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I. ДИАГНОСТИКА И ЛЕЧЕНИЕ
CASE OF METASTASIS OF BREAST CANCER IN THE RIGHT VENTRICLE OF THE HEART
МРНТИ 76.29.49
Li V.V., Baiguisova D.Z.
JSC "National scientific center of surgery named after A.N. Syzganov", Almaty, Kazakhstan
ABOUT THEАUTHORS
Baiguisova Dinara Zulkhanaevna - Doctor of Radiation Diagnostics, Head of the Department of Radiation Methods of Research JSC NSCS named after A.N. Syzganov.
Li Vladimir - Resident of radiology NSCS named after A.N. Syzganov.
Abstract
We report a case of metastatic cardiac tumor developed from breast cancer. It describes the diagnosis of the disease from the moment of arrival until discharge of the patient, as well as the difficulties caused by patient's deliberate withholding of information. Conclusions were made about the most and the least informative research methods for this diagnosis, the importance of thorough history recording, and the need to double check and compare the clinical data with the words of the patient.
Keywords
Heart metastasis, secondary cardiac tumor, EchoCG, computer tomography, right ventricle.
KYpeKTity оц карыншагындагы cyt 6e3i обырыньщ метастазасы
Ли В.В., Байгуисова Д.З.
«А.Н.Сьстанов атында?ы Улттык, ?ылыми хирургия орталь™» АК,, Алматы, К,азак,стан
Ацдатпа
Сут безi катерл'1 iciriHe байланыс дамыган метастатикальщ журек ютн'щ пайда болуы жайлы ха-барлаймыз. Мунда наукастын ауруханага тус'ш, емдел'ш шыгуга деШнп диагностикалык сипаттамасы, жэне емдеу барысында наукастын айтпаган ауруларынын шенберШде туындаган киыншылыктар жайлы да сипатталган. Осы диагноз шeнбeрiндe зeрттeудiн ен ти'1мд'1 жэне пайдалы тэсшдерш колдана отрып корытындылар жасалды, косымша кайта тексеруге жэне клиникалык магпуматтарды аурудын свздер'шен салыстыруга, анамнeздi мукият тексеруге нускаулык берmi.
АВТОРЛАР ТУРАЛЫ
Байгуисова Динара Зулхарнаев-
на - А.Н. Сызранов атындары YFXÜ сэулел1 тэслдермен зерттеу бeлiмiнiн менгерушю, сэулелi зерттеу дэргер.
Ли Владимир Вячеславович - А.Н. Сызранов атындары YFXÜ cэулeлi тэслдермен зерттеу бeлiмшесiнiн резидентi.
Туйш сездер
журек метастаздары, кайталама журек кэтeрлi itiri, ЭхоКГ, комnьютерлiк томография, ом жак карынша.
Случай метастазирования рака молочной железы в правый желудочек
Ли В.В., Байгуисова Д.З.
АО «Национальный научный центр хирургии им. А.Н. Сызганова», Алматы, Казахстан
Аннотация
Мы сообщаем о случае метастатической опухоли сердца, развившейся из рака молочной железы. В нем затрагивается диагностика заболевания с момента поступления до момента выписки пациентки, также трудности, вызванные непосредственно утаиванием ею информации. Были сделаны выводы о наиболее и наименее информативных методах исследования при данном диагнозе, о важности тщательного сбора анамнеза, и необходимости перепроверять и сопоставлять клинические данные со словами пациента.
ОБ АВТОРАХ
Байгуисова Динара Зулхарнаевна -
врач лучевой диагностики, заведующая отделом лучевых методов исследования ННЦХим. А.Н. Сызганова.
Ли Владимир Вячеславович - резидент отдела лучевых методов исследования ННЦХ им. А.Н. Сызганова.
Ключевые слова
метастазы в сердце, вторичная опухоль сердца, ЭхоКГ, компьютерная томография, правый желудочек.
Introduction
Primary cardiac tumors are rare with a frequency of about 0.0017-0.28% of patients at the autopsy [1,3]. Cardiac metastases occur more frequently than primary cardiac tumors, with a highly variable incidence ranging from 2.3% to 18.3% in autopsy reports [2]. Secondary or meta-static heart tumors are relatively more common, at least 6-40 times more often than primary heart tumors [1,4]. The cardiac metastasis rate varies in different autopsy series and ranges from 2.7% to 25% in all patients with cancer [5]. Patients often have symptoms associated with heart lesions, either due to functional disorders of the blood flow from the mass itself (fainting, heart failure, embolism) or arrhythmia, delayed conduction or pericardial effusions. Heart metastases usually indicate a systemic disease and are rarely solitary
[6]. The incidence of cardiovascular metastases identified at the autopsy, the number of cancer patients is 1.5% - 8.3% of patients dying from malignant diseases [2]. Heart metastases occur predominantly in patients in the sixth and seventh decades of life [7,8]. They are found in the heart more often at autopsy [9]. The most common tumors with metastatic potential in the heart are carcinomas of the lung, breast and esophagus, malignant lymphomas, leukemia and malignant melanoma. Malignant melanomas have a higher incidence of cardiac metastasis than carcinomas or malignant lymphomas. [7,3]. The pericardium, myocardium or endocardium may be involved separately or in combination. the disease may be clinically silent or have a wide range of non-specific symptoms and signs [2]. Pericardium, myocardium and endocardium are involved, from most to least frequent. The development of metastases in the pericardium or myocardium depends on the preferential metastatic path of the tumor origin
[7]. Cardiac metastasis most commonly involves the pericardium and epicardium comprising two thirds of all cardiac metastases, however, involvement of myocardium, endocardium, cardiac cavities, great vessel and coronaries can also occur [10]. Like primary heart tumors, metastases can mimic valvular heart defects or cause heart failure, ventricular or supraventricular cardiac rhythm disturbances, conduction defects, syncope, embolism, or, quite often, pericarditis. Often, invasion of heart tumors contributes to the mechanism of death of patients [7].
Case report
The patient 57 years old entered 10/19/2018 to the NSCS named after A.N. Syzganov with complaints of shortness of breath after light physical activity (walking up to 10 meters), shortness of
breath, dry cough, nausea, dizziness, palpitations. In anamnesis heredity is complicated with oncology.
Physical examination revealed swelling of neck veins. The border of the heart is left-1 cm outward from the left midclavicular, upper-3 intercostal space, right-on the right edge of the sternum. AP (dexter) -105/71 mmHg, AP (sinister) -105/71mmHg. At the time of admission, a series of instrumental and laboratory studies of biochemical blood tests were carried out: a slight increase in creatinine to 100 emol/l. ECG on which sinus tachycardia was determined. HR 100 beats / min. The vertical position of the EAH. Diffuse-dystrophic changes in the myocardium. EchoCG showed a massive formation in the cavity of the right ventricle (7.0 cm x 4.0 cm), obturating the fibrous ring of the three-fold valve and partially the output path of the right ventricle. The aorta is not dilated. Aortic valve 3-folding, intact. Heart cavities: Left Ventricle-squeezed, Right Atrium-enlarged. Indicators of systolic function of the myocardium in the normal range. The valves of the Mitral Valve move in antiphase. MR II Art. The tricuspid valve is obturated (measuring the systolic pressure of the pulmonary artery is not possible). Pericardial cavity fluid - separation of pericardial sheets along the posterior wall +1.0 cm, +1.5 cm of the anterior wall of the right ventricle closer to the apex. Thyroid ultrasound: a moderate enlargement of the thyroid gland. Diffuse changes in the parenchyma of the thyroid gland by type AIT. CT of the heart: The heart is dilated across, mainly due to the right sections. In the right ventricle, the presence of a formation with uneven contours, 80x64x64 mm in size, is noted; after the injection of a contrast agent, the structure of the structure determines the presence of vessels, as well as decay sites. Formation almost completely fills the right ventricle, involving its wall, right coronary artery, tricuspid valve, spread in the right atrium. A 7 mm thick layer of free fluid is found in the pericardium. Conclusion: CT scan of the V-formation of the right ventricle (sarcoma?). Free fluid in the pericardium.
Based on complaints, anamnesis and clinical data, the diagnosis was made: right ventricular sarcoma? It was decided to hospitalize the patient for surgical treatment. In the hospital, the patient was interviewed several times, after which they confessed that they were hiding the fact that in 2017 mastectomy was performed to treat a formation in the right breast. Due to new details, a number of required primary and additional examinations were carried out: radiography determined a slight dilatation of the heart to the left, the waist intact, underlined CTI-55%, and left-sided pleu-
risy. Ultrasound of the pelvic organs: Involutive changes of the pelvic organs. Ascites. Cervical cyst Mts lesion of the iliac and inguinal lymph nodes on the left. Ultrasound of the abdominal organs and kidneys: Diffuse changes in the liver parenchyma with the expansion of the IVC. Echo signs of chronic pyelonephritis of both kidneys. Interstitial effusion in the pelvis in small quantities. CT scan of abdominal organs: Hepatomegaly. Diffuse decrease in liver density, more likely to be of a stagnant nature. Cholelitiasis. Ascites. Adenopathy of the inguinal and iliac region on the left. MRI of the brain: Mr picture of moderate subatrophic changes in the brain. MR data for a secondary lesion is not determined. MRI of the pelvic organs: The MRI is more consistent with a secondary lesion of the lymph nodes of the external iliac, inguinal group and left sciatic bone. Ascites.
Consultation of the oncologist: Carcinoma of the right breast stage T4N0M0. Condition after sanitary amputation. Progression of the Mts process of the pelvic, iliac and inguinal lymph nodes on the left. Tumor of the right ventricle. Hormone therapy was recommended.
The concilium was held where it was decided that, given the prevalence of the tumor process, the presence of distant metastases, the risk of surgical intervention is extremely high and exceeds the risk of further disease. In this connection, the patient decided to transfer to conservative treatment. The patient was discharged for further treatment and observation at the place of residence. In this case, surgical treatment was not carried out due to the presence of distant metastases in the pelvic bones and iliac and inguinal lymph nodes.
Discussion
Secondary tumors of the heart are 100 times more common than primary tumors, but clinical manifestation is extremely rare [3]. Considering this clinical case in retrospect, it is worth to note a poor clinical picture, in which there was only a slight decrease in blood pressure and tachycardia, but at the same time the presence of an uncommon symptom - cervical vein swelling. The most informative research methods were echocardiog-raphy and cardiac CT [2,3,7,8,11]. This is supported by the research of other authors. The ECG also showed diffuse-dystrophic changes; other authors also reported similar changes [8,9]. The least informative was the radiography of the chest, which is confirmed in the publications of other authors. However, some researchers indicate that there may be no changes on the ECG, as well as on the radiograph [1]. As a rule, the differential diagno-
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Fig 1.
Formation of right ventricle in axial projection
Fig 2.
Formation of right ventricle in coronal projection
Fig 3.
Formation of right ventricle in sagittal projection
sis of metastatic heart disease does not cause difficulties, but without clinical manifestations it is difficult to suspect heart damage. This clinical case showed similar data with other clinical cases published in the literature that described a similar clinical picture and age.
Conclusion
This clinical case is interesting because without a clear anamnestic data, it is difficult to make a correct diagnosis, primarily because of the patient hiding the information. Its results show data similar to other published clinical cases, that describe a similar clinical picture, age and research methods.
References
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