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Cardiac involvement by tumour is found in 25% of patients who die from lung cancer and, in the majority of these patients, the involvement is asymptomatic.1 With a significant proportion of patients subjected to lung cancer surgery dying from disease progression within 6 months of surgery, the British Thoracic Society guidelines on the selection of patients with lung cancer for surgery may help to reduce this number.2,3 These guidelines acknowledge the excellent staging potential of PET scanning but only mention echocardiography in the context of valvular or ischaemic heart disease. Echocardiography is an excellent modality for detecting cardiac malignancy.4,5 An increasing number of anaesthetists are joining the already large number of cardiologists able to perform transoesophageal echocardiography (TOE). We suggest that patients presenting for lung cancer surgery who have either ECG abnormalities or poorly differentiated paracardiac tumours should undergo TOE before thoracotomy. The TOE examination would add little to the total operative time but would add contemporary information to existing older information regarding disease stage. Moreover, there would be a small number of patients who would be spared thoracotomy.
A recent case in which left atrial extension of a lung cancer was demonstrated by intraoperative TOE but missed by preoperative PET scanning and the standard staging methods lends anecdotal weight to our argument. Not only did our patient suffer an unnecessary thoracotomy, but also left popliteal artery tumour embolism. This is not the first time a patient has had a thoracotomy abandoned because of tumour involvement of the left atrium revealed only by intraoperative TOE.6 In both cases TOE in the anaesthetic room would have prevented thoracotomy and, in our case, distant tumour embolisation may not have occurred.
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