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JCCASE-551; No. of Pages 3

Journal of Cardiology Cases xxx (2014) xxxxxx

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Journal of Cardiology Cases

journal homepage: www.elsevier.com/locate/jccase

Case Report

Solitary right ventricular metastasis of endometrial adenocarcinoma

Fritz W. Horlbeck (MD)*, Nikos Werner (MD), Christoph Hammerstingl (MD),
Georg Nickenig (MD), Joerg O. Schwab (MD)
Department of Medicine Cardiology, University of Bonn, Bonn, Germany

A R T I C L E I N F O A B S T R A C T

Article history: A woman presented with a solitary cardiac metastasis 5 months after curative surgery for endometrial
Received 2 April 2014 adenocarcinoma (FIGO IB). The tumor was deemed inoperable and palliative ambulatory chemotherapy
Received in revised form 29 August 2014 was initiated. We aimed at a palliative reduction of tumor mass after chemotherapy and atypical
Accepted 24 September 2014
vascularization of the metastasis was demonstrated by coronary angiography. We identied two tumor
vessels originating from the ramus circumexus suitable to palliative percutaneous coronary
Keywords: intervention. Within 5 weeks, the initially mild dyspnea increased to New York Heart Association
Right heart failure
class III and readmission was planned. Regrettably, our patient died from congestive right heart failure
Metastasis
Endometrial adenocarcinoma
only 2 months after diagnosis of tumor recurrence. This report illustrates the need for resolute action
Intervention without delay even in cases of only mild right heart failure.
<Learning objective: Right ventricular metastasis of gynecologic cancer is a rare phenomenon and
prognosis of symptomatic patients is poor. In carefully selected patients with symptomatic disease, a
palliative percutaneous intervention is feasible and, if appropriate, should be discussed in an
interdisciplinary fashion without delay.>
2014 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.

Case report
A 64-year-old woman presented with swelling of her left leg
and mild dyspnea [New York Heart Association (NYHA) class II].
Her medical history consisted of a poorly differentiated adenos-
quamous carcinoma of the uterus (FIGO 1B, G3). To date, the
patient was classied disease-free 5 months after curative surgery
(hysterectomy and bilateral salpingo-oophorectomy) with post-
operative radiotherapy and denied any B symptoms.
Ultrasound revealed old iliacal deep venous thrombosis with
only mild elevation of D-dimer (1.2 mg/l). Subsequent computed
tomography detected diffuse pulmonary embolism as a probable
cause of dyspnea and, surprisingly, a large mass in the right
ventricle (RV). Echocardiography showed a nearly complete
obstruction of the dilated RV with the beginning of obstruction
of the inow tract, moderate tricuspid regurgitation, developing
hepatic congestion, and oating parts of the huge intracardiac
mass (Figs. 1 and 2). Echocardiographic measured RV pressure was
30 mmHg, basal RV and areas without direct tumor contact
* Corresponding author at: Department of Medicine Cardiology, University of
Bonn, 53105 Bonn, Germany. Tel.: +49 173 5251138; fax: +49 228 287 12737.
E-mail address: fritz.horlbeck@ukb.uni-bonn.de (F.W. Horlbeck).
showed good kinetics (tricuspid annular plane systolic excursion
or TAPSE was 2.2 cm).
Magnetic resonance imaging showed a 6 cm  5 cm homoge-
neous mass descending from the rear wall of the RV and a cardiac
tumor, most probably a solitary cardiac metastasis, was diagnosed.
Interestingly, the electrocardiogram (sinus rhythm 82/min)
showed negative T waves in the inferior leads but no right
bundle-branch block.
We performed a diagnostic pericardiocentesis of the moderate
pericardial effusion (2 cm) of minor hemodynamic signicance
without detection of malignant cells. An ultrasound-guided
transvascular RV biopsy then veried the diagnosis of a cardiac
metastasis of the endometrial adenocarcinoma (estrogen receptor
negative, pan-cytokeratin AE1/3 and Vimentin positive, Ki 67 index
40%) with adherent thrombus formation.
The tumor was deemed inoperable given its size and the vast
involvement of the myocardium.
Tumor staging revealed advanced disease (FIGO IVB) with
suspect iliacal lymph nodes and, after discussion at the tumor
board, palliative chemotherapy with carboplatin and paclitaxel
was initiated.
In order to gain symptom relief and improve quality of life, we
aimed at a palliative reduction of tumor mass after chemotherapy.
By means of coronary angiography, atypical vascularization of the
metastasis from the surrounding coronary artery system was

http://dx.doi.org/10.1016/j.jccase.2014.09.006
1878-5409/ 2014 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Horlbeck FW, et al. Solitary right ventricular metastasis of endometrial adenocarcinoma. J Cardiol
Cases (2014), http://dx.doi.org/10.1016/j.jccase.2014.09.006
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JCCASE-551; No. of Pages 3
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Cardiac metastasis causing nearly complete obstruction of the dilated
Fig. 1.
right ventricle, short-axis view.
Cardiac metastasis causing nearly complete obstruction of the dilated
Fig. 2.
right ventricle, apical four-chamber view.
demonstrated. We identied two tumor vessels originating from the
ramus circumexus suitable for palliative percutaneous coronary
intervention, analogous to transcoronary ablation of septal hyper-
trophy (TASH) (Fig. 3). Because of the stable hemodynamic status
and the availability of this established oncologic chemotherapy we
abstained from an immediate interventional approach and intended
a reevaluation after completion of the chemotherapy cycles.
Please cite this article in press as: Horlbeck FW, et al. Solitary right ventricular metastasis of endometrial adenocarcinoma. J Cardiol
Cases (2014), http://dx.doi.org/10.1016/j.jccase.2014.09.006
Downloaded from ClinicalKey.com at ClinicalKey Global Guest Users March 13, 2017.
For personal use only. No other uses without permission. Copyright 2017. Elsevier Inc. All rights reserved.
Fig. 3. Tumor vascularization originating from the circumex coronary artery.
Within 5 weeks, the initially mild dyspnea increased to NYHA
class III with peripheral edema, and readmission to our department
was planned. Regrettably, our patient died from congestive right
heart failure only 2 months after rst diagnosis of tumor
recurrence.
Discussion
Right ventricular metastasis is a generally rare phenomenon.
The three most common malignant neoplasms appear to be
carcinoma of the lung, esophageal carcinoma, and lymphoma [1]. A
literature search for particular metastatic spread of endometrial
adenocarcinoma to the right ventricle revealed only four cases [2
5]. Right heart catheterization and biopsy, if necessary, should be
performed under ultrasound guidance, for fatal adverse hemody-
namic consequences have been reported [6].
The intracardiac mass may initially be asymptomatic but
subsequent obstruction of the RV outow tract can swiftly
accelerate the course of the disease resulting in poor prognosis
[2,4,6].
To date, only few cases of interventional therapy of metastatic
RV obstruction are described in the literature. Valentin and Butz
reported one case each of coiling of tumor vessels (leiomyosar-
coma of the uterus and renal cell carcinoma) with an asymptom-
atic survival of over 10 and 19 months, respectively. Kotani et al.
reported a case of successful transcoronary chemoembolization for
relief of RV outow obstruction derived from hepatocellular
carcinoma [79].
The main objective of an intervention in the case of
symptomatic obstruction is a palliative tumor-mass reduction
with concomitant reduction of RV pressure and amelioration of
congestive right heart failure.
Denitive preinterventional identication of main tumor
feeding branches is obligatory and can be done by simple
coronary angiogram or by intracoronary contrast injection
through the balloon catheter under transesophageal echocardio-
graphic control prior to induction of the necrosis [7,8]. It remains
unclear whether chemoembolization or coiling of the tumor
vessels will lead to best results and carries the lowest risk of
complication (e.g. RV rupture). Recommended safety measures
should include periinterventional monitoring of vital function
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JCCASE-551; No. of Pages 3

F.W. Horlbeck et al. / Journal of Cardiology Cases xxx (2014) xxxxxx 3

and cardiac enzymes, pacemaker back up, and analgesic References

treatment with morphine.
Conclusion
Altogether, an interventional approach has been described as a
feasible procedure for interdisciplinary palliative therapy of
symptomatic metastatic RV obstruction and should be evaluated
early, while the natural course of symptomatic disease is rapidly
deteriorating and no time is to be lost.
Conict of interest statement
There are no disclosures or conicts of interest.
Acknowledgment
This report has been presented orally at the annual congress of
the German Cardiologic Society (DGK) in 10/2013.
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Please cite this article in press as: Horlbeck FW, et al. Solitary right ventricular metastasis of endometrial adenocarcinoma. J Cardiol
Cases (2014), http://dx.doi.org/10.1016/j.jccase.2014.09.006
Downloaded from ClinicalKey.com at ClinicalKey Global Guest Users March 13, 2017.
For personal use only. No other uses without permission. Copyright 2017. Elsevier Inc. All rights reserved.