Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Electrocardiography wikipedia , lookup
Management of acute coronary syndrome wikipedia , lookup
Cardiac contractility modulation wikipedia , lookup
Cardiac surgery wikipedia , lookup
Cardiothoracic surgery wikipedia , lookup
Arrhythmogenic right ventricular dysplasia wikipedia , lookup
285 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 183 286 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 184 Cardiac Metastasis of Colorectal Cancer 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 185 288 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 186 Cardiac Metastasis of Colorectal Cancer 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‐ 187 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. References 1) Bussani R, De-Giorgio F, Abbate A, Silvestri F. Cardiac metastasis. J Clin Pathol 2007; 60: 27– 34. 2) World Cancer Research Fund and American In‐ stitute for Cancer Research Food, Nutrition, Physical Activity, and the Prevention of Cancer: A Global Perspective. Washington, DC: Ameri‐ can Institute for Cancer Research; 2007. 3) August DA, Ottow RT, Sugarbaker PH. Clinical perspective of human colorectal cancer metasta‐ sis. Cancer Metastasis Rev 1984; 3: 303–324. 4) Burke A, Vermani R. Tumors of the heart and great vessels. Atlas of Tumor Pathology. 3rd Series, Fascicle 16. Washington, DC, Armed Forces Institute of Pathology, 1996. 5) Klatt EC, Heitz DR. Cardiac metastases. Cancer 1990; 65: 1456–1459. 6) Prichard RW. Tumours of the heart. Arch Path 1951; 51: 98–128. 7) Labib SB, Schick EC Jr, Isner J. Obstruction of Conclusion We have described a case of rapidly progressive cardiac metastasis that was discovered 4 months after 188 Cardiac Metastasis of Colorectal Cancer 8) 9) 10) 11) 12) 13) 14) right ventricular outflow tract caused by intraca‐ vitary metastatic disease: analysis of 14 cases. JACC 1992; 1664–1668. Kassop D, Donovan MS, Cheezum MK, Nguyen BT, Gambill NB, Blankstein R, Villines TC. Cardiac masses on cardiac CT: a review. Curr Cardiovasc Imaging Rep 2014; 7: 9281. Patel SA, Herfel BM, Nolan MA. Metastatic co‐ lon cancer involving the right atrium. Tex Heart Inst J 2012; 39: 79–83. Henuzet C, Franken P, Polis O, Fievez M. Car‐ diac metastasis of rectal adenocarcinoma diag‐ nosed by two-dimensional echocardiography. Am Heart J 1982; 104: 637–638. Nishida H, Grooters RK, Coster D, Soltanzadeh H, Thieman KC. Metastatic right atrial tumor in colon cancer with superior vena cava syndrome and tricuspid obstruction. Heart Vessels 1991; 6: 125–127. Case records of the Massachusetts General Hos‐ pital. Weekly clinicopathological exercises. Case 45-1992. A 75-year-old man with carcinoma of the colon and a right ventricular mass. N Engl J Med 1992; 327: 1442–1448. Parravicini R, Fahim NA, Cocconcelli F, Barch‐ etti M, Nafeh M, Benassi A, Grisendi A, Garuti W, Benimeo A. Cardiac metastasis of rectal ade‐ nocarcinoma. Surgical treatment. Tex Heart Inst J 1993; 20: 296–298. Testempassi E, Takeuchi H, Fukuda Y, Harada 15) 16) 17) 18) 19) 20) 21) 189 291 J, Tada S. Cardiac metastasis of colon adenocar‐ cinoma diagnosed by magnetic resonance imag‐ ing. Acta Cardiol 1994; 49: 191–196. Lord RV, Tie H, Tran D, Thorburn CW. Cardiac metastasis from a rectal adenocarcinoma. Clin Cardiol 1999; 22: 749. Koizumi J, Agematsu K, Ohkado A, Shiikawa A, Uchida T. Solitary cardiac metastasis of rec‐ tal adenocarcinoma. Jpn J Thorac Cardiovasc Surg 2003; 51: 330–332. Choi PW, Kim CN, Chang SH, Chang WI, Kim CY, Choi HM. Cardiac metastasis from colorec‐ tal cancer: a case report. World J Gastroenterol 2009; 15: 2675–2678. Makhija Z, Deshpande R, Desai J. Unusual tu‐ mours of the heart: diagnostic and prognostic implications. J Cardiothorac Surg 2009; 4: 4. Ngow HA, Khairina WW. Cardiac mass in a pa‐ tient with sigmoid adenocarcinoma: a metasta‐ sis? Cardiovasc J Africa 2012; 23: 10–12. Pizzicannella J, Ricci V, Gorla R, Spinapolice E, Esposito A. Isolated cardiac metastasis from colorectal cancer in a 35-year-old man. Case Rep Med 2012; 2012: 751761. Kasama K, Icchikawa Yasushi, Suwa Yusuke, Okudera K, Suzuki Shinichi, Masuda M. Late cardiac metastasis from colorectql carcinoma 15 year after surgery. Asian Cardiovasc Thorac Ann 2014; 9: 1–3.