Malignant cardiac metastasis from breast cancer: Imaging contribution to surgical attitude

doi:10.4236/crcm.2013.28118

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Vol.2, No.8, 450-453 (2013) Case Reports in Clinical Medicine

http://dx.doi.org/10.4236/crcm.2013.28118

Malignant cardiac metastasis from breast cancer:

Imaging contribution to surgical attitude

Victor J. Ovejero-Gomez1*, L. Martin-Cuesta2, V. Alija3, J. Villalba4, J. Rodríguez-Cabello2,

J. Perez5, J. M. Bajo-Arenas4

1Department of Surgery, Hospital Sierrallana de Torrelavega, Torrelavega, Spain; *Corresponding Author: [email protected]

2Department of Radiology, Hospital Sierrallana de Torrelavega, Torrelavega, Spain

3Department of Medical Oncology, Hospital Sierrallana de Torrelavega, Torrelavega, Spain

4Department of Gynaecology, Hospital Sierrallana de Torrelavega, Torrelavega, Spain

5Department of Cardiology, Hospital Sierrallana de Torr el avega, Torrelavega, Spain

Received 30 July 2013; revised 28 August 2013; accepted 30 September 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Metastasic cardiac disease from the breast is

rarely diagnosed in the lifetime. It has a poor

prognosis and limited management. Both echo-

cardiography and computerized tomography

(CT) should be the first imaging studies in sus-

picion of this entity. Other diagnostic methods

should be based on the possibilities of treat-

ment although a histopathological analysis of

the metastasic mass is needed to confirm the

diagnosis. Magnetic resonance imaging (MRI)

could be useful to complete a morphological

and functional evaluation in case of surgical re-

moval.

Keywords: Cancer; Breast; Metastasis; Cardiac;

Imaging

1. INTRODUCTION

The most common malignant neoplasms that metas-

tasize to the heart are lung, breast and esophageal cancers,

lymphoma, leukaemia and melanoma [1], which have the

highest prevalence of cardiac metastasis per 100 cases of

any neoplasm.

Malignant cardiac metastasis from breast cancer

usually appears late in the context of a wider involve-

ment and only 10% of them have symptoms. They

frequently contribute to the mechanism of death.

Advances in imaging techniques have improved cli-

nical diagnosis despite its poor prognosis. The treat-

ment includes a combination of surgery, radiotherapy and

chemotherapy.

The value of radiological findings could be helpful to

guide a therapeutic approach.

We present a female patient diagnosed with breast

carcinoma, who suffered from asymptomatic regional

recurrence and metastasic involvement of the right side

of the heart. Our aim is to analyze the current imaging

methods in cardiac metastasic neoplasms according to

both their cost-effective and therapeutic profitability.

2. CASE REPORT

A 54-year-old woman with previous medical history of

hypertension and hypercholesterolemia underwent tumo-

rectomy with negative margins and negative sentinel

lymph node for a left-breast ductal carcinoma with

hormone receptor-positive. Six months later, she pre-

sented palpable axillary nodes on physical examination.

A left-axillary lymphad enectomy was carried out and the

histologic specimen demonstrated two positive lymph

nodes over the fifteen removed. Postoperative, the pa-

tient was staged as pT2pN1M0.

It was indicated both adjuvant chemotherapy and

radiotherapy. In the clinical follow-up, the patient touched

a node on her surgical scar and a new biopsy indicated

malignancy. An analysis of biomarkers showed a high

value of Ca 15.3 (181.6 U/L, normal rate < 25) and CEA

(29.2 µg/L, normal rate < 3.5).

A simple mastectomy was performed and she was

treated with hormone agents.

She was in complete remission for a short-term due to

another asymptomatic local soft-tissue recurrence and

proposed for s urgical approach.

A CT-scan showed a local malignant progression onto

thoracic wall and a myocardial mass (Figures 1 and 2)

with repolarization changes in EKG, which were not

evident on radiological and clinical studies before.

V. J. Ovejero-Gomez et al. / Case Reports in Clinical Medic ine 2 (2013) 450-453 451

Figure 1. Axial contrast material-enhanced CT scan shows

myocardial mass with endocardial extension in the anterior

wall and septum of the right ventricle.

Figure 2. Triphasic helical CT. Axial image. Arterial (3a),

venous (3b) and delayed (3c) phases show a low attenuation

mass in the right ventricle myocardium with homogeneous

subtle enhancement and delayed wash-out.

An echocardiogram (Figure 3) showed a partial

myocardial wall achinesia in right ventricle and one

endoluminal lesion with a broad myocardial infiltration

as it could be demonstrated by a further magnetic re-

sonance imaging (Figure 4). A biopsy was taken but in-

flammation could only be evidenced on insufficient

sample.

She underwent palliative chemotherapy and surgical

approach was ruled out.

On the last follow-up two months later, there was a

progression of the disease. Shortly afterwards, our pa-

tient died from cardiogenic shock due to massive in-

volvement of the heart.

3. DISCUSSION

Breast cancer is the second most common cause of

Figure 3. Echocardiography in this patient shows akinetic

right ventricle with a space-occupying lesion suggestive of

infiltration of medioapical segments.

Figure 4. Axial (4a) and sagital (4b) MPR images display the

mass affecting the right ventricle myocardium with endo-

cardial growth and protrusion along the cardiac border.

cancer-related death in women, behind lung carcinoma.

The thorax is a common site of mammary metastasis as

both soft-tissue recurrence and lung metastasis. Nonethe-

less, the heart is often involved in patient lifetime,

although they are usually asymptomatic and found late,

even at autopsy [2,3]. This feature is common to other

metastasic tumours to the h eart [1].

Most of breast carcinoma metastasizes to the right side

of the heart by direct ex tention due to its close proximity

and the first metastasized layers are usually pericardium

and epicardium. Hematogenous and lymphatic pathways

are uncommon due to the strong and metabolic pecu-

liarities of myocardial striated muscle, and the fast blood

flow through the heart and lymph flow moving away

from the heart [4].

Some reported cases, similar to ours, were diagnosed

as a late cardiac disease on the left ventricle after a

mastectomy and pulmectomy which could support this

V. J. Ovejero-Gomez et al. / Case Reports in Clinical Medic ine 2 (2013) 450-453

452

sort of dissemination [5]. On the contrary, an early

soft-tissue recurrence on a rib cage and a right ventricle

mass seemed to suggest that this cancer was spread by a

direct pathway.

In patients with clinical suspicious of cardiac meta-

stases from breast, a first imaging study should be

performed to evaluate the chest wall, lung, pleura and

mediastinum to rule out other spreads which could

modify the therapeutic strategy.

A focused imaging study on cardiac metastasis should

be considered cost-effectiveness of the radiologic method

due to the poor progn osis of the disease, even thou gh the

surgical removal is indicated.

Echocardiography is a noninvasive imaging study and

the first diagnostic choice which could provide infor-

mation about th e size and locatio n of the metastasic mass

[6]. The cardiac CT scan and MRI could be useful to

evaluate the local recurrence and cardiothoracic

metastasis with regard to anatomical relations when a

surgical removal has been planned.

In fact, some of these patients present their first

recurrence either on the chest wall or lymph nodes. Pul-

monary and cardiac metastasis will appear soon after-

wards [7].

Nonetheless, CMR offers a better contrast resolution

to distinguish among the mass, thrombus and blood flow

artifact with typically low signal intensity on T1-

weighted images and higher signal intensity on T2-

weighted images unlike other cardiac metastasis as mela-

noma [8].

Nowadays, ultrasonography enables a better perfor-

mance from a practical point of view: A histological

sample can be obtained by transesophageal echo-guided

biopsy instead of cardiac catheterism, and a 3-dimen-

sional transthoracic echocardiography (3D-TTE) is able

to show cardiac functional volumes and 3D images about

tumoral mass’ surface, type, location and anatomic re-

lations with greater accuracy than 2D-TTE which under-

estimates the cardiac function and volume mass [9].

Positron emission tomography and other techniques of

scintigraphy are imaging methods to confirm the ma-

lignancy and card iac function although its co ntribution is

limited [10].

In the postoperative follow-up for breast cancer, local

recurrence should be evaluated primarily by physical

examination and mamography, with a sensitivity of 79

and 45% respectively, although this imaging technique

could be compromised by the presence of postoperative

distorsion and the increased density of an irradiated

breast. Ultrasonography could be more helpful thanks to

a higher sensitivity, superior to 90%.

However, computed tomography is the most sensitive

examination to detect thoracic metastasis and regional

recurrence. It should be the first choice in imaging

methods because it allows a more accurate determination

of recurrence and is able to demonstrate clinically

unsuspected disease in 49% of patients.

The use of other imaging studies depends on the

planned therapeutic management since its diagnosis is

not a surgical contraindication by itself if this option is

considered.

Most cardiac metastases from breast carcinoma are

incurable and a palliative therapy based on a systemic

chemotherapy only should be offered because radio-

therapy is rarely helpful and indicated to relieve symp-

toms [11]. An echocardiography, CT or MRI and echo-

guided biopsy could be enough to make a decision in

these cases.

Nonetheless, some patients who suffer from tampo-

nade or obstruction of blood flow could undergo pal-

liative emergency surgery although a lot of these cases

have been reported with a high postoperative mortality

due to cardiological complications [12].

This unforeseeable development of the natural history

of the disease should not justify a previous detailed

imaging study because the most common cause of death

is used to being a cardiorespiratory arrest without any

surgical chance.

A complete imaging study only should be indicated

when a surgical removal is planned.

Radiological contribution should focus on the diag-

nosis and functional or morphological characterization of

the heart by MRI and echocardiogram to support the

therapeutic management decision.

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ABBREVIATIONS

CT: Computed tomography

MRI: Magnetic resonance imaging

Ca 15.3: Carbohydr ate antigen 15.3

CEA: Carcinoembryonic antigen

EKG: Electrocardiogram

CMR: Cardiovascular magnetic resonance

3D-TTE: Three-dimensional transthoracic echocardiography

3D images: Tridimensional images

2D-TTE: Two-dim ensional transthoracic echocardiography

MPR: Multiplanar reconstru c tion.