Scientific Letter
Lung Cancer Invading a Coronary Artery Bypass Graft and Presenting as Refractory Atrial Flutter
Cáncer de pulmón que invade un bypass aortocoronario y produce un flúter auricular refractario
Luis Gorospea,
, Ana María Ayala-Carboneroa,b, Odile Ajuria-Illarramendic, Alberto Cabañero-Sánchezd
Corresponding author
a Department of Radiology, Ramón y Cajal University Hospital, Madrid, Spain
b Department of Pathology, Ramón y Cajal University Hospital, Madrid, Spain
c Department of Nuclear Medicine, Ramón y Cajal University Hospital, Madrid, Spain
d Department of Thoracic Surgery, Ramón y Cajal University Hospital, Madrid, Spain
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Axial CT image (mediastinal window) from the CT portion of the PET/CT (B) study shows an increase in the size of the left hilar mass (asterisk) and a greater secondary encasement of the left internal mammary artery graft (arrow) with respect to the previous imaging study. Coronal CT image (mediastinal window) from the CT portion of the PET/CT (C) better depicts the encasement of the coronary artery bypass graft (arrows) by the mass (asterisk).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Arrhythmias and electrocardiographic abnormalities have been documented to be the first manifestation of cardiac infiltration by different tumors, including primary lung cancer.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">1</span></a> We describe the case of a lung cancer in the left upper lobe invading a coronary artery bypass graft (CABG) and presenting as refractory atrial flutter (AF). Interestingly, AF was the only clinical symptom prior to the suspicion and diagnostic confirmation of malignancy. Although very rare, supraventricular arrhythmias may be the presenting symptom of lung cancer, and physicians should keep this important differential diagnosis in mind when patients have an unexplained persistent supraventricular arrhythmia, especially in cardiac patients with risk factors for lung cancer.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 70-year-old ex-smoker man (45 pack-year history of smoking; quit smoking 4 years earlier) presented to our hospital with a new-onset symptomatic AF. His past medical history was significant for coronary artery disease (treated with CABG four years earlier), mitral valve disease (treated with mitral valve replacement at the same time of the CABG), hyperlipidemia, and chronic obstructive pulmonary disease. Since the AF episodes became persistent in spite of medical treatment, a cavotricuspid isthmus (CTI) ablation was planned. The CTI ablation procedure was successful for controlling the patient's AF. A chest radiograph performed at that time showed a subtle left parahilar opacity that was presumed to be of infectious origin (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>); however, given the absence of thoracic symptoms, a thoracic computed tomography (CT) was recommended. A chest CT was performed 2 weeks later and showed a left hilar mass invading the mediastinum and the left internal mammary artery (LIMA) graft to the left anterior descending coronary artery, consistent with a lung cancer (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The patient denied any chest pain, hemoptysis or coughing in the previous weeks, and an electrocardiogram (ECG) performed at that time (post-CTI) did not show any abnormalities. A bronchoscopic biopsy confirmed a large cell undifferentiated lung carcinoma. A contrast-enhanced whole-body positron emission tomography (PET)/CT detected small liver and adrenal metastases, consistent with a stage IV lung cancer. The patient was started on systemic chemotherapy, but unfortunately the cancer did not respond to treatment. A follow-up PET/CT performed 3 months later showed an increase in the size of the lung mass, a decrease in the diameter of the LIMA graft secondary to an encasement by the surrounding tumor (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Shortly after this follow-up study, the patient presented to the Emergency Department with tachycardia, chest pain, a new ST elevation on ECG in the precordial and lateral leads, and elevation of cardiac troponin levels, consistent with an extensive myocardial infarction. The patient was admitted to the oncology unit and died from cardiac arrest 24<span class="elsevierStyleHsp" style=""></span>h later.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Arrhythmias and electrocardiographic abnormalities, although rare, have been documented to be the first manifestation of cardiac infiltration by different tumors.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">1</span></a> AF is well known to be associated with a variety of medical conditions, such as valvular heart disease, coronary artery disease, aging, hypertension, or thyroid dysfunction, among others.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">2</span></a> However, AF associated with lung cancer has been rarely reported.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">3</span></a> What makes our case unique compared with previous cases is that AF was the only clinical symptom prior to the suspicion and diagnostic confirmation of malignancy. We hypothesize that the possible pathogenesis of AF occurring in this patient could be the ischemic effect on the electric activity of the heart of the stenotic CABG by the encasing lung cancer as well as the enhanced micro-reentry activity when cancer cells infiltrate the left superior pulmonary vein and/or the left atrium.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Although very rare, supraventricular arrhythmias may be the presenting symptom of lung cancer. We believe that physicians should keep this important differential diagnosis in mind when patients have an unexplained persistent AF, especially in cardiac patients with risk factors for lung cancer.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 479 "Ancho" => 1505 "Tamanyo" => 86612 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Axial (A), coronal (B), and sagittal (C) maximum intensity projection (MIP) thoracic CT images (mediastinal window) show a left hilar mass (asterisk) encasing the left internal mammary artery graft to the left anterior descending coronary artery (arrows).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 463 "Ancho" => 1505 "Tamanyo" => 102581 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Axial fused PET/CT image (A) demonstrates a hypermetabolic mass (asterisk). Axial CT image (mediastinal window) from the CT portion of the PET/CT (B) study shows an increase in the size of the left hilar mass (asterisk) and a greater secondary encasement of the left internal mammary artery graft (arrow) with respect to the previous imaging study. Coronal CT image (mediastinal window) from the CT portion of the PET/CT (C) better depicts the encasement of the coronary artery bypass graft (arrows) by the mass (asterisk).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:3 [ 0 => array:3 [ "identificador" => "bib0020" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cardiac masses and tumours" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "C. Basso" 1 => "S. Rizzo" 2 => "M. Valente" 3 => "G. Thiene" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/heartjnl-2014-306364" "Revista" => array:6 [ "tituloSerie" => "Heart" "fecha" => "2016" "volumen" => "102" "paginaInicial" => "1230" "paginaFinal" => "1245" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27277840" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0025" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Update on atrial fibrillation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A. Khaji" 1 => "P.R. Kowey" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.tcm.2016.06.007" "Revista" => array:6 [ "tituloSerie" => "Trends Cardiovasc Med" "fecha" => "2017" "volumen" => "27" "paginaInicial" => "14" "paginaFinal" => "25" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27520496" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0030" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Atrial flutter and myocardial infarction-like ECG changes as manifestations of left ventricle involvement from lung carcinoma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "O. Juan" 1 => "E. Esteban" 2 => "J. Sotillo" 3 => "V. Alberola" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Clin Transl Oncol" "fecha" => "2008" "volumen" => "10" "paginaInicial" => "125" "paginaFinal" => "127" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18258512" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15792129/0000005500000011/v1_201911020900/S157921291930299X/v1_201911020900/en/main.assets" "Apartado" => array:4 [ "identificador" => "49861" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15792129/0000005500000011/v1_201911020900/S157921291930299X/v1_201911020900/en/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S157921291930299X?idApp=UINPBA00003Z" ]
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| 2024 April | 33 | 22 | 55 |
| 2024 March | 63 | 30 | 93 |
| 2024 February | 51 | 19 | 70 |
| 2023 March | 9 | 3 | 12 |
| 2023 February | 22 | 15 | 37 |
| 2023 January | 25 | 36 | 61 |
| 2022 December | 38 | 40 | 78 |
| 2022 November | 33 | 22 | 55 |
| 2022 October | 48 | 44 | 92 |
| 2022 September | 21 | 27 | 48 |
| 2022 August | 30 | 35 | 65 |
| 2022 July | 27 | 31 | 58 |
| 2022 June | 28 | 26 | 54 |
| 2022 May | 27 | 25 | 52 |
| 2022 April | 21 | 23 | 44 |
| 2022 March | 28 | 31 | 59 |
| 2022 February | 26 | 30 | 56 |
| 2022 January | 21 | 31 | 52 |
| 2021 December | 26 | 34 | 60 |
| 2021 November | 21 | 38 | 59 |
| 2020 April | 1 | 0 | 1 |
| 2020 March | 1 | 0 | 1 |
| 2019 November | 3 | 3 | 6 |
Show all
