Complete resection of a right atrial intracavitary metastatic melanoma

Cardiac metastasis of malignant melanoma: a case report

The heart is regularly involved in metastatic neoplasms with cardiac metastases being found in up to 20 % of autopsies. We present a case about a 42-year-old Caucasian female with a fatal metastatic melanoma to the heart. The five- year survival rate for stage IV melanoma (melanoma with metastases to other organs) is 15 to 20 %. If patients with malignant melanoma present with new onset of cardiac symptoms, clinicians should always be aware of the possibility of cardiac metastases and perform further investigations.

Surgical management of the patient with metastatic melanoma to the heart

Melanoma has a high propensity for cardiac seeding, with heart involvement noted in a significant number of patients at autopsy. Therapeutic options are currently limited, and the prognosis of cardiac metastasis is poor. We report two cases of cardiac metastasis of melanoma and review the current literature. In addition, we propose an algorithm for dealing with this difficult problem.

Case report and literature review: surgical treatment of a right atrial metastatic melanoma from a previously resected "advanced" primary site with regional lymph nodes involvement

Although melanoma of the right atrium is a rare cardiac tumor, melanoma in general has a high propensity to involve the heart. Unfortunately, however, when the tumor is involving the heart, widespread metastasis ensues and hence surgery becomes a questionable option. We report a case of a young female who presented with an advanced skin primary melanoma and regional lymph node involvement and a metastasis into the right atrium. Postoperatively tumor dissemination was controlled with adjuvant chemotherapy. A vigorous attempt aiming at tumor clearance followed by adjuvant multimodality therapy along with a tumor surveillance program may improve survival even in advanced cases.

Metastatic malignant melanoma manifesting as an intracardiac mass

INTRODUCTION

Antemortem diagnoses of intracardiac metastases are uncommon. Metastatic melanoma shows a propensity for cardiac involvement, but cardiac involvement by melanoma is rarely identified clinically due to a paucity of cardiac symptoms.

METHODS

The surgical pathology files of Mayo Clinic were searched for cases of metastatic melanoma presenting or manifesting as an intracardiac mass. The lesions were evaluated pathologically for diagnoses. Clinical information was obtained by chart review.

RESULTS

Seven patients, four female and three male (age 31 to 79 years), were identified. No patient had a history of metastatic melanoma. All patients presented with dyspnea and symptoms of outflow obstruction. Echocardiography or CT revealed an intracardiac mass (four atrial, three ventricular). Six cases involved the right side of the heart and one involved the left ventricle. Five of the seven patients had a history of malignant melanoma, but none had a history of metastases when they presented with cardiac symptoms. In four cases, the history of primary melanoma was remote, occurring 7, 9, 13, and 28 years prior to the discovery of their cardiac mass. One patient had no history of melanoma, and no primary melanoma was ever identified. One patient had a history of a benign melanocytic lesion biopsied 2 years before, but retrospective review showed malignant melanoma.

CONCLUSIONS

Melanoma is known to have an unpredictable and prolonged course. Neoplastic involvement of the heart should be considered in patients with cardiac symptoms when a documented malignancy exists, no matter how remote.

Surgical excision of metastatic malignant melanoma involving the tricuspid valve

An 83-year-old man presented with a large intracavitatory metastatic malignant melanoma, infiltrating the anterior leaflet of the tricuspid valve. The tumour was excised completely along with the anterior leaflet of the tricuspid valve which was replaced. The patient was well 2 months after surgery.

Intracardiac Extension of Lung Cancer Demonstrated on PET Scanning

Intracardiac tumors are unusual and can originate within the heart or spread from other sites. This is a report of a patient who presented with a TIA, and during the subsequent stroke workup, a right hilar nonsmall cell lung carcinoma was discovered. The tumor had extended into the left atrium through a pulmonary vein. The hilar tumor as well as intracardiac extension were demonstrated by PET scanning using FDG.

Neoplasms involving the heart, their simulators, and adverse consequences of their therapy

Primary cardiac tumors involving the heart may be either benign or malignant. Most of the benign tumors are myxomas, which are most commonly located in the left atrium. Primary malignant neoplasms usually involve the myocardium and the interior of the cardiac cavities, whereas neoplasms metastatic to the heart most commonly involve pericardium, and pericardial effusion and constriction are the most common consequences. Computed tomography and magnetic resonance imaging are becoming the most useful instruments of precision for the diagnosis of cardiac tumors. Pericardial cysts, teratomas, lipomatous hypertrophy of the atrial septum, papillary fibroelastomas, thrombi, and sarcoid are frequently mistaken for cardiac neoplasms. There are a number of cardiac consequences of malignancy, including radiation heart disease, cardiac hemorrhages, cardiac infection, cardiac adiposity or the corticosteroid-treated heart, cardiac hemosiderosis, and toxicity due to anthracycline chemotherapy.

Metastatic melanoma of the left ventricle: Cardiac imaging in the diagnosis and surgical approach

A mass lesion occupying the left ventricle was noted on a screening CT scan in a 42-year-old man with a history of malignant melanoma. Subsequent echocardiography and cardiac MR imaging provided further hemodynamic and anatomic characterization of the lesion. These studies were also essential in guiding the proper surgical approach to allow extensive resection of the large mass without disrupting cardiac structures and function. The unique clinical aspects of this case are the unusual location for a lone cardiac metastasis of melanoma and the asymptomatic presentation despite the large size of the tumor and its apparent obstruction of ventricular outflow. The clinical and imaging features of this patient's threatening cardiac lesion are presented.

Surgical treatment of malignant melanoma

The surgical management of melanoma has evolved over the last 100 years. when early concepts of lymphatic permeation of the tumors and metastases led surgeons to perform radical operative procedures. Wide excision of primary melanoma is now performed with 1- to 2-cm radial margins, significantly reducing the need for complex plastic closures, skin grafts. and hospital admissions. Although elective lymph node dissection remains controversial as a therapeutic procedure, the development of SL has improved the staging of the regional lymph nodes and diminished the morbidity of lymph node dissection. The role of SL for routine care of melanoma patients remains unknown. Metastasectomy, which is the surgical resection of distant metastases with tumor-free surgical margins, has not been popular for AJCC stage IV patients with multiple metastases, because surgery is considered a local therapy and therefore of little value for management of disseminated disease. Nevertheless, the many reports of long-term survival after resection of distant melanoma metastases to diverse soft tissue and organ sites clearly indicate that this form of cytoreductive surgery can be extremely successful in carefully selected patients. Unlike chemotherapy, complete surgical metastasectomy can rapidly render a patient disease-free with only a short period of postoperative morbidity. Most patients fully recover from the surgical procedure within 6 weeks, returning to most or all activities. The ability to select patients for surgery is based on the development of more sophisticated imaging techniques, which allow better preoperative differentiation of patients with single versus multiple metastases and improve the surgeon's ability to identify and resect multiple metastatic sites. The overall data suggest that patients whose metastases can be completely resected will experience improved overall survival and occasional long-term cure regardless of the metastatic organ site and number of metastases. We believe that increased understanding of the biology of the primary and metastases, dramatic improvement in the accuracy of staging metastatic disease, and better techniques of surgical resection provide the best chance for long-term palliation or cure of melanoma. Cytoreductive surgery should be considered a form of immunotherapy. The long-term clinical benefit of this therapy depends on the patient's immune response to, the surgical reduction in tumor burden: an immune response that controls subclinical micrometastases should optimize postoperative survival.

Resection of advanced thoracic malignancies requiring cardiopulmonary bypass

OBJECTIVES

Patients with malignancies involving cardiac structures have limited therapeutic options and significant risk of mortality. The decision to offer radical palliative or curative resection must be made only after consideration of the substantial surgical risks. The purpose of this retrospective study was to determine the feasibility and benefits of resection with cardiopulmonary bypass (CPB) of metastatic or non-cardiac primary malignancies extending directly into or metastasizing to the heart in select patients. Our results were examined to assess the risks and benefits of such radical therapy.

METHODS

We retrospectively reviewed patient charts and identified all patients with malignancies involving the cardiac chamber or great vessels (excluding renal carcinomas with caval extension) or with substantial cardiac compression who had undergone resection with CPB at The University of Texas M.D. Anderson Cancer Center between January 1995 and July 2000. We evaluated demographic data, symptomatology, tumor characteristics, and outcomes.

RESULTS

Nineteen patients (six males and 13 females; median age of patients, 47 years; age range, 17-67 years) were included in the study. Eleven patients underwent surgery with curative intent, and eight underwent surgery with palliative intent. Seventeen patients had tumors that required CPB because their tumors directly involved the heart and/or great vessels (nine sarcomas, seven epithelial carcinomas, and one unclassified), and two patients (both with sarcomas) required CPB to relieve tumor tamponade. The technique included CPB (n=5), CPB with diastolic arrest (n=12), and CPB with hypothermic circulatory arrest (n=2). Five patients underwent concomitant pneumonectomy, and three underwent lobectomy. Two patients (11%) died in the hospital after resection with palliative intent. Of the 11 patients who underwent resection with curative intent, ten (91%) had complete resections. The median time in the intensive care unit was 5.3 days (range, 0-37 days) and the median length of hospital stay was 17.2 days (range, 0-107 days). Major complications occurred in 11 patients (58%); the most common major complications were pneumonia (n=7 patients), mediastinal hematoma (n=4 patients), and acute respiratory distress syndrome (n=2 patients). The median follow-up duration was 27 months. The overall 1- and 2-year survival rates were 65 and 45%, respectively.

CONCLUSIONS

Extensive thoracic tumors involving cardiac structures can be resected with acceptable risk. When resection was performed with curative intent, excellent 1- and 2-year cumulative survival rates were achieved. Although resection with palliative intent was associated with greater mortality rates, some patients survived for 1 and 2 years. The use of CPB in selected patients with thoracic malignancies should be considered, especially when complete resection can be achieved.

Isolated amelanotic malignant melanoma of the heart

We report a 58-year-old woman presenting with dyspnoea and recurrent pulmonary embolism. Echocardiography revealed pericardial effusion and a tumour located in the atrioventricular groove. Surgical exploration showed tumorous infiltration of the ventricle wall and of parts of the atrium. Curative excision was not possible and the operation was discontinued. Histology revealed an amelanotic malignant melanoma. No other tumour location was detected by scanning procedures. This case represents a very rare manifestation of melanoma exclusively located in the atrioventricular groove of the heart leading to recurrent pulmonary embolism. A review of the literature on cardiac involvement of melanoma is provided.

Circulatory shock

Patients with malignancy may present with acute circulatory compromise requiring ICU monitoring and care. The clinician must be familiar with a multiplicity of acute and chronic medical conditions common to the general population and also with conditions directly related to cancer or therapy thereof.

A lost piece of melanoma history

The original descriptions of melanoma of the hand, foot, vulva, and metastatic melanoma to the heart and bowel were by Jean Cruveilhier in his Anatomie Pathologique du Corps Humains published between 1829 and 1842. Cruveilhier's descriptions predate publications currently ascribed as being the first case reports of these melanomas. Cruveilhier's atlas of pathology also contains the original descriptions of multiple sclerosis, hypertrophic pyloric stenosis, and gastric ulcers. Cruveilhier's work is well known to book collectors, but his melanoma discoveries have not been cited since Pemberton in 1858. Cruveilhier's case reports are reviewed in addition to a discussion of their significance and historical contexts. Current melanoma scholars will appreciate this lost piece of melanoma history with its early historical discoveries and magnificent illustrations.

Resection of a right atrial metastatic melanoma with unknown origin of primary tumor

Cardiac involvement of malignant melanoma is generally part of a widespread tumor dissemination, which is mostly multifocal. Hence the disease is usually not amenable to surgical intervention. We report successful resection of a large intracavitary melanoma to the right atrium, the primary origin of which was unknown. The right atrium was reconstructed with an autologous pericardial patch. At 12-month follow-up the patient remains asymptomatic.

Surgery for metastatic melanoma

The appearance of distant metastases in a patient with malignant melanoma usually prophesies an early death: median survival is only 5 to 8 months. Surgery definitely can palliate certain patients and lead to a prolongation of life for others. In selected surgical candidates, an isolated nonvisceral metastasis, complete resection with free surgical margins, and a longer disease-free interval all favorably affect prognosis. In such cases, median survival can even approach 10 years, with a 5-year survival of up to 35%. Lung metastases are often incidental findings, but if complete resection can be accomplished, sometimes a median survival of 19 months and a 5-year 25% survival can be seen. Patients rarely survive long-term after brain or gastrointestinal metastases present themselves, but surgical resection extends median survival to about 10 months in this group with a significant improvement in quality of life. General guidelines should be reasonably applied for surgical intervention, with each metastatic melanoma patient given special individual assessment. Little has changed since the topic of the surgical role in metastatic melanoma was last reviewed in this journal by Coit in 1993.

Right atrial metastatic melanoma in a patient with transient ischemic attacks

A 65-year-old-man was admitted for evaluation of a transient ischemic attack. A 4.5 x 5.3-cm right atrial mass and a patent foramen ovale were identified by echocardiography. A 0.5-cm lesion was identified in the left temporal lobe of the brain by magnetic resonance imaging. Positron emission tomography was used to differentiate a tumor from an infarct in the brain. The cardiac and the brain lesions were successfully resected. Histopathologic study of the atrial and cerebral tissue demonstrated that these were metastases from a previously excised scalp desmoplastic malignant melanoma. The patient remains well at 14 months' follow-up.