Metastases to the heart

Multimodal Imaging Demonstrated a Case of Buccal Cancer Cardiac Metastases Treated With Immune Checkpoint Inhibitor Therapy

A 35-year-old man with recurrent oral cancer underwent restaging FDG PET/CT imaging, which revealed neck lymph node metastasis and multiple distant metastases, including involvement of the right atrium, right ventricle, and pericardium. Doppler echocardiography and cardiac MRI confirmed the cardiac metastases while demonstrating preserved left ventricular systolic function. Follow-up FDG PET/CT imaging at 3 and 6 months after immune checkpoint inhibitor therapy, initiated due to high PD-L1 expression in the primary tumor, showed complete remission.

Safety and efficacy of immune checkpoint therapy for the treatment of patients with cardiac metastasis: a multicenter international retrospective study

BACKGROUND

Data on the safety profiles and clinical outcomes of patients with solid tumors and cardiac metastasis treated with immune checkpoint inhibitors (ICIs) are limited.

METHODS

This is an international multicenter retrospective study of patients with cancer and cardiac metastasis at baseline. Patients who had received ≥1 dose of ICI were included. Treatment-related adverse events (trAEs) were graded per Common Terminology Criteria for Adverse Event V.5.0. Objective response rates (ORR) were evaluated by Response Evaluation Criteria in Solid Tumors V.1.1 when available. Overall survival (OS) and progression-free survival (PFS) were estimated by the Kaplan-Meier method.

RESULTS

Among 110 pts, median age at ICI initiation was 65 (IQR: 59-75). Median follow-up time since ICI initiation was 36 (95% CI: 26 to 51) months. Melanoma (38%, n=42) and non-small cell lung cancer (24%, n=26) were the most common. 68 (62%) patients received ICIs as first-line, and 29 (26%) patients were treated with combination anti-programmed death-1 and anti-cytotoxic T-lymphocyte antigen 4. The most common location of cardiac metastasis was in the atria (37%, n=41) and ventricles (35%, n=39). 15 patients (13.6%) had bilateral cardiac/pericardial metastasis, 44 (40%) had left-sided, and 43 (39.8%) had right-sided. At ICI initiation, 21% (n=23) had a cardiac thrombus. Cardiology referrals and cardiac MRIs at the time of cancer diagnosis were completed on 58 (53%) and 52 (47%) patients, respectively. Cardiac events occurred in 40 (36%) patients, including arrhythmias (n=14, 13%), arterial/venous emboli (n=4, 3.6%), and cardiac tamponade (n=3, 2.7%). 53 (47%) patients developed trAEs; most common were colitis/diarrhea (n=16, 15%), dermatitis (n=13, 12%), and hepatitis (n=9, 8.2%). ICI-related major cardiac trAEs occurred in 2 (1.8%) patients. 22 patients (20%) developed grade ≥3 trAE. Patients with multiple cardiac metastases had significantly lower responses to ICI-based regimens compared with patients with single cardiac metastasis (11% vs 63%, p=0.02). For melanoma, ORR, median PFS, and median OS were 38%, 9.0 months, and 28.9 months, respectively. 83% of patients with melanoma had concordant responses in overall disease burden and cardiac disease. 91 patients discontinued ICIs, and the main reason was progression or death in 55 (49%) patients.

CONCLUSIONS

Among patients with pre-existing cardiac metastasis, ICIs demonstrated meaningful clinical efficacy with no increase in safety signals. Most patients had concordant responses in the overall disease burden and cardiac mass. Multidisciplinary teams are crucial for the appropriate management of patients with cardiac metastasis.

Metastatic extension of Ewing's sarcoma to the right heart chambers: a rare case report

BACKGROUND

Ewing's sarcoma (ES) is a common malignant bone tumor in adolescents and young adults. Its pelvic location is associated with a worse prognosis. Our case represents one of the rare instances in the literature involving an adult patient in whom the disease progressed fatally due to cardiac extension.

CASE PRESENTATION

We report the case of a 31-year-old female patient who initially presented with swelling in her right lower extremity, which was found to be caused by deep venous thrombosis (DVT) extending from the iliac vein to the inferior vena cava. A thoracic-abdominal CT scan, performed as part of the etiological workup, revealed a tumor in the right hip bone with a malignant appearance, exhibiting both endo and exopelvic extension, and extending to the inferior vena cava (IVC) and right heart chambers. An echo-guided biopsy of the tumor mass confirmed Ewing's sarcoma. The patient's condition rapidly deteriorated, leading to death due to the inoperability of the extensive tumor.

CONCLUSIONS

Ewing's sarcoma can affect adults, presenting with late-onset or rapidly metastatic forms. In its extensive form, ES requires multimodal imaging to assess operability and is associated with a poor prognosis. This case report represents one of the rare instances in the literature of Ewing's sarcoma metastasizing to the heart.

CARDIAC TUMORS: UPDATED CLASSIFICATIONS AND MAIN CLINICO-PATHOLOGIC FINDINGS

This review article - which is devoted to a wide range of physicians, e.g., pathologists, clinicians, radiologists, and general practitioners - is an up-to-date clinico-pathological description of cardiac tumours. Although rare, cardiac tumours are key components in oncology practice since both their early diagnosis and appropriate management denote urgent needs. Primary cardiac tumours (PCTs) are categorized in recent WHO classifications as well as in other scientific contributions. Their incidence is around 0.02% while their prevalence is between 0.001% and 0.03%. Among PCTs, benign lesions account for 85% of cases, while malignant neoplasms for 15%. Compared to PCTs, secondary cardiac tumours are 20-30-fold more common. The most frequent PCTs in adulthood are papillary fibroelastoma and cardiac myxoma, while, in childhood, cardiac rhabdomyoma. Heart metastases may occur through direct extension, or, indirectly, via bloodstream, lymphatics or intracavitary diffusion. Thoracic cancers (e.g. from pleura, lung, breast) are the most frequent cause of cardiac metastasis followed by oesophageal and haematological malignancies. Symptoms of PCTs (e.g. arrhythmias, dyspnoea, chest discomfort, syncope) are usually the result of both their regional involvement and location. Non-invasive imaging techniques (e.g. echocardiography, MRI, CT) and biopsy are key means in delineating tumour characteristics, size, and adjacent structure involvement. Most PCTs require surgery, which is recommended to prevent life-threatening complications. While many benign cardiac neoplasms may be completely resected, the treatment of choice for malignant PCTs and metastases is a combination of surgery, radio- and/or chemotherapy, as well as new alternative treatments, which may prolong survival in a small patient subset.

An Unusual Case of Metastatic Gastric Cancer Presenting with Right Heart Failure and Cardiac Metastasis

Cardiac metastasis is rarely detected in oncology practice. Herein we present a rare case of metastatic gastric cancer that metastasized to the right atrium and presented with right heart failure. A 51-year-old male patient with no known chronic disease presented with fatigue, abdominal distension and leg edema for 3 weeks. Physical examination revealed abdominal ascites, tachycardia and pretibial edema. Transthoracic echocardiography (TTE) revealed a hypoechoic, less-mobile mass that almost completely filled the right atrium. Moreover, 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) showed metastatic lesions and a primary tumor-suspicious area in the esophagogastric component. Upper GI endoscopic evaluation performed on the patient revealed an ulcerovegetating mass consistent with gastric adenocarcinoma. A human epidermal growth factor receptor 2 (HER-2) was positiveand programmed death-ligand 1 (PD-L1) combined positive score (CPS) was detected as 15 in immunohistochemistry (IHC). Thereafter, an anticoagulant treatment was started including pembrolizumab and trastuzumab every three weeks, and an oxaliplatin and 5-FU-based chemotherapy regimen was started every two weeks. There was no regression in the cardiac lesion during follow-up; thereafter, there was a significant risk of cardioembolic complications, and a 10 × 7 cm mass filling the right atrium and adhering to the inferior vena cava was resected. The pathology results of the excision material reported gastric carcinoma metastasis. Systemic evaluation performed 3 months later showed regression in primary and metastatic lesions. Cardiac metastases are rare and may not be discovered until autopsy due to the prominence of primary disease findings. Cardiac metastasis, although rare, should be kept in mind in gastric cancer patients presenting with heart failure.

Diagnostic Algorithm Using Multimodal Imaging for the Differential Diagnosis of Intra-Cardiac Masses

Cardiac masses are complex clinical conditions that frequently pose diagnostic challenges in cardiology practice. These masses can form within heart chambers or near the pericardium and are generally categorized as either non-neoplastic or neoplastic. These latter are further classified into benign and malignant (primary and secondary or metastatic). Diagnosing these conditions often requires a multiparametric approach that includes both clinical features, such as the patient's and associated clinical conditions, and multimodality imaging. However, histological examination of the resected specimen is often necessary to ascertain the nature of the mass. Given their heterogeneity and the rarity of many cardiac masses, there are no guidelines or consensus on the best diagnostic approach. Modern imaging protocols must be tailored to the specific clinical issues and patient characteristics, given the rapid advancements in technology. Thus, it is imperative to use a multimodality approach, combining different imaging techniques and multidisciplinary teamwork. Hereby, we propose a practical algorithm for evaluating cardiac lesions using a step-by-step implementation of multimodal imaging. Ultimately, the goal is to tailor the most suitable imaging technique to the patient's needs.

The Therapeutic Potential of Different Surgical Approaches in the Management of Cardiac Myxoma: A Systematic Review

Background: Cardiac myxomas are benign tumors of the heart. They occur mostly in the left atrium. The preferred treatment is surgical resection, which can be performed via conventional median sternotomy, minimally invasive, or robotic-assisted approaches. This study aimed to evaluate the outcomes, advantages, and limitations of these surgical methods, with a focus on their safety, efficacy, and impact on patient recovery. Methods: This systemic review was conducted according to PRISMA guidelines. The chosen databases were systematically searched using the keywords "cardiac myxoma", "resection", "approach", "minimally invasive", and "robotic surgery". The comparison between the surgical strategies was based on thirteen articles, which met the inclusion criteria. Results: Median sternotomy remains the standard technique, providing excellent surgical access but is associated with longer hospital stays, higher blood loss, and increased risk of complications such as stroke. Minimally invasive approaches demonstrated comparable safety with shorter ICU stays, reduced blood loss, and lower postoperative pain but presented challenges, including limited exposure and longer procedure times. Robotic-assisted surgery showed potential as a safe alternative but was limited by high costs and technical demands. However, the data on minimally invasive and robotic methods are limited due to the rarity of cardiac myxomas. Conclusions: The choice of surgical technique should be individualised by considering the tumour size, location, patient condition, and surgeon expertise. Routine postoperative echocardiographic monitoring is essential to detect residual or recurrent tumours. Further studies are needed to validate the long-term efficacy of minimally invasive and robotic approaches.

Cardiac Mass in a 78-Year-Old Patient With a History of Cancer: Diagnostic and Treatment Challenges

Primary cardiac angiosarcoma is a rare, aggressive malignancy that commonly metastasizes to various organs. The presenting symptoms are typically nonspecific, so a comprehensive examination is required to confirm the diagnosis promptly. This case report describes the presentation of an older patient with a history of neoplasms. Echocardiography and biopsy were performed, but despite surgical intervention to resect a large right atrial mass, the patient died. A final diagnosis of primary angiosarcoma was made based on the resected specimen.

Esophageal Cancer With Cardiac Metastasis: Approach to Cardiac Masses in Patients With a Known Malignancy

Cardiac metastases occur in a significant proportion of cancer patients and profoundly affect clinical outcomes and management strategies, especially in esophageal cancer, where the metastasis typically targets the left heart due to its unique lymphatic spread. Diagnostic imaging is crucial for patients with cardiac symptoms or electrocardiogram (EKG) changes, as it significantly influences treatment decisions, including the operability of the primary tumor and the risks associated with left-sided metastasis, such as the potential for embolization leading to stroke. This case report provides a detailed analysis of esophageal cancer metastasizing to the left atrium, highlighting diagnostic challenges and discussing the appearance of cardiac metastasis across various imaging modalities. The report examines the advantages and limitations of each imaging technique, offering insights into their roles in accurate diagnosis and effective management in complex clinical scenarios.

Scar-Related Monomorphic Ventricular Tachycardia After Treated Right Ventricular Metastatic Diffuse Large B-Cell Lymphoma

A patient with ventricular tachycardia (VT) and right ventricular (RV) metastatic diffuse large B-cell lymphoma had persistent RV gadolinium enhancement following chemotherapy and disease remission. Electrophysiology study demonstrated inducible sustained monomorphic VT requiring subcutaneous implantable cardioverter-defibrillator implantation. This highlights the arrhythmogenic potential of residual scar after resolution of cardiac masses.

Metastatic Penile Squamous Cell Carcinoma: Unmasked by an Acute Myocardial Infarction and Terminal Heart Failure

A young patient, recently treated for squamous cell penile carcinoma, presented with acute myocardial infarction and severe heart failure. Despite repeatedly ruling out metastatic disease on imaging, surgery for a mechanical assist device revealed unexpected squamous cell metastasis in the pericardium. Consequently, palliative care was initiated.

A Rare Encounter With Unusual Metastasis: Metastatic Right Ventricular Tumor Secondary to Cervical Cancer

Metastasis of cervical cancer to the heart is rare. Cervical carcinoma typically spreads to the lungs, liver, bones, and lymph nodes via hematogenous, lymphatic, transvenous, or direct extension. Cardiac metastasis from cervical carcinoma is uncommon and portends a dismal prognosis, with mean survival under six months post-diagnosis. A high index of suspicion and multimodal imaging is imperative for prompt diagnosis and improved outcomes in these patients. Here, we report a rare case where a 41-year-old African American female with stage IIIB cervical squamous cell carcinoma (SCC) presented with exertional dyspnea and chest pain concerning pulmonary embolism (PE). Computed tomography angiography showed no PE but revealed a right ventricular (RV) mass and diffuse pulmonary nodules. Echocardiography suggested an RV tumor versus a thrombus. Cardiac magnetic resonance imaging demonstrated a large RV infiltrative mass favoring metastasis over thrombus. A biopsy of one of the pulmonary nodules confirmed metastatic SCC. Despite treatment, the prognosis was poor.

STEMI or not STEMI? A multimodality imaging approach to a challenging intracardiac mass with a tricky presentation

Cardiac tumors, due to the various clinical scenarios and their histological subtypes, are still challenging for clinicians. They are differentiated into primary and secondary. The latest are more common and are usually lung and breast cancers, melanomas, and lymphoma metastasis. We present a case of a 73-year-old woman, with a history of breast cancer 10 years earlier, admitted to Cath lab for an elevation of the ST-segment of the electrocardiogram, myocardial infarction. Echocardiogram showed a curious abnormality in the myocardial wall. Thanks to a multimodality imaging strategy, including contrast-enhanced echocardiography and cardiac magnetic resonance, characterization of the underlying pathology was clear and, thus, the appropriate management and therapy.

A Giant Primary Angiosarcoma Invading the Right Heart in a Young Male: An Emergency Surgery

Primary cardiac angiosarcoma is very rare. In this report, we describe an interesting case of a 25-year-old male with a giant primary angiosarcoma invading the right heart. He was urgently admitted to the hospital for respiratory distress. Once the diagnosis was suspected by chest x-ray, echocardiography, and CT scan, and given the patient's hemodynamic and respiratory instability, an emergency open-heart surgery was necessary to prevent complications. Through a right atriotomy and a pulmonary infundibulotomy, the tumor was resected. Invaded by the tumoral process, the tricuspid valve was replaced with a biological prosthesis. The postoperative course was marked by severe right ventricular dysfunction with multiorgan failure. Histopathologic examination of the surgical specimen confirmed a primary cardiac angiosarcoma.

A Rare Case of Atrial Septal Mass Secondary to Lymphoma: Case Report and Review of Literature

The antemortem diagnosis of secondary cardiac involvement by lymphoma remains suboptimal. Prognosis is worse with delayed diagnosis as the tumor burden increases with the multicompartment participation. Chemotherapy may improve survival, but there is a risk of mortality due to treatment-related complications, such as myocardial rupture and fatal arrhythmias. Modified chemotherapy regimens may prevent such complications, but the data are limited. We report the case of a 72-year-old woman diagnosed with diffuse large B-cell lymphoma with cardiac involvement, where early diagnosis prevented cardiac complications from the disease and its treatment as well. The aim of this case report is to highlight the fact that cardiac involvement in lymphoma is frequent and can be easily missed, leading to complications. Treatment requires an individualized approach.

Transcaval and Intracardiac Extension of Type A Thymoma and Myxoma: A Report of Two Rare Cases

We report two cases of rare invasive tumors presenting with transvenous and intracardiac extensions. In one instance, an unusual invasive thymoma type A penetrated into the heart chamber; the other case was an extension of a myxoma into the right atrium that was associated with superior vena cava syndrome. Our interest was stimulated by the rarity of these clinicopathological observations and the unusual clinical features of diagnostic and therapeutic methods presented by these cases.

Cardiac Metastasis Presenting as ST-Elevation Myocardial Infarction

A 52-year-old woman with a history of lung cancer presented with progressive shortness of breath. Her ECG showed evidence of ST-elevation myocardial infarction (STEMI) though no evidence of obstructive coronary artery disease (CAD) was seen on coronary angiography. Further imaging with CT and cardiac MRI (CMRI) demonstrated tumor, likely metastatic cancer, within myocardial tissue. This case is demonstrative of the possible relationship between ST-segment elevation on ECG and corresponding tumor invasion and highlights the differential diagnoses of STEMI, including cardiac metastasis.

Beyond the norm: A rare case of cardiac and extracardiac metastatic urothelial carcinoma

Screening echocardiography aids in identifying cardiac emboli causes and asymptomatic cardiac metastases in high-grade neoplasms. Conversely, cardiac MRI provides advanced tissue characterization and broader extracardiac assessment.

A Case Report of an Isolated Cardiac Metastasis in a Patient with Esophageal Carcinoma

A 76-year-old Caucasian male presented with syncope, intermittent melena, anemia, and unexplained weight loss. Esophagogastroduodenoscopy revealed a friable non-obstructing esophageal tumor that appeared thickened on computed tomography (CT). Biopsies confirmed a poorly differentiated carcinoma. Fluorine-18 fluorodeoxyglucose positron emission tomography/CT (F-18 FDG PET/CT) showed intense FDG avidity with a maximum standardized uptake value (SUVmax) of 23. Although CT did not identify any lymphadenopathy or distant metastases, a mildly enhancing lobulated circumscribed mass with no internal calcification was incidentally identified in the left atrium. Cardiac magnetic resonance imaging (MRI) favored myxoma over thrombus given the signal characteristics and mild enhancement; however, F-18 FDG PET/CT showed an SUVmax of 18, more consistent with a metastasis. The cardiac mass was resected and shown to be a metastatic focus of poorly differentiated carcinoma, histologically identical to the esophageal mass. He received a single 8 Gray (Gy) fraction of urgent hemostatic radiotherapy for his primary tumor followed by palliative chemotherapy with cisplatin, capecitabine, and pembrolizumab. He was readmitted for transfusion due to recurrent bleeding from his primary tumor and given a second urgent hemostatic fraction of 8 Gy for stabilization. Systemic therapy was eventually discontinued due to declining performance status. He received consolidative palliative radiotherapy (20Gy in five fractions) but continued to deteriorate over the next three months and died in hospice, ten months from the time of his initial presentation.

Cardiac Masses Discovered by Echocardiogram; What to Do Next?

Cardiac tumors are rare conditions, typically diagnosed on autopsy, but with the advancement of imaging techniques they are now encountered more frequently in clinical practice. Echocardiography is often the initial method of investigation for cardiac masses and provides a quick and valuable springboard for their characterization. While some cardiac masses can be readily identified by echocardiography alone, several require incorporation of multiple data points to reach diagnostic certainty. Herein, we will provide an overview of the main clinical, diagnostic, and therapeutic characteristics of cardiac masses within the framework of their location.

Primary Cardiac Angiosarcoma: A Review

Primary cardiac angiosarcoma is a rare and aggressive malignancy originating from the endothelial lining of cardiac blood vessels. This review covers various aspects of the disease, including its pathogenesis, clinical presentation, diagnosis, treatment, and prognosis. The primary characteristic of cardiac angiosarcoma is the rapid growth of abnormal blood vessels that invade the heart muscle, leading to the destruction of healthy tissue. Due to its infiltrative nature and early spread, diagnosing and treating cardiac angiosarcoma present significant challenges. Transesophageal echocardiography (TEE) plays a crucial role in diagnosing cardiac tumors such as angiosarcoma due to its high sensitivity. Additional imaging techniques such as computed tomography (CT) and cardiac magnetic resonance imaging (MRI) help assess tumor anatomy and identify metastases. Histopathological examination and immunohistochemistry are essential for confirming the diagnosis, as they reveal distinct histological features and specific endothelial markers associated with primary cardiac angiosarcoma. Targeted therapies directed at the angiogenic mechanisms and molecular abnormalities hold promise for improving treatment outcomes. Early detection of primary cardiac angiosarcoma remains challenging due to its rarity, and the prognosis is generally poor due to advanced disease at the time of diagnosis. The review emphasizes the importance of a multidisciplinary approach and collaboration among different specialties to optimize the diagnosis, treatment, and follow-up care of patients with primary cardiac angiosarcoma. The ultimate goal is to enhance diagnostic methods and therapeutic approaches by advancing knowledge and promoting further research into this aggressive malignancy.

Challenges in diagnosis and therapeutic options for metastatic prostate cancer to the right ventricle

Our patient presented with right-sided heart failure symptoms and found to have a large mass protruding into the heart's right ventricle. Cardiac MRI delineated the morphological and tissue characteristics of the tumour. Although 18-fluorodeoxyglucose positron emission tomography (PET) did not reveal an intracardiac mass, the lesion was well demonstrated by Fluciclovine F18 PET/CT.

Metastatic Progression of an Aggressive Hepatoblastoma Involving the Left Atrium and Ventricle

Hepatoblastoma is the most common malignant liver tumor in early childhood. The metastatic extension of hepatoblastoma into the left atrium via the pulmonary vein and left ventricle is rare. Reported cases almost always involve right-sided approaches and occur in pediatric patients. However, we are reporting a case of a 22-year-old female with recurrent hepatoblastoma at multiple sites, including the left atrium, left ventricle, brain, and lung.

Cardiac metastasis mimicking STEMI-impact of point-of-care ultrasound on clinical decision-making: A case report

Introduction

The manifestations of cardiac metastases are extremely variable depending on their location and extension.

Case presentation

A 62-year-old man was admitted to the cardiac emergency department presenting with chest pain, worsening shortness of breath and palpitations. He had a history of esophageal squamous cell carcinoma treated with chemoradiotherapy, and he was not diagnosed with cardiovascular disease before. The electrocardiogram showed significant ST-segment elevations in leads II, III, and aVF. Initially, the patient was diagnosed with ST-segment elevation myocardial infarction. A cardiac point-of-care ultrasound was performed immediately revealing two large heterogeneous masses in the left ventricular wall and the apex, which changed the diagnosis and the management strategy. There was no significant change in serial cardiac biomarkers in the setting of persistent STE. Thoracic computed tomography and cardiac magnetic resonance confirmed that the patient was suffering from cardiac and lung metastases.

Conclusion

ECG findings of localized and prolonged STE without Q waves or changes in biomarkers may suggest myocardial tumor invasion, especially in the cancer setting. Cardiac point-of-care ultrasound is an effective, convenient, noninvasive imaging modality to guide real-time clinical decision-making.

Relapsed/refractory diffuse large B cell lymphoma with cardiac involvement: A case report and literature review

Background

Hematological malignancies of the heart (CHMs) are extremely rare, and include leukemia, lymphoma infiltration, and multiple myeloma with extramedullary manifestations. Cardiac lymphoma can be divided into primary cardiac lymphoma (PCL) and secondary cardiac lymphoma (SCL). Compared to PCL, SCL is relatively more common. Histologically, the most frequent SCL is diffuse large B-cell lymphoma (DLBCL). The prognosis of lymphoma in patients with cardiac involvement is extremely poor. CAR T-cell immunotherapy has been recently become a highly effective treatment for relapsed or refractory diffuse large B-cell lymphoma. To date, there are no guidelines that provide a clear consensus on the management of patients with secondary heart or pericardial involvement. We report a case of relapsed/refractory DLBCL that secondarily affected the heart.

Case presentation

A male patient was diagnosed with double-expressor DLBCL based on biopsies of mediastinal and peripancreatic masses and fluorescence in situ hybridization. The patient received first-line chemotherapy and anti-CD19 CAR T cell immunotherapy, but developed heart metastases after 12 months. Considering his physical condition and economic situation of the patient, two cycles of multiline chemotherapies were administered, followed by CAR-NK cell immunotherapy and allogeneic hematopoietic stem cell transplantation (allo-HSCT) at another hospital. After achieving a six-month survival, the patient died of severe pneumonia.

Conclusion

The response of our patient emphasizes the importance of early diagnosis and timely treatment to improve the prognosis of SCL and serves as an important reference for SCL treatment strategies.

Case report: Persistent ST-segment elevation due to cardiac metastasis from lung cancer

Patients with secondary cardiac cancer occasionally show ST segment elevation that mimics acute coronary syndrome despite the absence of coronary artery occlusion. We herein describe a rare case of secondary cardiac cancer that presented with ST-segment elevation. An 82-year-old Chinese man was admitted to the hospital with chest discomfort. Electrocardiography (ECG) showed ST segment elevation in the precordial leads and low-voltage QRS complexes in limb leads without the development of Q waves. Unexpectedly, emergency coronary angiography showed no significant stenosis of the coronary arteries. However, fortunately, transthoracic echocardiography (TTE) revealed massive pericardial effusion and a mass at the apex of the ventricular myocardium. Coincidentally, contrast-enhanced chest computed tomography showed primary lung cancer in the left lower lobe, pericardial effusion, and myocardial metastasis at the ventricular apex. The pericardiac fluid contained blood with significantly increased CEA levels and exfoliated tumor cells. The lung histopathological report suggested squamous cell carcinoma. Two months later, the patient died. These findings suggested that the persistent ST-segment without the development of Q waves was associated with ventricular invasion by primary lung cancer and may indicate a poor prognosis. In conclusion, physicians should be aware of persistent ST-segment elevation mimicking myocardial infarction due to cardiac metastasis with a poor prognosis.

Cardiac Metastasis From Solid Cancers: A 35-Year Single-Center Autopsy Study

CONTEXT.—

Cardiac metastases are more prevalent than primary cardiac tumors, and although rare, the incidence is anticipated to increase with the extended survival of oncology patients.

OBJECTIVE.—

To estimate the current incidence of cardiac metastasis from solid tumors in adult autopsies.

DESIGN.—

Adult autopsy cases from 1984 through 2019 from patients diagnosed with any type of solid cancer were retrieved. The medical charts and pathologic autopsy data were reviewed in detail.

RESULTS.—

A total of 1294 adult autopsies performed on patients diagnosed with any type of cancer within the past 35 years were reviewed. We found 124 secondary cardiac tumors. Eighty-five were due to cardiac involvement by solid tumors. Of these, 61 were true cardiac metastases of solid cancers. We focused on these 61 cases. The age range was 32 to 85 years. Forty-four patients were men and 17 were women. The lung was the most common primary site, with 21 cases (34.43%). The most frequent histologic type was carcinoma, with 54 cases (88.52%). The predominant layer of the heart involved was the pericardium, with 35 cases (57.38%). Twenty-one cases (34.43%) had pericardial effusion, with 4 being hemorrhagic. All cases had multiple extracardiac metastases, with 56 cases (91.8%) having distant metastases in 4 or more different organs.

CONCLUSIONS.—

Cardiac metastasis is a rare occurrence, with an incidence of 4.71% (61 of 1294 cases) in our series. Lung cancer accounted for most of the cardiac metastases seen, and carcinomas were the most frequent histologic type. The pericardium was the most frequent location. Cardiac metastases occurred most frequently in cases of massive metastatic dissemination.

[Synchronous left atrial myxoma and gastric cancer: a case report]

The authors present a 57-year-old patient with synchronous left atrial myxoma and gastric cancer undergoing staged treatment. Distal gastrectomy with gastroduodenostomy at the first stage was followed by resection of the left atrial myxoma after 22 days. Postoperative period was uneventful after both interventions. The follow-up examination revealed favorable clinical status and no cancer progression.

A rare case of bladder cancer that metastasized to brain, heart, and lung lymph nodes benefited from immunotherapy

Bladder cancer is a common malignant tumor of the genitourinary system, with the primary cause of death being metastasis. The most common metastatic sites are the lymph nodes, liver, lung, bone, peritoneum, pleura, kidney, adrenal gland, and the intestine. Brain and heart metastases are rare. In this report, we describe a patient who had pulmonary lymph node metastases more than a year after being diagnosed with bladder cancer, followed by brain and cardiac metastases more than two years later. Following the failure of standard first-line chemotherapy, the patient accepted 6 cycles of tislelizumab immunotherapy. The re-examination revealed that the bilateral frontal brain metastases had vanished, the right temporal lobe metastases had been greatly decreased, the neurological symptoms had been alleviated, and the cardiac metastases had disappeared. This is a rare clinical case with encouraging effects of tislelizumab and can serve as a model for the treatment of similar patients.

Cardiac lymphoma with early response to chemotherapy: A case report and review of the literature

Cardiac tumors are rare and benign masses account for the most part of the diagnosis. When malignant cancer is detected, primary or secondary cardiac lymphoma are quite frequent. Cardiac lymphoma may present as an intra or peri-cardiac mass or, rarely, it may diffusely infiltrate the myocardium. Although often asymptomatic, patients can have non-specific symptoms. Acute presentations with cardiogenic shock, unstable angina, or acute myocardial infarction are also described. Modern imaging techniques can help the clinicians not only in the diagnostic phase but also during administration of chemotherapy. A multidisciplinary counseling and serial multi-parametric assessment (echocardiography, cardiac troponin) seem to be the most effective approach to prevent possible fatal complications (i.e., cardiac rupture). Currently, only chemo- and radiotherapy are available options for treatment, but the prognosis remains poor. This is a case of secondary cardiac lymphoma presenting as a mediastinal mass with large infiltration of the heart and the great vessels with a good improvement after only one cycle of chemotherapy. It demonstrates the importance of an early diagnosis to modify the natural history of the disease.

Cardiac Involvement in Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma

Cardiac involvement of chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) is recognized extremely rarely. In addition, most CLL/SLL patients with heart infiltration are asymptomatic. In this review, we present the results of a literature search for English language articles concerning CLL/SLL or Richter transformation with symptomatic cardiac involvement. In total, 18 well-described cases with CLL/SLL and heart infiltration were identified. Only three patients were not diagnosed with CLL/SLL before the cardiac manifestation. In other patients, cardiac CLL/SLL was diagnosed between 5 months and 20 years from CLL/SLL diagnosis. All patients in these series had a diagnosis of secondary cardiac CLL/SLL. In addition, we identified four reported cases with Richter transformation in the heart. The treatment of patients with CLL/SLL and cardiac infiltration is variable and depends on the previous history and clinical characteristics of heart infiltration. In addition, no recommendations exist on how to treat patients with CLL/SLL and cardiac involvement.

Multiple Imaging and Surgical Characteristics in Cardiac Metastasis from Undifferentiated Uterine Sarcoma

Although cardiac metastasis of malignant tumors has often been reported, undifferentiated uterine sarcoma (UUS) is a rare and aggressive uterine tumor. Thus, little is known of the UUS as a primary site of cardiac metastasis. We report a case of a 66-year-old woman, with a history of uterine myoma for 30 years, who was hospitalized with a large uterine tumor and cardiac masses. Although we investigated cardiac masses using imaging modalities, such as ultrasound, cardiac computer tomography, and magnetic resonance imaging, it was challenging to determine the masses as metastasis or thrombi. Cardiac masses were removed by surgery to assess the tissue characteristics and were later identified as tumors due to their appearance. Then, pathological findings revealed that UUS spreads to the right ventricle. We attempted chemotherapy after surgery; however, the disease progressed very quickly and the patient died on the 49th day of admission. In this report, we described the case of a patient with a difficult diagnosis and rapid disease progression of cardiac metastasis from UUS.

An extensive surgical resection in stage T4 small cell lung cancer with cardiac invasion: A case report and literature review

Introduction and importance

We report a rare case of a patient with a mass involving both the hilum and the heart, but its specific nature could not be determined. SCLC was confirmed by postoperative pathology. It revealed that radical surgical resection for T4 SCLC should be considered an important part of multimodality treatment.

Case presentation

A 49-year-old gentleman complained of mild chest tightness for a week. Two large mass lesions were detected on CECT in the left atrium and left hilum. After an MDT discussion, an extended resection was recommended. Postoperative pathology denoted a complete excision with no residuals and negative lymph nodes.

Clinical discussion

Due to the rarity of lung metastases to the heart, it is vital to determine the homology between the hilar mass and the cardiac mass. Based on this, simultaneous surgical treatment is done and it is very beneficial for patients by eliminating those hazards, such as acute mechanical cardiac obstruction, and cardiac embolism. Our literature review demonstrates that the SCLC tumour progresses rapidly after cardiac metastasis, limiting the chance of a complete resection. Furthermore, complete resection of T4 tumours in NSCLC has been attempted many times, so it should also be tried on SCLC.

Conclusion

It is common for SCLC tumours to progress rapidly once they havemetastasized to the heart. An aggressive operation such as radical resection can reduce tumor burdens, minimize the risk of sudden acute death and improve patient follow-up treatment, all of which may prolong the survival of patients.

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In most cases, cardiac metastasis occurs in small-cell lung cancer with distant metastasis elsewhere. There are few cases in which there is no distant metastasis except lung and heart just like our case.

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Cases of extended resection of T4 stage NSCLC have been reported, but cases of extended resection of T4 stage SCLC are rare.

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We believe that the occurrence of cardiac metastasis in SCLC may indicate that the tumour enters the stage of accelerated growth. An extensive resection reduces the risks of embolism and cardiac pumping disorders brought by cardiac tumours to patients and is conducive to better acceptance of radiotherapy and chemotherapy in later stages.

Primary cardiac epithelioid angiosarcoma: A case report

Primary cardiac angiosarcoma is an extremely rare, high-grade malignancy. Here, we describe the case of a 44-year-old male patient with a heart tumor in the left atrium wall, which caused a large amount of pericardial effusion that invaded the surrounding area and is visible on transthoracic echocardiography, computed tomography, and magnetic resonance imaging. The postoperative histopathological results confirmed this case as a primary cardiac epithelioid angiosarcoma.

Secondary Cardiac Involvement From Diffuse Large B-cell Lymphoma: A Case Report

The cardiac localization of metastases is a rare condition, most often found on autopsy. Lymphoma is among the primary cancers often involved, as was the case for our patient in whom cardiac involvements were discovered during the extension assessment by imaging. Clinically asymptomatic in the majority of cases, we mainly find general symptoms related to the primary disease. Because histological diagnosis is rarely possible by biopsy, confirmation is made by imaging in the context of disseminated disease. The treatment of cardiac involvements of lymphomatous origin is often medical with a poor prognosis.

Contemporary demographics, diagnostics and outcomes in non-bacterial thrombotic endocarditis

OBJECTIVE

Non-bacterial thrombotic endocarditis (NBTE) is a syndrome characterised by cardiac valve vegetations and/or thickening due to non-infective mechanisms. Nowadays, a premortem diagnosis of NBTE is possible based on echocardiographic findings. Therefore, to better characterise this disease, we performed a contemporary review of the epidemiology, demographics, diagnosis and clinical outcomes of these patients.

METHODS

Adults with a diagnosis of NBTE seen within the Mayo Clinic Enterprise from December 2014 to December 2021 were included. NBTE diagnosis was identified by clinicians representing at least two specialties including cardiology, infectious diseases, rheumatology and oncology. Patients with positive blood cultures, infective endocarditis, culture-negative endocarditis and denial of research authorisation were excluded. All patients had a 1-year follow-up.

RESULTS

Forty-eight cases were identified; mean age was 60.0±13.8 years, 75% were female. The most prevalent comorbidities were malignancy (52.1%) and connective tissue disease (37.5%). Valvular abnormalities included 41 (85.4%) patients with vegetations, 43 (89.6%) patients with thickening and 26 (54.2%) with moderate to severe regurgitation. Thirty-eight (79.2%) patients had an embolic event (stroke in 26 (54.2%) patients) within 1 month of NBTE diagnosis and 16 (33.3%) patients died within 1 year of NBTE diagnosis. Metastatic tumours and lung cancer were associated with 1-year all-cause mortality (p=0.0017 and p=0.0004, respectively).

CONCLUSIONS

NBTE was more prevalent in females and embolic complications were the most frequent clinical finding. Overall, patients with NBTE had a poor prognosis, particularly in those with lung cancer or metastatic tumours. Further studies in patients with NBTE are needed given its morbidity and mortality.

Atrial invasion from primary lung adenocarcinoma extension via the pulmonary vein

Intravascular extension of lung adenocarcinoma is one of the four defined routes of metastasis to the heart but is rarely described in the literature. This is a rare case of primary lung adenocarcinoma with intravenous extension to the left atrium via the pulmonary vein. A 56-year-old female presented to the hospital with chest tightness and dyspnea. Chest computed tomography revealed a right hilar mass extending through the right superior pulmonary vein into the left atrium. Transthoracic echocardiography revealed a large, partially mobile left atrial mass occupying the entire atrial cavity and affecting mitral valve closure. Endobronchial ultrasound with transbronchial biopsy of the right middle lobe of the lung histologically showed a poorly differentiated adenocarcinoma compatible with the primary lung cancer. The patient was deemed a poor surgical candidate by cardiothoracic surgery due to the extent of metastasis and was started on chemoradiation. The patient's left atrial tumor mass started shrinking in size after starting the treatment. This unique case displaying intravascular extension of lung cancer to the left atrium has rarely been described in the literature.

Multiple cardiac metastases from urothelial carcinoma case report

Background

Cardiac metastases are rare and frequently remain undiagnosed due to the absence of clinical signs in the majority of cases. Malignancies found to most commonly metastasise to the heart include lung carcinoma, breast carcinoma and lymphoma, while urothelial carcinoma is a rare cause of cardiac metastasis. The patient presented with pyrexia, a rare presentation of metastatic cardiac involvement. Single metastatic lesions are mainly reported in the literature, while multiple metastatic deposits such as in this case are less common.

Case presentation

A 74-year-old gentleman presented with frequent febrile spikes, a month after undergoing a nephroureterectomy for poorly differentiated urothelial carcinoma. No febrile source was identified, and a computed tomography identified two cardiac lesions. A transthoracic echocardiogram could not detect the cardiac lesions; therefore, cardiac magnetic resonance (CMR) imaging was performed. Three spherical intramyocardial masses were noted at the basal septum, LV apex and the anteromedial papillary muscle. The lesions demonstrated signal characteristics suggestive of cardiac metastases (high fluid content, absence of fat, presence of a surrounding rim of increased extravascular space, absence of deformation within the masses) from the previously resected urothelial carcinoma. The patient was palliated, and he shortly succumbed to his condition.

Conclusions

Urothelial carcinoma is an exceedingly rare cause of cardiac metastasis. CMR is an important imaging modality for localisation and characterisation of suspicious cardiac lesions, aiding in the diagnosis of cardiac metastasis.

Cardiotoxicity of Systemic Melanoma Treatments

OPINION STATEMENT

Melanoma is the least common but most dangerous skin cancer, accounting for 75% of all deaths from a primary cutaneous malignancy, with incidence rates rising significantly over the last decade. Traditional treatments for melanoma including interferon and cytotoxic chemotherapy had marginal efficacy. With the advent of targeted and immunotherapies, the prognosis for patients with advanced melanoma has significantly improved including those with metastatic disease to the heart. BRAF and MEK inhibitors as well as immune checkpoint inhibitors have become front line therapy for eligible patients with metastatic melanoma and have led to long-term durable response and in some cases can be curative. Despite these oncologic advances, various treatment-limiting side effects can occur. In particular, cardiovascular toxicities can contribute to overall morbidity and mortality in these patients. Toxicities range from asymptomatic QT prolongation and mild LV dysfunction to fulminant myocarditis and potentially life-threatening arrhythmias. A multidisciplinary approach to the care of these patients which includes cardio-oncology evaluation is necessary to develop both risk mitigation and treatment strategies to ensure patients continue receiving necessary and effective melanoma treatments while minimizing long-term adverse cardiovascular effects.

Complete heart block ensuing from a metastatic small cell carcinoma: a case report

Introduction

Notwithstanding the diagnostic and therapeutic advancements, the incidence of cardiac metastases has increased in recent decades. Lung cancers are the most common primary malignant neoplasms with cardiac metastasis potential. The clinical presentation of cardiac metastases is either silent or vague, and largely depends on the infiltrated location and tumor burden. Although arrhythmias are not uncommon in metastatic cardiac tumors, complete heart block is relatively a rare manifestation. We present a case of complete heart block due to a metastatic small cell carcinoma in a 67-year-old male of African origin.

Case presentation

A 67-year-old male of African origin from rural Tanzania was referred to us for expert management. He is a retired agromechanic with over 30 years exposure to asbestos-containing brake linings. His past medical history was unremarkable, but the family-social history was evident for a heavy alcohol intake and chronic cigarette smoking. He presented with a 24-week history of progressive shortness of breath and an 8-week history of recurrent syncopal attacks coupled with a significant weight loss. He had normal echocardiographic findings, however, the electrocardiogram showed features of complete heart block. Chest X-ray showed a homogeneous opacification on the right side and computed tomography scan revealed a solid right lung mass with metastases to the liver, heart, bowels, and bone. He underwent bronchoscopy, which revealed an endobronchial mass obstructing the bronchus intermedius. Histological examination of a section of lung biopsy taken during bronchoscopy confirmed the diagnosis of a small cell carcinoma. The patient underwent dual chamber pacemaker implantation with successful sinus rhythm restoration. He made an informed refusal of chemotherapy and inevitably died 18 months post pacing.

Conclusions

Despite the advancements in medical diagnostics and management, lung cancers are often diagnosed in advanced stages, with an inevitable grave prognosis. Small cell carcinoma has the potential to metastasize to the heart, resulting in complete heart block.

Acute Myocardial Infarction Due to Coronary Occlusion Caused by a Metastatic Cardiac Tumor Arising from Squamous Cell Lung Cancer: An Evaluation with Three-dimensional Transthoracic Echocardiography

A 60-year-old man developed acute myocardial infarction from the total occlusion of the right coronary artery via metastatic squamous lung cancer and was treated with percutaneous coronary intervention (PCI). Computed tomography and transthoracic echocardiography (TTE) revealed a metastatic tumor, and three-dimensional TTE was useful for determining the size and location of the tumor in relation to the coronary artery. Six months after PCI, the patient died, and an autopsy confirmed extensive metastasis to the heart and nearby vessels as detected by three-dimensional TTE. Although rare, lung cancer metastasis to the heart may directly occlude the coronary artery.

Intracardiac masses: Single center experience within 12 years: I-MASS Study

Objective

The aim of this cross-sectional, retrospective, descriptive study was to review and classify cardiac masses systematically and to determine their frequencies.

Methods

The medical records of 64,862 consecutive patients were investigated within 12 years. Every patient with a cardiac mass imaged by transthoracic echocardiography (TTE) and confirmed with an advanced imaging modality such as transesophageal echocardiography (TEE), computed tomography (CT) and/or cardiac magnetic resonance imaging (CMR) was included. Acute coronary syndromes triggering thrombus formation, vegetations, intracardiac device and catheter related thrombi were excluded.

Results

Data demonstrated 127 (0.195%) intracardiac masses consisting of 33 (0.050%) primary benign, 3 (0.004%) primary malignant, 20 (0.030%) secondary tumors, 3 (0.004%) hydatid cysts and 68 (0.104%) thrombi respectively. The majority of primary cardiac tumors were benign (91.67%), predominantly myxomas (78.79%), and the less malignant (8.33%). Secondary cardiac tumors were common than the primary malignant tumors (20:3), with male dominancy (55%), lymphoma and lung cancers were the most frequent. Intracardiac thrombi was the majority of the cardiac masses, thrombi accompanying malignancies were in the first range (n = 17, 25%), followed by autoimmune diseases (n = 13, 19.12%) and ischemic heart disease with low ejection fraction (n = 12, 17.65%).

Conclusions

This retrospective analysis identified 127 patients with cardiac masses. The majority of benign tumors were myxoma, the most common tumors that metastasized to the heart were lymphoma and lung cancers, and the thrombi associated with malignancies and autoimmune diseases were the most frequent.

Imaging of cardiac masses: An updated overview

Studying cardiac masses is one of the most challenging tasks for cardiac imagers. The aim of this review article is to focus on the modern imaging of cardiac masses proceeding through the most frequent ones. Cardiac benign masses such as myxoma, cardiac papillary fibroelastoma, rhabdomyoma, lipoma, and hemangioma are browsed considering the usefulness of most common cardiovascular imaging tools, such as ultrasound techniques, cardiac computed tomography, cardiac magnetic resonance, and in the diagnostic process. In the same way, the most frequent malignant cardiac masses, such as angiosarcoma and metastases, are highlighted. Then, the article browses through nontumoral masses such as cysts, mitral caseous degenerative formations, thrombi, and vegetations, highlighting the differential diagnosis between them. In addition, the article helps in recognizing anatomic normal variants that should not be misdiagnosed as pathological entities.

Circulatory collapse secondary to intracardiac metastasis

Intracardiac metastasis is a relatively rare complication of cancer; however, it should be considered when a patient presents with a prerenal injury and circulatory collapse not responsive to medical treatment or haemofiltration as in this case.