CARDIAC METASTASIS MASQUERADE AS STEMI D R S R E E K A N T H K O D U R

CARDIAC METASTASIS MASQUERADE AS STEMI D R S R E E K A N T H K O D U R

MR OR, 68 YRS Smoker No prior cardiac hx Lives near Muswellbrook area Called ambulance 3 am Atypical chest pain Life net ecg transmitted to on call AT phone

ECG

Thrombolysed Brought to JHH ED ECG in ED : AF with RVR, ST segment Elevation inferior, Posterior, lateral not resolved Patient asymptomatic Looks well from bed end Troponin 0.88

ECG IN JHH ED

ECHO Akinetic lateral wall and thickened myocardium Overall LV function mildly impaired Infarction and possible LV thrombus

Further management?

MORE HISTORY FROM PATIENT Seen GP few weeks ago Cough/CP/SOB/ Weight loss CT chest performed Suspicious lesion left hilum Referred to Oncology outpatient clinic ECG performed (tachycardic) Abnormal (ST Elevation) Admitted to Tamworth hospital Troponin 0.52

ECG IN ONCOLOGY OUTPATIENTS

CT CHEST There is a filling defect in left ventricle measuring 5.2/2.4 cm confluent left ventricular myocardium,which could represent metastasis from left hilar mass

Diagnosis Likely Metastatic bronchogenic carcinoma (contralateral lung, lymph nodes) Metastasis to left ventricular myocardium

S E C O N D A R Y T U M O R S O F H E A R T Primary Tumors rare ( 0.02% in pooled a u topsy samples) Secondary Tumors (metastasis) up 100 times higher i nci dence Intra cavitary secondary tumors unusual H ence despite their frequency, rarely gain clinical attention

I N C I D E N C E P r e d o m i n a n t l y o c c u r s i n 6 th o r 7 th d e c a d e o f l i f e N o s e x p r e f e r e n c e S o l i t a r y m e t a s t a s i s i s r a r e ( u s u a l l y o c c u r s i n d i s s e m i n a t e d m e t a s t a t i c d i s e a s e ) F r e q u e n c y g e n e r a l l y u n d e r e s t i m a t e d I n c i d e n c e v a r i e s f r o m s e r i e s t o s e r i e s ( a u t o p s y ) U p 2 5 % w h o d i e d o f m a l i g n a n c i e s

Inci dence has i ncreased during recent decades (better treatment of local disease a nd longer survival) M etastasis t o heart increasingly take i n to a ccount, H ence looked for thoroughly during postmortem examination

T U M O R S O F O R I G I N Most common tumors with metastatic potential to heart ( Lung, Breast, Oesophagus, Lymphoma, Leukemia, m elanoma) M elanomas represent highest rate of cardiac m etastasis i n m ore than half cases ( haematogenous s pread)

SITE OF PRIMARY AND INCIDENCE OF CARDIAC METSTASIS

Autopsy series Period from 1972-2004 11 403 a u topsies were performed 2 928 (25.6%)the presence of malignant tumor was diagnosed Vojnosanit Pregl. 2005 Dec;62(12):915-20.

79 (2.7%) of these cases, m etastasis of the heart was found out Only 5 of the cases, the presence of m etastasis i n the heart was diagnosed during the lifetime M ost frequent metastases i n the heart were caused by lung cancer (18 cases)

In 40 (60.76%) cases, the metastasis was localized i n the m yocardium, often in the left v entricle 24 (30.38%) cases in the pericardium In 4 cases in the epi cardium In the 3 of them in the mitral a nd tricuspid v a lve.

M E T A S T A T I C S P R E A D H a e m a t o g e n o u s, L y m p h a t i c, D i r e c t, T r a n s v e n o u s L y m p h a t i c s p r e a d t e n d s t o g i v e t o p e r i c a r d i a l m e t s ( L u n g, b r e a s t, O e s o p h a g u s ) H a e m a t o g e n o u s s p r e a d t e n d t o g i v e m y o c a r d i a l m e t s ( m e l a n o m a, l e u k e m i a, l y m p h o m a ) T r a n s v e n o u s s p r e a d ( R e n a l c e l l c a r c i n o m a )

S Y M P T O M A T O L O G Y Usually remain silent No correlation between extent i nvolvement and symptoms Rapid Increase in heart size due to pericardial effusion Heart failure (Obliteration heart chambers, O u tflow tract obstruction, direct myocardial i nvasion etc)

Arrhythmias and conduction defects Angina a nd MI (embolism/i nvasion ) Ca lung and breast m etastasize preferentially to pericardium

D I A G N O S I S Intracavitary Mets : Murmurs (Systolic Interference of closure of AV v a lves, Diastolic - Tumor related obstruction of left or right v entricular filling) Gallop rhythm Pericardial friction rub Diminished heart sounds

E C G C H A N G E S Usually Non speci fic Pericarditis rarely associated with typical S T changes Low voltage complexes and electrical a lternans VT/SVT

Conduction defects Q waves S T elevation i nfarction ( infiltration or displacement of myocardium)

X R A Y S Increase in cardiac silhouette (pericardial effusion) Pleural effusion (heart failure / Lung tumor) Large size tumors (intra cavitary) a ppear a s filling defects in radio nucleotide or contrast angiography

E C H O Method of choice Thickened pericardium/myocardium Pericardial effusion Pericardiocentesis and fluid analysis

Negative cytology does not exclude m a lignant origin Pericardial bi opsy may be necessary Large myocardial M ets ( regional wall m otion abnormalities)

C T A N D M R I Size and Paracardial and Transpericardial tumor growth determined more precisely Ti ssue differentiation i s possible (Solid/Liquid/Haemorragic/Fatty lesions)

D I F F E R E N T I A L D I A G N O S I S Thrombus, Vegetation, Foreign body Myocardial/Pericardial damage ( Radio therapy or Chemotherapy (Doxo and Dauno rubicin) related

TREATMENT AND PROGNOSIS M a j o r i t y o f c a s e s c a r d i a c m e t a s t a s i s m a n i f e s t i n a d v a n c e d t u m o r d i s e a s e P a l l i a t i v e m e a s u r e s I n s o m e s i t u a t i o n s 1. S u r g i c a l r e s e c t i o n ( S o l i t a r y i n t r a c a v i t a r y m e t a s t a s i s ) 2. C o i l E m b o l i z a t i o n 3. C H B PPM 4. S c l e r o s i n g a g e n t s ( C i s p l a t i n u m s e e m s t o b e m o r e e f f i c a c i o u s ) 5. P e r i c a r d i a l w i n d o w

S I D E E F F E C T S O F C A N C E R T R E A T M E N T A F F E C T I N G H E A R T Radio therapy Fibrosis of myocardium C onduction s ystem disturbance Pericarditis Ischemic heart disease Chemo therapy C a rdiomyopathy ( Doxo /Dauno rubicin, cyclophosphamide etc)

P R E V E N T I O N O F C H E M O T H E R A P Y R E L A T E D L V D Y S F U N C T I O N E n a l a p r i l a n d C a r v e d i l o l f o r P r e v e n t i n g C h e m o t h e r a p y - I n d u c e d L e f t V e n t r i c u l a r S y s t o l i c D y s f u n c t i o n I n t e r v e n t i o n g r o u p h a d a l o w e r i n c i d e n c e o f t h e c o m b i n e d e v e n t o f d e a t h or h e a r t f a i l u r e ( 6. 7 % v s. 2 2 %, p = 0. 0 3 6 ) a n d o f d e a t h, h e a r t f a i l u r e, o r a f i n a l L V E F < 4 5 % ( 6. 7 % vs. 2 4. 4 %, p = 0. 0 2 ) O v e r a l l d i f f e r e n c e i n E F i n 6 % i n i n t e r v e t i o n a n d n o n i n t e r v e n t i o n g r o u p

R A D I O T H E R A P Y A N D I H D Population based case control study Breast cancer patients who received XRT Rates of major coronary events increased linearly with the mean dose to the heart by 7.4% per gray

N ENGL J MED 2013;368:987-98.

Bronchoscopy (Sep 2013) Left bronchus mass and Biopsied Sqamous cell carcinoma Patient underwent palliative chemotherapy (Gemcitabine and Carboplatin) Died, 3 months after diagnosis of malignancy

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