Metastatic tumor extending through the inferior vena cava into the right atrium: a case report of carcinoma of the uterine cervix with para-aortic lymph node metastases

A rare case of cardiac metastasis of squamous cell carcinoma of the cervix with a review of existing case reports and treatment modalities

•Cardiac metastasis is a rare complication of squamous cell carcinoma of the cervix.•Biologic agents may be a useful treatment modality for cardiac metastasis of squamous cell carcinoma of the cervix.•Multidisciplinary approach is required to treat cardiac metastasis of squamous cell carcinoma of the cervix.

Pulmonary tumor embolism: A retrospective study over a 30-year period

Background

Pulmonary tumor embolism (PTE) is difficult to detect before death, and it is unclear whether the discrepancy between antemortem clinical and postmortem diagnosis improves with the advance of the diagnostic technologies. In this study we determined the incidence of PTE and analyzed the discrepancy between antemortem clinical and postmortem diagnosis.

Methods

We performed a retrospective autopsy study on patients with the history of malignant solid tumors from 1990 to 2020 and reviewed all the slides of the patients with PTE. We also analyzed the discrepancies between antemortem clinical and postmortem diagnosis in 1999, 2009 and 2019 by using the Goldman criteria. Goldman category major 1 refers to cases in which an autopsy diagnosis was the direct cause of death and was not recognized clinically, but if it had been recognized, it may have changed treatment or prolonged survival.

Results

We found 20 (3%) cases with PTE out of the 658 autopsy cases with solid malignancies. Out of these 20 cases, urothelial carcinoma (30%, 6/20) and invasive ductal carcinoma of the breast (4/20, 20%) were the most common primary malignancies. Seven patients with shortness of breath died within 3–17 days (average 8.4±2.2 days) after onset of the symptoms. Pulmonary embolism was clinically suspected in seven out of twenty (35%, 7/20) patients before death, but only two patients (10, 2/20) were diagnosed by imaging studies before death. The rate of Goldman category major 1 was 13.2% (10/76) in 1999, 7.3% (4/55) in 2009 and 6.9% (8/116) in 2019. Although the rate of Goldman category major 1 appeared decreasing, the difference was not statistically significant. The autopsy rate was significantly higher in 2019 (8.4%, 116/1386) than in 2009 (4.4%, 55/1240).

Conclusions

The incidence of PTE is uncommon. Despite the advances of the radiological techniques, radiological imaging studies did not detect the majority of PTEs. The discrepancy between the antemortem clinical and the postmortem diagnosis has not improved significantly over the past 30 years, emphasizing the value of autopsy.

Pulmonary Tumor Embolism Due to Squamous Cell Carcinoma of the Uterine Cervix: A Case Report

BACKGROUND/AIM

We report on a case of pulmonary tumor embolism caused by squamous cell carcinoma of the uterine cervix.

PATIENTS AND METHODS

A 60-year-old female diagnosed with stage IVB (cT4N1M1) squamous cell carcinoma of the uterine cervix was admitted to our institution with a chief complaint of progressive dyspnea that developed within a few days after admission.

RESULTS

A chest CT scan showed dilated pulmonary arteries, right ventricular enlargement and mosaic ground-glass opacities in both lungs. An echocardiogram revealed elevated right ventricular pressure and a floppy mass in the right ventricle. Pulmonary tumor embolism was highly suspected. However, she died from respiratory failure on the fourth day after admission. Autopsy revealed diffuse tumor emboli in bilateral pulmonary arteries and arterioles.

CONCLUSION

Pulmonary tumor embolism should be considered when patients with malignant disease develop unexplained dyspnea, hypoxemia, and pulmonary hypertension.

Metastatic right ventricular mass with intracavitary obliteration

Metastatic cardiac tumors are more common than the primary cardiac tumors. Cervical cancer metastasizing outside of the pelvis is commonly spread to the lungs, liver, bones and lymph nodes than to the heart. Right-sided metastasis to the heart is more common than to the left side. Intramural spread is more common than intracavitary growth of metastatic cardiac tumors leading to delayed clinical presentation. Intracavitary mass can be confused with intracavitary thrombus which can be seen in the setting of pulmonary embolism. Transthoracic echocardiography plays a major role in the decision making and management of pulmonary embolism, and this modality can also be used to diagnose cardiac masses. Other modalities like TEE, cardiac CT, cardiac MRI and PET-CT scan have further utility in delineating these masses. This may help to plan appropriate management of the right ventricular mass particularly in cases where the patient history and CT pulmonary angiography results favor the diagnosis of pulmonary embolism. We present the case of a 49-year-old woman with a history of supracervical hysterectomy and salpingo-oophorectomy on oral estrogen therapy who was admitted with complaints of pleuritic chest pain and respiratory insufficiency after a long flight. Initial work-up showed sub-segmental pulmonary embolus in the right posterior lower lobe pulmonary artery, and the patient was managed on intravenous heparin. Lack of appropriate response to standard therapy led to further evaluation. Multimodality imaging and biopsies revealed a large right intracavitary ventricular metastatic squamous cell tumor, with the cervix as the primary source.

Biventricular metastatic invasion from cervical squamous cell carcinoma

Metastasis to the heart has been previously described with primary lung and breast carcinoma, lymphoma, leukaemia, mesothelioma and melanoma. However, left-ventricular cardiac metastasis from primary cervical squamous cell carcinoma is poorly described. This report describes the clinical presentation of a patient with cardiac metastatic invasion from cervical cancer.

Cardiac metastasis in cervical cancer

Metastasis of cervical carcinoma to the heart is uncommon. Most cases are found during autopsy. These type of metastasis occur mostly in epicardium and myocardium. We present a case report of a patient with carcinoma cervix stage IIIB who presented to the hospital with pitting edema of right lower limb, post 1 year of completion of treatment. PET-CT scan showed FDG avid inguinal, iliac and retroperitoneal lymph nodes, which were bulky on right side causing pedal edema. There was FDG avid uptake seen in right atrial wall and in the atrioventricular groove indicative of metastasis to the heart. Patient refused biopsy or further treatment and hence received best supportive care only. She had a disease free survival of 12 months, and survived for 11 months after being diagnosed with recurrence. Overall survival was 23 months.

Solitary cardiac metastasis of uterine cervical cancer with antemortem diagnosis: A case report and literature review

Cardiac metastasis of uterine cervical cancer with antemortem diagnosis is extremely rare. Therefore, its landscape epidemiology has not been well elucidated to date. In the present study, a case of solitary cardiac metastasis of uterine cervical cancer diagnosed antemortem is reported, and a review of the currently available literature (which includes 18 cases of cardiac metastasis of uterine cervical cancer) is conducted. In January 2013, a 78-year-old woman with squamous cell carcinoma (SCC) of the uterine cervix (International Federation of Gynecology and Obstetrics stage IIIb) underwent definitive radiotherapy at Gunma University Hospital (Gunma, Japan). Follow-up examination at 5 months after completion of the treatment indicated no evidence of recurrence or metastasis. In April 2014, the patient reported epigastric discomfort and general malaise. Electrocardiogram suggested myocardial dysfunction. Transthoracic echocardiography revealed the presence of a mass occupying the right ventricle and pericardial effusion. Cine magnetic resonance imaging demonstrated a filling defect in the right ventricle, and transcatheter biopsy confirmed SCC. The patient was diagnosed with a solitary cardiac metastasis of uterine cervical cancer. Despite aggressive medical therapy, the patient succumbed to disease 31 days after admission to hospital. A review of the current literature revealed that 84% of cases of cardiac metastasis develop within 2 years of completion of the initial treatment, and that electrocardiogram and echocardiography reveal findings of myocardial dysfunction and the presence of a mass in the right ventricle, respectively. A treatment strategy for cardiac metastasis of uterine cervical cancer has not been standardized thus far, and the prognosis is very poor, as the majority of patients succumbed to disease within 1 year. In summary, the current case and the literature review conducted in the present study suggest that: i) Cardiac metastasis should be included in the differential diagnosis in cases with nonspecific complaints such as epigastric discomfort and general malaise when patients have a history of uterine cervical cancer, particularly within the previous 2 years; and ii) electrocardiogram and echocardiography are convenient and effective modalities for the diagnosis of cardiac metastasis of uterine cervical cancer.

A case of cardiac metastasis from uterine cervical carcinoma

Cases of cardiac metastasis from uterine cervical carcinoma are rare. While they are occasionally found on autopsy, antemortem recognition is extremely rare. We confirmed a case of cardiac metastasis from cervical carcinoma antemortem, because we observed a decrease in platelet count during the course of treatment. The patient was a 27-year-old woman diagnosed with stage Ib1 uterine cervical carcinoma. Radical hysterectomy with pelvic lymphadenectomy was performed. Para-aortic lymph node metastasis was detected on positron emission tomography/computed tomography (PET-CT). Adjuvant chemotherapy was started, and most of the metastatic lesions disappeared. Pelvic lymph node recurrence was suspected on PET-CT during continued chemotherapy; therefore, treatment was shifted to radiation therapy. Tumor shrinkage was recognized, and the initial therapy was completed. A noticeable decrease in platelet count was recognized seven months after treatment. Multidetector CT was performed, and an intracardiac tumor was detected. The patient did not desire any further treatment. She died three weeks after the intracardiac tumor was confirmed. Few previous autopsy studies have reported cardiac metastasis from cervical carcinoma. Thus, it is necessary to consider the possibility of cardiac metastasis for patients diagnosed with terminal cervical carcinoma.

Diagnosis of cardiac metastasis from cervical cancer in a 33-year-old patient using multimodal imaging studies: a case report and literature review

We report a case of a 33-year-old woman with emergency admission due to dyspnoea and fever. History included squamous cell carcinoma of the cervix in complete remission. Contrast-enhanced computed tomography (CT) scanning of the chest, which was indicated to rule out pneumonia, revealed an infiltrative cardiac mass. Further assessment of the tumour by echocardiography and cardiac magnetic resonance imaging (MRI) showed transmural infiltration of the apical interventricular septum with a mass extending into the left and right ventricle cavities. The mass was highly suspicious for a cardiac metastasis. Cardiac metastases from cervical cancer are extremely rare. Recurrence of cervical carcinoma involving the heart should be considered even after a curative therapy approach. Non-invasive imaging plays a paramount role in investigating cardiac masses. Echocardiography, CT and MRI are complementary imaging modalities for complete work-up of intracardiac lesions.

Cardiac metastasis of uterine cervical squamous cell carcinoma: A case report and review of the literature

A 48-year-old woman was referred to the cardiology department due to a large mobile mass in the right ventricle. The patient had undergone radical hysterectomy and bilateral salpingo-oophorectomy for a uterine squamous cell carcinoma approximately 3.5 years before. In order to protect the patient from circulatory collapse, the intracardiac mass was resected surgically. A diagnosis of cardiac metastasis of the uterine cervical squamous cell carcinoma was confirmed histologically. Herein we discuss the possible therapeutic approach to and prognosis of this rare condition by reviewing 24 papers on intracardiac uterine cancer metastasis published in the past 10 years. <Learning objective: A woman who had undergone radical hysterectomy and bilateral salpingo-oophorectomy for a uterine squamous cell carcinoma 3.5 years before was referred to the cardiology department due to a large mass in the right ventricle. The diagnosis of cardiac metastasis of the uterine cervical squamous cell carcinoma was confirmed histologically. Although metastasis of cervical carcinoma to the cardiac cavity is rare, we should not overlook this possibility during the post-operative patient follow-up.>.

Intracardiac metastasis from known cervical cancer: a case report and literature review

Cardiac metastasis from known cervical cancer is rare. Even through a routine check-up, this type of metastasis can present as pulmonary emboli. Suspicion of this diagnosis in an oncology patient with complicating pulmonary emboli but no evidence of deep vein thrombosis is important, especially in cervical cancer patients with extensive pelvic lymph node metastasis and vascular invasion of a primary tumor. Early recognition may aid in improving the prognosis. We present a case of intracardiac metastasis arising from a squamous carcinoma of the cervix in a patient with pulmonary tumor emboli and review other cases from the literature.

Cervical Cancer With Cardiac Metastasis

A 48-year-old woman presented with fatigue and vaginal spotting and was subsequently diagnosed with squamous cell cancer of the cervix. Computed tomography and positron emission tomography scans suggested widespread disease including possible involvement of the right ventricle. A 2D echocardiogram with Doppler showed a large right ventricular mass obstructing the tricuspid valve inflow. This report demonstrates the use of echocardiography and Doppler ultrasound in the diagnosis of a rare case of cardiac metastasis from cervical cancer.

Cardiac metastasis from invasive thymoma via the superior vena cava: cardiac MRI findings

Cardiac tumors are rare, and metastatic deposits are more common than primary cardiac tumors. We present cardiac magnetic resonance imaging (MRI) findings of a 50-year-old woman with invasive thymoma. Cardiac MRI revealed a heterogeneous, lobulated anterior mediastinal mass invading the superior vena cava and extending to the right atrium. In cine images there was no invasion to the right atrial wall.