Download Assessment of a right ventricular metastasis using contrast

European Journal of Echocardiography (2008) 9, 326–328
doi:10.1093/ejechocard/jen067
Assessment of a right ventricular metastasis using
contrast echocardiography perfusion imaging
Sherif E. Moustafa, Claude Sauvé, and Robert Amyot*
Department of Cardiology, Hôpital du Sacré-Coeur de Montréal, University of Montreal, 5400 Boul.
Gouin W, Montreal, Quebec H4J 1C5, Canada
Received 30 August 2007; accepted after revision 6 October 2007
KEYWORDS
Contrast echocardiography;
Perfusion imaging;
Papillary thyroid carcinoma;
Intracardiac metastasis
Cardiac metastases of thyroid carcinomas are rarely diagnosed ante mortem and infrequently reported
in the literature. A 68-year-old man with known papillary thyroid carcinoma presented to the hospital
with progressive shortness of breath. A transthoracic echocardiogram revealed a right ventricular mass.
Contrast echocardiography perfusion imaging was used to evaluate the vascularity of the mass.
Cardiac tumours are an unusual pathologic finding and most
often represent metastatic involvement of the heart rather
than a primary cardiac tumour. Echocardiography is a useful
technique for the detection and evaluation of cardiac
tumours. Although the echo characteristics of an intracardiac mass and its associated cardiac findings may suggest
an etiology, its specific histologic nature cannot be determined. The vascularity of a mass may help discriminate
between benign tumours, malignant tumours, and thrombi.
We describe the case of an end-stage papillary thyroid
carcinoma with multiple metastases, including cardiac
involvement discovered at echocardiography and further
characterized by contrast echo perfusion imaging.
Case presentation
A very active 68-year-old man was admitted to the hospital
with progressive shortness of breath over the previous 4
weeks. Eleven years earlier, in 1996, he had been diagnosed
with end-stage papillary thyroid carcinoma for which he had
undergone total right lobectomy of the thyroid and 131I
therapy. Recurrence of his tumour in 2002 led to complete
thyroidectomy and a second course of 131I therapy. Two
years later, multiple metastases in the lungs, bones, and
lymph nodes were discovered. Physical examination
revealed a regular tachycardia at 107/min and a blood
pressure of 117/80 mmHg. Blood oxygen saturation was
98% on 2 L of oxygen. The cardiovascular examination
* Corresponding author. Tel: þ1 514 338 2222, ext 3809; fax: þ1 514 338
2381.
E-mail address: [email protected]
revealed normal heart sounds and no gallop or murmur.
Jugular venous pressure was normal. Grade 2/4 peripheral
oedema was present bilaterally. Rales were present bilaterally in the bases of the lungs. The liver was palpable 6 cm
below the costal margin in the right mid-clavicular line
and hard in consistency. The electrocardiogram showed
left axis deviation and non-specific repolarization changes
from V1 to V5. The chest X-ray revealed multiple metastases
bilaterally. Laboratory data revealed a normochromic normocytic anaemia with haemoglobin at 112 g/L (normal:
140–174 g/L), a hypoalbuminaemia at 25 g/L (normal:
35–50 g/L), and a mild elevation of troponin T at 0.13 ng/
mL (normal, 0.03 ng/mL).
Transthoracic echocardiography was technically difficult
and demonstrated a heterogeneous, 40 mm 24 mm mass
filling the right ventricular apex (Figure 1). Right ventricular contractility was normal at the basal and mid levels,
but, adjacent to the mass, the apex was akinetic. Left
ventricular dimensions and systolic function were normal
with an estimated left ventricular ejection fraction of
65% and mild diastolic dysfunction. No other intracavitary
mass or intramural lesions were detected. The inferior
vena cava was normal in diameter and response to respiration. To assess the vascularity of the mass, multiple
boluses of 0.1 to 0.2 mL of perflutren (DefinityTM,
Bristol-Myers Squibb Medical Imaging, North Billerica,
MA, USA) were administered intravenously. Images were
acquired with an HDI 5000 system (Advanced Technology
Laboratories, Seattle, WA, USA) using the low
mechanical-index, pulse-inversion modality. Images were
acquired with an HDI 5000 system (Advanced Technology
Laboratories, Seattle, WA, USA) using the low
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2008.
For permissions please email: [email protected].
Assessment of a right ventricular metastasis
Figure 1 Transthoracic echocardiogram in modified apical fivechamber view showing an intracardiac mass filling the right ventricular apex (arrow). LV, left ventricle; RV, right ventricle.
mechanical-index, pulse-inversion modality. Contrast
enhancement of the mass was observed, confirming a
highly vascularized lesion. Video intensity of the mass
(mean ¼ 7.7 dB) was comparable with the video intensity
of the adjacent myocardial tissue (mean ¼ 7.8 dB) and
less than the signal from the right ventricular blood pool
(mean ¼ 10.5 dB), confirming a highly vascularized mass
(see Supplementary material online, Video 1).
At this point, the patient was considered terminal and was
treated palliatively. He died 2 weeks later. The autopsy was
declined.
Discussion
Cardiac metastases have been described in autopsy series in
up to 20% of patients with malignancies of other organs, and
are up to 40 times more common than primary cardiac
tumours.1,2 Metastatic tumours can involve the heart by
direct invasion of adjacent malignancies, or by lymphatic
or haematogenous dissemination of distant malignancies.
Cardiac metastases originate most frequently from lung
and breast carcinomas, lymphoma, leukaemia, and malignant melanoma.3,4 The malignant melanoma is the tumour
with the highest rate of metastatic cardiac involvement,
affecting the heart in more than 50% of cases in autopsy
series.3,5 The most common echocardiographic finding in
patients with metastatic cardiac disease is pericardial effusion because of the frequency of pericardial seeding.6
Cardiac metastases are discovered principally in patients
with widespread systemic tumour dissemination. The heart
may be relatively spared from tumour deposition by vigorous
cardiac contractility and rapid coronary blood flow.2 The
frequency of thyroid metastasis to the heart was very low
(0–2%) in two large autopsy series and fewer than 20 cases
have been published in the literature over a 40-year
period, usually describing poorly differentiated tumours.
Giuffrida and co-workers7–9 published the first review
article to describe cardiac metastases from thyroid neoplasia and included 10 cases. Thyroid tumours usually have
a good prognosis. Nevertheless, as opposed to differentiated
thyroid tumours (papillary and follicular), anaplastic thyroid
tumours have a dismal outcome.
327
Echocardiography represents the first-line imaging
modality and allows dynamic evaluation of intracardiac
masses, but it is often difficult to differentiate thrombi
from tumours, and benign from malignant tumours. Such a
distinction between these etiologies carries major therapeutic and prognostic implications. Echocardiographic
characteristics suggesting a malignant lesion include rightsided tumours, extension to the heart through the venae
cavae or pulmonary veins, and intramural mass, commonly
with associated intracavitary or pericardial extension.
Although a benign mass is unlikely to display these features,
there are no pathognomonic findings of benign or malignant
tumours in two-dimensional echo.10 Commercially-available
echo contrast agents consist of microbubbles filled with
high-molecular-weight gases and comparable in size with
red blood cells. When injected intravenously, they first
appear in the right cardiac chamber, then cross the pulmonary circulation and reach the left heart, opacifying the left
cardiac chambers. Moreover, the microbubbles enter into
the coronary circulation and opacify the myocardium,
enabling the assessment of myocardial perfusion.11,12 Contrast echo perfusion imaging has been utilized to characterize the vascularity of cardiac masses and discriminate
malignant/highly vascular tumours from benign tumours
and thrombi.10 Kirkpatrick and co-workers3,13 demonstrated
that malignant and highly vascular tumours hyper-enhance
with contrast echo perfusion imaging, while stromal
tumours and thrombi hypo-enhance when compared with
the adjacent myocardium. Malignant or highly vascular
tumours showed higher video intensity than the myocardium
with contrast injection, whereas myxomas (less vascular)
demonstrated less perfusion than the myocardium, and
thrombi (mainly avascular) revealed no perfusion.
To the best of our knowledge, this is the first case report
in the literature assessing the vascularity of an intracardiac
end-stage papillary thyroid carcinoma metastasis using contrast echo perfusion imaging. Based on the clinical scenario,
the patient discussed in this report appeared to have an
intracardiac metastasis, since he was known to have metastatic end-stage papillary thyroid carcinoma. Moreover, the
echo features were in favour of a malignant process: right
ventricular location, and akinesia of adjacent myocardium
suggesting right ventricular wall infiltration. An alternate
diagnosis, although less likely, was a thrombus developing
in an akinetic right ventricular apex. This second hypothesis
was flawed by the atypical nature of primary contractile
abnormalities limited to the right ventricular apex and the
fact that thrombi described in the right chambers are
usually in transit. The contrast echo perfusion imaging
study demonstrating a highly vascularized mass definitely
excluded the possibility of a thrombus and was clearly in
favour of a malignant process.
Conclusions
Two-dimensional echocardiography is a non-invasive, inexpensive, and widely available imaging modality commonly
utilized to evaluate cardiac masses in order to narrow the
differential diagnosis and establish the most likely etiology.
Further characterization can be obtained by assessing the
vascularity of intracardiac masses using contrast echo perfusion imaging, providing additional information to differentiate malignant lesions from benign tumours and thrombi.
328
Supplementary material
Supplementary material associated with this article can be
found in the online version.
Conflict of interest: none declared.
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