Ann Thorac Surg 2003;75:1969-1971
© 2003 The Society of Thoracic Surgeons
Case report
Right ventricular mass: a histopathological surprise
Kalyan Thippeswamy Anand, MSa,
Soman Rema Krishna Manohar, MCha*,
Sivadasanpillai Harikrishnan, DMa,
Kurur Sankaran Neelakandhan, MCha
a Department of Cardiothoracic and Vascular Surgery, and Cardiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
Accepted for publication November 14, 2002.
* Address reprint requests to Prof Manohar, Department of Cardiothoracic and Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram 695 011 Kerala, India
e-mail: manohar{at}sctimst.ker.nic.in
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Abstract
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A 33-year-old woman in the postpartum period presented with a mass in the right ventricular outflow tract. She underwent excision of the mass under standard cardiopulmonary bypass. Histopathologic examination of the mass revealed a metastatic lesion from the thyroid, which was follicular carcinoma of the thyroid. Later she underwent total thyroidectomy with lymph node dissection of the neck and radioactive 131I ablation for the residual tumor in the neck. At 1-year follow-up, the patient has no evidence of residual lesion in the heart, neck, or anywhere else in the body. A detailed preoperative workup could have changed the order of interventions and probably avoided a heart operation.
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Introduction
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Cardiac neoplasms have protean manifestations that may be primary or secondary. Seventy percent of the neoplasms are benign, which basically arise from the heart. Malignant tumors metastatic to heart are more common than the primary malignant tumors.
A 33-year-old woman in her postpartum period was investigated elsewhere and was referred with the diagnosis of a mass in the right ventricle. She had generalized weakness. The clinical evaluation was unremarkable and routine hematological and biochemical investigations, electrocardiogram, and chest roentgenogram were within normal limits. Transthoracic and transesophageal echocardiography showed a well-defined mass measuring 16 x 22 mm in size occupying the right ventricular outflow tract with no intrinsic mobility. The mass was attached to the right ventricular free wall, with no right ventricular outflow gradient. There was no other mass seen in other chambers of the heart (Fig 1).
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Fig 1. (Top) Transthoracic Echocardiography (TTE) two-dimensional showing a 16/22 mass in right ventricular outflow tract, no intrinsic movement, attached to the right ventricular free wall, no right ventricular outflow tract obstruction, and dilated right ventricular outflow tract. (Bottom) Transesophageal echocardiography showing a 30-mm circular mass in right ventricular free wall.
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She was taken up for surgery for the possibility of a primary benign tumor of the heart. Under standard cardiopulmonary bypass with moderate hypothermia and cardioplegic arrest, a well-circumscribed grayish white mass measuring 20 x 20 mm in size attached to infundibulum was excised through a right atrial approach (Fig 2).
She had an uneventful postoperative recovery.
The histopathological examination of the mass turned out to be a metastatic deposit from Follicular carcinoma of thyroid (Figs 3, 4).
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Fig 3. Low power photomicrograph shows RV wall with a mural nodule consisting of thyroid follicles of varying size and containing eosinophilic colloid material. (Hematoxylin & eosin staining, x96.)
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Fig 4. Higher magnification shows marked variation in size of follicles lined by cuboidal cells with pleomorphic vesicular nuclei and many mitotic figures. (Hematoxylin & eosin staining, x240.)
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She was reexamined after obtaining the histopathology report concentrating on the thyroid gland and was found to have a solitary nodule on the left lobe. She was referred to the Regional Cancer Center, where fine needle aspiration cytology of the nodule revealed follicular carcinoma.
She was operated on for a total thyroidectomy and lymph node dissection of the neck, and the specimen showed papillary carcinoma of the thyroid with a follicular variant with lymphocytic thyroiditis.
She was given a radioiodine 131I whole body scan to look for any residual thyroid tissue and secondaries, which showed residual uptake in the neck for which she underwent 131I radioablation.
She was reviewed after 1 year and had no evidence of residual or recurrent tumor in the heart or neck. She has been on thyroid replacement therapy and is clinically euthyroid.
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Comment
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Secondary tumors in the heart are 20 to 40 times more common than primary cardiac lesions [1]. Common malignancies that involve the heart include the breasts, lungs, lymphoma, melanomas, and sarcomas. The order of frequency of involvement is pericardium, epicardium, myocardium, and endocardium [1, 2].
Cardiac metastasis rarely is solitary. Symptoms by cardiac metastasis are produced in only 10% of patients. Most of the symptoms produced are by pericardial effusion and tamponade [3], refractory arrhythmia [4], or congestive heart failure.
Metastasis to the heart as the first sign of thyroid cancer has been reported [5]. In one patient, the endocardial deposit from a follicular carcinoma presented with fatal ventricular tachycardia [4]. In another patient, echocardiography diagnosis of right ventricular outflow obstructing mass led to the early detection and treatment of the highly differentiated follicular carcinoma of the thyroid [5].
In the present patient, unfortunately we did not consider the possibility of a secondary deposit in the right ventricle as the mass was well circumscribed and we were also unaware of the remote possibility of a secondary from a thyroid carcinoma. If we had done a proper clinical examination, fine needle aspiration cytology from the thyroid nodule could have saved our patient from major cardiac surgery.
Because secondary tumors in the heart are much more common than primary tumors in a patient presenting with a cardiac mass lesion, and if the mass has features that are not very typical of a myxoma, then a remote possibility of a metastatic deposit should be kept in mind, even if the patient is otherwise asymptomatic. A detailed clinical examination with a thyroid and abdominal scan can sometimes save the patient from an unnecessary cardiac operation.
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References
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- Randolph W., Chitwood J.R. Cardiac neoplasms: current diagnosis, pathology and therapy. J Cardiac Surg 1988;3:119-154.[Medline]
- Kutalek S.P., Panidis I.P., Kotler M.N., Mintz G.S., Carver J., Ross J.J. Metastatic tumors of the heart detected by two dimensional echocardiography. Am Heart J 1985;109:343-349.[Medline]
- Chiewvit S., Pusuwan P., Plechachinda R., Attanatho V., Mongkharuk J. Metastatic follicular carcinoma of thyroid to pericardium. J Med Assoc Thai 1998;81(10):799-802.[Medline]
- Clare-Salzer M.J., Van Herle A.J., Varki N.M., Tillish J. Endocardial metastasis of follicular carcinoma: a case report and review of literature. Eur J Surg Oncol 1991;17(2):219-223.[Medline]
- Kasprzak J.D., Religa W., Krzeminska-Pakula M., Masrszal-Marciniak M., Zaslonka J., Pawlowski W. Right ventricular outflow tract obstruction by cardiac metastasis as the first manifestation of follicular thyroid carcinoma. J Am Soc of Echocardiography 1996;9(5):733-735.
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Abstract
Introduction
