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Introduction

Metastatic malignancies involving theheart occur more frequently than primaryones. Cardiac metastases arise from virtuallyany malignant neoplasm; however, tumorsthat more often metastasize to the heart arecarcinoma of the lung and breast, mesothe-lioma, melanoma and lymphomas, whilesecondary colorectal tumors are rare1,2. Un-fortunately, a complete surgical extirpationof a cardiac metastasis can be rarely obtainedand the only available therapeutic option isoften restricted to a palliative treatment likedrainage of pericardial effusions.

We report the case of a woman previ-ously operated on of colon cancer, present-ing with symptoms of congestive heart fail-ure due to the presence of a mass com-pletely invading the right ventricular cavity.In this case also, surgical intervention wasunsuccessful and the patient died in thepostoperative phase.

Case report

A 69-year-old woman was admitted tothe Cardiology Unit of the S. Orsola Hos-pital for progressively worsening dyspnea.Three years before she had been operatedon of colon resection for a T3,N1,M0 ade-nocarcinoma followed by both chemother-apy and radiotherapy. After a 2-year period

of well-being, she had undergone atypicalwedge resection for metastatic involvementof the right and left lung. Some days beforeadmission to the hospital she developed bi-lateral ankle edema and oliguria and wassent to cardiological evaluation. The clini-cal examination was consistent with the di-agnosis of congestive heart failure whilethe electrocardiogram showed non-specificST-T changes. At transthoracic echocardio-graphy a homogeneous echogenic massfilling almost completely the right ventric-ular cavity was observed, with preservedblood flow only in proximity of the inter-ventricular septum. The mass joined thepulmonary valve without crossing it. Asmall pericardial effusion was also present.

At transesophageal echocardiography itwas observed that the mass not only filledalmost completely the right ventricle (Fig.1A), but also reached the right atriumacross the tricuspid valve (Fig. 1B). As firsthypothesis we considered that of a cancer-related thrombotic nature of the mass andan attempt of pharmacological thromboly-sis with tissue-type plasminogen activatorwas deemed appropriate but was unsuc-cessful, so that the possibility of a metasta-tic origin of the mass was taken into con-sideration. The patient was therefore re-ferred to the University Division of CardiacSurgery. After conventional median ster-notomy, the ascending aorta and both venaecavae were cannulated and cardiopul-

Key words:Colon cancer;Echocardiography;Heart failure; Heartmetastasis.

© 2005 CEPI Srl

Received January 18,2005; revision receivedApril 4, 2005; acceptedApril 7, 2005.

Address:

Dr. Carlo Oneglia

Via Acquafredda, 4125064 Gussago (BS)E-mail:carlo.oneglia@libero.it

Congestive heart failure secondary to rightventricular metastasis of colon cancer.A case report and review of the literatureCarlo Oneglia, Alberto Negri*, Daniele Bonora-Ottoni**, Marco Gambarotti***,Gianluigi Bisleri*, Cesare Rusconi, Claudio Muneretto*

Cardiology Unit, Fatebenefratelli “S. Orsola” Hospital, *Division of Cardiac Surgery, University of Brescia MedicalSchool, **Thoracic Surgery Unit, Fatebenefratelli “S. Orsola” Hospital, ***Second Institute of Pathology, Universityof Brescia Medical School, Brescia, Italy

Although metastatic tumors of the heart occur more frequently than primary ones, infiltration ofthe right heart by a metastatic colon cancer has rarely been reported. We report the case of a womanpreviously operated on for colon cancer, presenting with symptoms of congestive heart failure due tometastatic invasion of the right ventricular cavity. Both transthoracic and transesophageal echocar-diography were useful in detecting the mass, but not in defining its nature. The patient underwent apalliative surgical resection of the neoplastic mass but died soon after the intervention.

(Ital Heart J 2005; 6 (9): 778-781)

monary bypass instituted. The free wall of the rightventricle was thick and woody, infiltrated and calcifiedon its margin. After opening of the right atrium, themetastatic mass was seen protruding into the right atri-al cavity: neoplastic involvement of the tricuspid annu-lus and both the anterior and posterior leaflets were al-so detected (Fig. 2), leaving only a virtual orifice closeto the interventricular septum. The pulmonary valvewas not affected by the cardiac metastasis. Despite acareful resection, the deep infiltration of the tricuspidannulus did not allow replacement of the native valveby means of a prosthesis. A considerable hemodynam-ic instability along with respiratory failure occurred,thus hampering the weaning from cardiopulmonary by-pass and requiring the placement of an extracorporealmembrane oxygenation device. The patient did not re-cover from the mechanical support and died for multi-organ failure.

The histology on the autoptic samples colored withhematoxylin-eosin showed muscular tissue infiltrated

by carcinomatous neoplasia with epithelial cells orga-nized in mostly atypical gland structures (Fig. 3). Histo-chemical analysis with PAS showed intracellular pres-ence of mucus (Fig. 4). Immunochemistry with PANkeratin and cytokeratin 20 confirmed the epithelial ori-gin of the neoplastic cells (Fig. 5). The morphologic,histochemical and immunohistochemical diagnosis wastherefore that of heart metastasis from moderately dif-ferentiated mucinous adenocarcinoma of colonic origin.

Discussion

Cardiac involvement by primary and secondary tu-mors is one of the least investigated issues in oncology,although being a true clinical problem. Old data quotedby Abraham and derived from unselected autopsieswere consistent with an incidence of 0.0017% for pri-mary tumors and of 0.24 to 6.45% for cardiac metas-tases, while Abraham1 himself in 1990 found an inci-

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A B

Figure 1. Transesophageal imaging of right ventricular invasion by the tumoral mass (M) (A) and protrusion of the mass into the right atrium (RA) (B).AO = aorta; LA = left atrium; LV = left ventricle.

Figure 2. Intraoperative view of the tricuspid annulus following excisionof the valvular leaflets.

Figure 3. Hematoxylin-eosin (�10).

dence of 95 cases of cardiac involvement in 806 autop-sies with some kind of malignancy (11.8%), from anoverall number of 3314 consecutive autopsies per-formed over a 14-year period. Later, in their review of12 485 consecutive unselected autopsies performedover a 20-year period in Hong Kong, Lam et al.3 re-ported an incidence of 0.056% for primary and of1.23% for secondary heart tumors, respectively. On theother hand Klatt and Heitz4 had found cardiac metas-tases in 10.7% of 1029 autopsies in which a malignantneoplasm had been diagnosed, while previous studieshad reported a rate of involvement of 1.6 to 20% in sim-ilar settings. Similarly, the Italian study of Silvestri etal.2 on 1928 cancer patients showed an incidence of8.4% of cardiac metastases with a significant decreasein frequency in elderly patients.

Metastatic cancer to the heart assumes greater im-portance nowadays as the incidence of cancer rises andsurvival of neoplastic patients is prolonged due to ear-

lier diagnosis and advances in radiotherapy andchemotherapy, so that the incidence of secondary tu-mors to the heart will be progressively increasing. Theprobability of heart metastases must therefore bedeemed higher than in the past and more often suspect-ed after considering the nature of the primary tumor: inthe study of Silvestri et al.2 mesothelioma, melanomaand lung cancer, as origin of cardiac metastases, had thehighest frequency in males (100, 50 and 31% respec-tively), while in females the sequence in decreasing or-der was that of melanoma (45%), lung tumors (26%)and renal neoplasms (20%). Data from Lam et al.3 alsoreport lung carcinoma as the overall most frequentsource of heart lesions, followed by esophageal carci-noma and lymphoma.

Neoplasms originating in colon and rectum andcausing secondary heart lesions are rather rare: in theirstudy of 1095 primary cardiac tumors in 1029 autopsiesof malignancies (two separate malignant neoplasmswere found in 66 cases), Klatt and Heitz4 reported on 72cases of colon and rectum as primary sites of tumor,with only 2 metastatic cardiac sites from the 64 patientswith adenocarcinoma (3.1%), while 8 cases of malig-nant carcinoid and of neuroendocrine, cloacogenic andsquamous cell carcinoma did not originate secondary le-sions. A similar value was reported by Abraham et al.1

in their population of 95 patients with secondary heartlesions, where the percentage of subjects with primarycolon cancer was of 3 out of 95, that is 3.2%. In thestudy of Klatt and Heitz4, the epicardium was the regionmost often involved by metastases (75.5%), followed bythe myocardium (38.2%) and the endocardium (15.5%),and of the 2 patients with primary colon tumor, one hadepicardial and the other myocardial involvement.

Cases of ante-mortem diagnosis of heart metastasesfrom colon carcinoma are mainly anecdotal and proba-bly the first reported is that of a patient with tricuspidobstruction and superior vena cava syndrome, causedby a large tumor mass in the right atrium diagnosed bytwo-dimensional echocardiography and confirmed byautopsy5. Teixeira et al.6 reported a similar case of rightatrial obstruction in whom the differential diagnosis be-tween metastasis and thrombotic mass was also dis-cussed but not supported by an autopsy, refused by thepatient’s relatives. Metastases to the right ventriclefrom mucinous colon carcinoma are also rare and de-mand an accurate differential diagnosis7.

The importance of a transthoracic echographic diag-nosis in patients with heart metastases is well recog-nized8-10, and we also reported an echocardiographic di-agnosis of a secondary lesion discovered 5 months afterliver transplantation for cancer11. On the other hand,transesophageal echocardiography did not appear to addmany elements to the diagnosis in the present case: itwas useful in better imaging the mass but did not helpdiagnose its nature nor did help ascertain the severe de-gree of tricuspid annular and leaflet infiltration. Indeedechocardiography can provide preliminary diagnostic

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Figure 4. Staining with PAS (�20).

Figure 5. Anti-cytokeratin-PAN (�40).

information for evaluation of cardiac masses whilecomputed tomography and magnetic resonance imaging(MRI) provide the most complete characterization, fortheir superior tissue resolution and tumor demarca-tion12. Even though excellent in assessment of the leftside of the heart, echocardiography appears limited inthe evaluation of the right heart, mediastinum and parac-ardiac structures, while computed tomography with cur-rent multislice technology allows an excellent visualiza-tion of the extracardiac anatomy. However, computedtomography requires radiation, is limited in the assess-ment of valvular function and, if compared to MRI, isless effective at tissue characterization and tumor delin-eation: therefore, MRI probably plays a more importantrole also since gadolinium-enhanced MRI is superior tocomputed tomography for detection of myocardial in-volvement and usually distinguishes between tumor andintracavitary thrombus, though there may be some over-lap with organized thrombi13. A case of ante-mortemMRI diagnosis of metastatic colon cancer to the rightventricle has been reported by Testempassi et al.14.

Even though in our patient we considered of beingcompelled to an urgent intervention for the rapid wors-ening of the clinical conditions, surgery should perhapshave been avoided if the neoplastic nature of the masshad been more definitely ascertained: definite thera-peutic guidelines for these pathologies have not beenestablished until now, the patient’s outcome seems un-favorable in any case and surgery is not therapeutic,even if in sporadic cases an aggressive surgery has en-abled prolonged survival15. We however also consid-ered that among alternative choices, chemotherapy isgenerally judged inadequate by the oncologists, for po-tential fragmentation and dissemination of the mass,while radiotherapy seems to be avoided for its radia-tion-induced effects on the pericardium and myocardialwall. On the other hand, patients not sent to interven-tion can die of intractable shock16, while for those op-erated on there is the risk of metastatic spreading to thelungs and consequent respiratory failure. This was thecase of our patient, as for a previous one affected bysecondary cardiac melanoma observed by our group17,and for others already reported by the current litera-ture5. On this subject, clamping the pulmonary arteryand opening and flushing the right heart circuit beforeestablishing pulmonary blood flow has been suggestedas a surgical technique to prevent pulmonary emboliza-tion from these very friable tumors5.

In conclusion, the possibility of secondary cardiaclesions should be taken into consideration in patientsalready operated on of resection of a primary neoplasiaand not affected by preexisting heart disease, present-ing with new-onset dyspnea, palpitations or other car-diac symptoms. In the present era of widely availablenon-invasive diagnostic techniques we suggest earlytransthoracic and transesophageal echographic studies,at least in those cancer patients with more likely cardiacmetastatic potential: prompt echocardiographic investi-

gations in such patients could detect secondary lesionsof the heart in the earliest possible phase. So discover-ing a malignant tumor in this location may assist inplanning newer surgical techniques or in the choice ofalternative therapeutic options18, with the further helpof accurate and also non-invasive investigations likeMRI and/or computed tomography.

References

1. Abraham KP, Reddy V, Gattuso P. Neoplasms metastatic tothe heart: review of 3314 consecutive autopsies. Am J Car-diovasc Pathol 1990; 3: 195-8.

2. Silvestri F, Bussani R, Pavletic N, Mannone T. Metastases ofthe heart and pericardium. G Ital Cardiol 1997; 27: 1252-5.

3. Lam KY, Dickens P, Chan AC. Tumors of the heart. A 20-year experience with a review of 12 485 consecutive autop-sies. Arch Pathol Lab Med 1993; 117: 1027-31.

4. Klatt EC, Heitz DR. Cardiac metastases. Cancer 1990; 65:1456-9.

5. Nishida H, Grooters RK, Coster D, Soltanzadeh H, Thie-man KC. Metastatic right atrial tumor in colon cancer withsuperior vena cava syndrome and tricuspid obstruction.Heart Vessels 1991; 6: 125-7.

6. Teixeira H, Timoteo T, Marcao I. Cardiac metastases from acolonic tumor. Acta Med Port 1997; 10: 331-4.

7. Case records of the Massachusetts General Hospital. A 75-year-old man with carcinoma of the colon and a right ven-tricular mass. N Engl J Med 1992; 327: 1442-8.

8. Reynaud P, Roudaut R, Dallocchio M. Secondary tumors ofthe right heart. Echocardiographic aspects. Apropos of 6cases in the adult. Arch Mal Coeur Vaiss 1986; 79: 369-76.

9. Roudaut R, Reynaud P, Koch M, Durandet P, Gosse P, Dal-locchio M. Two-dimensional echocardiography in the diag-nosis of intracardiac metastases. Arch Mal Coeur Vaiss1990; 83: 1435-9.

10. Lestuzzi C, Biasi S, Nicolosi GL, et al. Secondary neoplas-tic infiltration of the myocardium diagnosed by two-dimen-sional echocardiography in seven cases with anatomic con-firmation. J Am Coll Cardiol 1987; 9: 439-45.

11. Oneglia C, Neuhaus P, Simoncelli U, Graffeo M, RusconiC. Cardiac metastasis of a hepatocellular carcinoma afterliver transplantation. Presse Med 1994; 23: 1224.

12. Restrepo CS, Largoza A, Lemos DF, et al. CT and MRimaging findings of malignant cardiac tumors. Curr ProblDiagn Radiol 2005; 34: 1-11.

13. Gilkeson RC, Chiles C. MR evaluation of cardiac and peri-cardial malignancy. Magn Reson Imaging Clin N Am 2003;11: 173-86.

14. Testempassi E, Takeuchi H, Fukuda Y, Harada J, Tada S.Cardiac metastasis of colon adenocarcinoma diagnosed bymagnetic resonance imaging. Acta Cardiol 1994; 49: 191-6.

15. Harting MT, Messner GN, Gregoric ID, Frazier OH. Sarcomametastatic to the right ventricle: surgical intervention fol-lowed by prolonged survival. Tex Heart Inst J 2004; 31: 93-5.

16. Mailapur R, Khaneja SC, Schein M, Gerst PH. Intractableobstructive shock as a result of isolated cardiac metastases:a case report. Int Surg 2001; 86: 198-200.

17. Rusconi C, Faggiano P, Ghizzoni G, Sorgato A, Minzioni G,Sabatini T. Congestive heart failure due to rapid right ven-tricular obliteration by metastatic malignant melanoma.Minerva Cardioangiol 1996; 44: 123-5.

18. Gopal AS, Stathopoulos JA, Arora N, Banerjee S, MessineoF. Differential diagnosis of intracavitary tumors obstructingthe right ventricular outflow tract. J Am Soc Echocardiogr2001; 14: 937-40.

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