Cardiac metastases
Introduction
Introduction to cardiac metastases A cardiac metastatic tumor is a tumor formed by a systemic malignant tumor that is transferred to the heart by various routes and grown there. basic knowledge Sickness ratio: 4% Susceptible people: no special people Mode of infection: non-infectious Complications: congestive heart failure, arrhythmia, myocardial infarction
Cause
Cause of cardiac metastases
(1) Causes of the disease
Cardiac metastasis can occur in all malignant tumors. The most common tumor is lung cancer. Other common breast cancers, melanoma, malignant lymphoma, etc. The most prone to cardiac metastasis is melanoma. The most common cell type is Adenocarcinoma, in recent years, due to the increased incidence of AIDS, AIDS-induced lymphoma and cardiac metastasis of Kaposi sarcoma also play an important role, the main primary diseases are:
1. Acute leukemia: Roberts WC et al reported that in acute leukemia patients, the infiltration rate of myocardial leukemia was 37%, the heart wall infiltrating the heart chamber, the adipose tissue under the pericardium and pericardium, and the deposition of leukemia were almost focal, often Located in the endocardium, the infiltration is often accompanied by bleeding, but there are also differences between these two local conditions. In many patients, these infiltration and/or bleeding do not produce identifiable symptoms or signs, the degree of myocardial leukemia cell infiltration and ECG changes seem to be related.
2. Melanoma: Glancy DL et al reported that in metastatic tumors, melanoma has the highest incidence of heart involvement, and in cardiac metastases, more metastasis to the heart muscle than in the epicardium, suggesting that metastasis to the heart is through the bloodway. .
3. Lymphoma: Metastasis of malignant lymphoma, according to Mc Donnellp et al, in the pericardium of various tumors transferred to the heart or periphery, accounting for about 9%, lymphoma involving the clinical manifestations of the heart, generally non-specific Or when the patient is alive, it is not enough to identify, the tumor invades the heart far more widely than the clinical suspicion. Perry MC found that there are three types of heart involvement: the pericardium, the epicardium-outer membrane, and the diffuse interstitial-vascular circumference, These three types are associated with direct spread, countercurrent flow through the heart lymphatic pathway, and blood flow spread.
4. Lung cancer or breast cancer: Lung cancer and breast cancer involve the heart through direct diffusion or countercurrent transfer through the lymphatic pathway to the heart and pericardium, the latter pathway may lead to multiple small nodules metastases, and direct spread usually It is a part of the invasion, Burnett RC and so on, blood transfer is still the most common way.
5. Adrenal adenoma: Adrenal adenoma is known for its sometimes spreading into the inferior vena cava into the right atrium, or even the right ventricle. Choh JH et al believe that aggressive surgical procedures may result in successful resection.
(two) pathogenesis
1. Pathway of tumor metastasis
(1) Direct infiltration: mostly chest wall, lung and mediastinal tumor, mainly invading the pericardium, but also involving the myocardium.
(2) lymphatic spread: can affect the myocardium to varying degrees, the most common in lymphoma and Hodgkin's disease.
(3) blood transfer: menstrual blood, through the coronary artery into the myocardium, lesions often multiple, seen in melanoma, lymphoma and so on.
(4) Planting: Mainly planted into the pericardium, which can lead to exudate, stud, or constrictive pericarditis.
2. Tumor metastasis site
(1) pericardial metastasis: the most common accounted for 34%, transfer to the pericardium can lead to pericardial effusion, pericardial tamponade, or constrictive pericarditis.
(2) Myocardial metastasis: 21%, extracardiac tumor metastasis to the right atrium, similar to atrial myxoma and involving the tricuspid valve, many types of tumors, such as sarcoma, lymphoma, Wilms' tumor (Wilms tumor) Cardiac metastases such as adrenal adenoma, testicular cancer, and pheochromocytoma can produce these manifestations, secondary to right ventricular obstruction secondary to metastatic cancer, right ventricular outflow obstruction with shortness of breath, and due to excessive right ventricular overload. Sudden death, in some patients, metastatic lesions are caused by solitary lesions, making diagnosis more difficult, Calaroney et al reported that metastatic tumor left atrial involvement can also produce intermittent valvular obstruction, similar to atrial myxoma; or broken After causing arterial embolization and metastasis to the left ventricular cavity, it can cause obstruction of the left ventricular outflow tract. Hanley has made a biopsy to make a diagnosis by taking the intracardiac tumor tissue.
(3) endocardial metastasis: 5%, extracardiac tumor metastasis directly to the endocardium or heart valve surface is rare, may be associated with less blood vessels in these tissues, typical cases, involving the endocardial performance is similar to two The cusp or tricuspid stenosis, Perry reports, such as endometrial tumor thrombus from cancer, testis, liver, lung or thyroid cancer, can produce hemodynamic obstruction, heart murmur, and systemic embolism.
(4) Pericardial and myocardial involvement at the same time: 40%, the heart of the compartment can be affected.
The rare causes of cardiac metastatic tumors are related to the following factors: strong myocardial activity, less endocardial vessels, and a special metabolic pathway in the heart's striated muscle system, rapid blood flow through the heart chamber, and heart and The lack of lymphatic vessel traffic in the surrounding structure makes this kind of diffusion difficult. In addition, the coronary artery is perpendicular to the aorta, making it difficult for tumor cells to spread through this bloodway.
Prevention
Cardiac metastasis prevention
Early detection, effective treatment of primary tumors is the key to preventing cardiac metastases.
Complication
Cardiac metastases complications Complications congestive heart failure arrhythmia myocardial infarction
Complications such as congestive heart failure, arrhythmia, pericardial tamponade, myocardial infarction and heart rupture may occur.
Symptom
Symptoms of cardiac metastases Common symptoms Arrhythmia angina pectoris Heart failure Pericardial filling Pericardial effusion Myocardial infarction Sudden cardiac rupture Heart metastasis
The age of onset of cardiac metastases is 2.5 to 58 years old, 77.7% of 21 to 40 years old, and the ratio of male to female is 2.7:1. There are no specific symptoms and signs in this disease. The clinical manifestations are based on the location, type and heart of the primary tumor. The parts of the transfer vary in scope. Common manifestations are:
1. Congestive heart failure: Only tumors appear when the heart is extensively infiltrated, and are intractable and refractory.
2. Arrhythmia: Tumors invade the myocardium, various types of ectopic beats and tachyarrhythmias can occur, and atrioventricular or indoor conduction disturbances occur in the interventricular septum and conduction system, and severe sudden death can occur.
3. Pericardial tamponade: more common in pericardial metastases, also seen in myocardial metastases.
4. If the metastatic tumor occurs in the atrioventricular valve or ventricular outflow tract, symptoms and signs of obstruction in the corresponding site may occur. In addition, some cases may have stubborn angina, and a few may have myocardial infarction and heart rupture.
Examine
Cardiac metastases examination
Pericardial effusion cytology and myocardial biopsy have certain value in the diagnosis of metastatic cardiac tumors.
1. Electrocardiogram: In patients without myocardial ischemia, once the ischemic ST-T changes, the specificity of the diagnosis of tumor cardiac metastasis is 96%, and various arrhythmias and ventricular hypertrophy can be found.
2. Heart X-ray: It can be characterized by enlarged heart, irregular heart shadow, and heart shadow connected to adjacent mass (Fig. 1A).
3. Echocardiography: manifested as enlarged heart, thickening of local or multiple sites, decreased wall activity, and superior transesophageal echocardiography (Fig. 1B).
4. Heart CT: Can understand the relationship between tumor size, location, tumor and other thoracic structures.
5. Magnetic resonance imaging: Some authors believe that it is the first choice for non-invasive examination. It can observe the heart and adjacent tissues, identify secondary or primary tumors, understand the location and extent of the tumor, and have high definition and high resolution.
6. Cardiac angiography: Coronary angiography is mostly negative. Ventricular angiography shows enlargement of the heart, deformation, filling defects, and changes in local wall motion.
Diagnosis
Diagnosis and differentiation of cardiac metastases
Diagnostic criteria
The disease has a low prenatal diagnosis rate and has been diagnosed as a malignant tumor. If the following conditions occur, the possibility of tumor heart metastasis may be considered:
1. Rapidly developing pericardial effusion.
2. Unknown arrhythmia.
3. Sudden heart failure or intractable heart failure.
4. X-ray examination of the heart shows that the heart shadow is huge or limited.
5. There is no coronary heart disease, angina pectoris or acute myocardial infarction, and the effect of vasodilator is not good.
6. Unexplained "myocarditis".
Patients with suspected cardiac metastases can be diagnosed with electrocardiogram, cardiac X-ray, echocardiography, cardiac CT, magnetic resonance, cardiac angiography (ventricular angiography), etc. In addition, pericardial effusion cytology and myocardial biopsy for the diagnosis of metastatic heart Tumors have a certain value.
Differential diagnosis
1. Identification with primary cardiac tumors: The incidence of the latter is extremely low, only 1/20 of the former, the age of onset is small, and benign cardiac myxoma is more common, and no extracardiac malignant tumor is the main basis for identification.
2. Identification of dilated cardiomyopathy: Both can be characterized as congestive heart failure. The examination shows that the heart is enlarged and the activity is decreased, but the cardiac metastases develop faster, and the treatment effect on digitalis and diuretics is poor. The slice can be seen with irregular heart shape, B-ultrasound, CT and magnetic resonance can be found in tumor lesions.
3. Identification of pericardial effusion with other causes: the former is mostly bloody, rapid development, cancer cells can be found in the effusion, and the treatment effect is poor.
In addition, the arrhythmia and ST-T changes associated with this disease should be distinguished from those caused by other diseases. Cardiac mass and primary tumor are the key to identification.
