Symptomatic cardiac metastases of breast cancer 27 years after mastectomy: a case report with literature review--pathophysiology of molecular mechanisms and metastatic pathways, clinical aspects, diagnostic procedures and treatment modalities

Abstract

Metastases to the heart and pericardium are rare but more common than primary cardiac tumours and are generally associated with a rather poor prognosis. Most cases are clinically silent and are undiagnosed in vivo until the autopsy. We present a female patient with a 27-year-old history of an operated primary breast cancer who was presented with dyspnoea, paroxysmal nocturnal dyspnoea and orthopnoea. The clinical signs and symptoms aroused suspicion of congestive heart failure. However, the cardiac metastases were detected during a routine cardiologic evaluation and confirmed with computed tomography imaging. Additionally, this paper outlines the pathophysiology of molecular and clinical mechanisms involved in the metastatic spreading, clinical presentation, diagnostic procedures and treatment of heart metastases. The present case demonstrates that a complete surgical resection and systemic chemotherapy may result in a favourable outcome for many years. However, a lifelong medical follow-up, with the purpose of a detection of metastases, is highly recommended. We strongly call the attention of clinicians to the fact that during the follow-up of all cancer patients, such heart failure may be a harbinger of the secondary heart involvement.

Figure 1

Histopathological evaluation. Hematoxylin and eosin (HE) histologic analysis revealed a highly cellular malignant tumour with solid clusters of atypical, polymorphic epithelial cells (image A, high-power photomicrograph, original magnification, ×400; HE stain). The tumour was partially necrotic (image B, low-power photomicrograph, original magnification, ×100; HE stain). Immunohistochemical study shows that the tumour cells stained positive for estrogene receptors (ER) (image C, low-power photomicrograph, original magnification, ×200) and HER-2/neu receptors (image D, low-power photomicrograph, original magnification, ×200) consistent with diagnosis of breast adenocarcinoma.

Figure 2

Echocardiographic evaluation. Four-chamber 2-dimensional transthoracic echocardiogram shows a large, irregular metastatic mass (2.3×1.1 cm), which infiltrated pericardium and myocardium (predominantly anteroapical and lateral walls of the left ventricle) with intracavitary propagation (arrows).

Figure 3

Radiological evaluation. Contrast-enhanced axial (Figures 3A-3C), coronal (Figure 3D) and sagittal (Figure 3E) multislice computed tomography scan of the chest revealed massive, predominantly necrotic metastatic tumour mass (13×10 cm in size on axial view) with pericardial and heart involvement (arrows). The tumour was partially necrotic and infiltrated the thoracic aorta and the pulmonary trunk with extension into the left atrium.