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Case Report: Thymic Carcinoma With Intracardiac Invasion: Adjunct Role of TOE Guidance During SVC and Right Atrial Reconstruction

Varuna Varma MCh.* Nirmal Gupta MCh.* Prabhat Tewari MD.#

Department of CVTS, #Department of Anesthesiology, SGPGIMS, Raibareli Road, Lucknow, India. 226014.

Corresponding author: Prof Nirmal Gupta Head of Cardiovascular and Thoracic Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.

Abstract: A medical student presented with exertional dyspnea and edema of face and the right upper limb. He had an anterior mediastinal mass for which excisional biopsy was planned. The mass had invaded SVC, right atrial wall and its cavity. Right atrial cavity extension was not evident on 64-slice CT done preoperatively. Trans-esophageal echocardiography routinely placed in the patient helped in the safe dissection between the tumor and the heart during CPB. Surgery was completed using DHCA along with SVC and right atrial free wall reconstruction using bovine pericardium. Frozen section biopsy and histopathological study reported the mass as invasive thymic carcinoma. This report highlights the usefulness and helpful role of adjunct intraoperative TOE in execution of successful surgical procedure, modifying the operative plan that was earlier planned as closed heart procedure based on 64-slice CT images. Based on TOE moving images and flow guidance the extent of tumor invasion was detected during operating and intracardiac tumor removal and reconstruction of SVC, part of right atrium could be successfully performed with the assistance of biological tissue membranes that were lost for a complete en-block excision. The role of trans-esophageal echocardiography as a valuable tool to identify and confirm anatomic details in intended pericardiac mass excision was also successfully established.

Key words: Trans-esophageal echocardiography, Invasive thymic carcinoma, Intracardiac Invasion.

Main Text: Thymic tumors commonly invade the capsule and the adjacent organs such as the pleura, pericardium, lung or great vessels. SVC obstruction is commonly caused by extrinsic compression of the tumor, but less commonly by tumor invasion. (Ref-1)

Tumours may invade the heart by one of the four mechanisms: lymphatic extension, haematogenous metastasis, direct invasion or transvenous extension. The transvenous route of tumor spread relies on the extension of tumor thrombus into the right atrium via the superior vena cava in the case of lung cancer or via the inferior vena cava in case of primary renal or hepatic tumours. (Ref-2) Surgical resection in great vessels and extra- and intracardiac chamber involvement presents a formidable challenge not only in resection but also in pathways reconstruction and prevention of tumor embolization into pulmonary arteries during surgery. The most effective treatment is still a complete surgical resection but better survival rates are seen with adjunct radiotherapy.

There are a only few reports that have described the successful role of intraoperative adjunct use of TOE and DHCA in dealing with malignancies invading into the great vessels and cardiac chambers c.f. inferior venacava and right atrium. Images acquired by 64-slice CT being reconstructed images can sometimes miss important diagnoses in the area of interest however; TOE being real time with flow pattern delineation at 1mm distance is more sensitive in this role.

In our patient tumor invasion of the SVC, huge size of tumor and tumor ingrowth around the great vessels of the heart posed a significant difficulty in its resection. However, already placed TOE probe assisted in identification of the extent of the tumor invasion not only around the cardiac structures but also inside the SVC and RA. Flow pattern also helped identification of correct plane of excision at around the apex of heart during surgical resection.

Figures:

Fig 1. Bicaval View (right rotated): Arrow shows tumor mass inside SVC

In our patient tumor invasion of the SVC, huge size of tumor and tumor ingrowth around

Fig. 2 ME Aortic short axis view (CFD): White arrow shows flow around the tumor mass inside SVC.

In our patient tumor invasion of the SVC, huge size of tumor and tumor ingrowth around

Fig.3 Black arrow shows Reconstructed SVC with Bovine pericardium.

In our patient tumor invasion of the SVC, huge size of tumor and tumor ingrowth around

Fig.4 (a) Coronal views of reconstructed 64-slice CT Scan failing to show intracardiac extension of thymic mass.

Fig.4 (a) Coronal views of reconstructed 64-slice CT Scan failing to show intracardiac extension of thymic

4(b) Cross section views of reconstructed 64-slice CT Scan failing to show intracardiac extension of thymic mass.

Fig.4 (a) Coronal views of reconstructed 64-slice CT Scan failing to show intracardiac extension of thymic

References:

1. Airan B, Sharma R, Iyer KS, et al. Malignant thymoma presenting as intracardiac tumor and superior vena caval obstruction. Ann Thorac Surg 1990; 50: 98991

2. Chiles C, Woodard PK, Gutierrez FR, Link KM. Metastatic involvement of the heart and pericardium: CT and MR imaging. Radiographics 2001;21:43949