|Year : 2016 | Volume
| Issue : 2 | Page : 84-86
Cardiac metastasis of lung cancer: Case report and review of literature
Rajendra Prasad, Saurabh Karmakar, Ahbab Hussain
Department of Pulmonary Medicine, Era's Lucknow Medical College and Hospital, Lucknow, Uttar Pradesh, India
|Date of Web Publication||10-Jun-2016|
Flat B-1, Doctor's Residence, Era's Lucknow Medical College and Hospital, Sarfarazganj, Hardoi Road, Lucknow - 226 003, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
The heart is a rare site of metastasis of cancers. Although lung cancer is the most common malignancy worldwide, cardiac metastasis of lung cancer has been rarely described in literature. We describe a patient with lung cancer who presented with metastasis to the left atrium of heart. We also reviewed the literature regarding cardiac metastasis of lung cancer.
Keywords: Cardiac, lung cancer, metastasis
|How to cite this article:|
Prasad R, Karmakar S, Hussain A. Cardiac metastasis of lung cancer: Case report and review of literature. J Assoc Chest Physicians 2016;4:84-6
| Introduction|| |
Cardiac metastasis is rare although half of all patients with newly diagnosed lung cancer have metastasis to another organ.
The absence of early symptoms makes clinical diagnosis of cardiac metastasis difficult. Even when present, they may be masked by the clinical features of advanced lung cancer. Thus, cardiac metastasis of lung cancer poses a diagnostic dilemma and therapeutic issue.
Although it is rare, a myriad variety of complications may arise due to cardiac metastasis. Cardiac metastases represent a rare source of morbidity and mortality in patients with lung cancer. A high index of suspicion will aid prompt diagnosis and treatments.
| Case Report|| |
A 65-year-old elderly patient presented to Pulmonary Medicine Outpatient Department of Era's Lucknow Medical College with complaint of progressively increasing breathlessness for 4 months. The patient also had complaints of cough and right-sided chest pain for 2 months. Appetite and oral intake had diminished for 2 months. History was unremarkable. He was a current smoker with a pack year of 20.
On initial examination, his respiratory rate was 36/min, and oxygen saturation was 91%. His blood pressure was 116/80 mmHg, and pulse rate was 120/min. Rest of general physical examination was within normal limits, and there was no cyanosis. Auscultation revealed diminished breath sounds in the right infrascapular/right infraaxillary and right mammary/inframammary area. There was no peripheral lymphadenopathy. Evaluation of the rest of systems was normal.
The hemogram (total leukocyte count, red blood cells, and platelet count) except for hemoglobin, coagulogram (APTT, INR, and fibrin degradation product level), and routine blood biochemistry (serum urea, creatinine, and random blood sugar) were within normal limits. Hemoglobin was 9 g/dL. A chest X-ray posteroanterior view showed right-sided pleural effusion and cardiomegaly [Figure 1]. A thoracocentesis was done, and 750 ml of hemorrhagic pleural fluid was evacuated. Biochemical analysis revealed it to be exudative lymphocytic predominant on differential cell count with adenosine deaminase value of 18 IU/ml. Pleural fluid smear was negative for acid-fast bacilli or any microorganism on smear.
|Figure 1: Chest X-ray posteroanterior view showing right-sided pleural effusion and cardiomegaly|
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A contrast-enhanced computed tomography (CT) thorax was done [Figure 2]. It showed an irregular marginated mass, with areas of necrosis in the right middle lobe, and middle mediastinum. The mass was seen invading the left atrium of the heart, along with possible erosion of anterior vertebral body and hypodense opacity in segment VII of liver, likely metastasis. A transthoracic two-dimensional echo was suggestive of a mass in the left atrial chamber adherent to the wall [Figure 3].
|Figure 2: A contrast-enhanced computed tomography thorax showing irregular marginated mass in the right middle lobe and left atrium of the heart|
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|Figure 3: Transthoracic two-dimensional echo showing metastasis in left atrium|
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Due to the central location of the mass and possibility of endobronchial involvement on CT appearance, we did a fiberoptic bronchoscopy (FOB). FOB revealed an irregular mass in the ostia of the anterior segment of the right upper lobe and right middle lobe bronchus. Endobronchial biopsies of the mass were taken and histopathology suggestive of squamous cell carcinoma. Based on seventh tumor node metastasis staging of lung cancer, we diagnosed it as a case of squamous cell carcinoma lung T4NxM1b, Stage IV. We took an oncology opinion, and the patient was advised chemotherapy, which he refused and subsequently was lost to follow-up.
| Discussion|| |
Lung cancer is the most common type of cancer in the world and also the most common cause of cancer-related mortality. Metastasis is the most common cause of death from lung cancer. The most common sites of metastasis of lung cancer are to lymph nodes, liver, brain, bone, and adrenal glands in decreasing order of frequency.
Cardiac metastases occur predominantly between the sixth and eighth decade, and there is no gender predisposition.
Rate of metastasis of lung cancer to heart varies with the histopathological subtype. Adenocarcinoma metastasizes to the heart in 26% of cases, whereas squamous cell carcinoma in 23.4%, undifferentiated carcinoma in 21.2%, and bronchoalveolar carcinoma in 17.4% of cases.
The most common site of cardiac metastasis is epicardium/pericardium. Myocardial involvement is less common. Endocardial, intracavitary, or valvular metastasis is very rare. The right atrium is the most commonly affected chamber, and 80% of metastasis occurs to the right chambers. This is due to the filtering role of the pulmonary circulation and the slower flow in the right chambers.
The mechanisms of cardiac metastasis are lymphatic spread (most common), direct extension from the adjacent viscera, hematogenous spread, and transvenous extension.
Transvenous spread of metastasis occurs into the right atrium through the superior/inferior vena cava and into the left atrium through the pulmonary veins. Renal cell carcinoma is most common malignancy extending into the right atrium via inferior vena cava. Bronchogenic carcinoma and metastases from osteogenic sarcoma extend into the left atrium through pulmonary veins.
In majority (approximately 90%) of the patients, cardiac metastasis is silent and diagnosed only on autopsy. The clinical features are extremely variable and depend on the anatomic location, the size of the tumor and, the invasion of adjacent tissues. Clinical manifestations are caused by direct obstruction of cardiac or valve function, interruption of coronary flow (by obstruction or embolization), interference with electrophysiology of contraction, and pericardial effusion. Intramural tumors cause arrhythmias and may cause obstruction of the right or left outflow tract or compression of the cardiac chambers. Intracardiac tumors cause clinical features of right-sided (peripheral edema) or left-sided heart failure (orthopnea).
The anchorage of cancer cells to the right heart chambers is favored by the low intracavitary pressure, by the slower blood flow, and by the lighter contractile strength. The introduction and widespread use of sophisticated imaging modalities have resulted in a significant increase in the incidental detection of metastasis.
Echocardiography is the investigation of choice for the diagnosis. Transesophageal echo has a better visualization of the atria and the great vessels than transthoracic echo, CT, magnetic resonance imaging (MRI), and angiography. CT and MRI are also useful tools in imaging cardiac metastasis. They image the location, morphological features, extent, presence of local invasion, and mediastinal or pulmonary involvement. They also offer some degree of histological characterization of metastasis by the identification of fat, calcification, fibrous tissue, melanin, hemorrhage, or cystic changes. Administration of contrast helps in differentiating between tumor and thrombus.
Due to proximity between them, cardiac metastasis from advanced lung cancer may get overlooked as the clinical focus is directed toward the primary malignancy. Cardiac metastasis generally reflects widespread disseminated malignancy and poor prognosis. Patients with lung cancer are surviving longer due to more effective therapy. Cardiac metastasis will be diagnosed more often with the availability of advanced diagnostic modalities. We need to expand our understanding of metastasis of lung cancer to rare sites.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]