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Journal of Clinical Oncology, Vol 22, No 13 (July 1), 2004: pp. 2740-2742 © 2004 American Society of Clinical Oncology. DOI: 10.1200/JCO.2004.08.104
Cardiac Involvement in MalignanciesCASE 1. Favorable Outcome of a Patient With Cardiac Invasion From Non–Small-Cell Lung CarcinomaDepartments of Emergency Medicine, Internal Medicine and Pathology, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan A 65-year-old man presented with productive cough and hemoptysis for half a month. Right lower chest pain and a thinner body figure were also noted. There was no fever, chills, or dyspnea. Physical examination revealed decreased breath sounds over the right lower chest. Chest radiograph showed a right hilar mass with right diaphragm tenting. Bronchoscopy revealed a right middle lobe tumor with nearly total obstruction of the lumen and tumor infiltration of the right common basal bronchus. Pathology showed a poorly differentiated non–small-cell carcinoma, (Fig 1) which was immunoreactive to cytokeratin but not to chromogranin and synaptophysin. Transthoracic echocardiography revealed direct tumor invasion of the right atrium with an extension floating in the chamber (Fig 2, arrow). Contrast-enhanced chest computed tomography (CT) showed a large heterogeneous mass at the hilum that invaded into the right atrium and nearly occluded the superior vena cava, which resulted in prominent azygous vein. The right superior and inferior pulmonary veins and right pulmonary artery were also encased by the tumor (Fig 3). Irregular narrowing of the right intermediate bronchus, lymphadenopathy in the pretracheal region, and a right pleural effusion were also noticed. Pleural effusion cytology was negative. No other metastatic lesions were noted on abdominal sonography, brain CT, and bone scans. ECG showed low QRS voltage in all leads. The patient refused chemotherapy initially and received radiotherapy with 48 Gy totally to the mediastinum and right lung mass. Chest CT 4 months later showed progression of tumor. He then received chemotherapy for six courses with gemcitabine and cisplatin. Further follow-up approximately 1 year later showed a remission and disappearance of the cardiac mass (Fig 4). Only mildly increased thickness of the pericardium was noticed. Decreased size of the right hilar mass with right lung atelectasis was also noted. The patient has been regularly followed for more than 2 years with stationary status.
Both primary and metastatic tumors of the heart are rare1 and might undergo surgical intervention to relieve or prevent possible complications.2,3 Poorly differentiated lung carcinoma with cardiac metastases has been rarely reported.3 The most common neoplasms associated with cardiac metastases are lung cancer, lymphoma, breast cancer, leukemia, gastric cancer, and melanoma.1 Cardiac metastases may be present in up to 25% of patients of lung cancer at autopsy.4 The metastatic pathways to the heart can be divided into lymphatic and hematogenous patterns; the lymphatic pathway is more frequently observed. Hilar involvement is usually associated with peripheral primary lung tumors, and mediastinal involvement is associated with central tumors.5 The pericardium is the main part of the heart affected by metastatic neoplasms, with a reported incidence of up to 21% in some autopsy series of cancer patients.6 The right heart is more commonly involved than the left heart. Involvement of the right heart is usually clinically silent, as our patient demonstrated. In contrast, involvement of the left heart may cause dyspnea and pulmonary congestion due to obstructed pulmonary venous flow, myocardial infarction due to systemic embolization, or with syncope.2,7 Several image techniques, such as echocardiography (either transthoracic or transoesophageal echocardiography [TEE]), contrast-enhanced CT, magnetic resonance imaging, or angiography are applied in the detection of intracardiac metastases.2,7-10 TEE is considered superior in the diagnosis of hilar masses invading a pulmonary vein or the left atrium because of the close proximity of the esophagus to these structures. The study of pulmonary venous flow patterns via TEE can delineate causes of dyspnea in patients with metastatic tumors invading the left atrium.9 A case of colon cancer metastasizing to the lung and mediastinum, and invading the left atrium was reported wherein transthoracic echocardiography did not detect the direct tumor invasion of the heart, but the contrast-enhanced CT made the correct diagnosis.7 Because CT is the usual image in the evaluation of pulmonary masses, we can expect a more and exact incidence of cardiac metastases of lung cancer in clinical diagnosis than before. Most cardiac tumors are noticed at autopsy.3,6,11 Metastatic cancer in the heart diagnosed before death is very uncommon, with some of them requiring surgical intervention to relieve complications.3,12-17 Several case reports have demonstrated successful surgical removal of the intracardiac tumors.15-17 However, without surgical intervention, the survival is usually short when treatment is only radiotherapy or chemotherapy.2,7 This may be attributed to the better physical condition of these patients who received surgical intervention. Our patient did not receive surgical intervention, because of direct invasion of the right atrial wall. He survived for more than 2 years with remission of the disease after radiotherapy and chemotherapy. This may be explained by several factors, such as involvement of the right heart, which is usually clinically silent, and no other distant metastases. A multidisciplinary discussion for management of all such patients should be carried out. Authors' Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest.
REFERENCES 1. Smith C: Tumors of the heart. Arch Pathol Lab Med 110:371-374, 1986[Medline] 2. Vallot F, Berghmans T, Delhaye F, et al: Electrocardiographic manifestations of heart metastasis from a primary lung cancer. Support Care Cancer 9:275-277, 2001[CrossRef][Medline] 3. Mazzoccoli G, Carughi S, La Viola M, et al: Cardiac metastasis of poorly differentiated adenocarcinoma of unknown primary site. Ital Heart J 3:1112-1116, 2002[Medline]
4. Strauss BL, Matthews MJ, Cohen NM, et al: Cardiac metastasis in lung cancer. Chest 71:607-611, 1977 5. Tamura A, Matsubara O, Yoshimura N, et al: Cardiac metastasis of lung cancer: A study of metastatic pathways and clinical manifestations. Cancer 70:437-442, 1992[CrossRef][Medline]
6. Thurber D, Edwards J, Achor R: Secondary malignant tumors of the pericardium. Circulation 26:228-241, 1962 7. Zissin R, Shapiro-Feinberg M, Rachmani R, et al: Lung metastasis invading the left atrium—CT diagnosis. Br J Radiol 72:1211-1212, 1999[Abstract] 8. Lynch M, Balk MA, Lee RB, et al: Role of transesophageal echocardiography in the management of patients with bronchogenic carcinoma invading the left atrium. Am J Cardiol 76:1101-1102, 1995[CrossRef][Medline] 9. Lee TM, Chen MF, Liau CS, et al: Role of transesophageal echocardiography in the management of metastatic tumors invading the left atrium. Cardiology 88:214-217, 1997[Medline] 10. Kishore RA, Desai N, Nayak G: Choriocarcinoma presenting as intracavitary tumor in the left atrium. Int J Cardiol 35:405-407, 1992[CrossRef][Medline] 11. Abraham KP, Reddy V, Gattuso P: Neoplasms metastatic to the heart: Review of 3314 consecutive autopsies. Am J Cardiovasc Pathol 3:195-198, 1990[Medline] 12. Masaki N, Hayashi S, Maruyama T, et al: Marked clinical improvement in patients with hepatocellular carcinoma by surgical removal of extended tumor mass in right atrium and pulmonary arteries. Cancer Chemother Pharmacol 33:S7-S11, 1994 13. Inoue H, Shimokawa S, Iguro Y, et al: Involvement of the right atrium by malignant lymphoma as a cause of right cardiac failure: Report of a case. Surg Today 30:394-396, 2000[CrossRef][Medline] 14. Vargas-Barron J, Keirns C, Barragan-Garcia R, et al: Intracardiac extension of malignant uterine tumors: Echocardiographic detection and successful surgical resection. J Thorac Cardiovasc Surg 99:1099-1103, 1990 (abstr)[Abstract] 15. Glock Y, Herreros J, Duboucher C, et al: Cardiac tumor mass: Diagnostic and therapeutic approach—Apropos of 46 cases. Ann Chir 44:85-89, 1990[Medline] 16. Akcentin Z, Schafhauser W, Kuhn R, et al: Interdisciplinary surgical therapy of renal tumors with intracardiac tumor thrombi. Urologe A 35:115-119, 1996[Medline] 17. Sohn JW, Yoon YM, Lee MH, et al: Right atrial mass associated with hepatoma: 2 case reports. Korean J Intern Med 9:116-119, 1994[Medline]
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Copyright © 2004 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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