Asymptomatic Cardiac Metastases From Esophageal Cancer: A Case Report Of Ante-mortem Detection And Literature Review

Abstract

Metastatic spread to the heart from neoplasms is very rare, often silent and rarely gains clinical attention. Usually, it correlates with widespread metastatic disease and is suggestive of a poor prognosis. Most cardiac metastases (CM) are detected following post-mortem studies with only a handful reported antemortemly. Here, we report a case of an asymptomatic cardiac metastasis from esophageal carcinoma and a review of the literature. In late July 2014, a 73-year-old woman diagnosed with locally advanced esophageal squamous cell carcinoma was admitted to our institution. Cardiothoracic metastases were not detected at basal computed tomography (CT) scan. The patient was submitted to concurrent cisplatin and radiotherapy. Just before surgery, a CT scan revealed two metastases in the right ventricle and in the interventricular septum. Transthoracic echocardiography and an endomyocardial biopsy confirmed the diagnosis of squamous cell carcinoma from the esophageal origin. In February 2015, chemotherapy was started, but after two courses of gemcitabine, a pulmonary embolism and then a congestive heart failure caused death of the patient on April 2015. Reviewing the literature, 14 cases with an antemortem diagnosis of CM from esophageal cancer were reported. Our patient should be the fifteenth case with an uncommon presentation without symptoms or signs in the diagnosis. Our case highlights that patients should be evaluated using echocardiography for CM, even if asymptomatic.

Keywords: ante-mortem detection; cancer case report; cardiac imaging; cardiac metastases; esophageal cancer.

Figure 1. Computed tomography (CT) scan of the heart

Axial plane contrast-enhanced.

Figure 2. Computed tomography (CT) scan of the heart

Multi planar reformation contrast-enhanced. Evidence of filling defect within the right ventricular cavity in correspondence with the interventricular septum.

Figure 3. Transthoracic echocardiography

A. Short-axis, great vessels off-axis view, showing a lobulated, cerebriform mass in the right ventricle near to the outflow tract. B. Short-axis, middle ventricle view, showing a mass occupying the right ventricle, adherent to the interventricular septum, with an anechoic central core. C. Subcostal view, showing a mass, with multiple anechoic foci, occupying a large amount of the right ventricle.

Figure 4. Cardiac magnetic resonance imaging (MRI)

Four chambers cine MRI.

Figure 5. Cardiac magnetic resonance imaging (MRI)

Four chambers cine MRI.

Figure 6. Cardiac magnetic resonance imaging (MRI)

TSE_T1 2 chambers cine MRI targeted for the study of the right ventricle.

Figure 7. Cardiac magnetic resonance imaging (MRI)

Turbo inversion recovery magnitude (TIRM) MRI. Confirmation of the expansive formation already observed on computed tomography-scan, another expansive lesion in the free wall of the right ventricle; evidence of necrosis within the mass.

Figure 8. Photomicrograph of cardiac metastases biopsy

A. Histopathological examination of the specimen shows that the tumor is a squamous cell carcinoma p63 immunostaining (hematoxylin and eosin stain; original magnification, ×100). B. Squamous cell carcinoma infiltrating the myocardial striated muscle, E-E. C. Squamous cell carcinoma p63 immunostaining. High magnification.