Cardiac metastasis from gastric adenocarcinoma: A rare case report

Abstract

Introduction and significance

Cardiac dissemination of gastric adenocarcinoma represents an exceedingly uncommon clinical scenario. To date, there is an absence of documentation concerning the presence of tumor emboli within the cardiac chambers originating from gastric cancer, particularly following a possible transvenous migration.

Case presentation

This report delineates the clinical journey of a 60-year-old female diagnosed with inoperable diffuse gastric adenocarcinoma, who developed cardiac metastases.

Clinical Discussion

The prognostication of isolated cardiac metastasis in oncology patients is fraught with difficulty due to its infrequency and non-specific clinical manifestations. While systematic screening for cardiac metastasis is not part of standard oncological protocols, heightened vigilance is warranted in specific scenarios such as advanced-stage malignancies or in the presence of suggestive cardiac symptomatology, thereby prompting further exploration.

Conclusion

Cardiac metastasis, while infrequent, constitutes a dire clinical entity that must be contemplated in the differential diagnosis of cardiac mass presentations in individuals with a neoplastic history. Prompt recognition and deployment of appropriate diagnostic imaging are pivotal for informed therapeutic decision-making. An integrative, multidisciplinary strategy is imperative for the formulation of an optimal treatment paradigm, encompassing surgical and palliative care options.

Key clinical message

Cardiac metastasis of gastric adenocarcinoma are extremely rare, however, in gastric cancer cases with cardiopulmonary manifestation should be considered as a probable differential diagnoses.

Highlights

• •Cardiac metastasis of gastric adenocarcinoma is extremely rare, however should be considered in cases with cardiopulmonary manifestation.
• •There is no report of tumor emboli with gastric adenocarcinoma origin in litratures.
• •The possible pathway for cardiac tumor emboli originating from gastric cancer, is intravenous seeding.
• •In this paper a 60-yaer-old female with inoperable diffuse gastric cancer with cardiac metastasis is reported.

1. Introduction

The metastatic invasion of neoplastic cells to the cardiac milieu, known as cardiac metastasis, is an event of marked rarity and clinical understatement. Typically asymptomatic, these secondary cardiac malignancies are often only unveiled posthumously during autopsy examinations.

Out of all autopsies conducted in previous studies, approximately 1.2 % of cases showed evidence of cancer cells spreading to the heart [1].

The propensity for cardiac metastasis is not uniform across all cancer types; rather, it is more frequently associated with malignancies such as melanoma, lymphoma, leukemia, and carcinomas originating from the lung, breast, and esophagus. In stark contrast, cancers arising from abdominal organs located below the diaphragm—specifically the liver, pancreas, and kidneys—are seldom implicated in cardiac metastatic disease [2].

Cardiac metastasis typically emerges within the context of widespread metastatic cancer, indicating a disseminated disease state rather than an isolated cardiac involvement. The predictability of a cardiac-only metastasis in patients with cancer remains an enigma within oncological medicine. [3]

Overall, cardiac metastasis is a rare phenomenon that is often asymptomatic and may only be recognized after death. It is more frequently encountered in certain malignancies and in the setting of extensive metastatic burden.

In this study, a 60-year-old female patient reported a known case of inoperable diffuse sclerosing gastric adenocarcinoma who presented to the hospital with complaints of dyspnea and progressive chest pain, and laboratory studies demonstrated isolated cardiac metastasis from gastric adenocarcinoma.

The work has been reported in line with the SCARE criteria [4].

2. Case presentation

We present the case of a 60-year-old female with a diagnosis of unresectable diffuse sclerosing adenocarcinoma of the stomach, who was under a chemotherapy regimen. The patient's oncological journey began eight months prior, when persistent epigastric pain, refractory to proton pump inhibitor therapy, led to an upper gastrointestinal endoscopy which revealed gastric cancer. Given the inoperable nature of the malignancy, she was enrolled in a chemotherapeutic protocol. The patient came to the hospital with complaints of progressive shortness of breath and chest pain. Her clinical presentation was not complicated by cough, fatigue, myalgia, headache, diarrhea, or anosmia. On physical examination, she was afebrile with a temperature of 36.8 °C, maintained oxygen saturation at 98 %, and showed no abnormal pulmonary auscultation findings. Also, blood pressure was 90/50; Heart rate 120. Auscultation revealed a cardiac murmur, and she was experiencing dyspnea classified as NYHA functional class III-IV. The initial workup included a negative nasal PT-PCR test for COVID-19. A spiral chest computed tomography scan without contrast did not demonstrate any evidence of coronavirus infection. Therefore, transthoracic and transesophageal echocardiography was conducted. These imaging modalities uncovered severe right ventricular enlargement and systolic dysfunction, a D-shaped interventricular septum due to right ventricular overload, and a sizable, hypermobile vermiform mass within the right atrium, measuring over 6 cm in length and 1 cm in thickness. This mass appeared to be free-floating and intermittently occluding the tricuspid valve during diastole, suggestive of an embolic phenomenon (as depicted in Fig. 1 and Supplementary Video 1).

Fig. 1.

The echocardiography with transthoracic view of tumor thrombosis with extension into right ventricle cavity.

The clinical decision was made to proceed with urgent cardiac surgical intervention. The mass was successfully excised using a total inflow occlusion technique on the beating heart (illustrated in Fig. 2). Postoperatively, the patient required mechanical support with a right ventricular assist device due to severe right ventricular dysfunction. A whole-body positron emission tomography (PET) scan was conducted, revealing no evidence of extra-cardiac metastatic disease. Pathological examination of the excised mass confirmed the suspicion of a tumor embolus, with its origin traced to gastric adenocarcinoma.

Fig. 2.

Gross specimen of removed lesion from right atrium.

3. Discussion

The occurrence of cardiac metastasis is indeed a rare phenomenon and frequently goes undetected due to its asymptomatic nature. The fact that it is usually discovered during postmortem examinations highlights the difficulty in diagnosing this condition in living patients. This raises questions about the need for improved screening methods and diagnostic tools to detect cardiac metastasis at an earlier stage [5].

One important aspect to consider is the types of cancer that are more prone to spreading to the heart. It has been observed that cancers originating below the diaphragm are less likely to metastasize to the heart. This suggests that there may be certain biological or anatomical factors that make the heart less susceptible to metastatic spread from these types of cancers. This observation points to potential biological or anatomical barriers that could inspire preventive strategies or targeted therapies [6].

Young JM's work is relevant here; of 476 tumor-related deaths with cardiac involvement, only 2 had metastatic cardiac lesions, and none had solitary cardiac metastasis, suggesting hematogenous spread [7]. Bussani et al. reported a mere 8 % of cardiac metastases in autopsies originated from stomach cancer and typically involved the pericardium, again without solitary cardiac metastasis [8]. In a study involving 12,485 autopsies, KY Lam et al. discovered that 4 % of cardiac metastases have a gastrointestinal origin.

The tumor's highly rare thrombotic condition, which caused the lesion to float and become hypermobile, is what makes the current case special. The pericardium typically becomes infiltrated by adenocarcinoma that has spread to the heart via the lymphatic system.

Several factors such as the heart's vigorous motion, myocardial cell properties, rapid intracardiac blood flow, and efficient lymphatic drainage are believed to mitigate against cardiac metastasis. [9] Despite these protective mechanisms, metastasis can occur via direct extension, hematogenous spread, lymphatic channels, transvenous routes, or a combination thereof. Lymphatic spread is presumed to be the predominant pathway for cancers that have spread to adjacent organs, such as the lungs. [1,2,11]

In our case, the characteristics of the metastatic mass in the right atrium, and the absence of infiltration, suggest a transvenous metastasis [10]. The lymphatic route would more likely result in pericardial involvement, while the seeding from gastric tumor cells would follow the path to the liver, inferior vena cava, and ultimately the right atrium.

As in our case, the patient experienced NYHA class III-IV dyspnea with appropriate O2 Saturation and an elevated respiratory rate, which was the first indicator of a cardiac cavity metastatic tumor in previous research. The viral acute respiratory syndrome was initially diagnosed as a result of the COVID-19 pandemic. However, the reverse transcriptase chain reaction test for COVID-19 RNA yielded negative results at the subsequent stage. There were no additional signs of COVID-19 infection, and hemodynamic abnormalities raised the possibility that there might be a cardiac etiology. This led us to undertake transesophageal echocardiography, which identified the tumor in the right atrium. Hypotension, a muffled heart sound on auscultation, tachycardia, arrhythmia, cardiomegaly, heart failure, and in one instance, jugular vein distension and pulsus paradoxus, are additional first symptoms [1,5,9,11].

The symptoms arise from the mass's obstructive effects on the cardiac structures or infiltrative complications such as pericardial effusion or tamponade [6].

Cardiac metastasis tends to present more commonly in multi-organ metastatic scenarios, suggesting a correlation between widespread metastasis and cardiac involvement, warranting further research [12].

This case highlights the difficulty in accurately diagnosing cardiac metastasis, as it can often mimic other conditions such as thrombosis or vegetation. Trans-Esophageal echocardiography is a useful tool in identifying cardiac masses, but further testing such as immunohistochemistry may be necessary to confirm the diagnosis [13].

The fact that the initial diagnosis was thought to be a thrombus emphasizes the need for thorough investigation and consideration of all possible causes when a cardiac mass is identified. This suggests that imaging techniques such as cardiac MRI and CT can be valuable in detecting and assessing the extent of cardiac metastasis. These imaging modalities can provide important information for accurate diagnosis and treatment planning [1,14].

Overall, this case highlights the importance of considering cardiac metastasis as a potential cause of cardiac masses, especially in patients with a history of malignancy. Thorough investigation and appropriate imaging techniques, such as trans-esophageal echocardiography, immunohistochemistry, and late gadolinium-enhanced cardiac MRI, can aid in accurate diagnosis and management of these cases.

Patients with cardiac metastatic tumors have a dreadful prognosis. The patient needs the metastatic mass removed right away to preserve his or her life due to the obstructive mass, low cardiac input and subsequently reduced output, hypotension, potential arrhythmia, and in certain circumstances, pericardial effusion and tamponade (as previously indicated). This operation carries a very high risk of bleeding, ventricular dysfunction, tumor cells seeding, or, in some circumstances, mortality because of difficult surgical procedures and compromised patient characteristics [15].

The management of cardiac metastasis requires careful consideration of the risks and benefits of surgical intervention. In some cases, surgery may be helpful in relieving symptoms or providing palliation, particularly in solitary metastatic tumors. However, in cases where surgery is not feasible, palliative chemotherapy may be considered to shrink the tumor, maintain cardiac output, and improve survivability [1,16]. The study by Goldberg AD et al. also admitted the concept as well [17].

Predicting the development of isolated cardiac metastasis in cancer patients remains a challenge. Given its rarity and lack of specific symptoms, routine screening for cardiac metastasis is not currently recommended. However, in cases where there is a high suspicion or risk, such as patients with advanced cancer or those with symptoms suggestive of cardiac involvement, further investigations may be warranted [9].

In conclusion, cardiac metastasis is a rare but potentially life-threatening condition that should be considered in patients with a history of malignancy presenting with cardiac masses. Early diagnosis and appropriate imaging techniques are crucial for accurate diagnosis and management. A multidisciplinary approach is necessary to determine the best course of treatment, whether it be surgical intervention or palliative measures. Further research is needed to improve our understanding of cardiac metastasis and develop more effective treatment strategies.

The following are the supplementary data related to this article.

Video 1

Transthoracic ecocardiography.

Consent for publication

Written informed consent was obtained from the patient to publish this case report and any accompanying images. A copy of the written consent is available for review by the journal's Editor-in-Chief.

Availability of data and materials

Data in the current study are available from the corresponding author on reasonable request.

Ethical approval

Our institution does not require ethical approval for reporting individual cases or case series. The present study complies with ethical and research standards involving humans. This article does not contain any studies involving animals performed by any of the authors.

Funding

This study has no financial source and support.

Author contribution

Study concept and design: FJ, SZ

Acquisition of data: FJ, SZ

Drafting of the manuscript: FJ, AP, DN, MME

Critical revision of the manuscript for important intellectual content: SZ

Study supervision: FJ, SZ

All authors read and approved the final manuscript

Guarantor

Fatemeh Jahanshahi

All authors read and approved the final manuscript.

Data in the current study are available from the corresponding author on reasonable request.

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The present study complies with ethical standards and standards of research involving humans. This article does not contain any studies involving animals performed by any of the authors. In our institute at the time of the study, case report studies were not presented to the ethics committee and therefor were not assigned an ethical code. But there was a rule to which information of the patient should not be revealed in the study findings.

Written informed consent was obtained from the patient to publish this case report and any accompanying images. A copy of the written consent is available for review by the journal's Editor-in-Chief.

Conflict of interest statement

There is no conflict of interest to declare.