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Cardiac metastases from osteosarcoma a report of two cases
JOURNAL
OF COMPUTED
TOMOGRAPHY
1983;7:41-43
CARDIAC METASTASES FROM OSTEOSARCOMA A REPORT OF TWO CASES ALAN
DANEMAN,
DAVID
J. MARTIN,
Two children who developed cardiac metastases from osteogenic sarcoma are described, and the value of computed tomography in making an antemortem diagnosis is illustrated. Computed tomographic images with a narrow window width will reveal the presence of calcification within the cardiac metastases. Images in this mode should always be studied in patients with osteogenic sarcoma who are undergoing chest computed tomography scans to detect pulmonary metastases. KEY WORDS:
Osteosarcoma,Cardiac metastases; Echocardiography
The diagnosis of cardiac metastases is rarely made during life [l]. We report two children in whom the antemortem diagnosis of cardiac metastases from osteogenic sarcoma was made with computed tomography (CT). CASE REPORTS
Case 1 A diagnosis of osteosarcoma of the left distal femur was made in a 16-year-old girl. After an above-knee amputation, she received adjuvant chemotherapy consisting of Adriamycin (Adna Laboratories, Dublin, Oh.) and high-dose Methotrexate with Leucovorum (Lederle Laboratories, Wayne, N.J.) rescue.
From the Department of Radiology (A.D., D.J.M.) and the Division of Oncology and Hematology, Department of Pediatrics (H.S.L.C.), Hospital for Sick Children, Toronto, Canada. Address reprint requests to: Dr. Alan Daneman, Radiology Department, Hospital for Sick Children, 555 Universitv Avenue. Toronto, Ontario; Canada M5G 1X8. Received August 13,198X 0 1983 by Elsevier Science Publishing Co., Inc. 52 Vanderbilt Ave., New York NY 10017 0149-936x/83/010041-03$3.00
AND HELEN
S .L. CHAN
Five months after diagnosis, while asymptomatic, she was noted to have a progressive decrease of the ejection fraction on M-mode echocardiography from 58% to 49%. Her electrocardiogram was reported to show a bundle branch block on the right side. Eight months after diagnosis her CT scan showed bilateral pulmonary met&stases. She was also noted to have a calcified lesion in the region of her right ventricle both on chest x ray film and CT scan (Figure 1). In retrospect, this calcified lesion first appeared faintly on chest x ray films 5 months after diagnosis. A two-dimensional echocardiogram demonstrated a mass in the right ventricular septum. Her parents refused consent for surgery, and no further investigations were performed. She is still alive 9 months after diagnosis.
Case 2 Osteogenic sarcoma of the distal right femur was diagnosed in a 16-year-old girl. After a high aboveknee amputation she received an 6-month course of Adriamycin and high-dose Methotrexate with Leucovorum rescue. One-and-one-half years after her diagnosis she had sudden onset of dyspnea and cyanosis and went into hypovolemic shock. Her electrocardiogram showed sinus tachycardia, deviation of the right axis, and low voltage in the limb leads suggesting right atria1 overload. There were prominent R waves and no S waves in lead V, and ST segment elevation in leads V, and V,. The chest radiograph showed hypoperfusion of the lung fields and a calcified lesion was noted overlying the cardiac shadow. A CT scan localized thi/scalcified mass as being in the right ventricle (Figure 2). An arteriogram confirmed a filling defect in the right ventricle. During surgery under cardio@lmonary bypass, the right ventricle was found to he completely filled by a huge, rock-hard loculated tumor that originated
42
DANEMAN ET AL.
A
THE JOURNAL OF COMPUTED TOMOGRAPHY VOL.
B
7,
NO. 1
C
Figure 1. Case 1: a l&year-old girl. (A) Posterior-anterior radiograph of the chest 8 months after an above-knee amputation for distal fermoral osteogenic sarcoma. Arrows
indicate a calcified metastasis. (B,C) A CT scan through the lower chest (with a narrow window width) shows a heavily ossified cardiac metastasis in the right ventricle.
from the ventricular septum and extended to involve the tricuspid valve. The bulk of the tumor was removed. She died shortly afterwards from postoperative complications. The pathological specimen was characteristic of osteogenic sarcoma.
this time period, 5103 patients with malignant disease were seen at this institution. In this series the commonest tumors with metastatic disease involving the heart were non-Hodgkin’s lymphoma (42%) and neuroblastoma (29%). The two patients reported in this paper were the only patients with cardiac metastases from osteogenic sarcoma. Only 13% of all the children in this series were diagnosed prior to death. Definitive antemortem diagnosis was made by CT, angiocardiography, inferior and two-dimensional echocarvenocavography, diography. We were unable to find a comparable large series of children reported with metastatic disease of the heart. In adults, the commonest tumors metastasizing to the heart are malignant melanoma and carcinoma of the lung and breast [l]. Osteogenic sarcoma is said to be the commonest sarcoma with cardiac metastases [11. In 1978, Dalal et al. [2] reviewed the literature and found only 10 patients reported with cardiac metastases due to osteogenic sarcoma. In 1981, Dunnick et al. [l] reported another patient in whom the antemortem diagnosis was confirmed by CT. The computed tomographic appearance in this patient was similar to that noted in the two patients reported in the present paper. In 1982 Seibert et al. [3] reported three additional patients with cardiac metastases and reviewed the literature of those previous patients who had been reported in detail. These authors found that cardiac metastases from osteogenic sarcoma are much more commonly found on the right side of the heart than on the left, and that intracavitary lesions are more common than lesions occurring only in the wall of the heart. Lesions in the epicardium are unusual.
DISCUSSION During the 62year period 1919-1982, 45 children were found on record at the Hospital for Sick Children, Toronto, with metastatic disease involving the heart and pericardium (unpublished data). During Figure 2. Case 2: a 16-year-old girl. One-and-a-half years after an above-knee amputation for distal femoral osteogenic sarcoma, the CT scan [with narrow window width) shows a heavily ossified metastasis from an osteogenic sarcoma in the right ventricle.
FEBRUARY
METASTATIC
1983
One patient had lesions on both sides of the heart. The symptoms and signs of cardiac metastases are nonspecific [I, 31 and often disproportionately few compared with the large size of many of these lesions. The prognosis is usually poor, but surgical resection has been reported in some patients [l]. Although a solitary cardiac metastasis has been reported [2], widespread metastatic disease is usually present at the time of diagnosis [l,21.With the use of aggressive therapy the antemortem detection of cardiac metastases may become clinically significant [l]. In all patients undergoing chest CT scans for pulmonary metastases, we routinely view the images with both a wide and narrow window width. We have found this particularly useful in patients with osteogenic sarcoma in whom small pulmonary metastases with ossification are not seen clearly with the wide window width but the ossification is better
OSTEOSARCOMA
43
seen when the window is narrowed. This technique proved extremely useful in the two patients presented in this paper in that the cardiac metastases were not evident with the images viewed with a wide window. We recommend that all patients be examined in this way.
REFERENCES Dunnick NR, Seibert K, Cramer HR. Cardiac metastasis osteosarcoma. J Comput Assist Tomogr 1981;5:253-55. Dalal BI, Raju BS, Datta BN, Khatri coma of heart: report of a case and Cancer 1978;15:84-6. Seibert KA, Rettenmeir Roberts WC. Osteogenic Med 1982;73:136-41. Accepted
13 August
from
HN. Metastatic osteosarreview of literature. Int J
CW, Waller BF, Battle WE, Levine AS, sarcoma metastatic to the heart. Am J
1982
OF COMPUTED
TOMOGRAPHY
1983;7:41-43
CARDIAC METASTASES FROM OSTEOSARCOMA A REPORT OF TWO CASES ALAN
DANEMAN,
DAVID
J. MARTIN,
Two children who developed cardiac metastases from osteogenic sarcoma are described, and the value of computed tomography in making an antemortem diagnosis is illustrated. Computed tomographic images with a narrow window width will reveal the presence of calcification within the cardiac metastases. Images in this mode should always be studied in patients with osteogenic sarcoma who are undergoing chest computed tomography scans to detect pulmonary metastases. KEY WORDS:
Osteosarcoma,Cardiac metastases; Echocardiography
The diagnosis of cardiac metastases is rarely made during life [l]. We report two children in whom the antemortem diagnosis of cardiac metastases from osteogenic sarcoma was made with computed tomography (CT). CASE REPORTS
Case 1 A diagnosis of osteosarcoma of the left distal femur was made in a 16-year-old girl. After an above-knee amputation, she received adjuvant chemotherapy consisting of Adriamycin (Adna Laboratories, Dublin, Oh.) and high-dose Methotrexate with Leucovorum (Lederle Laboratories, Wayne, N.J.) rescue.
From the Department of Radiology (A.D., D.J.M.) and the Division of Oncology and Hematology, Department of Pediatrics (H.S.L.C.), Hospital for Sick Children, Toronto, Canada. Address reprint requests to: Dr. Alan Daneman, Radiology Department, Hospital for Sick Children, 555 Universitv Avenue. Toronto, Ontario; Canada M5G 1X8. Received August 13,198X 0 1983 by Elsevier Science Publishing Co., Inc. 52 Vanderbilt Ave., New York NY 10017 0149-936x/83/010041-03$3.00
AND HELEN
S .L. CHAN
Five months after diagnosis, while asymptomatic, she was noted to have a progressive decrease of the ejection fraction on M-mode echocardiography from 58% to 49%. Her electrocardiogram was reported to show a bundle branch block on the right side. Eight months after diagnosis her CT scan showed bilateral pulmonary met&stases. She was also noted to have a calcified lesion in the region of her right ventricle both on chest x ray film and CT scan (Figure 1). In retrospect, this calcified lesion first appeared faintly on chest x ray films 5 months after diagnosis. A two-dimensional echocardiogram demonstrated a mass in the right ventricular septum. Her parents refused consent for surgery, and no further investigations were performed. She is still alive 9 months after diagnosis.
Case 2 Osteogenic sarcoma of the distal right femur was diagnosed in a 16-year-old girl. After a high aboveknee amputation she received an 6-month course of Adriamycin and high-dose Methotrexate with Leucovorum rescue. One-and-one-half years after her diagnosis she had sudden onset of dyspnea and cyanosis and went into hypovolemic shock. Her electrocardiogram showed sinus tachycardia, deviation of the right axis, and low voltage in the limb leads suggesting right atria1 overload. There were prominent R waves and no S waves in lead V, and ST segment elevation in leads V, and V,. The chest radiograph showed hypoperfusion of the lung fields and a calcified lesion was noted overlying the cardiac shadow. A CT scan localized thi/scalcified mass as being in the right ventricle (Figure 2). An arteriogram confirmed a filling defect in the right ventricle. During surgery under cardio@lmonary bypass, the right ventricle was found to he completely filled by a huge, rock-hard loculated tumor that originated
42
DANEMAN ET AL.
A
THE JOURNAL OF COMPUTED TOMOGRAPHY VOL.
B
7,
NO. 1
C
Figure 1. Case 1: a l&year-old girl. (A) Posterior-anterior radiograph of the chest 8 months after an above-knee amputation for distal fermoral osteogenic sarcoma. Arrows
indicate a calcified metastasis. (B,C) A CT scan through the lower chest (with a narrow window width) shows a heavily ossified cardiac metastasis in the right ventricle.
from the ventricular septum and extended to involve the tricuspid valve. The bulk of the tumor was removed. She died shortly afterwards from postoperative complications. The pathological specimen was characteristic of osteogenic sarcoma.
this time period, 5103 patients with malignant disease were seen at this institution. In this series the commonest tumors with metastatic disease involving the heart were non-Hodgkin’s lymphoma (42%) and neuroblastoma (29%). The two patients reported in this paper were the only patients with cardiac metastases from osteogenic sarcoma. Only 13% of all the children in this series were diagnosed prior to death. Definitive antemortem diagnosis was made by CT, angiocardiography, inferior and two-dimensional echocarvenocavography, diography. We were unable to find a comparable large series of children reported with metastatic disease of the heart. In adults, the commonest tumors metastasizing to the heart are malignant melanoma and carcinoma of the lung and breast [l]. Osteogenic sarcoma is said to be the commonest sarcoma with cardiac metastases [11. In 1978, Dalal et al. [2] reviewed the literature and found only 10 patients reported with cardiac metastases due to osteogenic sarcoma. In 1981, Dunnick et al. [l] reported another patient in whom the antemortem diagnosis was confirmed by CT. The computed tomographic appearance in this patient was similar to that noted in the two patients reported in the present paper. In 1982 Seibert et al. [3] reported three additional patients with cardiac metastases and reviewed the literature of those previous patients who had been reported in detail. These authors found that cardiac metastases from osteogenic sarcoma are much more commonly found on the right side of the heart than on the left, and that intracavitary lesions are more common than lesions occurring only in the wall of the heart. Lesions in the epicardium are unusual.
DISCUSSION During the 62year period 1919-1982, 45 children were found on record at the Hospital for Sick Children, Toronto, with metastatic disease involving the heart and pericardium (unpublished data). During Figure 2. Case 2: a 16-year-old girl. One-and-a-half years after an above-knee amputation for distal femoral osteogenic sarcoma, the CT scan [with narrow window width) shows a heavily ossified metastasis from an osteogenic sarcoma in the right ventricle.
FEBRUARY
METASTATIC
1983
One patient had lesions on both sides of the heart. The symptoms and signs of cardiac metastases are nonspecific [I, 31 and often disproportionately few compared with the large size of many of these lesions. The prognosis is usually poor, but surgical resection has been reported in some patients [l]. Although a solitary cardiac metastasis has been reported [2], widespread metastatic disease is usually present at the time of diagnosis [l,21.With the use of aggressive therapy the antemortem detection of cardiac metastases may become clinically significant [l]. In all patients undergoing chest CT scans for pulmonary metastases, we routinely view the images with both a wide and narrow window width. We have found this particularly useful in patients with osteogenic sarcoma in whom small pulmonary metastases with ossification are not seen clearly with the wide window width but the ossification is better
OSTEOSARCOMA
43
seen when the window is narrowed. This technique proved extremely useful in the two patients presented in this paper in that the cardiac metastases were not evident with the images viewed with a wide window. We recommend that all patients be examined in this way.
REFERENCES Dunnick NR, Seibert K, Cramer HR. Cardiac metastasis osteosarcoma. J Comput Assist Tomogr 1981;5:253-55. Dalal BI, Raju BS, Datta BN, Khatri coma of heart: report of a case and Cancer 1978;15:84-6. Seibert KA, Rettenmeir Roberts WC. Osteogenic Med 1982;73:136-41. Accepted
13 August
from
HN. Metastatic osteosarreview of literature. Int J
CW, Waller BF, Battle WE, Levine AS, sarcoma metastatic to the heart. Am J
1982