Transcript Cardiac Computed Tomography Guided Treatment of

Cardiac Computed Tomography Guided Treatment of
Metastatic Leiomyosarcoma to the Right Lung with
Direct Extension into the Left Atrium of the Heart
Islam Abudayyeh MD, Axel Joob MD, Edward Passen MD
Division of Cardiology, Advocate Lutheran General Hospital
Methods and Significance:
Introduction:
Cardiac leiomyosarcoma (LMS) is usually a metastatic rather than primary tumor.
Cardiac CT angiography (CTA) was requested to evaluate the left atrial mass
LMS rarely involves multiple heart chambers through hematogenious spread. Its
intra-cardiac occurrence usually portends a poor outcome. LMS is often resistant to
chemotherapy or radiation and best treated with surgical resection if the tumor is
small and localized in-situ.
The
Patient Case:
and assess for coronary artery disease prior to palliative cardiac surgery.
right lung mass was confined to the upper lobe, extending into and
confined within the pulmonary vein and contiguous with the left atrial mass.
Cardiac CTA demonstrated a homogeneous well-circumscribed avascular 21 by
40 mm left atrial mass without attachment to the atrial wall, extending only from
the right upper pulmonary vein which separately enters the left atrium. Coronary
CTA showed normal coronary arteries
Figure 5.
Separate right upper
pulmonary vein with mass
Figure 6.
Cardiac CTA showing normal coronary
arteries
Outcome:
A 64-year-old woman had uterine leiomyosarcoma treated with hysterectomy
and metastatic pulmonary nodules treated with left lower lobectomy and right
lower lobe wedge resection. Two years later she developed an enlarging right
mid-lung mass and then a new left atrial mass which appeared separate from
the lung mass on surveillance chest CTs.
The patient underwent a block resection of the right upper lobe with its
pulmonary vein and left atrial mass. Pathologic analysis demonstrated
leiomyosarcoma. Follow-up over three years demonstrated no lung or
cardiac masses.
Figure 9.
3 year follow-up cardiac CTA of right middle and lower pulmonary veins entering
the left atrium, right upper pulmonary vein and artery surgical clips and right
upper lobectomy suture line
Conclusions:
Recent advances in imaging with cardiac and coronary CT
angiography provides clear images of cardiac and coronary anatomy
as well as adjacent structures. To take full advantage of the technology
requires additional training and an advanced level of competency.
Moreover, image analysis from multiple planes by the cardiologist or
cardiac surgeon guides management of complex cardiac conditions.
In this case:
 Cardiac CTA permits assessment of cardiac and extra-cardiac structures as
well as coronary arteries in any plane. A multiplanar approach allowed better
visualization of the mass and its extension showing that it was a single tumor
rather than multiple metastasis.
 Cardiac
CTA may improve diagnosis and treatment options resulting in a
real difference in clinical outcome. Advanced imaging in our patient
demonstrated a single mass which was resected en-block, resulting in survival
due to a curative surgical approach rather than palliative management.
Figure 3.
Multiplanar cardiac CTA showing the direct extension from the right upper lobe
through the pulmonary vein to the left atrium (standard axes shown on right)
References:
Figure 1.
Cardiac CTA axial, coronal, and
sagittal views of the cardiac left
atrial mass
Figure 2.
Cardiac CTA axial, coronal and
sagittal views of the right lung
mass
Figure 4.
Multiplanar cardiac CTA showing the direct extension from the right upper lobe
through the pulmonary vein to the left atrium (standard axes shown on right)
Figure 7.
3 year follow-up cardiac CTA axial,
coronal, and sagittal views of the
cardiac left atrium
Figure 8.
3 year follow-up cardiac CTA axial,
coronal, and sagittal views of the
right lung
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