Professional Documents
Culture Documents
Metastases To Heart Explained
Metastases To Heart Explained
Primary tumors of the heart are rare, occurring at a frequency of diagnostic tools and aggressive treatment of localized malignant
∼0.02% in pooled autopsy series [1]. Histologically, three-quarters tumors by surgery and/or radiotherapy has led to longer survival
of primary heart tumors turn out to be benign, almost half of them of tumor patients; in tumors with a high propensity to spread meta-
being myxomas [2]. Whether benign or malignant, the majority of stases, however, this is with the downside of a higher probability
primary cardiac tumors are intracavitary and preferentially that the patient finally goes through diffuse tumor disease. There-
develop in the left atrium, thereby leading to left ventricular fore, the incidence of cardiac metastases has increased during
inflow obstruction. Embolism is also common. Secondary or recent decades [3–19]. Furthermore, metastases to the heart,
Metastatic pathways gland [57, 58] through the superior vena cava into the right atrium.
Rarely, bronchial carcinoma spreads through the pulmonary veins
Metastases may reach the heart via the lymphatic or hemato- into the left-side heart cavities [59, 60].
genous route, or by direct or transvenous extension. Lymphatic
spread tends to give rise to pericardial metastases, hematogenous
spread preferentially gives rise to myocardial metastases. Only Symptomatology
rarely are endocardial tumor deposits found. Tumors such as the
Since the clinical picture is chiefly dominated by generalized
bronchial or esophageal carcinoma, which develop near the heart,
may expand by direct extension into the heart, but these tumors tumor spread, cardiac metastases usually remain clinically silent,
predominantly attain to the heart by the lymphatics. Similar obser- particularly as the vast majority of cardiac metastases are small.
vations were made for carcinomas of the breast. Via mediastinal Frequently, cardiac involvement is not noticed until after death. In
lymph nodes, tumor cells invade at first the epicardial, and then retrospective studies, only about one-tenth of patients who died of
the myocardial lymphatic system [12]. Owing to their topography tumor disease and showed cardiac spread as identified at post-
and prevalence, carcinomas of lung and breast are the most mortem examination presented with symptoms or findings indica-
common tumors originating cardiac metastases. Owing to their tive of cardiac involvement [7, 11]. Obviously, there is no strong
preferred metastatic pathway, both preferentially affect the peri- correlation between the extent of cardiac involvement and clinical
cardium. Cardiac metastases of infradiaphragmatic tumors are manifestations. Not infrequently, post-mortem findings reveal
markedly less frequent. Malignant melanoma, lymphoma, leuke- cardiac involvement to be more extensive than clinical findings
mia, soft tissue and bone sarcoma usually spread hematogenously. have suggested.
Secondary heart tumors that have partial or total intracavitary At the time when malignant disease is diagnosed, cardiac meta-
growth are very rare; when they do occur, they are often covered stases are the clinically prevailing finding in a few single cases
by thrombotic material [25–40]. Even more rare are clusters of only [13, 26, 29, 61, 62]. Occasionally, however, metastases to the
tumor cells on heart valves. This type of tumor infiltration has led heart are detected during initial tumor staging. On the other hand,
to heart valve stenosis or regurgitation only in isolated cases [20, they may not become apparent clinically until many years after
41–43]. cancer diagnosis, if at all. For example, heart metastases of
Extracardiac tumors may also reach the atria and even the sarcomas have caused clinical symptoms not before 11 and 25 years
chambers of the heart by transvenous extension. Intraluminal after resection of the original tumor, respectively, just as meta-
growth of renal cell carcinoma (hypernephroma) through the vena stases of malignant melanomas not before 14 and 22 years,
renalis and vena cava inferior into the right atrium (in 1% of these respectively [63–67]. Heralds of metastases to the heart are a rapid
tumors) has been reported [29, 44–47]. Furthermore, hepatocellular increase in heart size by pericardial effusion, new signs of heart
carcinoma [48], leiomyoma of the uterus [49, 50], nephro- failure or valve disease, conduction defects, and atrial or ven-
blastoma (Wilm’s tumor) [51, 52], pheochromocytoma [53] and tricular heart rhythm disturbances [3, 5, 10, 11, 13, 20, 21, 28].
carcinoma of the adrenal cortex [54–56] have been observed to Symptoms such as dyspnea or tachypnea, and clinical findings
extend through the inferior, and carcinoma of the lung and thyroid such as systolic heart murmur, peripheral edema, pleural or peri-
377
cardial effusion, or ascites, however, may also be the result of occur in relation to their location, size and mobility [10, 33]. The
tumor-associated anemia and hypoproteinemia, or of lung meta- nature of the murmur in mobile tumors may change with body
stases. position. Diastolic murmurs reflect tumor-related obstruction of
It is less the histological type than the localization of metastases the left or right ventricular filling, and systolic murmurs the inter-
that determines the symptomatology. Pericardial involvement can ference with the closure of atrioventricular valves or the narrow-
lead to pericarditis with pericardial effusion, which can be sero- ing of the ventricular outflow tract. In cases of heart failure, gallop
sanguineous or hemorrhagic and may lack hemodynamic com- rhythm can develop; in cases of pericarditis, pericardial friction;
promise. However, in cases of rapid increase in pericardial fluid and in cases of larger pericardial effusion, heart sounds often
and low compliance of the pericardium, cardiac tamponade can diminish [7, 8, 11].
result and necessitate immediate pericardiocentesis [5, 9, 18, 20, Electrocardiographic recordings are usually unspecific but may
29, 62, 68–71]. Cardiac output can only be maintained as long as document possible ventricular or supraventricular arrhythmias, or
the reduction in stroke volume due to increasing pericardial pres- conduction defects. Pericarditis is rarely accompanied by the
sure can be compensated for by tachycardia and peripheral vaso- typical ST-segment elevations. Not infrequently, only non-specific
constriction. Hypotension, dyspnea and peripheral cyanosis, ST-segment changes are found. Pericardial effusion can cause low
pulsus paradoxus (systolic blood pressure decreases by more than voltage and electrical alternans [5, 7–11, 20, 68, 69, 71, 74, 75].
10 mmHg during inspiration), and venous congestion are also Q-waves can occur as residues of tumor-related myocardial
hallmarks of clinical diagnosis. Venous congestion is manifested infarction; an electrocardiographic picture of infarction can also
by distended neck veins and paradoxical increase in venous pres- result from infiltration or displacement of myocardium by the
Supplemental diagnostic imaging methods are computer tom- rescinded by radiotherapy [10]. Usually, cardiac infiltrates in
ography and magnetic resonance imaging. These two methods leukemia and lymphoma respond well to radio- or chemotherapy
provide sections of cardiac, mediastinal, pulmonic and thoracic [10, 69].
structures in any desired plane, without overlapping. Thus, size Not infrequently, pericardial involvement requires specific
and extension of paracardial or transpericardial tumor growth can efforts. Malignant pericardial effusion may be diminished by local
be determined more precisely than by sonography. In addition, radiotherapy or systemic chemotherapy [10, 69, 71]. Cardiac
and in contrast to ultrasound, tissue differentiation is partly tamponade, however, makes percutaneous pericardiocentesis
possible between solid, liquid, hemorrhagic or fatty lesions [64, necessary as soon as possible [68–71]. The immediate success rate
81, 82, 85, 86], and myocardial metastases can be better demar- is high (>95%) and complications are rare, and include puncture
cated. of a coronary artery or the myocardium, rhythm disturbances or
In cases in which a malignant tumor was resected many years pneumothorax [92]. Nearly half of effusions can be definitely
before detection of a cardiac tumor mass, exploratory thoracotomy controlled by this approach [92]. If not, chemotherapeutics or
and open biopsy might be necessary to confirm the diagnosis of radioisotopes may be instilled through the catheter to prevent
metastasis [76]. recurrence of the effusion (by direct cytostatic and/or by slerosing
activity with adhesion of the visceral and the parietal pericardium
Differential diagnosis as a result of inflammatory reactions) [70, 71, 92–95]. For this
purpose in particular, bleomycin sulfate [96–98], cisplatin
Table 1. Substances used for pericardial sclerosis treatment, and their doses and side effects
a
Previous instillation of 100 mg lidocaine intrapericardially advisable.
therapy may be available, palliative measures may improve the 13. Davies MJ. Tumours of the heart and pericardium. In Pommerance A,
quality of life of affected patients. Davies MJ (eds): The Pathology of the Heart. Oxford: Blackwell Scient-
ific Publications 1975: 413–439.
14. Wohlgemuth B, Engelstädter A. Beitrag zur Häufigkeit und Diagnostik
Acknowledgements von Herzmetastasen im Sektionsgut. Zentralbl Allg Pathol 1977; 121:
409–416.
We are indebted to Eugene Braunwald, MD, for review of this 15. Lockwood WB, Broghamer WL. The changing prevalence of secondary
manuscript. cardiac neoplasms as related to cancer therapy. Cancer 1980; 45: 2659–
2662.
16. Fiala W, Schneider J. Herzmetastasen maligner Tumoren. Eine Autopsie-
References Studie. Schweiz med Wochenschr 1982; 112: 1497–1501.
1. Reynen K. Frequency of primary tumors of the heart. Am J Cardiol 1996; 17. Smith C. Tumors of the heart. Arch Pathol Lab Med 1986; 110: 371–374.
77: 107. 18. Klatt EC, Heitz DR. Cardiac metastases. Cancer 1990; 65: 1456–1459.
2. Reynen K. Cardiac myxomas. N Engl J Med 1995; 333: 1610–1617. 19. Lam KY, Dickens P, Chan ACL. Tumors of the heart. A 20-year experi-
3. Burke A, Virmani R. Tumors of the Cardiovascular System, Atlas of ence with a review of 12485 consecutive autopsies. Arch Pathol Lab Med
Tumor Pathology, 3rd Series, Fascicle 16. Washington, DC: Armed 1993; 117: 1027–1031.
Forces Institute of Pathology 1996. 20. Glancy DL, Roberts WC. The heart in malignant melanoma. A study of 70
4. MacGee W. Metastatic and invasive tumours involving the heart in a autopsy cases. Am J Cardiol 1968; 21: 555–571.
geriatric population: A necropsy study. Virchows Arch A Pathol Anat 21. Heath D. Pathology of cardiac tumors. Am J Cardiol 1968; 21: 315–327.
Histol 1991; 419: 183–189. 22. McDonnell PJ, Mann RB, Bulkley BH. Involvement of the heart by malig-
5. Scott RW, Garvin CF. Tumors of the heart and pericardium. Am Heart J nant lymphoma: A clinicopathologic study. Cancer 1982; 49: 944–951.
1939; 17: 431–436. 23. Benjamin HS. Primary fibromyxoma of the heart. Arch Pathol 1939; 27:
6. Prichard RW. Tumors of the heart. Review of the subject and report of one 950.
hundred and fifty cases. Arch Pathol 1951; 51: 98–128. 24. Berge T, Sievers J. Myocardial metastases. A pathological and electro-
7. Bisel HF, Wróblewski F, LaDue JS. Incidence and clinical manifestations cardiographic study. Br Heart J 1968; 30: 383–390.
of cardiac metastases. JAMA 1953; 153: 712–715. 25. Steiner RM, Bull MI, Kumpel F et al. The diagnosis of intracardiac meta-
8. Young JM, Goldman IR. Tumor metastasis to the heart. Circulation 1954; stasis of colon carcinoma by radioisotopic and roentgenographic studies.
9: 220–229. Am J Cardiol 1970; 26: 300–304.
9. Gassman HS, Meadows R, Baker LA. Metastatic tumors of the heart. Am 26. Hepp A, Larbig D, Bader H. Left atrial metastasis of chorion carcinoma,
J Med 1955; 19: 357–365. presenting as mitral stenosis. Br Heart J 1977; 39: 1154–1156.
10. Hanfling SM. Metastatic cancer to the heart. Review of the literature and 27. Steffens TG, Mayer HS, Das SK. Echocardiographic diagnosis of a right
report of 127 cases. Circulation 1960; 22: 474–483. ventricular metastatic tumor. Arch Intern Med 1980; 140: 122–123.
11. Malaret GE, Aliaga P. Metastatic disease to the heart. Cancer 1968; 22: 28. Seibert KA, Rettenmier CW, Waller BF et al. Osteogenic sarcoma meta-
457–466. static to the heart. Am J Med 1982; 73: 136–141.
12. Kline IK. Cardiac lymphatic involvement by metastatic tumor. Cancer 29. Johnson MH, Soulen RL. Echocardiography of cardiac metastases. AJR
1972; 29: 799–808. Am J Roentgenol 1983; 141: 677–681.
380
30. Itoh K, Matsubara T, Yanagisawa K et al. Right ventricular metastasis of 53. Rote AR, Flint LD, Ellis FH. Intracaval recurrence of pheochromocytoma
cervical squamous cell carcinoma. Am Heart J 1984; 108: 1369–1371. extending into right atrium. Surgical management using extracorporal
31. Kutalek SP, Panidis IP, Kotler MN et al. Metastatic tumors of the heart circulation. N Engl J Med 1977; 296: 1269–1271.
detected by two-dimensional echocardiography. Am Heart J 1985; 109: 54. Schramek P, Dünser E, Bhargabha A et al. Adrenal cortical carcinoma:
343–349. preoperative demonstration of right atrial extension by sonography and
32. Pillai R, Blauth C, Peckham M et al. Intracardiac metastases from malig- computerized tomography. J Urol 1985; 133: 260–262.
nant teratoma of the testis. J Thorac Cardiovasc Surg 1986; 92: 118–120. 55. Cheung PSY, Thompson NW. Right atrial extension of adrenocortical
33. Esper RJ, Machado RA, Schapira L et al. Loud systolic and diastolic mur- carcinoma. Surgical management using hypothermia and cardiopulmonary
murs originating on a right atrial metastatic tumor. Chest 1987; 91: 926– bypass. Cancer 1989; 64: 812–815.
927. 56. Godine LB, Berdon WE, Brasch RC, Leonidas JC. Adrenocortical carcin-
34. Gindea AJ, Gentin B, Naidich DP et al. Unusual cardiac metastasis in oma with extension into inferior vena cava and right atrium: report of
hypernephroma: The complementary role of echocardiography and mag- 3 cases in children. Pediatr Radiol 1990; 20: 166–168.
netic resonance imaging. Am Heart J 1988; 116: 1359–1361. 57. Jacobi M, Seltzer J. Cardiac metastasis from carcinoma of thyroid. Am
35. Moser C, Risse N, Langer H-J et al. Herzmetastase als Ursache einer Heart J 1936; 12: 473–482.
therapierefraktären Herzinsuffizienz. Dtsch Med Wochenschr 1991; 116: 58. Kim RH, Mautner L, Henning J, Volpe R. An unusual case of thyroid
1670–1674. carcinoma with direct extension to great veins, right heart, and pulmonary
36. Dickens P, Poon CSP, Wat MS. Sudden death associated with solitary arteries. Can Med Assoc J 1966; 94: 238–243.
intracavitary right atrial metastatic tumour deposit. Forensic Sci Int 1992; 59. Mead CH. Metastatic carcinoma of the heart secondary to primary carcin-
57: 169–173. oma of the lung. J Thorac Surg 1932; 2: 87–98.
78. Gindea AJ, Steele P, Rumancik WM et al. Biventricular cavity oblitera- 96. van Belle SJ, Volckaert A, Taeymans Y et al. Treatment of malignant
tion by metastatic malignant melanoma: Role of magnetic resonance pericardial tamponade with sclerosis induced by instillation of bleomycin.
imaging in the diagnosis. Am Heart J 1987; 114: 1249–1253. Int J Cardiol 1987; 16: 155–160.
79. Copeland JG, Valdes-Cruz L, Sahn DJ. Endomyocardial biopsy with 97. Cormican MC, Nyman CR. Intrapericardial bleomycin for the manage-
fluoroscopic and two-dimensional echocardiographic guidance: case ment of cardiac tamponade secondary to malignant pericardial effusion.
report of a patient suspected of having multiple cardiac tumors. Clin Br Heart J 1990; 63: 61–62.
Cardiol 1984; 7: 449–452. 98. Liu G, Crump M, Goss PE et al. Prospective comparison of the sclerosing
80. Salka S, Siegel R, Sagar KB. Transvenous biopsy of intracardiac tumor agents doxycycline and bleomycin for the primary management of malig-
under transesophageal echocardiographic guidance. Am Heart J 1993; nant pericardial effusion and cardiac tamponade. J Clin Oncol 1996; 14:
125: 1782–1784. 3141–3147.
81. Engberding R, Daniel WG, Erbel R et al. Diagnosis of heart tumors by
99. Fiorentino MV, Daniele O, Morandi P et al. Intrapericardial instillation of
transesophageal echocardiography: A multicentre study in 154 patients.
platin in malignant pericardial effusion. Cancer 1988; 62: 1904–1906.
Eur Heart J 1993; 14: 1223–1228.
100.Tomkowski W, Szturmowicz M, Fijalkowska A et al. New approaches to
82. Schartl M, Claussen C, Disselhoff W et al. Diagnostik intra- und parakar-
the management and treatment of malignant pericardial effusion. Support
dialer Raumforderungen. Vergleich zwischen zweidimensionaler
Care Cancer 1997; 5: 64–66.
Echokardiographie und Computertomographie. Z Kardiol 1983; 72: 334–
339. 101.Tomkowski WZ, Filipecki S. Intrapericardial administration of cisplatin
83. Chandraratna PAN, Aronow WS. Detection of pericardial metastases by in treatment of metastatic pericardial involvement in adenocarcinoma of
cross-sectional echocardiography. Circulation 1981; 63: 197–199. the lung. Monaldi Arch Chest Dis 1997; 52: 221–224.
102.Maisch B, RistiM AD, Pankuweit S et al. Neoplastic pericardial effusion.