open access

Vol 14, No 1 (2019)
Case Reports
Published online: 2019-04-10
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Pulmonary embolism and left atrial tumor in a patient with lung cancer — diagnostic and therapeutic difficulties

Emilia Sawicka, Tomasz Olesiewicz, Anna Tomaszuk-Kazberuk, Małgorzata Knapp, Agnieszka Tycińska, Andrzej Ustymowicz, Bożena Sobkowicz, Anna Lisowska
DOI: 10.5603/FC.2019.0003
·
Folia Cardiologica 2019;14(1):89-93.

open access

Vol 14, No 1 (2019)
Case Reports
Published online: 2019-04-10

Abstract

A 64 year-old female with a history of hypertension and chronic obstructive pulmonary disease after radical treatment (radiotherapy and chemotherapy) of squamous cell carcinoma of the right lung in 2016, was admitted to the Depart- ment of Cardiology due to pulmonary embolism, confirmed in an angio-CT. Moreover, cancer recurrence on the right lung and a mass spreading through the right upper pulmonary vein to the left atrium (LA) that might be considered to be a thrombus, were demonstrated. 

The patient, for the week before admission, had suffered from exercise dyspnoea, pain in the lower limbs, and syncope. On admission, the patient presented in a serious general condition. In laboratory tests, elevated D-dimer and NT-proBNP (450 pg/ml) concentrations as well as mild normocytic anaemia were revealed. Echocardiography showed preserved systolic (ejection fraction = 55%) and impaired diastolic left ventricle function, without signs of valvular heart disease. In transoesophageal echocardiography (TEE) in the LA an additional echo of 18 × 12 mm, spreading through the right upper pulmonary vein that might be considered to be a thrombus was revealed. However, due to the location of neo- plastic lesions in the right lung, a cancerous tumour spreading throughout could not be excluded. An abdominal and pelvis CT did not reveal any metastasis. 

Low molecular weight heparin in a therapeutic dose and acetylsalicylic acid were incorporated into the therapy. A mul- tidisciplinary consultation (oncologist, cardiac surgeon, cardiologist, anaesthesiologist) was conducted and the mass in the LA was initially qualified for surgical resection. Prior to surgery, spirometry and the exclusion of thromboembolic material in the lower limb veins were required. Spirometry demonstrated moderate bronchial obstruction. In ultrasound of the lower limb, deep vein thrombosis was excluded, but a few hypoechal nodules in the shank muscles of the right lower limb were visualised. A suspicion of metastases was confirmed using angio-CT. 

In the TEE performed after five days of low molecular weight heparin therapy, the previously described mass in the LA reduced its echogenicity and dimensions (to 10 × 8 mm). The patient’s general condition improved slightly. The patient was re-consulted by the cardiac surgeon and, due to presence of distant metastases, was disqualified from surgery. Another oncologist consultation was performed, and further diagnostic and therapeutic aims were established. The therapeutic dose of heparin was maintained. 

Abstract

A 64 year-old female with a history of hypertension and chronic obstructive pulmonary disease after radical treatment (radiotherapy and chemotherapy) of squamous cell carcinoma of the right lung in 2016, was admitted to the Depart- ment of Cardiology due to pulmonary embolism, confirmed in an angio-CT. Moreover, cancer recurrence on the right lung and a mass spreading through the right upper pulmonary vein to the left atrium (LA) that might be considered to be a thrombus, were demonstrated. 

The patient, for the week before admission, had suffered from exercise dyspnoea, pain in the lower limbs, and syncope. On admission, the patient presented in a serious general condition. In laboratory tests, elevated D-dimer and NT-proBNP (450 pg/ml) concentrations as well as mild normocytic anaemia were revealed. Echocardiography showed preserved systolic (ejection fraction = 55%) and impaired diastolic left ventricle function, without signs of valvular heart disease. In transoesophageal echocardiography (TEE) in the LA an additional echo of 18 × 12 mm, spreading through the right upper pulmonary vein that might be considered to be a thrombus was revealed. However, due to the location of neo- plastic lesions in the right lung, a cancerous tumour spreading throughout could not be excluded. An abdominal and pelvis CT did not reveal any metastasis. 

Low molecular weight heparin in a therapeutic dose and acetylsalicylic acid were incorporated into the therapy. A mul- tidisciplinary consultation (oncologist, cardiac surgeon, cardiologist, anaesthesiologist) was conducted and the mass in the LA was initially qualified for surgical resection. Prior to surgery, spirometry and the exclusion of thromboembolic material in the lower limb veins were required. Spirometry demonstrated moderate bronchial obstruction. In ultrasound of the lower limb, deep vein thrombosis was excluded, but a few hypoechal nodules in the shank muscles of the right lower limb were visualised. A suspicion of metastases was confirmed using angio-CT. 

In the TEE performed after five days of low molecular weight heparin therapy, the previously described mass in the LA reduced its echogenicity and dimensions (to 10 × 8 mm). The patient’s general condition improved slightly. The patient was re-consulted by the cardiac surgeon and, due to presence of distant metastases, was disqualified from surgery. Another oncologist consultation was performed, and further diagnostic and therapeutic aims were established. The therapeutic dose of heparin was maintained. 

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Keywords

pulmonary embolism; left atrial tumour; lung cancer

About this article
Title

Pulmonary embolism and left atrial tumor in a patient with lung cancer — diagnostic and therapeutic difficulties

Journal

Folia Cardiologica

Issue

Vol 14, No 1 (2019)

Pages

89-93

Published online

2019-04-10

DOI

10.5603/FC.2019.0003

Bibliographic record

Folia Cardiologica 2019;14(1):89-93.

Keywords

pulmonary embolism
left atrial tumour
lung cancer

Authors

Emilia Sawicka
Tomasz Olesiewicz
Anna Tomaszuk-Kazberuk
Małgorzata Knapp
Agnieszka Tycińska
Andrzej Ustymowicz
Bożena Sobkowicz
Anna Lisowska

References (8)
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  2. Lam KY, Dickens P, Chan AC. Tumors of the heart. A 20-year experience with a review of 12,485 consecutive autopsies. Arch Pathol Lab Med. 1993; 117(10): 1027–1031.
  3. Dore R, Alerci M, D'Andrea F, et al. Intracardiac extension of lung cancer via pulmonary veins: CT diagnosis. J Comput Assist Tomogr. 1988; 12(4): 565–568.
  4. Ma Q, Liu D, Liu P, et al. Extensive invasion of the left atrium by lung cancer. Ann Thorac Surg. 2013; 96(2): 685–687.
  5. Wang W, Li X, Song W, et al. An atypically large, free-floating thrombus extending from the lung to the left atrium via a pulmonary vein: a case report. Medicine (Baltimore). 2015; 94(46): e1853.
  6. Ucak A, Inan K, Onan B, et al. Free-floating tumor thrombus in the left atrium associated with non-small cell lung cancer. J Card Surg. 2009; 24(6): 686–689.
  7. Li Y, Lou J, Qiu S, et al. Stereotactic radiotherapy for the treatment of lung cancer with a giant left atrial tumor thrombus: A case report and literature review. Oncol Lett. 2016; 11(3): 2229–2232.
  8. Bao T, Xiao F, Liu D, et al. [Surgical procedures and perioperative management for non-small cell lung cancer complicated with left atrial tumor thrombus]. Zhongguo Fei Ai Za Zhi. 2018; 21(1): 24–31.

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