comment
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Superior vena cava obstruction (SVCO) results from neoplasia in 85% of cases. The correct localization of the primary tumor is identified in the majority of these cases (80%). The causes of SVCO include intraluminal obstruction with benign or neoplastic thrombus, mural infiltration, and direct extraluminal compression by bronchogenic tumor or malignant lymph nodes. In addition, the necessity of port-a catheter insertion for chemotherapy administration raises the risk of SVCO by thrombus formation at the tip of the catheter [1]. Some authors reported the potential development of a tumor at the site of catheter insertion in patients with disseminated cancer throughout the chest, but the dates are incomplete [2]. The causes of this complication are not clear. One possibility is advanced, but it is unrecognized or ignored as pleural invasion before the placement of the catheter. To avoid this complication, the authors recommended the placement of the central catheter contralateral to known pleural effusion.
In the majority of cases, invasion of the SVC is considered inoperable, but serial reports have advanced the feasibility of limited resection and reconstruction of SVC [3]. The survival benefit is reported, but the degree of vessel involvement is a significant prognostic factor [4]. When thrombectomy is impossible due to the thrombus adhesion to the vessel, extended resection of the vein and replacement with a prosthesis under cardiopulmonary bypass can be performed. Several authors have performed stenting of the vessel plus radiotherapy, but long-term outcome remain insufficiently explored.
The survival data after resection of the SVC are still controversial and influenced by the low number of patients. In the series of Suzuki, the prognosis is better for the patients with SVCO by direct tumor extension (survival rate, 5-year at 36%) when compared with SVCO by metastatic mediastinal lymph nodes (6.6% survival rate) [4]. In contrast, Spaggiari [5] reported in a small number of patients no significant differences in the postoperative survival between SVCO by direct tumor involvement and compression by the lymph nodes.
Routinely, extension of the neoplastic thrombus in the right atrium is demonstrated after inferior vena cava (IVC) invasion secondary to retroperitoneal tumor (ie, renal cell carcinoma) or abdominal tumor (ie, hepatocellular carcinoma or uterine cancer). Few cases (14) of SVC invasion with intra-atrial extension are reported in the English medical literature, most commonly occurring after thyroid cancer or small cell lung cancer [3, 6, 7]. The prognosis is probably poor for intra-atrial extension of the tumor, with a high mortality rate due to the complication that might occur at any time (ie, pulmonary embolism or tricuspid obstruction). The elective surgery is necessary to remove the intra-atrial tumor. In some cases, the necessity of the cardiopulmonary bypass to remove the tumor might increase the risk of hematogenous tumor dissemination.
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References
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- Wilson P, Bezjak A, Asch M, et al. The difficulties of a randomized study in superior vena caval obstruction J Thorac Oncol 2007;2:514-519.[Medline]
- Crook JL, Breathnach OS, Cruser D, Johnson BE. Lung carcinoma metastasis at the site of central venous access Chest 1998;114:1772-1774.[Abstract/Free Full Text]
- Misthos P, Papagiannakis G, Kokotsakis J, Lazopoulos G, Skouteli E, Lioulias. Surgical management of lung cancer invading the aorta or the superior vena cava Lung Cancer 2007;56:223-227.[Medline]
- Suzuki K, Asamura H, Watanabe S-i, Tsuchiya R. Combined resection of superior vena cava for lung carcinoma: prognostic significance of patterns of superior vena cava invasion Ann Thorac Surg 2004;78:1184-1189.[Abstract/Free Full Text]
- Spaggiari L, Leo F, Veronesi G. Superior vena cava resection for lung and mediastinal malignancies: a single-center experience with 70 cases Ann Thorac Surg 2007;83:223-230.[Abstract/Free Full Text]
- Okereke OU, Nzewi OC, Chikwendu VC, Odigwe E, Onuigbo WB. Radical excision of invasive thymoma with intracardiac extension Cardiovasc Surg (Torino) 1994;35:355-358.
- Korobkin M, Gasano VA. Intracaval and intracardiac extension of malignant thymoma: CT diagnosis J Comput Assist Tomogr 1989;13:348-350.[Medline]
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Abstract
Introduction
