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Introduction
Metastatic malignancies involving theheart occur more frequently
than primaryones. Cardiac metastases arise from virtuallyany
malignant neoplasm; however, tumorsthat more often metastasize to
the heart arecarcinoma of the lung and breast, mesothe-lioma,
melanoma and lymphomas, whilesecondary colorectal tumors are
rare1,2. Un-fortunately, a complete surgical extirpationof a
cardiac metastasis can be rarely obtainedand the only available
therapeutic option isoften restricted to a palliative treatment
likedrainage of pericardial effusions.
We report the case of a woman previ-ously operated on of colon
cancer, present-ing with symptoms of congestive heart fail-ure due
to the presence of a mass com-pletely invading the right
ventricular cavity.In this case also, surgical intervention
wasunsuccessful and the patient died in thepostoperative phase.
Case report
A 69-year-old woman was admitted tothe Cardiology Unit of the S.
Orsola Hos-pital for progressively worsening dyspnea.Three years
before she had been operatedon of colon resection for a T3,N1,M0
ade-nocarcinoma followed by both chemother-apy and radiotherapy.
After a 2-year period
of well-being, she had undergone atypicalwedge resection for
metastatic involvementof the right and left lung. Some days
beforeadmission to the hospital she developed bi-lateral ankle
edema and oliguria and wassent to cardiological evaluation. The
clini-cal examination was consistent with the di-agnosis of
congestive heart failure whilethe electrocardiogram showed
non-specificST-T changes. At transthoracic echocardio-graphy a
homogeneous echogenic massfilling almost completely the right
ventric-ular cavity was observed, with preservedblood flow only in
proximity of the inter-ventricular septum. The mass joined
thepulmonary valve without crossing it. Asmall pericardial effusion
was also present.
At transesophageal echocardiography itwas observed that the mass
not only filledalmost completely the right ventricle (Fig.1A), but
also reached the right atriumacross the tricuspid valve (Fig. 1B).
As firsthypothesis we considered that of a cancer-related
thrombotic nature of the mass andan attempt of pharmacological
thromboly-sis with tissue-type plasminogen activatorwas deemed
appropriate but was unsuc-cessful, so that the possibility of a
metasta-tic origin of the mass was taken into con-sideration. The
patient was therefore re-ferred to the University Division of
CardiacSurgery. After conventional median ster-notomy, the
ascending aorta and both venaecavae were cannulated and
cardiopul-
Key words:Colon cancer;Echocardiography;Heart failure;
Heartmetastasis.
© 2005 CEPI Srl
Received January 18,2005; revision receivedApril 4, 2005;
acceptedApril 7, 2005.
Address:
Dr. Carlo Oneglia
Via Acquafredda, 4125064 Gussago
(BS)E-mail:[email protected]
Congestive heart failure secondary to rightventricular
metastasis of colon cancer.A case report and review of the
literatureCarlo Oneglia, Alberto Negri*, Daniele Bonora-Ottoni**,
Marco Gambarotti***,Gianluigi Bisleri*, Cesare Rusconi, Claudio
Muneretto*
Cardiology Unit, Fatebenefratelli “S. Orsola” Hospital,
*Division of Cardiac Surgery, University of Brescia MedicalSchool,
**Thoracic Surgery Unit, Fatebenefratelli “S. Orsola” Hospital,
***Second Institute of Pathology, Universityof Brescia Medical
School, Brescia, Italy
Although metastatic tumors of the heart occur more frequently
than primary ones, infiltration ofthe right heart by a metastatic
colon cancer has rarely been reported. We report the case of a
womanpreviously operated on for colon cancer, presenting with
symptoms of congestive heart failure due tometastatic invasion of
the right ventricular cavity. Both transthoracic and
transesophageal echocar-diography were useful in detecting the
mass, but not in defining its nature. The patient underwent
apalliative surgical resection of the neoplastic mass but died soon
after the intervention.
(Ital Heart J 2005; 6 (9): 778-781)
-
monary bypass instituted. The free wall of the rightventricle
was thick and woody, infiltrated and calcifiedon its margin. After
opening of the right atrium, themetastatic mass was seen protruding
into the right atri-al cavity: neoplastic involvement of the
tricuspid annu-lus and both the anterior and posterior leaflets
were al-so detected (Fig. 2), leaving only a virtual orifice
closeto the interventricular septum. The pulmonary valvewas not
affected by the cardiac metastasis. Despite acareful resection, the
deep infiltration of the tricuspidannulus did not allow replacement
of the native valveby means of a prosthesis. A considerable
hemodynam-ic instability along with respiratory failure
occurred,thus hampering the weaning from cardiopulmonary by-pass
and requiring the placement of an extracorporealmembrane
oxygenation device. The patient did not re-cover from the
mechanical support and died for multi-organ failure.
The histology on the autoptic samples colored
withhematoxylin-eosin showed muscular tissue infiltrated
by carcinomatous neoplasia with epithelial cells orga-nized in
mostly atypical gland structures (Fig. 3). Histo-chemical analysis
with PAS showed intracellular pres-ence of mucus (Fig. 4).
Immunochemistry with PANkeratin and cytokeratin 20 confirmed the
epithelial ori-gin of the neoplastic cells (Fig. 5). The
morphologic,histochemical and immunohistochemical diagnosis
wastherefore that of heart metastasis from moderately
dif-ferentiated mucinous adenocarcinoma of colonic origin.
Discussion
Cardiac involvement by primary and secondary tu-mors is one of
the least investigated issues in oncology,although being a true
clinical problem. Old data quotedby Abraham and derived from
unselected autopsieswere consistent with an incidence of 0.0017%
for pri-mary tumors and of 0.24 to 6.45% for cardiac metas-tases,
while Abraham1 himself in 1990 found an inci-
C Oneglia et al - Echographic diagnosis of a cardiac
metastasis
779
A B
Figure 1. Transesophageal imaging of right ventricular invasion
by the tumoral mass (M) (A) and protrusion of the mass into the
right atrium (RA) (B).AO = aorta; LA = left atrium; LV = left
ventricle.
Figure 2. Intraoperative view of the tricuspid annulus following
excisionof the valvular leaflets.
Figure 3. Hematoxylin-eosin (�10).
-
dence of 95 cases of cardiac involvement in 806 autop-sies with
some kind of malignancy (11.8%), from anoverall number of 3314
consecutive autopsies per-formed over a 14-year period. Later, in
their review of12 485 consecutive unselected autopsies
performedover a 20-year period in Hong Kong, Lam et al.3 re-ported
an incidence of 0.056% for primary and of1.23% for secondary heart
tumors, respectively. On theother hand Klatt and Heitz4 had found
cardiac metas-tases in 10.7% of 1029 autopsies in which a
malignantneoplasm had been diagnosed, while previous studieshad
reported a rate of involvement of 1.6 to 20% in sim-ilar settings.
Similarly, the Italian study of Silvestri etal.2 on 1928 cancer
patients showed an incidence of8.4% of cardiac metastases with a
significant decreasein frequency in elderly patients.
Metastatic cancer to the heart assumes greater im-portance
nowadays as the incidence of cancer rises andsurvival of neoplastic
patients is prolonged due to ear-
lier diagnosis and advances in radiotherapy andchemotherapy, so
that the incidence of secondary tu-mors to the heart will be
progressively increasing. Theprobability of heart metastases must
therefore bedeemed higher than in the past and more often
suspect-ed after considering the nature of the primary tumor: inthe
study of Silvestri et al.2 mesothelioma, melanomaand lung cancer,
as origin of cardiac metastases, had thehighest frequency in males
(100, 50 and 31% respec-tively), while in females the sequence in
decreasing or-der was that of melanoma (45%), lung tumors (26%)and
renal neoplasms (20%). Data from Lam et al.3 alsoreport lung
carcinoma as the overall most frequentsource of heart lesions,
followed by esophageal carci-noma and lymphoma.
Neoplasms originating in colon and rectum andcausing secondary
heart lesions are rather rare: in theirstudy of 1095 primary
cardiac tumors in 1029 autopsiesof malignancies (two separate
malignant neoplasmswere found in 66 cases), Klatt and Heitz4
reported on 72cases of colon and rectum as primary sites of
tumor,with only 2 metastatic cardiac sites from the 64 patientswith
adenocarcinoma (3.1%), while 8 cases of malig-nant carcinoid and of
neuroendocrine, cloacogenic andsquamous cell carcinoma did not
originate secondary le-sions. A similar value was reported by
Abraham et al.1
in their population of 95 patients with secondary heartlesions,
where the percentage of subjects with primarycolon cancer was of 3
out of 95, that is 3.2%. In thestudy of Klatt and Heitz4, the
epicardium was the regionmost often involved by metastases (75.5%),
followed bythe myocardium (38.2%) and the endocardium (15.5%),and
of the 2 patients with primary colon tumor, one hadepicardial and
the other myocardial involvement.
Cases of ante-mortem diagnosis of heart metastasesfrom colon
carcinoma are mainly anecdotal and proba-bly the first reported is
that of a patient with tricuspidobstruction and superior vena cava
syndrome, causedby a large tumor mass in the right atrium diagnosed
bytwo-dimensional echocardiography and confirmed byautopsy5.
Teixeira et al.6 reported a similar case of rightatrial obstruction
in whom the differential diagnosis be-tween metastasis and
thrombotic mass was also dis-cussed but not supported by an
autopsy, refused by thepatient’s relatives. Metastases to the right
ventriclefrom mucinous colon carcinoma are also rare and de-mand an
accurate differential diagnosis7.
The importance of a transthoracic echographic diag-nosis in
patients with heart metastases is well recog-nized8-10, and we also
reported an echocardiographic di-agnosis of a secondary lesion
discovered 5 months afterliver transplantation for cancer11. On the
other hand,transesophageal echocardiography did not appear to
addmany elements to the diagnosis in the present case: itwas useful
in better imaging the mass but did not helpdiagnose its nature nor
did help ascertain the severe de-gree of tricuspid annular and
leaflet infiltration. Indeedechocardiography can provide
preliminary diagnostic
780
Ital Heart J Vol 6 September 2005
Figure 4. Staining with PAS (�20).
Figure 5. Anti-cytokeratin-PAN (�40).
-
information for evaluation of cardiac masses whilecomputed
tomography and magnetic resonance imaging(MRI) provide the most
complete characterization, fortheir superior tissue resolution and
tumor demarca-tion12. Even though excellent in assessment of the
leftside of the heart, echocardiography appears limited inthe
evaluation of the right heart, mediastinum and parac-ardiac
structures, while computed tomography with cur-rent multislice
technology allows an excellent visualiza-tion of the extracardiac
anatomy. However, computedtomography requires radiation, is limited
in the assess-ment of valvular function and, if compared to MRI,
isless effective at tissue characterization and tumor delin-eation:
therefore, MRI probably plays a more importantrole also since
gadolinium-enhanced MRI is superior tocomputed tomography for
detection of myocardial in-volvement and usually distinguishes
between tumor andintracavitary thrombus, though there may be some
over-lap with organized thrombi13. A case of ante-mortemMRI
diagnosis of metastatic colon cancer to the rightventricle has been
reported by Testempassi et al.14.
Even though in our patient we considered of beingcompelled to an
urgent intervention for the rapid wors-ening of the clinical
conditions, surgery should perhapshave been avoided if the
neoplastic nature of the masshad been more definitely ascertained:
definite thera-peutic guidelines for these pathologies have not
beenestablished until now, the patient’s outcome seems un-favorable
in any case and surgery is not therapeutic,even if in sporadic
cases an aggressive surgery has en-abled prolonged survival15. We
however also consid-ered that among alternative choices,
chemotherapy isgenerally judged inadequate by the oncologists, for
po-tential fragmentation and dissemination of the mass,while
radiotherapy seems to be avoided for its radia-tion-induced effects
on the pericardium and myocardialwall. On the other hand, patients
not sent to interven-tion can die of intractable shock16, while for
those op-erated on there is the risk of metastatic spreading to
thelungs and consequent respiratory failure. This was thecase of
our patient, as for a previous one affected bysecondary cardiac
melanoma observed by our group17,and for others already reported by
the current litera-ture5. On this subject, clamping the pulmonary
arteryand opening and flushing the right heart circuit
beforeestablishing pulmonary blood flow has been suggestedas a
surgical technique to prevent pulmonary emboliza-tion from these
very friable tumors5.
In conclusion, the possibility of secondary cardiaclesions
should be taken into consideration in patientsalready operated on
of resection of a primary neoplasiaand not affected by preexisting
heart disease, present-ing with new-onset dyspnea, palpitations or
other car-diac symptoms. In the present era of widely
availablenon-invasive diagnostic techniques we suggest
earlytransthoracic and transesophageal echographic studies,at least
in those cancer patients with more likely cardiacmetastatic
potential: prompt echocardiographic investi-
gations in such patients could detect secondary lesionsof the
heart in the earliest possible phase. So discover-ing a malignant
tumor in this location may assist inplanning newer surgical
techniques or in the choice ofalternative therapeutic options18,
with the further helpof accurate and also non-invasive
investigations likeMRI and/or computed tomography.
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