CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 7, August 2012
e10
AFRICA
Case Report
Cardiac mass in a patient with sigmoid adenocarcinoma:
a metastasis?
HARRIS A NGOW, WMN WAN KHAIRINA
Department of Medicine, International Islamic University
Malaysia, Hospital Tengku Ampuan Afzan, Kuantan, Pahang,
Malaysia
HARRIS A NGOW, MD, MMed (Int Med),
Paediatric Department, Hospital Tengku Ampuan Afzan,
Kuantan, Pahang, Malaysia
WMN WAN KHAIRINA, MB BS, MMed (Paed)
Abstract
Cardiac metastasis from a bowel malignancy seldom occurs
and there is a limited number of case reports published on
this subject.Although colorectal cancer is the third common-
est malignancy in Malaysia, the incidence of cardiac metas-
tasis has never been reported. We report a case of an elderly
man with recently diagnosed adenocarcinoma of the sigmoid
colon, who presented with congestive cardiac failure second-
ary to mechanical obstruction by a right atrial mass. The
intractable shock led to his sudden death before any inter-
vention could be planned. If an intra-cavity cardiac mass is
detected in a patient with an underlying metastatic malig-
nancy, cardiac metastasis should be suspected. However,
primary cardiac tumour or thrombus could also be the
differential diagnosis. In our case, the definitive cardiac
pathology remained unsolved as an autopsy was refused.
Keywords:
colorectal adenocarcinoma, cardiac tumour,
metastasis, echocardiography
Submitted 28/9/10, accepted 13/3/12
Cardiovasc J Afr
2012;
23
: e10–e12
DOI: 10.5830/CVJA-2012-027
Colorectal cancer is the third most common malignancy in
Malaysia.
1
The estimated prevalence is about eight per 100 000
population per year. It is also the third most common cause
of mortality in Malaysia. Cardiac metastasis from colorectal
adenocarcinoma is rare and usually a sign of extensive disease.
The reported incidence in Malaysia is unknown. In the literature
there are only a few cases reported thus far.
In reported autopsy series of all cause of deaths, cardiac
metastases appear in 1% of all cases.
2
In autopsies of patients
diagnosed with cancer, the incidence ranges from 1.6 to 15.4%.
3-5
In colorectal cancer, the incidence of cardiac metastasis was 1.4
to 7.2% in autopsy studies.
6
We report a case of a single cardiac
mass in the right atrium from a patient with recently diagnosed
sigmoid colon adenocarcinoma.
Case report
A 59-year-old Chinese man was referred for progressive
dyspnoea of three weeks’ duration. This was associated with
orthopnoea, paroxysmal nocturnal dyspnoea and bilateral leg
swelling. He also complained of reduced effort tolerance and
progressive abdominal distension in the two weeks prior to
admission. He had had altered bowel habits of one-month
duration with diarrhoea and haematochezia. His appetite had
been poor and he had had significant weight loss of 6 kg within
one month. There was no significant past medical history. He did
not smoke or consume alcohol. There was no family history of
bowel malignancy or other tumours. He also denied a history of
blood transfusion or risky behaviour.
At presentation he was wasted and cachexic. The sclera
were yellow with pale conjunctiva. His blood pressure was
110/70 mmHg. The pulse rate was 82 beat per minute and
he was afebrile. There was no palpable lymphadenopathy.
Chest examination showed reduced breath sounds with dullness
bibasally. The precordium revealed normal heart sounds with
no added sound or murmur. Abdominal examination revealed a
distended abdomen with ascites. There was hepatomegaly with
mild tenderness.
The haemoglobin count was 10.4 g/dl, platelet count was
196
×
10
9
/l, and total white cell count was 11.3
×
10
9
/l. The liver-
function test showed a cholestatic picture with total bilirubin
of 161.7 µmol/l (direct bilirubin 77.8 µmol/l and indirect
bilirubin 83.9 µmol/l). Serum albumin was 22.9 g/l, and serum
transaminases and alkaline phosphatase were normal. The INR
was 1.4. Tumour markers including carcinoembryonic antigen
(CEA) and alpha fetoprotein (AFP) were elevated at 13.4 ng/ml
and 40.9 U/ml, respectively.
The chest X-ray revealed a cannon-ball appearance.Abdominal
ultrasound revealed coarse liver echotexture with gross ascites.
Echogenic focal liver lesions were noted. Computed tomography
of the chest, abdomen and pelvis revealed extensive lung nodules
of varying sizes in both lung fields. Minimal pleural effusion
was noted with multiple pretracheal, precarinal and subcarinal
lymphadenopathy. The liver was enlarged with multiple liver
nodules. Gross ascites was noted.
A colonoscopy revealed a tumour at the sigmoid colon about
20 cm from the anal verge. The histopathological examination
showed a dysplastic adenomatous polyp with features of
invasive adenocarcinoma (Fig. 1). An echocardiogram showed
a large homogeneous mobile mass at the right atrium measuring
5 × 6 cm (Fig. 2).
While waiting for a decision on further management, the
patient had cardio-respiratory arrest in the ward and died. This
