Original
Article
Myocardial Metastasis from Primary Lung Cancer:
Myocardial Infarction-like
ECGChanges and Pathologic
Findings
Shosaku ABE, Naomi WATANABE,Shigeaki OGURA, Hiroshi KUNIKANE, Hiroshi ISOBE, Etsuro YAMAGUCHI,Mitsuru MUNAKATA and Yoshikazu KAWAKAMI Myocardial metastasis from neoplastic disease is often clinically unapparent, and very difficult to diagnose. Of 151 consecutive autopsies of lung cancer patients, cardiac metastases were found in 67 patients (44.4%). Myocardial metastasis was found in only 8 patients (ll.9%). ECGof patients with myocardial metastasis revealed ST-Twavechanges and various types of arrhythmia. ST-Twavechanges were observed in 4 with myocardial metastasis, and in 6 without myocardial metastasis (pericardial metastasis alone). ST-T wave changes is not a specific finding of myocardial metastasis. Twovery rare cases with myocardial metastasis showing progressive ST segment elevation with a QSpattern are presented. The appearance of ST segment elevation with a QS pattern in clinically stable lung cancer patients without cardiac symptoms suggestive of myocardial injury indicates the possibility of myocardial metastasis. Myocardial metastasis is often elusive, thus careful observation of ECGchanges is of primary importance for the antemortem diagnosis. Key words: Cardiac metastasis,
ST elevation
with QS pattern
The heart is frequently the site of metastasis of various malignant tumors. Of these tumors, lung cancer is the most frequent primary tumor, and cardiac metastasis maybe detected in 29-53%of patients with fatal lung cancer (1-3). The majority of cardiac metastases from lung cancer occur in the pericardium by direct extension and/or retrograde lymphatic dissemination from involved mediastinal lymph nodes, whereas hematogenic metastasis in the
myocardiumis commonlyregarded as a rare condition. The incidence of myocardial metastasis from lung cancer is 5.3-10.6% (4, 5). Electrocardiographic (ECG) abnormalities
associated with myocardial metastasis have been reported (2-4). An abnormal Q wave (QS pattern)
MATERIALS AND METHODS We retrospectively analyzed 151 consecutive
autopsies of lung cancer patients performed at the First Department of Medicine, Hokkaido University during the period from 1973 to 1988. Cardiac metastases were defined so as to include any macroscopic or microscopic evidence of tumor in the pericardium, myocardium or endocardium. Sixty-seven patients (44.4%) had cardiac
metastasis, 54 were male and 13 were female (age range,
33 to 85 yr;
mean 67 yr).
Of these
67
patients, ll had squamous cell carcinoma; 40 had adenocarcinoma; 12 had small cell carcinoma; and 4 had large cell carcinoma. The site of tumor in-
elevation with a QSpattern the relationship between
volvement was the pericardium alone in 59 patients (88. 1 %), both the pericardium and the myocardium in 5 patients (7.4%), the pericardium, the myocardium and the endocardium in 2 patients (3.0%)
ECGabnormalities
(1.5%).
among these ECGfindings is a rare abnormality. In two very rare cases with myocardial infarctionlike
ECG changes,
and progressive
ST segment
the pathologic findings of myocardial metastasis and was studied.
and the myocardium alone in only one patient The ECG
findings
of the
12-lead
ECG
From First Department of Medicine, School of Medicine, Hokkaido University, Sapporo Received for publication May 15, 1990; Accepted for publication November 13, 1990 Reprint requests should be addressed to Shosaku Abe, MD,First Department of Internal Medicine, School of Medicine, Hokkaido University, North 15, West 7, Sapporo 060, Japan Jpn J Med Vol 30, No 3 (May, June 1991)
213
Abe et al
recorded at the first medical examination and within 1-2 months before death were evaluated. RESULTS
ECGswere available for 44 of these 67 patients with cardiac metastasis. The relationship between EGG findings
and the metastatic
site of these
patients is summarized in Table 1. ST-T wave changes were observed in 10 patients (14.9%). Of these 10 patients, 4 had myocardial metastasis, and 6 had tumor involvement in the pericardium alone. Lowvoltage of the QRScomplex was observed in 17 patients. Almost all patients had pericardial metastasis. No abnormal ECG findings were
observed in 10 patients.
Clinical characteristics, pathologic findings and ECG findings in 8 patients with myocardial metastasis are summarized in Table 2. The clinical stage of all patients at the first medical examination
was the progressive stage (clinical stage IV). The histological type of 7 of 8 patients was adeno-
carcinoma in the peripheral lung field. Five patients
showed sinus bradycardia, atrial fibrillation, premature atrial contraction and premature ventricular contraction. ST-T wave changes were
observed in four patients. Myocardial infarction-like
ECG changes were observed in the two patients described below.
Case 1 The patient
was a 54-year-old
man. Chest
X-ray film on June 16 showed a primary tumor shadow in the right upper lung field. Histologically, the primary tumor was adenocarcinoma. The serial ECGchanges are shown in Fig. 1. The ECGre-
corded at the first medical examination (June 17) exhibited no abnormal finding but an incomplete right bundle branch block. The ECGon July 4
showed the QS pattern in lead V1? ST segment
elevation in leads Vj, V2, V3, V4, V5 and T wave flattness in leads II, III and aVF. He had no chest pain suggestive myocardial infarction. On July 5,
the QS pattern progressed in leads V2 and V3. The ECGfindings on July 9 showed the QS pattern in lead V4and ST segment elevation in leads I, aVL, V4 and V5. On July 10, the QS pattern progressed
in leads I and aVL. No elevation of SGOT, LDH and CPKvalues was found. Neither arrhythmia nor low voltage were found at anytime during his
hospitalization. The serial ECGchanges indicated a strong suspicion of myocardial infarction of the anterior and high lateral walls. He died due to heart failure in July 12. At autopsy, extensive transmural tumor invasion into myocardium (5.3 X 10 x 0.6 cm) was observed, but no occlusion of the left coronary artery by tumor embolization was observed (Fig. 2). Case 2 The
patient
was a 68-year-old
woman.
Table 1. Metastatic site and ECGfindings in patients with cardiac metastasis M eta sta tic site ECG pattern Pe r i a n d M y o . P eri. P e ri, an d M y o . a n d E n d o . M y o . n = 36 n = 5 n= 2 n = l ST - T c h a n g e s O S pa t t e rn A trial fib rilla tio n L o w v ol t a g e PA C PV C S in u s b r ad y c ar d ia N o rm a l
15
0
T o ta l n = 44 10 2 8 17 4 3 1 10
Peri, pericardium; PVC, Myo, premature myocardium;ventricular Endo, endocardium; PAC, premature atrial contraction; contraction 214
Jpn J Med Vol 30, No 3 (May, June 1991)
Myocardial Metastasis and ECGChanges
Table 2. Clinical, electrocardiographic Case Age Primary site tt-Sex , i Histology
and pathologic findings of patients with myocardial metastasis
Clinical stage ,Main . ..metastatic site ECGfindings
L.B2peripheral 58 M IV 54MR.B2peripheral IV 68FR.B6 peripheral IV 52ML.B3 peripheral IV 64ML.B.1 peripheral IV 56 L.B8 peripheral K1 M IV 57MR.B8 peripheral IV 55 L.L.B. Central Adenoca. Atrial septum Left coronary Adenoca. Adenoca. artery Anterolateral Inferior Adenoca.
,
Anterior
Adenoca. Inferior Posterior Sinus vi,2,3,4: 1 aVL' V1>2)3,4)5: PAC, aVL vi,2:II Atrial II III
bradycardia RR: 1.52s Qs STpattern, elevation III aVF: ST depression Qs Pattern fibrillation, Low voltage
aVF: T inversion PVC No abnormal findings
Adenoca. Anterolateral
IV M Adenoca. Small cell
ca.
Anterolateral, ST depression, Inferior II III TaVF: inversion Left atrium
Atrial fibrillation,
I
II
June
Low voltage
ffl
aVR
aVL aVF
Vi
V2
V3
V4
Vs
V6
17
å illI:III
iil ii^ ntt iii iti ^ta i July
ii
4
ctWzK -PH3 -ucn itt July
July
Sill
§§
5
~ur 331
~^m
:it#
m
-LJ_i;
-UM'
tm
-^ ztzizi
9
å å 4-Uj
mm-m- m^ i
!~T!
-4-h-+ -i-M-4 .-l-Ll
tzti:
:" i
CCT . 1.ll £fep 4^^ 4j4J ^G i !-|4 å i-|-+ irr Br rrtr-t
-j
Fig. 1. SerialECGchanges
Jpn J Med Vol 30, No 3 (May, June 1991)
of case 1 on June 17, July4, 5 and9. 1 mV=10mm
215
Abe et al
Fig. 2. Horizontal section (a) shows extensive tumor invasion into myocardium (arrow). Slice section (b) shows metastatic lesion invading around the left coronary artery, x 30
contraction, and a QSpattern with ST segment elevation in leads aVL, Vj and V2. No low voltage
Chest X-ray at the first medical examination (Feb. 15) showed an abnormal shadow in the right lower lung field. Histologically, the primary tumor was adenocarcinoma. The ECGrecorded on Feb. 15 showed no abnormal findings but T wave flattness in leads II, III and aVF (Fig. 3). On May 18, the ECGshowed sinus tachycardia with premature atrial I
May
II
HI
aVR
*8 ,., ,=
Fig. 3. ECG findings
aVL
aVr
of the QRS complexes was observed.
During
hospitalization, the values of SGOTand LDHwere within the normal ranges. From these ECGchanges, she was diagnosed as having myocardial infarction of the anterior wall and ischemia of the inferior wall. Vi
V2
V3
V4
V5
Ve
'i:l Lli l
of case 2onFeb. 15 andMay 18. 1 mV=10 mm
Fig. 4. Horizontal section (a) and microscopic view (b) of the heart (case 2) show extensive metastasis of the tumor invading almost all of the myocardium(arrow), x 200 216
Jpn J Med Vol 30, No 3 (May, June 1991)
Myocardial Metastasis and ECGChanges
She died on June 1. At autopsy, transmural inva-
sion of the tumor into myocardium, anterior and inferior walls of the left ventricle (4.8 x 10.2x 1.2 cm) was observed (Fig. 4). DISCUSSION
Wereported the ECGchanges of patients with myocardial metastasis. ST-T wave changes were observed in four patients. ST-T wave changes seem to be a more specific sign of myocardial injury due
to metastasis (3, 6). However, Cates et al (3) revealed that ST-Twavechanges are observed not only in patients with myocardial ischemia and injury, but also in patients with pericarditis, hypertensive heart disease and as a result of somedrug treatments. In this study, we found the ST-Twaveabnormalities in 4 patients with myocardial metastasis, and in 6 patients with tumor involvement in pericardium alone. ST-T wave changes are not specific findings of myocardial metastasis, so these changes are not sufficiently sensitive to facilitate the diagnosis of
myocardial metastasis.
Myocardial infarction-like electrocardiographic changes due to metastatic involvement in the myocardiumare a rare finding. Koiwaya et al (7) described a 54-year-old man with lung cancer. An ECG of this patient showed ST segment elevation in leads I, II, III, aVL, aVF, V4, V5 and V6 without
a QS pattern. Malignant tumor had invaded into the postero-lateral walls of the left ventricle. Hartman et al (8) reported a 68-year-old man with lung cancer. The ECGof this patient showed ST segment elevation in leads I, aVL, V3, V4, V5, and V6 without a
QSpattern. No abnormal Qwave (QS pattern) was shown in these two cases. The most characteristic
ECGfinding in myo-
cardial infarction is ST elevation with a QSpattern. However, an abnormal Q wave is observed on the occasion of variable pathophysiologic condition. The ECGfindings of the present two cases showedpersistent and progressive ST segment elevation with QS pattern, but laboratory data (GOT, LDH, CPK) demonstrated no appreciable change. Franciosa and
Lawrinson (9) described a patient with myocardial infarction
caused by direct tumor invasion of a
major epicardial coronary artery. The ECGof this case showed ST segment elevation in leads Vj, V2, V3 and V4 with QS pattern in leads I, aVL, V2 and Jpn J Med Vol 30, No 3 (May, June 1991)
V3, and the values of SGOT, LDHand CPK were
increased. Harris et al (10) reported a 64-year-old womanwith extensive invasion into the myocardium from lung cancer. The ECGof this patient showed ST segment elevation,
T-wave inversion
and a
definite abnormal Q wave, but no elevation of SGOT,
LDH or CPK values
was found.
The
appearance of the abnormal Q wave (QS pattern)
in patients with myocardial metastasis results from a loss of electromotive force of myocardium.The QS pattern due to myocardial metastasis is a rare ECGchange, because the transmural tumor invasion into myocardiumfrom lung cancer is a very rare pathologic change. In the present two patients, the extensive transmural tumor invasion into myocardium was observed. The ECGfindings in these patients was probably caused by complete
transmural invasion of the tumor in myocardium. If there is no history of ischemic heart disease, the appearance of persistent and progressive ST segment elevation with a QSpattern in lung cancer patients seems to be a more specific sign of myocardial metastasis. Myocardial metastases are often clinically unapparent, but have important prognostic significance. In clinically stable patients without cardiac symptoms suggestive of myocardial ischemia and injury, careful observation of ECG may be used as a first-step screening test for myocardial invasion in patients
with lung cancer. REFERENCES
1) Skhvatsabaja LV. Secondary malignant lesions of the heart43: and103, pericardium in neoplastic disease. Oncology 1986. 2)
Adenle
AD, Edwards
JE. Clinical
and pathologic
features of metastatic neoplasms of the pericardium. Chest
81:
166,
1982.
3) Cates CU, Virmani R, Vaughn WK, Robertson RM. Electrocardiographic 4)
Heart
J 112:
Berge
T,
1297,
Sievers
markers of cardiac metastasis.
Am
1986.
J.
Myocardial
pathological and electrocardiographic J 30: 383, 1968.
metastases.
A
study. Br Heart
5) Strauss BL, Matthews MJ, Cohen MH, Simon R, Tejada F. 1977.Cardiac metastases in lung cancer. Chest 71: 607, 6)
Lestuzzi C, Nicolosi GL, Biasi S, Piotti P, Zanuttini D. Sensitivity and specificity of electrocardiographic ST-T changes as markers of neoplastic myocardial infiltration. Echocardiographic correlation. Chest 95: 980, 217
Abe et al 1989.
Koiwaya Y, Nakamura M, Yamamoto K. Progressive ECG alterations in metastatic cardiac mural tumor. Am Heart J 105: 339, 1983. Hartman RB, Clark PI, Schulman P. Pronounced and prolonged ST segment elevation. A pathognomonic sign of 1917, tumor 1982. invasion of the heart. Arch Intern Med142:
218
Franciosa JA, Lawrinson W. Coronary artery occlusion due to neoplasm. A rare cause of acute myocardial infarction. Arch Intern Med 128: 797, 1971. Harris TR, Copeland GD, Brody DA. Progressive injury current with metastatic tumor of the heart. Case report and review of the literature. AmHeart J 69: 392, 1965.
Jpn J Med Vol 30, No 3 (May, June 1991)
Article
Myocardial Metastasis from Primary Lung Cancer:
Myocardial Infarction-like
ECGChanges and Pathologic
Findings
Shosaku ABE, Naomi WATANABE,Shigeaki OGURA, Hiroshi KUNIKANE, Hiroshi ISOBE, Etsuro YAMAGUCHI,Mitsuru MUNAKATA and Yoshikazu KAWAKAMI Myocardial metastasis from neoplastic disease is often clinically unapparent, and very difficult to diagnose. Of 151 consecutive autopsies of lung cancer patients, cardiac metastases were found in 67 patients (44.4%). Myocardial metastasis was found in only 8 patients (ll.9%). ECGof patients with myocardial metastasis revealed ST-Twavechanges and various types of arrhythmia. ST-Twavechanges were observed in 4 with myocardial metastasis, and in 6 without myocardial metastasis (pericardial metastasis alone). ST-T wave changes is not a specific finding of myocardial metastasis. Twovery rare cases with myocardial metastasis showing progressive ST segment elevation with a QSpattern are presented. The appearance of ST segment elevation with a QS pattern in clinically stable lung cancer patients without cardiac symptoms suggestive of myocardial injury indicates the possibility of myocardial metastasis. Myocardial metastasis is often elusive, thus careful observation of ECGchanges is of primary importance for the antemortem diagnosis. Key words: Cardiac metastasis,
ST elevation
with QS pattern
The heart is frequently the site of metastasis of various malignant tumors. Of these tumors, lung cancer is the most frequent primary tumor, and cardiac metastasis maybe detected in 29-53%of patients with fatal lung cancer (1-3). The majority of cardiac metastases from lung cancer occur in the pericardium by direct extension and/or retrograde lymphatic dissemination from involved mediastinal lymph nodes, whereas hematogenic metastasis in the
myocardiumis commonlyregarded as a rare condition. The incidence of myocardial metastasis from lung cancer is 5.3-10.6% (4, 5). Electrocardiographic (ECG) abnormalities
associated with myocardial metastasis have been reported (2-4). An abnormal Q wave (QS pattern)
MATERIALS AND METHODS We retrospectively analyzed 151 consecutive
autopsies of lung cancer patients performed at the First Department of Medicine, Hokkaido University during the period from 1973 to 1988. Cardiac metastases were defined so as to include any macroscopic or microscopic evidence of tumor in the pericardium, myocardium or endocardium. Sixty-seven patients (44.4%) had cardiac
metastasis, 54 were male and 13 were female (age range,
33 to 85 yr;
mean 67 yr).
Of these
67
patients, ll had squamous cell carcinoma; 40 had adenocarcinoma; 12 had small cell carcinoma; and 4 had large cell carcinoma. The site of tumor in-
elevation with a QSpattern the relationship between
volvement was the pericardium alone in 59 patients (88. 1 %), both the pericardium and the myocardium in 5 patients (7.4%), the pericardium, the myocardium and the endocardium in 2 patients (3.0%)
ECGabnormalities
(1.5%).
among these ECGfindings is a rare abnormality. In two very rare cases with myocardial infarctionlike
ECG changes,
and progressive
ST segment
the pathologic findings of myocardial metastasis and was studied.
and the myocardium alone in only one patient The ECG
findings
of the
12-lead
ECG
From First Department of Medicine, School of Medicine, Hokkaido University, Sapporo Received for publication May 15, 1990; Accepted for publication November 13, 1990 Reprint requests should be addressed to Shosaku Abe, MD,First Department of Internal Medicine, School of Medicine, Hokkaido University, North 15, West 7, Sapporo 060, Japan Jpn J Med Vol 30, No 3 (May, June 1991)
213
Abe et al
recorded at the first medical examination and within 1-2 months before death were evaluated. RESULTS
ECGswere available for 44 of these 67 patients with cardiac metastasis. The relationship between EGG findings
and the metastatic
site of these
patients is summarized in Table 1. ST-T wave changes were observed in 10 patients (14.9%). Of these 10 patients, 4 had myocardial metastasis, and 6 had tumor involvement in the pericardium alone. Lowvoltage of the QRScomplex was observed in 17 patients. Almost all patients had pericardial metastasis. No abnormal ECG findings were
observed in 10 patients.
Clinical characteristics, pathologic findings and ECG findings in 8 patients with myocardial metastasis are summarized in Table 2. The clinical stage of all patients at the first medical examination
was the progressive stage (clinical stage IV). The histological type of 7 of 8 patients was adeno-
carcinoma in the peripheral lung field. Five patients
showed sinus bradycardia, atrial fibrillation, premature atrial contraction and premature ventricular contraction. ST-T wave changes were
observed in four patients. Myocardial infarction-like
ECG changes were observed in the two patients described below.
Case 1 The patient
was a 54-year-old
man. Chest
X-ray film on June 16 showed a primary tumor shadow in the right upper lung field. Histologically, the primary tumor was adenocarcinoma. The serial ECGchanges are shown in Fig. 1. The ECGre-
corded at the first medical examination (June 17) exhibited no abnormal finding but an incomplete right bundle branch block. The ECGon July 4
showed the QS pattern in lead V1? ST segment
elevation in leads Vj, V2, V3, V4, V5 and T wave flattness in leads II, III and aVF. He had no chest pain suggestive myocardial infarction. On July 5,
the QS pattern progressed in leads V2 and V3. The ECGfindings on July 9 showed the QS pattern in lead V4and ST segment elevation in leads I, aVL, V4 and V5. On July 10, the QS pattern progressed
in leads I and aVL. No elevation of SGOT, LDH and CPKvalues was found. Neither arrhythmia nor low voltage were found at anytime during his
hospitalization. The serial ECGchanges indicated a strong suspicion of myocardial infarction of the anterior and high lateral walls. He died due to heart failure in July 12. At autopsy, extensive transmural tumor invasion into myocardium (5.3 X 10 x 0.6 cm) was observed, but no occlusion of the left coronary artery by tumor embolization was observed (Fig. 2). Case 2 The
patient
was a 68-year-old
woman.
Table 1. Metastatic site and ECGfindings in patients with cardiac metastasis M eta sta tic site ECG pattern Pe r i a n d M y o . P eri. P e ri, an d M y o . a n d E n d o . M y o . n = 36 n = 5 n= 2 n = l ST - T c h a n g e s O S pa t t e rn A trial fib rilla tio n L o w v ol t a g e PA C PV C S in u s b r ad y c ar d ia N o rm a l
15
0
T o ta l n = 44 10 2 8 17 4 3 1 10
Peri, pericardium; PVC, Myo, premature myocardium;ventricular Endo, endocardium; PAC, premature atrial contraction; contraction 214
Jpn J Med Vol 30, No 3 (May, June 1991)
Myocardial Metastasis and ECGChanges
Table 2. Clinical, electrocardiographic Case Age Primary site tt-Sex , i Histology
and pathologic findings of patients with myocardial metastasis
Clinical stage ,Main . ..metastatic site ECGfindings
L.B2peripheral 58 M IV 54MR.B2peripheral IV 68FR.B6 peripheral IV 52ML.B3 peripheral IV 64ML.B.1 peripheral IV 56 L.B8 peripheral K1 M IV 57MR.B8 peripheral IV 55 L.L.B. Central Adenoca. Atrial septum Left coronary Adenoca. Adenoca. artery Anterolateral Inferior Adenoca.
,
Anterior
Adenoca. Inferior Posterior Sinus vi,2,3,4: 1 aVL' V1>2)3,4)5: PAC, aVL vi,2:II Atrial II III
bradycardia RR: 1.52s Qs STpattern, elevation III aVF: ST depression Qs Pattern fibrillation, Low voltage
aVF: T inversion PVC No abnormal findings
Adenoca. Anterolateral
IV M Adenoca. Small cell
ca.
Anterolateral, ST depression, Inferior II III TaVF: inversion Left atrium
Atrial fibrillation,
I
II
June
Low voltage
ffl
aVR
aVL aVF
Vi
V2
V3
V4
Vs
V6
17
å illI:III
iil ii^ ntt iii iti ^ta i July
ii
4
ctWzK -PH3 -ucn itt July
July
Sill
§§
5
~ur 331
~^m
:it#
m
-LJ_i;
-UM'
tm
-^ ztzizi
9
å å 4-Uj
mm-m- m^ i
!~T!
-4-h-+ -i-M-4 .-l-Ll
tzti:
:" i
CCT . 1.ll £fep 4^^ 4j4J ^G i !-|4 å i-|-+ irr Br rrtr-t
-j
Fig. 1. SerialECGchanges
Jpn J Med Vol 30, No 3 (May, June 1991)
of case 1 on June 17, July4, 5 and9. 1 mV=10mm
215
Abe et al
Fig. 2. Horizontal section (a) shows extensive tumor invasion into myocardium (arrow). Slice section (b) shows metastatic lesion invading around the left coronary artery, x 30
contraction, and a QSpattern with ST segment elevation in leads aVL, Vj and V2. No low voltage
Chest X-ray at the first medical examination (Feb. 15) showed an abnormal shadow in the right lower lung field. Histologically, the primary tumor was adenocarcinoma. The ECGrecorded on Feb. 15 showed no abnormal findings but T wave flattness in leads II, III and aVF (Fig. 3). On May 18, the ECGshowed sinus tachycardia with premature atrial I
May
II
HI
aVR
*8 ,., ,=
Fig. 3. ECG findings
aVL
aVr
of the QRS complexes was observed.
During
hospitalization, the values of SGOTand LDHwere within the normal ranges. From these ECGchanges, she was diagnosed as having myocardial infarction of the anterior wall and ischemia of the inferior wall. Vi
V2
V3
V4
V5
Ve
'i:l Lli l
of case 2onFeb. 15 andMay 18. 1 mV=10 mm
Fig. 4. Horizontal section (a) and microscopic view (b) of the heart (case 2) show extensive metastasis of the tumor invading almost all of the myocardium(arrow), x 200 216
Jpn J Med Vol 30, No 3 (May, June 1991)
Myocardial Metastasis and ECGChanges
She died on June 1. At autopsy, transmural inva-
sion of the tumor into myocardium, anterior and inferior walls of the left ventricle (4.8 x 10.2x 1.2 cm) was observed (Fig. 4). DISCUSSION
Wereported the ECGchanges of patients with myocardial metastasis. ST-T wave changes were observed in four patients. ST-T wave changes seem to be a more specific sign of myocardial injury due
to metastasis (3, 6). However, Cates et al (3) revealed that ST-Twavechanges are observed not only in patients with myocardial ischemia and injury, but also in patients with pericarditis, hypertensive heart disease and as a result of somedrug treatments. In this study, we found the ST-Twaveabnormalities in 4 patients with myocardial metastasis, and in 6 patients with tumor involvement in pericardium alone. ST-T wave changes are not specific findings of myocardial metastasis, so these changes are not sufficiently sensitive to facilitate the diagnosis of
myocardial metastasis.
Myocardial infarction-like electrocardiographic changes due to metastatic involvement in the myocardiumare a rare finding. Koiwaya et al (7) described a 54-year-old man with lung cancer. An ECG of this patient showed ST segment elevation in leads I, II, III, aVL, aVF, V4, V5 and V6 without
a QS pattern. Malignant tumor had invaded into the postero-lateral walls of the left ventricle. Hartman et al (8) reported a 68-year-old man with lung cancer. The ECGof this patient showed ST segment elevation in leads I, aVL, V3, V4, V5, and V6 without a
QSpattern. No abnormal Qwave (QS pattern) was shown in these two cases. The most characteristic
ECGfinding in myo-
cardial infarction is ST elevation with a QSpattern. However, an abnormal Q wave is observed on the occasion of variable pathophysiologic condition. The ECGfindings of the present two cases showedpersistent and progressive ST segment elevation with QS pattern, but laboratory data (GOT, LDH, CPK) demonstrated no appreciable change. Franciosa and
Lawrinson (9) described a patient with myocardial infarction
caused by direct tumor invasion of a
major epicardial coronary artery. The ECGof this case showed ST segment elevation in leads Vj, V2, V3 and V4 with QS pattern in leads I, aVL, V2 and Jpn J Med Vol 30, No 3 (May, June 1991)
V3, and the values of SGOT, LDHand CPK were
increased. Harris et al (10) reported a 64-year-old womanwith extensive invasion into the myocardium from lung cancer. The ECGof this patient showed ST segment elevation,
T-wave inversion
and a
definite abnormal Q wave, but no elevation of SGOT,
LDH or CPK values
was found.
The
appearance of the abnormal Q wave (QS pattern)
in patients with myocardial metastasis results from a loss of electromotive force of myocardium.The QS pattern due to myocardial metastasis is a rare ECGchange, because the transmural tumor invasion into myocardiumfrom lung cancer is a very rare pathologic change. In the present two patients, the extensive transmural tumor invasion into myocardium was observed. The ECGfindings in these patients was probably caused by complete
transmural invasion of the tumor in myocardium. If there is no history of ischemic heart disease, the appearance of persistent and progressive ST segment elevation with a QSpattern in lung cancer patients seems to be a more specific sign of myocardial metastasis. Myocardial metastases are often clinically unapparent, but have important prognostic significance. In clinically stable patients without cardiac symptoms suggestive of myocardial ischemia and injury, careful observation of ECG may be used as a first-step screening test for myocardial invasion in patients
with lung cancer. REFERENCES
1) Skhvatsabaja LV. Secondary malignant lesions of the heart43: and103, pericardium in neoplastic disease. Oncology 1986. 2)
Adenle
AD, Edwards
JE. Clinical
and pathologic
features of metastatic neoplasms of the pericardium. Chest
81:
166,
1982.
3) Cates CU, Virmani R, Vaughn WK, Robertson RM. Electrocardiographic 4)
Heart
J 112:
Berge
T,
1297,
Sievers
markers of cardiac metastasis.
Am
1986.
J.
Myocardial
pathological and electrocardiographic J 30: 383, 1968.
metastases.
A
study. Br Heart
5) Strauss BL, Matthews MJ, Cohen MH, Simon R, Tejada F. 1977.Cardiac metastases in lung cancer. Chest 71: 607, 6)
Lestuzzi C, Nicolosi GL, Biasi S, Piotti P, Zanuttini D. Sensitivity and specificity of electrocardiographic ST-T changes as markers of neoplastic myocardial infiltration. Echocardiographic correlation. Chest 95: 980, 217
Abe et al 1989.
Koiwaya Y, Nakamura M, Yamamoto K. Progressive ECG alterations in metastatic cardiac mural tumor. Am Heart J 105: 339, 1983. Hartman RB, Clark PI, Schulman P. Pronounced and prolonged ST segment elevation. A pathognomonic sign of 1917, tumor 1982. invasion of the heart. Arch Intern Med142:
218
Franciosa JA, Lawrinson W. Coronary artery occlusion due to neoplasm. A rare cause of acute myocardial infarction. Arch Intern Med 128: 797, 1971. Harris TR, Copeland GD, Brody DA. Progressive injury current with metastatic tumor of the heart. Case report and review of the literature. AmHeart J 69: 392, 1965.
Jpn J Med Vol 30, No 3 (May, June 1991)
