An unusual place to go for an unusual type of tumor

SESSION TITLE: Imaging the Unexpected SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/09/2023 02:10 pm - 02:55 pm INTRODUCTION: Cardiac metastases from cervical cancer are rare with an incidence of 3-4%, most commonly found on autopsy. Of such metastases, 60% are seen in the epicardium, 30% in the myocardium, 6% in the endocardium, and 3% are intraventricular. Additionally, 80% occur in the right side of the heart. Metastasis in the heart is explained by the hematogenous spread of malignant cells, however, it can arise from retrograde regional lymphatic invasion into the mediastinum, pericardium, and epicardium. Generally, most cardiac metastases are diagnosed by transthoracic echocardiogram, but cardiac MRI can increase the yield. CASE PRESENTATION: A 33-year-old female patient with a medical history of poorly differentiated squamous cell carcinoma of the cervix that was previously treated with chemotherapy and radiation presented to the hospital complaining of chest pain. Initial CT angiogram of the chest showed a bulky mass in the right upper lobe encasing the superior vena cava and the right main bronchus with right pleural effusion. CT scan of the abdomen showed a large, heterogeneous pelvic mass inseparable from the uterus, left adnexa, posterior urinary bladder, and anterior rectum. Echocardiogram showed a preserved ejection fraction along with multiple masses within the left ventricle, the largest of which measured 1cm by cm. This was highly suspicious for cardiac metastases. The patient underwent a robotic-assisted right pleurectomy along with right talc pleurodesis. A nephrostomy tube was placed due to tumor obstruction of the urinary outflow tract. Surgical right parietal specimens were positive for poorly differentiated squamous cell carcinoma with sarcomatoid features. Unfortunately, before treatment with chemotherapy was initiated, she had a cardiac arrest due to cardiogenic shock leading to death. DISCUSSION: Cardiac metastases within the left ventricle, as seen in the case, occur rarely. This phenomenon is uncommonly seen due to the filtering system of the pulmonary circulation and slow flow in the right side of the heart. Symptoms vary from patient to patient depending on the size and location of metastases in the heart. Early diagnosis plays a significant role in the prognosis of the patient. However, the prognosis is extremely poor due to the rarity of antemortem diagnosis. The recommended treatment is aggressive systemic and local chemotherapy. In our case, the multidisciplinary approach was favored for palliative chemotherapy. Radiation therapy was not recommended due to the risk of myocardial rupture. Cardiac surgery is reserved for patients with compressing pericardial effusion or obstructive masses. CONCLUSIONS: Distant metastases of cervical carcinoma rarely have cardiac involvement. Reports of metastases to the left ventricle are uncommon in the literature. Such cases carry high mortality as the patients develop heart failure symptoms or metastasis progression to other sites. REFERENCE #1: Lam KY, Dickens P, Chan AC. Tumors of the heart. A 20-year experience with a review of 12,485 consecutive autopsies. Arch Pathol Lab Med. 1993 Oct;117(10):1027-31. PMID: 8215825. REFERENCE #2: Byun SW, Park ST, Ki EY, Song H, Hong SH, Park JS. Intracardiac metastasis from known cervical cancer: a case report and literature review. World J Surg Oncol. 2013 May 23;11:107. doi: 10.1186/1477-7819-11-107. PMID: 23702302; PMCID: PMC3667008. REFERENCE #3: Kim HS, Park NH, Kang SB. Rare metastases of recurrent cervical cancer to the pericardium and abdominal muscle. Arch Gynecol Obstet. 2008 Nov;278(5):479-82. doi: 10.1007/s00404-008-0602-y. Epub 2008 Feb 26. PMID: 18299864. DISCLOSURES: No relevant relationships by Jose Acosta-Rullan No relevant relationships by Christian Almanzar Zorrilla No relevant relationships by Sabrina Arshed No relevant relationships by Manjot Malhi No relevant relationships by Rafael Miret No relevant relationships by Kishankumar Patel