Metastatic Tumor of the Heart

Clinical History

Increasing dyspnea. History of breast cancer (1970), for which she had undergone a total left mastectomy and adjuvant radiotherapy, chemotherapy and hormonal therapy according to the progression. Known with metastasis in the liver (1977) and skeleton (1992). A recent chest radiograph showed cardiomegaly.

Imaging Findings

The patient, suffering from increasing dyspnea presented with a medical history of breast cancer (1970), for which she had undergone a total left mastectomy and adjuvant radiotherapy, chemotherapy and hormonal therapy according to the progression. She is known with metastasis in the liver (1977) and skeleton (1992). A recent chest radiograph showed cardiomegaly. CT demonstrated a pericardial effusion, associated with multiple nodules on the pericardial surface and a mass of the apical pericardial recess and another one adjacent to the left atrium (fig 2). Echocardiography confirmed the CT findings. At autopsy, one week later, the multiple pericardial masses were demonstrated macroscopically. The largest mass lateral from the left atrium had infiltrated the atrial wall. The pericardial space contained 380 ml of bloody fluid. Histological examination revealed the several pericardial masses to be pericardial metastases from a breast carcinoma.

Discussion

Primary tumors giving rise to cardiac metastasis in descending order of frequency are lung cancer, breast cancer, melanoma and hematologic malignancies (leukemia and lymphoma). Although the radiological diagnosis of pericardial metastases remains rare, autopsy series report a frequency of 5 to 10% of all cancer patients having metastasis to the pericardium. Often these pericardial deposits remain asymptomatic. In many cases they are accompanied by a pericardial effusion. If the pericardial effusion becomes large progressive dyspnea will be the main complaint. Metastatic dissemination to the heart most frequently involves the pericardium. It results from direct extension or through retrograde lymphatic spread. Myocardial involvement is related to direct extension from pericardial and epicardial metastasis or hematogeneous spread. In this case direct extension of a pericardial metastasis to the atrial wall was suggested on CT and histologically confirmed. Endocardial involvement is less frequent and results from a direct extension from myocardial metastasis. Echocardiography can depict large pericardial masses and pericardial effusion. It is widely available but differences in body habitus can be a major obstacle. Although MRI is more sensitive in characterizing heart neoplasm and in demonstrating pericardial effusion, CT can provide excellent density resolution. It is a sensitive, non-invasive imaging method to localize pericardial masses. Pericardiocentesis or thoracotomy and biopsy are necessary for the definitive diagnosis of pericardial metastasis. The most severe complication of primary or metastatic neoplasm is heart tamponade. This is secondary to a large pericardial effusion or an infiltrating tumor mass. Differential diagnosis has to be made with primary neoplastic disease of the heart. The most frequent primary heart tumors are myxoma and rhabdomyoma.

Differential Diagnosis List

Final Diagnosis

Metastatic tumor of the heart

URL:	https://eurorad.org/case/941
DOI:	10.1594/EURORAD/CASE.941
ISSN:	1563-4086