A 65-year-old male with clear cell carcinoma of the lung and left atrial invasion was successfully managed with individualized systemic anticoagulation and palliative radiotherapy.
Case Report (n=1)
This case highlights the need for individualized multidisciplinary decision-making regarding the risks and benefits of anticoagulation in patients with advanced lung cancer invading the left atrium and associated pulmonary emboli.
Abstract Introduction Clear cell carcinoma of the lung is a rare cytologic variant of non-small cell lung cancer, typically associated with adenocarcinoma or squamous cell carcinoma (1). Although uncommon, pulmonary neoplasms extending into the left atrium through the pulmonary veins have been documented in case reports (1-3). Such vascular invasion increases the risk of hemorrhage, particularly in the presence of malignancy-associated complications such as thrombocytopenia or tumor-related vessel fragility (4-6). Case description A 65-year-old male with chronic obstructive pulmonary disease, remote non-Hodgkin’s lymphoma treated with chemotherapy and partial gastrectomy, and a 45-pack-year smoking history, presented with right sided chest pain and dyspnea. He had recently been diagnosed with clear cell carcinoma of the lung following endobronchial ultrasound with transbronchial biopsies complicated by pneumothorax just weeks prior to presentation. Computed tomography (CT) of his chest on admission revealed bilateral pulmonary emboli and a large right hilar mass (8.5 x 9.7 cm) invading the mediastinum and left atrium with right heart strain (Figure 1). On presentation, hemodynamics were stable and oxygen saturations remained adequate on ambient air. Additional work up identified extensive lower-extremity deep venous thromboses, prompting inferior vena cava filter placement. Records were secured from the outside hospital which confirmed the histopathologic diagnosis along with immunohistochemical markers. Anticoagulation was initially deferred during palliative radiotherapy due to bleeding risk, then resumed after two fractions with repeat imaging showing no interval progression. He was discharged on systemic anticoagulation with plans for outpatient PET scan and chemotherapy. Records also indicated that his MRI brain was positive for left hemispheric intracranial metastasis. Discussion Mediastinal invasion of lung cancer is an unfortunate finding in some cases of advanced cancer, particularly lung, breast, gastrointestinal and ovarian malignancies, however direct cardiac invasion is still rare. This finding often portends a poor prognosis (7). With regard to the tumor burden and proximity to clot burden found on imaging, it was felt that the atrial tumor was thrombogenic and directly causing some of the clot burden as evidenced by the appearance on CT imaging. This raised concern that anticoagulation would cause extensive hemorrhage if treated. Once the patient tolerated the radiation therapy, and after extensive multidisciplinary discussion about anticoagulation, it was felt that anticoagulation could be trialed again to treat the remaining clot burden. This case for this reason is an ideal example of the need for individualized patient care and decision-making regarding risks and benefits of anticoagulation in cancer treatment. This abstract is funded by: None
Tang et al. (Fri,) conducted a case report in Clear cell carcinoma of the lung (n=1). Systemic anticoagulation and palliative radiotherapy was evaluated. A 65-year-old male with clear cell carcinoma of the lung and left atrial invasion was successfully managed with individualized systemic anticoagulation and palliative radiotherapy.
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