INTRODUCTION:Advanced cervical cancers frequently invade local pelvic structures prior to involvement of regional lymph nodes. Distant metastasis by hematogenous or lymphatic routes is also observed, most affecting the liver and lungs. Antemortem identification of intracardiac metastasis of cervical squamous cell carcinoma however, is extremely uncommon. We present an unreported manifestation of intracardiac metastasis of cervical squamous cell carcinoma.
CASE PRESENTATION:A 54-year-old white woman with poorly differentiated squamous cell carcinoma of the cervix previously treated with cisplatin and topotecan, external beam radiation and total abdominal hysterectomy with bilateral salpingo-oopherectomy presented for evaluation of rapidly progressive dyspnea and chest pain. She reported a 2-3 week decline in physical activity due to dyspnea, chest pain, orthopnea and occasional presyncopal symptoms. She denied fever, cough, sputum production or hempotysis. Physical exam was unremarkable except for requiring 4L/min of oxygen supplementation to maintain adequate oxyhemoglobin saturation. A CT angiogram of the chest was performed revealing multiple bilateral segmental filling defects, numerous bilateral pulmonary nodules and a large filling defect suggestive of a thrombus in the right ventricle. The patient was admitted to the hospital for anticoagulation and further evaluation. A transthoracic echocardiogram was performed showing a large right ventricular mass with near occlusion of the outflow tract, a patent foramen ovale, and an elevated right ventricular systolic pressure (estimated 85 mmHg). The left ventricular function was found to be normal. Due to the size and location of the mass, as well as the high pulmonary arterial pressures it was thought that without thrombectomy, heart failure was certain to develop. The patient then underwent cardiopulmonary bypass, repair of the patent foramen ovale and right ventricular exploration. Intraoperatively an intraventricular mass was found extending along the right ventricular outflow tract to the pulmonic valve. The mass was debulked sufficiently to normalize right ventricular function, though complete resection could not be achieved. Pathology revealed squamous cell carcinoma, consistent with metastatic cervical cancer. The patient tolerated the procedure well and was eventually discharged from the hospital on supplemental oxygen and anticoagulation. Four months later, she reports significant improvement in dyspnea, though still on oxygen, and has resumed chemotherapy with carboplatin and paclitaxel.
DISCUSSIONS:The most common tumors in the adult heart are myxomas which represent approximately 25% of all cardiac neoplasms. Cardiac metastasis, while relatively uncommon, are up to 40 times more common than primary malignancies, with only melanoma preferentially metastasizing to the heart. The finding of cardiac metastasis from cervical carcinoma of any cell type is extremely rare and is a poor prognostic finding, with most patients dying within a year. Debulking and adjuvant chemotherapy are the only therapeutic options.
CONCLUSION:Metastasis of squamous cell carcinoma of the cervix to the endocardium is extremely uncommon. To our knowledge this is the first case of such metastasis presenting with both pulmonary emboli and right ventricular outflow tract obstruction.
DISCLOSURE:Alberto Colomer, No Financial Disclosure Information; No Product/Research Disclosure Information