Ann Thorac Surg 1996;61:1255-1257
© 1996 The Society of Thoracic Surgeons
Case Report
Complete Resection of a Right Atrial Intracavitary Metastatic Melanoma
Ray H. Chen, MD,
Carlos M. Gaos, MD,
O. H. Frazier, MD
Departments of Cardiology and Cardiovascular and Thoracic Surgery, Texas Heart Institute at St. Luke's Episcopal Hospital, Houston, Texas
Accepted for publication October 19, 1995.
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Abstract
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We report a case of complete resection of a very large intracavitary metastatic melanoma of the right atrium. We describe a technique for resecting without damaging the atrium and for preventing the narrowing of the right atrium. In such cases, complete resection may be indicated despite widespread disease.
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Introduction
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Melanoma is unique in its high frequency of cardiac metastasis, ranging from 50% to 71% in autopsy studies [1–3]. Cardiac involvement is only rarely isolated; generally, it is part of a widespread dissemination. The dissemination is also mostly multifocal and usually not amenable to surgical intervention. We recently completely resected a very large right atrial intracavitary melanoma 26 years after the patient's cutaneous primary lesion had been excised.
A 56-year-old woman had a junctional nevus removed 26 years ago and left axillary dissection for one positive lymph node of metastatic melanoma 6 years later. In 1985, she underwent a partial hepatectomy for solitary left lobe metastasis. The patient remained asymptomatic until November 1994, when she presented right eye pain, especially when the eyeball moved laterally. After computed tomography, she was treated for pseudotumor cerebri with 80 mg of prednisone daily. She experienced some improvement. Subsequent computed tomographic and magnetic resonance imaging studies showed a very large right atrial intracavitary lesion. The patient was referred to our institution on February 8, 1995. She had had mild shortness of breath and a nonproductive cough for 1 week but still enjoyed swimming every day. Her Karnofsky performance status was 90%. Puffiness in her face was considered a side effect of the prednisone. No hepatomegaly and no peripheral edema were found. An electrocardiogram and a chest roentgenogram were normal except for fullness at the dome of the right side of the diaphragm. An echocardiogram showed atrial enlargement and a very large right atrial intracavitary lesion (Fig 1
). Her ejection fraction was 0.50 to 0.55.
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Fig 1. . Echocardiogram showing a large lesion within the right atrium. (LV = left ventricle; RV = right ventricle; T = tumor; TV = tricuspid valve.)
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On February 9, 1995, a midsternotomy incision was made. A dark discoloration approximately 2 x 3 cm was noted on the enlarged right atrium above the junction of the inferior vena cava; the presence of a mass inside the atrium was also noted. A dark, 1-cm nodule was found at the upper lobe of the left lung, and a bulging mass approximately 3 x 4 x 4 cm was found under the right side of the diaphragm. The left common femoral vein was exposed. After systemic heparinization, arterial cannulation was performed at the distal ascending aorta. A 32F venous cannula was placed from the left common femoral vein into the inferior vena cava, and a separate right-angled 32F cannula was inserted directly into the superior vena cava. Moderate hypothermia was achieved with cardiopulmonary bypass. After the aorta was cross-clamped and antegrade crystalloid cardioplegia was begun, the inferior vena cava was clamped and the superior vena cava was snared before the right atrial appendage was opened. The melanoma was approximately 5 x 8 cm and occupied almost the entire lumen; it was firmly attached to the discolored wall (Fig 2). A 1-cm margin of normal atrium was excised with the specimen. No septal or valvular involvement was found. To prevent narrowing of the inferior vena caval orifice, glutaraldehyde-treated pericardium was used to enlarge and patch the inferior aspect. The patient was easily removed from cardiopulmonary bypass. Temporary pacing wires were placed on the right ventricle as a routine precaution. Cannulas were removed and the right femoral vein was repaired. After protamine reversal, wedge resection of the left lung lesion confirmed the melanoma metastasis. The liver lesion was left intact.
Postoperatively, diuretics were necessary for 3 days and the prednisone dose was tapered. One week after the operation, the patient was released to another hospital for additional therapy for her cancer. One month later, a follow-up echocardiogram showed a normal right atrium, normal cardiac wall motion, and an ejection fraction of 0.70. A computed tomographic scan revealed no new lesions in the lung and no change in the liver lesion. Chemotherapy (vinblastine, dacarbazine, cisplatin, interleukin-2, and interferon-alpha) was started 2 months after the operation. Currently, 5 months postoperatively, the patient has normal spontaneous sinus rhythm, no shortness of breath, and no cough. She has tolerated two courses of chemotherapy well and can undertake her normal activities without assistance.
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Comment
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As cancer treatment has improved and patient survival time has increased, the incidence of cardiac metastasis has become progressively greater [2, 3]. Lung cancer is the chief source for cardiac metastases [2, 3], followed by lymphoma, breast cancer, melanoma, and gastrointestinal malignancy. The high incidence of cardiac melanomas is largely a manifestation of the tumor's propensity to metastasize widely before causing death [1]. Cardiac involvement in melanoma can be very extensive but is symptomatic in less than 16% of patients who eventually die of the disease [1]. All cardiac structures can be involved, although valves are only rarely [1, 4]. Melanoma is more likely to be present in the right heart chambers [1]. Because of refinements in echocardiography, computed tomography, and magnetic resonance imaging, intracavitary metastasis is now more readily diagnosed [5, 8]. Successful excision of separate single cases of right ventricular [5] and left atrial metastasis [6] have been reported. There have also been two reports of exploration of a right atrial intracavitary melanoma. One resulted in a biopsy of the pericardium only, because of involvement of the atrioventricular groove [7]. The other report described palliative resection (with residual malignancy left behind the inferior vena caval junction) using an inflow occlusion technique without cardiopulmonary bypass [8].
The venous cannulation of the left common femoral vein and the superior vena cava permitted an undisturbed and dry field in which to mobilize and deliver the very large intracavitary lesion. The pericardial patch was used to prevent narrowing of the entrance of the inferior vena cava after the removal of a margin of normal atrium.
The operation enabled the patient to avoid an impending cardiac catastrophe and has improved the quality of her remaining life. Complete resection of cardiac metastasis of a melanoma may be indicated and achievable in selected cases, especially if the patient (as in this case) has a Karnofsky performance status greater than 80% preoperatively.
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Footnotes
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Address reprint requests to Dr Frazier, Texas Heart Institute, MC 3-147, PO Box 20345, Houston, TX 77225-0345.
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References
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- Glancy DL, Roberts WC. The heart in malignant melanoma: a study of 70 autopsy cases. Am J Cardiol 1968;21:555–71.[Medline]
- Klatt EC, Heitz DR. Cardiac metastases. Cancer 1990;65:1456–9.[Medline]
- MacGee W. Metastatic and invasive tumours involving the heart in a geriatric population: a necropsy study. Virchows Arch [A] 1991;419:183–9.
- Thomas JH, Panoussopoulos DG, Jewell WR, Pierce GE. Tricuspid stenosis secondary to metastatic melanoma. Cancer 1977;39:1732–7.[Medline]
- Emmot WW, Vacek JL, Agee K, Moran J, Dunn MI. Metastatic malignant melanoma presenting clinically as obstruction of the right ventricular inflow and outflow tracts. Characterization by magnetic resonance imaging. Chest 1987;92:362–4.[Abstract/Free Full Text]
- Canver CC, Lajos TZ, Bernstein Z, DuBois DP, Mentzer RM Jr. Intracavitary melanoma of the left atrium. Ann Thorac Surg 1990;49:312–3.[Abstract/Free Full Text]
- Vetto JT, Heelan RT, Burt M. Malignant melanoma metastatic to the right atrium: an asymptomatic solitary metastasis diagnosed incidentally by magnetic resonance imaging [Letter]. J Thorac Cardiovasc Surg 1992;104:843–4.[Medline]
- Merer DM, Dutcher JP, Mercando A, et al. Case report: Clinical findings and successful resection of melanoma metastatic to the right atrium. Cancer Invest 1994;12:409–13.[Medline]
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Abstract
Introduction
