Metastatic malignant melanoma manifesting as an intracardiac mass

Disseminated Melanoma: A Disappearing Left Ventricular Mass

•Melanoma may lead to asymptomatic cardiac metastasis. •Resolution of the intracardiac mass occurred with nonsurgical treatment. •Echocardiography is important for screening for metastatic involvement.

Cardiac Metastasis of Malignant Melanoma Detected by 18F-FDG PET/CT

A 63-year-old man with a history of right plantar malignant melanoma (T3bN0M0, IIb) developed multiple metastases in bilateral lungs 19 months after surgery. Subsequent ¹⁸F-FDG PET/CT revealed multiple pulmonary metastases with intense FDG uptake and detected a hypermetabolic lesion in the lateral wall of the left ventricle, which was considered to be a cardiac metastasis of malignant melanoma. This lesion was later confirmed in the dynamic myocardial perfusion MR. This case demonstrates the effectiveness of ¹⁸F-FDG PET/CT in detecting occult cardiac metastases of malignant melanoma.

Metastatic Melanoma Extending along the Pulmonary Vein into the Left Atrium: A Rare Route of Metastasis Characterized by Transesophageal Echocardiography

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Melanoma commonly metastasizes to the heart through hematogenous spread.

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These metastases can resemble benign cardiac tumors.

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Isolated left-sided cardiac involvement is rare with metastatic melanoma.

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Metastasis can atypically take a course through the pulmonary vein.

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Multimodality imaging is useful for characterization of these intracardiac masses.

Metastatic melanoma of the heart: Retrospective cohort study and systematic review of prevalence, clinical characteristics, and outcomes

BACKGROUND

Cardiac metastasis of melanoma is rare and typically diagnosed post-mortem. Here we perform a retrospective cohort study and systematic review of patients with metastatic melanoma to characterize prevalence, clinical characteristics, and outcomes of cardiac metastasis.

METHODS

We reviewed the electronic medical records of all outpatients with metastatic melanoma who underwent evaluation at the University of Michigan in Ann Arbor from January 2009 to January 2022, identifying patients with a clinical or histopathologic diagnosis of cardiac metastasis. We performed a systematic review of the literature to summarize the clinical characteristics and outcomes of patients with melanoma and cardiac metastasis.

RESULTS

Overall, 23 of 1254 (1.8%) patients with metastatic melanoma were diagnosed with cardiac metastasis. Cardiac metastasis was reported in the right ventricle (65%), left ventricle (35%), and right atrium (35%). A total of 11 (48%) patients experienced at least one cardiovascular complication after the diagnosis of cardiac metastasis, the most common being arrhythmia (30%), heart failure (22%), and pericardial effusion (17%). Immunotherapy was more commonly used in patients with cardiac metastasis (80% vs 65%; p = 0.005). Mortality at 2-years post-diagnosis was higher for patients with cardiac metastasis compared to those without (59% vs 37%; p = 0.034). Progression of malignancy was the underlying cause of death of all patients.

CONCLUSIONS

Cardiac metastasis occurs in <2% of patients with metastatic melanoma, can affect all cardiac structures, and is associated with various cardiovascular complications and high mortality.

The Role of Echocardiography in the Cancer Patient

PURPOSE OF REVIEW

To review the uses of echocardiography in patients with cancer and how it has expanded beyond the typical monitoring of systolic function during potentially cardiotoxic cancer therapeutics.

RECENT FINDINGS

In addition to myocardial strain imaging being a predictor of subsequent left ventricular dysfunction, it can be used for pattern recognition to help identify patients with cardiac amyloidosis or Takotsubo cardiomyopathy. Echocardiography is essential for diagnosis and planning of intervention for aortic stenosis in radiation-induced valvular disease, for which transcutaneous aortic valve replacement that gives many cancer patients that are not surgical candidates an option for treatment. The safety of transesophageal echocardiography has recently been demonstrated in patients with cancer with thrombocytopenia and depleted white blood cell counts who are at increased risk of endocarditis. Echocardiography is an essential tool for evaluating common conditions in cancer patients such as pericardial disease, radiation-induced heart disease, and intracardiac tumors-with specific uses of specialized echocardiography techniques such as deformation imaging, transesophageal echocardiography, and point-of-care ultrasound.

Left atrial tumor thrombus with emboli to the brain and distal extremities: A case report

Cardiac metastases are an uncommon phenomenon associated with neoplasms from a variety of primary sites. Pulmonary involvement often accompanies metastases involving the left atrium or ventricle and clinical presentation may be associated with stroke or emboli involving distal sites. We report a patient who presented acutely to the Emergency Department with symptoms of a cerebrovascular accident and bilateral cold pulseless lower extremities. Computerized Tomographic (CT) angiogram of the chest, abdomen, pelvis and lower extremities disclosed pulmonary veins with large filling defects in the right superior and inferior vessels as well as the left atrium and atrial appendage. Mediastinal and hilar adenopathy was detected. The patient had a history of tonsillar squamous cell carcinoma eighteen months prior. The patient underwent operative intervention with removal of a large left intra-atrial mass, histologic evaluation of which demonstrated groups of malignant squamous cells meshed in fibrin clot. The patient died three days post operatively due to multiple brain infarctions.

Evaluation and Management of Cardiac Tumors

PURPOSE OF REVIEW

Our purpose is to discuss the importance of multimodality imaging in the assessment of cardiac tumors and management. We have compiled a recent review of the scientific literature and embedded our clinical pathways and recommendations based on data and clinical experience.

RECENT FINDINGS

The use of contrast echocardiography in the assessment of cardiac masses has been shown to be helpful in distinguishing tumor from thrombus. Deformation imaging of cardiac tumors has been shown to differentiate better rhabdomyomas from fibromas in pediatric patients. Cardiac MRI (CMR) appears to be helpful in determining whether cardiac tumors are benign or malignant by identifying presence of infiltration, uptake of contrast in first pass perfusion and gadolinium enhancement. Patients with evidence of cardiac metastases by CMR show similar survival to stage IV cancer without cardiac metastases. In our institution, we use a standardized approach for the evaluation of cardiac masses, which includes multimodality imaging in the appropriate clinical context. The autotransplantation surgical technique has shown some promise in improving survival in patients with primary cardiac sarcomas. In our institution, we do not routinely recommend anticoagulation for "tumor-thrombus" in renal cell carcinoma due to risk of bleeding from primary tumor. Cardiac masses are often found incidentally, but sometimes can present with cardiovascular symptoms due to obstruction and valvular dysfunction, which may prompt imaging. It is important to determine whether the mass is a normal variant, imaging artifact, vegetation, thrombus, or tumor. Transthoracic echocardiography is ideally suited to be the initial imaging modality because of the portability, wide availability, lack of radiation, and relatively low cost. The gold standard cardiac imaging technique to distinguish tumor from thrombus is contrast enhanced CMR with prolonged inversion time. Advantages of CMR when compared to echocardiography regarding characterization of cardiac tumors are as follows: larger field of view, better spatial resolution, better tissue characterization, lack of attenuation, and ability to image at any prescribed plane. Primary and secondary cardiac tumors have particular characteristics in echocardiography and CMR. Imaging of cardiac tumors plays an important role in establishing a diagnosis and in planning management.

Imaging characteristics of cardiac metastases in patients with malignant melanoma

BACKGROUND

Due to prolonged survival and technical advances in CT imaging, cardiac metastases in patients with malignant melanoma are observed more frequently nowadays. The aim of the present study was to assess the anatomic distribution as well as the morphologic and histologic appearance of cardiac metastases from malignant melanoma.

METHODS

Twenty five patients with known metastasized melanoma and with incidental finding of cardiac metastases during routine staging CT were retrospectively included in this study. CT images were assessed for the presence, localization and extent of cardiac metastases. Histological results, mutational analysis and tumor markers were reviewed.

RESULTS

Fourteen out of 25 patients presented with singular cardiac mass (56%), whereas ten patients (40%) presented with multifocal and one patient with disseminated cardiac metastases. Twelve patients presented with endocardial (48%), eight with myocardial and two with pericardial metastases. Most frequent site involved in endocardial metastases was the right atrium (67%) followed by the right ventricle (33%). There seems to be a correlation between histological subtype and location of cardiac metastasis. Median survival after diagnosis of cardiac metastases was 8 months, with no significant difference regarding the localization of metastases within the heart.

CONCLUSION

Cardiac metastases can involve every part of the heart possibly in dependence of histological subtype. The awareness of different types of cardiac metastases and their characteristic appearance on CT images is necessary for further investigations and might contribute to targeted therapy.

Cardiac metastases of melanoma as first manifestation of the disease

Cardiac metastases are rare, but more common than primary cardiac tumours, and metastatic melanoma involves heart or pericardium in greater than 50% of the cases, although cardiac metastasis are rarely diagnosed ante mortem because of the lack of symptoms. A multimodality approach may help to obtain a more timely diagnosis and in some cases a quicker and better diagnosis can enable a surgical resection to prevent cardiac failure or to reduce the tumour before chemotherapy. We present a case of a patient with cardiac metastasis as first evidence of a malignant melanoma: in this case the patient underwent echocardiography, cardiac magnetic resonance and computed tomography. This case underlines the importance of advanced diagnostic techniques, such as cardiac magnetic resonance, not only for the detection of cardiac masses, but also for a better anatomic definition and tissue characterization, to enable a quick and accurate diagnosis which can be followed by appropriate treatment.

Metastatic melanoma to the heart

Melanoma is a common neoplasm with a propensity to metastasize to the heart. Although cardiac metastasis is rarely diagnosed ante mortem, using a multimodality approach, several imaging findings may be seen. Echocardiography is often the initial imaging method used to detect cardiac metastases and their complications. On computed tomography, intraluminal filling defects and myocardial/pericardial nodules may be seen. On magnetic resonance imaging, metastatic melanoma is classically hyperintense on T1 images and hypointense on T2 images, a result of the T1 shortening of melanin; however, this is seen in a minority of cases. As melanoma metastases are fluorine-18-fluorodeoxyglucose avid, fluorine-18-fluorodeoxyglucose positron emission tomography may also be used to detect cardiac metastases.

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.