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Direct Extension of Bronchogenic Carcinoma Through Pulmonary Veins into the Left Atrium Mimicking Left Atrial Myxoma
with improvement in ventilation and dust control at the processing facility.' The particular clinician who saw this patient participated in the Sentinel Event Notification for Occupational Risks (SENSOR) programlO and received repeated encouragement to report patients with occupational asthma to the State Health Department. Similar programs exist in nine other states. Public health follow-up at the facility was important in the identification of the cause and management of this patient's asthma as well as in providing recommendations to the company on ways to improve ventilation controls and housekeeping practices. We would encourage other physicians to inform state health departments when they diagnose occupational disease. ACKNOWLEDGMENTS: Partial funding for this activity is from the National Institute of Occupational Safety and Health (NIOSH), Cooperative agreement U6OCCU502998. Drs. Richard Horbal and MicLael Harbut were essential in their initial recognition of the work-relatedness of the patient's symptoms. Soecial thanks to Sue Blonsbine and Sam McMahon, M.D. for the conduct of the bronchoprovocation testing. Jean Doss' assistance was instrumental in conducting foUowup activities at the facility. Credit for manuscript preparation is due Ruth VanderWaals.
REFERENCES 1 Buechner HA, Prevatt AL, Thompson J, Butz O. Bagassosis: a review with further historical data, studies of pulmonary function and results of adrenal steroid therapy. Am J Med 1958; 25:234-47 2 Pierce AX, Nicholson Of, Miller JM, Johnson RL. Pulmonary function in bagasse worker's lung disease. Am Rev Respir Dis 1968; 97:561-70 3 Pepys J, Hutchcroft BJ. Bronchial provocation tests in etiologic diagnosis and analysis of asthma. Am Rev Respir Dis 1975; 112:829-59 4 Forster H\v, Crook B, Platts B\v, Lacey J, Topping MD. Investigation of organic aerosols generated during sugar beet slicing. Am Ind Hyg Assoc J 1989; 50:44-50 5 Topping MD, Scarlsbrick DA, Luczynska CM, Clarke EC, Seaton A. Clinical and immunological reactions to A8per'gillu8 niger among workers at a biotechnology plant. Br J Ind Med 1985; 42:312-18 6 Losada E, Hinojosa M, Monea I, Dominguez J, Gomez MLD, Ibanez MD. Occupational asthma caused by ceUulase. J Anergy Clin Immunoll986; 77:635-39 7 Pauwels R, Devos M, Callens L, VanderStraeten M. Respiratory hazards from proteolytic enzymes. Lancet 1978; 1:669 8 Bauer X, Sauer \v, Weiss W Baking additives as new allergens in baker's asthma. Respiration 1988; 54:7()'2 9 Mehta SIC, Sandhu RS. Immunologicalsigni6cance of A8pergillui fumigtJtw in cane-sugar mills. Arch Environ Health 1983; 38:41-6 10 Baker EL. Sentinel event notification system for occupational risks. Scand J Work Environ Health 1988; 14(suppll):11()'12
Direct extention of bronchogenic carcinoma via pulmonary veins into the left atrium is rare. We describe two such cases, one which presented as a left atrial mass with pulmonary edema, and another which was detected at autopsy. (Cheat 1992; 101:1722·23) involvement of the heart is relatively common Secondary at autopsy in patients with malignant tumors. These I •2
lesions seldom manifest, are less frequently clinically significant. and very rarely are the presenting feature.'" We present a case of bronchogenic carcinoma with direct extention into the left atrium via pulmonary veins, whose presentation mimicked that ofa left atrial myxoma. On going through our autopsy records, a similar case, which was not diagnosed clinically, was encountered. CASE REPORTS CASE
1
A 3().yeaNlld woman presented with a IS-day history of NYHA class 2 dyspnea, low-grade fever and cough. Her symptoms rapidly progressed to class 4 during over the next 12 days. She gave no history suggestive of acute rheumatic fever in the past. Examination revealed a sick-looking, tachypneic patient with a pulse rate of 130 beats per minute and blood pressure of 110170 mm Hg with prominent a waves in the jugular venous pulse. Auscultation of the chest revealed bilateral extensive crepitations and rhonchi, a loud 6rst heart sound and a short grade 116 middiastolic murmur at the mitral area. The electrocardiogram disclosed no abnormalities except for a sinus tachycardia of 130 per min. The chest roentgenogram showed a cardiothoracic ratio of 50 percent with evidence of severe pulmonary edema (Fig I). Two dimensional echocardiography revealed a mobile mass 5 cm in diameter in the I,ft alrium prulap 'inl!: a ross tlHi' mitral valv during diaslol '. The
Direct Extension of Bronchogenic carcinoma Through Pulmonary Veins Into the Left Atrium Mimicking Left Atrial Myxoma· Vivel K. Mehan, M.D.; JmJa Duhpande. M.D.; Bhar"tlt V. DGloi. M.D.; and ftlrshottam A. Kole. M.D.
-From the Departments of Cardiology and Pathology, IC.E.M. Hospital, Parer, Bombay. India.
1722
FIGURE 1. Portable chest roentgenogram, at the time of admission, showing severe bilateral pulmonary edema.
Dlrec:t ExIen8Ion oI8Iollchogelllc C8rclnoma (Mehan et aI)
FIGUHE 2. Autopsy specimen, opened out to reveal the tumor infiltrating the left lower lobe pulmonary vein (arrow) and producing a mass (M) in the left atrium. A small piece of this mass which has infiltrated the posterior wall of the LA is seen lateral to the main mass (M) from which it broke away on opening the LA at autopsy. LPV= left pulmonary vein; LV= left ventricle; !I1V= mitral valve.
mitral valve was normal and there was evidence of mild pulmonary hypertension. The working diagnosis at this time was a left atrial myxoma obstructing the mitral orifice leading to acute pulmonary edema. A decision was made to remove of the myxoma surgically, bul before this could be accomplished, the patient went into a lowoulput state and died. At autopsy, the lungs were congested and filled with fluid with a large necrotic tumor mass occupying the whole of the hasal segment of the left lung, with central cavitation. The mass extended into the pleura and infiltrated into the left lower lobe hronchus. There were smaller discrete nodules in the rest of the left lung parenchyma. The right lung did not show the presence of any malignant tumor. The pulmonary vein draining the lower lohe of the left Illng was totally occluded by tllmor mass, which extended into the left atrium. The left atrium was dilated and occupied hy a large mass measuring 5 Clll in diameter, which was seen to be arising from the left lower pulmonary vein and protruded through the mitral valve orifice into the left ventricle. This mass had infiltrated and involved the posterior wall of the left atrium at one point (Fig 2). Histopathologic studies revealed an adenocarcinoma of the lung. The mass in the left atrium was seen to consist of adcnocarcinoma cells admixed with thrombus. CASE
2
This case was not diagnosed clinically, and was heing managed primarily as a carcinoma of the lung. This patient similarly had gone into pulmonary edema suddenly and death soon followed. A cardiac pathologic finding had not been suspected, since the patient had extensive lung involvement which was thought to he the cause of her symptoms. Autopsy revealed a large tumor mass in the upper lohe of the right lung parenchyma and hronchus. The left atrium was enlarged and contained a nodular tumor mass measuring 6 cm in diameter, which was attached hy a gelatinous stalk to protruding tumor masses in the right superior pulmonary vein. On histopathologic examinalion, the lung tumor and the left atrial tumor showed features of a Illucoid secreting adenocarcinoma. DISCUSSION
Secondary involvement of the heart is pathologically common in patients with carcinoma with a reported incidence of 3.4 to 21 percent.'·" However, it rarely manifests itself as significant cardiac disease."" Secondary involvement commonly includes the pericardium or epicardium.5- 7 1ntra-
cavitary involvement is very uncommon and usually results from direct invasion from mediastinal or pulmonary masses, or rarely from extension via venous channels,s.7 as in our patient. Melanomas have been reported to have a propensity to metastasize to the endocardium and to project as intracavitary masses which may be detected with the use of twodimensional echocardiography.' Whereas tumors involving the right atrium by intravascular spread via the superior or inferior vena cava have been reported,'·fi-R direct extention of a tumor into the left atrial cavity via the pulmonary veins is extremely uncommon.·· H•9 Intracavitary tumors may present with peripherial embolization, mechanical hemolysis or intracavitary obstruction, I as in our patient. The occurrence of paroxysmal symptoms that are out of proportion to the clinical findings, and the presence of normal sinus rhythm, favor the diagnosis of a left atrial tumor over mitral stenosis."IO While intra-atrial thrombi may at times mimic intracardiac tumor masses,"" a pedunculated, mobile tumor mass within the left atrium in the presence of a normal mitral valve is most commonly a left atrial myxoma." Indeed, the two-dimensional echocardiographic appearance is so characteristic that one can proceed directly to surgery without any invasive diagnostic procedures.'·s." A secondary tumor extending via the pulmonary veins which presents in this manner, mimicking a left atrial myxoma clinically and on two-dimensional echocardiographic examination, has not been described in the literature heretofore, Since secondary tumors of the heart occur 20 to 40 times more frequently than primary tumors,3S.• it is natural that some of them may present as described previously. We propose that in a case of a suspected "left atrial myxoma" the pulmonary veins should be examined carefully on Doppler to rule out this rare condition.
REFERENCES
2
3
4
5 6
7
8 9 10
11
Goodwin JF, The spectrum of cardiac tumours. Am J Cardiol 1968; 21:307-14 Malaret GE, Aliaga P. Metastatic diseases of the heart. Cancer 1968; 22:457-61 Hall RJ, Cooley DA, McAllister HA Jr, Frazier OH. Neoplastic heart disease. In: Hurst JI;\\ ed. The heart. New York: McGraw II ill Information Services Co, 1990:1382- L403 Birmingham CL, Peretz OJ. Metastatic carcinoma presenting as ohstruction of the right ventricular outflow tract. Am Heart J 1979; 97:229-32 Johnson M H, Soulen RL. Echocardiography of cardiac masses. AJR 1983; 141:677-81 Hudson REB. Cardiovascular pathology. London: Edward Arnold, 1965:1598-99 KlItalek Sp' Panidis Ip, Kotler MN, Mintz GS, Carver J, Ross Jj. Metastatic tumors of the heart detected by two dimensional echocardiography. Am Heart J 1985; 109:343-49 Rogen AS, Moffat AD. Unusual secondary tumour of the heart. Br Heart J 1967; 29:638-40 Onuigbo WlB. Direct extention of cancer hetween pulmonary veins and the left atrium. Chest 1972; 62:444-46 Colucci WS, Braunwald E. Primary tumors of the heart. In: Brallnwald E, ed. Heart Disease. Philadelphia: WB Saunders Co, 1988:1470-83 DePace NL, Soulen RL, Kotler MN, Mintz GS. Two dimensional echocardiographic detection of intraatrial masses. Am J Cardiol 1981; 48:954-60 CHEST / 101 / 6 / JUNE. 1992
1723
REFERENCES 1 Buechner HA, Prevatt AL, Thompson J, Butz O. Bagassosis: a review with further historical data, studies of pulmonary function and results of adrenal steroid therapy. Am J Med 1958; 25:234-47 2 Pierce AX, Nicholson Of, Miller JM, Johnson RL. Pulmonary function in bagasse worker's lung disease. Am Rev Respir Dis 1968; 97:561-70 3 Pepys J, Hutchcroft BJ. Bronchial provocation tests in etiologic diagnosis and analysis of asthma. Am Rev Respir Dis 1975; 112:829-59 4 Forster H\v, Crook B, Platts B\v, Lacey J, Topping MD. Investigation of organic aerosols generated during sugar beet slicing. Am Ind Hyg Assoc J 1989; 50:44-50 5 Topping MD, Scarlsbrick DA, Luczynska CM, Clarke EC, Seaton A. Clinical and immunological reactions to A8per'gillu8 niger among workers at a biotechnology plant. Br J Ind Med 1985; 42:312-18 6 Losada E, Hinojosa M, Monea I, Dominguez J, Gomez MLD, Ibanez MD. Occupational asthma caused by ceUulase. J Anergy Clin Immunoll986; 77:635-39 7 Pauwels R, Devos M, Callens L, VanderStraeten M. Respiratory hazards from proteolytic enzymes. Lancet 1978; 1:669 8 Bauer X, Sauer \v, Weiss W Baking additives as new allergens in baker's asthma. Respiration 1988; 54:7()'2 9 Mehta SIC, Sandhu RS. Immunologicalsigni6cance of A8pergillui fumigtJtw in cane-sugar mills. Arch Environ Health 1983; 38:41-6 10 Baker EL. Sentinel event notification system for occupational risks. Scand J Work Environ Health 1988; 14(suppll):11()'12
Direct extention of bronchogenic carcinoma via pulmonary veins into the left atrium is rare. We describe two such cases, one which presented as a left atrial mass with pulmonary edema, and another which was detected at autopsy. (Cheat 1992; 101:1722·23) involvement of the heart is relatively common Secondary at autopsy in patients with malignant tumors. These I •2
lesions seldom manifest, are less frequently clinically significant. and very rarely are the presenting feature.'" We present a case of bronchogenic carcinoma with direct extention into the left atrium via pulmonary veins, whose presentation mimicked that ofa left atrial myxoma. On going through our autopsy records, a similar case, which was not diagnosed clinically, was encountered. CASE REPORTS CASE
1
A 3().yeaNlld woman presented with a IS-day history of NYHA class 2 dyspnea, low-grade fever and cough. Her symptoms rapidly progressed to class 4 during over the next 12 days. She gave no history suggestive of acute rheumatic fever in the past. Examination revealed a sick-looking, tachypneic patient with a pulse rate of 130 beats per minute and blood pressure of 110170 mm Hg with prominent a waves in the jugular venous pulse. Auscultation of the chest revealed bilateral extensive crepitations and rhonchi, a loud 6rst heart sound and a short grade 116 middiastolic murmur at the mitral area. The electrocardiogram disclosed no abnormalities except for a sinus tachycardia of 130 per min. The chest roentgenogram showed a cardiothoracic ratio of 50 percent with evidence of severe pulmonary edema (Fig I). Two dimensional echocardiography revealed a mobile mass 5 cm in diameter in the I,ft alrium prulap 'inl!: a ross tlHi' mitral valv during diaslol '. The
Direct Extension of Bronchogenic carcinoma Through Pulmonary Veins Into the Left Atrium Mimicking Left Atrial Myxoma· Vivel K. Mehan, M.D.; JmJa Duhpande. M.D.; Bhar"tlt V. DGloi. M.D.; and ftlrshottam A. Kole. M.D.
-From the Departments of Cardiology and Pathology, IC.E.M. Hospital, Parer, Bombay. India.
1722
FIGURE 1. Portable chest roentgenogram, at the time of admission, showing severe bilateral pulmonary edema.
Dlrec:t ExIen8Ion oI8Iollchogelllc C8rclnoma (Mehan et aI)
FIGUHE 2. Autopsy specimen, opened out to reveal the tumor infiltrating the left lower lobe pulmonary vein (arrow) and producing a mass (M) in the left atrium. A small piece of this mass which has infiltrated the posterior wall of the LA is seen lateral to the main mass (M) from which it broke away on opening the LA at autopsy. LPV= left pulmonary vein; LV= left ventricle; !I1V= mitral valve.
mitral valve was normal and there was evidence of mild pulmonary hypertension. The working diagnosis at this time was a left atrial myxoma obstructing the mitral orifice leading to acute pulmonary edema. A decision was made to remove of the myxoma surgically, bul before this could be accomplished, the patient went into a lowoulput state and died. At autopsy, the lungs were congested and filled with fluid with a large necrotic tumor mass occupying the whole of the hasal segment of the left lung, with central cavitation. The mass extended into the pleura and infiltrated into the left lower lobe hronchus. There were smaller discrete nodules in the rest of the left lung parenchyma. The right lung did not show the presence of any malignant tumor. The pulmonary vein draining the lower lohe of the left Illng was totally occluded by tllmor mass, which extended into the left atrium. The left atrium was dilated and occupied hy a large mass measuring 5 Clll in diameter, which was seen to be arising from the left lower pulmonary vein and protruded through the mitral valve orifice into the left ventricle. This mass had infiltrated and involved the posterior wall of the left atrium at one point (Fig 2). Histopathologic studies revealed an adenocarcinoma of the lung. The mass in the left atrium was seen to consist of adcnocarcinoma cells admixed with thrombus. CASE
2
This case was not diagnosed clinically, and was heing managed primarily as a carcinoma of the lung. This patient similarly had gone into pulmonary edema suddenly and death soon followed. A cardiac pathologic finding had not been suspected, since the patient had extensive lung involvement which was thought to he the cause of her symptoms. Autopsy revealed a large tumor mass in the upper lohe of the right lung parenchyma and hronchus. The left atrium was enlarged and contained a nodular tumor mass measuring 6 cm in diameter, which was attached hy a gelatinous stalk to protruding tumor masses in the right superior pulmonary vein. On histopathologic examinalion, the lung tumor and the left atrial tumor showed features of a Illucoid secreting adenocarcinoma. DISCUSSION
Secondary involvement of the heart is pathologically common in patients with carcinoma with a reported incidence of 3.4 to 21 percent.'·" However, it rarely manifests itself as significant cardiac disease."" Secondary involvement commonly includes the pericardium or epicardium.5- 7 1ntra-
cavitary involvement is very uncommon and usually results from direct invasion from mediastinal or pulmonary masses, or rarely from extension via venous channels,s.7 as in our patient. Melanomas have been reported to have a propensity to metastasize to the endocardium and to project as intracavitary masses which may be detected with the use of twodimensional echocardiography.' Whereas tumors involving the right atrium by intravascular spread via the superior or inferior vena cava have been reported,'·fi-R direct extention of a tumor into the left atrial cavity via the pulmonary veins is extremely uncommon.·· H•9 Intracavitary tumors may present with peripherial embolization, mechanical hemolysis or intracavitary obstruction, I as in our patient. The occurrence of paroxysmal symptoms that are out of proportion to the clinical findings, and the presence of normal sinus rhythm, favor the diagnosis of a left atrial tumor over mitral stenosis."IO While intra-atrial thrombi may at times mimic intracardiac tumor masses,"" a pedunculated, mobile tumor mass within the left atrium in the presence of a normal mitral valve is most commonly a left atrial myxoma." Indeed, the two-dimensional echocardiographic appearance is so characteristic that one can proceed directly to surgery without any invasive diagnostic procedures.'·s." A secondary tumor extending via the pulmonary veins which presents in this manner, mimicking a left atrial myxoma clinically and on two-dimensional echocardiographic examination, has not been described in the literature heretofore, Since secondary tumors of the heart occur 20 to 40 times more frequently than primary tumors,3S.• it is natural that some of them may present as described previously. We propose that in a case of a suspected "left atrial myxoma" the pulmonary veins should be examined carefully on Doppler to rule out this rare condition.
REFERENCES
2
3
4
5 6
7
8 9 10
11
Goodwin JF, The spectrum of cardiac tumours. Am J Cardiol 1968; 21:307-14 Malaret GE, Aliaga P. Metastatic diseases of the heart. Cancer 1968; 22:457-61 Hall RJ, Cooley DA, McAllister HA Jr, Frazier OH. Neoplastic heart disease. In: Hurst JI;\\ ed. The heart. New York: McGraw II ill Information Services Co, 1990:1382- L403 Birmingham CL, Peretz OJ. Metastatic carcinoma presenting as ohstruction of the right ventricular outflow tract. Am Heart J 1979; 97:229-32 Johnson M H, Soulen RL. Echocardiography of cardiac masses. AJR 1983; 141:677-81 Hudson REB. Cardiovascular pathology. London: Edward Arnold, 1965:1598-99 KlItalek Sp' Panidis Ip, Kotler MN, Mintz GS, Carver J, Ross Jj. Metastatic tumors of the heart detected by two dimensional echocardiography. Am Heart J 1985; 109:343-49 Rogen AS, Moffat AD. Unusual secondary tumour of the heart. Br Heart J 1967; 29:638-40 Onuigbo WlB. Direct extention of cancer hetween pulmonary veins and the left atrium. Chest 1972; 62:444-46 Colucci WS, Braunwald E. Primary tumors of the heart. In: Brallnwald E, ed. Heart Disease. Philadelphia: WB Saunders Co, 1988:1470-83 DePace NL, Soulen RL, Kotler MN, Mintz GS. Two dimensional echocardiographic detection of intraatrial masses. Am J Cardiol 1981; 48:954-60 CHEST / 101 / 6 / JUNE. 1992
1723