Effects Of Cancer On The Heart

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Mass Effect: Extracardiac Compression or Intracavitary Obstruction

Even tumors that do not directly involve the heart and pericardium can occasionally be seen by echocardiography. Anterior mediastinal masses (cysts, thymomas, teratomas, lymphomas) can compress the right ventricular outflow tract, whereas posterior masses (sarcomas) or pleural tumors can compress the left atrium and ventricle. Figure 18 is an example of a pleural mesothelioma impinging on the right atrium and right ventricular inflow tract (please see companion DVD for corresponding video). Infiltrative growth of a tumor can cause obstruction to cardiac inflow or outflow, as in the superior vena cava syndrome. If the tumor invades onto a valve, prolapse of the involved leaflets and associated regurgitation ensues (the cause of the myxoma tumor "plop" in the Case Vignette).

Direct Infiltration of the Myocardium

Direct infiltration of the myocardium can lead to segmental wall motion abnormalities or restrictive disease, causing congestive heart failure. Less frequently, conduction disturbances have been described when malignant tissue invades the area of the atri-oventricular node or septum, which contains the conduction system.

Carcinoid Heart Echocardiography

Fig. 19. (A) Transthoracic echocardiography showing the classic findings in carcinoid heart disease. Right ventricular inflow and apical four-chamber (A4C) views show the characteristic immobility of the tricuspid valve leaflets (arrows). Wide-open tricuspid regurgitation is seen in the upper- and bottom-right panels. (B) The pulmonic valve cusps of the patient with the carcinoid syndrome (A), were thickened, retracted, and fixed with a stenotic pulmonary valve orifice (left panel, parasternal short-axis view). Color flow Doppler evaluation shows flow acceleration and turbulence across the stenotic pulmonary valve. (Please see companion DVD for corresponding video.)

Fig. 19. (A) Transthoracic echocardiography showing the classic findings in carcinoid heart disease. Right ventricular inflow and apical four-chamber (A4C) views show the characteristic immobility of the tricuspid valve leaflets (arrows). Wide-open tricuspid regurgitation is seen in the upper- and bottom-right panels. (B) The pulmonic valve cusps of the patient with the carcinoid syndrome (A), were thickened, retracted, and fixed with a stenotic pulmonary valve orifice (left panel, parasternal short-axis view). Color flow Doppler evaluation shows flow acceleration and turbulence across the stenotic pulmonary valve. (Please see companion DVD for corresponding video.)

Fig. 20. These transthoracic images are from a 31-yr-old female who presented postpartum with a large pericardial effusion with echocardiography signs of tamponade. Following removal of almost 1 L of fluid, a large anterior mediastinal mass (curved arrow) that displaced the heart posteriorly, compressing the aorta and left atrium (arrow) was noted on the parasternal long-axis (PLAX, B). Computed tomography scans and computed tomography-guided biopsy and histology confirmed a lymphoma.

Transthoracic Biopsy

Fig. 20. These transthoracic images are from a 31-yr-old female who presented postpartum with a large pericardial effusion with echocardiography signs of tamponade. Following removal of almost 1 L of fluid, a large anterior mediastinal mass (curved arrow) that displaced the heart posteriorly, compressing the aorta and left atrium (arrow) was noted on the parasternal long-axis (PLAX, B). Computed tomography scans and computed tomography-guided biopsy and histology confirmed a lymphoma.

Valvular Involvement

Valvular involvement by a tumor can cause leaflet prolapse and associated regurgitation (e.g., the mechanisms behind the myxoma "plop" detected by auscultation), as well as a functional stenosis because of obstruction. Atrial fibrillation may be the indirect result. Carcinoid heart disease is a distinctive clinical syndrome associated with malignant carcinoid tumors (particularly APUDomas and bronchial tumors), which secrete sero-toninergic substances into the bloodstream. These vasoactive peptides cause episodic symptoms such as flushing and diarrhea. Within the heart, the hormones cause severe thickening and fibrosis of the atrioventricular valves, leading to retraction and fixation of the leaflets in the open position during diastole, and hence severe regurgitation. Typically with tumors involving hepatic metastases, the tricuspid valve and/or pulmonic valves are affected, whereas tumors involving the lungs cause left-sided valvular abnormalities. Figure 19 shows apical and right ventricle inflow views of the tricuspid valve in a patient with carcinoid heart disease; note the immobilized leaflets without closure, and consequent severe tricuspid regurgitation by color Doppler (please see companion DVD for corresponding video). Also note the Eustachian valve within the right atrium, which is a normal anatomic structure.

Pericardial Involvement

Pericardial involvement is a common sequelae of cancers that have invaded the pericardial space by direct extension, or else via hematogenous or lymphatic spread. The echolucent space is caused by effusive pericarditis, which can occasionally be hemorraghic (especially when caused by mesotheliomas) and expand rapidly enough to cause tamponade. Areas of solid tumor are usually seen as highly reflective, relatively thick or nodular echodensities adjacent to the visceral or parietal pericardium, which may invade underlying myocardium as well (Fig. 20). If solid tumor encases a significant portion of the pericardial sac, constrictive pericarditis can occur in addition to effusive pericarditis.

Late and/or Indirect Effects

Finally, even when cancers do not directly involve the heart, the treatment may have cardiac effects, despite remission or even cure of the primary malignancy. Chemotherapeutics of the vincristine class (adri-amycin, daunorubicin, and others) are notorious for causing dilated cardiomyopathy as a side effect in some patients. The anti-HER2 monoclonal antibody, her-ceptin, is often used in combination with anthra-cyclines, and appears to cause heart failure, particularly in patients who are older or have other cardiac risk factors. Thus, the ejection fraction should be followed serially in these patients. Radiation therapy to the mediastinum can cause radiation pericarditis, which may be eventually evolve into constrictive pericarditis; exposure to such radiation also associated with accelerated coronary artery disease in cancer survivors.

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Responses

  • JESSICA
    Can an anterior mediastinal mass affect left ventricular wall motion?
    11 months ago

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