Cancer Therapy Vol 3, 1-4, 2005

1Gynecology Oncology Department, Vali —Asr Hospital, Tehran University of Medical Sciences, Keshavarz Blvd., Tehran 14194,Iran

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Key words: Cervical carcinoma, Heart metastasis

Cervical carcinoma is the 3^rd 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.

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.

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.

Figure 1. Echocardiography showing right ventricular tumor

Table 1. Cases of reported premortem diagnosis of cardiac metastasis from cervical carcinoma