Eur J Cardiothorac Surg 1999;15:373-375
© 1999 Elsevier Science NL
Resection of a right atrial metastatic melanoma with unknown origin of primary tumor
T. Bossert,
J.A.M. van Son,
R. Autschbach,
F.W. Mohr
Department of Cardiac Surgery, Herzzentrum, University of Leipzig, Russenstrasse 19, D-04289 Leipzig, Germany
Received 28 September 1998;
received in revised form 7 December 1998;
accepted 16 December 1998.
Corresponding author. Tel.: +49-341-865-1421; fax: +49-341-865-1452.
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Abstract
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Cardiac involvement of malignant melanoma is generally part of a widespread tumor dissemination, which is mostly multifocal. Hence the disease is usually not amenable to surgical intervention. We report successful resection of a large intracavitary melanoma to the right atrium, the primary origin of which was unknown. The right atrium was reconstructed with an autologous pericardial patch. At 12-month follow-up the patient remains asymptomatic.
Key Words: Malignant melanoma • Cardiac neoplasm
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Introduction
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Primary tumors of the heart are rare with a reported frequency of less than 0.1%
[1]. In contrast, cardiac metastases have been reported in 10.7% of autopsies when a malignancy was diagnosed, with 36.4% originating from the lung and 4.5% from the skin
[2]. Malignant melanoma in particular has a great propensity to involve the heart, with more than a 50% incidence
[3]. Cardiac involvement of malignant melanoma is generally part of a widespread tumor dissemination, which is mostly multifocal. Hence the disease is usually not amenable to surgical intervention. In this report, we present the unique case of a patient who underwent surgical resection of an isolated metastatic melanoma to the heart with unknown primary origin.
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Case report
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We report on a 56-year-old woman who had complaints of dyspnea on exertion, palpitations, and signs of congestive heart failure. Several weeks prior to admission she had experienced a transient ischemic attack. The patient was referred to our center because of an echocardiographically documented large right atrial intracavitary mass. On auscultation there was a loud diastolic murmur. Otherwise the physical examination was normal; notably, skin lesions such as suspicious naevi or depigmented areas were absent. The cardiac rhythm was sinus.
Preoperative transesophageal echocardiography demonstrated a 5-cm large echodense mass in the enlarged right atrium (
Fig. 1 ); the ventricular function was normal. On the basis of this observation we suspected the presence of a neoplastic process. However, in spite of an extensive tumor search including computed tomography (CT) of the chest, abdomen and brain, a primary tumor was not found.
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Fig. 1. Transesophageal echocardiogram (four-chamber view) demonstrating a 5-cm mass (T) (between arrows) adherent to right atrial wall. LA, left atrium; RV, right ventricle.
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At operation through a median sternotomy the right atrium was confirmed to be enlarged. The remainder of the heart and the mediastinum appeared normal. Using cardiopulmonary bypass with venous cannulation of the right femoral vein and the superior vena cava, the right atrium was opened. A 5-cm large mass with black pigmentation was seen to be firmly adherent to the lateral right atrial wall. The tumor with the adjacent part of the right atrial wall was excised. The 5x4 cm large defect created in the right atrial wall was reconstructed with untreated autologous pericardial patch.
Histologic examination of the mass including immunohistochemistry confirmed the preliminary diagnosis of malignant melanoma with infiltration of the right atrium (
Fig. 2
). The postoperative course was uncomplicated. A repeated physical examination including an ophthalmologic examination was negative. The patient remained in sinus rhythm and was discharged from the hospital on the tenth postoperative day. At 12 month follow-up, including CT of the chest, abdomen and brain, the patient remains asymptomatic. An echocardiographic examination demonstrated a normal right atrium and excellent ventricular function.
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Fig. 2. Microphotograph demonstrating infiltration of malignant melanoma into right atrial wall (hematoxylin and eosin stain, original magnification x300).
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Discussion
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Cardiac metastases of melanoma are strongly associated with systemic tumor dissemination and isolated metastatic melanoma limited to the heart is rare. Malignant melanoma has great propensity to involve the heart, with more than a 50% incidence
[2]
[3]. It can involve any and all chambers of the heart, with the right atrium involved most frequently. An intracavitary melanoma may cause right ventricular inflow and outflow obstruction or can progressively obliterate the right or left ventricle or both ventricles
[4]
[5]
[6]. Table 1 summarizes the reported cases. Three of the four patients in these reports had disseminated melanoma; the follow-up ranged from 5 to 14 months
[7]
[8]
[9]
[10]. To our knowledge, successful surgical resection of isolated cardiac melanoma to the right atrium with unknown primary tumor has not been reported previously. In all of the previous reports the primary site of the tumor was known; in addition, in most reports metastases in organs other than the heart were present.
In the early stage of the disease process, most patients with metastatic cardiac melanoma are not symptomatic. Depending on the location of the melanoma (pericardial, myocardial or, rarely, endocardial), a variety of manifestations may suggest cardiac involvement: 1, acute pericarditis; 2, pericardial effusion (often with rapid increase of heart size and accompanied by cardiac tamponade or constriction); 3, congestive heart failure; 4, second- or third-degree atrioventricular block; 5, atrial tachycardia; 6, transient ischemic attack
[7]
[8]
[9]
[10].
Despite the difficult clinical diagnosis of cardiac melanoma, early detection has important therapeutic and prognostic implications. Echocardiography is the most common diagnostic modality. Additional information can be obtained from CT or magnetic resonance imaging and positron emission tomography.
With regard to operative technique, venous cannulation of the femoral vein and superior vena cava allows an undisturbed and dry operative field, which aids in careful mobilization and complete resection of the tumor. Augmentation of the right atrium and, if necessary, the inferior or superior caval vein with a pericardial patch may prevent narrowing of these structures. For this purpose we prefer to use untreated autologous pericardium because this is pliable and adjusts optimally to pressure changes in the right atrium or venae cavae.
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References
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- McAllister HA Jr, Hall RJ, Cooley DA. Surgical pathology of tumors and cysts of the heart and pericardium. In: Waller BF, ed. Pathology of the heart and great vessels. New York: Churchill Livingstone, 1988:343.
- Klatt E.C., Heitz D.R. Cardiac metastases. Cancer 1990;65:1456-1459.[Medline]
- Glancy D.L., Roberts W.C. The heart in malignant melanoma, a study of 70 autopsy cases. Am J Cardiol 1968;21:555-571.[Medline]
- Hanley P.C., Shub C., Seward J.B., Wold L.E. Intracavitary cardiac melanoma diagnosed by endomyocardial left ventricular biopsy. Chest 1983;84:195-198.[Abstract/Free Full Text]
- Rubin D.C., Ziskind A.A., Hawke M.W., Plotnick G.D. Transesophageal echocardiographically guided percutaneous biopsy of a right atrial cardiac mass. Am Heart J 1994;127:935-936.[Medline]
- Waller B.F., Gottdiener J.S., Virmani R., Roberts W.C. The `charcoal heart': melanoma of the cor. Chest 1980;77:671-676.[Free Full Text]
- Prabhakar G., Vasilakis A., Hill R.C., Cruzzavala J.L., Graeber G.M., Gustafson R.A., Murray G.F. Right atrial metastatic melanoma in a patient with transient ischemic attacks. Ann Thorac Surg 1998;65:844-846.[Abstract/Free Full Text]
- Canver C.C., Lajos T.Z., Bernstein Z., Du Bois D.P., Mentzer R.M., Jr. Intracavitary melanoma of the left atrium. Ann Thorac Surg 1990;49:312-313.[Abstract]
- Merer D.M., Dutcher J.P., Mercando A., Brodman R., Suhrland M.J., Bhandari A., Zimmerman D., Mitchell M.S., Wiernik P.H. Case report: clinical findings and successful resection of melanoma metastatic to the right atrium. Cancer Invest 1994;12:409-413.[Medline]
- Chen R.H., Gaos C.M., Frazier O.H. Complete resection of a right atrial intracavitary metastatic melanoma. Ann Thorac Surg 1996;61:1255-1257.[Abstract/Free Full Text]
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Abstract
Introduction
