European Journal of Echocardiography Advance Access originally published online on March 19, 2008
European Journal of Echocardiography 2008 9(3):428-429; doi:10.1093/ejechocard/jen027
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Cardiac tamponade because of left atrium direct invasion by a large cell neuroendocrine metastatic carcinoma of the lung
Department of Cardiology, University Hospital of Coventry and Warwickshire, Coventry CV2 2DX, UK
Received 24 November 2007; accepted after revision 23 December 2007; online publish-ahead-of-print 19 March 2008.
* Correspondent author: Tel: +44 247 696 5666; fax: +44 247 696 5657. E-mail address: dlysitsas{at}doctors.org.uk
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A 53-year-old man presented with cardiac tamponade due to direct invasion of left atrium by a large cell neuroendocrine metastatic lung adenocarcinoma. Direct invasion of left atrial cavity by this type of lung tumour is rare. When cardiac involvement is suspected, two-dimensional echocardiography is the first-line diagnostic tool. Computerized tomography and magnetic resonance imaging can provide additional anatomical information and, as in this case, further delineation of the relation between intracavity masses and normal structures, including the mural site of attachment and tumour extension.
Keywords: Left atrium; Secondary cardiac tumours; Large cell lung cancer; Cardiac tamponade
A 53-year-old man presented with progressively worsening dyspnea and tachycardia. He had been diagnosed with a large cell neuroendocrine metastatic adenocarcinoma based on biopsy, and positivity for thyroid transcription factor-1 (TTF-1) on immunocytochemistry suggested lung by far as the most likely primary site. Clinical examination demonstrated raised jugular venous pressure with positive Kussmaul's sign as well as pulsus paradoxus, indicating cardiac tamponade. A transthoracic echocardiogram revealed a global pericardial effusion of 12 mm maximal dimension and an echogenic mass possibly invading the posterior surface of the pericardium without been clearly defined if the left atrial wall was compressed or directly invaded (Figure 1). A computerized tomography (CT) of his upper abdomen and chest showed mediastinal lymphadenopathy with a pulmonary large left lower lobe mass and demonstrated clearly a subcarinal mass (9.7 cm axial diameter) invading the left atrial cavity (Figure 2). Abnormal tumour masses were also abutting onto the right kidney and tail of the pancreas. Aggressive treatment was clearly not appropriate and patient died within 24 h of admission. Post-mortem was not performed.
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The vast majority of tumours affecting the heart are of metastatic rather than of primary origin.1 Highest rate of cardiac involvement has been observed with lung and breast cancer, melanoma, lymphomyeloproliferative neoplasms, and tumours of the gastrointestinal system.1,2 The main route is haematogenous dissemination although direct extension, lymphatic and transvenous spread can also occur.1 Pericardium is the most frequent cardiac structure involved, followed by myocardium and endocardium.1 Clinical presentation is highly variable, dependent on the site and extent of the lesion and frequently overlooked because of the severity of the underlying primary diagnosis. Pericardial effusions, arrhythmias, recurrent emboli, congestive heart failure, and even myocardial infarction are reported clinical patterns.1 When cardiac involvement is suspected two-dimensional echocardiography is the first-line diagnostic tool. CT and magnetic resonance imaging can provide additional anatomical information and, as in this case, further delineation of the relation between intracavity masses and normal structures, including the mural site of attachment and tumour extension.3,4
Heart metastases occur late in the course of malignant diseases and unfortunately are associated with poor prognosis. Nevertheless, early detection using the appropriate investigations can lead to the optimal therapeutic or palliative management decision.
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[Abstract/Free Full Text]
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