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CLINICAL PROGRESS Metastatic Cancer to the Heart Review of the Literature and Report of 127 Cases By STANLEY M. HANFLING, M.D. Downloaded from http://circ.ahajournals.org/ by guest on April 30, 2017 METASTATIC caneer to the heart assumes greater diagnostic and therapeutic importance as the incidence of cancer rises. The condition evidently was first described by Boneti in 1700.1 A report in the English literature appeared in 1822 of a case of testicular cancer with tumor filling the vena eava and extending to the edge of the Eustachian valve.2 Subsequent reports described metastases to all parts of the heart from many types of cancer arising from almost every organ of the body.3 8 Characteristically, authors nmentioned the paucity or coniplete absence of symptoms, often despite extensive involvement of the heart by tumor. The first correct antemortem diagnosis of cancer in the heart was reported in 1913, but nlot until 1930 did reports of this nature appear in the English literature.9 10 Comparatively few articles have been written on treatment and the effects of treatment on caneer metastatic to the heart."1-'3 Pathology Neoplastic growths may involve any or all parts of the heart. Most commonly, embolic tumor cells reach the heart by a hematogenous route entering the snialler coronary vessels from which they invade the heart. More uncommonly, fibrin forms on tumor cells freed in the venous system, supporting the further growth of tumor and resulting in a tumor thrombus that may extend into the heart chambers. Tumors may also reaeh the heart by direct extension from an intrathoracie cancer. Finally, tumor may reach the heart by retrograde flow through mediastinal and tracheobronchial lymphatic channels. Microscopically, the superficial lymph channels of the heart may be filled with malignant cells,14 a finding known as carcinomatous lymphangitis. Pathologically, heart metastases are usually small, firm, and nodular, microscopically resembling the primary lesion. Necrosis is uncommon. Leukemia usually causes diffuse and focal infiltrations radiating around blood vessels; in the absence of invasion, leukemic cells miay nevertheless be seen in the lumen of smaller vessels. Emboli from cancers of different origin may also be seen occasionlally in the lumen of coronary vessels.15 Incidence and Data of Observed Cases There has been a gradual rise in the ineideniee of cardiac metastases, probably because of the rising incidence of cancer itself in patients living longer with their disease (table 1). The incidence of metastatic cancer to the heart in patienits dying of cancer ranges from 1.5 to 13.9 per cent, with a general increase in recent series. Results The New York Hospital is a private volultary hospital. In the 7-year period, 1947 through 1953, 2,652 autopsies were performed. Of these, 694 were deaths from cancer, including 169 cases of lymphoma, leukemia, and myeloma. The 127 cases of metastatic cancer to the heart eonstituted an incidence of 4.8 From the Department of Pathology, New York Hospital, New York, N.Y. Dr. Hanfling 's present address is Department of Medicine, University of California Medical Center, San Francisco 22, Calif. 474 Circulation, Volume XXII, September 1960 475 METASTATIC CANCER TO THE HEART Table 1 Incidence of Metastatic Cancer to the Heart (Collected Series) Author and reference Year reported Total cases Heart metastases 1708 25 19 9 5 14 .29 .17 .17 5- .61 Downloaded from http://circ.ahajournals.org/ by guest on April 30, 2017 Pic and Bret"' 1{arrenstei n' Syminers19 Morris19 Burke4 Lym burner'4 1891 1908 1917 1927 1934 5155 1934 8550 Helwig" Pollia' Selmitkerl" Scott' 1935 1936 1937 1939 1941 1942 1950 1951 1953 1953 1955 1000 12,000 3570 1450 11,100 1082 Ritchie2 Herbutal Dimmette2" Prichard' DeLoaeh' Bisel'5 Gassmane3 6655 327 1815 4375 2547 7952 per cent of all autopsies and 18.3 per cent of deaths from caneer. Of 525 deaths from visceral and cutaneous cancers (ineluding brain tumors), 61 showed gross nietastases to the heart (tables 2, 3, and 4). Of 169 cases of lymphoma, leukemia, and myelonia, 61 showed netastases to the heart, mostly microscopic (table 5). Of the 61 cases of gross metastases to the heart from viseeral and cutaneous sources, metastases occurred to the pericardium in 36. myocardium and epicardium in 22, and pericardium and myocardium in 2. There was I tumor thrombosis. Most patients were in the sixth and seventh decades of life, although the age span was 6 to 83. There were 38 male and 23 female patients in this series. Two cases showed no metastases elsewhere; the heart was involved by direct extension. In a case of retroperitoneal fibroliposarcoma, the coronary arteries were involved by direct extension of the tumor. The other was an adrenal cortical careinoma with tumor throinbosis. All others showed metastatic foci elsewhere. Of concomitant metastases, lymph nodes, liver, and adrenal glands were each involved in over 50 per cent of cases, kidney in over 33 per cent, pancreas in over 25 per cent, and thyroid gland in 16 per cent. Circulation, Volume XXII, September 1960 298 3000 3000 4050 Percentage of heart metastases Cancer Total cases cases Cancer cases 640 455 980 340 4124 1.5 4.3) 9 .90 29 .24 19 .53 1.06 1.30 .87 2.11 3.4 5.3 118 39 35 38 146 137 37 217 3.1 2.0 10.9 5.5 8.4 13.9 12.1 .03 Careinoma of the lung anid breast, lymphoma, leukemia, and malignant melanon1a spread to the heart with great frequiency, although practically all cancers may involve the heart.23 31-3 Of 74 cases of leukemia in the present series, the heart was involved in 46 per cent (table 5). Malignant melanoma also has a tendency to in-vade the heart. Bisel found 15 cases of cardiac involvement in 34 cases.29 Metastatic cancer to the heart is usually a late manifestationi of cancer and accompanied by foci elsewhere, although. in rare cases, the heart is the sole imetastatic site.25' 34 In Most instanees the tumor is associated with primary or secondary intrathoracie malignancy. De Loach found this in 136 of 137 cases.28 Lymburner14 found it in 88 per cent of his series. In the present series of 61, gross metastatic cancers to the heart, primary or secondary malignancy occurred in 93 per cent. Pollia and Gogol2' concluded from similar findings that "the presence of primary or metastatic cancer of respiratory thoracic tissues should suggest the possibility of involvement of the heart. " Symptomatology The symptomatology of heart metastases is variable, depending as much or more on loca- 476 HANFLING. Table 2 Table 3 Incidence of Cardiac Metastases from Cancer(New York Hospital Data 1947-1953) Incidence of Pericardtal Metastases from CanecerM (New York Hospital Da!ta 1947-1953) Numnber of patients No. with cardiac involvementti Perce ?ntage Total Type Carcinoma Carcinoma C(areinoma Carcinoma Downloaded from http://circ.ahajournals.org/ by guest on April 30, 2017 of luntg of breast of stomnach of panereas Carcinonia of bladder MIalignant melanoma Si-te undeteralniied Mesothelioma of lung Undifferentiated sarcoiia -Neuroblastoma Adrenal cortical careinoma Careinioma of jejunum Ewing tuaior Fibrosarcoma of forearmii 93 24 49 27 32 9 6 2 2 4 1 I, 1 1 !3 33 8 1L1 9 8 4 3 3 34,3 3 3 5 2 2 1 1 1 I 1 I10,iow0o 1 2 100 100 100 100 Retroperitoneal 10 0 1 1 fibroliposarcoma 20 1 Carcinoma of gallbladdler 5 Carcinoma of 1 a extrahepatie duetst 6 1 Carcinoma of esophagus 16 I I15 7 Carcinoma of kidney 4) 45 Careinioma of colon 28 4 Carcinoma of ovary 0 158 Other tumors 525 61 Total 11.6 *Excluding lynmphoma, leukemia ai(lndiveloaua. tGross involvement only. 20 TIncluding cancer of coinmoii bile dlucts. tion than on size. Extensive involvement may with few or 11o symptoms. Yater proposed a classification of the symptomatology in 1931, dividing the synmptoms into 2 groups: elinical types suggestive of tumors and types not suggestive (table 6).3 This classificationl does not stress tumor lolation that is responsible in large nmeasure for the symptoms anid signis that develop. The outlines in tables 7 through 10 differ in emphasis and are suggested as a supplemuenit to the Yater classification. occur Pericardial Involvement Pericardial involvemenlt may occur alone or may be associated with metastases elsewhere in the heart (table 7). Mletastases arise from Number of patients No. with pericardial involveType Total 93 Carcinoma of lung 24 Carcinionia of breast Careinoma of pancreas 27 32) Carcinonma of bladder 9 Malignant melanoma Carcinoma of esophagus 16C 49 Carcinoma of stomach I Careinoma of jejunum 4a5 Carceiniomna of coloni 28 Carcinoma of ovary 1 Ewing tumor 2 Mesothelionia of lung Fibrosarcomia of forearm 1 2 Sarcoma 6 Undetermined site 189 Other tumors 525 Total menttr Perezentage 17t 5 18 3 11 16 11 1 1 1 I1 1 1 1 1 1 0 38 -1 6 1[00 4 IL00 50 L00 50 17 0 *Excluding lymphoma, leukemia and(l myeloma. fGross involvement only. tIneluding onie case involving myoca rdiuni. § Involving myocardiunm also. hematogenous or lymphatic dissemination of tunmor. Initrathoracie growths, usually carci- iionoa of the lung or breast or lymphoina, may extend directly into the pericardium. From the pericardium, the tumor may invade the epicardium, the myocardiumn, and occasionally the endocardium. There are usually no syimptoms of pericardial tumor.36 The most conmmon signs of pericardial metastases are pericarditis and pericardial effusion. The effusion may be serous or bloody. The diagnosis of metastatic pericardial tumor has been established in many cases by finding neoplastic cells in aspirated pericardial fluid.37 Rarely, tumor involvement causes constrictive pericarditis. Wallace and Logue35 reported a case of bronchogenie carcinoma with right heart failure a prominent symptom. Electrocardiographic tracings suggested chronic pericarditis. At necropsy, there was extensive infiltration of the pericardium by firm, nodular, tumor tissue which formed a mass 2.5 cm. Circulation, Volume XXII, September 1960 477 METASTATIC CANCER TO THE HEART Table 4 Table 5 Incidence of Myocardial (and Ep,icardial) Metastases from Cancer" (New York Hospital Data 1947-1953) Incidence of Infiltration in the Hear t fromsb Lymphoma, Leukemia, and Myelomacz (New York Hospital Data, 1947-1953) Type Careinomna of lunig Carcinoma of breast Careinoma of stomiiachl Malignant melanomna Site undeterminied Cancer of kidney Number of patients No. with myocardial and epicardial involvementt Per(centage Tota11'I Downloaded from http://circ.ahajournals.org/ by guest on April 30, 2017 fibroliposarcomla 74 85 34 27 46 32 10 169 0 61 0 36 5 13 6 33 Lymphomas+ 0 933 1 7 20 2 4 1 1 1 1 50 95 25 1 1 1100 *Infiltration mainly microscopic. tIncludes acute and chronic myelogenous, moinocytic, and stem-cell leukemia. +Includes Hodgkin 's disease, mnalignant lymphoma with leukemia, r eticulum-cell sarcoma, and follicular type lymphoma. Five cases of cancer from visceral or cutaneous sources showed nmieroscopic metastases to the heart. 93 24 49 9 6 15 5f+ 3 3 5 3++ Carcinoma of extrahepatic ducts Carcinoma of bladder Mesothelioma of lung Neuroblastoma Retroperitoneal Type Leukeiniaf Number of patients No. with involvement Percentage Total 32 1 2 Sarcoimia 50 1 Careinomiia of gallbladder a 20 0 0 278 Other tumors 24 4.6 525 Total *Excluding lymphoma, leukeniia and myeloma. tGross metastases only. tIncludes 1 ease involving pericardium in additioni. thick, completely encasing the heart. Slater et al.39 reported a case of constrictive pericarditis from metastatic breast cancer to the pericardium. Pericarditis also suggests tumor. Smith40 reported a case of a patient with malignianit mnelanomia with a pericardial friction rub at the base of the heart. Along the right border was an area of increased density that extended into the pulmonary parenchyma. Necropsy revealed extensive neoplastic infiltration of the pericardium. Levy4l diagnosed metastasis on the basis of a pericardial friction rub with electrocardiographic evidence of pericarditis in a patient with bronchogenic carcinoma. The electrocardiogram may be helpful in demonstrating pericarditis, but as Lamberta and co-workers36 concluded, ". . . the electrocardiographic changes illustrative of pericarditis are minimal in miialignianecv of the pericalrdiumn unless ther e is suifficient inivolvemlenit. ' Fischer42 mentionied that the introductioll of Circulation, Volume XXII, September 1960 Multiple (plasma cell) myeloma Total air into the pericardial sac has been recommended as an aid in delineating the presence or absence of tuimor. Epicardial and Myocardial Involvement Cancer cells reach the heart most often by the hematogenous route (table 8). From the nyocardium, tumor mav spread to the pericardium and epicardium. Spread to the m yocardiunir also occurs from retrograde lymphatic flow through bronchom-iediastina] lymphatic channiiels and from direct extensioni fronm pericardial inetastases. In the past, the low ineidence of canieer to the heart has beeni explained on the theory that the heart was not receptive to tumor cells. Prichard27 mentioned the kneading action of the muscle, the metabolic peculiarity of striated muscle, alnd the rapid blood flow as factors accounting for the low incidence. Later authors considered that the low incidence more likely was a result of inadequate observation, and Burnett and Shimkin43 concluded, "in tunmours that have spread beyond the lung and liver filters, there is almost an equal likelihood of the thvroid, the adrenial gland and the heart to be inivolved with mnetastases.'" Botlh sides of the heart appear to be affecte(d equally. Generally, myvocardial im-etastases are asymi-p- HANFLING 478 Table 7 Table 6 Symptomatology of Heart Metasta.ses-Yater Classification Downloaded from http://circ.ahajournals.org/ by guest on April 30, 2017 Clinical types not suggestive of tumor to the heart Abseniee of synmptoms referrable to the lheart Symptoms of cardiac embarrassmeint terrminally Symptoms of congestive heart failure Sudden death Symptoms suggestive of subacute bacterial endocarditis Clinical types suggestive of tulmor of the heart Heart block Symptoms referrable to location of the tunmor other than heart block Symptoms of cardiac dysfunction developing without apparent cause in a patient with a know ii nmalignant process Accuniulation of henmorrhagic fluid, pericardial ande pleural Suggestive roentgen observations tomatic. Symptoms may occur from encroachment on the pericardium, endocardium, or eonduction system by infiltration of cancer. In the latter instance, the arrhythnmias or rate changes provide important clues for antemortem diagnosis. Doane and Pressman44 stated that whenever the right heart is involved, the intervenltricular septum is likely to share in the process and the conductioni systemn is apt to be embarrassed. Arrhythmias may occur, however, without septal invasion. Tumor nodules in the ventricular muscle mass usually are asymptomatic and do not produce any characteristic x-ray, fluoroseopie, or electrocardiographic signs. Atrial flutter or fibrillation may occur although the mechanism is obscure. Depending on their location, tumors mnay cause other symptoms and signs. Tumor enboli occasionally plug a vessel and produce coronary insufficiency, angina peetoris, or myocardial infaretion. Pilcher45 reported a ease characterized by clinical electrocardiographic evidence of coronary thrombosis with encroachment or invasion of coronary vessels by malignant tissue at niecropsy. Metastases to the heamit imiay affect thle inuscle sufficienitly to produce congestive failure. Scott anid Garvin23 concluded that the developnment of congestive failure without appareint Pericardial Tumor In rolvement Route Hematogeinous Direct extensiont fromn intrathoracic nieoplasmii Spread from mnyocardial and epicardial nietastases Retrograde lymphatic spread fromn tracheal anfd bronchomediastinal lymphatic chaninels Symptoms and Signs No clinical mainifestations Pericarditis Pericardial effusion, serous oIr bloody Constrictive pericarditis Diagnosis Awareness of presence of intrathoracic nieoplasmn Examinationi of pericardial fluid for mialignant cells X-ray general enlargemnent of the heart Fluoroscopy fixationi of the r ight border of the heart lintroductioni of air inlto the pericardial sac to outliine nodules Therapeutic test-irradiation of pericardium cause in patiellts with malignanit disease raises the possibility of cardiac metastases. MeNamara and associates46 reported cardiac rupture from metastatic caneer in a patient with rheumatic mitral disease. At necropsy, rupture of the posterior wall of the left atrium was observed. No other case of cardiae rupture froin metastatie caneer has been reported. The electrocardiogram has been of some help in the diagnosis of metastatic cancer to the heart. Bisel et al.29 reported that eardiae metastases may cause T-wave changes, S-T deviations, and Q waves. Rosenbaum's group47 reported a case of esophageal cancer with persistent and pronounced upward displacement of the RS-T segment. Necropsy revealed extensive infiltration of the heart by metastases. Siegel and Young48 reported a case of lymphosarcoma with inverted T waves and isoelectric S-T segments in all leads. Necropsy revealed tumor in the veentricular wall and interventricular septuml. Electrocardiographic changes occur witb leukemic infiltration usually when clinical evi(leinee of involvement is presen-t.49 Occasionally. the electrocardiogram may be the first evidenee of nivoceardial infiltrationi. As wTith other eancers to the heart, there are 110 diagnostic patterns. Circulation, Volnmve XXII, September i960 METASTATIC CANCER TO THE HEART Table 8 Epicardial and Myocardial Involvement 479 Table 9 Endocardial Tumor lInvolvement Route Routte Hemriatogenous Retrograde fro lymphatic-bronchomediastinal channels Extension fromii pericardial involvenient Symptoms and Signs No clinical mlanifestations Changes in rate or rhythm Unexplained tachyeardia Atrial flutter Atrial fibrillation Heart block, complete or inicomplete Atrioventricular rhythm Premature beats Electrocardiographic changes Persistent RS-t elevation Persistent T-wave inversion Buncdle-branch block low-voltage QRS Sudden death (severe arrlhytlhmia, heart rupture) Congestive heart failure Coronary occlusion Angina pectoris m Downloaded from http://circ.ahajournals.org/ by guest on April 30, 2017 Diagnosis Awa reniess Unexplained arrlhythmia in patients with caneer Unexplained electrocardiographic changes in patienits with cancer The diagnosis of mnetastatic tumor in the myocardium has usually been made when an arrhythmia develops in a patient with metastatic eancer elsewhere. The first correct antemortem diagnosis of myocardial mnetastases was reported by Rdsler in 1924.50 The patient had metastatic cancer and developed a persistent slow and regular cardiac rate of 26 to 28 per minute, with an atrial rate of 108. The author ascribed the phenomenon to tunmor involvement of the bundle, a diagnosis that was confirmed at autopsy. In the English literature, Willius and Amberg'0 reported the first correct diagnosis, when incomplete bundlebranch block appeared in a patient with sarcoma of the femur. Levy4l and Fishberg9 reported patients with bronchogenie carcinioma; eanieer of the heart was suspeeted because of onset of atrial fibrillationi, the findings were coonfirmed at autopsy. Schniitker an-d Bailey=2 diagonosed a case correctly beeause the "presCirculation, Volume XXII, September 1960 Hematogenous to chambers with direct implantation Extension fromti nmyocardial metastases Symptoms and Signs No clinical manifestations Murmurs of stenosis Sudden death Diagnosis Awareness-development of a murmlur Chaniginig mnurmur s witlh position Angiocardiography Table 10 Chamber Involvemenet-Tumor Thrombosis Route Right heart Inferior rena eava -> right atrium (hypernephroma, testicular tumors) Superior rena eava -- right atrium (careinomua of lunig) Left heart Pulmoniary vein-s left atrium (carcinoma of lunig) Symptoms and Signs No clinical manifestations Murmurs of stenosis Soft heart sounids of poor quality Superior or inferior venia caval syndrome Diagnosis Angiocardiography ence of auricular flutter with the suspicioIn of bronchogenic neoplasmn suggested that there might be encroachment of tumor growth oii the right auricle of the heart." Other cases have been reported by Brick anid Greenfieldi Shelburue and Aronison,13 anid Dresdale anld co-workers.32 Endocardial Involvement Neoplastic implantation on the endocar- dium is uncommnonl (table 9). Tumor emboli reaching the heart chamnbers may implant on the endocardiumn directly with "subsequent development in the direction of least resistaiiee, i.e., out into the cavity and between the nuscular trabeculae. "51 Coller and associates52 reported there were only 9 cases of tumor depositioni oni the enidocardimnu in the literature, of which 6 were iIm- 4HANFLING 480 planted on the valves. He believed a certain amount of valvular dainage was necessary for tunlor implantationi to occur, for it seemed improbable that tuLmor could implant oin anl Downloaded from http://circ.ahajournals.org/ by guest on April 30, 2017 intact cusp with smooth surface. The tricuspid valve or the tricuspid and imitral valves mnay be involved. Nieholls53 and Blumenthal and Peterson134 reported cases with attachment on the surface of the right ventricle. MoragueS54 reported a case of malignant melanonma implanting in the region of the conus arteriosus. The growth, large and peduneulated, almost plugged the pulmoiiary orifice conmpletely. Watts55 reported a case in which an intracardiae imetastasis probably arose by direct implantation on the wall of the right atrium. Ragle56 reported a somewhat similar case. Most of the endocardial growths cause little disability during life, and, like most metastatic canieer of the heart, are usually an unexpeeted and incidental autopsy finding. Endocardial metastases muay also mimnic bacterial enidocarditis. Chamber Involvement-Tumor Thrombosis Tumor muay invade the heart chambers themselves (table 10) ; tumor cells that infiltrate the lumen of a great vein may initiate the deposition of fibrin upon them. The fibrin, in turn, serves as a framework for continued cancer growth. This "symbiosis" produces a thrombus in which caneer cells are ali integral part. The tumor thrombosis may extend along the vein to the heart chambers, hinderimig blood flow and effeetive cardiac action. Tumor thrombosis of the inferior vena eava and right atriuni commonly oceurs from caneer of the kidney57-58 and testes and occasionally the liver,59 whereas growth into the superior vena eava producing tumor thrombosis to the right atrium oceurs from carcinoma of the lung,60 lymphosarcoma, aild caneer of the thyroid gland.6'-62 The left atrium may be invaded from extension of tumor thrombosis of the pulmonary veins, most comumonily resultinig fro.m careinoma of the lung.13 64 Primnary pulmonary sarcoina and osteogeinie sarcoma muetastasiziiig to the heart by tum-Lor th-rombosis haave also beei reported. Murmurs typical of stenosis may be caused by an intracardiae tumor and nmay change with position. Pedunculated tumor masses may cause considerable interferenee with blood flow through the heart. Linell65 reported a case of a patient with carcinoma of the larynx, with a rapidly deteriorating course. At neeropsy, a large antem-lortem clot was found in the cardiac chambers. Upon removal, a peasized papillomatous mass was found projectinlg inlto the heart cavity from the endocardial wall. The author concluded that the patient's terminal course was precipitated by thrombus formation promoted by the endocardial tumor. The symptoms and signs of venous and intracardiae involvement are often minimal in relation to the extensive involvement seen. Intracardiac involvement may be masked by superior or inferior vena eaval syndromes. Tumors may cause valvular murmurs practically identical to those of established valvular disease. Tumor thrombosis, like metastatic growths elsewhere in the heart, may produce sudden death. Culpepper and Von Haam59 reported a case of carcinoma of the liver with sudden death shown to have a tumor thrombosis of the inferior venia eava that protruded into the right atrium, which may have caused suddendeath by its ball-valve action. Angiography may be valuable in delineating the presence or abselnce of intracardiae tunmor muasses. Treatment of Metastatic Cancer to the Heart There have been only a few reports of treatment of metastatic caneer to the heart, but successful, though temporary relief, has been given with symptomeatic eancer of the heart. Blotner and Sosmnantm reported a case of leukemia with 2 :1 heart block, attributed to leukemic infiltration or a leukemic nodule in the bundle of His. X-ray therapy was followed by disappearance of the block for a number of days, with temporary disappearance for a second tinme after additionmal therapy. Shelburne and AronIsonl13 reported an instanice where a patient with caneer developed heart block with a large pericardial effusion. As a result of deep x-ray therapy, the heart Circulation, Volume XXYII, September 1960 481 METASTATIC CANCER TO THE HEART block disappeared and the effusion resolved completely without discernible adverse effects on the heart. Hsiung 's group12 treated a patient with metastatic tumor to the heart aind pericardiumn with x-ray and found evidence of reduction in heart size and disappearance of the pericardial effusion. They concluded that irradiation can also serve as a therapeutic test and substantiate the diagnosis of metastatic cancer to the heart, if the tumor is radioselnsitive. Digitalis may control the arrhythmias so produced, but in somie instances,18 it is ineffectual. Downloaded from http://circ.ahajournals.org/ by guest on April 30, 2017 Summary A review of the literature of metastatic cancer to the heart is presented, and a new classification offered. Autopsy data of The New York Hospital have been analyzed. In the 7-vear period, 1947 to 1953, in 694 deaths from calncer, an over-all incideniee of 18.3 per cent (127 eases) of nmetastases to the heart was observed. In a group of 169 cases of lynmphoma, leukemia, and myeloma, there was an incidence of 36 per cent (61 cases) of metastases to the heart. In the remaining 525 cases, there was an incidencee of 12.6 per cent (66 cases) of metastases to the heart. In 61 of these, gross lesions were present, an incidence of 11.6 per cent (61 cases) of gross metastases to the heart. These figures are comparable to those reported in other series. Summario in Interlingua Es presentate un revista del litteratura de eanceres metastasiate al corde. Un iiove classification es pro- ponite. Le protocollos autoptic del Hospital New York esseva anialysate. In le eurso del 7 annos ab 1947. usque a 1953, le serie total de 694 ml-ortes ab eancererevelava un incideintia de 127 casos (i.e. 18,3 pro cento) de mietastases al corde. In le subgruppo de 169 casos de lymphomia, leucemia, e myeloma, ii habeva 61 nmetastases al corde, i.e. un incidentia de 36 pro cento. In le remanente 525 casos del serie total, 66 metastases al corde esseva nlotate, i.e. un incidentia de 12,6 pro cento. In 61 de iste 66 mnetastases, i.e. in 11,6 pr o eeato del del serie de 525 easos, le lesiones cardiac esseva de importantia miiacroscopic. Iste cifras e;, comparabile al cifras reportate pro altere series. Circulation, Volume XXII, September 1960 References 1. TEDESCHI, A.: Beitrag zum Studium der Herzgeschwiilste. Prag. nmed. wvchnschr. 18: 121, 1893. 2. COATES, B. H.: Case of a singular tumor within the vena cava and attached to the Eustachian valve. Philadelphia J. M. & Phys. Soc. 4: 334, 1822. 3. BRICK, I. B., AND GREENFIELD, M.: Reticulum cell sarcoma with cardiac metastasis; report of two cases with antemortem diagnosis of one. Am. Heart J. 34: 599, 1947. 4. BURKE, E. M.: M-etastatic tumors of heart. Am. J. Cancer 20: 33, 1934. 5. CRISCITIELLO, M., JR.: Case of sarcomatous degeneration of uterine leiomyoma with metastases to lungs and heart. Am. J. Cancer 18: 919, 1933. 6. LEPLACE, E., AND KARSNER, H. T.: Metastatic sarcoma of heart. Primary sarcoma of femur aind nietastatic sarcomiia of heart. Proe. Path. Soc., Philadelphia 14ns: 106, 1911. 7. NAKADA, J. R.: Primary careinomiia of adreinals wvitlh metastases in skin and iimyocardliiumii. J. Missouri M. A. 27: 367, 1930. 8. NUSBnAUM1, W. D., AND HEYER, F. W.: Carcinioma mietastases to heart anid subeutaneous tissues. Am. J. Cancer 24: 831, 1935. 9. FiSHBaRG, A. M.: Auricular fibrillation anid flutter inl mietastatic growths of right auricle. Amii. J. M. Se. 180: 629, 1930. 10. WILLIUS, F. A., AND AmBERG, S.: Two cases of secondary tumor of heart in children, in one of which diagnosis was made during life. M. Cliin. North America 13: 1307, 1930. 11. BLOTNER, H., AND SOSMAN, M. C.: X-ray therapy of heart inl patient with leukemia, hleart block and hypertension; report of case. New England J. Med. 230: 793, 1944. 12. HSIUNG, S. C., SZUTU, C., HSIEH, C. K., AND LIEU, J. T.: Metastatic tumors of heart; report of two cases diagnosed clinically. Chinese M. J. 57: 1, 1940. 13. SHELBURNE, S. A., AND ARONSON, H. S.: Tumors of the heart; report of secondary tumor of heart involving pericardium and bunidle of His with remission following deep roentgen-ray therapy. Ainn. Int. Med. 14: 728, 1940. 14. LYMBURNER, R. M.: Tunlors of heart; histopathological and cliinical study. Caniad. M. A. J. 30: 368, 1934. 15. LiSA, J. R., HIRSCHHORN, L., AND HART, C. A.: Tumnors of heart: Report of four cases; review of literature. Arch. IJut. Med. 67: 91, 1941. 16. PiC, A., AND BREET, J.: Canceer seconidaire du coeur. Rev. de mdd. 11: 1322, 1891. 17. KARRENSTEIN: Eim Fall voni Fibroelastomiy-xoim des Herzes unid Kasuiztisches zur Frage der HANFLING 482 18. 19. 20. 21. 22. 23. Downloaded from http://circ.ahajournals.org/ by guest on April 30, 2017 24. 25. 2'6. 27. 28. 29. 30. 3 1. 32. 33. 34. 35. 3J6. Herzgeschwiilste besoniders der Myxoma. Virchow's Arch. f. path. anat. 194: 127, 1908. SYMMERS, D.: The metastasis of tumors: A study of 298 cases of malignant growth exhibited among 5155 autopsies at Bellevue Hospital. Am. J. M. Sc. 154: 223, 1917. MORRIs, L. M.: Metastases to heart from malignant tumors. Am. Heart J. 3: 329, 1927. HELWIG, F. C.: Tumors of heart. J. Kansas M. Soc. 36: 265, 1935. POLLIA, J. A., AND GOGOL, L. J.: Some notes on malignancies of heart. Am. J. Cancer 27: 329, 1936. SCHNITKER, M. A., AND BAILEY, 0. T.: Metastatic tumor of the heart a case diagnosed during life. J.A.M.A. 108: 1787, 1937. SCOTT, R. W., AND GARVIN, 0. 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L., AND VON HAAM, E.: Priniary careinomia of liver with extensive metastasis to right heart anid tumnor-thrombosis of inferior vena cava. Am. J. Cancer 21: 355, 1934. CRUZ, P. T., AND STAMBAUGH, E. F.: Intracardiae extension of bronchogenic carcinoma. Dis. Chest 29: 441, 1956. 483 61. HOLT, W. L., JR.: Extenisioni of mimaligInant tumiiors of thyroid iiito great veins and right heart. J.A.M.A. 102: 1921, 1934. 62. JACOBI, MA., AND SELTZER, J.: C(ardiac metastasis from careinioma of thyroid. Am. Heart J. 12: 473, 1936. 63. MCDONALD, W. S., JR., AND HEATHER, J. C.: Neoplastic inivasioni of pulniioinary veinis andcl left auriele. J. Patlh. & Bact. 48: 533, 1939. 64. MEAD, C. H.: Metastatic careinoma of heart seeondary to primary carcinomiia of lungs. J. Thoracic Surg. 2: 87, 1932. 65. LINELL, E. A.: Ail uiusual cause of deatlh frolml canieer. Brit. -M. J. 1: 872, 1922. 66. LAUtRAIN, A. R.: Intracardial tumuor cultur e of osteogeniic sarcoama w ith fatal tumuor eml-bolisnm: Report of a case. AI11. J. Cliii. PathI. 27: 664, 1957. Austin Flint Austin Flint was born on October 20, 1812, at Petersham, Massachusetts, the fourth in a succession of a medical ancestry, his father having been a surgeon. He was educated at Amherst College and graduated at the age of 21 from the Harvard Medical School, where he had been influenced by teachers such as James Jackson, Sr., John C. Warren, and Jacob Bigelow. He praticed medicine in Boston and Northampton and later in Buffalo, and at the age of 32 was called to Chicago as Professor of Medical Theory and Practice at the Rush Medical College. He subsequently occupied iuany ilmlportant positions including professorships at the University of Louisville, Buffalo Medical College, and New Orleans School of Medicine. In 1860 at the age of 48 he became Physician to the Bellevue Hospital in New York City and Professor of the Principles and Practice of Medicine. For 8 years he was simultaneously Professor of Pathology and Practical Medicine in the Long Island College Hospital, until overwork forced hiiii to curtail his activities. He was a talented teacher and an ardent student of disease, addressing his efforts particularly to the refinement of the diagnostic procedures of Auenbrugger and Laennee. His numerous publications were based on voluminous, handwritten memoranda which are said to have comprised over 16,000 pages. Austin Flint is best rememabered by the eponym which bears his naine "The Austin Flint Murmnur." This phenomenon was first noted in 1860 and described in detail in 1862 in the publication "On Cardiac Murmurs" that appeared in the American Joutrnal of Medical Sciences. Austin Flint died on March 13, 1886, at the age of 74, of cerebral apoplexy and was buried in Boston. His contemporary, Dr. Samuel D. Gross, paid the following tribute to him, "As a diagnostician in diseases of the chest he has few equals. Nor is this fact at all surprising when we bear in miind the time and the immense labor which, from an early period of his professional life, he has devoted to their investigation. I know of no one who is so well entitled as Austin Flint, Sr. to be regarded as the Americain Laennec." -EPITT0, Circmlation, Volume XXII, September 496Q Metastatic Cancer to the Heart: Review of the Literature and Report of 127 Cases STANLEY M. HANFLING Downloaded from http://circ.ahajournals.org/ by guest on April 30, 2017 Circulation. 1960;22:474-483 doi: 10.1161/01.CIR.22.3.474 Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 1960 American Heart Association, Inc. All rights reserved. Print ISSN: 0009-7322. 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