A 66-year-old man presented with progressive exertional dyspnea and chest discomfort for 1 week. Initial physical examination was unremarkable. Electrocardiography (ECG) showed sinus tachycardia with extensive ST-segment elevation at leads I, II, III, aVF, and V3-V6 (Fig. 1A) without significant dynamic change on serial follow-up ECG. Emergency coronary angiography was performed, which demonstrated normal coronary arteries. Transthoracic echocardiography revealed an infiltrative mass (Fig. 1B) occupying the left ventricular (LV) apex with apical hypokinesis. Late gadolinium enhancement cardiac magnetic resonance imaging confirmed the ill-defined intramyocardial mass at the mid-to-apical lateral LV wall, with peripheral enhancement and central necrosis (Fig. 1C), suggestive of cardiac metastasis. Contrast-enhanced computed tomography of the chest revealed a cavitating mass with an irregular margin at the right upper lung field (Fig. 1D) along with mediastinal lymphadenopathy. Histopathologic findings from the bronchoscopic biopsy of the lung unveiled moderately differentiated keratinizing squamous cell carcinoma (Fig. 1E). All the findings were suggestive of LV myocardial metastasis of primary lung cancer causing persistent ST-segment elevation. Although receiving palliative chemoradiation therapy, ST-segment elevation was persistent, and the patient died 2 months later.
Figure 1.
(A) Electrocardiography showed sinus tachycardia with extensive ST-segment elevation at leads I, II, III, aVF, and V3-V6. (B) Transthoracic echocardiography depicted an infiltrative mass (asterisk). (C) Late gadolinium enhancement cardiac magnetic resonance imaging demonstrated the ill-defined intramyocardial mass at the mid-to-apical lateral LV wall with peripheral enhancement and central necrosis (asterisk). (D) Contrast-enhanced computed tomography of the chest revealed a cavitating mass with an irregular margin at the right upper lung field (white arrow) and mediastinal lymphadenopathy. (E) Bronchoscopic biopsy of the lung unveiled moderately differentiated keratinizing squamous cell carcinoma (red arrow). LV, left ventricle; RV right ventricle
Cardiac metastasis is usually considered a rare condition; however, its incidence ranges from 2.3% to 18.3% of cancer cases evaluated at autopsy and up to 31% for primary lung cancer.1,2 Clinical presentations of cardiac metastasis are highly variable.1 Direct invasion of the myocardium, even without coronary obstruction, can result in clinical findings that might mimic acute coronary syndrome.3 In patients with underlying cancer, although some clinical features—for example, subacute to chronic onset of symptoms, diffuse and persistent ST-segment elevation on ECG, and presence of cardiac mass or pericardial effusion on cardiac imaging—may favour cardiac metastasis, acute coronary syndrome cannot be excluded until coronary angiography is performed. The survival time of cardiac metastasis, when presented with ST-segment elevation, ranges from 2 days to 3 months, indicating poor prognosis.3 Multimodality imaging plays a major role in the assessment of the extent of disease, providing a differential diagnosis and helping with assessment of prognosis and treatment planning.
Novel Teaching Points.
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Direct invasion of the myocardium from metastasis, even without coronary obstruction, can result in clinical findings that might mimic acute coronary syndrome (ACS).
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Even in the circumstance that cardiac metastasis is the favouring cause of ST-segment elevation, ACS cannot be excluded until coronary angiography is performed.
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ST-segment elevation caused by cardiac metastasis can persist for a long duration.
Acknowledgements
The authors acknowledge the support for article processing from the Cardiac Center, King Chulalongkorn Memorial Hospital.
Ethics Statement
The research reported has adhered to the relevant ethical guidelines.
Patient Consent
This is a retrospective case report using deidentified data; therefore, the instutional review board (IRB) did not require consent from the patient.
Funding Sources
No funding was provided for this paper.
Disclosures
The authors have no conflicts of interest to disclose.
Footnotes
See page 58 for disclosure information.
References
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