Title: Cardiac Computed Tomography Guided Treatment of Metastatic Leiomyosarcoma to the Right Lung with Direct Extension into the Left Atrium of the Heart
1Cardiac Computed Tomography Guided Treatment
ofMetastatic Leiomyosarcoma to the Right Lung
withDirect 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. 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.
- Cardiac CT angiography (CTA) was requested to
evaluate the left atrial mass and assess for
coronary artery disease prior to palliative
cardiac surgery. - The 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 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
Figure 6. Cardiac CTA showing normal coronary
arteries
Patient Case
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.
Conclusions
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.
- 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
- Cardiac metastasis from uterine leio- myosarcoma.
Moreno Anton F, Casado Herraez A, Puente Vazquez
J, etal. Clin Transl Oncol 20068375-8 - Extensive Cardiac Metastases Secondary to Uterine
Leiomyosarcoma. Anna M. Calleja, Clinton V.
Wellnitz, etal. J Am Soc Echocardiogr
2009221419.e5-1419.e7 - Complete resection of a leiomyosarcoma of the
left atrium invading the mitral anterior leaflet
and obstructing the mitral orifice. Turkyilmaz E,
Yilmaz F, Ozkan A, etal. Eur J Echocardiogr ,
Jan, 1 2008 9(1)123-5 - Intravenous Leioma Extending into the Right
Ventricle. Hose A. Rocha-Filho , Leonid D.
Shturman, David R. Okada, Suhny Abbara, Wilfred
Mamuya. J Cardiovascular Computed Tomography,
Jan, 2010 - Noncardiac findings on cardiac CT part I Pros
and cons. Killeen RP, Doss JD, Cury RC. J
Cardiovasc Comput Tomogr. 2009 Sep-Oct3(5)293-9.
Epub 2009 May 13. - Leiomyosarcoma of the right ventricle extending
into the pulmonary trunk. Heart 200186e2
doi10.1136/heart.86.1.e2 - Cardiac leiomyosarcoma primary or secondary? A G
Nicol and G M McAndrew. Br Heart J. 1968 May
30(3) 432435. - Primary Chest Wall Tumors. Asad A Shah, MD,
Thomas A DAmico. J Am Coll Surg. Vol. 210, No.
3, March 2010 - Cardiac Epithelioid Leiomyosarcoma and the Role
of Cardiac Imaging in the Differentiation of
Intracardiac Masses. Christine Jellis, Joseph
Doyle, Tom Sutherland. Etal. Clin. Cardiol. 33,
6, E6 E9 (2010). - Intravenous leiomyomatosis extending into the
right ventricle after subtotal hysterectomy.
Mehmet Sah Topcuoglu, Hafize Yaliniz, Hakan
Poyrazoglu. Etal. Ann Thorac Surg 200478330-332 - Magnetic Resonance Imaging of Pericardial Disease
and Cardiac Masses. John D. Grizzard, Gregory B.
Ang. Cardiol Clin 25 (2007) 111140.
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 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
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)