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Metastatic choriocarcinoma of the lung
Metastatic Invasion
Choriocarcinoma
of Pulrnonary
Veins with Extension
Left Atrium .JAMES D. MACLOWRY,
of the Lung
and Mitral M.D. and WILLIAM
Bethesda,
into the
Orifice* C. ROBERTS,
M. D.
Maryland
genicls4-ln and metastatic
A
thyroid carcinoma.” The present report describes a patient with choriocarcinoma metastatic to the lung with extension of the tumor into the left atria1 cavit). and mitral orifice by way of the pulmonar) veins.
MONGthe causes of stenosis of the puhnonary veins are primary and metastatic neoplasms of the lung and mediastinum, chronic mediastinitis, phlebitis, thrombosis, constrictive pericarditis and congenital malformations. Neoplasms may obstruct the pulmonary veins by extravascular compression or by direct invasion of the wall of the vessel by intravascular growth. The tumor most commonly associated with obstruction of the pulmonary veins is bronchogenic carcinonla. Studies in recent years have demonstrated that gross invasion of the pulmonary veins occurs in approximately 40 per cent of patients with this turnor,1-3 and in an equal number of patients the pulmonary arteries also are invaded.3 The peripheral pulmonary vessels are the ones usually involved and the extraparenchymal pulmonary veins, Review of the reports defar less frequently.2 scribing neoplastic invasion of the major pulmonary veins with extension of tumor into the left atrium discloses this occurrence in broncho-
KEPORT
OF PATIENT
A 28 year old woman, gravida IV, para II, abortus II, whose previous pregnancy five years earlier terminated in a hydatidiform mole, delivered a normal infant by caesarean section on Mar. 10, 1965. Thereafter, daily vaginal bleeding occurred, and two months following delivery unilateral headaches, facial weakness and blurred vision suddenly appeared, and bilateral papilledema was observed. Carotid arteriograms disclosed a space-occupying lesion in the right parietal area; at craniotomy on June 7, this mass was removed and diagnosed histologically as choriocarcinoma. One week later she was admitted to the Clinical Center of the National Institutes of Health. The uterus was twice normal size and the 24-hour urinary chorionic gonadotrophin titer was betlveen 2 and 5
FIG. 1. Chest roentgtnqrams. A, taken four years before death when the patient was well. There is a mass in the right lung but no cardiomegaly. B, taken two weeks before death. * From the Pathologic
Anatomy
Branch,
National
Cancer 938
Institute,
National THE
Institutes AMERICAN
of Health, JOURNAL
Bethesda,
Md.
OF CARDIOLOGY
Metastatic I
II
AVR
m
AVL
Choriocarcinoma
of Lung
.-AVF
Posterior
/ha:,-nrn d~pu/.~ thr tumor in thr rqht lung, growitlg into thy upper (U.P.V.) and lower (L.P.V.) pulmonary YWX. and extending into the left atrium and mitral valvular endocardium, hut firmly attached to the walls K.P.A. = right pulmonary of the pulmonary veins.
Fir;. 3.
artxv:
1.t. P.V.
=
lrft pulmonary
veins.
&xl&or IIILC’ ~/f/v lurnor in thr ri,fht lun,q extending into the right lower FIG. 4. ~li.I..) and right uppczr (KU.) pulmonary wins and into the left atrium / I ..:2.)completely tilling its cavity. The pulmonary artery (P.X.) to the right L.U. and L.L. = left upper and lower pulmonary lung is free of tumor. wins, respectively: I~..\..\. = left atria1 appendaqe; L,.V. = left ventricle; R. = bronchus.
FIG. 5.
/ L.V.)
The left atrium (L.A.),
mtral
ualce and lrft mztriclr
arc opened (upper photograph) showing the tumor filling the atrium and extending through the mitral orifice. The tumor in the mitral orifice, as seen from the left ventricular aspwt. is shown in thr lower photograph.
View
‘,_i’)
MacLowry
940
The heart was not enlarged by million mouse units. roentgenogram, but a mass \~as present in the mid and lower lung fields (Fig. 1). ?‘hr electrocardiogram disclosed prominent P waves and large QRS Methotrexate and prednisolone complexes (Fig. 2). \vere administered, but she died on June 30 from At no time was a increased intracranial pressure. precordial murmur detected, nor could any of heI symptoms be attributed to cardiopulmonary disease. ,4utopsy (A6.5- 723) revealed choriocarcinoma in the uterus, lungs, spleen, liver, kidneys, small intestine. brain and perineum. The middle and lower lobes of the right lung contained tumor which totally obstructed the right superior and inferior pulmonary veins, extended into and almost filled the left atria1 and projected through the mitral valvular cavity, orifice (Fig. 3-5). The choriocarcinoma was totally adherent to the major pulmonary veins from the right lung (Fig. 6) but was not adherent to the endocardium of the normal-sized left atrium or mitral valve. The heart was of normal size and weighed 270 gm. The right ventricular cavity was moderately dilated, and the right ventricular wall measured 0.2 cm. in The left ventricular cavity was of maximal thickness. normal size and its wall measured 1.1 cm. in maxima1 thickness.
COMMENTS Despite the extension of this tumor through the mitral valvular orifice and the total obstruc-
aud Kotjer-ts
tion of the right lllajor pkllrnonary veins, there were no s!.lnptotns of cardiac disease, no precordial murI11ur and no cardiomegaly. The electrocardiogram, however, did suggest right Histologically, heart strain. the left atria1 tumor was necrotic except for a thin rim of viable tumor at the periphery. Whether or not the tumor would have fragmented or become dislodged from its attachment to the wall of the pulmonary veins when these remaining tumor cells degenerated, possibly as a result of chemis a matter of speculation. It is otherapy, possib’e that the tumor deposits in the brain, spleen, liver, kidney and small intestine were the result of dislodged fragments of left atria1 tumor. SUMMARY
The clinical and pathologic features of a patient with choriocarcinoma, metastatic to the lungs, with obstruction of the right major pulmonary veins and extension into the left atrimn and mitral valvular orifice are described. ADDENDUM Since this paper was submitted, Sterns and associates’? reported on a 33 year old man who died of a metastatic rhabdomyosarcoma to the THE
AMERICAN
JOURNAL
OF
CARDIOLOGY
VOI.lJME
18.
DECEMBER
1966
Choriocarcinoma
of Pulrnonary
Veins with Extension
Left Atrium .JAMES D. MACLOWRY,
of the Lung
and Mitral M.D. and WILLIAM
Bethesda,
into the
Orifice* C. ROBERTS,
M. D.
Maryland
genicls4-ln and metastatic
A
thyroid carcinoma.” The present report describes a patient with choriocarcinoma metastatic to the lung with extension of the tumor into the left atria1 cavit). and mitral orifice by way of the pulmonar) veins.
MONGthe causes of stenosis of the puhnonary veins are primary and metastatic neoplasms of the lung and mediastinum, chronic mediastinitis, phlebitis, thrombosis, constrictive pericarditis and congenital malformations. Neoplasms may obstruct the pulmonary veins by extravascular compression or by direct invasion of the wall of the vessel by intravascular growth. The tumor most commonly associated with obstruction of the pulmonary veins is bronchogenic carcinonla. Studies in recent years have demonstrated that gross invasion of the pulmonary veins occurs in approximately 40 per cent of patients with this turnor,1-3 and in an equal number of patients the pulmonary arteries also are invaded.3 The peripheral pulmonary vessels are the ones usually involved and the extraparenchymal pulmonary veins, Review of the reports defar less frequently.2 scribing neoplastic invasion of the major pulmonary veins with extension of tumor into the left atrium discloses this occurrence in broncho-
KEPORT
OF PATIENT
A 28 year old woman, gravida IV, para II, abortus II, whose previous pregnancy five years earlier terminated in a hydatidiform mole, delivered a normal infant by caesarean section on Mar. 10, 1965. Thereafter, daily vaginal bleeding occurred, and two months following delivery unilateral headaches, facial weakness and blurred vision suddenly appeared, and bilateral papilledema was observed. Carotid arteriograms disclosed a space-occupying lesion in the right parietal area; at craniotomy on June 7, this mass was removed and diagnosed histologically as choriocarcinoma. One week later she was admitted to the Clinical Center of the National Institutes of Health. The uterus was twice normal size and the 24-hour urinary chorionic gonadotrophin titer was betlveen 2 and 5
FIG. 1. Chest roentgtnqrams. A, taken four years before death when the patient was well. There is a mass in the right lung but no cardiomegaly. B, taken two weeks before death. * From the Pathologic
Anatomy
Branch,
National
Cancer 938
Institute,
National THE
Institutes AMERICAN
of Health, JOURNAL
Bethesda,
Md.
OF CARDIOLOGY
Metastatic I
II
AVR
m
AVL
Choriocarcinoma
of Lung
.-AVF
Posterior
/ha:,-nrn d~pu/.~ thr tumor in thr rqht lung, growitlg into thy upper (U.P.V.) and lower (L.P.V.) pulmonary YWX. and extending into the left atrium and mitral valvular endocardium, hut firmly attached to the walls K.P.A. = right pulmonary of the pulmonary veins.
Fir;. 3.
artxv:
1.t. P.V.
=
lrft pulmonary
veins.
&xl&or IIILC’ ~/f/v lurnor in thr ri,fht lun,q extending into the right lower FIG. 4. ~li.I..) and right uppczr (KU.) pulmonary wins and into the left atrium / I ..:2.)completely tilling its cavity. The pulmonary artery (P.X.) to the right L.U. and L.L. = left upper and lower pulmonary lung is free of tumor. wins, respectively: I~..\..\. = left atria1 appendaqe; L,.V. = left ventricle; R. = bronchus.
FIG. 5.
/ L.V.)
The left atrium (L.A.),
mtral
ualce and lrft mztriclr
arc opened (upper photograph) showing the tumor filling the atrium and extending through the mitral orifice. The tumor in the mitral orifice, as seen from the left ventricular aspwt. is shown in thr lower photograph.
View
‘,_i’)
MacLowry
940
The heart was not enlarged by million mouse units. roentgenogram, but a mass \~as present in the mid and lower lung fields (Fig. 1). ?‘hr electrocardiogram disclosed prominent P waves and large QRS Methotrexate and prednisolone complexes (Fig. 2). \vere administered, but she died on June 30 from At no time was a increased intracranial pressure. precordial murmur detected, nor could any of heI symptoms be attributed to cardiopulmonary disease. ,4utopsy (A6.5- 723) revealed choriocarcinoma in the uterus, lungs, spleen, liver, kidneys, small intestine. brain and perineum. The middle and lower lobes of the right lung contained tumor which totally obstructed the right superior and inferior pulmonary veins, extended into and almost filled the left atria1 and projected through the mitral valvular cavity, orifice (Fig. 3-5). The choriocarcinoma was totally adherent to the major pulmonary veins from the right lung (Fig. 6) but was not adherent to the endocardium of the normal-sized left atrium or mitral valve. The heart was of normal size and weighed 270 gm. The right ventricular cavity was moderately dilated, and the right ventricular wall measured 0.2 cm. in The left ventricular cavity was of maximal thickness. normal size and its wall measured 1.1 cm. in maxima1 thickness.
COMMENTS Despite the extension of this tumor through the mitral valvular orifice and the total obstruc-
aud Kotjer-ts
tion of the right lllajor pkllrnonary veins, there were no s!.lnptotns of cardiac disease, no precordial murI11ur and no cardiomegaly. The electrocardiogram, however, did suggest right Histologically, heart strain. the left atria1 tumor was necrotic except for a thin rim of viable tumor at the periphery. Whether or not the tumor would have fragmented or become dislodged from its attachment to the wall of the pulmonary veins when these remaining tumor cells degenerated, possibly as a result of chemis a matter of speculation. It is otherapy, possib’e that the tumor deposits in the brain, spleen, liver, kidney and small intestine were the result of dislodged fragments of left atria1 tumor. SUMMARY
The clinical and pathologic features of a patient with choriocarcinoma, metastatic to the lungs, with obstruction of the right major pulmonary veins and extension into the left atrimn and mitral valvular orifice are described. ADDENDUM Since this paper was submitted, Sterns and associates’? reported on a 33 year old man who died of a metastatic rhabdomyosarcoma to the THE
AMERICAN
JOURNAL
OF
CARDIOLOGY
VOI.lJME
18.
DECEMBER
1966