Cardiovascular Pathology 23 (2014) 178–180
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Cardiovascular Pathology
Case Report
Cardiac metastasis from a urothelial cell carcinoma: a commented case report Aylin Hatice Yamac a,⁎, Dzenita Insanic b, Clemens Bockmeyer c a b c
Department of Cardiology, Bezmialem Foundation University, Istanbul, Turkey Department of Cardiology and Angiology, University Clinic Erlangen, Germany Department of Pathology, Medical School Hannover, Hannover, Germany
a r t i c l e
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Article history: Received 1 January 2014 Received in revised form 11 January 2014 Accepted 13 January 2014 Keywords: Cardiac metastasis Urothelial cell carcinoma Echocardiography Paradoxic Embolism
a b s t r a c t We present a case of a middle-aged male patient who was admitted to our institution because of the supposed diagnosis of endocarditis/myocarditis. Echocardiographic findings revealed cystic mass in the left myocardial wall as well as floating structures at the lateral papillary muscle, mimicking endocarditis/myocarditis. Due to progressive urinary retention and clinical signs of a beginning ileus, an abdominal and thoracic computed tomographic scan was performed, which demonstrated a large diverticle of the urinary bladder with expansive tumorous wall mass. One week later, the patient died of acute cardiorespiratory failure. On autopsy, the tumorous mass in the urinary bladder with large carcinosis of the peritoneum and multiple left and right ventricular metastases were confirmed; the histological analysis indicated a less differentiated urothelial cell carcinoma with its origin in the large diverticle of the urinary bladder with subsequent cardiac metastases. © 2014 Elsevier Inc. All rights reserved.
1. Introduction Primary tumors of the heart are rare, with a frequency of 0.02% in autopsy series [1]. Histologically, three quarters of primary heart tumors are benign, almost half of them being myxomas [2]. Secondary or metastatic heart tumors occur comparatively more frequently, with an at least 100 times higher incidence than primary tumors of the heart [3]. In contrast the presence of cardiac metastasis from urothelial cell carcinoma is extremely rare. Therefore, metastatic heart tumors like urothelial cell carcinoma only rarely gain clinical attention. Like primary tumors of the heart, metastases may imitate valvular heart disease or cause cardiac failure; ventricular or supraventricular heart rhythm disturbances; conduction defects; syncope; embolism; or, quite often, pericardial effusion. Thus, echocardiographic imaging is of paramount importance in the evaluation of cardiac metastasis. Here, we present a case of urothelial cell carcinoma with metastatic involvement of the heart.
had suffered a left hemispheric infarction 6 months ago with persisting residues consisting of right-side hemiplegia and speech disorder. He had previously undergone pneumonia and was treated with diverse antibiotics. The blood infection parameters, including C-reactive protein and white cell fraction, were moderately elevated without progress. A transthoracic echocardiogram, performed a few months ago, revealed a grossly thickened left ventricular wall with good contractility and cystic mass in the left myocardial wall as well as floating formation
2. The case A middle-aged male patient was referred to our institution with a history of progressive fatigue on effort and intermittent fever. There were no other cardiac symptoms and no history of chest pain. Besides, he also
⁎ Corresponding author at: Bezmialem Foundation University, School of Medicine, Department of Cardiology, Adnan Menderes Avenue, Vatan Street. 34093, Fatih/Istanbul, Turkey. Tel.: +90 212 453 17 00; fax: +90 212 533 23 26. E-mail address:
[email protected] (A.H. Yamac). 1054-8807/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.carpath.2014.01.005
Fig. 1. Transthoracic echocardiography. Four-chamber view: 13×10-mm-sized cystic mass that originated from the apex and floating left ventricle formations at the lateral papillary muscle (indicated by arrows).
A.H. Yamac et al. / Cardiovascular Pathology 23 (2014) 178–180
Fig. 2. Abdominal CT scan. Representative scans of the urinary bladder (indicated by white arrow) and related large diverticle (indicated by blue arrow) with tumorous wall mass (indicated by red arrow).
at the lateral papillary muscle (Fig. 1). Due to positive blood cultures with isolation of Staphylococcus aureus and the echocardiographic results, the disease was assumed as endocarditis/myocarditis. Thus, the patient was treated with several antibiotics, including linezolid, and discharged without significant clinical recovery. On admission to our hospital, the examination revealed normal heart sounds without murmur, and there were bibasal crepitations and rales on chest auscultation. Clinical signs of a systemic bacterial infection were not observed. In several blood cultures, there were no infective organisms found. We detected a urinary tract infection, which was treated with ciprofloxacin for 5 days. The initially elevated blood infection parameters decreased, but only poor clinical response was observed. Later, we discovered beginning pulmonary infiltration in the chest xray and progressive pulmonary rales, indicating pneumonia. Thus, we started antibiotic treatment with tazobactam and levofloxacin. Due to the medical history, we investigated transthoracic and transesophageal echocardiography, which showed a 13×10-mmsized cystic mass that originated from the apex and floating left
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ventricle structures at the lateral papillary muscle. Besides, we observed a patent foramen ovale with little left–right shunt and detected circularly localized pericardial effusion of 15-mm diameter. These pathologic findings seemed to occur within a few months, considering the echocardiograms performed 6 months ago with normal myocardial morphology. Due to previous stroke and the incidental finding of a patent foramen ovale, we supposed a paradoxic embolism, and therefore, a duplex sonography was initiated to search for potential thrombus origins in the pelvic/femoral vessels. The duplex sonography of the pelvic/femoral venous system indicated several bilateral venous thromboses of the major veins. We also demonstrated a partly occluding thrombosis in the left popliteal artery with sufficient hemodynamic compensation at rest. Thus, we initiated an anticoagulation therapy with enoxaparin. Due to progressive urinary retention and clinical signs of a beginning ileus, an abdominal and thoracic computed tomographic (CT) scan was performed, which demonstrated a large diverticle of the urinary bladder with expansive tumorous wall mass and multiple skeletal lesions (Fig. 2). A mechanic intestinal occlusion was not detected; thus, we supposed a paralytic ileus induced by tumor metastases. The thoracic CT scan indicated pulmonary embolism without yielding significant right ventricular dysfunction, evaluated by echocardiogram. In conclusion, we assumed a malignant tumor of the urogenital tract with widespread metastases and cardiac involvement. Almost 2 weeks after admission, the patient died of acute cardiorespiratory failure. On autopsy, the tumorous mass in the urinary bladder with large carcinosis of the peritoneum and multiple left and right ventricular metastases were confirmed (Fig. 3). The histological analysis indicated a less differentiated urothelial cell carcinoma (aT4, aN0, aMI, G3), with its origin in the large diverticle of the urinary bladder with subsequent cardiac metastases (Fig. 4). 3. Discussion The frequency of urothelial metastasis to the heart is very low. To our knowledge, over the last 20 years, only a few cases have been reported in the entire literature. Metastatic cardiac involvement occurs most often during the terminal stage. A number of theories have been advanced to explain the route of involvement of the heart by metastatic carcinoma. One is embolic tumor seeding by hematogenous spread or by invasion through the thoracic duct into the right side of the heart [4]. Another is direct invasion through the lymphatics of the heart. Although the most common sites for metastatic disease in the heart are the pericardium and the epicardium [5], frequently, the endocardium, myocardium, and cardiac chambers are also affected, as shown in this case. Although,
Fig. 3. Representative macroscopic sections of the cardiac metastasis: left ventricular outflow tract (A); right ventricular outflow tract (B).
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A
generally, the right side of the heart is more commonly involved than the left [6], we indicated multiple metastases in both ventricles. Local factors are also important in determining the patterns of metastatic spread [5,7]. As shown in the echocardiographic results, our patient had a functionally patent foramen ovale with little left– right shunt, as does 27.3% of the general population. The patent foramen ovale indicates a high probability of paradoxic embolism of thrombi and tumor material from the right to the left atrial chamber with following systemic embolization to the organs, including brain and left popliteal artery. 4. Conclusion
B
In conclusion, cardiac metastasis from all types of cancer has a poor prognosis, and in most cases, survival is limited to a few weeks or months. The myocardial mass evaluated by echocardiography, especially in connection with clinical infection signs, can mimic endocarditis/myocarditis. In general, clinical diagnosis of metastatic carcinoma to the heart is difficult because there are no early symptoms [4,6]. Signs of cardiac involvement are often overlooked, until the symptoms of disseminated tumor disease prevail. Here we did not observe common cardiac symptoms; instead, we found diverse signs for paradoxic embolism triggered by PFO. Besides, anamnestic evaluation was not possible due to neurological deficit. Thus, we could only focus on diagnostic devices including echocardiography and CT scan. Acknowledgments The authors would like to thank Prof. Bernhard Schieffer for his contribution and support. References
Fig. 4. Representative histology and immunohistochemistry of intramyocardial pleomorphic tumor cells. Micrograph of the tumor at low power (A, 100× magnification) displaying a poorly differentiated carcinoma characterized by a highly cellular proliferation of pleomorphic epitheloid cells invading cardiac parenchyma accompanied by a desmoplastic reaction. High-power field demonstrates fibroblasts, cardiomyocytes, and tumor cells indicated by arrows (B, 200× magnification).
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