Asian Cardiovasc Thorac Ann 2000;8:283-284
© 2000 Asia Publishing EXchange Pte Ltd
Squamous Cell Carcinoma Metastases to Right and Left Heart
Ali Asgar Behranwala, MCh,
Thiagarajamurthy Sundaramoorthi, FRCS,
Sudhir G Bhate, MCh
Department of Cardiothoracic Surgery
Poona Chest Hospital
Pune, India
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For reprint information contact: Ali Asgar Behranwala, MCh Tel: 91 22 201 4365 Fax: 91 22 207 4210 email: abehranwala{at}hotmail.com 285 Thakurdwar Road, Mohamadeli Rogay Apartments, 5th floor, Bombay 400002, India.
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Abstract
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A 54-year-old man presented with cough, breathlessness, and fatigue. Echocardiography showed multiple masses in the left atrium, right atrium, and left ventricle. The patient underwent emergency surgery with a diagnosis of multicentric myxoma. Postoperative histopathology showed squamous cell carcinoma.
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Introduction
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Metastasis of squamous cell carcinoma to the heart is a rare occurrence but it has been encountered more frequently in recent autopsies due to increased survival of cancer patients.
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Metastasis in the heart usually comes to light in the setting of an already evident primary carcinoma. The right side of the heart is the most common site for metastatic malignancies because of the pattern of venous return; involvement of both sides of the heart is a rare clinical event.
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Case Report
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A 54-year-old man presented with cough and breathless-ness, mild fever, and easy fatigability for 6 months. Clinical examination did not reveal any abnormality. Chest radiography showed mild cardiomegaly and blunting of the left cardiophrenic angle. Echocardiography demon-strated multiple mass lesions in the left atrium, right atrium, and left ventricle. The masses were diagnosed as a multicentric myxoma and the patient underwent immediate surgery to prevent embolic complications. Through a median sternotomy, routine cardiopulmonary bypass was established with separate cannulation of the venae cavae and return of oxygenated blood to the ascending aorta. Warm blood cardioplegia was given to achieve cardiac arrest. Tumors were situated in the right atrium near the opening of the inferior vena cava and at the annulus of the tricuspid valve near the septal leaflet. The left atrium had a large tumor protruding into the right superior pulmonary vein that needed extensive dissection to achieve tumor clearance. Another small mass was found on the anterior papillary muscle in the left ventricle. All of the tumor masses were sessile, granular, and grayish white in appearance. The patient was weaned off cardiopulmonary bypass without inotropic support. In the postoperative period, he was hemodynamically stable and could be weaned off ventilation easily. The masses were analyzed histopathologically and found to be squamous cell carcinoma. A search for the primary tumor was made. Ultrasonography of the abdomen indicated moderate diffuse hepatomegaly, a small gall bladder polyp, and minimal pleural effusion on the left side. Computed tomography of the thorax revealed slight left-sided pleural thickening but no other abnormality. A bone scan showed extensive skeletal metastases in the vertebrae, ribs, and right tibia. The patient developed sternal dehiscence with secondary infiltrative nodules in the wound margin and malignant cachexia. He expired one month after surgery due to related complications.
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Discussion
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Cardiac tumors are rare and only 30% are malignant. Metastases to the heart are more common than primary tumors and diagnosis is usually made at postmortem examination.
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The most common primary benign tumors are myxoma (29.3%) and lipoma (10.1%). The most common primary malignant tumors are angiosarcoma (8.8%) and rhabdomyosarcoma (5.8%). Metastatic tumors in the heart are most often melanoma (43%), followed by leukemia (29%), lung cancer (21%), and lymphoma (20%).
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The site of metastases is usually the pericardium; endocardium is a very rare site.
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It is postulated that the myocardium is usually protected from tumor seeding by rapid blood flow through the heart, its lymphatic channels draining away from heart, the kneading action of cardiac contraction, and metabolic peculiarities of the heart muscle.
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Meticulous tumor clearance was performed in this patient to avoid embolic complications. The histopathological finding of carcinoma of squamous cell origin initiated further investigations to find the primary tumor, since primary squamous cell carcinoma of the heart is unknown. Extensive bone metastases were detected but the dete-riorating general health of the patient prevented further invasive investigations. The possibility of malignancy was not considered preoperatively as the patient had intracavitary lesions on both sides of the heart, which pointed to a multicentric myxoma. Tumors with venous drainage into the systemic circulation will metastasize to the right side of the heart and tumors arising in the pulmonary circulation can metastasize to the left side of the heart. Involvement of both sides of the heart is rare except in terminal malignancy, in which case the patient should have been symptomatic. Intracavitary tumor masses are more frequent on the right side. This is possibly due to the filtering role of the pulmonary microcirculation, which prevents tumor emboli to the left side of the heart.3 Our patient presented in an unusual way because he had metastasis to both sides of the heart with no secondaries to the lungs, an unknown primary tumor, and no positive clinical findings. This case emphasizes the fact that even with a multicentric cardiac mass, there should be strong clinical suspicion of metastasis.
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References
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Abstract
Introduction
