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Keywords:

  • acute heart failure;
  • cardiac metastases;
  • renal pelvic cancer;
  • ventricular outflow tract obstruction

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Case report
  5. Discussion
  6. References

Abstract:  A 66-year-old man was referred to our hospital with chest discomfort and shortness of breath. Seven months previously he had undergone a laparoscopic left nephroureterectomy for a left renal pelvic tumor and was given two cycles of adjuvant chemotherapy (methotrexate, epirubicin and cisplatin). Echocardiogram showed an 8-mm sized mass extending from the right atrium into the right ventricle. On computed tomography, multiple lung tumors, as well as the right atrial and ventricular mass, were seen. The patient died of acute heart failure caused by right ventricular outflow obstruction. On autopsy, a right atrial and ventricular metastasis of the initial transitional cell carcinoma was found. The patient’s cause of death was acute heart failure as a result of cardiac metastasis of his initial renal pelvic carcinoma.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Case report
  5. Discussion
  6. References

Cardiac metastases are found in 6–20% of autopsies done on patients with carcinoma.1,2 However, most patients with this finding die with clinically silent cardiac metastases, because metastatic lesions large enough to cause right ventricular outflow tract obstruction are rare. Of the neoplasms that metastasize to the heart, the lungs are the most frequent primary site (36.4%), and adenocarcinoma is the most frequent cell type (36.4%).2 In urothelial carcinoma, 10% of autopsies show cardiac metastases.3 However, few cases of symptomatic cardiac metastases from transitional cell carcinoma have been reported. We report a rare case of a symptomatic cardiac metastasis of a transitional cell carcinoma.

Case report

  1. Top of page
  2. Abstract
  3. Introduction
  4. Case report
  5. Discussion
  6. References

In August 2003, a 66-year-old man underwent a laparoscopic left nephroureterectomy for a left renal pelvic tumor. Because strong adhesions around the kidney, the operation time was longer than usual. On pathology, the tumor was a pT3,v(+),ly(+) grade 2 transitional cell carcinoma. There was no lymph node metastasis. Postoperatively, the patient received two cycles of adjuvant MEC chemotherapy (methotrexate, 30 mg/m2; epirubicin, 30 mg/m2; cisplatin, 70 mg/m2). On postchemotherapy computed tomography (CT) there was no evidence of local recurrence and no metastases. Seven months after the operation, the patient presented with chest discomfort and shortness of breath. On chest X-ray, an enlarged cardiac silhouette was noted, and the electrocardiogram showed a bradycardia. On echocardiography, slight pulmonary hypertension and a small pericardial effusion, but no asynergy, were noted. The patient was given standard therapy for heart failure but his symptoms failed to improve. One month later, the patient’s symptoms worsened, and the patient was admitted to hospital. On echocardiography, an 8-mm sized mass extending from the right atrium into the right ventricle was seen (Fig. 1). The patient’s pulmonary hypertension had worsened, and the pericardial effusion had increased, but there was no asynergy. On chest CT, multiple lung tumors and a right atrial and ventricular mass were noted (Fig. 2). Shortly thereafter, the patient died as a result of acute heart failure caused by right ventricular outflow tract obstruction. On autopsy, metastases in the lungs, liver, adrenal glands and right atrium and ventricle were noted (Fig. 3). On histology, a grade 2 transitional cell carcinoma was diagnosed (Fig. 4).

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Figure 1. On echocardiogram, a solid mass in the right atrium was seen (arrow).

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Figure 2. On chest computed tomography, a solid mass in the right ventricle was seen (arrow).

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Figure 3. On autopsy of the heart, a 2.5-cm sized mass extended from the right atrium to the ventricle.

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Figure 4. The mass in the right ventricle was a G2 transitional cell carcinoma, the same type as the initial renal pelvic cancer.

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Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Case report
  5. Discussion
  6. References

Transitional cell carcinoma is histologically the most common urothelial carcinoma. In the advanced stage, it metastasizes primarily to the lymph nodes and lungs, but rarely to the heart. Cardiac metastases are found in 10% of autopsies of patients with cancer and in 11% of patients with bladder cancers, but clinical manifestations are rare.4 Only six cases of symptomatic cardiac metastases arising from transitional cell carcinoma have been reported: three locally advanced bladder cancers; one superficial bladder cancer; and two advanced renal pelvic cancers.1,3–7 In all cases, the cardiac metastases were not treated with chemotherapy or surgery. The majority of cardiac metastases arising from bladder carcinoma are clinically silent; electrocardiograms and CT scans are usually normal.5 Cardiac metastases are usually caused by hematogenous spread through the vena cava, and they obstruct the right ventricular outflow tract, which results in acute heart failure. The prognosis of patients with symptomatic cardiac metastases from a transitional cell carcinoma is poor. All seven patients, including our case, died within weeks of the diagnosis of acute heart failure. Although transitional cell carcinoma might respond to chemotherapy (M-VAC, MEC etc.), patients with symptomatic cardiac metastases do not have the luxury of the time that is needed to receive chemotherapy and to then await a response. Although the surgical removal of a solitary cardiac metastasis might be more effective than chemotherapy for palliative symptomatic treatment, surgical treatment cannot be expected to be curative. However, if cardiac metastases are detected on echocardiogram or CT during the asymptomatic stage, the prognosis might be improved by the surgical removal of the tumor and several courses of systemic chemotherapy.1,34

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Case report
  5. Discussion
  6. References