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J Thorac Cardiovasc Surg 2002;123:564-566
© 2002 The American Association for Thoracic Surgery
Brief Communications |
From the Divisions of Thoracic and Cardiac Surgery and Department of Radiology, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada.
Received for publication Aug 20, 2001; accepted for publication Aug 28, 2001. Address for reprints: Pasquale Ferraro, MD, Division of Thoracic Surgery, Hôpital Notre Dame, 1560 Sherbrooke St East, Montréal, Québec, Canada H2L 4M1 (E-mail: pasquale.ferraro{at}umontreal.ca).
Lipomatous hypertrophy of the interatrial septum (LHIS) is a rare benign tumor of the heart consisting of a nonencapsulated accumulation of mature fat, multivacuolated adipose cells, and enlarged cardiac myocytes.
1-3 We report herein a case investigated for lung cancer in which LHIS was found incidentally. The cardiac tumor presented as a noncharacteristic form of LHIS with a pseudotumoral growth pattern. The cardiac and pulmonary tumors were removed through a right thoracotomy.
Clinical summary
A 59-year-old woman was evaluated for dyspnea on exertion and increased sputum production. Results of the chest and cardiac examinations and electrocardiogram were unremarkable. The chest x-ray film and computed tomographic (CT) scan revealed an ill-defined 3.5-cm mass in the posterior segment of the right upper lobe with slightly enlarged ipsilateral mediastinal lymph nodes. Also, a 4 x 5 x 7-cm mass consisting of adipose tissue was found posteriorly in the right atrium near the superior vena cava junction (Figure 1). Transthoracic echocardiography revealed a large, globular echogenic mass of 18 cm2 (surface area) in the right atrium extending toward the superior vena cava. The mass had a broad-based attachment to the interatrial posterior septum. The rest of the septum was 10-mm thick and infiltrated by adipose tissue. The fossa ovalis was normal. Thoracic magnetic resonance imaging confirmed the presence of the cardiac tumor in the interatrial septum (Figure 2). Bronchoscopic examination showed no endoluminal lesion but cytologic studies were positive for a non-small cell lung carcinoma. The metastatic workup showed no abnormalities, and pulmonary function tests showed adequate function.
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Histologically, the cardiac tumor was characterized by a mixture of mature fat cells and multivacuolated cells, resembling brown fetal fat cells. Trapped myocardial fibers were also found, showing hypertrophy with large, somewhat polymorphic star-shaped nuclei (Figure 3). Electronic microscopic and immunohistochemical analysis confirmed the diagnosis of LHIS. The lung tumor was a grade III squamous cell carcinoma with no lymph node involvement and negative resection margins (stage T2 N0 [IB]).
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years' follow-up, the patient is doing well with no evidence of recurrent disease. Comment
LHIS was first described by Prior 2 in 1964. The great majority of early cases were incidentally found at autopsy. The first in vivo diagnosis of LHIS was not made until 1982 by Isner and associates. 4 In its typical form, LHIS is characterized by an echo-dense globular thickening of the septum (>15 mm), sparing the fossa ovalis and giving the characteristic sandglass appearance. LHIS is often associated with cardiac arrhythmias and sudden death, but most patients remain asymptomatic. 3,5,6 The best form of treatment for LHIS remains controversial. Some authors suggest that asymptomatic LHIS detected by chance should not be surgically corrected. 5,7,8
We report a case in which LHIS was found during investigation for lung cancer. The tumor was initially believed to be a liposarcoma or a benign lipoma. The decision to proceed with surgical removal was based on the large size of the tumor, its location, and compression of the interatrial septum. The right thoracotomy provided excellent exposure of the mediastinum, lung, great vessels, and right atrium and thus permitted excision of both lesions.
In summary, we present a rare atypical form of LHIS with a pseudotumoral growth pattern. In the presence of a large, globular, echogenic mass of adipose tissue in the interatrial septum, other features of LHIS must be sought. These features include thickening of the interatrial septum with a sandglass appearance and a normal fossa ovalis. LHIS discovered by chance should be considered for resection if there is evidence of obstruction or compression of neighboring structures or doubt as to the neoplastic nature of the tumor exists.
References
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, atrial septum.
