Solitary right ventricular metastasis of endometrial adenocarcinoma

Abstract

A woman presented with a solitary cardiac metastasis 5 months after curative surgery for endometrial adenocarcinoma (FIGO IB). The tumor was deemed inoperable and palliative ambulatory chemotherapy was initiated. We aimed at a palliative reduction of tumor mass after chemotherapy and atypical vascularization of the metastasis was demonstrated by coronary angiography. We identified two tumor vessels originating from the ramus circumflexus suitable to palliative percutaneous coronary intervention. Within 5 weeks, the initially mild dyspnea increased to New York Heart Association class III and readmission was planned. Regrettably, our patient died from congestive right heart failure only 2 months after diagnosis of tumor recurrence. This report illustrates the need for resolute action without delay even in cases of only mild right heart failure.

<Learning objective: Right ventricular metastasis of gynecologic cancer is a rare phenomenon and prognosis of symptomatic patients is poor. In carefully selected patients with symptomatic disease, a palliative percutaneous intervention is feasible and, if appropriate, should be discussed in an interdisciplinary fashion without delay.>

Case report

A 64-year-old woman presented with swelling of her left leg and mild dyspnea [New York Heart Association (NYHA) class II]. Her medical history consisted of a poorly differentiated adenosquamous carcinoma of the uterus (FIGO 1B, G3). To date, the patient was classified disease-free 5 months after curative surgery (hysterectomy and bilateral salpingo-oophorectomy) with postoperative radiotherapy and denied any B symptoms.

Ultrasound revealed old iliacal deep venous thrombosis with only mild elevation of d-dimer (1.2 mg/l). Subsequent computed tomography detected diffuse pulmonary embolism as a probable cause of dyspnea and, surprisingly, a large mass in the right ventricle (RV). Echocardiography showed a nearly complete obstruction of the dilated RV with the beginning of obstruction of the inflow tract, moderate tricuspid regurgitation, developing hepatic congestion, and floating parts of the huge intracardiac mass (Fig. 1, Fig. 2). Echocardiographic measured RV pressure was 30 mmHg, basal RV and areas without direct tumor contact showed good kinetics (tricuspid annular plane systolic excursion or TAPSE was 2.2 cm).

Fig. 1.

Cardiac metastasis causing nearly complete obstruction of the dilated right ventricle, short-axis view.

Fig. 2.

Cardiac metastasis causing nearly complete obstruction of the dilated right ventricle, apical four-chamber view.

Magnetic resonance imaging showed a 6 cm × 5 cm homogeneous mass descending from the rear wall of the RV and a cardiac tumor, most probably a solitary cardiac metastasis, was diagnosed. Interestingly, the electrocardiogram (sinus rhythm 82/min) showed negative T waves in the inferior leads but no right bundle-branch block.

We performed a diagnostic pericardiocentesis of the moderate pericardial effusion (2 cm) of minor hemodynamic significance without detection of malignant cells. An ultrasound-guided transvascular RV biopsy then verified the diagnosis of a cardiac metastasis of the endometrial adenocarcinoma (estrogen receptor negative, pan-cytokeratin AE1/3 and Vimentin positive, Ki 67 index 40%) with adherent thrombus formation.

The tumor was deemed inoperable given its size and the vast involvement of the myocardium.

Tumor staging revealed advanced disease (FIGO IVB) with suspect iliacal lymph nodes and, after discussion at the tumor board, palliative chemotherapy with carboplatin and paclitaxel was initiated.

In order to gain symptom relief and improve quality of life, we aimed at a palliative reduction of tumor mass after chemotherapy. By means of coronary angiography, atypical vascularization of the metastasis from the surrounding coronary artery system was demonstrated. We identified two tumor vessels originating from the ramus circumflexus suitable for palliative percutaneous coronary intervention, analogous to transcoronary ablation of septal hypertrophy (TASH) (Fig. 3). Because of the stable hemodynamic status and the availability of this established oncologic chemotherapy we abstained from an immediate interventional approach and intended a reevaluation after completion of the chemotherapy cycles.

Fig. 3.

Tumor vascularization originating from the circumflex coronary artery.

Within 5 weeks, the initially mild dyspnea increased to NYHA class III with peripheral edema, and readmission to our department was planned. Regrettably, our patient died from congestive right heart failure only 2 months after first diagnosis of tumor recurrence.

Discussion

Right ventricular metastasis is a generally rare phenomenon. The three most common malignant neoplasms appear to be carcinoma of the lung, esophageal carcinoma, and lymphoma [1]. A literature search for particular metastatic spread of endometrial adenocarcinoma to the right ventricle revealed only four cases 2, 3, 4, 5. Right heart catheterization and biopsy, if necessary, should be performed under ultrasound guidance, for fatal adverse hemodynamic consequences have been reported [6].

The intracardiac mass may initially be asymptomatic but subsequent obstruction of the RV outflow tract can swiftly accelerate the course of the disease resulting in poor prognosis 2, 4, 6.

To date, only few cases of interventional therapy of metastatic RV obstruction are described in the literature. Valentin and Butz reported one case each of coiling of tumor vessels (leiomyosarcoma of the uterus and renal cell carcinoma) with an asymptomatic survival of over 10 and 19 months, respectively. Kotani et al. reported a case of successful transcoronary chemoembolization for relief of RV outflow obstruction derived from hepatocellular carcinoma 7, 8, 9.

The main objective of an intervention in the case of symptomatic obstruction is a palliative tumor-mass reduction with concomitant reduction of RV pressure and amelioration of congestive right heart failure.

Definitive preinterventional identification of main tumor feeding branches is obligatory and can be done by simple coronary angiogram or by intracoronary contrast injection through the balloon catheter under transesophageal echocardiographic control prior to induction of the necrosis 7, 8. It remains unclear whether chemoembolization or coiling of the tumor vessels will lead to best results and carries the lowest risk of complication (e.g. RV rupture). Recommended safety measures should include periinterventional monitoring of vital function and cardiac enzymes, pacemaker back up, and analgesic treatment with morphine.

Conclusion

Altogether, an interventional approach has been described as a feasible procedure for interdisciplinary palliative therapy of symptomatic metastatic RV obstruction and should be evaluated early, while the natural course of symptomatic disease is rapidly deteriorating and no time is to be lost.

Conflict of interest statement

There are no disclosures or conflicts of interest.