Neoplastic disease of the heart

Abstract

1. 1. Neoplastic disease of the heart is seldom recognized even though it is no longer considered unusual. 2. 2. Cardiac lesions are found at autopsy in 20 per cent of the patients dying of malignancy. This type of disease usually causes no cardiac signs and symptoms but can be diagnosed clinically in about 5 to 10 per cent of such patients. 3. 3. Primary neoplasms of the heart and pericardium are exceedingly rare but must be considered in the differential diagnosis of unusual heart disease. 4. 4. From a clinical standpoint, one can think in terms of (1) a clinical picture due to neoplastic involvement of the endocardial region, (2) a clinical picture due to neoplastic involvement of the myocardium, (3) a clinical picture due to neoplastic involvement of the pericardium. Such a classification is not intended to imply that the new growth actually originates in the region which produces the symptoms and signs. 5. 5. Endocardial implants of neoplastic metastatic tissue seldom produce symptoms or signs of heart disease. Degenerative verrucal endocardial lesions are occasionally related to a malignant neoplasm and are considered fertile ground for the development of bacterial endocarditis. The curious syndrome of carcinoid of the small intestine and pulmonary stenosis is mentioned. Myxomas make up 50 per cent of the primary tumors of the heart and 75 per cent of such tumors as are located in the left atrium. Symptoms occur because of obstruction to the mitral valve, pulmonary veins, tricuspid valve, and superior and inferior vena cava. The patient's symptoms and signs may simulate rheumatic mitral stenosis, ball-valve blockade of the mitral or tricuspid valve, rheumatic tricuspid stenosis, and constrictive pericarditis. Clues that are useful in suspecting the true nature of the disease are pointed out. 6. 6. Extensive metastatic neoplastic involvement of the myocardium may produce congestive heart failure. One should consider this type of disease when a patient with known malignancy develops congestive heart failure without obvious cause. The physical finding of bronchial breathing over the sternum may indicate anterior mediastinal neoplastic involvement, including the heart and pericardium, from the trachea and bronchi to the sternum. Small lesions in the myocardium produce arrhythmias and various electrocardiographic abnormalities. The most common primary myocardial tumor is the rhabdomyoma, and this tumor is frequently associated with tuberous sclerosis of the brain and adenoma sebaceum of the skin. Primary and secondary neoplastic involvement of the heart may involve the conduction system of the heart and produce the various grades of heart block. 7. 7. Neoplastic involvement of the pericardium must always be considered when the symptoms, signs, and electrocardiographic abnormalities characteristic of pericardial disease make their appearance in a patient with a malignancy. Acute pericarditis, pericardial effusion, and constrictive pericarditis can be the result of primary and secondary neoplasms. Certain diagnostic clues are pointed out in a brief discussion of the various types of pericardial disease. 8. 8. All types of cardiac arrhythmias have been reported to occur in cases of primary and secondary neoplastic disease of the heart. High grades of atrio-ventricular conduction defects are more diagnostic of cardiac involvement than are other arrhythmias in younger patients with known malignancy. 9. 9. Nonspecific electrocardiographic abnormalities are common in patients with neoplastic disease of the heart. Nonspecific T-wave abnormalities, bizarre P waves, evidence of pericarditis or pericardial effusion, and the QRS abnormalities of “dead zone” have all been reported in addition to the various cardiac arrhythmias. 10. 10. The x-ray findings of neoplastic disease of the heart have been listed, and several indications for angiocardiography have been emphasized. 11. 11. It is hoped that some intracavitary cardiac tumors can be removed (i.e., myxoma of the left atrium). X-ray therapy may offer transient benefit for neoplastic involvement of the myocardium and pericardium when the tissue is radiosensitive. The surgical production of a pleuropericardial window or pericardial resection is considered the treatment of choice for massive hemorrhagic pericardial effusion that reaccumulates rapidly.