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 Table of Contents  
INTERESTING CASE REPORT
Year : 2019  |  Volume : 3  |  Issue : 3  |  Page : 189-191

An Extremely Rare Case of Carcinoma Rectum Metastasizing to the Heart


Department of Non Invasive Cardiology, Max Super Speciality Hospital, New Delhi, India

Date of Submission21-Dec-2018
Date of Decision23-Jan-2019
Date of Acceptance27-Jan-2019
Date of Web Publication18-Dec-2019

Correspondence Address:
Rahul Mehrotra
Max Super Speciality Hospital, 2, Press Enclave Road, Saket, New Delhi - 110 017
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiae.jiae_51_18

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  Abstract 

The incidence of cardiac metastases has increased over the last 3 decades. The commonest source of cardiac metastasis however remain the lungs and breast. Pericardium is the most commonly involved part of heart in metastatic disease. We report an extremely rare case of carcinoma rectum with metastasis to right ventricle and inferior vena cava through hematogenous route.

Keywords: Carcinoma rectum, metastasis, right ventricle


How to cite this article:
Mehrotra R, Kumar R, Bhat SH, Bansal B, Khatri JS, Raj M. An Extremely Rare Case of Carcinoma Rectum Metastasizing to the Heart. J Indian Acad Echocardiogr Cardiovasc Imaging 2019;3:189-91

How to cite this URL:
Mehrotra R, Kumar R, Bhat SH, Bansal B, Khatri JS, Raj M. An Extremely Rare Case of Carcinoma Rectum Metastasizing to the Heart. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2019 [cited 2020 Jan 26];3:189-91. Available from: http://www.jiaecho.org/text.asp?2019/3/3/189/273302


  Introduction Top


Cardiac tumors are among the most challenging disease entities to diagnose because of their rarity and their highly variable and usually nonspecific clinical presentations. Although primary cardiac tumors are rare (generally between 0.01% and 0.1% on postmortem analysis), the frequency of secondary metastatic tumors to the pericardium, myocardium, great vessels, or coronary arteries is between 0.7% and 3.5% at autopsy in the general population and up to 9.1% in patients with known malignancies.[1],[2],[3],[4] In a study, 41.2% of patients with multiple distant metastases were also found to have cardiac involvement.[5] The incidence of cardiac metastases has increased over the last 3 decades, perhaps due to increased life expectancy in cancer patients owing to the advances in cancer diagnosis and management.[4]

Symptoms from cardiac metastasis are generally seen in advanced stage and portend poor prognosis. Cardiac metastasis of carcinoma rectum is an extremely rare occurrence. Here, we present a case of carcinoma rectum with metastasis in the inferior vena cava (IVC) and involving right ventricle (RV) but sparing the right atrium (RA) or the pericardium.


  Clinical Presentation Top


A 48-year-old male presented to us with a history of progressive exertional dyspnea (NYHA class III) associated with palpitations for the past 2 weeks. He had been diagnosed with carcinoma rectum and treated with chemotherapy and radiotherapy 6 years ago. His vitals, general physical examination, and blood investigations were unremarkable. His chest X-ray and electrocardiogram were also in the normal range.

His transthoracic echocardiography, however, showed a large mass (size ~ 6.5 cm × 5.5 cm), with heterogeneous echotexture in the right ventricular cavity (almost completely filling the cavity) [Figure 1] and [Figure 2]. The RA was clear and without any mass [Figure 3], but the IVC was also filled with this solid mass [Figure 4]. The RA and RV were dilated, but the left atrium and ventricle were of normal size. Biventricular systolic function was normal. There was small pericardial effusion.
Figure 1: Transthoracic echocardiography with parasternal long axis view showing a mass (*) completely filling the right ventricular cavity

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Figure 2: Echocardiography with parasternal short axis view at papillary muscle level with huge, heterogeneous mass (*) filling the right ventricular cavity. LV: Left ventricle

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Figure 3: Transthoracic echocardiography with modified apical four-chamber view showing right ventricle cavity full of homogenous mass with the interventricular septum bulging toward the left. RV: Right ventricle, LA: Left atrium, RA: Right atrium

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Figure 4: Transthoracic echocardiography with subcostal view showing inferior vena cava full of tumor. IVC: Inferior vena cava; RA: Right atrium

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He subsequently underwent whole-body18 F-fluorodeoxyglucose positron emission tomography-computed tomography (18 F-FDG PET-CT) scan which revealed diffuse increased FDG uptake in the RV reaching up to the main pulmonary trunk [Figure 5] along with few FDG-avid nodules in the right lung (maximal 1.6 cm × 1.1 cm) and in the right hilum (maximal 2.8 cm × 2.3 cm). In the abdominal scan, diffuse FDG uptake was seen in the length of IVC extending from L2 vertebra, involving the entire intrahepatic IVC [Figure 6] along with right renal vein and in the right adrenal region (4.3 cm × 4.0 cm). Both the kidneys were normal in size, shape, and attenuation, and there was no abnormal FDG uptake noted in liver parenchyma. The patient underwent excision of the mass from RV and supradiaphragmatic part of IVC, but succumbed to multiorgan failure 10 days later. Excision biopsy report of the RV mass revealed poorly differentiated adenocarcinoma with thrombus [Figure 7].
Figure 5: Transverse section 18F-fluorodeoxyglucose positron emission computed tomography image showing diffuse increased uptake in the right ventricle (*) while the rest of the heart is seen normally

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Figure 6: Coronal section 18F-fluorodeoxyglucose positron emission computed tomography image of the thoracoabdominal region, showing diffuse increased uptake in the inferior vena cava indicated by the arrow.
IVC: Inferior vena cava


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Figure 7: Resolution microscope image of the excised tissue from the right ventricle showing poorly differentiated adenocarcinoma

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  Discussion Top


Most common malignant neoplasms that involve the pericardium include lung cancer (36%–39% of cardiac metastases), breast cancer (10%–12%), and hematologic malignancies (10%–21%). Melanoma has an unusual proclivity to involve the heart, with estimates of 28%–56% of patients with metastatic melanoma having some cardiac involvement. Epicardial involvement (25%–34%) and myocardial involvement (29%–32%) represent the second and third most common sites of cardiac metastasis[6] and are rare. Depending on their location, cardiac metastases may result in a variety of life-threatening complications including, rarely, cardiac rupture, cardiac tamponade, and sudden death.[7],[8],[9]

Involvement of the superior or IVC can be a prelude to cardiac metastasis. In particular, renal cell and hepatocellular carcinomas may spread via an endovascular route from the IVC to the RA.[1],[3] Hematogenous spread from gastrointestinal malignancies such as the rectum, as in our case, is an extremely rare occurrence.[10],[11]


  Conclusions Top


Cardiac metastasis in malignant tumors is rare but increasing. It is more common in certain malignancies but exceedingly rare in case of carcinoma rectum. Cardiac metastasis usually is asymptomatic until late in the course of the disease, but sometimes may result in symptoms and may be the presenting complaints as in our patient.

Echocardiography is the initial imaging test for the detection of cardiac metastasis, although cardiac magnetic resonance, cardiac CT, and PET/CT may further help characterize and delineate the extent of disease. Treatment of cardiac metastasis depends on their immediate cardiac complications, as well as the clinical context, prognosis, and functional status of the patient.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Bussani R, De-Giorgio F, Abbate A, Silvestri F. Cardiac metastases. J Clin Pathol 2007;60:27-34.  Back to cited text no. 1
    
2.
Bruce CJ. Cardiac tumours: Diagnosis and management. Heart 2011;97:151-60.  Back to cited text no. 2
    
3.
Yusuf SW, Bathina JD, Qureshi S, Kaynak HE, Banchs J, Trent JC, et al. Cardiac tumors in a tertiary care cancer hospital: Clinical features, echocardiographic findings, treatment and outcomes. Heart Int 2012;7:e4.  Back to cited text no. 3
    
4.
Al-Mamgani A, Baartman L, Baaijens M, de Pree I, Incrocci L, Levendag PC, et al. Cardiac metastases. Int J Clin Oncol 2008;13:369-72.  Back to cited text no. 4
    
5.
Reynen K, Köckeritz U, Strasser RH. Metastases to the heart. Ann Oncol 2004;15:375-81.  Back to cited text no. 5
    
6.
Butany J, Leong SW, Carmichael K, Komeda M. A 30-year analysis of cardiac neoplasms at autopsy. Can J Cardiol 2005;21:675-80.  Back to cited text no. 6
    
7.
Casella M, Carbucicchio C, Dello Russo A, Tundo F, Bartoletti S, Monti L, et al. Radiofrequency catheter ablation of life-threatening ventricular arrhythmias caused by left ventricular metastatic infiltration. Circ Arrhythm Electrophysiol 2011;4:e7-10.  Back to cited text no. 7
    
8.
Perazzolo Marra M, Thiene G, De Lazzari M, Calabrese F, Lacognata C, Rizzo S, et al. Concealed metastatic lung carcinoma presenting as acute coronary syndrome with progressive conduction abnormalities. Circulation 2012;125:e499-502.  Back to cited text no. 8
    
9.
Garg N, Moorthy N, Agrawal SK, Pandey S, Kumari N. Delayed cardiac metastasis from phyllodes breast tumor presenting as cardiogenic shock. Tex Heart Inst J 2011;38:441-4.  Back to cited text no. 9
    
10.
Parravicini R, Fahim NA, Cocconcelli F, Barchetti M, Nafeh M, Benassi A, et al. Cardiac metastasis of rectal adenocarcinoma. Surgical treatment. Tex Heart Inst J 1993;20:296-8.  Back to cited text no. 10
    
11.
Chu PH, Ko YL, Liao WB, Chiang CW. Metastatic colonic carcinoma with intracavitary right ventricular outflow tract obstruction and cardiac tamponade: A case report. Changgeng Yi Xue Za Zhi 1996;19:264-7.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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