Original Article
Prognostic Implication of Direct Cardiac Invasion from Lung Cancer in Non-Operatively Treated Patients Based on Lung Computed Tomography Imaging

https://doi.org/10.1016/j.hlc.2021.10.018Get rights and content

Background

Lung cancer with direct cardiac invasion (LCCI+) exerts a significant influence on the survival of patients. There is a paucity of comparative research into the prognosis of advanced lung cancer with and without direct cardiac invasion.

Method

In this study, 50 LCCI+ patients and 50 sex-, age-, and TNM stage-matched patients without direct cardiac invasion (LCCI–) were retrospectively analysed. LCCI+ was defined as lung cancer directly invading the heart by penetrating mediastinum or extending into the atrium via the pulmonary vein. The study endpoint was all-cause death. In this study, the survival time was defined as the time from the first detection of direct cardiac invasion to the end of the event.

Results

During a median follow-up period of 31 months, all-cause death occurred in 44 patients (88.0%) in the LCCI+ group and in 36 patients (72.0%) in the LCCI– group; the overall survival (OS) time among patients in the LCCI+ group was significantly lower compared with those in the LCCI– group (5.0 [interquartile range (IQR), 2.0–12.0] vs 13.8 [IQR, 4.0–18.4] mo; p<0.001); the OS rate in the LCCI+ group was significantly lower compared with patients in the LCCI– group (log-rank, p=0.0002). Multivariate Cox regression analysis showed that direct cardiac invasion was an independent predictor of survival in patients with advanced lung cancer (hazard ratio, 2.255; 95% confidence interval, 1.443–3.524). Further analysis indicated that in patients with small cell lung cancer, the survival rate between the LCCI+ group and LCCI– group was insignificant (log-rank, p=0.075; survival time: 4.0 [IQR, 2.0–11.5] vs 11.5 [IQR, 5.0–18.3] mo); in patients with non-small cell lung cancer (NSCLC), the survival rate in the LCCI+ group was lower than that of the LCCI– group (log-rank, p=0.01; survival time: 6.0 [IQR, 3.0–13.3] vs 16.3 [IQR, 10.4–27.2] mo).

Conclusions

Direct cardiac invasion from lung cancer was an independent prognostic factor for survival time in patients with lung cancer. Patients with direct cardiac invasion by NSCLC have a poorer clinical outcome than those without direct cardiac invasion. A careful preoperative evaluation is mandatory and appropriate management of cardiac involvement should be considered in the treatment of NSCLC.

Introduction

Cardiac metastasis is a potentially life-threatening complication in patients with cancer and affects clinical decision-making [1]. Current understanding of the pattern and prognostic significance of cardiac metastasis is limited. Pun et al. [2] found that the prognosis for patients with cardiac metastasis is akin to that for stage IV cancer controls matched for cancer aetiology; however, in this study, the primary tumours were far from the heart, and the cancer cells usually colonised multiple organ sites either sequentially or synchronously, rather than in a cardiac-specific manner. Thus, their results may reflect prognosis in selected patient populations with multiple organ failure in the very final stage of cancer progression, rather than reveal mortality related to cardiac involvement.

Leading cancer types that result in cardiac metastasis include sarcoma, melanoma, and gastrointestinal, while the detection of cardiac involvement in patients with lung cancer is relatively uncommon in clinical practice [[3], [4], [5]]. Previous research has shown that the proportion of lung cancers with cardiac metastasis was 9.1–33% [[6], [7], [8], [9], [10], [11]]. Given its cardiopulmonary anatomy, the heart is the sentinel metastatic organ or sole metastatic organ in patients with direct cardiac invasion from lung cancer. Therefore, it is reasonable to assume that cardiac involvement is the culprit in potentially life-threatening events in this population. To study the anatomical location and mode of metastasis, and to determine the prognosis of patients with cardiac metastasis versus controls matched for primary lung cancer without direct cardiac involvement, this study exclusively enrolled patients with lung cancer associated with direct cardiac involvement to ensure greater homogeneity of the dataset.

Section snippets

Study Population and Baseline Characteristics

From January 2016 to December 2020, 50 patients with lung cancer with direct cardiac invasion (LCCI+ group) who were referred to the First Affiliated Hospital of China Medical University were collected retrospectively. The control group was constructed using sex-, age-, TNM stage-, tumour anatomical classification-, and invasion date-matched patients with lung cancer without direct cardiac invasion (LCCI– group) who were referred to the same institution in a 1:1 ratio. All patients were

Population and Baseline Characteristics

A total of 10,003 patients who were diagnosed with lung cancer were identified through lung CT examination and other related examinations in the hospital during the follow-up period (from 2016 to 2020), of whom 50 (0.5%) with advanced LCCI+ were enrolled in the study. In Table 1, the clinical and imaging characteristics of this population are listed, which allows comparisons between those with and without cardiac invasion. As shown in Table 1, age, sex, smoking status, hypertension, diabetes,

Discussion

This study provides information on the prognosis of advanced lung cancer patients with direct cardiac invasion. The main findings of this study are as follows: (1) the long-term survival time of patients with NSCLC in the LCCI+ group was significantly lower compared with those in the LCCI– group; and (2) cardiac invasion was an independent prognostic factor for patients with advanced lung cancer.

Firstly, all 50 retrospectively recruited LCCI+ patients included 49 cases (98%) of central lung

Conclusion

Direct cardiac invasion is an independent prognostic factor of the survival of patients with lung cancer. Patients with direct cardiac invasion by NSCLC have a poorer clinical outcome than those without cardiac invasion. A careful preoperative evaluation is mandatory, and appropriate management of the cardiac involvement should be considered during the treatment of NSCLC.

Funding Sources

This study was supported by The National Natural Science Foundation of China (grant no. 81801661).

Conflicts of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships.

Acknowledgements

The authors thank all participants in this study.

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    © 2021 Published by Elsevier B.V. on behalf of Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ).