1992, The British Journal of Radiology, 65, 672-673

lntracardiac metastases from germ cell tumours—an unusual but important site of metastasis By Dirk Pickuth, MD, Rosalind Eeles, MA, MRCP, FRCR, Malcolm Mason, MRCP, FRCR, 'Charles Pumphrey, DM, MRCP, tPeter Goldstraw, MB, ChB, FRCS and Alan Horwich, PhD, MRCP, FRCR Academic Unit of Radiotherapy and Oncology, The Royal Marsden Hospital, Downs Road, Sutton, Surrey SM2 5PT; "Department of Cardiology, St George's Hospital, Blackshaw Road, London SW17 OQT and tDepartment of Thoracic Surgery, The Royal Bromptom Hospital, Sydney Street, London SW3 6NP, UK

(Received 25 September 1991 and in revised form 31 January 1991, accepted 6 March 1992) Keywords: Germ cell tumours, Testicular neoplasms, Teratoma, Metastases, Heart

Abstract. Two cases of intracardiac deposits from testicular teratomas diagnosed by echocardiography and angiocardiography, respectively, are described. The importance of recognizing this as an uncommon site of metastasis from germ cell tumours is discussed.

The most common sites of metastatic involvement from non-seminomatous germ cell tumours are the locoregional lymph nodes and lungs (Williams et al, 1989). Metastastic deposits from testicular tumours to unusual sites have been described (Husband & Bellamy, 1985). We describe two patients wth intracardiac metastases. The development of a cardiac murmur in a patient with a germ cell tumour should alert the oncologist to this rare, potentially lethal, but treatable site of metastasis. Case reports

Case 1 A 23-year-old man presented with bilateral pulmonary metastases from a right-sided testicular teratoma (malignant teratoma undifferentiated). He was treated abroad by orchidectomy and chemotherapy with cisplatinum, vinblastine and bleomycin, to which he had a partial response. This was followed by whole lung irradiation. 3 years later his chest disease progressed and he was referred to The Royal Marsden Hospital. Cardiac examination was initially normal, but examination a week later revealed a systolic murmur audible on exercise in the pulmonary area. Subsequently the patient developed an acute episode of right ventricular failure. An echocardiogram showed a large mass filling most of the right ventricle, extending up into the right ventricular outflow tract with a projection reaching towards the tricuspid valve (Fig. 1). There was right atrial enlargement, but no filling defect within the right atrium. In view of the acute cardiac decompensation he began urgent chemotherapy with carboplatin, vincristine and bleomycin. There was an improvement in his dyspnoea and a reduction in the size of the pulmonary metastases. A second echocardiogram showed that the mass in the right ventricle was reduced to half the original size. However, after initial improvement, his condition again deteriorated owing to the development of Haemophilus influenzae pneumonia which failed to respond to treatment. He died 1 month after starting chemotherapy. There was no postmortem.

a left-sided testicular teratoma (malignant teratoma intermediate). He was treated by orchidectomy and chemotherapy with bleomycin, etoposide and cisplatinum followed by excision of residual masses in the left side of the neck and the para-aortic region. He relapsed with para-aortic and mediastinal disease 1 year later and was treated with two further courses of bleomycin, etoposide and cisplatinum, followed by excision of the para-aortic mass. Physical examination before his abdominal surgery revealed a systolic and diastolic murmur in the pulmonary area which had not been noted before. An echocardiogram showed a polypoid tumour arising from the right atrium, or possibly the tricuspid valve. The tumour did not have the appearance of myxoma. Cardiac catheterization was performed prior to open heart surgery and detected a large fimbriated mass arising from the left atrium and passing through the right atrium, the right ventricle into the pulmonary artery (Fig. 2). At operation, a semi-solid tumour mass was found within the right atrium with a tongue of tumour extending into the superior vena cava and the left innominate

Case 2 A 40-year-old man presented with posterior mediastinal, para-aortic and left-sided cervical lymph node metastases from

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Figure 1. Echocardiogram of Case 1 showing the metastasis in the right ventricle (arrow). The British Journal of Radiology, August 1992

Intracardiac metastases from germ cell tumours

obstruction and myocardial involvement produced heart failure in one patient (Case 1). Acute obstruction of the blood flow through a valve may also lead to sudden symptoms of convulsions and unconsciousness (Colucci & Braunwald, 1991). Both the radiologist and oncologist must be aware of all potential sites of residual and recurrent disease. Although rare, it is important to know about the possibility of intracardiac metastases, because teratomas are usually chemo-sensitive and even if residual differentiated teratoma remains after chemotherapy, it can be successfully removed. The sudden development of a cardiac murmur should alert the clinician to the possibility of an intracardiac metastasis which can be diagnosed non-invasively by echocardiography.

Figure 2. Angiocardiogram of Case 2 showing the metastasis in the right ventricle. M = metastasis, RA = right atrium, RV = right ventricle.

vein. Histology showed differentiated teratoma (Pillai et al, 1986). He subsequently relapsed in the retrocrural area and this was refractory to chemotherapy. He died 3 years after his initial chemotherapy. There was no postmortem.

Acknowledgements We should like to thank the staff of the echocardiographic and cardiac catheterization departments at St Heifer's Hospital, Carshalton and The Royal Brompton Hospital, London. We should also like to thank Judy Nicholls and Gillian Jay for heJp with data collection and Christine Evans of the Academic Unit of Radiotherapy and Oncology, Sutton for typing the manuscript. This work was supported by Cancer Research Campaign, Bob Champion Cancer Trust and The Royal Marsden Hospital. References

Discussion

Metastases to the heart are rare, although they account for the majority of cardiac tumours (Colucci & Braunwald, 1991). When they occur, they are usually secondary to locoregional extension and limited to the pericardium or myocardium (Kerbrat et al, 1990). Haematogeneous metastases to the heart usually originate from primaries in the breast or lung (Colucci & Braunwald, 1991). Intracardiac deposits from testicular tumours are extremely uncommon. Melvin et al (1983) reported the first case of an intracardiac metastasis from an embryonal carcinoma of the testis which was successfully removed. Heart murmurs can be caused by turbulent flow within the heart due to intracardiac metastases. In our cases, signs suggestive of intracardiac involvement, in patients with previously normal cardiac physical examinations, were a systolic murmur in the pulmonary area (Case 1) and a systolic and diastolic murmur in the pulmonary area (Case 2). In both patients the metastases nearly plugged the pulmonary valve. Valvular

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Intracardiac metastases from germ cell tumours--an unusual but important site of metastasis.

Two cases of intracardiac deposits from testicular teratomas diagnosed by echocardiography and angiocardiography, respectively, are described. The imp...
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