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Journal of Clinical Oncology, Vol 26, No 6 (February 20), 2008: pp. 1010-1011 © 2008 American Society of Clinical Oncology. DOI: 10.1200/JCO.2007.14.9328
Cardiac Involvement at Presentation of Non–Small-Cell Lung Cancer ska-Mielcarek bieta Senkus-Konefka
Department of Oncology and Radiotherapy, Medical University of Gda
Department of Hypertension and Diabetology, Medical University of Gda
Department of Pathology, Medical University of Gda A 61-year-old man with a history of active smoking (70 pack years) presented with progressive dyspnea and fatigue. His physical examination was unremarkable with Karnofsky performance status of 70. Abnormalities in laboratory tests included elevated D-dimers (924 µg/L), leukocytosis (13.04 x 103/mm3), thrombocytopenia (132.4 x 103/mm3), and decreased partial oxygen pressure (pO2-49 mmHg). Lung perfusion scintigraphy performed because of suspicion of pulmonary thromboembolism demonstrated impaired perfusion of the left lung apex and upper lobe of the right lung. Transthoracic echocardiography showed dilation of the right heart with thrombus in the lumen of right ventricle and partly in the right atrium (Fig 1). Venous Doppler ultrasonography of lower extremities was normal. Computer tomography of the chest and abdomen demonstrated pathologic mass encompassing the right ventricle and right atrium (with suggestion of myxoma), enlarged mediastinal lymph nodes, and pleural and pericardial effusion (Fig 2). The patient was referred for cardiac surgery. Intraoperatively, the tumor was found to occupy the right atrium and to penetrate to the right ventricle, with infiltration of the tricuspid valve and partial closing of the ostium of inferior vena cava. The gross tumor was removed successfully within limits of normal tissues. Microscopic examination revealed presence of poorly differentiated squamous cell carcinoma arising in subendocardial layer and combined with elements of thrombus (Fig 3). Subsequent bronchofiberoscopy demonstrated malignant infiltration of the left bronchus. Pathological examination confirmed diagnosis of squamous cell lung cancer. Patient was administered palliative chemotherapy with single-agent paclitaxel (60 mg/m2 weekly) as, due to congestive heart failure that developed after cardiac surgery, he was considered not to be fit enough for platinum treatment. He died of progressive disease after the fourth infusion of chemotherapy.
Cardiac metastases are 20 to 40 times more common than primary tumors.1 They are observed in approximately 30% of advanced lung cancer cases, mainly at autopsy.2 These lesions usually occur in late stages of the disease and carry unfavorable prognosis. Lung cancer is responsible for approximately 36% of cardiac metastases. Other malignancies that are most likely to spread to the heart are breast cancer, esophageal cancer, leukemia, lymphoma, and melanoma.3 Of the three suggested pathways of cancer spread to the heart—lymphatic, hematogenous, and by direct contiguous extension—the first occurs most frequently.4 Parts of the heart usually involved in the order of frequency are pericardium, myocardium, and endocardium.5 In the majority of cases, heart metastases are clinically silent. Impairment of cardiac function is observed in approximately 30% of patients, especially if the left heart is involved.6 Cardiac metastases may lead to myocardial infarction, arrhythmia, cardiac tamponade, or congestive heart failure, which can manifest with dyspnea, cough, chest pain, or palpitation.4 ECG usually shows a T wave and ST segment modifications.7 Echocardiography allows for the rapid assessment of lesion location, size, and related hemodynamic changes, whereas computer tomography and magnetic resonance enable evaluation of the disease in thorax and can be helpful in differentiation between primary and metastatic tumor.8 Additionally, magnetic resonance provides distinction between tumor, thrombus, or blood flow artifact.8 Successful surgical resection seems to extend survival when compared with chemotherapy or radiotherapy alone.9 Our patient presented initially with dyspnea and cardiac mass that was finally diagnosed as metastatic lung cancer. Despite successful removal of cardiac tumor, he died 6 weeks later due to disease progression. Heart metastases as the first presentation of malignant disease are uncommon, may cause diagnostic difficulties, and consequently delay treatment. AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The author(s) indicated no potential conflicts of interest.
REFERENCES 1. Prichard RW: Tumors of the heart: Review of the subject and report of one hundred and fifty cases. Arch Pathol 51:98-128, 1951 2. Strauss BL, Matthews MJ, Cohen MH, et al: Cardiac metastases in lung cancer. Chest 71:607-611, 1977[CrossRef][Medline] 3. Klatt EC, Heitz DR: Cardiac metastases. Cancer 65:1456-1459, 1990[CrossRef][Medline] 4. 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] 5. Sterns LP, Eliot RS, Varco RL: Intracavitary cardiac neoplasms: A review of 15 cases. Br Heart Journal 28:75-83, 1966[CrossRef][Medline] 6. Thurber DL, Edwards JE, Achor RWP: Secondary malignant tumors of the pericardium. Circulation 26:228-241, 1962 7. Abe S, Watanabe N, Ogura S, et al: Myocardial metastasis from primary lung cancer: Myocardial infarction-like ECG changes and pathologic findings. Jpn J Med 30:213-218, 1991[Medline] 8. Chiles C, Woodard PK, Gutierrez FR, et al: Metastatic involvement of the heart and pericardium: CT and MR imaging. Radiographics 21:439-449, 2001 9. Glock Y, Herreros J, Duboucher C, et al: Cardiac tumor mass: Diagnostic and therapeutic approach—Apropos of 46 cases [French]. Ann Chir 44:85-89, 1990[Medline]
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Copyright © 2008 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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aw Jendrzejewski
