78
Cardiac Metastases from Malignant Melanoma
Peter Gibbs, M.D.1
Jonathan S. Cebon, M.D., Ph.D.1
Paul Calafiore, M.D.2
William A. Robinson, M.D., Ph.D.3
1
Ludwig Institute for Cancer Research and the
Medical Oncology Department of the Austin and
Repatriation Medical Centre, Heidelberg, Australia.
2
Cardiology Department, Austin and Repatriation
Medical Centre, Heidelberg, Australia.
3
Ludwig Institute for Cancer Research and Walter
and Eliza Hall Institute for Medical Research, Royal
Melbourne Hospital, Victoria, Australia.
Address for reprints: William A Robinson, M.D.,
Ph.D., Ludwig Institute for Cancer Research, Post
Office Royal Melbourne Hospital, Victoria 3050,
Australia.
Received June 11, 1998; accepted July 9, 1998.
© 1999 American Cancer Society
BACKGROUND. Cardiac metastases are uncommon, with the exception of malignant
melanoma. More cases of cardiac involvement are being diagnosed in association
with the rising incidence and increasing survival of patients with melanoma.
Surgical intervention may be an effective palliative measure and should be con-
sidered for selected patients who present with this problem.
METHODS. In this article, the authors present clinical, laboratory, and imaging data
from two patients with malignant melanoma who presented with cardiac metas-
tases. A discussion of these patients is accompanied by a review of the current
literature on this topic.
RESULTS. Two females with known metastatic malignant melanoma presented
with nonspecific pulmonary symptoms and were found to have intracardiac me-
tastases involving the right heart. One patient underwent successful surgical re-
moval of a large tumor mass, which resulted in relief of symptoms and prevention
of imminent death from cardiac complications. Together with the literature review,
these cases demonstrate the important clinical features of cardiac metastases from
melanoma and define the best means of diagnosis as well as the potential benefits
of surgical intervention.
CONCLUSIONS. Cardiac involvement by malignant melanoma is now diagnosed
with increasing frequency. A diagnosis can be made with relative ease, but clinical
suspicion must precede it. Surgery may be useful to palliate symptoms and prevent
death from cardiac complications. Cancer 1999;85:78 – 84.
© 1999 American Cancer Society.
KEYWORDS: melanoma, metastasis, heart, surgery.
T he “melanotic heart” was originally described in 1820 by William
Norris, M.D., as part of the first case of melanoma reported in the
literature published in English.1 Although cardiac involvement is
found at autopsy in greater than 50% of patients with metastatic
malignant melanoma,2– 4 until recently this was rarely detected ante-
mortmen. In the past, the typical absence of specific symptoms, the
tendency for cardiac involvement to occur late as part of widely
disseminated disease, and the limitations of diagnostic imaging made
this a challenging diagnosis. Two cases of melanoma involving the
heart that were recently seen at our institution illustrate some of the
important diagnostic and therapeutic implications of this presenta-
tion.
Case 1
A female age 46 years was first seen at the Melanoma Clinic of the
Austin and Repatriation Medical Center in July 1997 for management
of metastatic melanoma. A primary cutaneous malignant melanoma
had been removed from the left neck 25 years earlier, the details of
which were unavailable. She remained disease free until June 1996,
when she presented with multiple subcutaneous metastases. A com-

puted tomography (CT) scan of the chest performed
then suggested a right atrial mass; however, no lesion
was detected on further investigation with transtho-
racic echocardiography (TTE). No further imaging and
no systemic therapy for melanoma was given. Over the
next 12 months, the patient chose to pursue alterna-
tive treatment modalities along with surgical resection
of further subcutaneous metastases, which slowly ap-
peared over this time period.
At initial presentation to our clinic, the only symp-
toms were mild exertional dyspnea and pleuritic chest
pain on the right side. The Karnofsky performance
score was 90. Clinical examination revealed 20 or
more subcutaneous metastases up to 3 cm in size and
slightly reduced air entry at the right lung base. Car-
diac examination was unremarkable, and dyspnea was
thought to be most likely due to pulmonary involve-
ment by metastatic melanoma. Two weeks later, the
dyspnea had increased and was associated with inter-
mittent rapid and regular palpitations. On the day of
presentation, an isolated presyncopal episode had oc-
curred. Clinical examination revealed a respiratory
rate of 20, a sinus tachycardia of 130, and a blood
pressure of 100/70. On ausculation of the precordium,
no murmurs or extra cardiac sounds were heard. CT
scan of the chest and abdomen revealed a 5.5 ⫻ 5 cm
right atrial mass in association with a dilated inferior
vena cava. No other major organ involvement was
evident. The other abnormal findings were minimal
right pleural thickening, retroperitoneal metastases up
to 3 cm in greatest dimension, and multiple subcuta-
neous metastases.
The patient was admitted for cardiac monitoring
and further cardiac studies. TTE revealed a mildly
dilated right atrium with a 5 ⫻ 4 cm mass occupying
most of the atrial cavity. Prolapse through the tricus-
pid valve during diastole produced a functional tricus-
pid stenosis. No point of attachment could be defined.
Transesophageal echocardiography (TEE) revealed a
7 ⫻ 7 cm mass, attached via a pedicle to the right atrial
wall (Figs. 1a and 1b). As the metastatic disease at
other sites was not life-threatening and her disease
had been indolent, an attempt at surgical resection
was elected.
At surgery, a darkly pigmented, friable, 8 ⫻ 8 cm
mass was found to be almost completely filling the
right atrium. Multiple smaller tumor deposits, several
millimeters in size, were found disseminated through-
out the right atrial and ventricular cavities and at-
tached to the chordae tendinae of the tricuspid valve.
The left side of the heart was not formally examined.
The atrial mass was excised piecemeal but was not
totally removed, as this would have necessitated major
cardiac reconstruction, which was not considered jus-
Melanoma Cardiac Metastases/Gibbs et al. 79
tified in the context of palliative surgery. Histopathol-
ogy confirmed the diagnosis of metastatic melanoma.
The postoperative course was uncomplicated, and the
patient was sent home 5 days after surgery with com-
plete relief of her dyspnea and no further palpitations.
The patient elected to continue pursuing alternative
treatment modalities following discharge. At fol-
low-up 6 months after surgery, the multiple subcuta-
neous and soft tissue metastases had slowly pro-
gressed, but she remained well and free of cardiac
symptoms.
Case 2
A female age 74 years presented in August 1993 with a
4-month history of slowly progressive dyspnea and dry
cough. A TTE performed by her private physician re-
portedly showed thickening of the right heart free wall,
impaired left ventricular function, and a small pericar-
dial effusion. Her past medical history included exci-
sion of a melanoma of unknown depth from the right
anterior lower leg 23 years earlier and recurrences
involving the right inguinal lymph nodes in 1990 and
1991, which were completely excised.
On clinical examination she was tachypneic at rest
with a respiratory rate of 22 and a plethoric, swollen
face. Other vital signs were within normal limits. A
hard, 2 cm lymph node mass was felt in the right
axilla. Cardiac examination was consistent with car-
diac failure on the right side. The chest was clear to
auscultation.
On full blood examination, the platelet count
was 32 ⫻ 109/L, hemoglobin was 12.7 g/dL, and the
white blood cell count was 7.8 ⫻ 1012/L. There was
no evidence of DIC. Bone marrow biopsy showed
mild hypercellularity consistent with peripheral
platelet consumption but no evidence of metastatic
melanoma. The antinuclear antibody titer was
markedly elevated at 5120 (normal ⬍160). TEE dem-
onstrated a mass that occupied more than 90% of
the right ventricular cavity and extended into the
right ventricular outflow tract and through the tri-
cuspid valve into the right atrium (Figs. 2a and 2b).
An additional mass measuring 2 ⫻ 3 cm was seen at
the apex of the left ventricle. CT scan revealed no
extracardiac metastases except for the clinically ev-
ident enlarged right axillary lymph nodes.
The platelet count improved to 70 ⫻ 109/L after
2 weeks of treatment with prednisolone 50mg daily
and intravenous gamma globulin. A transvenous bi-
opsy of the right ventricular mass was then at-
tempted under radiologic and echocardiographic vi-
sion following transfusion of 10 units of platelets.
The procedure was complicated by the abrupt onset
of profound hypotension and bradycardia following
80 CANCER January 1, 1999 / Volume 85 / Number 1
attempted biopsy of the intracardiac mass. Doppler
echocardiography revealed a large pericardial fluid
collection and pressure recordings that were consis-
tent with cardiac tamponade. Attempted resuscita-
tion was unsuccessful. Postmortem examination de-
termined the cause of death to be puncture of the
right ventricular wall at the time of biopsy. Malig-
nant melanoma involving the right heart was con-
firmed histologically. The left ventricular mass was
shown to be organized thrombus.
FIGURE 1. A transesophageal echo-
cardiogram of Case 1 is shown. (a) A
diastolic, apical four-chamber view
shows the large tumor mass occupying
most of the right atrium and prolapsing
through the tricuspid valve into the right
ventricle, causing tricuspid stenosis. (b)
A basal view of the heart at the level of
the aortic valve demonstrates attach-
ment of the tumor mass to the atrial
septum. RA: right atrium; LA: left atrium;
LV: left ventricle; RVOT: right ventricular
outflow tract; AV: aortic valve; TV: tricus-
pid valve.
DISCUSSION
Malignant melanoma has the highest rate of cardiac
metastases of any tumor.2-4 Until recently, this was
only rarely detected antemortem, despite sometimes
massive involvement.2,5,6 The two cases described
above have many features in common with an in-
creasing number of case reports that have highlighted
specific aspects of this presentation.
Malignant melanoma can involve any of the car-
diac structures, but most metastases are located in the
 Melanoma Cardiac Metastases/Gibbs et al. 81

FIGURE 2. A transesophageal echo-

cardiogram of Case 2 is shown. (a) An
apical four-chamber view shows the tu-
mor mass occupying the majority of the
right ventricular cavity. (b) A basal lon-
gitudinal view shows the right ventricu-
lar outflow tract. The tumor mass is
occupying a large percentage of the
right ventricular outflow tract, infundib-
ulum and prolapsing through the pulmo-
nary valve into the pulmonary artery. RA:
right atrium; LA: left atrium; LV: left ven-
tricle; ROVT: right ventricular outflow
tract; LVOT: left ventricular outflow tract;
MPA: main pulmonary artery; PV: pulmo-
nary valve; AV: aortic valve; TV: tricuspid
valve; MV mitral valve.

myocardium, and valvular involvement is rare. In the
largest reported autopsy series of metastatic mela-
noma, Glancy et al. found cardiac involvement in 45 of
70 cases.2 The majority had multiple small metastases
throughout the heart, with the right atrium the most
commonly involved chamber. The extent of cardiac
involvement at autopsy correlated poorly with the
presence of clinical features such as tachycardia, dys-
pnea, and edema, which were often absent or attrib-
uted to noncardiac disease. Electrocardiogram (ECG)
findings were typically nonspecific, occurred late, and
were unrelated to disease extent. All of these findings
were consistent with the poor correlation found be-
tween clinical features, ECG changes, and objective
evidence of cardiac metastases in other large studies
of multiple different malignancies,7,8 as well as the
82 CANCER January 1, 1999 / Volume 85 / Number 1
case reports of cardiac involvement by malignant mel-
anoma.5,6,9 –24
Reports detailing intracavitary metastases from
malignant melanoma make up the majority of the
published cases, many of these having been an inci-
dental finding in the course of investigation for other
indications.9 –23 This particular presentation is the eas-
iest to diagnose and evaluate further, and it is also the
most amenable to intervention. Other sites of involve-
ment and modes of presentation are less often re-
ported and include arrhythmias,23 valvular dysfunc-
tion,24 and congestive cardiac failure due to massive
myocardial involvement.5,6 These are typically late
presentations that occur in the context of widely met-
astatic disease; significant intervention is difficult, and
outcomes are almost invariably poor.
Due to its high sensitivity and rapid availability,
echocardiography has been extensively used and re-
ported in the imaging of cardiac metastases. As sug-
gested by the 2 cases described in this article, TEE is
superior to TTE for the characterization of intracar-
diac masses, as it better defines features such as size,
mobility, and site of attachment.26 –28 This is particu-
larly so where patient characteristics such as obesity
or body habitus limit the images obtainable by TTE or
for imaging the atria, where TTE may miss up to 50%
of mass lesions.25–28 Although incidental cardiac pa-
thology may be detected by conventional CT, as in
Case 1, the further role of this modality is limited by
poor image quality due to motion artefacts.29,30 Reso-
lution can be substantially improved by gating the CT
acquisition to the cardiac cycle or the use of ultrafast
CT where these facilities are available.31
Gated cardiac magnetic resonance imaging (MRI)
has been a major advance in cardiac imaging. Each of
the cardiac segments are imaged with equal clarity,
and multiplanar reconstruction permits the size, loca-
tion, borders, and surface characteristics of cardiac
masses to be accurately determined.32–34 MRI has
been shown to be superior to TEE in defining such
features as the site of mural attachment and extension
of tumor into adjacent mediastinal structures.32,33 Ma-
lignant melanoma produces a characteristic hyperin-
tense signal on T1-weighted images9,35 due to para-
magnetic scavenging by melanin,36 which contrasts
with the low signal produced by other tumors.
Histologic diagnosis can be obtained via echocar-
diographically guided transvenous biopsy. This has
been highlighted as a safe and efficient way to obtain
tissue without thoracotomy.14 –20 The fatal outcome in
our second case demonstrated that this procedure is
not without risk, although thrombocytopenia may
have also contributed to this patient’s death. When
the diagnosis is probable and therapeutic surgical in-
tervention is warranted, it would be reasonable to
proceed directly to thoracotomy without a confirma-
tory tissue diagnosis.
When intracavitary masses are diagnosed, opera-
tive intervention should be considered as first-line
therapy, particularly if cardiac function is compro-
mised by the tumor mass. Even if total resection is not
possible, conservative surgery can be performed with
minimal morbidity in an attempt to relieve symptoms
and prevent imminent cardiac failure (and death).
Other reports in the literature also describe the suc-
cessful palliation of cardiac symptoms by debulking or
resection of metastatic melanoma deposits.9 –13,21,22
Although cardiac involvement can be readily eval-
uated, the decision to proceed with operative inter-
vention needs to be carefully considered. The majority
of patients who develop cardiac involvement will do
so late in the natural course of their disease and will
typically have extracardiac disease, which will impact
on their quality of life and survival.
Patients presenting while on systemic chemother-
apy are unlikely to respond to second-line treatment,
and other patient-related prognostic factors also need
to be considered. In addition to the safety concerns
related to cardiac surgery, the survival benefit is de-
termined by the total tumor burden, the sites of ex-
tracardiac involvement, and the rate of tumor progres-
sion. Although many patients would be excluded from
an aggressive surgical approach by these consider-
ations, a small percentage are likely to have a signifi-
cant benefit. Ideal candidates would be similar to our
first case, with a good performance status, limited
involvement of other sites, and an indolent disease
course. Management issues related to cardiac involve-
ment are likely to become of even greater importance
in the future as further advances are made in imaging,
surgery, and systemic therapy for patients with malig-
nant melanoma.
The propensity for cardiac involvement by meta-
static melanoma is intriguing, as involvement of mus-
cles elsewhere in the body is rarely observed. Along
with more extensively described patterns of metastatic
spread, the mechanisms responsible for the homing of
circulating melanoma cells to this specific site remain
largely uncharacterized and a subject of intense re-
search.37,38 The long disease free intervals of 24 and 23
years, respectively, of our 2 cases, the slow progression
after the first appearance of metastatic disease, and
the lack of other major organ involvement is remark-
able. Similarly, for 3 other reported cases the presen-
tation with cardiac involvement was greater than 20
years from diagnosis of the primary.13,16,18,19 These
cases may represent a highly selected subset, as in the
previously mentioned autopsy series of 70 patients

with metastatic melanoma the longest survival from
initial diagnosis of melanoma was 15 years and all
patients with cardiac involvement had extensive met-
astatic disease at other sites.2
In conclusion, for patients with known malignant
melanoma who present with possible cardiac symp-
toms, the clinician should be alert to the possibility of
cardiac metastases. Such involvement may be difficult
to diagnose clinically but has important therapeutic
and prognostic implications. Cardiac involvement can
be reliably characterized by the employment of mul-
tiple imaging modalities, particularly TEE and MRI.
For the majority of patients with cardiac metastases,
the therapeutic options are limited to palliative man-
agement of symptoms or a trial of systemic therapies.
However, for a small but significant population of
patients, surgical intervention may be an effective pal-
liative measure and should be strongly considered for
suitable patients in whom the heart is the major site of
disease. These patients may achieve prolonged symp-
tom free intervals and should be considered for fur-
ther appropriate systemic therapy after cardiac sur-
gery.
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