Myocardial metastasis from primary lung cancer: myocardial infarction-like ECG changes and pathologic findings

Stalactites in the Right Ventricle

Heart metastatic tumors are more frequent than primary heart tumors. Cardiac metastasis is a rare phenomenon, occurring mainly by direct spread, especially from lung cancer. Cardiac metastases may be asymptomatic or cause arrhythmias, nonspecific electrocardiographic alterations, or mimic a myocardial infarction. In this case report, we illustrate a rare case of pulmonary adenocarcinoma, which through the bloodstream developed a stalactite-shaped metastasis within the right ventricle of conspicuous size (20 mm × 34 mm × 12 mm). In addition, the tumor compressed the right pulmonary trunk, causing pulmonary hypertension. It is essential to characterize metastasis with multimodality imaging. Such lesions within the right cavities can cause massive pulmonary embolism, as in our case, leading to the patient's death, thrombolytic therapy not being effective.

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.

Interventricular septum mass presenting as a late acute coronary syndrome with ST-segment elevation: a case report

Background

Intracardiac masses are relatively rare but the diagnosis can be challenging for the cardiologist and the clinical presentation can be misleading. While most of the cardiac masses are benign, malignant masses are mostly metastatic tumours.

Case summary

An 81-year-old man was admitted to the cardiology department for congestive heart failure with the complaint of recent dyspnoea. The initial electrocardiogram was suggestive of a late presentation of an anterior myocardial infarction. Blood test showed mild and stable elevation of troponin and brain natriuretic peptide. Doppler-echocardiography revealed an interventricular septal thickening. Contrast echocardiography revealed a mass with a possibly necrotic centre and peripheral hypervascularization. Cardiac computed tomography (CT) confirmed the existence of a cardiac tumour with a hypodense centre and also revealed the presence of a large tumour of the lung’s left lower lobe with multiple enlarged lymph nodes associated with possible left adrenal gland metastasis. Computed tomography-guided percutaneous biopsy of the pulmonary mass demonstrated a squamous cell lung cancer which was likely the primary cancer. The patient was discharged home waiting for chemotherapy to start but died a few days later at home of an unknown cause.

Discussion

Diagnosis of intracardiac mass is difficult, often requiring multiple imaging modalities. Contrast-enhanced echocardiography may help early diagnosis and can be easily implemented with other imaging modalities such as cardiac magnetic resonance imaging or CT.

A Patient with a Massive Single Cardiac Metastasis of Lung Adenocarcinoma, Diagnosed via a Biopsy

A patient with a history of lung adenocarcinoma was admitted because of palpitation. Transthoracic echocardiogram revealed a mass (74×42 mm) in the right ventricle. Computed tomography showed a tumor lesion in the right ventricular cavity but no other distant metastasis. Coronary angiography revealed well-developed small branches to the tumor. After right heart catheterization, a pathological analysis of a tumor biopsy demonstrated adenocarcinoma. We diagnosed the patient with right ventricular metastasis of lung cancer. With large cardiac metastasis, a tumor biopsy with a right heart catheter may help obtain a pathological diagnosis and also serve as a re-biopsy to confirm the gene mutation status.

A case of gingival cancer with pulmonary metastases that developed complete atrioventricular block and ventricular fibrillation as a result of myocardial metastases

We present a rare case of gingival cancer with pulmonary metastases that developed life‐threatening complete atrioventricular block and ventricular fibrillation as a result of myocardial metastases. This case suggests that implantable cardioverter defibrillators significantly improve the quality of life in these patients and maintain their performance status.

Tumor Invasion of Myocardium Presented with Acute Coronary Syndrome

Cardiac metastases of malignant tumors are rare but associated with various presentations, including arrhythmia, heart failure and myocardial infarction. However, it may also cause typical electrocardiographic (ECG) changes, mimicking ST-segment elevated myocardial infarction (STEMI) when patients have chest pain. We reported a 59 year-old woman with cardiac metastases of buccal squamous cell carcinoma, which presented with myocardial infarction ECG pattern due to both atrial and ventricular involvements. Rather than alternatives to emergent coronary angiogram may be considered, thrombolytic therapy for acute myocardial infarction could be inappropriate in that it creates a risk for patients with malignancies in certain situations mimicking STEMI.

KEY WORDS

Arrhythmia; Cardiac tumor; ST-segment elevated myocardial infarction.

[A case of lung adenocarcinoma with uncontrollable myocardial metastasis and pericardial effusion]

A 73-year-old Japanese man visited a local hospital due to palpitations and dyspnea. He was diagnosed as having lung cancer (adenocarcinoma, cT1aN2M1b (BRA), stage Ⅳ), but he did not want to receive any anticancer medications, and was simply being observed. Several months later, he was referred to our hospital due to exacerbation of the dyspnea. His chest computed tomography revealed massive pericardial effusion, therefore he was diagnosed as having cardiac tamponade due to carcinomatous pericarditis and was immediately hospitalized. Upon admission, pericardial fenestration was firstly applied in order to drain pericardial effusion, and intraoperative cardiac findings showed suspicion of myocardial and pericardial metastasis. Immediately after the pericardiotomy, he suffered from cardiac arrest caused by shock. In lung cancer patients with pericardial effusion, even though it is rare, myocardial metastasis in addition to carcinomatous pericarditis and pericardial metastasis should be kept in mind.

Unusual left ventricular endocardial metastasis from primary lung cancer

The heart is frequently the site of metastasis of various malignant tumors. Lung cancer is one of the most common primary tumors of cardiac metastasis and usually involves the pericardium or epicardium by direct invasion and/or lymphatic spread. However, metastasis of lung cancer involving the left ventricular endocardium is extremely rare. We report a patient with adenocarcinoma of lung, metastasized to the left ventricular myocardium and endocardium, diagnosed by echocardiography and 18-fludeoxyglucose positron emission tomography-computed tomography.

Misdiagnosis Cardiac Metastasis Presented as a Pseudo-Infarction on Electrocardiography

Most tumor invasion into the heart is nonspecific and clinically silent. Myocardium metastasis rarely mimics a myocardial infarction. In this case, a cardiac metastasis from a squamous cell carcinoma presented with both persistent ST elevation and paroxysmal supraventricular tachycardia. The secondary lesion was located in the anterior wall and lateral wall of the left ventricle and induced electrocardiographic changes imitating an acute myocardial infarction.

Persistent and Progressive ST Segment Elevation Caused by Myocardial Metastasis

This is a case of a female patient with collecting duct carcinoma of the right kidney and myocardial metastasis. On electrocardiogram the myocardial metastasis presented with a prolonged and progressive ST elevation and a gradual decrease of the R wave amplitude in leads V3-V6. Echocardiography and autopsy findings confirmed the diagnosis.

A case of double cancers with myocardial metastasis mimicking acute myocardial infarction both on an electrocardiogram and on Tc-99m-MIBI myocardial SPECT

We report a rare case of double cancers with myocardial metastasis presenting acute myocardial infarction (AMI)-like findings both on an electrocardiogram (ECG) and on Tc-99m-MIBI myocardial SPECT. The ECG showed abnormal Q-waves and ST-segment elevation in leads V1-V4, and Tc-99m-MIBI SPECT showed a photon deficient area in the anteroseptum. These findings were suggestive of AMI, but the patient had been simultaneously suffering from two adenocarcinomas, which were lung cancer and gastric cancer, and consecutive ultrasonic cardiography (UCG) demonstrated a growing mass lesion in the septal aspect of the left ventricle. After a month he died of severe heart failure. The histological diagnosis of a specimen of the cardiac mass lesion was invasive adenocarcinoma infiltrating to the heart, which revealed that the myocardial metastasis had mimicked AMI. This case shows that it is difficult to distinguish between myocardial infarction and myocardial metastasis with myocardial perfusion SPECT. It is necessary to consider the possibility of myocardial metastasis when a patient with malignancy presents AMI-like findings.

Lung cancer mimicking acute myocardial infarction on electrocardiogram

Myocardial involvement by malignant neoplasm is rare and often not clinically manifested. The diagnosis is usually made only at autopsy. A 71-year-old man with squamous cell lung cancer presented with chest discomfort. His electrocardiogram was diagnostic of acute myocardial infarction. However, because of the lack of classic symptoms and signs of acute myocardial infarction and normal serum levels of cardiac enzymes, an echocardiography was performed before initiation of thrombolytic therapy. The echocardiography showed a huge hyperechoic mass located in the posterolateral aspect of the left ventricle with myocardium invasion. Thrombolytic therapy was withheld. In patients with lung cancer, an electrocardiogram representative of acute myocardial infarction can rarely be induced by myocardial involvement with lung cancer.