Metastatic Cardiac Tumors Research Articles

Basic Concepts in Metastatic Cardiac Disease.

The involvement of the heart in metastatic cancer is a rare clinical diagnosis, as it may be asymptomatic or symptoms, when present, may be attributed to other causes. Issues regarding incidence, intracardiac location, clinical presentation, diagnosis and treatment of metastatic cardiac tumors will be discussed here.

Case report of death from falling: Did heart tumor cause syncope?

A healthy man in his 30s was working on the balustrade of stairs on the second floor. He suddenly fell downstairs without saying anything. On emergency hospitalization, chest echogram showed left hemothorax. Cardiac echogram showed a floating mass from the mitral valve in the left ventricle and severe mitral regurgitation. Surgery for hemothorax and pulmonary contusion was immediately undertaken. However, bleeding from pulmonary contusion could not be controlled and he underwent cardiopulmonary arrest. Autopsy showed a white, elastic, pendulous mass in the left atrium and a white mass in the lower lobe of the left lung. Tumor histology showed a reticular pattern, Schiller-Duval bodies, eosinophilic hyaline globules, and positive staining for α-fetoprotein. We diagnosed primary lung yolk sac tumor with metastatic intracardiac yolk sac tumor, a rare and highly malignant germ cell tumor. It usually arises in the ovaries and testes, and intracardiac yolk sac tumor is rare. Intracavitary tumors induce obstruction of inflow into and outflow from the ventricular cavity. The most common clinical presentation is dyspnea and syncope. In the present case, metastatic cardiac yolk sac tumor might have disturbed cardiac outflow and affected hemodynamics, probably causing syncope. Unfortunately, he was in a high place at that time and fell to receive pulmonary contusion that led to death. Autopsy may sometimes reveal latent diseases which might be related to the cause of death. We should perform autopsy thoroughly to diagnose not only the cause of death but also the factors leading to death.

Cardiac Tumors

Primary cardiac tumors are extremely rare. The frequency of cardiac tumor is approximately 0.02% corresponding to 200 tumors in one million autopsies.1 The occurrence of metastatic cardiac tumors has been reported a 100-fold more commonly than primary lesions.2 Clinical manifestations are usually determined by the location of the tumor in the heart, such as obstruction of the circulation being symptomatic of heart failure. The tumor may not only invade the myocardium but also the adjacent lung,3 which can cause pulmonary symptoms.

A Case of Aborted Sudden Cardiac Death and Consequent Extreme Electrical Storm Secondary to a Metastatic Cardiac Tumor

We report a 43-year-old man with an implantable cardioverter defibrillator for aborted sudden cardiac death. He represents in extreme electrical storm with 111 different ventricular fibrillation episodes. Successful treatment was achieved with multiple antiarrhythmic agents, mechanical ventilation, external shocks, and ultimately overdrive pacing. A cardiac magnetic resonance scan revealed two cardiac lesions that were later diagnosed as metastatic fibrosarcoma. This case highlights two very important and increasingly common cardiological dilemmas: the management of extreme electrical storm and the role of magnetic resonance imaging in aborted cardiac death patients with an apparent "normal" heart.

A Case of Cerebral Embolism With Metastatic Chondrosarcoma in the Left Atrium

Cardiac tumor is a rare, but clinically important source of cerebral embolism. We report a case of metastatic chondrosarcoma in the left atrium with multiple cerebral emboli. A computed tomography scan of the chest revealed a large mass in the left atrium and pulmonary vein. The patient underwent heart surgery to remove the metastatic chondrosarcoma in the left atrium, to prevent the formation of further systemic emboli and possible sudden death. The cardiac tumor resection was successful, and the patient was discharged from the hospital without any handicap. This is a rare case of metastatic cardiac tumor that was a source of emboli into the brain and was eradicated.

Characterization and Management of Cardiac Tumors

Cardiac tumors are infrequent clinical entities with an autopsy frequency ranging from 0.001% to 0.030%. The occurrence of metastatic cardiac tumors has been reported a 100-fold more commonly than primary lesions. Three quarters of primary cardiac tumors are benign; approximately half of these are cardiac myxomas, and the rest are lipomas, papillary fibroelastomas, and rhabdomyomas. Among malignant primary cardiac tumors, the most reported are those histopathologically considered as undifferentiated, followed by angiosarcomas and leiomyosarcomas. Traditionally, cardiac tumors have been identified as curious autopsy findings resulting in a literature paucity of large clinical series, therefore, providing knowledge mostly based on case report collection. However, recent technological advances in noninvasive imaging modalities such as echocardiography and cardiac magnetic resonance imaging (MRI) have resulted in a rapid acquisition of real-time heart images with high spatial and temporal resolution and an excellent tissue characterization of the tumor. This consequent earlier, more frequent, and more complete assessment of cardiac tumors before significant symptoms develop has challenged cardiologists, cardiac anesthesiologists, and surgeons to create a tailored referral pattern and approach.

Pericardial and Intracardiac Metastasis of Breast Cancer

Received July 23, 2009, from Medical Clinic II, Cardiology and Angiology, Berufsgenossenschaftliches Universitatsklinikum Bergmannsheil, Bochum, Germany. Revision requested August 31, 2009. Revised manuscript accepted for publication September 8, 2009. Address correspondence to Alfried Germing, MD, Medical Clinic II, Cardiology and Angiology, Berufsgenossenschaftliches Universitatsklinikum Bergmannsheil, Burkle-de-la-Camp Platz 1, 44789 Bochum, Germany. E-mail: alfried.germing@rub.de 79-year-old female patient presented with suspected deep venous thrombosis. Five years previously, she underwent mastectomy for right-sided breast cancer. A pathologic fracture of the left upper arm and the right femur was treated with osteosynthesis and radiation therapy 3 months before presentation. A pericardial tamponade with hemorrhagic effusion requiring pericardiocentesis was described several months earlier. Currently, deep venous thrombosis could be ruled out by color duplex sonography, but further diagnostic evaluation revealed intracardiac masses and a metastasis in the cerebellum. Transthoracic 2-dimensional echocardiography showed 2 round homogeneous tumors inside the left ventricle (Figure 1 and Videos 1 and 2). One tumor was adherent to the papillary muscle, and the other was located at the left ventricular apex. A third tumor with the same echogenicity was detected at the lateral annulus of the tricuspid valve (Figure 2 and Video 3). The interatrial septum was thickened and suspicious for diffuse neoplastic infiltration. In addition, a suspicious intrapericardial structure was detected at the left atrial wall (Figure 1). Besides supportive care, specific therapy for intracardiac masses was not done because of the patient’s reduced general condition. Cortisone therapy was initiated because of the cerebral metastasis. Most cardiac tumors are benign. However, the heart and pericardium are affected in about 10% of malignant tumors. Secondary neoplasms are much more common than primary cardiac malignancies. Several types of cancer with intracardiac metastases have been described in the literature.1 The highest rates of metastases to the heart are found in melanoma, germ cell neoplasms, and thymoma. However, the greatest numbers of malignant cardiac lesions are induced by common types of cancer of the stomach, liver, ovary, and colon.2 Metastatic cardiac tumors may represent anatomic extensions from intra-abdominal or intrathoracic neoplasia or spread hematogenously. Cardiac involvement can be localized or diffuse. At the time of diagnosis, metastases usually involve multiple areas of the myocardium.

Acute coronary syndrome due to coronary artery compression by a metastatic cardiac tumor

A 60-year-old female without coronary risk factors was admitted to the hospital with ST-elevation acute coronary syndrome (ACS). She had previously suffered breast cancer and received radical mastectomy followed by chemotherapy and radiation. Emergent coronary angiography showed an occlusion of the proximal left anterior descending coronary artery (LAD) and coronary angioplasty was performed. Coronary computed tomography (CT) angiography (CTA) disclosed a tumor invading the left ventricular anterior wall and surrounding the coronary artery. Myocardial single-photon-emission CT (SPECT) using 123I-BMIPP showed a defect in the same portion. A fusion image of the CTA and the SPECT delineated a tumor surrounding the coronary artery. She finally died two months later from a terminal condition. Autopsy demonstrated a tumor involving the left ventricular anterior wall and surrounding the LAD. Pathology of the affected LAD showed only fibrous plaque without vulnerable plaque, thrombus, or tumor invasion to the coronary wall. Thus, compression of the coronary artery by the metastatic tumor was the most likely mechanism of ACS.

Extensive Cardiac Metastases Secondary to Uterine Leiomyosarcoma

Uterine leiomyosarcoma metastatic to multiple cardiac chambers occurs infrequently. Over the past 4 decades, there have been only 11 reported cases of cardiac metastasis secondary to uterine leiomyosarcoma. Metastatic cardiac tumors are commonly diagnosed postmortem, although it may be possible to diagnose them during life. The authors report a rare case of a 48-year-old woman with uterine leiomyosarcoma who was diagnosed with extensive cardiac metastases (in the left atrium, right and left ventricles, pulmonary artery, and pulmonary vein). Although extensive cardiac metastases are suggestive of imminent death, aggressive treatment resulted in survival for >1 year for this patient, which underscores the importance of treatment in select patients.

Isolated Right Ventricular Intracavitary Metastasis of Hepatocellular Carcinoma in a 74-year-old Woman

A 74-year-old woman with a history of chronic hepatitis C and transcatheter arterial chemoembolization for an unresectable hepatocellular carcinoma (HCC) 2 years previously presented with progressive exertional dyspnea of 1 month's duration. Two-dimensional echocardiography revealed a huge right ventricular mass with right atrial and right ventricular outflow tract extension. Palliative resection of the tumor and adjunctive chemotherapy was performed. However, the right ventricular mass recurred 1 month later and the patient died 4 months after the operation. To our knowledge, this is the oldest patient reported with isolated right ventricular intracavitary metastasis of HCC, and this report reemphasizes the lower surgical indication in patients with metastatic cardiac tumors.

Isolated Left-Sided Metastatic Sarcoma of the Heart with Limb Ischemia

Soft-tissue sarcomas are rare causes of metastatic tumors of the heart1,2, which often involve the right side of the heart and rarely present as intracavitary lesions1,2. Despite their frequency of occurrence, metastatic cardiac tumors often remain subclinical since symptoms of disseminated disease prevail. An isolated metastatic heart tumor is rare and may present with a spectrum of clinical signs and symptoms1,3-5. We present the case of a patient who had an isolated left-sided metastatic heart tumor along with a coexisting atrial septal defect. The tumor presented as acute thromboembolic limb ischemia three months after neoadjuvant chemotherapy, wide local resection, and brachytherapy for a high-grade undifferentiated pleomorphic sarcoma of the contralateral calf. The husband of our patient was informed that data concerning the case would be submitted for publication, and he consented. A twenty-nine-year-old woman was referred to the office for evaluation of an enlarging painful mass in the right calf. The mass, which had first appeared three months previously, was insidious in onset and was not associated with any preceding trauma. It had been previously diagnosed elsewhere as a hematoma on the basis of magnetic resonance images, but concerns were raised when subsequent studies showed that the size of the mass had increased. The pain had worsened two weeks prior to our evaluation, and the patient required a cane to walk. She had no resting or nocturnal pain, constitutional symptoms, or numbness or weakness in the limb, but she did have occasional calf spasms. Her medical history included a cesarean section nine months previously and use of oral contraceptives. On clinical examination, the patient was a healthy-appearing woman who was in mild discomfort. There was tender, diffuse swelling over the proximal aspect of the right leg. …

Metastatic adenocarcinoma in the right atrium and secondary Budd–Chiari syndrome (a case report)

Budd–Chiari syndrome is a rare clinical syndrome which is characterized by the occlusion of the major hepatic veins or the inferior vena cava at the suprahepatic level. Metastatic cardiac tumors (MCT) are much more common than the primary cardiac tumors. Although MCT are frequently clinically silent, rarely pericardial tamponade or effusion may be the first clinical sign of MCT. Budd–Chiari syndrome rarely developed secondary to MCT.We report an unusual case of Budd–Chiari syndrome which was associated with metastatic right atrial adenocarcinoma with unknown origin in a 60-year-old woman. This combination in Budd–Chiari syndrome has been never published before.

Benign cardiac tumor in a patient with lung malignancy

Dr. Jochen W.U. Fries Institute of Pathology University of Cologne Kerpener Str. 62 50937 Cologne, Germany Sirs: With an incidence of approximately 0.02% in autopsy series, primary tumors of the heart are very rare [15]. While 80–90% of primary cardiac neoplasms seen in the left atrium are benign myxomas, tumors of the right side of the heart are always suspicious of malignancy [15]. Metastatic cardiac tumors are 20 to 40 times more common than primary heart neoplasms and have been reported in up to 20.6% of patients with extracardiac malignancies [7]. In most of these patients cardiac involvement is a sign of poor prognosis. We present a patient with squamous cell lung cancer and a concomitant huge right-atrial mass, in whom precise cardiac evaluation and subsequent histopathological diagnosis were essential for further therapy.

Bidirectional Ventricular Tachycardia with Alternating Right and Left Bundle Branch Block Morphology in a Patient with Metastatic Cardiac Tumors

A case is reported of bidirectional ventricular tachycardia and syncope in a 16-year-old male with a previous history of a paratesticular rhabdomyosarcoma that achieved complete remission with treatment. At the electrophysiological study, frequent ectopy of both right and left bundle branch block pattern were present, with runs of monomorphic and bidirectional VT alternating the two morphologies. The study suggested a single focus at the interventricular septum with two exit sites, depolarizing the right and left ventricle in an alternate fashion. Reassessment of the malignancy status showed multiple cardiac metastases with a 4 mm nodule at the interventricular septum.

Emergency Management of Severe Right Ventricular Inflow Obstruction Secondary to a Metastatic Cardiac Tumor

We report the case of a 21-year-old female with previous history of primitive neuroectodermal tumor of the anterior abdominal wall who developed severe manifestations of right heart failure due to a mass obliterating the right ventricular cavity. She underwent emergent resection of the mass with histopathologic confirmation of metastatic neuroectodermal tumor. To the best of our knowledge, this is the first case of emergent surgical excision of a metastatic cardiac tumor of primitive neuroectodermal origin.

MR EVALUATION OF THE PERICARDIUM AND CARDIAC MALIGNANCIES

The pericardium and cardiac malignancies are well visualized on MR imaging because of the superb contrast resolution and multiplanar capability of the technique. This article highlights some of the clinical uses of MR imaging in evaluating the pericardium and cardiac lesions and provides comparison with echocardiography and CT scan. Specific diseases that are described include pericardial effusion, constrictive pericarditis, neoplastic pericardial disease, congenital abnormalities of the pericardium, benign, malignant and metastatic cardiac tumors, and paracardiac masses. This article discusses the impact of newer MR techniques such as cine MR imaging on the assessment of pericardial disease and cardiac lesions.

A clinicopathologic analysis of 64 autopsy cases with metastatic cardiac tumor

A clinicopathologic analysis of 64 autopsy cases with metastatic cardiac tumor

The value of transesophageal echocardiography in the diagnosis of cardiac metastasis.

To assess the diagnostic value of transesophageal two-dimensional echocardiography (TEE) as compared with transthoracic echocardiography (TTE), TTE and TEE were performed in eight consecutive patients (age range from 20 to 76 years, six male and two female) with clinical evidence of malignant tumors arising from the liver (n = 1), lung (n = 3), larynx (n = 1), osteogenic sarcoma (n = 1), lymphoma (n = 1), and yolk sac tumor in the anterior mediastinum (n = 1). In one case, the gastroscope could not be inserted because of tumor compression of the esophagus. Transesophageal echocardiography provided superior imaging in the detection of intracavitary metastatic lesions. In the case of right ventricular outflow tract tumor and greater vessel involvement, TTE may provide more imaging than TEE due to a blind area in this region by the transesophageal approach. In conclusion, TEE is complementary to TTE in the diagnosis of metastatic cardiac tumor.

Two-dimensional echocardiography for evaluation of metastatic cardiac tumors in pediatric patients

We have studied five patients with metastatic cancer in whom two-dimensional echocardiography (2DE) demonstrated cardiac or pericardial involvement. Echo studies may guide the clinician in instituting and/or modifying cardiac and cancer therapy in such patients.

Progressive ECG alterations in metastatic cardiac mural tumor

ular myocardium. They noted that intracavitary right ventricular potentials from these areas resembled left ventricular recordings. Direct stimulation of these fibers may preferentially excite the left ventricle. Our data could support the hypothesis that the posterior stimulation sites in the right ventricle preferentially excite such specialized myocardial bands. However, pacing patterns from the epicardially located coronary sinus/middle cardiac vein area are similar to the one described herein.& The RBBB QRS pattern can also be explained by a posteroanterior QRS vector in the horizontal plane. In conclusion, the occurrence of a RBBB QRS morphology during right ventricular pacing does not exclude a right ventricular endocardial electrode location and verification of lead position remains desirable. Since this report was written, two more patients with RBBB paced QRS complexes during posterior right ventricular endocardial pacing have been observed.