Detection of an asymptomatic right-ventricle cardiac metastasis from a small-cell lung cancer by F-18-FDG PET/CT

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.

Non-Small Cell Lung Cancer Presenting as a Mobile Left Atrial Mass

Primary cardiac tumors are extremely rare and mostly metastatic in origin. The signs and symptoms depend on the location of the tumor rather than its histopathology and, rarely, may be the first presentation of the malignant disease. We report a 54-year-old woman diagnosed with non-small lung cancer with new-onset heart murmur and dyspnea on exertion as the first clinical manifestations.

Atypical metastatic lung cancer of the right ventricle on FDG PET/CT

Although primary cardiac tumours are extremely uncommon, secondary tumours or cardiac metastasis are not. We present a 68-year-old gentleman with squamous cell carcinoma of the right lower lobe with bony metastasis to the right clavicle who was treated with radiotherapy to the lung and clavicle as well as combination immunotherapy (Pembrolizumab) and chemotherapy (Carboplatin/Paclitaxel). Despite completing the above treatment regime, ¹⁸F-FDG PET/CT scan showed progression with two new sites of metastasis including a focus in the lateral wall of the right ventricle which correlate to a soft tissue density mass on CT as well as a FDG avid mass in the left masseter. Identification of cardiac lesions with ¹⁸F-FDG PET/CT maybe challenging with routine preparation due high physiological FDG uptake in the myocardium and significant variability, nevertheless, focal FDG uptake in the heart should be carefully assessed for the possibility of cardiac metastasis.

Small cell carcinoma presenting as a biatrial mass with obstructive physiology: a case report

Background

Small cell carcinoma is a highly aggressive and often fatal cancer that most commonly arises in the lung, although it can occasionally arise from other sites, such as the gastrointestinal tract, prostate or cervix. Cardiac involvement, however, is extremely uncommon and therefore has been poorly documented in the literature.

Case presentation

We describe a rare case of a 31-year-old male with small cell carcinoma presenting as a massive, 15-cm cardiac tumor invading the bilateral atria, interatrial septum, and pericardium without an apparent primary malignancy on PET CT and cardiac MRI. With extensive tissue necrosis, traditional methods of obtaining a right atrial endomyocardial biopsy via internal jugular venous access failed and a diagnosis was made via endoscopic ultrasound guided transesophageal fine needle aspiration of the left atrial mass. Due to the extensive tumor invasion, the patient was not a suitable candidate for surgical resection, debulking, or heart transplant. The patient was treated with etoposide, carboplatin, atezolizumab, and radiation therapy with initial monitoring in the intensive care unit due to concern that tumor lysis may cause rapid cardiac decompensation. Unfortunately, 4 months after chemoradiation therapy, the malignancy progressed and the patient passed away 6 months after the initial diagnosis.

Conclusion

We describe a rare occurrence of small cell carcinoma presenting as a massive cardiac tumor without apparent primary malignancy. This case demonstrates useful alternative diagnostic strategies and treatment considerations for patients presenting with a rare cardiac mass.

A Multimodal Approach to Evaluate for Cardiac Metastasis in a Case of Non-Small Cell Lung Cancer

Malignancies have demonstrated the ability to metastasize to cardiac tissue. However, an optimal diagnostic algorithm for cardiac tumors has not yet been established, due at least in part to the scarcity of symptomatic cases. Several case reports describe how the usage of ¹⁸F-labeled fluorodeoxyglucose positron emission tomography (¹⁸F-FDG PET) incidentally revealed cardiac neoplasia. This modality, which indicates uptake sites of the radioisotope ¹⁸F-FDG, allows for whole-body imaging and is often used for preoperative determination of malignant metastasis or for assessing response to therapy over time. However, findings of false positivity are often reported due to increased FDG avidity caused by a range of other, nonmetastatic processes, most notably inflammation and infection. In this case report, an 84-year-old male with stage IV non-small cell lung cancer presented a clinical course, echocardiogram, and ¹⁸F-FDG PET-CT findings that were suggestive of endocardial metastasis. Nine months into therapy, after extensive consultation, the patient finally consented to a more complete workup using cardiac MRI (CMRI), which showed no evidence of cardiac metastasis. This case report supports the utility of CMRI as a means of further interpreting intracardiac, localized FDG uptake foci in PET-CT findings, in order to avoid false positivity and further refine proposed cardiac differential diagnoses in cancer patients.

Focal mass-like cardiac uptake on oncologic FDG PET/CT: Real lesion or atypical pattern of physiologic uptake?

BACKGROUND

Cardiac uptake on oncologic FDG PET/CT can be unpredictable. Focal or mass-like cardiac uptake not confined to normal pattern is a real challenge for interpretation due to great variability in physiologic uptake and rarity of either primary or metastatic cardiac neoplasms.

METHODS AND RESULTS

Eight patients with suspicious mass-like cardiac uptake on oncologic FDG PET/CT were retrospectively analyzed with correlation to cardiac workups including contrast CT, echocardiography, and repeat PET/CT. Four patients had real cardiac lesions or metastases. Focal uptake was benign and might represent papillary muscle in the other four. SUVmax ratio between the cardiac focus and surrounding background cardiac uptake was statistically higher in the true-positive group than that in the false-positive group. In addition, the patients with true-positive cardiac uptake had more diffuse distant metastases compared to those with false-positive cardiac uptake.

CONCLUSIONS

Focal suspicious cardiac uptake on oncology FDG PET/CT warranted further evaluation. SUVmax ratio between the cardiac focus and surrounding background cardiac uptake and status of distant metastases might help to differentiate malignant from benign nature of the focal cardiac uptake on FDG PET/CT. Focal uptake of the right ventricle on oncologic FDG PET/CT is more likely suggestive of a neoplasm.

Small Cell Lung Cancer Invading the Left Atrium With Subsequent Malignant Embolic Stroke: A Case Report and Review of Literature

Cardiac tumors are uncommon, and the vast majority of them are metastases from extracardiac sources. Metastatic spread to the heart causes symptoms by mechanical obstruction of circulation, direct myocardial invasion, or distal embolization. We herein report a case of a 58-year-old male who presented to the hospital with multilobar intracranial embolic infarcts who was found to have small cell lung cancer (SCLC) with invasion of the left atrium and pulmonary artery resulting in malignant embolic stroke. Cerebral tumor thromboembolism from SCLC is extremely rare. This case demonstrates the thromboembolic risk associated with metastatic endoluminal cardiac tumors.

Identification of multiple cardiac metastases from nonsmall-cell lung cancer by 18F-FDG PET/CT: A case report

INTRODUCTION

Multiple cardiac metastases from nonsmall-cell lung cancer are extremely rare. Multiple cardiac metastases detected by F-fluorodeoxyglucose positron-emission tomography/computed tomography (F-FDG PET/CT) have not been previously reported.

PATIENT CONCERNS

A 53-year-old man was admitted to the hospital with left back pain for 1 month.

DIAGNOSES

A contrast-enhanced computed tomography (CECT) scan showed a moderately enhancing mass with a necrotic area in the upper left lobe of the lung and a filling defect in the interventricular septum. Two-dimensional transthoracic echocardiography identified a mass attaching to the endocardial surface of interventricular septum. F-FDG PET/CT showed multiple intense F-FDG uptakes in the cardiac region. Nonsmall-cell lung cancer was confirmed by histopathologic examination of the mass in the upper left lobe of the lung.

INTERVENTION

The patient was treated with Gemcitabine chemotherapy.

OUTCOMES

After 18 months of follow-up, the patient achieved stable disease status according to the Response Evaluation Criteria In Solid Tumors guidelines.

LESSONS

Our case demonstrates thatF-FDG PET/CT is a sensitive and feasible imaging modality to diagnosis multiple cardiac metastases.

18F-FDG-PET/CT imaging in cardiac tumors: illustrative clinical cases and review of the literature

Cardiac tumors are a very rare condition. Mostly, they are benign tumors (75%), with myxomas being the most frequent. The remaining 25% are malignant; either primary malignant sarcoma or secondary metastases. Given the small number of cases reported and the lack of prospective and randomized clinical trials, the level of evidence for the optimal multimodal treatment of primary cardiac sarcomas is very low and the optimal imaging diagnostic workup is not well established. In particular, ¹⁸F-FDG-PET/CT is not yet included in routine diagnosis of cardiac masses. Here, we report four illustrative clinical cases and a review of the literature on the current available data on the role of ¹⁸F-fluorodeoxyglucose PET/CT imaging in cardiac tumors.

Silent Neoplastic Cardiac Invasion in Small Cell Lung Cancer: A Case Report and Review of the Literature

Patient: Female, 66

Final Diagnosis: Small cell lung cancer

Symptoms: Impaired memory

Medication: —

Clinical Procedure: Chest X-ray • computed tomography • magnetic resonance imaging • electrocardiogram

Specialty: Oncology

A Right Ventricular Mass in a Patient with Squamous Cell Lung Cancer: A Case Report and Review of Literature

Cardiac metastasis is much more common than primary cardiac tumors. Lung cancer is one of the most common primary malignancies to metastasize to the heart. It is not common for metastasis in the heart to present as a cavitary mass. To our knowledge, four cases have been reported in the literature showing metastatic lung cancer to the heart, presenting as a right ventricular mass.

Superior Vena Cava as Gateway to Heart: Metastatic Breast Carcinoma Causing Ball in a Loop Metastasis to Right Atrium

Breast carcinoma is the most common invasive cancer in women worldwide. It metastasizes commonly to bone, lungs, regional lymph nodes and brain. Cardiac metastasis of lung and breast cancers is a known but rare complication of advanced disease with tumour metastasising to pericardium via the locoregional lymphatic system. Here we present a case of 59-year-old female presenting with right upper limb oedema, facial puffiness and features of Superior Vena Cava (SVC) syndrome 15 years after mastectomy and adjuvant chemotherapy, radiotherapy for carcinoma of the right breast. Further evaluation revealed extensive thrombus invading the right internal jugular vein, subclavian vein, SVC with intraluminal extension into right atrium causing ball in a loop obstruction at tricuspid valve. Whole body Positron emission tomography scan confirmed the diagnosis of extensive metastatic disease and patient was managed on palliative therapy. Haematogenous spread and intraluminal growth of metastatic deposits from breast carcinoma 15 years ago is rare and clinical presentation as SVC obstruction has not been reported in our review of literature.

Right ventricular metastatic tumor from a primary carcinoma of uterine cervix: A cause of pulmonary embolism

The presence of intracavitary cardiac metastasis from squamous cell carcinoma of the uterine cervix is extremely rare. The diagnosis is made almost exclusively postmortem. Apart from causing intracardiac obstruction, it can present as pulmonary emboli and the prognosis is extremely poor. It is important to suspect this diagnosis in patient with recurrent pulmonary emboli. Due to the rarity of this condition it is very difficult to standardize care for these patients. However, it is possible that aggressive therapy may lengthen patients' survival and quality of life. We present a case of isolated intracavitary cardiac metastasis arising from a squamous cell carcinoma of the cervix, 44-year-old woman, diagnosed as stage complaint of fatigue and dyspnea on mild exertion. The echocardiogram showed a mass in the right ventricle and suspicious pulmonary embolism. We took an aggressive therapeutic approach. The pathological examination of the resected tissue revealed metastatic squamous cell carcinoma.

Surgical Resection for Solitary Myocardial Metastasis of Gastric Cancer

Six years after primary surgical treatment for gastric cancer, fluoro-deoxy-glucose positron emission tomography/computed tomography was performed in a 72-year-old man, and demonstrated an increased fluoro-deoxy-glucose uptake in the apex of the left ventricle. Magnetic resonance imaging also revealed a solitary small myocardial tumor. Under cardiopulmonary bypass, tumorectomy was performed with a macroscopically sufficient margin. Histopathologic examination showed adenocarcinoma with poor differentiation developed in the myocardium and pericardial fat; these findings were compatible with the previously resected gastric cancer. The postoperative course was uneventful; the patient has been alive for 29 months without any evidence of local recurrence or cardiac events.

Role of palliative radiotherapy in the management of mural cardiac metastases: who, when and how to treat? A case series of 10 patients

Cardiac metastases (CM), although a rare manifestation of metastatic cancer, are increasing in incidence with the improved prognosis and increased longevity of many patients with cancer. This condition may be life‐threatening, especially for bulky rapidly growing tumors. Such cancer presentations may be amenable to palliative radiotherapy to improve symptoms and to prevent further cardiac function decline. Here, we report on our experience with 10 patients with mural CM who received radiotherapy (RT) to the heart with palliative intent. The radiation treatment was given in different clinical situations using different dose and fractionation, and with a variety of outcomes. Palliative RT was a reasonably effective treatment, leading to good radiographic response in five patients who were evaluable for radiologic response. The mean duration of response in responding patients was 6.3 months (range: 3–11 months). This report describing clinical dilemmas around CM radiation therapy summarizes the previous experiences with radiation in treatment of CM and may assist in the considerations of palliative treatment for these patients.

Palatine Tonsillar Metastasis of Small-Cell Neuroendocrine Carcinoma from the Lung Detected by FDG-PET/CT After Tonsillectomy: A Case Report

Metastasis from a malignant tumor to the palatine tonsils is rare, accounting for only 0.8% of all tonsillar tumors, with only 100 cases reported in the English-language literature. Various malignant lung carcinomas may metastasize to the tonsils. A few cases of tonsillar metastasis from neuroendocrine lung carcinoma have been reported. A 67-year-old female underwent a right tonsillectomy because of a sore throat and an enlarged right tonsil. The postoperative pathology showed right tonsillar small cell neuroendocrine carcinoma (SCNC). Fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) demonstrated metabolic activity in the lower lobe of the right lung. In addition, hypermetabolic foci were noted in the lymph nodes of the right neck and mediastinum. A needle biopsy of the pulmonary mass showed SCNC. The patient received chemotherapy and died of multiple distant metastases after 6 months. This is the first report using PET/CT to evaluate tonsillar metastasis from lung SCNC.

Myocardial metastasis from oesophageal cancer

Three years after surgical resection of oesophageal tumour, during the regular instrumental oncologic follow-up performed by thoracic computed tomography scan in an otherwise asymptomatic 48-year-old man, a left ventricular mass was detected. It developed during a 6-month-period, and at the time of discovery it measured 63 × 61 mm. The mass was further evaluated with echocardiography and cardiac magnetic resonance imaging, and a histology specimen was obtained by myocardial biopsy, revealing it was a metastasis from the primitive tumour, in the absence of other organ involvement. The diagnostic process and possible therapeutic options for solitary intracardiac metastasis in the absence of involvement of other organs are briefly discussed.

Metastatic melanoma to the heart

Melanoma is a common neoplasm with a propensity to metastasize to the heart. Although cardiac metastasis is rarely diagnosed ante mortem, using a multimodality approach, several imaging findings may be seen. Echocardiography is often the initial imaging method used to detect cardiac metastases and their complications. On computed tomography, intraluminal filling defects and myocardial/pericardial nodules may be seen. On magnetic resonance imaging, metastatic melanoma is classically hyperintense on T1 images and hypointense on T2 images, a result of the T1 shortening of melanin; however, this is seen in a minority of cases. As melanoma metastases are fluorine-18-fluorodeoxyglucose avid, fluorine-18-fluorodeoxyglucose positron emission tomography may also be used to detect cardiac metastases.

Spectrum of physiological and pathological cardiac and pericardial uptake of FDG in oncology PET-CT

Cardiac uptake of 2-[(18)F]-fluoro-2-deoxy-d-glucose (FDG) is frequently observed on FDG positron-emission tomography combined with computed tomography (PET-CT) performed for diagnosis, staging, and assessment of therapeutic response of lymphoma and solid cancers, despite careful patient preparation to limit myocardial glucose substrate utilisation. We illustrate the varied physiological patterns of cardiac FDG uptake, and show a spectrum of pathological conditions causing FDG uptake within myocardial and pericardial structures, due to clinically important benign and malignant diseases. Recognition and awareness of these various causes of FDG uptake in the heart, along with the appropriate use of correlative contrast-enhanced CT and magnetic resonance imaging (MRI) will facilitate correct interpretation.

Radiotherapy is effective for a primary lung cancer invading the left atrium

Atrial involvement is an uncommon feature of advanced non-small-cell lung cancer, occurring in up to 10% of patients with bronchogenic carcinoma. Additionally, cardiac metastases from other sources are documented in up to 7% of cancer patients at autopsy. Because atrial invasion can lead to systemic embolisation and/or outflow obstruction, it is treated regardless of the overall prognosis. While the gold standard treatment has historically been surgical resection, advances in radiotherapy allow for the safe treatment of cardiac disease. Here we present the case of a woman with pulmonary adenocarcinoma of the left lower lobe that progressed to invade the pulmonary vein and left atrium while maintained on standard chemotherapy. She was treated with intensity-modulated radiotherapy and had a complete response in terms of her atrial disease within 3 months. She suffered no acute toxicity or complications as a result of the radiation therapy.

Differentiation of malignant and benign cardiac tumors using 18F-FDG PET/CT

In the diagnostic algorithm of cardiac tumors, the noninvasive determination of malignancy and metastatic spread is of major interest to stratify patients and to select and monitor therapies. In the diagnostic work-up, morphologic imaging modalities such as echocardiography or magnetic resonance tomography offer information on, for example, size, invasiveness, and vascularization. However, preoperative assessment of malignancy may be unsatisfactory. The aim of this study was to evaluate the diagnostic value of (18)F-FDG PET and the incremental diagnostic value of an optimized CT score in this clinical scenario.

METHODS

(18)F-FDG PET/CT scans (whole-body imaging with low-dose CT) of 24 consecutive patients with newly diagnosed cardiac tumors were analyzed (11 men, 13 women; mean age ± SD, 59 ± 13 y). The maximum standardized uptake values (SUV(max)) of the tumors were measured. Patients were divided into 2 groups: benign cardiac tumors (n = 7) and malignant cardiac tumors (n = 17) (cardiac primaries [n = 8] and metastases [n = 9]). SUV(max) was compared between the 2 groups. Results were compared with contrast-enhanced CT, using standardized criteria of malignancy. Histology served as ground truth.

RESULTS

Mean SUV(max) was 2.8 ± 0.6 in benign cardiac tumors and significantly higher both in malignant primary and in secondary cardiac tumors (8.0 ± 2.1 and 10.8 ± 4.9, P < 0.01). Malignancy was determined with a sensitivity of 100% and specificity of 86% (accuracy, 96%), after a cutoff with high sensitivity (SUV(max) of 3.5) was chosen to avoid false-negatives. Morphologic imaging reached a sensitivity of 82% and a specificity of 86% (accuracy, 83%). Both false-positive and false-negative decisions in morphology could be corrected in all but 1 case using a metabolic threshold with an SUV(max) of 3.5. In addition, extracardiac tumor manifestations were detected in 4 patients by whole-body (18)F-FDG PET/CT.

CONCLUSION

(18)F-FDG PET/CT can aid the noninvasive preoperative determination of malignancy and may be helpful in detecting metastases of malignant cardiac tumors.

FDG-PET and chemotherapy for successful diagnosis and treatment of cardiac metastasis from non-small cell lung cancer

Non-small cell lung cancer was metastasized at the septal side of right atrium in 59-year-old woman who had undergone surgery for lung cancer 11 years ago. The cardiac metastasis was found by whole-body 18F-fluoro-deoxy-glucose positron emission tomography/computed tomography (FDG-PET/CT), and cytologically confirmed by myocardial aspiration biopsy with right heart catheterization. The patient was treated with 4 cycles of carboplatin/pemetrexed followed by maintenance therapy with pemetrexed. The metastatic cardiac tumor shrank, and the atrioventricular (AV) block in ECG was improved. In this case, FDG-PET and chemotherapy were valuable for diagnosis and treatment of cardiac metastasis from non-small cell lung cancer.

Successful radiation treatment of anaplastic thyroid carcinoma metastatic to the right cardiac atrium and ventricle in a pacemaker-dependent patient

Anaplastic thyroid carcinoma (ATC) is a rare, aggressive malignancy, which is known to metastasize to the heart. We report a case of a patient with ATC with metastatic involvement of the pacemaker leads within the right atrium and right ventricle. The patient survived external beam radiation treatment to his heart, with a radiographic response to treatment. Cardiac metastases are usually reported on autopsy; to our knowledge, this is the first report of the successful treatment of cardiac metastases encasing the leads of a pacemaker, and of cardiac metastases from ATCs, with a review of the pertinent literature.

Physiology and pathophysiology of incidental findings detected on FDG-PET scintigraphy

A routine feature of positron emission tomography/computed tomography (PET/CT) imaging is whole-body acquisition that results in many unexpected findings identified outside of the primary region of abnormality. Furthermore, (18)F-fluorodeoxyglucose (FDG) is a marker of glycolysis and does not specifically accumulate in malignancy. Understanding the physiology and pathophysiology of normal FDG distribution and common incidental findings is therefore essential to the physician interpreting whole-body FDG-PET/CT studies. Whereas many incidental findings are benign and of limited clinical significance, others represent uncommon manifestations of the primary malignancy, second malignancies, or various clinically significant pathologic processes. Patients with a single malignancy are at greater risk of developing synchronous or metachronous second malignancies, possibly related to exposure to shared carcinogenic agents or presence of prooncogenic mutations. The decision of how to pursue an intervention on the basis of an incidental finding is generally left to clinical judgment.

Myocardial metastasis from squamous cell carcinoma of the esophagus

A 62-year-old woman was admitted to our hospital because of cancer of the middle thoracic esophagus. We performed a right transthoracic subtotal esophagectomy with systemic three-field lymphadenectomy. Histopathological findings resulted in a diagnosis of well-differentiated squamous cell carcinoma staged as pT3N0M0, pStage IIA, with clear surgical margins. Although she had no clinical symptoms, solitary cardiac metastasis located in the ventricular septum close to the apex was detected on the follow-up computed tomography scans during postoperative month 6. Regardless of chemotherapy followed by radiotherapy, she died of the cancer 17 months after the initial operation. An autopsy revealed metastatic lesions to the heart, lungs, kidneys, and liver. There were two metastatic masses in the heart without direct invasion from the outside of the heart. In cases of esophageal cancer, tumor spread to the heart is usually caused by direct invasion; thus, solitary hematopoietic cardiac metastasis is quite rare.