DOI:10.2214/AJR.05.0970
AJR 2006; 187:S473-S475
© American Roentgen Ray Society
AJR Teaching File: Necrotic Mass Invading the Heart
Alvin C. Silva1
1 Department of Radiology, Mayo Clinic Scottsdale, 13400 E Shea Blvd.,
Scottsdale, AZ 85259
Received June 7, 2005;
accepted after revision August 18, 2005.
Address correspondence to A. C. Silva
(silva.alvin{at}mayo.edu).
Keywords: heart • leiomyosarcoma • metastasis • uterus
Clinical History
An asymptomatic 43-year-old woman presents for routine surveillance
following total abdominal hysterectomy with bilateral salpingo-oophorectomy 4
years earlier as a result of uterine leiomyosarcoma.
Radiologic Description
Contiguous axial CT images (Figs.
1A and
1B) show a necrotic mass
invading the pericardium and extending into the left atrium via the left
inferior pulmonary vein. T2-weighted MRI shows an intrapelvic mass and a
proximal left thigh mass (Fig.
1C). A small-bowel follow-through depicts the typical
coiled-spring appearance of an intussusception
(Fig. 1D). Subsequent
contrast-enhanced MRI shows the irregularly enhancing lead point
(Fig. 1E) and a large
metastasis involving the proximal left thigh
(Fig. 1F).
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Fig. 1A —43-year-old woman with uterine leiomyosarcoma metastases. Contiguous
contrast-enhanced axial CT images show large left pericardial mass
(arrows) with transvenous extension (arrowheads,
B).
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Fig. 1B —43-year-old woman with uterine leiomyosarcoma metastases. Contiguous
contrast-enhanced axial CT images show large left pericardial mass
(arrows) with transvenous extension (arrowheads,
B).
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Fig. 1D —43-year-old woman with uterine leiomyosarcoma metastases. Spot image
from small-bowel follow-through examination shows classic appearance of
intussusception (arrows) as sequela of intrapelvic metastasis.
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Fig. 1E —43-year-old woman with uterine leiomyosarcoma metastases.
Contrast-enhanced axial T1-weighted MR images show heterogeneous hypervascular
enhancement of metastatic lead point (arrow, E) and
leiomyosarcoma metastasis in left thigh (arrow, F).
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Fig. 1F —43-year-old woman with uterine leiomyosarcoma metastases.
Contrast-enhanced axial T1-weighted MR images show heterogeneous hypervascular
enhancement of metastatic lead point (arrow, E) and
leiomyosarcoma metastasis in left thigh (arrow, F).
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Differential Diagnosis
The differential diagnosis in a patient with a cardiac mass includes
myxoma, leiomyosarcoma, papillary fibroelastoma, and angiosarcoma.
Diagnosis
The diagnosis is leiomyosarcoma metastatic to the heart.
Commentary
Cardiac metastases are more prevalent than primary neoplasms of the heart
and generally portend a less favorable prognosis. In contradistinction,
primary leiomyosarcomas of the heart are more common than secondary
involvement, which is highly invasive and more often fatal.
In 1999, the patient had a hysterectomy as a result of leiomyosarcoma. Two
years later, an intraperitoneal metastasis with resultant intussusception
(Figs. 1D and
1E) developed, as did
soft-tissue metastases (Fig.
1F). A subsequent metastasis to the pericardium had transvenous
extension (Figs. 1A and
1B).
Although metastatic cardiac disease is 16-50 times more common than primary
cardiac malignancy [1], uterine
leiomyosarcoma metastases to the heart are extremely rare
[2,
3] because these highly
aggressive tumors have a proclivity for local invasion. However, the incidence
of their metastasizing to the heart appears to be increasing
[3], likely because of
prolonged cancer survival. Thus, the onset of new cardiac symptoms in affected
patients should raise the index of suspicion for cardiac involvement.
The most common cardiac or pericardiac metastases are due to breast cancer,
lung cancer, melanoma, or lymphoma
[4]. Such metastases generally
do not occur as isolated events but instead are more likely to occur in
patients with widespread disease. Since 1996, the incidence of metastases to
the heart has increased to more than 10%, compared with a previously reported
range of 0.2-6% [5]. The
increase is presumably attributable to the increased longevity of patients
treated with improved therapeutic regimens.
Secondary malignancies can involve the heart and pericardium by direct
invasion, by hematogenous or lymphatic dissemination, or by transvenous
propagation. Direct invasion occurs from the contiguous spread of tumors in
the chest cavity, most commonly from the lung, breast, or esophagus, or from
lymphoma or thymoma. However, when a patient has widespread disease, it may be
difficult to differentiate a tumor with direct involvement from metastatic
mediastinal or hilar adenopathy with retrograde extension.
Hematogenous dissemination to the heart also occurs in conjunction with
hematogenous metastases to the rest of the body, with melanoma having the
greatest propensity for involvement. Classic primary tumors that exploit the
transvenous route include renal and adrenal malignancies (by way of the
inferior vena cava [IVC]), hepatic malignancies (via the IVC), thyroid
malignancies (via the superior vena cava [SVC]), and bronchogenic malignancies
(via the pulmonary veins and SVC)
[5-7].
The other considerations in the differential diagnosis are unlikely for
several reasons. Although myxomas are the most common benign primary tumor in
adults [8], these masses are
predominantly intracardiac, without an extracardiac component, which is in
contradistinction to this patient. Angiosarcomas, the most common primary
cardiac malignancy, typically involve the right atrium, arising from the free
wall and sparing the atrial septum
[9]. Finally, papillary
fibroelastomas are avascular tumors that typically involve the aortic valve.
As such, they must be differentiated from endocarditis, and they are generally
not detectable with CT [8].
Objective
The educational objective of this teaching article is to describe the
imaging features in a case of cardiac metastases from uterine
leiomyosarcoma.
Conclusion
Cardiac metastases are more common than primary cardiac tumors, are
generally a late manifestation of the primary malignancy, and are usually
indicative of a fatal outcome.
References
- Greenwald EF, Breen JL, Gregori CA. Cardiac metastases associated
with gynecologic malignancies. Gynecol Oncol1980; 10:75
-83[CrossRef][Medline]
- Rose PG, Piver MS, Tsukada Y, Lau T. Patterns of metastasis in
uterine sarcoma: an autopsy study. Cancer1989; 63:935
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- Cordioli E, Pizzi C, Bugiardini R. Left ventricular metastasis from
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: 1001-1003[Medline]
- Hoy F, Boucher R, Brody A. Uterine leiomyosarcoma with cardiac
metastases. Can J Surg 1988;31
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- Butany J, Nair V, Naseemuddin A, Nair GM, Catton C, Yau T. Cardiac
tumours: diagnosis and management. Lancet Oncol2005; 6:219
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- Chiles C, Woodard PK, Gutierrez FR, Link KM. Metastatic involvement
of the heart and pericardium: CT and MR imaging.
RadioGraphics 2001;21
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- Gilkeson RC, Chiles C. MR evaluation of cardiac and pericardial
malignancy. Magn Reson Imaging Clin N Am2003; 11:173
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- Araoz PA, Mulvagh SL, Tazelaar HD, Julsrud PR, Breen JF. CT and MR
imaging of benign primary cardiac neoplasms with echocardiographic
correlation. RadioGraphics 2000;20
: 1303-1319[Abstract/Free Full Text]
- Janigan DT, Husain A, Robinson NA. Cardiac angiosarcomas: a review
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Clinical History
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