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Journal of Cancer Research and Therapeutics, Vol. 6, No. 3, July-September, 2010, pp. 359-361 Case Report Cardiac involvement in melanoma: A case report and review of the literature Faruk Tas1, Ayse Mudun2, Cevat Kirma3 1 Department of Medical Oncology, Institute of Oncology, University of Istanbul, Onkoloji Enstitusu, Capa, 34390, Istanbul, Turkey Correspondence Address:Faruk Tas, Istanbul Universitesi, Onkoloji Enstitusu, Capa, 34390, Istanbul, Turkey, faruktas2002@yahoo.com Code Number: cr10087 PMID: 21119277 DOI: 10.4103/0973-1482.73371 Abstract Heart is rarely involved in metastatic cancer. A 44-year-old woman diagnosed with melanoma, with extensive metastases to whole body including interatrial septum demonstrated by PET/CT and echocardiography, was presented and discussed in light of the literature.Keywords: Heart, melanoma, metastasis Introduction Heart is rarely involved in metastatic cancer. A 44-year-old woman diagnosed with melanoma, with extensive metastases to whole body including interatrial septum demonstrated by PET/CT and echocardiography, was presented and discussed in light of the literature. Case Report A 44-year-old woman admitted to our Oncology Clinic with stage III melanoma on the occipital region. The patient underwent wide local excision and posterolateral neck dissection in April 2005. The Breslow thickness was 18 mm, Clark level was V, and lesion was ulcerated. Two of twelve dissected lymph node were involved with melanoma cells. Distant metastasis-searching procedures were done and all of them were negative. Therefore, the disease was staged as stage III. Following radiotherapy to neck region, adjuvant therapy with intermediate-dose interferon alpha 2b was started. At sixth month of the interferon therapy, a brain metastasis appeared and lesion was radiated immediately. The metastases work-up used by PET/CT demonstrated extensive metastases to locally lymph nodes, lungs, liver, bones, and subcutaneous soft tissues. In addition to this, PET/CT showed an intense FDG involvement at interatrial region in her heart [Figure - 1]. Its SUV max value was 6.3. At that time, transthoracic echocardiography was performed and a lesion with 0.3 cm diameter was determined [Figure - 2]. The patient was completely asymptomatic for cardiac symptomatology and any cardiac dysarrythmia was not found. Treatment with combination chemotherapy including temozolomide and fotemustine was started. After two cycles of therapy, the cardiac metastasis persisted in image of PET/CT [Figure - 3]. Similar finding was also found in transthoracic and transesophageal echocardiography. Discussion Cardiac tumors are extremely rare. [1] Metastatic disease to the heart is more frequent than primary heart tumors. [2] Cardiac metastasis was found that in 3.4% of the general autopsies and in 11.6% of autopsies in cancer patients. [3] The tumors that most frequently metastasize to the heart are lung and breast cancers, lymphoma, and melanomas, in decreasing order. [1],[4] Recently, melanoma has become a major health problem in many countries. The incidence rate of melanoma is increasing worldwide in a much more rapid fashion than any other human malignancy. The most important feature of melanoma is its extremely high potential to develop metastases. Nearly one third of melanoma patients develop metastatic disease. The most common metastatic sites are the lungs, liver, brain, and bones. Cardiac involvement is rarely identified in clinical base, less than 10%; but is found in over half of patients at autopsy [1],[4],[5] Melanoma accounts for 4.4% of all cardiac metastases. [6] Moreover, melanoma has the highest prevalence of cardiac metastases among malignant diseases. [7],[8] Melanoma spreads to the heart via hematogenous route. Hematogenous metastases to the heart are often associated with hematogenous metastases to other organs similar to our patients. Even though all cardiac structures can be invaded, the metastases mainly involve the pericardium. [1],[2],[4] The left ventricular free wall and the ventricular septum are the most common sites for myocardial lesions. Endocardial metastases manifest as intracavitary lesions. The majority of patients with cardiac metastases are completely asymptomatic because of the small size of the mass and the fact that they do not affect the cardiac function. [9] Actually, most of the cardiac metastases were relatively small, measuring a fraction of a millimeter to less than 5 mm. [1] Therefore, the diagnosis of cardiac metastases was an incidental finding during metastatic work-up process. Likewise, our patient had minimal cardiac metastasis and, therefore, was asymptomatic. When present, clinical signs and symptoms of cardiac metastases are nonspecific and are developed depending on the site and intensity of the involved portion of heart such as pericardial effusion, arrhythmia, obstructed flow, and embolic disorders. Thickening or involvement of cardiac structures cannot be considered as a special sign of metastatic involvement. But, in presence of extracardiac metastatic disease, recognition of the disorder of the patients with cardiac metastatic involvement is not a difficult problem. However, the diagnosis is not so simple when the cardiac involvement is isolated. Cardiac MR imaging and currently PET scanning is clinically indicated to differentiate between cardiac tumor and other space-occupying lesions such as intracardiac thrombus, the most encountered lesion. Conventional staging tests consist of ultrasonography, tomographic scanning of chest and abdomen, magnetic resonance imaging of brain, with or without bone scanning have limited sensitivity and specificity for the detection of melanoma metastases, particularly in asymptomatic patients. [10],[11] In studies of patients with advanced stage melanoma, these routine imaging techniques have a sensitivity of 57%-81% and a specificity of 45%-87% for single melanoma lesions. [10] Whole-body 18 F-FDG has been proven to be superior to standard diagnostic procedures for the detection of distant metastases. [10],[11] In studies and meta-analyses reported in the literature, the sensitivity, specificity, and accuracy of 18 F-FDG PET for detecting recurrent melanoma ranged from 70% to 100% [10],[12] 18 F-FDG PET was also found to be particularly sensitive and specific for the detection of soft-tissue and lymph node metastases that could not be assessed by clinical examination and that were not demonstrated by computerized tomography. [10] Most lesions typically less than 1 cm in diameter missed by 18 F-FDG PET can be detected by CT or MRI for the metastases. Therefore, 18 F-FDG PET should complement rather than replace CT or MRI in patients with suspected melanoma disease. [10] Recently, PET/CT was found to be significantly more accurate than PET alone and CT alone for the staging of visceral and nonvisceral metastases. [10] The superior accuracy of PET/CT over that of PET in the assessment of metastatic melanoma has been reported. [10],[13] PET/CT has a significant impact on the interpretation of suspected metastatic lesions. [10] It is also helpful for the staging of unusual sites of primary melanoma, such as ocular melanoma and vaginal melanoma. [10] Because of limited benefit of chemotherapy, treatment of choice of cases with cardiac metastasis due to melanoma was only palliative. [9] However, for a minority of patients with cardiac metastasis, chemotherapy may be an option. Similarly, our patient received two cycles of chemotherapy and treated unsuccessfully with persistence of the lesion. In conclusion, the growing prevalence of melanoma and FDG-PET can highlight metastases at unusual sites that are easily missed with conventional imaging modalities, cardiac metastasis due to melanoma are encountered in clinical basis as more frequently than formerly. Despite high frequency in autopsy surveys, the clinical diagnosis is made only in few patients. An accurate study of the heart should be planned in initial staging and follow-up of melanoma patients. [ 5] References
Copyright 2010 - Journal of Cancer Research and Therapeutics The following images related to this document are available:Photo images[cr10087f2.jpg] [cr10087f3.jpg] [cr10087f1.jpg] |
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