Obstruction of right ventricular outflow tract by extended cardiac metastasis from esophageal cancer

Solitary Cardiac Metastasis from Esophageal Cancer

A 72-year-old woman with past medical history of rectal cancer resection (adenocarcinoma, pT3N1aM0) presented with a 2-month history of dysphagia. Imaging studies found a thoracic esophageal cancer, for which subtotal esophagectomy with gastric conduit reconstruction via retrosternal route followed by chemoradiotherapy were performed (squamous cell carcinoma, pT4N1M0, RM1). Seven months after the esophagectomy, a contrast-enhanced computed tomography (CT) demonstrated a new asymptomatic mass inside the right atrium. A thrombus or a tumorous lesion was suspected. Positron emission tomography (PET)/CT showed abnormal uptake in the mass. After a thorough discussion by a multidisciplinary oncology group, we performed 1-week anticoagulant therapy first, resulting in mass enlargement. Then tumorectomy was carried out. The final pathological findings revealed that the mass was squamous cell carcinoma, yielding the diagnosis of cardiac metastasis from esophageal cancer. The patient's postoperative course was unremarkable. PET/CT may help to estimate malignancy and to omit invasive heart surgery.

Cardiac metastasis after esophagogastrectomy for esophageal adenocarcinoma with an antemortem diagnosis

Cardiac metastasis is uncommon and rarely diagnosed antemortem. Here, we describe a case of symptomatic cardiac metastasis from esophageal adenocarcinoma. A 64-year-old man developed chest symptoms 26 months after curative esophagogastrectomy for esophageal adenocarcinoma. Initially, ischemic cardiac disease was suspected based on electrocardiography findings, but an infiltrative tumor was seen morphologically in the wall of the interventricular septum and apex. No other lesions were detected. Histological examination of a transcatheter biopsy specimen indicated that the cardiac tumor was metastasis from esophageal adenocarcinoma. Chemoradiotherapy with cisplatin relieved his symptoms, and he had resumed normal activities. However, he opted not to undergo further aggressive treatment due to severe adverse effects from cisplatin. Seventeen months after completion of chemoradiotherapy, metastases to the right ventricle and the left thighbone were detected and he died 27 and 24 months after the diagnosis of cardiac metastasis and completion of chemoradiotherapy, respectively.

Right Ventricular Outflow Tract Obstruction in Adults: A Systematic Review and Meta-analysis

Background

Right ventricular outflow tract obstruction (RVOTO) is a cause of hemodynamic instability that can occur in several situations, including cardiac surgery, lung transplantation, and thoracic surgery, and in critically ill patients. The timely diagnosis of RVOTO is important because it requires specific considerations, including the adverse effects of positive inotropes, and depending on the etiology, the requirement for urgent surgical intervention.

Methods

The objective of this systematic review and meta-analysis was to determine the prevalence of RVOTO in adult patients, and the distribution of all reported cases by etiology.

Results

Of 233 available reports, there were 229 case reports or series, and 4 retrospective cohort studies, with one study also reporting a prospective cohort. Of 291 reported cases of RVOTO, 61 (21%) were congenital, 56 (19%) were iatrogenic, and 174 (60%) were neither congenital nor iatrogenic (including intracardiac tumour). The mechanism of RVOTO was an intrinsic obstruction in 169 cases (58%), and an extrinsic obstruction in 122 cases (42%). A mechanical obstruction causing RVOTO was present in 262 cases (90%), and 29 cases of dynamic RVOTO (10%) were reported. In the 5 included cohorts, with a total of 1122 patients, the overall prevalence was estimated to be 4.0% (1%-9%).

Conclusions

RVOTO, though rare, remains clinically important, and therefore, multicentre studies are warranted to better understand the prevalence, causes, and consequences of RVOTO.

Asymptomatic Cardiac Metastases From Esophageal Cancer: A Case Report Of Ante-mortem Detection And Literature Review

Metastatic spread to the heart from neoplasms is very rare, often silent and rarely gains clinical attention. Usually, it correlates with widespread metastatic disease and is suggestive of a poor prognosis. Most cardiac metastases (CM) are detected following post-mortem studies with only a handful reported antemortemly. Here, we report a case of an asymptomatic cardiac metastasis from esophageal carcinoma and a review of the literature. In late July 2014, a 73-year-old woman diagnosed with locally advanced esophageal squamous cell carcinoma was admitted to our institution. Cardiothoracic metastases were not detected at basal computed tomography (CT) scan. The patient was submitted to concurrent cisplatin and radiotherapy. Just before surgery, a CT scan revealed two metastases in the right ventricle and in the interventricular septum. Transthoracic echocardiography and an endomyocardial biopsy confirmed the diagnosis of squamous cell carcinoma from the esophageal origin. In February 2015, chemotherapy was started, but after two courses of gemcitabine, a pulmonary embolism and then a congestive heart failure caused death of the patient on April 2015. Reviewing the literature, 14 cases with an antemortem diagnosis of CM from esophageal cancer were reported. Our patient should be the fifteenth case with an uncommon presentation without symptoms or signs in the diagnosis. Our case highlights that patients should be evaluated using echocardiography for CM, even if asymptomatic.

Esophageal Cancer Metastases to Unexpected Sites: A Systematic Review

The most common pattern of esophageal cancer metastases (ECM) is to the lymph nodes, lung, liver, bones, adrenal glands, and brain. On the other hand, unexpected metastasis (UM) spread to uncommon sites has increasingly reported and consequently affected the pathway of diagnosis, staging, and management. Using the PubMed database, a systematic search of the following headings “Esophageal” and “Metastasis” or “Metastases” was performed, 10049 articles were identified, and the articles were included if they demonstrated unexpected ECM. 84% of cases were men with an average age of 60.7 years. EC was located in the lower third in 65%. Two-thirds of the UM originated from the lower esophagus, and the two major histological types were adenocarcinoma 40% and squamous cell carcinoma 60%. Metastases were disseminated toward five main anatomical sites: the head and neck (42%), thoracic (17%), abdomen and pelvis (25%), extremities (9%), and multiple skin and muscle metastases (7%). The EC metastases were found to be synchronous 42% and metachronous 58%, isolated in 53.5% and multiple in 46.5%. The overall survival rate was 10.2 months. Since distant metastases are responsible for most EC-related deaths, understanding of ECM dissemination patterns needs more extensive studies. These critical data are the cornerstone of optimal cancer approach and treatment.

Sonography and Transthoracic Echocardiography for Diagnosis of Systemic Cardiovascular Metastatic Tumor Thrombi

Sonography and transthoracic echocardiography (TTE) are seldom used for assessment of metastatic tumor thrombi in the cardiovascular system in routine clinical practice. We performed this retrospective study to evaluate the combination of sonography with TTE for diagnosis of metastatic tumor thrombi in heart and systemic vessels. Vascular, abdominal, pelvic, and small-part sonography was applied in 18 patients, and TTE was conducted simultaneously in 14 patients. Tumor thrombi invaded into the inferior vena cava system in 12 patients, superior vena cava system in 5 patients, and aorta in 1 patient; they extended to the right cardiac chambers in 11 patients. Six patients had diagnoses by pathologic examination. The primary neoplasms were identified by conventional imaging in 17 patients. The morphologic and echogenic characteristics of the tumor thrombi were diverse and depended on their original tumors. The thrombi were either contiguous or discrete from the original tumors. The neoplastic vascularity of the thrombi and the invasive extension were the primary characteristics that distinguished them from bland thrombi. Simultaneous application of sonography and TTE is a feasible way to comprehensively evaluate cardiovascular metastatic tumor thrombi in most patients.

Isolated cardiac metastasis from squamous cell esophageal cancer

Although heart metastases are uncommon and generally a sign of disseminated disease, they are up to 40 times more frequent than primary cancers of the heart, and typically arise from melanoma or primary mediastinal cancer, but also from lymphoma, breast cancer, esophageal cancer, and leukemia. They are usually asymptomatic and found only at autopsy. Symptomatic patients generally die within a few weeks of diagnosis and usual treatments are chemotherapy, radiotherapy, or both. Surgical resection is recommended only for a single lesion, which is rare. We describe a 49-year-old man treated for squamous cell cancer of the esophagus in whom a single asymptomatic left heart metastasis was discovered incidentally during follow-up. The lesion was debulked surgically and multimodal treatment followed. The patient survived 1 year after diagnosis with good performance status during which time no other lesion was discovered. Cardiac metastasis is challenging and necessitates skilled multidisciplinary management to maximize the clinical outcome.

An unusual right ventricle metastasis from mandible squamous cell carcinoma detected on FDG PET/CT

A patient with history of mandible squamous cell carcinoma underwent an FDG PET/CT scan. A focal hypermetabolic right ventricle lesion was noted and suggestive of metastasis. A cardiac MRI verified the right ventricle wall mass. Further endomyocardial biopsy confirmed the diagnosis of metastatic squamous cell carcinoma.

[Metastatic tumor of the right ventricle: an unusual location of tumor involvement in laryngeal carcinoma]

Secondary tumors are much more frequent than primary tumors, but cardiac metastasis of laryngeal carcinoma is uncommon. The authors report the case of a 71-year-old man, with a history of laryngeal carcinoma, admitted to the emergency room with symptoms of two weeks' evolution suggestive of respiratory infection. Due to lack of therapeutic response and progressive clinical deterioration, a transthoracic echocardiogram was performed which revealed a large infiltrating mass within the right ventricle, involving the apex, interventricular septum and free wall, not causing significant right ventricular outflow tract obstruction. Evaluation by computed tomography showed signs of widespread metastasis from the previously diagnosed laryngeal cancer.

A rare case of squamous cell carcinoma of the bladder presenting as a metastatic right ventricular mass

A 74-year-old woman presented with bilateral lower extremity swelling, worsening dyspnea on exertion, and mild hemoptysis. An echocardiogram at time of admission showed a mass in the right ventricle. The pathology of a sample obtained via transvenous biopsy was consistent with squamous cell carcinoma; no primary source could initially be identified. Severe thrombocytopenia, likely consumptive, precluded surgical intervention, so the patient underwent palliative radiation. Unfortunately, she developed fatal respiratory failure. Upon autopsy, the bladder was found to contain polyps of invasive squamous cell carcinoma, similar in morphology to the tumor mass in the heart. Her lungs contained multiple tumor emboli at different stages, which was likely the final cause of her death. Squamous cell carcinoma metastases to the endocardium are extremely rare and without defined treatment. Surgery can improve prognosis in those with primary tumors that are benign or without metastases. In those with symptomatic metastatic tumors, palliative debulking can done although generally will not improve prognosis. It is currently unknown whether radiation improves survival. In this case, irradiation did destroy a portion of the tumor as the final pathology showed extensive necrosis of the tumor; unfortunately, it did not change her symptoms and did not change the final outcome.

Cardiac Metastasis From Lung Adenocarcinoma Causing Atrioventricular Block and Left Ventricular Outflow Tract Obstruction

Cardiac metastasis from lung cancer is rarely diagnosed antemortem, as it usually causes no symptoms or signs. We report the case of a 56-year-old man with recurrent lung adenocarcinoma in whom developed a large mass in the ventricular septum, complete atrioventricular block, and obstruction of the left ventricular outflow tract.

Coronary angiography of cardiac myxoma

BACKGROUND

Myxoma usually presents with nonspecific symptoms. Preoperative coronary angiography is presently only considered if patients are at increased risk of coronary artery disease (CAD). The angiographic patterns of cardiac myxoma have not been fully described.

HYPOTHESIS

The aim of our study was to investigate coronary angiograms as well as patterns of tumor vascularity in patients with cardiac myxoma.

METHODS

From January 1990 to December 2003, 33 patients with cardiac myxoma, who had received surgical resection at our hospital, were enrolled; of these, 9 patients underwent preoperative coronary angiography. The severity and extent of coronary artery stenosis, as well as tumor angiographic patterns, were analyzed. Coronary artery disease is defined as a > 50% stenosis in diameter at any segment of the coronary artery viewed by two orthogonal views on cineangiogram.

RESULTS

Four (44.4%) patients showed concomitant CAD. The presence of coronary risk factors was not different between patients with and without CAD. Contrast media-enhanced tumor vasculature was found in five (55.6%) patients. Four (80%) patients had multiple feeding arteries. There was the characteristic "sea anemone" appearance of the tumor vasculature composed of (1) basal vascular network, (2) vessel stem, (3) backbone branches, and (4) dye brushes. These findings were characteristic of cardiac myxoma.

CONCLUSION

Coronary angiography can detect the concomitant coronary disease and the unique vascular appearances of cardiac myxoma. Familiarity with the "sea-anemone" angiographic findings may help in the diagnosis of cardiac myxoma.

Sudden death from metastatic esophageal cancer to the ventricular septum

A 67-year-old man was admitted to our hospital due to esophageal cancer. Cancer existed at the lower esophagus and subtotal esophagectomy and lymphadenectomy was performed. The postoperative course was uneventful. Pathological findings revealed moderately differentiated squamous cell carcinoma that metastasized to the abdominal lymph nodes which include the paraaortic lymph nodes. He complained of anorexia three months after the operation and was found to have multiple liver and mediastinal lymph node metastases. He was admitted for chemotherapy. Before starting chemotherapy, he suddenly died without any sign of hemorrhage or respiratory disorder. Autopsy showed metastatic lesions to the heart and mediastinal lymph nodes, liver, thoracic vertebrae, kidney, adrenal gland and heart. Metastatic nodules in the heart were on the ventricular septum where the conducting system exists. No direct invasion from the pericardium was observed. Blockade of the conducting system of the heart was considered to have caused the severe arrhythmia and sudden cardiac arrest.