Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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 Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21547/ on 05/03/2017 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 Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21547/ on 05/03/2017 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 Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21547/ on 05/03/2017