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Solitary Cardiac Metastasis From a Clear Cell Carcinoma of the Kidney. A Case Report and Review of the Literature

Posted on: Friday, 8 April 2005, 03:00 CDT

A case of solitary septal metastasis from a clear cell carcinoma of the kidney is reported in a 55-year-old man who 5 years before had undergone right nephrectomy and adrenalectomy. Since then, he had been successfully treated by means of chemotherapy, radiation therapy, or operated on, at almost yearly intervals, for secondary pancreatic, pulmonary and cerebral single metastases. Diagnosis was obtained by routine computed tomography. The septal mass was surgically removed and the patient was discharged on the 4th postoperative day.

KEY WORDS: Cardiac neoplasms, secondary * Metastases * Clear cell carcinoma * Tomography, emission computed * Surgery.

Cardiac metastatic involvement by malignancies has been well documented by old autopsy series 1 where pericardial, myocardial and endocardial metastases were essentially described as post-mortem observations.

As a consequence of the increasing life expectancy, the improvement in oncological treatment and the widespread use of imaging techniques such as echocardiography, computed tomography (CT) and nuclear magnetic resonance (NMR),2 the frequency of ante- mortem diagnosis of cardiac metastases- and obviously of primary cardiac tumors- has been increasing rapidly in the last 20 years, thus opening the question of their more appropriate treatment.

Pericardial metastases usually manifest with signs and symptoms of cardiac tamponade in the clinical setting of an advanced disease with multiple localization and are best treated conservatively - i.e. simple pericardial drainage. This palliative procedure, obviously, cannot modify the outcome of the basic disease. On the other hand, since myocardial and endocardial metastases are often isolated and surgically resectable, in these cases surgical treatment could improve the long term prognosis of such patients.

The aim of this paper is to describe a case of solitary septal metastasis from a clear cell carcinoma of the kidney, with some atypical aspects, which has been successfully operated on at our Institution and to review the related literature.

Case report

A 55-year-old man was referred to our attention for a mass of unknown nature located within the ventricular septum. Five years before he had undergone right nephrectomy and adrenalectomy for a clear cell aclenocarcinoma of the kidney. Since then, he had had to be operated on for resection of a single pancreatic metastasis (1 year later) and had been successfully treated by means of chemotherapy and radiation, 3 years after the first operation, for pulmonary and cerebral single metastases. So far, at the time of presentation, he was an otherwise healthy man with a solitary cardiac mass of highly suspect nature. he was totally symptom-free and the neoplasm was discovered by a routine annual total body CT scan. An echo (Figure 1) located the mass at the apex of the right ventricle, while NMR (Figure 2) clearly showed it to be within the mid third of the septum protruding towards the right ventricular cavity. An ultrasound-guided percutaneous biopsy failed to extract a specimen. Coronary angiography showed a spherical mass, supplied by the second septal branch, 2 cm below the anterior descending coronary artery (Figure 3).

Figure 1.-Echocardiogram showing the mass within the lower part of the ventricular septum.

Figure 2.-Nuclear magnetic resonance image. The mass is protruding towards the right ventricular outlet.

Figure 3.-Coronary angiography showing the close relationship between the mass and the second septal branch.

Figure 4.-Gross appearance of the tumor.

Figure 5.-Intraoperative appearance after division of a thin muscle layer.

Figure 6.-After blunt enucleation, no residual septal defect was present. The resulting gap was directly closed with an over and over suture.

At operation a soft thrill was palpable along the pulmonary infundibulum. A longitudinal infundibulotomy was done showing a bulging nodule, 3 by 3 cm (Figure 4), covered by a thin layer of septal muscle. The overlying muscle was sharply divided and the mass could be bluntly removed. No Dacron patch septal reconstruction was necessary as the resultant cavity was obliterated with a simple running suture with 5/0 Prolene. Histologie examination of the removed specimen confirmed the diagnosis of a metastasis from a clear cell carcinoma of the kidney. On the 4th day the patient was discharged after a smooth postoperative course.

The patient is presently doing well, leading a normal life 14 months after the operation. Two months ago he had underwent a new brain metastasectomy without residual problems.

Discussion

Carcinomas can often be a source of cardiac metastases, followed by non-solid tumors (leukemia and lymphoma);3,4 considering the incidence, melanoma actually invades heart structures more frequently: in 2 recent autopsy series, it is shown that melanoma spread to the heart in more than 40% of cases.4,5

As a matter of fact, it is really difficult to assess frequency of cardiac involvement in malignant diseases for the following reasons:

* Primary tumors show a relatively high incidence in some geographic areas if compared to others: for example, carcinoma of the esophagus is much more frequent in Asian than in European people, which can explain the more frequent cardiac involvement.6 - Pericardial metastases are not included among cardiac metastases by many authors5 in some series cardiac metastases are more frequent than in others. For example, the incidence of cardiac involvement by melanoma can vary from 4.5% to as high as 46% when pericardial locations are included. This means that the pericardium is the most frequent site of cardiac metastases.

* Where non-solid tumors are concerned, their frequency is now steadily increasing as a consequence of the world-wide diffusion of immune deficiency syndrome.3

* At post-mortem histology, the presence of malignant cells within the intravascular spaces does not necessarily mean a direct cardiac involvement.13, 7

* Gender can influence cardiac involvement: uterus, cervix, ovarian and breast carcinomas spread to the heart more than male carcinomas (testis carcinoma).

It should be considered that the mode of spreading to the heart can influence the feasibility of surgical treatment. When a tumor reaches the heart by continuity or through lymphatic drainage, as in the case of metastases from thoracic organs like lung, breast and oesophagus,8 cardiac metastasis is usually a terminal manifestation in the clinical setting of a diffuse disease which contraindicates surgical resection. In effect, surgical reports of metastasectomy from lung or breast cancer are very rare if compared to those from other organs, and are associated with a very poor outcome. There is a particular way of dissemination in lung cancer: the tumor can reach the left atrium through a neoplastic thrombus within a pulmonary vein. In this case, since other organ involvement seems unlikely, surgical metastasectomy associated with lobectomy could be indicated.

Hematogenous solitary myocardial metastases, when other organ involvement can be excluded, are probably the best indication for surgical resection: there have been an increasing number of reports dealing with surgical excision of secondarisms from cancer of the uterus, cervix, thyroid, kidney, adrenal gland and, very rarely, from almost all types of primary tumour.3,4,9-11 Finally, the possibility of transferring a donor neoplasm by means of an allograft during a transplant procedure should be emphasized: a donor hypernephroma transmitted to a cardiac allograft recipient has been reported.12

Most papers dealing with surgical metastasectomy have been anedoctal, reporting single cases or at most a very limited number of patients. But these reports can represent the basis for the future assessment of heart surgery in the multimodality therapy of cancer.

Adenocarcinoma of the kidney is a relatively frequent source of cardiac metastasis and more than 100 surgical cases have been reported in the literature.13-17 In most cases the tumor reaches the heart by continuity through a neoplastic thrombus within the inferior vena cava, invading the right cavities.13 To our knowledge the case reported is the 4th surgically treated solitary myocardial metastasis, without invasion of the cava by a thrombus, but through hematogenous spreading.18-20 We attempted to obtain a preoperative histological diagnosis by percutaneous biopsy, without success. Indeed, at operation the mass was overlayed by a thin layer of muscle which impeded the extraction of specimens by the percutaneous route. We feel that endomyocardial biopsy could be a useful diagnostic tool when the tumor reaches the heart by continuity from adjacent structures,8 but not in cases of truly hematogenous diffusion from within the wall or the septum. Nuclear magnetic resonance has been very helpful in precisely locating the mass, allowing for a small right ventriculotomy well over the tumor.

Of some interest is the fact that this lesion appeared 1 year after the last operation for a cerebral mass. This seems a peculiarity of clear cell carcinoma of the kidney for which metastases have been described as many as 20 years after primary nephrectomy.19

Conclusions

Echocardiography as well as NMR used in the follow-up of cancer patients have led to an ever increasing \number of cases in which a solitary heart metastasis can be detected. The key to surgical success in improving long term survival is the preoperative demonstration that a mass is truly solitary, which means that other organ involvement could be reasonably excluded.

A close follow-up of cardiac metastasectomy patients is warranted, and will allow definitive conclusions about its efficacy in improving the prognosis of cancer patients. As to the case reported here, clear cell carcinoma of the kidney is probably more prone than other types of cancer to produce isolated, solitary metastases. In our case, the aggressive multimodality (medical, surgical and radiation) treatment of single pancreatic, pulmonary, cerebral and cardiac metastases has led to a better, almost symptom- free, long term patient survival and seems to justify an aggressive approach in selected patients.

References

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4. Roberts WC. Primary and secondary neoplasms of the heart. Am J Crdiol 1997;80:671-2.

5. Ambrosio GB. Frequency of cardiac metastasis: rewiew of 2222 autopsies and critical assessment. Arch Sci Med 1980;137:29-32.

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7. Bisel HF, Wroblewski F, Ladue JS. Incidence and clinical manifestations of cardiac metastases. JAMA 1953;153:712-S.

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10. Batchelor WB, Butany J, Liu P, Silver MD. Cardiac metastasis from primary cervical squamous cell carcinoma: three case reports and a review of the literature. Can J Cardiol 1997;13:767-70.

11. LagrangeJL, Despins P, Spielman M, Le Chevalier T, De Lajartre AY, Fontaine F et al. Cardiac metastasis. case report on an isolated cardiac metastasis of a myxoid liposarcoma. Cancer 1986;58:2333-7.

12. Sack FU, Lange R, Mehmanesh H, Amman K, Schnabel P, Zimmermann R etal. Transferral of extrathoracic donor neoplasm by the cardiac allograft. J Heart Lung Transplant 1997:16:298-301.

13. Staehler G, Brkovic D. The role of radical surgery for renal cell carcinoma with extention into the vena cava. J Urol 2000; 163: 1671-5.

14. Carroll JC, Quinn CC, Weitzel J, Sant GR. Metastatic renal cell carcinoma to the right cardiac ventricle without contiguous vena cava involvement. J Urol 19lM;151:133-4.

15. Abu-Zidan FM, Sabha M, Salama AL, Nilson T, Shuhaiber H. Three staged approach to the surgical management of renal cell carcinoma extending into the right atrium. case report. J Cardiovasc Surg (Torino) 1990;31:595-8.

16. Santo-Tomas M, Mahr NC. Robinson MJ, Agatston AS. Metastatic renal cellcarcinoma invading right ventricular myocardium without caval involvement. J Cardiovasc Surg (Torino) 19l)8;39:811-2.

17. Riccioni L, Damiani S. Pasquinelli G, Scarani P. Solitary left ventricle metastasis by renal cell carcinoma with sarcomatoid features. Tumori 1996:82:266-9.

18. Sobue T, Iwase M, Aoki T, Noda A, Tanaka M, Yokota M. Solitary left ventricular metastasis of renal cell carcinoma. Am Heart J 1993;! 25:1801-2.

19. Bradley SM, Boiling SF. Late renal cell carcinoma metastasis to the left ventricular outflow tract. Ann Thorac Surg 1995;60:2040 - 6.

20. PataneJ, Flum DR, McGinnJTJr, Tyras DH. Surgical approach for renal cell carcinoma metastatic to left atrium. Ann Thorac Surg 1996;62:891-2.

Unit of Cardiac Surgery, IRCCS Policlinico S. Matteo

University of Pavia, Pavia, Italy

Address reprint requests to: G. Zattera, Divisione di Cardiochirurgia, Polidinico S. Matteo, Piazzale Golgi 2, 27100 Pavia, Italy. E-mail: gzattera@libero.it

Copyright Edizioni Minerva Medica Dec 2004

Source: Journal of Cardiovascular Surgery

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