Article, Oncology

Unusual metastatic localization of osteosarcoma in a teenager with ventricular tachycardia

Case Report

Unusual metastatic localization of osteosarcoma in a teenager with ventricular tachycardia

Abstract

Most malignant tumors of the heart are metastatic. Metastatic cardiac tumors are usually associated with Wilms tumor, neuroblastoma, and non-Hodgkin lymphoma in children (Br J Radiol 71:336-339). Osteosarcoma rarely metastasizes to the heart. Twenty-four cases have been reported in the literature so far. The right side of the heart is more commonly involved than the left, and the pericardium and/or myocardium is more frequently involved than the endocardium (Br J Radiol 71:336-339). We report a rare case of osteogenic sarcoma of the right femur with left ventricular metastases presenting with ventricular tachycar- dia that has not been reported previously.

Cardiac tumors are extremely rare, found at a frequency of only 0.001% to 0.28% at autopsy series. The incidence of secondary cardiac tumors is much higher than that of primary cardiac tumors [1]. Secondary intracardiac neo- plasms arise most frequently from Renal cell carcinoma, bronchogenic carcinoma, Wilms tumor, chondrosarcoma, and osteogenic sarcoma [2]. There are several reports of metastatic childhood osteosarcoma involving the cardiac chambers. However, endocardial left cardiac chamber

involvement is very rare [3]. There are 2 cases of metastatic osteosarcoma to the left ventricular in the literature [4,5]. We describe here a 17-year-old adolescent girl who has left ventricular metastatic osteosarcoma presenting with ven- tricular tachycardia.

A 17-year-old adolescent girl was admitted to the emergency department with the complaint of sudden-onset palpitation. On admission, her blood pressure was 90/60 mm Hg; and her pulse rate was 175/min. Physical examination revealed a 2/6 systolic cardiac murmur at the apex, and she had a midsternal incision scar. Electrocar- diographic monitoring showed ventricular tachycardia (Fig. 1). Amiodarone infusion was started, and the tachycardia abruptly terminated during infusion. Two- dimensional echocardiography examinations revealed 3.2

x 2.4-cm and 2.12 x 1.43-cm masses in the left ventricular apex (Fig. 2). cardiac magnetic resonance imaging confirmed apical masses (Fig. 3).

Her history in detail revealed that she had been followed with the diagnosis of osteosarcoma of the right femur for the last 3 years. After an above-the-knee amputation, she had received adjuvant chemotherapy. Two years ago, she had been operated because of lung metastases (right inferior lob); and 18 months ago, she had been operated for cardiac metastases. In that operation, 2.4 x 3.5 x 2.8-cm and 1.8 x 0.8 x 0.8-cm masses were removed from the left ventricle.

Fig. 1 Electrocardiogram presents ventricular tachycardia.

0735-6757/$ – see front matter (C) 2010

1059.e2 Case Report

Fig. 2 Apical 4-chamber view of echocardiography shows masses protruding to left ventricular lumen.

Oncology consultant recommended chemotherapy for the patient. One month later, echocardiographic examina- tion showed that ventricular masses were increased in size, although the patient remained asymptomatic and hemodynamically stable. Therefore, amiodarone treatment was continued.

Cardiac metastasis occurs in a variety of malignancies, most commonly in melanoma and in lung and breast cancers in adults. Sarcomas rarely metastasize to the heart; of all sarcomas, osteosarcoma does so most frequently. Osteosar- coma metastasizes predominantly through the hematogenous route, most frequently to the lungs. Although osteosarcoma commonly metastasizes to the lung, metastases to other locations within the thorax are rare but important findings [6]. The right side of the heart is more commonly involved than the left, and the pericardium and/or myocardium is more frequently involved than the endocardium [3].

Fig. 3 Axial T1-weighted postcontrast image shows apical mass with mild contrast uptake.

Patients may present with various cardiac symptoms, including arrhythmias and features of infective endocardi- tis, but are more commonly asymptomatic with the cardiac abnormality detected on radiology [3]. Primary (lipoma, myxoma, rhabdomyofibroma, fibromyoma, fibroma, angio- matosis) and secondary (lymphoma) left ventricular tumors had been issued in the literature with presenting ventricular tachycardia [1,7-9]. Many cases have been diagnosed postmortem, but more cases are being detected antemortem by noninvasive Imaging techniques [3]. Postmortem examination by Seibert and colleagues [10] showed that 4 of 20 osteogenic sarcomas had metastasis to the heart and one of them was presented with recurrent ventricular tachycardia.

Echocardiography, particularly 2-dimensional imaging, is the most sensitive tool for detecting metastatic disease to the heart; and its use has increased the rate of diagnosis [11].

Magnetic resonance imaging is better than transthoracic echocardiography for detecting the presence, location, and extent of tumors within the heart [3].

Patients with arrhythmias due to cardiac tumors should initially receive medical treatment such as antiarrhythmic agents. Surgical resection is indicated when there is no response to medical treatment or when the patient’s condition worsens [1]. In our case, sinus rhythm was easily restored with amiodarone infusion. In cases of antiarrhyth- mic-resistant ventricular tachycardia, electrical cardioversion should be performed. Surgical excision of the mass should also be decided in recurrent Malignant arrhythmias.

The prognosis of osteosarcoma with metastasis is generally poor, but may be improved by early diagnosis and the addition of chemotherapy, radiotherapy, and surgical resection [3]. Although not so common, patients presenting with malignant arrhythmia and having a history of previous malignancy should be considered for cardiac metastasis [12].

Ebru Tekbas MD

Department of Cardiology Dicle University Medical School 21280 Diyarbakir, Turkey

E-mail address: [email protected]

Guven Tekbas MD

Department of Radiology Dicle University Medical School 21280 Diyarbakir, Turkey

Yahya Islamoglu MD Zuhal A. Atilgan MD

Habib Cil MD

Department of Cardiology Dicle University Medical School 21280 Diyarbakir, Turkey

Case Report 1059.e3

Faysal Ekici MD Hatice Gumus MD Hakan Onder MD Department of Radiology

Dicle University Medical School 21280 Diyarbakir, Turkey

doi:10.1016/j.ajem.2010.01.021

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