European Journal of Echocardiography (2008) 9, 391–392 doi:10.1016/j.euje.2006.12.008
Multiple cardiac metastases from a malignant melanoma Dimitrios N. Chrissos*1, Pavlos N. Stougiannos2, Dimitrios Z. Mytas*, Andreas A. Katsaros3, George K. Andrikopoulos4, and Ioannis E. Kallikazaros5 Cardiology Department, Hippokration Hospital, 114 Vas. Sofias Street, 11527 Athens, Greece Received 11 November 2006; accepted after revision 15 December 2006; online publish-ahead-of-print 12 March 2007
KEYWORDS Melanoma; Heart metastases; Echocardiography
Case presentation A 36-year-old patient, with a history of a malignant skin melanoma surgically removed 4 years ago, was admitted due to fatigue, dyspnea and frequent episodes of presyncope and syncope during the last month. On admission, the patient had tachypnea, tachycardia, pericardial friction rub and paradoxus pulse. The electrocardiogram showed sinus tachycardia with low voltages, while chest radiography revealed an enlarged cardiac silhouette. The echo study identified multiple metastases in the heart, which involved the pericardium (large pericardial effusion with diastolic collapse of right ventricle, signs of evolving tamponade), the myocardium (a well rounded
* Corresponding author. Tel: þ30 69 3693 8650; fax: þ30 21 0653 2499. E-mail addresses:
[email protected] (D.N. Chrissos), drpavlos@ hotmail.com (P.N. Stougiannos),
[email protected], d.mitas@ yahoo.gr (D.Z. Mytas),
[email protected] (A.A. Katsaros), andrikop@ hotmail.com (G.K. Andrikopoulos),
[email protected] (I.E. Kallikazaros). 1 Present address: 12 Matrozou Street, 11741 Koukaki, Athens, Greece. Tel: þ30 6945555490; fax: þ30 2109239393. 2 Present address: 6 Dionysou Street, 12132 Peristeri, Athens, Greece. Tel: þ30 6977 649898; fax: þ30 2741021407. 3 Present address: 95 Naxou Street, 11255 Athens, Greece. Tel:fax: þ30 2102214135. 4 Present address: 18 Parmenionos Street, 13676 Thrakomakedones, Athens, Greece. Tel: þ30 2102436143. 5 Present address: 12 Anapauseos Street, 15125 Marousi, Athens, Greece. Tel: þ30 6944387805.
mass inside the posterior myocardial wall) (Figure 1) and a large mobile mass which was virtually filling the right atrium and during diastole prolapsed through the tricuspid valve creating mechanical valve stenosis (Figure 2). In the transesophageal view there was also a mass behind the heart, which seemed to infiltrate the cardiac walls (Figure 3). Pericardiocentesis revealed malignant cells in the pericardial fluid. Despite chemotherapy, he died 4 months later. Cardiac metastases of malignant melanoma were confirmed by autopsy study.
Discussion Metastatic tumors to the pericardium in the heart are far more common than primary ones.1 Although cardiac metastases from malignant melanoma are quite frequent, in the early stages, the majority of patients have non-specific symptoms or they are mainly asymptomatic. Unfortunately, correct diagnosis is made antemortem in only 30% of these cases.1,2 Nevertheless, a variety of manifestations may suggest cardiac involvement such as acute pericarditis, pericardial effusion, congestive heart failure, arrhythmias, embolic events and rarely syncope.3 Echocardiography is the most useful diagnostic modality and transesophageal approach may be the technique of choice, while CT or MRI may offer additional information.4
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Metastatic tumors in the pericardium or the heart are more common than primary tumors and their incidence has increased during the last decades due to the prolonged survival of patients with cancer and the increased prevalence of the disease in the general population. We present the case of a 36-year-old patient admitted to our hospital due to fatigue, dyspnea, and episodes of dizziness and fainting during the last month. He had a history of a malignant skin melanoma surgically removed 4 years ago. The echo study identified multiple metastases in the heart involving the pericardium, the myocardium and the right atrium, where the tumor was mobile creating mechanical tricuspid valve stenosis. Malignant metastasis was confirmed by pericardiocentesis and, although treatment with chemotherapy was promptly initiated, the patient died 4 months later. Despite the difficulty in clinical diagnosis of cardiac melanoma, early detection has important therapeutic and prognostic implications. Echocardiography is the most common diagnostic modality and transesophageal approach may be the technique of choice to image intracardiac metastatic tumors.
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Figure 3 Transesophageal echocardiography. Modified fourchamber view. A mass behind the heart is possibly infiltrating the cardiac wall. RA ¼ right atrium, RV ¼ right ventricle, T ¼ tumor. Figure 1 2D-parasternal long axis view. Large pericardial effusion and a well rounded mass (tumor) inside the posterior myocardial wall. AO ¼ aorta, LA ¼ left atrium, LV ¼ left ventricle, PE ¼ pericardial effusion, T ¼ tumor.
References
Figure 2 2D-apical four chamber view. Tumor filling the right atrium. LA ¼ left atrium, LV ¼ left ventricle, RA ¼ right atrium, RV ¼ right ventricle, T ¼ tumor.
1. Barman N. Cardiac tumors. In: Griffin BP, Topol EJ editors. Manual of cardiovascular medicine. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2004. p. 275–80. 2. Gibbs P, Cebon JS, Calafiore P, Robinson WA. Cardiac metastases from malignant melanoma. Cancer 1999;85:78–84. 3. Rosario RT, DiMaio DJ, Lapham RL, Sweeney M, Smalling R, Barasch E. Metastatic ocular melanoma to the left ventricle inducing near-syncope attacks in an 84-year-old woman. Chest 2000;118:551–3. 4. Houmsse M, Raman SV, Leier CV, Orsinelli DA. Metastatic melanoma of the left ventricle: cardiac imaging in the diagnosis and surgical approach. Int J Cardiovasc Imaging 2004 Dec;20:523–6 [discussion 527–8]
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Considering our patient, his clinical manifestations raised the possibility of cardiac involvement, which was confirmed by echocardiography. Unfortunately, due to the advanced stage of his disease, chemotherapy was unsuccessful. In the current era, with the rapidly increasing incidence of malignant skin melanoma, cardiac involvement should be readily suspected, especially in patients with the aforementioned clinical presentation. Moreover, early diagnosis is of profound value if the patient is to benefit from the recent advances in cancer therapy.
