Vol.2, No.8, 450-453 (2013) Case Reports in Clinical Medicine
http://dx.doi.org/10.4236/crcm.2013.28118
Malignant cardiac metastasis from breast cancer:
Imaging contribution to surgical attitude
Victor J. Ovejero-Gomez1*, L. Martin-Cuesta2, V. Alija3, J. Villalba4, J. Rodríguez-Cabello2,
J. Perez5, J. M. Bajo-Arenas4
1Department of Surgery, Hospital Sierrallana de Torrelavega, Torrelavega, Spain; *Corresponding Author:
2Department of Radiology, Hospital Sierrallana de Torrelavega, Torrelavega, Spain
3Department of Medical Oncology, Hospital Sierrallana de Torrelavega, Torrelavega, Spain
4Department of Gynaecology, Hospital Sierrallana de Torrelavega, Torrelavega, Spain
5Department of Cardiology, Hospital Sierrallana de Torr el avega, Torrelavega, Spain
Received 30 July 2013; revised 28 August 2013; accepted 30 September 2013
Copyright © 2013 Victor Ovejero et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Metastasic cardiac disease from the breast is
rarely diagnosed in the lifetime. It has a poor
prognosis and limited management. Both echo-
cardiography and computerized tomography
(CT) should be the first imaging studies in sus-
picion of this entity. Other diagnostic methods
should be based on the possibilities of treat-
ment although a histopathological analysis of
the metastasic mass is needed to confirm the
diagnosis. Magnetic resonance imaging (MRI)
could be useful to complete a morphological
and functional evaluation in case of surgical re-
moval.
Keywords: Cancer; Breast; Metastasis; Cardiac;
Imaging
1. INTRODUCTION
The most common malignant neoplasms that metas-
tasize to the heart are lung, breast and esophageal cancers,
lymphoma, leukaemia and melanoma [1], which have the
highest prevalence of cardiac metastasis per 100 cases of
any neoplasm.
Malignant cardiac metastasis from breast cancer
usually appears late in the context of a wider involve-
ment and only 10% of them have symptoms. They
frequently contribute to the mechanism of death.
Advances in imaging techniques have improved cli-
nical diagnosis despite its poor prognosis. The treat-
ment includes a combination of surgery, radiotherapy and
chemotherapy.
The value of radiological findings could be helpful to
guide a therapeutic approach.
We present a female patient diagnosed with breast
carcinoma, who suffered from asymptomatic regional
recurrence and metastasic involvement of the right side
of the heart. Our aim is to analyze the current imaging
methods in cardiac metastasic neoplasms according to
both their cost-effective and therapeutic profitability.
2. CASE REPORT
A 54-year-old woman with previous medical history of
hypertension and hypercholesterolemia underwent tumo-
rectomy with negative margins and negative sentinel
lymph node for a left-breast ductal carcinoma with
hormone receptor-positive. Six months later, she pre-
sented palpable axillary nodes on physical examination.
A left-axillary lymphad enectomy was carried out and the
histologic specimen demonstrated two positive lymph
nodes over the fifteen removed. Postoperative, the pa-
tient was staged as pT2pN1M0.
It was indicated both adjuvant chemotherapy and
radiotherapy. In the clinical follow-up, the patient touched
a node on her surgical scar and a new biopsy indicated
malignancy. An analysis of biomarkers showed a high
value of Ca 15.3 (181.6 U/L, normal rate < 25) and CEA
(29.2 µg/L, normal rate < 3.5).
A simple mastectomy was performed and she was
treated with hormone agents.
She was in complete remission for a short-term due to
another asymptomatic local soft-tissue recurrence and
proposed for s urgical approach.
A CT-scan showed a local malignant progression onto
thoracic wall and a myocardial mass (Figures 1 and 2)
with repolarization changes in EKG, which were not
evident on radiological and clinical studies before.

V. J. Ovejero-Gomez et al. / Case Reports in Clinical Medic ine 2 (2013) 450-453 451
Figure 1. Axial contrast material-enhanced CT scan shows
myocardial mass with endocardial extension in the anterior
wall and septum of the right ventricle.
Figure 2. Triphasic helical CT. Axial image. Arterial (3a),
venous (3b) and delayed (3c) phases show a low attenuation
mass in the right ventricle myocardium with homogeneous
subtle enhancement and delayed wash-out.
An echocardiogram (Figure 3) showed a partial
myocardial wall achinesia in right ventricle and one
endoluminal lesion with a broad myocardial infiltration
as it could be demonstrated by a further magnetic re-
sonance imaging (Figure 4). A biopsy was taken but in-
flammation could only be evidenced on insufficient
sample.
She underwent palliative chemotherapy and surgical
approach was ruled out.
On the last follow-up two months later, there was a
progression of the disease. Shortly afterwards, our pa-
tient died from cardiogenic shock due to massive in-
volvement of the heart.
3. DISCUSSION
Breast cancer is the second most common cause of
Figure 3. Echocardiography in this patient shows akinetic
right ventricle with a space-occupying lesion suggestive of
infiltration of medioapical segments.
Figure 4. Axial (4a) and sagital (4b) MPR images display the
mass affecting the right ventricle myocardium with endo-
cardial growth and protrusion along the cardiac border.
cancer-related death in women, behind lung carcinoma.
The thorax is a common site of mammary metastasis as
both soft-tissue recurrence and lung metastasis. Nonethe-
less, the heart is often involved in patient lifetime,
although they are usually asymptomatic and found late,
even at autopsy [2,3]. This feature is common to other
metastasic tumours to the h eart [1].
Most of breast carcinoma metastasizes to the right side
of the heart by direct ex tention due to its close proximity
and the first metastasized layers are usually pericardium
and epicardium. Hematogenous and lymphatic pathways
are uncommon due to the strong and metabolic pecu-
liarities of myocardial striated muscle, and the fast blood
flow through the heart and lymph flow moving away
from the heart [4].
Some reported cases, similar to ours, were diagnosed
as a late cardiac disease on the left ventricle after a
mastectomy and pulmectomy which could support this

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452
sort of dissemination [5]. On the contrary, an early
soft-tissue recurrence on a rib cage and a right ventricle
mass seemed to suggest that this cancer was spread by a
direct pathway.
In patients with clinical suspicious of cardiac meta-
stases from breast, a first imaging study should be
performed to evaluate the chest wall, lung, pleura and
mediastinum to rule out other spreads which could
modify the therapeutic strategy.
A focused imaging study on cardiac metastasis should
be considered cost-effectiveness of the radiologic method
due to the poor progn osis of the disease, even thou gh the
surgical removal is indicated.
Echocardiography is a noninvasive imaging study and
the first diagnostic choice which could provide infor-
mation about th e size and locatio n of the metastasic mass
[6]. The cardiac CT scan and MRI could be useful to
evaluate the local recurrence and cardiothoracic
metastasis with regard to anatomical relations when a
surgical removal has been planned.
In fact, some of these patients present their first
recurrence either on the chest wall or lymph nodes. Pul-
monary and cardiac metastasis will appear soon after-
wards [7].
Nonetheless, CMR offers a better contrast resolution
to distinguish among the mass, thrombus and blood flow
artifact with typically low signal intensity on T1-
weighted images and higher signal intensity on T2-
weighted images unlike other cardiac metastasis as mela-
noma [8].
Nowadays, ultrasonography enables a better perfor-
mance from a practical point of view: A histological
sample can be obtained by transesophageal echo-guided
biopsy instead of cardiac catheterism, and a 3-dimen-
sional transthoracic echocardiography (3D-TTE) is able
to show cardiac functional volumes and 3D images about
tumoral mass’ surface, type, location and anatomic re-
lations with greater accuracy than 2D-TTE which under-
estimates the cardiac function and volume mass [9].
Positron emission tomography and other techniques of
scintigraphy are imaging methods to confirm the ma-
lignancy and card iac function although its co ntribution is
limited [10].
In the postoperative follow-up for breast cancer, local
recurrence should be evaluated primarily by physical
examination and mamography, with a sensitivity of 79
and 45% respectively, although this imaging technique
could be compromised by the presence of postoperative
distorsion and the increased density of an irradiated
breast. Ultrasonography could be more helpful thanks to
a higher sensitivity, superior to 90%.
However, computed tomography is the most sensitive
examination to detect thoracic metastasis and regional
recurrence. It should be the first choice in imaging
methods because it allows a more accurate determination
of recurrence and is able to demonstrate clinically
unsuspected disease in 49% of patients.
The use of other imaging studies depends on the
planned therapeutic management since its diagnosis is
not a surgical contraindication by itself if this option is
considered.
Most cardiac metastases from breast carcinoma are
incurable and a palliative therapy based on a systemic
chemotherapy only should be offered because radio-
therapy is rarely helpful and indicated to relieve symp-
toms [11]. An echocardiography, CT or MRI and echo-
guided biopsy could be enough to make a decision in
these cases.
Nonetheless, some patients who suffer from tampo-
nade or obstruction of blood flow could undergo pal-
liative emergency surgery although a lot of these cases
have been reported with a high postoperative mortality
due to cardiological complications [12].
This unforeseeable development of the natural history
of the disease should not justify a previous detailed
imaging study because the most common cause of death
is used to being a cardiorespiratory arrest without any
surgical chance.
A complete imaging study only should be indicated
when a surgical removal is planned.
Radiological contribution should focus on the diag-
nosis and functional or morphological characterization of
the heart by MRI and echocardiogram to support the
therapeutic management decision.
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ABBREVIATIONS
CT: Computed tomography
MRI: Magnetic resonance imaging
Ca 15.3: Carbohydr ate antigen 15.3
CEA: Carcinoembryonic antigen
EKG: Electrocardiogram
CMR: Cardiovascular magnetic resonance
3D-TTE: Three-dimensional transthoracic echocardiography
3D images: Tridimensional images
2D-TTE: Two-dim ensional transthoracic echocardiography
MPR: Multiplanar reconstru c tion.