Download Direct Extension of Cancer between Pulmonary Veins and the Left

Direct Extension of Cancer between
Pulmonary Veins and the Left Atrium*
Wilson I . B. Onuigbo, M.B., Ph.D.* O
Direct extension of tumor thrombns from the pulmonary veins into the left
atrium is reputed to be rare and to have been first reported in 1865. This study
draws attention to one case published in 1833 and contributes three cases found
in 100 lung cancer necropsies. Thus, it is likely that this entity, whose chances
of detection are probably increased by removing the lungs m d heart in continuity, is not rare.
ung cancer spreads far more corn~onlyinto
veins than into arteries and may project from a
pulmonary vein into the left atrium.' In 1970,
Schiller and Madge2 noted the rarity of reports of
tumor thrombi from primary and secondary neoplasms of the lung extending from the pulmonary
veins into the left atrium. They stated that this
entity was first described in 1865 and were able to
collect only 15 cases from the literature to which
they added one case of their own. As is common
with retrospective studies, some details may be
missing; this is evident in their tabulated cases. As
regards their 1865 citatioq3 the relevant pathologic
description was the single sentence: "Projecting into
the interior of the left auricle from.the orifice of the
left pulmonary vein, which it completely obstructs,
is a small nodulated, button-shaped tumour."
I wish to draw attention to a detailed case
published before 1865 and to contribute three cases
encountered in 100 lung cancer necropsies at the
University of Glasgow, Scotland, between 1960 and
1962 inclusive. In all probability, this entity is not
rare but underdiagnosed.
On January 22, 1833, John Sims,' physician to the St. Maryle-Bone Infirmary, read a paper before the Medical and
Chirurgical Society of London subtitled "Malignant tumour
affecting the right lung, and penetrating the left auricle of
the heart."
'From the Department of Pathology, General Hospital,
Enugu, Nigeria.
"Senior Consultant Pathologist.
Reprint requests: Dr. Onuigbo, General Hospital, Enugu,
Nigeria
His patient, a 43-year-old man, had complained of cough,
dyspnea and hemoptysis. He later developed enlargement of
the neck veins, swelling of the face, and severe headache.
At necropsy, a tumor was found in the right main
bronchus. The pericardium contained several deposits. The
left pulmonary veins were fr&. One right pulmonary vein
was dilated and its coats thinned out by intraluminal tumor,
while the other vein was difficult to trace because it had
passed into the center of some contiguous growths. A tumor
of the size of hazel nut was lying free in the interior of the
left atrium from where a "slender peduncle" connected it
directly "to the inside of one of the right pulmonary veins."
A 54-year-old man developed cough associated with chest
pain and hemoptysis. There was a blowing ventricular systolic
murmur at the left sternal edge. The pulmonary second sound
was widely split and accentuated. Radiography demonstrated
collapse of the apical posterior segment with consolidation of
the rest of the left upper lobe, the appearances being suggestive of neoplasm. Bronchoscopy disclosed a growth protruding
from this lobe and biopsy revealed a poorly differentiated
squamous cell carcinoma. No infiltration was noted in excised scalene lymph nodes. A year after his 6rst admission,
he developed massive left pleural effusion and died about a
month after this.
Necropsy c o n k e d that he had a polypoid squarnous cell
carcinoma obstructing the left upper lobe bronchus and extending into the main bronchus of the left lung for a distance
of 3 cm. Beyond the obstruction, the left upper lobe was
largely cavitated, only a thin shell of shaggy infiltrated
pulmonary. .
parenchyma remained, while the lower lobe was
completely consolidated. The right lung was massively
edematous. The ~ericardiumwas infiltrated su~ero~osteriorly. The left upper pulmonary vein was completely occluded
by tumor tissue which therefrom extended into the chamber
of the left atrium.
CHEST, VOL. 62, NO. 4, OCTOBER, 1972
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DIRECT EXTENSION OF CANCER
A 52-year-old man was admitted with cough and weight
loss. Examination revealed pure heart sounds. Radiography
showed the presence of an effusion into the left costophrenic
angle and congestion of the left lower zone; bronchoscopy
indicated mucosal thickening in the left lower lobe; and biopsy showed mucosal hypertrophy and submucosal fibrosis.
Later, a soft circular opacity appeared below the left hilum
and there were increasing density and probable collapse of the
left lower lobe. He became confused, disorientated and
somnolent. His general condition deteriorated very rapidly
and he died three months after admission.
Necropsy showed several ulcerated oat cell tumors in the
distal half of the left main bronchus and its divisions, especially the lower ones. Tumor tissue extensively sheathed the
smaller bronchi and vessels. The uninvolved parts of this lung
showed edema, whereas the right lung manifested congestion. The left side of the. pericardium was infiltrated, with
extension to the right side, round the base of the heart.
Between the base of the heart and the main branches of the
pulmonary artery was a mass of growths, which inferiorly
invaded the left atrium, reaching the endocardium at one
point. In addition, tumor pouted into the atrial cavity through
a superior pulmonary vein.
A 50-year-old man was admitted with dyspnea and hemoptysis. The first heart sound was loud and sharp. Radiography
showed a soft tissue opacity in the left lower lobe suggestive
of neoplasm. Bronchoscopy revealed malignant infiltration of
the left main bronchus and biopsy confirmed the presence of a
squamous cell carcinoma. The patient gradually deteriorated
and died following hemoptysis.
Necropsy confirmed the presence of a squamous cell tumor
which ulcerated the main bronchus of the left lung. The
branch bronchi and pulmonary parenchyma were markedly
infiltrated by growths, particularly in the lower zones. These
growths were cavitated in the lower lobe and associated with
more localized suppuration in the upper lobe. The right lung
was much distended because of emphysema, especially in the
upper lobe; the mediastinum was shifted to the left side. The
pericardium appeared normal but the heart was striking
because of a 4 x 3 x 2 cm mass of tumor which had grown
into the cavity of the left atrium from the single left pulmonary vein.
An important point was made by Bates5: ''Exarqination of the pulmonary veins at autopsy may
sometimes be less than ideal when the heart is not
removed in continuity with the lungs." It is of interest that Sims4 himself pointed out that he was
compelled by circumstances to remove the heart in
continuity with the lung-bearing tumor. As for my
personal cases, a monoblock technique6 ensured that
the heart was removed in continuity with the
lungs. The use of formalin-fixation before final dissection also facilitated the observation in situ of
undisturbed tumor thrombus, and thus increased
the chances of detecting its occurrence.
There is need to draw lines of distinction between direct extension and metastasis to the atrium,
as was done elsewhere7 for the invasion of the
brachial plexus in lung cancer. Though Schiller and
Madge2 considered that "direct extension within
the pulmonary veins into the left atrium is a rare
form of cardiac metastasis," their own description
points to the noninvasion of the heart itself. The
mere formation of a continuous tumor thrombus
within the pulmonary vein and atrial cavity should
be distinguished as "direct extension" in contrast to
"metastasis" whose definitions should be made in
terms of discontinuous ( discrete ) spread.
Another point of interest in Schiller and Madge's2
paper is the question of the postulates of Edwards
and BurchellQas regards the respective areas of
lung drained by either the occluded or patent
pulmonary veins. The gross findings of the latter
authors were: "Severe pulmonary congestion was
present in the lobe without venous obstruction, but
cong~stionwas not present in the other lobes." The
obstructive and secondary inflammatory changes
caused by the tumor itself make such comparison
difficult in primary lung cancer. Thus, in cases 1 and
3, cavitation with either consolidation or suppuration disorganized the obstructed side, while the
contralateral unobstructed lobes displayed massive
edema and emphysema respectively. Case 2 provided comparable conditions: the obstructed lobe
showed edema, while the contralateral lobes displayed congestion, contrary to expectations from
Edwards and Burchell's experience. Microscopy in
cases 2 and 3, whose small blood vessels were
studied. in connection with tumor embolization
from the thoracic duct,I0 showed no helpful findings. Anyway, it should be remembered that the
postulates in question were elucidated from a case
with uncomplicated, extrinn'c and multiple venous
obstruction, whereas, in the present cases, the
obstruction was associated with complicating factors, the obstructing material was developed within
the vein, and the individual vein was occluded
rather than several veins.
Finally, there is the question of heart murmurs.
The finding of a systolic murmur in case 1 is in
keeping with the review of Schiller and Madge,2
who noted that all three published cases with
munnurs had them systolically.
ACKNOWLEDGMENTS: The material for this study was
collected at the University of Glasgow, thanks to the facilities
granted by Professor D. F. Cappell. The three cases reported
above were all among those which Dr. J. F. Boyd allowed me
to necropsy at the Ruchill Hospital. For replenishing the
necropsy records that I lost during the Nigerian Civil War, I
am grateful for the help of Professor J. R. Anderson and Drs.
A. M. Chalmers, J. F. Boyd, A. T. Sandison, Mary Catto,
G . B. M. Clarke, R. R. Wilson, Brenda Gray and 0. A. Ojuri.
CHEST, VOL. 62, NO. 4, OCTOBER, 1972
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WILSON I. 6. ONUIGBO
The librarian of the Royal Society of Medicine, London, provided much needed photocopies, whose postage cost was
borne by Upjohn Limited.
1 d'Abreu AL: A Practice of Thoracic Surgery. London,
Arnold and Company, 1953, p 267
2 Schiller HM, Madge GE: Neoplasms within the pulmonary veins. Chest 58:535, 1970
3 Andrew: Primary cancer of the left lung and of the
mediastinal glands. Trans Path Soc Lond 16:51, 1865
4 Sirns J : On malignant turnours, connected with the heart
and lungs. Medico-chir Trans 18:281, 1833
5 Bates HR: Postmortem examination of pulmonary veins.
Am J Clin Path 37:639, 1962
6 Onuigbo WIB: A mono-block formalin-hation method
for investigating cancer metastasis. Z Krebsforsch 65:209,
1964
7 Onuigbo WIB: Lung cancer and shoulder pain. Dis Chest
45:488, 1964
8 Robbins SL: Textbook of Pathology. Philadelphia, W. B.
Saunders Company, 1957, p 41
9 Edwards JE, Bruchell HB: Multilobar pulmonary venous
obstruction with pulmonary hypertension. "Protective"
arterial lesions in the involved lobes. Arch Intern Med
87:372, 1951
10 Onuigbo WIB: The carriage of cancer cells by the
thoracic duct. Br J Cancer 21:496, 1967
Facts and Fancy About Ozone
Ozone ( 0 3 ) , a colorless gas of biting, acrid odor
somewhat similar to that of chlorine, is a triatomic form
of oxygen. It is generated from the latter through exposure to ultraviolet radiation in the stratosphere and
mesosphere. In 1840, C F Schonbein coined its name
from the Greek ozein, meaning "to smell." Its inhitesima1 amounts in the higher atmosphere absorb excess
ultraviolet radiation of the sun and thus protect life on
earth. It is a potent oxidant air pollutant detrimental to
plants (particularly tobacco, white pine, tomato, beans)
and humans. Motor vehicle exhausts contain oxides of
nitrogen, and hydrocarbons. The latter, when subjected
to solar radiation in the presence of oxides of nitrogen, go
through photochemical reactions with resultant ozone
and ozonoids, as first proved by Haagen-Smit et a1
(Indust Engin Chem 45:2086, 1953). Potential industrial exposure to ozone may be encountered in welders,
electroplaters, photoengravers, ultraviolet lamp workers,
textile-, wax-, oil- and flour bleachers, water treaters,
sewage gas treaters, organic chemical synthesizers and
others. Its recommended preventive threshold limit is 0.1
ppm parts of air by volume. Exposure to 0 3 of 0.5 to 1
ppm causes initation and dryness of the throat, eyes, and
headache. Dobrogorski found (USPHS Air Pollution
Seminar, 1956) that in mice, inhalation of ozone of
lppm to 3ppm for four hours resulted in pulmonary
edema, with leukocytes in the alveoli, alveolar septa and
about terminal bronchioles. In similar experiments he
observed pulmonary fibrosis and increased death rate
from pneumonia. Confirmatory observations were recorded by Stokinger et al (Arch Indust Health 16:514,
1957). Others, including Clamann et a1 (Advances in
Chem No. 21, 1959) noted increased residual volume
and decreased pulmonary diffusion capacity in healthy
persons from inhalation of 1.25ppm of 03, Goldstein et a1
(Nature 229:262, 1971) found impaired pulmonary antibacterial defenses in mice exposed to inhalation of less
than lppm of 0 3 . Coffin et a1 (Arch Environ Health 16:
633, 1968) observed decreased phagocytic function of
pulmonary alveolar macrophages following brief exposures to 0.3-4ppm of 0 3 . Exacerbation of bronchial asthma and aggravation of chronic bronchitis and emphysema
may be brought about by 03-induced increased susceptibility to histamine, with consequent enhanced proclivity to bronchoconstriction. Substernal tightness, chest
pain and impaired mental function were recorded by
Griswold et a1 (Arch Indust Health 15:108, 1957) in
men experimentally exposed to 2ppm of 0 3 for two
hours. Enzymatic function may be inhibited by the
oxidizing effect of 0 3 . Stokinger states (Arch Indust
Hyg & Occup Med 9:367, 1954) that aging effects
similar to those seen from chronic low-level irradiation
develop in animals chronically exposed to low 0 3 levels.
Popular notions associate the word ozone with wholesome, pure air and refreshing and invigorating effect
upon the body. Assertions of this sort are but products
of sheer ignorance and primitive wishful thinking.
Andrew L. Banyai, M.D.
CHEST, VOL. 62, NO. 4, OCTOBER, 1972
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