Download METASTATIC CARCINOMA OF THE HEART Metastasis to the heart

METASTATIC CARCINOMA O F T H E HEART
R. L. HAMILTON, M.D.
Snyre, Pennsylvania
Metastasis to the heart is rare. In most of the cases reported
the cardiac involvement was discovered microscopically. There
are very few records of diffuse involvement. Metastasis has occurred generally from a carcinoma within the thoracic cavity.
According to Nicholls and Morris metastasis to the heart
occurs in approximately 0.28 per cent of cases of carcinoma and is
the most frequent form of malignant new growth involving the
heart. Sarcoma metastasis to the heart is second in frequency,
being found i n 0.7 per cent of all patients dying from sarcoma.
Primary carcinoma of the heart is much less frequent than metastatic carcinoma, and primary sarcoma is still rarer. It is interesting to note that a diagnosis of carcinoma of the heart has apparently
rarely been made intra vitam.
H. I., white, aged forty-eight, a railroad switchman, was admitted to
the Guthrie Clinic on Jan. 6, 1930. Six months earlier, in July 1929,
he had suffered several severe choking spells. A physician's advice was
sought, but apparently nothing definite was found t o account for the
trouble. A non-productive, hacking cough developed, and in September
1929 the patient began to suffer from pain in the left upper chest, occasionally radiating to the back, between the shoulder blades. H e
noticed, a t t,his time, that the left side of t,he face and left upper chest.
left arm, and hand perspired a little more freely than the corresponding
areas on the right side. Slight loss of weight was noted. The paticnt
was admitted to a sanitarium, with the diagnosis of bilateral pulmonary
tuberculosis. Two months of sanitarium care, however, brought about
no favorable response. The loss of weight continued and the pain
became more severe and more pronounced in the back. There was a
definitely noticeable loss of strength. Perspiration on the left side of
the body, principally the upper portions, became more marked. Having
been granted ti short furlough from the sanitarium, he reported to the
Guthrie Clinic in tho hope of obtaining somc relief from pain.
Nicholls, A. G.: Secondary carcinoma implanted on the endocardium of the right
ventricle, Canad. M. A. J. 17: 798, 19'27.
Morris, Laird M.: Metastasis to the heart from malignant tumors, Am. Heart J.
3: 219, 1927.
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R. L. HAMILTON
The patient's family history was irrelevant. He had had a rather
severe case of influenza in 1918, and had had numerous attacks of
tonsillitis. There had never been any known contact with tuberculosis.
Examination' showed a rather undernourished, yet well developed
adult; temperature a t 4 P.M. 98 115"; pulse 100; blood pressure 114176.
The blood vessels showed a slight degree of thickening. The tonsils were
moderately enlarged and diseased. The larynx showed some conge~t~ion
of the epiglottis and cords. The left cord was fixed in a mid-position, and
there was no motion with breathing or phonation. The glandular
system failed to reveal any adenopathy. There was a slight tremor of
the hands and a little curvature of the finger nails, but no evidence of
arthropathy. The heart sounds were distant. There was a moderate
tachycardia, but no other evidence of pathology. The lungs showed a
definitely limited excursion on both sides, more marked on the right. I n
the right lower chest posteriorly there were slightly diminished vocal
resonance and tactile fremitus. I n the left axilla and a t the right base
there were a few scattered moist rkles. The abdomen was essentially
normal.
The central nervous system showed no abnormal reflexes. No
definite areas of anesthesia or hyperesthesia were demonstrable, but there
was a definite increase in the moisture of the skin of the left side of the
face, left arm, hand, shoulder, and upper part of the left chest. The
spine showed some rigidity, more marked in the dorsal and lumber areas.
Just to the left of the vertebral column, opposite the 10th and l l t , h dorsal
vertebrae, there was a small, hard, nodular fixed mass. Rectal ex:unination showed a small, smooth, regular prostate.
The hemoglobin was 75 per cent, red blood count 4,040,000, white
count 8,400, and differential 64-36. The blood urea was 17 mg. per 100
c.c., and the blood sugar 100 mg. per 100 C.C. The Kahn and Wassermann
tests were negative. The urine was normal except for a trace of albumin.
Spinal puncture revealed a normal pressure, 5 cells per c. mm., ammonium
sulphate test 1 plus, Pandy test 1 plus, and Wassermann negative.
Examination of stools was negative.
Fluoroscopic examination of ohest and stereoscopic plates showcd
the hilus shadows to be very dense. The mediastinal space in the upper
portion appeared to be encroached upon by a fairly dense mass, which
seemed to pulsate. I t was a question whet,her this was an aortic aneurysm
or a mass within the limits of the aortic arch. The fact that the mass
did not appear to be expansile ruled out aortic aneurysm. A bronchoscopic examination revealed a definitely widened carina, which suggested
a tumor growing just beneath it and pressing against the inner portions
of both of the main bronchi. Approximately 1% inches from the carina,
on the inner side of the left bronchus, there was a n erosion about the size
of a twenty-five cent piece.
A diagnosis was made of carcinoma of the left bronchus with involvement of t,he peribronchial and peritracheal glands. A piece of tissue was
taken for biopsy from the mass protruding through the muscles, just to
the left of the tenth dorsal vertebra. The pathologic report was "adenocarcinoma" surrounded by a marked amount of fibrous tissue.
METASTATIC CARCINOMA OF THE HEART
207
On Jan. 17, 1930, the patient was given some deep x-ray therapy, then
advised that he might return home, if he would report regularly for x-ray
treatment. H e returned every two weeks for treatment until March
1930. From that time on he failed rapidly. A swelling of both upper
extremities became noticeable. The cough was almost persistent, and
considerable mucus was raised, which was occasionally blood stained.
Repeated examination of the heart revealed a progressive diminution in
the int,ensity of its sounds. On May 22, 1930, the patient went into a
stat,e of coma. He died on the following day.
On opening the chest, a t a u t o p ~ ythe
, ~ mediastinurn was found to be
normally adherent to the chest wall, The right lung was large and
showed anthracosis. No tumor masses were apparent, but, upon removal
of the lung, a small solid area about the main bronchus was seen. The
left lung was smaller than the right,, contained several areas of new
growth, and was adherent throughout to the chest wall. Microscopic
examination of the tumor mass in the bronchus showed it to be adenocarcinoma. There was some bloody fluid in the left chest cavity and
many adhesions were separat'ed. The pericardium was greatly thickened
and showed a large amount of new growth.
The heart was covered in its entirety by new growth. No myocardium
For the pathologic notes I am indebted to Dr. C. H. De Wan.
208
R. L. HAMILTON
could be seen (Fig. 1). The pericardium, heart, left lung, and mediastinum
were removed. There was such diffuse upper mediastinal involvement by
new growth that it was almost impossible to tie off the main blood vessels.
On opening the heart the ventricles were found markedly intruded upon.
The whole muscle, internally and externally, seemed to be almost
completely replaced by carcinoma. The valvular orifices were narrowed
by encroachment of the neoplasm, but there was no considerable obwas t,hst of
struction. The hist,ologic structure of the heart meta~t~asis
adenocarcinoma (Fig. 2).
The liver was about normal size and was studded with new growths.
The spleen was small but not involved. Both the kidneys showed very
small areas of metastasis. Neither the lymph nodes along the spleen nor
in the pelvis were involved. The prostate was normal. The stomach
and intestines apparently were normal. The gallbladder was distended
but no stones were felt.
A case of diffuse metastatic carcinoma of t h e heart, primary in
t h e left bronchus, is reported. I n this case t h e lung showed relatively little involvement compared with t h e extensive involvement
of t h e myocardium.
METASTATIC CARCINOMA OF THE HEART
209
Notwithstanding the encroachment of the neoplasm on the
coronary circulation and on the cavities of the heart, the symptoms
suggesting myocardial involvement were surprisingly few and mild.
The diagnosis of metastasis to the heart was not made during life,
although involvement of the pericardium was suspected.