Nonbacterial Thrombotic Endocarditis in Association with Metastatic Mucin-Secreting Adenocarcinoma in Heart

Arti Rameshrao Anvikar; Alka Vikas Gosavi; Nayan Anant Ramteerthakar; Bhakti Dattatray Deshmukh; Kalpana Ranjitsingh Sulhyan

doi:10.4103/2321-449X.158880

CASE REPORT

Year : 2015 | Volume : 3 | Issue : 2 | Page : 52-53

Nonbacterial Thrombotic Endocarditis in Association with Metastatic Mucin-Secreting Adenocarcinoma in Heart

Arti Rameshrao Anvikar, Alka Vikas Gosavi, Nayan Anant Ramteerthakar, Bhakti Dattatray Deshmukh, Kalpana Ranjitsingh Sulhyan
Department of Pathology, Government Medical College, Miraj, Maharashtra, India

Date of Web Publication

16-Jun-2015

Correspondence Address:
Dr. Arti Rameshrao Anvikar
56, Rama Udyan, Phase-3, Pandharpur Road, Miraj, Sangli - 416 410, Maharashtra
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/2321-449X.158880

Abstract

Nonbacterial thrombotic endocarditis (NBTE) is characterized by the deposition of thrombi on cardiac valves in the absence of bloodstream bacterial infection. It is usually associated with advanced stage malignancy and chronic debilitating diseases. We present an autopsy case report of a 45-year-old man with NBTE in association with metastatic mucin-secreting adenocarcinoma involving the heart.

Keywords: Heart, mucin-secreting adenocarcinoma, nonbacterial thrombotic endocarditis

How to cite this article:
Anvikar AR, Gosavi AV, Ramteerthakar NA, Deshmukh BD, Sulhyan KR. Nonbacterial Thrombotic Endocarditis in Association with Metastatic Mucin-Secreting Adenocarcinoma in Heart. Heart India 2015;3:52-3

How to cite this URL:
Anvikar AR, Gosavi AV, Ramteerthakar NA, Deshmukh BD, Sulhyan KR. Nonbacterial Thrombotic Endocarditis in Association with Metastatic Mucin-Secreting Adenocarcinoma in Heart. Heart India [serial online] 2015 [cited 2023 Mar 22];3:52-3. Available from: https://www.heartindia.net/text.asp?2015/3/2/52/158880

Introduction

Nonbacterial thrombotic endocarditis (NBTE) formerly known as marantic endocarditis is characterized by the presence of vegetations on previously undamaged cardiac valves. These vegetations consist of fibrin and platelets and are devoid of inflammatory cells or micro-organisms. It usually occurs in patients with an advanced stage malignancy or chronic debilitating diseases such as tuberculosis, uremia, acquired immunodeficiency syndrome, autoimmune disorders, connective tissue disorders, and hypercoagulable states. ^[1],[2]

We present an autopsy case report of NBTE in association with metastatic mucin-secreting adenocarcinoma involving heart in a 45-year-old man.

Case Report

A 45-year-old man was admitted to our hospital with the complaints of dyspnea, pain in the abdomen and moderate grade fever. The patient expired on the same day of admission. Medico-legal postmortem was performed and whole heart along with pieces of brain, lung, and liver were sent for histopathological examination. Grossly, the heart was enlarged and showed multiple, tiny grayish-white nodules measuring 1-3 mm in diameter on the pericardium of left ventricle [Figure 1]a. On opening the heart, the mitral valve showed multiple small, friable, light brown vegetations on the atrial surface of the cusps along their lines of closure [Figure 2]a. All other valves appeared normal.

Figure 1: (a) Gross photograph of the heart showing multiple, tiny grayish-white nodules (arrows) on the pericardium of the left ventricle. (b) Microphotograph showing metastatic deposit of mucin-secreting adenocarcinoma in pericardium (H and E, ×100), (c) High power view showing clusters of tumor cells floating in pools of extracellular mucin (H and E, ×400)

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Figure 2: (a) Gross photograph of mitral valve vegetations. (b) Microscopy of vegetation (H and E, ×100), (c) High power view of vegetation showing thrombus with absence of bacteria or inflammatory cells (H and E, ×400)

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Histopathological examination of the heart revealed multiple metastatic deposits of mucin-secreting adenocarcinoma in the myocardium and pericardium [Figure 1]b. The tumor deposits were composed of round to oval cells having pleomorphic vesicular nuclei with prominent nucleoli and eosinophilic cytoplasm arranged in glandular pattern and clusters floating in abundant pools of extracellular mucin [Figure 1]c.

Microscopic examination of the mitral valve vegetations revealed thrombi devoid of inflammatory infiltrate or bacterial colonies [Figure 2]b and c. The valve cusps showed fibrosis and proliferating capillaries. The coronary arteries and aorta showed changes of atherosclerosis.

Lungs showed evidence of bronchopneumonia, fresh hemorrhagic infarct and a focus of metastatic mucin-secreting adenocarcinoma. Pulmonary arteries showed multiple fresh and organized thrombi in their lumina [Figure 3] and changes of pulmonary hypertension including cellular intimal hyperplasia and medial wall hypertrophy. Brain and liver did not reveal any pathology. As whole viscera were not received, the primary could not be identified.

Figure 3: Microphotograph showing organizing thrombi in pulmonary arteries (H and E, ×100)

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Discussion

Cardiac tumors are more commonly metastatic than primary. In autopsy series of cancer patients, metastatic cardiac tumors have a prevalence of 1.5-20%. The most common malignancies metastasizing to the heart include melanoma, lymphoma, carcinomas of the lung, breast, and esophagus, and leukemia. Metastatic mucin-secreting adenocarcinoma from the gut has also been reported. These tumors usually involve pericardium followed by myocardium. ^[3] Our patient had metastatic involvement of pericardium and myocardium of left ventricle.

The association of NBTE and malignancy is well-established in the literature. Malignancies associated with NBTE include mucin-secreting adenocarcinoma of gut and lung, carcinomas of pancreas, ovary, adenocarcinomas of the unknown primary site, and hematological malignancies. ^[1],[2]

The typical clinical manifestations of NBTE are due to systemic embolization rather than valvular dysfunction. The friable vegetations of NBTE easily detach and cause extensive infarction more frequently than the vegetations in infective endocarditis (IE). ^[4] Systemic or pulmonary emboli frequently occur in patients with NBTE. Common sites for systemic emboli include brain, kidney, spleen, mesenteric bed and extremities. ^[1],[2] In our case, pulmonary vasculature showed multiple thromboemboli and pulmonary arteries showed changes suggestive of thrombotic pulmonary hypertension including cellular intimal hyperplasia and medial wall hypertrophy. ^[5]

Clinically, the distinction between NBTE and IE is crucial to select the appropriate therapy. Vegetations along the coaptation lines of valves without leaflet destruction (regurgitation), the simultaneous occurrence of venous thromboembolism, negative blood cultures, and absence of clinical signs of infection are all suggestive of NBTE. ^[4]

To conclude, the possibility of NBTE should be considered in cancer patients suffering from an episode of thromboembolism.

References

1.	el-Shami K, Griffiths E, Streiff M. Nonbacterial thrombotic endocarditis in cancer patients: Pathogenesis, diagnosis, and treatment. Oncologist 2007;12:518-23.
2.	Asopa S, Patel A, Khan OA, Sharma R, Ohri SK. Non-bacterial thrombotic endocarditis. Eur J Cardiothorac Surg 2007;32:696-701.
3.	Patel SA, Herfel BM, Nolan MA. Metastatic colon cancer involving the right atrium. Tex Heart Inst J 2012;39:79-83.
4.	Norisada K, Tanaka H, Onishi T, Kaneko A, Tsuji T, Yamawaki K, et al. Nonbacterial thrombotic endocarditis associated with cancer of unknown origin complicated with thrombus in the left auricular appendage: Case report. Cardiovasc Ultrasound 2011;9:8.
5.	Katzenstein AL, editor. Pulmonary hypertension and other vascular disorders. In: Katzenstein and Askin′s, Surgical Pathology of Nonneoplastic Lung Disease. 4 ^th ed. Philadelphia: Saunders; 2006. p. 351-84.