Unusual sites of metastatic involvement: intracardiac metastasis from laryngeal carcinoma
1 Department of Internal Medicine, Henry Ford Health System, Detroit, MI, USA
2 Department of Cardiology, Henry Ford Health System, Detroit, MI, USA
3 School of Medicine, Damascus University, Damascus, Syria
Received 31 August 2007; accepted after revision 8 October 2007.
* Corresponding author. E-mail address: mhakeem1980{at}yahoo.com
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Abstract |
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Cardiac metastatic squamous cell laryngeal carcinoma is rare. We report the case of a 49-year-old man with recurrent squamous laryngeal carcinoma presenting with right leg acute ischaemia and large mobile right and left cardiac masses. The patient has history of laryngeal squamous cell cancer surgically treated with total laryngectomy, thyroidectomy, and tracheostomy 2 years ago. He was admitted to our intensive care unit with acute right leg pain, left sided chest pain, hypotension 92/55, and tachycardia 112 bpm. On physical exam, he had a faint pulse of his right Posterior Tibial artery with a cold foot, but no discoloration. Heart sounds were normal with no murmur. Initial workup showed a Troponin of 0.27. An electrocardiogram showed sinus tachycardia, with inverted T waves in the Infero-lateral leads. Emergent surgical thrombectomy was done on his right leg with restoration of arterial blood flow to the affected limb. An echocardiogram showed a preserved left ventricular function with multiple areas of echogenic masses in all four cardiac chambers located at the annulus of the tricuspid valve, the right ventricular free wall and along the inter-ventricular septum. No intracardiac shunt was detected by contrast study. Computed tomography scan of the heart confirmed the presence of multiple exophytic intracardiac masses within the left atrium, the right ventricle, interventricular septum, and lateral free wall of the left ventricle. Immunohistochemical staining with cytokeratin of the emboli was consistent with malignant squamous cell carcinoma consistent with metastases of his known laryngeal squamous cell cancer.
Keywords: Electrocardiography; Chest-radiograph; Two-dimensional echocardiography ultrasound; Computed tomography (CT) scan
In patients with cancer, metastases to the heart are rare and usually difficult to diagnose unless they cause symptoms. Cardiac metastasis of laryngeal carcinoma is also rarely reported in the literature. A 49-year-old man was admitted with sudden onset of right foot pain associated with chronic chest pain. He had a history of laryngeal cell carcinoma, which had been treated surgically. Block dissection revealed a large 2.2 cm tumour mass and two (out of 12) lymph node micrometastasis. One year after this procedure, the patient went through radiation therapy and his carcinoma went into remission. Two months thereafter, the patient was admitted with right foot pain.
The patient was dyspnoeic. Blood pressure was 93/51 mmHg, pulse rate 112 bpm, body temperature 36.8°C. There was no sign of pulsus paradoxus. Heart sounds were normal. Examination of the thorax showed signs of left-sided pleural effusion. There was no peripheral oedema but a faint pulse of his right Posterior Tibial (PT) artery with a cold foot, but no discoloration.
Electrocardiography revealed a normal sinus rhythm, with rate of 107 min–1, with inverted T waves in the infero-lateral leads.
Laboratory tests showed normal blood gas-analysis, haematologic values, kidney function, electrolytes, and liver enzymes. The creatinine phosphokinase was normal, whereas the troponin was slightly elevated of 0.27 (normal value less than 0.2). A chest-radiograph showed a normal cardiac size and left-sided pleural effusion with mild pulmonary congestion. Given the past history and the presence of weak right PT pulse, the clinical diagnosis of peripheral thromboembolic event was made, and emergent surgical thrombectomy was done on his right leg with restoration of arterial blood flow to the affected limb.
Two-dimensional echocardiography ultrasound revealed a preserved left ventricular function with multiple areas of echogenic masses in all four cardiac chambers located at the annulus of the tricuspid valve, the right ventricular free wall and along the interventricular septum. No intracardiac shunt was detected by contrast study (Figure 1A–C).
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Computed tomography (CT) scan of the heart confirmed the presence of multiple exophytic intracardiac masses within the left atrium, the right ventricle, interventricular septum, and lateral free wall of the left ventricle (Figure 2A–C).
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Immunohistochemical staining with cytokeratin of the emboli was consistent with malignant squamous cell carcinoma consistent with metastases of his known laryngeal squamous cell cancer (Figure 3A and B).
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Metastatic disease to the heart is a rare finding at autopsy in an unselected group of patients.1,2 However, large autopsy studies showed intracardiac metastases in
15% of patients with disseminated cancer.3 Remarkably, these metastases are asymptomatic in the majority of cases. Tumours with a high tendency of metastasis to the heart are malignant melanoma, leukaemia,4 malignant germ cell tumours, and malignant thymoma.3 Although carcinoma of the lung and breast do not metastasize to the heart frequently, because of the high incidence of these tumours, they account for the greatest numbers of cardiac metastases. Intracardiac metastases are more often located within the right side of the heart.3,5 Here we present a male patient, aged 49 years, with laryngeal carcinoma with heart metastasis, a rare condition reported three decades ago by Harrer et al.6
Heart metastases are not usually discovered except at autopsy;7 they are often not clinically apparent but have much impact on a patient's survival. Cates et al.8 found that 10% of the cases with cardiac metastasis had new ECG changes suggestive of myocardial ischaemia or injury, including either diffuse or segmental T wave inversion or ST elevation.
The most common clinical manifestations result from pericardial effusion, tachyarrhythmias, atrioventricular block, and congestive heart failure. Furthermore, symptoms arising from obstruction of the superior vena cava can be observed.5 Occlusion of a coronary artery with or without tumour embolus may result in ischaemia.3 Other rare clinical manifestations include arterial embolic event with result of ischaemic bowel or limbs, as was the case in our patient.
Echocardiography, particularly two-dimensional imaging, is the most sensitive tool for detecting metastatic disease to the heart,9 and its use has increased the rate of diagnosis. Cardiac involvement by primary and secondary tumours is one of the least investigated subjects in oncology. Lam et al.10 reviewed seven cases of primary and 154 cases of secondary cardiac tumours from autopsies performed over a 20-year period at Queen Mary Hospital Hong Kong. In this study, the incidence of primary and secondary heart tumours in 12 485 autopsies performed was 0.056 and 1.23%, respectively. For secondary tumours involving the heart, the three most common malignant neoplasms encountered were carcinoma of the lung, oesophageal carcinoma, and lymphoma.10
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