|Year : 2014 | Volume
| Issue : 3 | Page : 80-82
Solitary intracavitory cardiac metastasis
Subhadeep Banerjee, Tanmoy Pal, Dilip Roy, Aindril Bhowmik
Department of Internal Medicine, Medical College and Hospital, Kolkata, West Bengal, India
|Date of Web Publication||5-Sep-2014|
P-1/C, Second Street, Modern Park, Santoshpur, Kolkata, West Bengal
Source of Support: None, Conflict of Interest: None
Metastatic cardiac tumors are more common than the primary ones and they most commonly involve the pericardium or myocardium. Very rarely they may show partial or total intracavitory growth. Ours is one such case of solitary intracavitory cardiac metastasis in a patient with adenocarcinoma of the right lung who presented with hemoptysis and palpitation. Echocardiography and histopathological study clinched the diagnosis.
Keywords: Adenocarcinoma lung, intracavitory cardiac metastasis, solitary
|How to cite this article:|
Banerjee S, Pal T, Roy D, Bhowmik A. Solitary intracavitory cardiac metastasis. Heart India 2014;2:80-2
| Introduction|| |
Cardiac tumors as usually known are mostly metastatic in nature. The common primary sites being carcinoma of lung, breast, malignant melanoma, lymphoma and leukemia from where tumors spread by hematogeneous routes, lymphatic, transvenous routes or by direct invasion to involve most commonly the pericardium or myocardium. However, solitary intracavitory metastasis is very rare. Here, we describe one such case of solitary intracavitory cardiac metastasis in a patient with adenocarcinoma of the right lung.
| Case report|| |
The case we present here is about a 38-year-old non-diabetic, normotensive,euthyroid Hindu housewife coming from Howrah was admitted to our hospital with cough and recurrent bouts of hemoptysis for 6 months and a sudden onset continuous thudding sensation in the left side of her chest for last 6 weeks. On admission, there was tachypnea. In the respiratory system examination an area with decreased vesicular breath sound was noted in the right infrascapular region. Cardiovascular system examination revealed a loud, diastolic additional heart sound that varies both in intensity and timing with each cardiac cycle and with change of posture of the patient. This could be heard all over the precordium. A grade IV mid-diastolic murmur of varying duration was heard at the apex without any radiation. A loud P2 was heard in the pulmonary area. Other systemic examinations were within normal limits (WNLs).
Investigation revealed normocytic normochromic anemia with high erythrocyte sedimentation rate (75 mm in 1 st h). Other blood investigations including bleeding time and clotting time was WNLs. Chest X-ray posteroanterior view showed a homogeneous opacity without any air bronchogram in the right lower lobe [Figure 1]. Echocardiography report showed a fairly large globular mass in the left atrium (LA) is seen to be attached to another mass in pulmonary vein by a pedicle and it is moving to and fro from LA to the left ventricle through the mitral valve opening [Figure 2] and [Figure 3]. Contrast enhanced computed tomography (CT) thorax revealed a space occupying lesion (? Neoplastic nature) in the right lower posterior basal lobe measuring about 79 mm × 48 mm [Figure 4]. Histopathology study of a tru-cut biopsy specimen from that lung mass showed features suggestive of adenocarcinoma of the lung [Figure 5]. Biopsy of the intracardiac lesion could not be done due to poor general condition of the patient.
|Figure 1: Chest X-ray posteroanterior view showing right lower lobe homogeneous opacity|
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|Figure 3: 2D echo in the long axis view showing attachment of the mass to pulmonary vein|
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|Figure 4: Contrast enhanced computed tomography thorax showing a neoplastic lesion in the right lower zone (79 mm × 48 mm)|
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| Discussion|| |
Cardiac tumors are mostly metastatic in nature; commonly occur in a setting of disseminated tumor disease, in 6-7 th decade of life and without any sex predilection.  In one study, cardiac metastasis has been found in 6-20% of autopsies of patients with malignant neoplasm.  Cardiac metastases are usually small and multiple; however, single large tumor lesions are also observed. It is assumed that the right side of the heart is more frequently involved than the left. In descending order of frequency, pericardium, myocardium and endocardium are involved. Intracavitory growth of tumor is unusual and involvement of valve cusps by metastatic disease is even rarer. Tumor may involve the heart and pericardium by one of four pathways: retrograde lymphatic extension (to pericardium), hematogenous spread (to myocardium), direct contiguous extension, or transvenous extension. The most common primary site are carcinomas of the lung, the breast and the esophagus, malignant lymphoma, leukemia, and malignant melanoma.  Autopsy shows that bronchogenic carcinoma is the primary tumor in 36% of patients with cardiac metastases; non-solid primary malignancies (e.g., leukemia, lymphoma, and Kaposi sarcoma) account for 20%; carcinoma of the breast accounts for 7%; and carcinoma of the esophagus is the primary tumor in 6%.  Myocardial metastases, which are less frequent, are usually associated with melanoma or lymphoma and are suggestive of hematogenous invasion. Most cardiac metastasis remain clinically asymptomatic are discovered incidentally on autopsy. Symptomatic cases usually presents with features due to pericardial effusion or tamponade. Tachycardia, heart failure, arrhythmia, angina pectoris and recent onset murmurs are also described as clinical features. The method of choice to detect cardiac metastases and their complications is two-dimensional echocardiography  as it is non-invasive, cost-effective and readily available. However, magnetic resonance (MR) imaging and CT offer advantages in providing a large field of view, which allows evaluation of disease throughout the thorax. Differentiation between tumor and myocardium and the distinction between tumor, thrombus, or blood flow artifact can be made more readily with MR imaging.  The prognosis is usually grave and treatment is mostly confined to palliative measures with chemoradiation. Surgical resection is only indicated in exceptional cases of solitary intracavitory metastasis. 
| Conclusion|| |
Although a rarity, the diagnosis of secondary cardiac tumor should always be kept in mind while evaluating a case of lung mass with a recent onset continuous palpitation irrespective of the age of the patient.
| Acknowledgment|| |
Professor Satyabrata Ganguly, Department of Internal Medicine, Medical College and Hospital, Kolkata, West Bengal.
| References|| |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]