Case Report Open Access
Copyright ©2009 The WJG Press and Baishideng. All rights reserved.
World J Gastroenterol. Jun 7, 2009; 15(21): 2675-2678
Published online Jun 7, 2009. doi: 10.3748/wjg.15.2675
Cardiac metastasis from colorectal cancer: A case report
Pyong Wha Choi, Chul Nam Kim, Department of Surgery, Ilsan Paik Hospital, Inje University College of Medicine, 411-806, Goyang, South Korea
Sun Hee Chang, Department of Diagnostic Pathology, Ilsan Paik Hospital, Inje University College of Medicine, 411-806, Goyang, South Korea
Woo Ik Chang, Chang Young Kim, Department of Chest Surgery, Ilsan Paik Hospital, Inje University College of Medicine, 411-806, Goyang, South Korea
Hyun Min Choi, Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, 411-806, Goyang, South Korea
Author contributions: Choi PW performed the colorectal surgery and wrote the manuscript; Kim CN contributed the clinical data; Chang SH interpreted the histological and immunohistochemical data; Chang WI and Kim CY performed the cardiac surgery and contributed the clinical data; Choi HM contributed to the clinical data and performed the physical examination.
Correspondence to: Pyong Wha Choi, MD, Department of Surgery, Inje University College of Medicine, Ilsan Paik Hospital, 2240 Daehwa-dong, Ilsanseo-gu, Goyang-si, Gyeonggi-do, 411-806, Goyang, South Korea. eacechoi@hanmail.net
Telephone: +82-31-9107622
Fax: +82-31-9107319
Received: March 9, 2009
Revised: April 29, 2009
Accepted: May 6, 2009
Published online: June 7, 2009

Abstract

The heart is an unusual site of metastasis from any malignancy. We report a case of cardiac metastasis from colorectal cancer. A 70-year-old woman was referred with a presumptive diagnosis of sigmoid colon cancer with cardiac myxoma. Two-dimensional echocardiography showed a 4 cm × 4.5 cm mobile mass on the lateral right atrial wall, and computed tomography revealed a low attenuated lobulating mass in the right atrium. The patient underwent anterior resection for sigmoid colon cancer (T4N2). Thereafter, she experienced progressive shortness of breath. Therefore, a cardiac operation was performed 2 wk after the colorectal operation. Histological examination revealed adenocarcinoma, which was identical to the primary lesion. Although two-dimensional echocardiography has become the diagnostic test of choice for detecting cardiac tumors, in patients with colorectal cancer showing a cardiac mass, further diagnostic evaluation such as a magnetic resonance imaging might be necessary.

Key Words: Heart, Cardiac metastasis, Colorectal cancer, Atrial myxoma, Magnetic resonance imaging



INTRODUCTION

Metastases from colorectal cancer can occur either by lymphatic or hematogenous spreading, and the sites most commonly involved are the liver and lung. Unusual metastases from colorectal cancer into organs including the spleen, thyroid gland, spermatic cord, and skeletal muscle have been reported[14]. Although metastases to these sites might occur as a feature of end stage-disease, metastasis to the heart from colorectal cancer is extremely rare. To our knowledge, only nine cases of cardiac metastasis from colorectal cancer have been previously described[513]. Here, we report a case of cardiac metastasis from colorectal cancer that presented preoperatively as a benign atrial myxoma.

CASE REPORT

A 70-year-old woman, presenting with bloody stools, was admitted to our hospital. She experienced shortness of breath and had lost 4 kg in weight in the past 3 mo. A colonoscopy revealed an encircling mass in the sigmoid colon, nearly obstructing the lumen of the colon. A pediatric colonoscope could not be passed beyond this point. The biopsy gave evidence of an adenocarcinoma of the sigmoid colon. Laboratory studies, on admission, were within the normal limits, except for carcinoembryonic antigen, which was 9.2 ng/mL. A routine transthoracic echocardiography showed the presence of a right atrial (RA) enlargement and mobile, round, spherical, and inhomogenous mass (3.72 cm × 4.15 cm) adjacent to the lateral RA wall (Figure 1). This pedunculated mass had a broad stalk (1.88 cm), and projected through the tricuspid valve into the right ventricular (RV) cavity, obstructing the RV inflow during the diastolic phase. A chest X-ray showed cardiomegaly and a prominent aorta. Computed tomography revealed a low attenuated lobulating mass in the right atrium (Figure 2). Preoperative diagnosis was synchronous sigmoid colon cancer and right atrial myxoma. We planned to perform cardiac surgery 4 wk after colorectal surgery. An anterior resection with a colorectal anastomosis was performed. Histological investigation of the excised portion confirmed the existence of a moderately differentiated adenocarcinoma invading the serosa with lymphovascular invasion and perineural invasion. The staging of the lesion was T4N2. Although the patient complained of mild shortness breath, the postoperative course was uneventful. However, 2 wk postoperatively, the shortness of breath had worsened. Thus, the patient was taken immediately into cardiac surgery. After a sternotomy, the pericardium was opened, and a cardiopulmonary bypass was installed to open the right atrium. The mass was present in the right atrial wall near the atrioventricular groove, and was growing toward the tricuspid valve. After removal of the mass, the right atrial wall was reconstructed with bovine pericardium (Figure 3). The atrial mass showed a nodular necrotic appearance grossly measuring 5.5 cm × 5 cm × 3 cm; histological examination revealed adenocarcinoma that was identical to the primary lesion (Figure 4). A further operation was performed because of postoperative cardiac bleeding; however, the patient died of recurrent cardiac bleeding on the 3rd postoperative day.

Figure 1
Figure 1 Transthoracic echocardiography. A: A mobile, round, spherical, and echogenic mass (white arrows) is seen adjacent to the lateral right atrial wall on an apical four chamber view of the transthoracic echocardiography; B: A magnified image of the right atrial mass shows a pedunculated character with a broad stalk (tris-arrows). RA: Right atrium; LA: Left atrium; LV: Left ventricle.
Figure 2
Figure 2 Computed tomography scan revealed that the mass (arrow) was located in the right atrium, obstructing the tricuspid valve opening.
Figure 3
Figure 3 Operative finding. On opening the right atrium, a large multiple lobulating mass (arrow) with a rough surface was located on the antero-inferior side of the right atrial free wall. The mass was near the atrioventricular groove, with invasion into the right atrium.
Figure 4
Figure 4 Microscopic findings. A: Tall malignant columnar cells line large irregular glands; some forming a cribriform architecture containing intraluminal necrotic debris in primary colon cancer (HE, × 100); B: The cardiac mass shows similar histological findings to Figure 4A.
DISCUSSION

The regional lymph nodes, liver, and lung are the most common sites of metastasis from colorectal cancer. Infrequent sites of metastases, including the spleen, thyroid gland, spermatic cord, and skeletal muscle have been reported[14]. Although metastases of these unusual sites from colorectal cancer might occur with the status of widespread disease, cardiac metastasis from colorectal cancer is extremely rare[513]. The incidence of cardiac metastasis in patients with malignancy might be underestimated because cardiac metastatic lesions are clinically silent in most cases[1314]. Therefore, the incidence of cardiac metastasis might best be determined by reviewing autopsy studies. The incidence of cardiac metastasis from any malignancy has been reported as 10%-18% in autopsy studies[1517]. Malignant melanoma has been reported as the most common disease[1619]. Leukemia and lymphoma also showed a high incidence of cardiac metastasis in the past, but this incidence is decreasing because of improvements in chemotherapy[1620]. In colorectal cancer, to our knowledge, only nine reports have been described in the literature (Table 1); however, the incidence of cardiac metastasis was 1.4%-7.2% in autopsy studies[121617]. Thus, the true incidence of cardiac metastasis from colorectal cancer might be higher than the cases reported so far.

Table 1 Clinical features of cardiac metastasis from colorectal cancer reported in English literature.
Author (yr)Age/sexLocation of primary tumorPrimary tumor stageDiagnosis of cardiac metastasis made by/atLocation of heartMetastatic tumor size (cm)Operation of metastatic massOutcome
Henuzet (1982)[13]60/MRectumNAEchocardiographyRight ventricle2ResectionDead
Massachusetts General Hospital (1992)[12]75/MColonNAAutopsyRight ventricle7.5 × 4.5 × 4NoDead
Parravicini (1993)[8]47/MRectumNASurgeryRight ventricle10 × 4 × 3.5ResectionDead
Testempassi (1994)[7]71/FColonStage IIIMagnetic resonance imagingRight ventricleNANANA
Lord (1999)[6]71/MRectumDukes’ CBiopsyRight ventricleNANoDead
Koizumi[11] (2003)65/MRectumDukes’ CSurgeryRight atrium6 × 5ResectionDead
Present case (2009)70/FColonT4N2SurgeryRight atrium5.5 × 5 × 3ResectionDead

Some factors that might account for the infrequency of cardiac metastasis have been suggested: the strong kneading action of the myocardium, metabolic peculiarities of striated muscle, the rapid flow of blood through the heart, and lymph flow normally moving away from the heart. The blood flow of the coronary system is the highest in the body, and the lymphatics of the heart is divided into a superficial and a deep group, joining and draining through two trunks into the tracheobronchial lymph nodes. Thus, metastasis must occur against the direction of flow[19]. Although the reasons for its rarity have not been well established, cardiac metastasis from malignancies might occur by direct extension, lymphatic spread, hematogenous spread, or a combination of two or three of the above[14161719]. Klatt et al[16] reported that the lung was the most common primary site, and sites closer to the heart contributed to the greatest number of cardiac metastases; they suggested that the lymphatic drainage from nearby sites represents the most likely means of spread. Mukai et al[17] suggested that the relative importance of these various routes would appear to depend on the type of primary tumor and on the completeness of the autopsy examination. In our case, although regional lymph node metastases were identified, we postulate that hematogenous spread might be the most likely route in colorectal cancer.

The incidence of colorectal cancer with cardiac metastasis is rare, therefore surgery as a treatment modality has not been investigated. Koizumi et al[11] reported that although surgery is rarely recommended for treating metastatic cardiac tumors, surgical treatment could be especially effective in occurrences of obstructive and solitary lesions to ensure relief from symptoms and elongation of life expectancy. In our case, the purpose of surgical treatment was the release of symptoms, even though the preoperative diagnosis was cardiac myxoma and the patient died from postoperative bleeding. With the improvement of diagnostic procedures and a prolonged life span, the incidence of cardiac metastasis from colorectal cancer is likely to increase. Therefore, to clearly delineate the role of surgical treatment in cardiac metastasis from colorectal cancer, further studies are necessary.

In general, an endocardial myxoma, the most common form of primary cardiac tumor, can be diagnosed by echocardiography, which provides the differential diagnosis of intracavitary atrial echoes, including vegetation, thrombi, and primary or secondary cardiac tumors; however, the detection of cardiac metastasis by echocardiography might be difficult in cases of an infiltrative nature[1321]. In our case, although the mass was found to have invaded into the right atrium in operative finding, the preoperative echocardiography showed a mobile cardiac mass. Thus, the presumptive diagnosis was atrial myxoma. The differential diagnoses of cardiac myxoma and cardiac metastasis from colorectal cancer might be difficult to determine by echocardiography alone, as in our case, because synchronous cardiac myxoma and colorectal cancer have been reported[22]. Magnetic resonance imaging (MRI) is effective in the evaluation of secondary cardiac tumors, because it can accurately define the pericardium, the myocardial walls, and the cardiac chambers, especially in cases with an infiltrative nature[2324]. Therefore, in patients with colorectal cancer with a cardiac mass, further diagnostic evaluation such as an MRI, in addition to echocardiography, might be helpful in the differential diagnosis of the cardiac mass.

In conclusion, as reported in autopsy studies, cardiac metastasis from colorectal cancer might not be so rare, and with improvements in diagnostic procedures, the incidence of cardiac metastasis from colorectal cancer is likely to increase. Thus, in patients with colorectal cancer showing a cardiac mass, further diagnostic evaluation, such as an MRI, might be necessary.

Footnotes

Peer reviewer: Takayuki Yamamoto, MD, Inflammatory Bowel Disease Center, Yokkaichi Social Insurance Hospital, 10-8 Hazuyamacho, Yokkaichi 510-0016, Japan

References
1.  Bigot P, Goodman C, Hamy A, Teyssedou C, Arnaud JP. Isolated splenic metastasis from colorectal cancer: report of a case. J Gastrointest Surg. 2008;12:981-982.  [PubMed]  [DOI]  [Cited in This Article: ]
2.  Choi PW, Kim CN, Kim HS, Lee JM, Heo TG, Park JH, Lee MS, Chang SH. Skeletal Muscle Metastasis from Colorectal Cancer: Report of a Case. J Korean Soc Coloproctol. 2008;24:492-496.  [PubMed]  [DOI]  [Cited in This Article: ]
3.  Matsumoto G, Ise H, Inoue H, Ogawa H, Suzuki N, Matsuno S. Metastatic colon carcinoma found within an inguinal hernia sac: report of a case. Surg Today. 2000;30:74-77.  [PubMed]  [DOI]  [Cited in This Article: ]
4.  Phillips JS, Lishman S, Jani P. Colonic carcinoma metastasis to the thyroid: a case of skip metastasis. J Laryngol Otol. 2005;119:834-836.  [PubMed]  [DOI]  [Cited in This Article: ]
5.  Teixeira H, Timóteo T, Marcão I. [Cardiac metastases from a colonic tumor]. Acta Med Port. 1997;10:331-334.  [PubMed]  [DOI]  [Cited in This Article: ]
6.  Lord RV, Tie H, Tran D, Thorburn CW. Cardiac metastasis from a rectal adenocarcinoma. Clin Cardiol. 1999;22:749.  [PubMed]  [DOI]  [Cited in This Article: ]
7.  Testempassi E, Takeuchi H, Fukuda Y, Harada J, Tada S. Cardiac metastasis of colon adenocarcinoma diagnosed by magnetic resonance imaging. Acta Cardiol. 1994;49:191-196.  [PubMed]  [DOI]  [Cited in This Article: ]
8.  Parravicini R, Fahim NA, Cocconcelli F, Barchetti M, Nafeh M, Benassi A, Grisendi A, Garuti W, Benimeo A. Cardiac metastasis of rectal adenocarcinoma. Surgical treatment. Tex Heart Inst J. 1993;20:296-298.  [PubMed]  [DOI]  [Cited in This Article: ]
9.  Oneglia C, Negri A, Bonora-Ottoni D, Gambarotti M, Bisleri G, Rusconi C, Muneretto C. Congestive heart failure secondary to right ventricular metastasis of colon cancer. A case report and review of the literature. Ital Heart J. 2005;6:778-781.  [PubMed]  [DOI]  [Cited in This Article: ]
10.  Chu PH, Ko YL, Liao WB, Chiang CW. Metastatic colonic carcinoma with intracavitary right ventricular outflow tract obstruction and cardiac tamponade: a case report. Changgeng Yi Xue Za Zhi. 1996;19:264-267.  [PubMed]  [DOI]  [Cited in This Article: ]
11.  Koizumi J, Agematsu K, Ohkado A, Shiikawa A, Uchida T. Solitary cardiac metastasis of rectal adenocarcinoma. Jpn J Thorac Cardiovasc Surg. 2003;51:330-332.  [PubMed]  [DOI]  [Cited in This Article: ]
12.  Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 45-1992. A 75-year-old man with carcinoma of the colon and a right ventricular mass. N Engl J Med. 1992;327:1442-1448.  [PubMed]  [DOI]  [Cited in This Article: ]
13.  Henuzet C, Franken P, Polis O, Fievez M. Cardiac metastasis of rectal adenocarcinoma diagnosed by two-dimensional echocardiography. Am Heart J. 1982;104:637-638.  [PubMed]  [DOI]  [Cited in This Article: ]
14.  Smith C. Tumors of the heart. Arch Pathol Lab Med. 1986;110:371-374.  [PubMed]  [DOI]  [Cited in This Article: ]
15.  Hanfling SM. Metastatic cancer to the heart. Review of the literature and report of 127 cases. Circulation. 1960;22:474-483.  [PubMed]  [DOI]  [Cited in This Article: ]
16.  Klatt EC, Heitz DR. Cardiac metastases. Cancer. 1990;65:1456-1459.  [PubMed]  [DOI]  [Cited in This Article: ]
17.  Mukai K, Shinkai T, Tominaga K, Shimosato Y. The incidence of secondary tumors of the heart and pericardium: a 10-year study. Jpn J Clin Oncol. 1988;18:195-201.  [PubMed]  [DOI]  [Cited in This Article: ]
18.  Deloach JF, Haynes JW. Secondary tumors of heart and pericardium; review of the subject and report of one hundred thirty-seven cases. AMA Arch Intern Med. 1953;91:224-249.  [PubMed]  [DOI]  [Cited in This Article: ]
19.  Prichard RW. Tumors of the heart; review of the subject and report of 150 cases. AMA Arch Pathol. 1951;51:98-128.  [PubMed]  [DOI]  [Cited in This Article: ]
20.  Bisel HF, Wroblewski F, Ladue JS. Incidence and clinical manifestations of cardiac metastases. J Am Med Assoc. 1953;153:712-715.  [PubMed]  [DOI]  [Cited in This Article: ]
21.  Mich RJ, Gillam LD, Weyman AE. Osteogenic sarcomas mimicking left atrial myxomas: clinical and two-dimensional echocardiographic features. J Am Coll Cardiol. 1985;6:1422-1427.  [PubMed]  [DOI]  [Cited in This Article: ]
22.  Nuño IN, Kang TY 4th, Arroyo H, Starnes VA. Synchronous cardiac myxoma and colorectal cancer: a case report. Tex Heart Inst J. 2001;28:215-217.  [PubMed]  [DOI]  [Cited in This Article: ]
23.  Brown JJ, Barakos JA, Higgins CB. Magnetic resonance imaging of cardiac and paracardiac masses. J Thorac Imaging. 1989;4:58-64.  [PubMed]  [DOI]  [Cited in This Article: ]
24.  Higgins CB. Overview of MR of the heart--1986. AJR Am J Roentgenol. 1986;146:907-918.  [PubMed]  [DOI]  [Cited in This Article: ]