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J. St. Marianna Univ.
Vol. 6, pp. 285–291, 2015
Case Report
Cardiac Metastasis from Ascending Colon Cancer:
A Case Report and Review of the Literature
Shinya Mikami1, Junichi Tsuchiya1, Kuniyasu Horikoshi2, Ryoji Makizumi1,
Tsukasa Shimamura3, Akira Hanai1, Satoshi Tsukikawa1, Hirotaka Koizumi4,
Tetsu Fukunaga1, Yukihito Kokuba2, Nobuyoshi Miyajima5, and Takehito Otsubo1
(Received for Publication: August 25, 2015)
Abstract
Cardiac metastasis from colorectal cancer is rare. Such metastasis is usually discovered during autopsy;
antemortem diagnosis is rare. A 76-year-old woman in whom we had performed right hemicolectomy for as‐
cending colon cancer was noted to have elevated tumor markers during a follow-up examination 4 months after
the surgery. Chest CT indicated a cardiac tumor that was approximately 6 cm in diameter, and we suspected a
metastatic cardiac tumor. Subsequently, obstructive jaundice developed as a result of lymph node metastases
around an extrahepatic bile duct, and a stent was placed. The patient refused aggressive treatment and was sim‐
ply followed up clinically. Within 2 months, the cardiac tumor enlarged enough to cause cardiac failure, and
death ensued 7 months after the surgery. Autopsy revealed a myocardial tumor, approximately 7 x 5 cm, that
extended from the right atrium to the right ventricle. The histopathologic diagnosis was cardiac metastasis from
ascending colon cancer. We describe in detail this case of rapidly progressive cardiac metastasis that was dis‐
covered after surgical treatment of ascending colon cancer. In searching the medical literature, we found only 14
cases of metastasis of colorectal cancer to the heart. We describe our case in detail and review our experience in
light of the available literature.
Key Words
cardiac metastasis, ascending colon cancer
metastases1). Cardiac metastasis from colorectal can‐
cer is rare. Here, we report a case of rapidly progres‐
sive cardiac metastasis that was discovered 4 months
after the patient had undergone surgery for ascending
colon cancer.
Introduction
Primary cardiac tumors are exceedingly rare,
with a reported incidence of 0.001–0.28%, and the
majority are benign. The reported incidence of secon‐
dary cardiac tumors is 2.3–18.3%, and these are fre‐
quently not found until autopsy1). Often in cases of
cardiac metastasis, the primary tumor is a pleural
mesothelioma or malignant melanoma, and malignant
epithelial tumors, such as lung cancer and breast can‐
cer, tend to account for a high percentage of cardiac
Case
The patient was a 76-year-old woman who was
admitted to our hospital with a complaint of abdomi‐
nal distension. She was being treated pharmacologi‐
cally for diabetes mellitus and angina pectoris. The
1 Division of Gastrointestinal and General Surgery, St. Marianna University School of Medicine
2 Division of Gastroenterogical and General Surgery, St. Marianna University School of Medicine, Yokohama City Seibu
Hospital
3 Division of Gastrointestinal and General Surgery, Kawasaki Municipal Tama Hospital
4 Division of Pathology, St. Marianna University School of Medicine
5 Digestive Disease Center, St. Marianna University School of Medicine, Toyoko Hospital
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Mikami S Tsuchiya J et al
patient was anemic, with an hemogrobin level of 9.4
g/dL.. Her carcinoembryonic antigen (CEA) level
was elevated at 17.8 U/mL, and her carbohydrate an‐
tigen 19-9 (CA 19-9) level was also elevated at 315
ng/mL. Colonoscopy revealed an encircling mass in
the ascending colon. The colonoscope could not be
passed beyond this point (Fig. 1), and biopsy re‐
vealed a adenocarcinoma. Chest and abdominal re‐
vealed a tumor of approximately 7-cm in the ascend‐
ing colon as well as regional lymph node swelling but
no remote metastasis (Fig. 2). Under a diagnosis of
ascending colon cancer, right hemicolectomy with
D3 lymphadenectomy was performed. The postoper‐
ative clinical course was satisfactory, and the patient
was discharged on postoperative day 18. Upon visual
inspection of the surgical specimen, we found the tu‐
mor to be 8.0 x 6.0 cm (Fig. 3a), and histopathologic
examination confirmed the diagnosis of adenocarci‐
noma (Fig. 3b). The tumor was classified as a
T3N1bM0 Stage IIIb cancer. The patient was then
treated with an anticancer drug regimen as an outpa‐
tient.
Follow-up blood tests performed 4 months after
the surgery revealed CEA and CA19-9 elevation, and
the patient was hospitalized for further examination.
Upon admission, her height was 155 cm and weight
was 59 kg. Her blood pressure was 144/72 mmHg,
temperature was 36.4°C, and pulse was 72 bpm. The
palpebral conjunctiva was not yellow, and the color
of the tunica conjunctiva palpebrarum was indicative
of anemia. Neither rales nor heart murmurs were
heard, and the patient reported no subjective symp‐
toms. Laboratory data obtained on admission are
shown in Table 1. Blood tests revealed that her CEA
level had risen to 66 U/mL and her CA19-9 level to
1300 ng/mL. Chest and abdominal CT revealed an ir‐
regular tumor, approximately 6 cm across, extending
from the right atrium to the right ventricle (Fig. 4).
No abnormalities were found in the liver or lungs. On
the basis of the clinical course and the X-ray findings,
we diagnosed the tumor as a cardiac metastasis from
the ascending colon cancer.
We planned to begin chemotherapy, but a blood
test performed 3 weeks after the patient’s hospitaliza‐
tion revealed sudden increases in the patient’s total
bilirubin to 12.0 mg/dL and direct bilirubin to 9.0
mg/dL. Abdominal CT revealed dilation of several
intrahepatic bile ducts (Fig. 5). It was clear that meta‐
static involvement of lymph nodes around the hepato‐
duodenal ligament had caused bile duct obstruction.
Percutaneous transhepatic biliary drainage was per‐
Figure 1. Pre-operative colonoscopic image.
Colonoscopy revealed an encircling mass in the
ascending colon.
Figure 2. Post-surgical contrast-enhanced abdominal com‐
puted tomography (CT) image.
CT revealed a tumor of approximately 7 cm in
the ascending colon (arrow) and regional lymph
node swelling.
formed for the obstructive jaundice, and the stenosis
was treated with a biliary stent.
Because the patient refused aggressive treatment
of the secondary tumor, we recommended palliative
care at home. By 6 months after the surgery, the pa‐
tient was having breathing difficulties and showed
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287
Table 1. Laboratory Data on Admis‐
sion
Figure 3. Features of the primary tumor.
a: Macroscopic appearance of the resected pri‐
mary tumor. The resected ascending colon tu‐
mor was 8 x 6-cm.
b: H&E-stained tissue slides (×100 magnifica‐
tion) prepared from the resected primary tumor.
Histologically, the tumor was identified as a
highly differentiated tubular adenocarcinoma.
same structure as the ascending colon cancer. Fur‐
thermore, immunostaining of the cardiac tumor for
CDX2 was positive (Fig. 9), and the final diagnosis at
autopsy was cardiac metastasis from ascending colon
cancer.
Discussion
signs of disturbed consciousness. She was hospital‐
ized on an emergency basis. CT revealed that the car‐
diac tumor had enlarged rapidly (Fig. 6), and cardiac
failure ensued, leading to the patient’s death 7
months after the surgery.
Upon autopsy, right heart hypertrophy and a 7 x
5-cm yellowish-white, solid tumor occupying the ma‐
jority of the myocardium were observed (Fig. 7).
Compression by the tumor caused intraluminal ob‐
struction of the ventricle. Lymph nodes within the
hepatoduodenal ligament were enlarged, and direct
infiltration of carcinoma into the adjacent bile duct
was seen. Small white nodules were also observed in
both lungs, both kidneys, and the right adrenal gland.
Histologically, all lesions in the heart (Fig. 8), lungs,
kidneys, adrenal glands, and lymph nodes were of the
Colorectal cancer is the third most common can‐
cer worldwide2). Approximately 20% of patients with
colorectal cancer have distant metastasis at the time
of diagnosis, and approximately 30% suffer metasta‐
sis during the clinical course3). Metastasis from color‐
ectal cancer occurs hematogenously and via the lym‐
phatic system, with metastasis to the liver, lungs, and
regional lymph nodes occurring frequently. Metasta‐
sis to the heart represents a unique metastatic pat‐
tern3).
Primary cardiac tumors are found in only 0.001–
0.28% of autopsy cases and are thus considered ex‐
ceedingly rare1). Approximately 75% of all primary
cardiac tumors are benign, with myxomas accounting
for about half of the benign cardiac tumors, and the
remaining 25% are malignant, with sarcoma being
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Mikami S Tsuchiya J et al
Figure 6. Contrast-enhanced chest CT image obtained 6
months after surgery. The heart tumor had en‐
larged rapidly (arrows).
Figure 4. Contrast-enhanced chest computed tomography
image obtained 4 months after surgery. A tumor
of approximately 6 cm was depicted in the right
ventricle (arrows).
lung (18.2%), and breast cancer (15.5%) tend to be
most common. The reported incidences of cardiac
metastasis from gastrointestinal cancers are low, at
8.0% from gastric cancer, 6.4% from pancreatic can‐
cer, and 1.2% from liver cancer; metastasis from co‐
lon cancer was documented in 13 of 1066 patients
(1.2%).
We believe that the route of metastasis to the
heart may be hematogenous or lymphatic and include
direct infiltration from adjacent organs and/or intraca‐
vitary diffusion via the inferior vena cava or pulmo‐
nary vessels. In approximately two thirds of cases of
cardiac metastasis, the site was the pericardium
(69.4%), with the epicardium and myocardium ac‐
counting nearly equally for the remaining third.
Metastasis to the endocardium occurred at a low rate
of 5%1). Metastasis to the pericardium tends to occur
via the lymphatic system, whereas metastasis to the
myocardium is usually hematogenous5). Cardiac
metastases are more common on the right side than
on the left, with metastasis to the right ventricle said
to be most common6). The right ventricle is a site of
ultimate venous and lymphatic drainage, which ex‐
plains why metastasis to this location is most com‐
mon7). No metastasis to the pericardium was ob‐
served in the present case, and the tumor cells spread
to the myocardium of the right ventricle, presumably
hematogenously.
Echocardiography, CT, MRI, and FDG-PET/CT
are useful for diagnosing metastatic cardiac tu‐
mors8,9). More than 90% of metastatic cardiac tumors
are asymptomatic9), but when the tumor enlarges,
symptoms such as dyspnea, chest pain, palpitations,
Figure 5. Contrast-enhanced abdominal computed tomog‐
raphy (CT) image obtained 5 months after sur‐
gery. Abdominal CT revealed stenosis of an ex‐
trahepatic bile duct and dilation of several
intrahepatic bile ducts.
the most common cardiac malignancy4). The heart is
an unusual site of metastasis from any malignancy,
although the reasons for its rarity have not been well
established. Metastatic cardiac tumors are found in
2.3–18.3% of autopsy cases1). From a study of 7289
autopsy cases, Bussani et al.1) reported cardiac meta‐
stasis in 9.1% of all cases of malignant tumor. The
rate of cardiac metastasis was highest when the pri‐
mary tumor was a pleural mesothelioma (48.5%) or
malignant melanoma (27.8%). Of the epithelial ma‐
lignant tumors resulting in cardiac metastasis, pulmo‐
nary cancer (21%), squamous cell carcinoma of the
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289
Figure 7. Macroscopic appearance of the cardiac tumor. A yellowish-white, solid tumor extended
from the right atrium to the right ventricular wall.
Figure 8. H&E-stained tissue slides (×40 magnification)
prepared from the resected cardiac tumor. The
tissue structure resembled that of the ascending
colon cancer.
Figure 9. Sections of the resected cardiac tumor (×100
magnification) subjected to immunohistochemi‐
cal staining. Tumor cells were positive for CDX.
and edema occur7). Cardiac metastasis can also cause
pericardial effusion, pericarditis, and cardiac tampo‐
nade. Conduction disorders, arrhythmia, valve insuf‐
ficiency, and acute coronary syndrome have been ob‐
served in patients with cardiac metastasis, and there
have been cases resulting in sudden cardiac death9).
In our patient, the metastatic tumor led to hypertro‐
phy of the right ventricular wall and intraluminal in‐
filtration and ultimate ventricular outflow tract ob‐
struction. We presume the cause of death to be
cardiac failure due to right ventricular outflow tract
stenosis.
Cardiac metastases from colorectal cancer are
usually discovered during autopsy; antemortem diag‐
nosis is rare. To the best of our knowledge, there are
only 14 reported cases of cardiac metastasis from col‐
orectal cancer9–21). These 14 cases plus our case are
shown in Table 2. Mean age of the patients was 67.1
(35–81) years, the male/female sex ratio was 12/3,
and the patients had either colon cancer (n=10) or
rectal cancer (n=5). Metastasis was to the right side
of the heart in all 15 patients (the right atrium in 8 pa‐
tients and right ventricle in 7 patients). The meta‐
static lesion was quite large (tumor diameter>5 cm)
in 10 patients. Surgical resection of the metastatic le‐
sion was performed in 5 patients, anti-cancer drug
therapy in 3, and no treatment in 6. The 13 patients
for whom outcomes were reported (including ours)
died. Cardiac metastasis from colorectal cancer is
rare; therefore, surgery as a treatment modality has
not been thoroughly investigated. There are a few re‐
ports of surgical treatment of a solitary cardiac meta‐
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Mikami S Tsuchiya J et al
290
Table 2. Cases of Cardiac Metastasis From Colorectal Cancer Reported in the English Literature
stasis from colorectal cancer11,13,16,17). Koizumi et al16)
reported that although surgery is rarely recommended
for treating metastatic cardiac tumors, surgical treat‐
ment could be especially effective in occurrences of
obstructive and solitary lesions to ensure relief from
symptoms and to prolong the patient’s life. However,
the mean postoperative survival time of 5 patients af‐
ter surgical resection was 9 months. Thus, prognosis
in cases of tumor recurrence in the form of cardiac
metastasis is poor.
Cardiac metastasis from colorectal cancer usu‐
ally occurs as a part of multi-organ metastasis in the
terminal stage of cancer. Therefore, most cases are
reported as autopsy cases. In our case, metastatic
lung lesions, metastatic kidney lesions, and adrenal
metastatic focus were all small and noted only during
autopsy, in addition to the cardiac metastasis and in‐
volved lymph nodes that had been revealed by CT be‐
fore the patient’s death. We have learned that when a
sudden rise in tumor markers occurs after surgery for
colorectal cancer and no metastasis is found in the
liver or lungs, the possibility of cardiac metastasis
should be investigated.
the patient had undergone surgery for ascending co‐
lon cancer. Our experience highlights the fact that a
sudden increase in tumor markers after surgery for
colorectal cancer may indicate cardiac metastasis and
makes diagnostic imaging imperative.
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We have described a case of rapidly progressive
cardiac metastasis that was discovered 4 months after
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