European Journal of Echocardiography 2008 9(2):286-288; doi:10.1016/j.euje.2006.09.001
Published on behalf of the European Society of Cardiography. All rights reserved. © The Author 2007. For permissions please email: journals.permissions@oxfordjournals.org
Two-dimensional and three-dimensional transthoracic echocardiography in surgical planning for right atrial metastatic melanoma
James J.H. Chong1,
David A. Richards2,
Richard Chard2,
Tanya McKay1 and
Liza Thomas2,*
1 Westmead Hospital, Sydney, Australia
2 University of Sydney/Westmead Hospital, Sydney, Australia
Received 1 August 2006; accepted after revision 13 September 2006; online publish-ahead-of-print 7 November 2007.
* Corresponding author: Department of Cardiology, Westmead Hospital, Darcy Road, Westmead, 2145 NSW, Sydney, Australia. Tel: +61 2 98456795; fax: +61 2 98458323. E-mail address: lizat{at}westgate.wh.usyd.edu.au (L. Thomas).
 |
Abstract
|
|---|
Melanoma is the most common form of cardiac metastases. Surgical
excision has been shown to be an effective palliative measure.
This requires detailed definition of cardiac anatomy in relation
to the tumour. Two-dimensional (2D), three-dimensional (3D)
transthoracic (TTE) and transoesophageal echocardiography (TEE),
spiral computerised tomography (CT) and magnetic resonance imaging
(MRI) have all been described in aiding surgical planning for
excision of cardiac tumours. In this case report, 3D-TTE provided
excellent anatomical definition for surgical planning of a large
right atrial melanoma precluding the need for more invasive
and expensive investigations.
Keywords: Atrial melanoma; Atrial tumour; Three-dimensional echocardiography
|
Case presentation
|
|---|
A 55-year-old male amateur cyclist was referred for evaluation
of exercise induced hypertension and subjective decrease in
exercise capacity of several months duration. Three years prior
he underwent surgical excision of cutaneous melanoma (depth
0.45 mm/Clark stage IV) with regular follow up and no sign of
recurrence. Previous medical history included hypercholesterolaemia
and Hashimoto's thyroiditis. On examination blood pressure was
130/80 mm Hg, pulse rate at 72 beats per minute and cardiovascular
examination was unremarkable. Resting electrocardiogram showed
sinus rhythm with non-specific anterior T-wave changes. An exercise
stress test was negative for ischaemia at stage 4. Routine serum
haematology and biochemistry, urinary noradrenaline excretion,
cerebral computerised tomography (CT) scan and chest radiograph
were all unremarkable.
2D-TTE revealed a 6 cm spherical right atrial mass. The point of attachment of the mass to the right atrium as well as encroachment on the tricuspid valve, superior vena cava and inferior vena cava was difficult to determine. Real time three-dimensional (3D) TTE showed a distinct stalk/point of attachment of the mass to the right atrial roof and also demonstrated that the tricuspid valve, coronary sinus, inferior and superior vena cavae were not involved (see Figures 1–
4) Echolucent areas within the mass suggesting the presence of necrotic areas were present. A decision to proceed with surgical excision was made. Operative findings showed the mass to be partially necrotic and confirmed it to be free from important structures. Histopathological examination confirmed the diagnosis of metastatic melanoma to the right atrium.
View larger version (73K):
[in this window]
[in a new window]
[Download PowerPoint slide]
|
Figure 1 Left: 2D image showing the mass in the right atrium. Right: 3D full volume image demonstrating the mass with necrotic areas and a distinct stalk attachment. RV, right ventricle; M, mass; arrows, stalk.
|
|
View larger version (45K):
[in this window]
[in a new window]
[Download PowerPoint slide]
|
Figure 2 Left: 2D slice of the 3D full volume on the right. Right: 3D full volume showing the coronary sinus unobstructed by the mass. RA, right atrium; LA, left atrium; TV, tricuspid valve; CS, coronary sinus.
|
|
View larger version (81K):
[in this window]
[in a new window]
[Download PowerPoint slide]
|
Figure 4 Left: 2D image with colour Doppler shows difficulty demonstrating the tricuspid inflow. Middle: 3D full volume with colour Doppler demonstrating tricuspid inflow. Right: 3D full volume with colour Doppler demonstrating tricuspid inflow from behind the mass (180° rotation about the sagittal axis). M, mass; RV, right ventricle.
|
|
|
Discussion
|
|---|
Cardiac metastases are rare. When present, melanoma is the most
common source of primary tumour and surgical excision has been
shown to be an effective mode for palliation.
1 Precise definition
of cardiac anatomy in relation to the tumour is crucial in planning
any surgical intervention. Involvement of valves, major coronary
arteries, or great vessels increases risk and reduces the chance
of long-term palliation. 2D-TTE, 2D and 3D transoesophageal
echocardiography (TEE), spiral CT and magnetic resonance imaging
(MRI) are helpful in defining characteristics of cardiac tumours
including melanoma.
2–5 Spiral CT and MRI use is limited
by expense and ease of accessibility and TEE has the limitation
of requiring sedation and is a semi-invasive procedure. In the
present case 3D-TTE was able to demonstrate the large right
atrial melanoma and delineate its relationship to adjacent structures.
This precluded the need for more invasive and expensive investigation
and was instrumental in the decision to proceed with surgical
resection as opposed to non-surgical treatment.
|
Acknowledgements
|
|---|
We would like to acknowledge Prof. Rick Kefford for his help
in obtaining and sharing clinical information.
|
References
|
|---|
- Savoia P, Fierro MT, Zaccagna A, Bernengo MG. Metastatic melanoma of the heart. J Surg Oncol (2000) 75:203–7.[CrossRef][Web of Science][Medline]
- Restrepo CS, Largoza A, Lemos DF, Diethelm L, Koshy P, Castillo P, et al. CT and MR imaging findings of malignant cardiac tumors. Curr Probl Diagn Radiol (2005) 34:1–11.[CrossRef][Medline]
- Burn PR, Chinn R, King DM. Right atrial metastatic melanoma detected by dynamic contrast enhanced spiral CT. Br J Radiol (1999) 72:395–6.[Abstract]
- Ellis CJ, Dennison EM, Simpson IA. Imaging of cardiac metastatic melanoma: trans-oesophageal echocardiography or magnetic resonance imaging? Int J Cardiol (1993) 41:176–9.[CrossRef][Web of Science][Medline]
- Borges AC, Witt C, Bartel T, Muller S, Konertz W, Baumann G. Preoperative two- and three-dimensional transesophageal echocardiographic assessment of heart tumors. Ann Thorac Surg (1996) 61:1163–7.[Abstract/Free Full Text]
CiteULike 
Connotea 
Del.icio.us What's this?
Top
Abstract
Case presentation