An 80-year-old man pre-sented with a 3-week history of cough productive of blood-tinged sputum. Four years previously, a chest radiograph obtained preop-eratively for a transuretheral prostate resection showed a left hilar mass. The mass was presumed to be a bron-chogenic carcinoma based in part on its radiographic characteristics and the patient’s 50-pack per year smoking history. However, he was not a candidate for surgery or chemotherapy due to severe chronic obstructive pulmonary dis-ease, with an FEV1 of 1.17 on pulmonary function test-ing. The 4-year follow-up chest radiographs disclosed progression in the size of the mass (figure 1). Since he was now symptomatic and might benefit from radiation ther-apy, a CT scan was per-formed (figures 2 and 3).
Prepared by Glenn Anthony Blackwood, MD and Stephen Schabel,
MD of the Department of Radiology, Medical University of South
Carolina, Charleston, SC.
CASE SUMMARY:
An 80-year-old man presented with a 3-week history of cough
productive of blood-tinged sputum. Four years previously, a chest
radiograph obtained preoperatively for a transuretheral prostate
resection showed a left hilar mass. The mass was presumed to be a
bronchogenic carcinoma based in part on its radiographic
characteristics and the patient's 50-pack per year smoking history.
However, he was not a candidate for surgery or chemotherapy due to
severe chronic obstructive pulmonary disease, with an FEV
1
of 1.17 on pulmonary function testing. The 4-year follow-up chest
radiographs disclosed progression in the size of the mass (figure
1). Since he was now symptomatic and might benefit from radiation
therapy, a CT scan was performed (figures 2 and 3).
DIAGNOSIS:
Contiguous extension of bronchogenic carcinoma into the left
atrium through the pulmonary veins
IMAGING FINDINGS:
The enhanced CT revealed a heterogeneous 6 * 6.3 cm (AP *
transverse) soft tissue mass in the left lung parenchyma invading
the left hilum (figure 2). There was a 1.2 * 1.4 cm pedunculated
polypoid filling defect in the left atrium. There was no breach of
the pericardium, confirming extension of the tumor through the left
pulmonary veins.
DISCUSSION:
Metastatic tumors of the heart and pericardium are approximately
20 to 40 times more common than primary cardiac tumors.
1
There are three routes through which a bronchopulmonary primary or
secondary neoplasm can invade the heart: 1) metastses to the
pericardium or myocardium, 2) direct infiltration of the
mediastinal pleura and pericardium, and 3) growth through the
superior or inferior vena cava into the right atrium or through the
pulmonary veins into the left atrium.
2
Tumor thrombus from renal cell carcinoma not infrequently
extends into the right atrium through the inferior vena cava.
Direct tumor extension into the left atrium through the pulmonary
veins is rare.
2
There are reported cases of renal cell carcinoma, esophageal
adenocarcinoma, osteosarcoma, and chondrosarcoma spreading to the
heart through the pulmonary veins.
3-6
Primary lung tumors comprise a majority of cases cited in the
literature.
Patients may present with signs and symptoms suggestive of a
left atrial myxoma, such as a heart murmur or syncope from
obstruction of the mitral orifice.
1
Complications include systemic embolization resulting in stroke or
brain metastases.
7-9
Historically, tumor thrombus extending into the left atrium was
found at autopsy. Enhanced CT, transesophageal echocardiography,
and MR imaging now allow noninvasive characterization and
preoperative surgical planning.
References
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