Cardiovascular magnetic resonance of the charcoal heart
© Rathi et al; licensee BioMed Central Ltd. 2008
Received: 09 May 2008
Accepted: 09 July 2008
Published: 09 July 2008
We report a case of malignant melanoma metastasis to the heart presenting as complete heart block. The highlight of the case is to demonstrate that silent cardiac metastasis is not uncommon and CMR has the potential to characterize these cardiac metastases and should be used routinely as a screening tool for those cancers with a high chance of cardiac involvement.
Metastasis to cardiac structures is rare. The common tumors that metastasize to the heart are breast cancer (direct extension), malignant melanoma (hematogenous), lung carcinoma (venous extension, direct invasion) and hypernephroma (venous extension) [1, 2]. Cardiac metastasis of malignant melanoma bears poor prognosis, especially as it may not produce any symptoms due to the indolent nature of the metastasis. We present a case of malignant melanoma metastasis to the heart, incidentally diagnosed due to bradycardia and complete heart block detected on a routine evaluation.
Among all the malignancies metastasizing to the heart, malignant melanoma has the highest incidence (40% to 60% chance of cardiac metastasis in some series) [1–3]. The diagnosis of cardiac metastatic melanoma is usually incidental on antemortem diagnostic studies. The cardiac involvement of the metastasis is usually limited to the myocardium and pericardium; however, valvular and endocardial metastasis may be seen primarily in the right heart. There have been few case reports of conduction system involvement primarily by septal invasion of the tumor, but none describing the CMR characteristics of the extensive myocardial metastasis .
The gated CMR of the heart can characterize cardiac tumors into benign vs. malignant based on the signal characteristics of the T1-weighted; T2-weighted and post-gadolinium contrast enhancement of the myocardial masses . Also, the cine sequences provide information about the chamber and valvular function in these cases. The T1 signal characteristics of malignant melanoma metastasis are dependent on the degree of melanin present in the tumor . Most metastasis will be hyperintense on T1-weighted images due to high melanin content, which shortens the T1 relaxation time. The T2-weighted images are less influenced by melanin and are generally hyperintense due to increased proton density or water content of the tumor (Fig. 4B). The post-gadolinium images demonstrate enhancement due to increased vascularity and interstitial space between the disorganized anaplastic cells. There have been autopsy reports showing myocardial tissue replaced by extensive metastatic malignant melanoma nodular deposits appearing as pigmented epicardial melanotic (black) implants viewed on the surface of the heart by the naked eye, hence the name charcoal heart . In our case, despite extensive myocardial replacement, the left ventricular systolic function was preserved. This intriguing finding was also reported by Waller BF et al .
This case highlights the importance of surveillance and high suspicion of metastatic disease to the heart despite no cardiovascular clinical signs or symptoms. This case also underscores the importance of advanced diagnostic techniques such as CMR which can localize and characterize the metastasis. Most importantly, the CMR findings mimic the autopsy specimen of a similar case described by Waller BF et al, suggesting high pathological correlation. The cardiac presentation is often late and by that time the prognosis is ominous. Therefore a high suspicion of cardiac metastasis should be present and early referral and sequential follow-up with CMR should be encouraged.
Our patient underwent treatment with the investigational drug YM 155 in the past and more recently was on IL-2. She was started on prednisone and was receiving radiation treatment for intracranial metastasis. Due to her poor prognosis, a decision was reached between the treating physician and the patient to refrain from pacemaker treatment of complete heart block. She continued to be in intermittent complete heart block without cardiac symptoms when she was discharged from the hospital.
Written informed consent was obtained from the patient for publication of this Case report and accompanying photographs and images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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