Cancer Therapy Vol 3, 1-4, 2005
Cardiac metastasis from carcinoma of the cervix
Case Report
Nadereh Behtash*1, Haleh Ayatollahi1, Fereshteh
Fakor1, Morteza M Dini2
1Gynecology
Oncology Department, Vali –Asr Hospital, Tehran University of Medical
Sciences, Keshavarz Blvd., Tehran 14194,Iran
2Gynecologic
Oncology, Advocate Illinois Masonic,Medical Center,Rush Medical College, 836
Wellington Chicago IL 60657
__________________________________________________________________________________
*Correspondence: Nadereh
Behtash, Associate Professor, Gynecologist Oncologist, Tehran University of
Medical Sciences. Gynecology Oncology Department, Vali-e-Asr Hospital, Imam
Khomeini Hospital Complex, Keshavarz Blvd., Tehran 14194, Iran. Phone:
#98-21-6939320, Fax: #98-21-6937321, E-mail: valrec2@yahoo.com,
nadbehtash@yahoo.com
Key words: Cervical
carcinoma, Heart metastasis
Abbreviations: patients, (pts); squamous cell
carcinoma, (SCC);
Received: 24 December 2004; Accepted: 14 January 2005;
electronically published: January 2005
Summary
The presence
of cardiac metastasis from cervical carcinoma is extremely rare. Most of the
cases were diagnosed postrmortem. There are a few cases of premortem diagnosis
and it is believed that in these cases, the prognosis is extremely poor. We
present the only case of premortem diagnosis of cardiac metastasis of more than
500 cases of cervical carcinoma in our center during the last 10 years. We present
a 59 years-old woman with multiple ventricular metastasis from cervical
carcinoma, 2.5 years after the primary diagnosis. She died 10 days after
echocardiographic diagnosis of multiple metastatic lesions in heart, following
a massive DIC. The rapidly progressive DIC, and death, in the presenting case,
confirms the previous finding of poor prognosis of patients (pts) with
premortem diagnosis of cardiac metastasis of cervical carcinoma.
I. Introduction
Cervical carcinoma is the
3rd most common cancers in women throughout the world (Disaia and
Creasman, 2002).
In contrast to the
industerialized world, cancer of the cervix remains the primary cancer killer
of women in third–world countries (Disaia and Creasman, 2002).
The incidence of cardiac
metastases at autopsy ranges from 15% to 20% (mean 6%) in patients with
malignant diseases (Abraham, 1990; MacGee, 1991; Lam et al, 1993). Carcinoma of
the lung and breast, malignant melanoma, lymphoma, and leukemias rank among the
most common tumors associated with this condition (Nelson and Rose, 1993;
Shulman et al, 1997). The most common sites of extrapelvic metastasis in
cervical carcinoma are lung, bone, cervical or supracervical lymph node
(Brenner, 1982). The presence of cardiac metastases from cervical carcinoma is
rare (1.8-3%) (Disaia and Creasman, 2002).
Only with a high index of
suspicious, it is possible to make a diagnosis antemortem. It is believed that,
when present, cardiac metastasis from cervical carcinoma represents a rapidly
fatal condition (Jamshed et al, 1996). Presented here is a case of right
ventricular metastases from a stage IIa cervical carcinoma, who died rapidly
after diagnosis.
II. Case
A 59 year–old female, Gravida 8 Para 7 had been
referred to Gynecology Oncologic service in Vali Asr University Hospital in
January 1999. She had postmenopausal bleeding for almost 2 years. In pelvic
exam, there was a large firm endophytic tumoral cervical mass measured 45mm
diameter. Biopsy showed SCC (squamous cell carcinoma).
She underwent a class III
Rutledge Radical Hysterectomy and pelvic and paraaortic lymphadenectomy and
upper vaginectomy in February /99 following 3 courses of neoadjuvant
chemotherapy (Bulky stage IIa) with vincristin plus cisplatin. Preoperative
metastatic work up revealed no abnormal findings in pelvic and abdominal CT
scan, and chest XR. Pathologic report showed involvement of one iliac node and
lower segment of uterus, vaginal margine and parametrium were free of tumor.
She had normal pelvic exam, pap smear ,chest XR and CT , and pelvic CT in
follow-up period of 24 months. In early postoperative visits, she had some
uninary retention symptoms, responded to antibiotic therapy. In June 2001, she
was hospitalized with intractable cough, Chest XR and bronchoscopy showed no
abnormal finding. Her respiratory symptoms diminished after medical management
for asthma. The patient did well until she started to develop dyspnea, weakness
and lower limb edema in early September 2001. Again admitted to the hospital,
abdominal and pelvic CT showed free fluid in pelvis. Echocardiography revealed
multiple right ventricular tumors (Figure
1).This was believed to be consistent with a myocardial metastasis. A few
days later, the patient, deteriorated rapidly and developed DIC, cerebral
hemorrhage and coma, she died on September 2001 one week from diagnosis of
cardiac metastasis.
III. Discussion
Cardiac
metastasis from malignant neoplasm was first described by Bonet in 1700, but
the first antemortem diagnosis of cardiac metastasis was not made until 1924 (Hanfling,
1960). Of all malignancies involving the heart, more than 96% are metastatic
compared to primary (Lam et al, 1993; Nelson and Rose, 1993). The incidence of cardiac metastasis from
carcinoma has increased from 1% in 1891 to 12% in 1953 and has remained stable
at about 10-15% since that time (Prichard, 1951; Murphy et al, 1986). It seems
the more sophisticated diagnostic techniques, are the main cause of this
increasing incidence. Because Patient live longer from their primary malignancy
with metastatic disease in other sites controlled, less common sites of
metastatic involvement have become evident. A number of theories have been
advanced to explain routes of involvement of the heart by metastatic carcinoma.
These include embolic tumor emptying into right side of the heart, other
mechanisms include direct invasion through either direct extension through the
lymphatics of the heart and mediastinal nodes or retrograde lymphatic flow
(Murphy et al, 1986; Kountz, 1993). The occurrences of cardiac metastasis
in general are a relatively rare
event. Prichard suggested four factors possibly contributing to the low
incidence of cardiac metastasis: 1-.The strong kneading action of the
myocardium, 2- metabolic pecularitites of striated muscle 3- the rapid flow of
blood through the heart and 4- lymph flow normally moving away from the heart
(Prichard, 1951).
The incidence of heart
metastases in two most large series, was 10.7%-11.6% in all kinds of human
malignancies (Burke and Virmari, 1996; Senzaki et al, 1999).
The literature lists
breast, lung, lymphoma, lukemia and melanoma as the most frequent primary sites
(Nelson and Rose, 1993; Shulman et al, 1997). The most common location of
cardiac involvement is the pericardium and an endocardium site is very rare (Burke
and Virmari, 1996). The right side of the heart is more commonly involved than
the left side, probably due to direct seeding of the heart by microemboli from
lymphatics and venous return (Yanuck et al, 1991).
One of cardinal feature
involving diagnosis of metastatic carcinoma to the heart is that there is no
early symptom, this was the same as for our patient, she had respiratory
problems and intractable cough for more than 4 months. As the condition
progresses, however,patients will typically complain of dyspnea. Other symptoms
include: pericardial effusion, pericarditis, cardiac tamponade, arrythmias and
sudden death (Yanuck et al, 1991; Kountz, 1993; Okamoto et al, 1993). The
diagnosis is usually made only by a strong index of suspicion.
Chest X- ray finding, can
include pleural effusion and cardiomegaly, though the latter can be absent in
cases of endomyocardial metastases, as with our patient. Other helpful
diagnostic clues are electrocardiographic changes, echocardiography, cardiac
catheterization, CT scanning, MRI scanning and transvenous biopsy (Hanfling,
1960; Cacciapuot et al, 1988; Lee and Fisher, 1989; Shulman et al, 1997).
One report of 1100
gynecologic cancer patients revealed only 6 cases of cardiac metastases
(Greenwald, 1980).
The first antemortem
diagnosis for cervical carcinoma was made by Charles et al, (1977).Badib and
colleauges reported cases of cardiac metastasis from 278 consecutive autopsy
cases with the carcinoma of the uterine cervix (Badib et al, 1968). Antemortem
diagnosis of cervical carcinoma metastatic to the heart is, however exteremely
rare, with only a few cases reported (Table
1).
Interestingly, in many
cases of heart metastases from cervical carcinoma, the tumor metastasizes only
to the right ventricle, and no other site (including the lung) just the same as
our case.
A review of the English
language literature revealed that 22 casesof antemortem diagnosis of cardiac metastasis
from cervival carcinoma have been described (Table 1).
The mean age of these
patients is 45 years (range 28-64). The clinical stage was Ib in 7cases, IIa in
3 cases, IIb is 6 cases, III is 5 cases, IV in 2 cases. The stage of the
disease at initial presentation dose not predict the future development of
cardiac metestasis. The common symptom was shortness of breath and dyspnea
(78%).
The prognosis of these
cases was poor. Patient died on average of 5/5 month after diagnosis.
In conclusion we report a case of stage
IIa squamous cell carcinoma of the cervix, in a 59 year-old woman. She underwent a radical
hysterectomy after 3 courses of neoadjuvant chemotherapy and presented with a
long standing intractable cough and finally dyspnea 30 months after primary
diagnosis. She died rapidly after echocardiographic diagnosis. Imaging
investigations showed no other site of metastasis (Ando et al, 1997).
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