|Year : 2015 | Volume
| Issue : 4 | Page : 502-504
Cardiac metastasis and right ventricular outflow tract obstruction in anaplastic carcinoma of the thyroid
Rao Mugula Sudhakar1, Seshadri Sneha1, Devasia Tom2, Rao Lakshmi3
1 Department of Medicine, KMC Manipal, Manipal, Udupi, Karnataka, India
2 Department of Cardiology, KMC Manipal, Manipal, Udupi, Karnataka, India
3 Department of Pathology, KMC Manipal, Manipal, Udupi, Karnataka, India
|Date of Web Publication||14-Jul-2015|
Department of Medicine, KMC Manipal, Manipal - 576 104, Udupi, Karnataka
Source of Support: None, Conflict of Interest: None
Cardiac metastasis is more frequent than primary tumors, with low absolute incidence reported. Cardiac metastases are common secondary to malignant melanoma, carcinoma of the lung, lymphoma, and carcinoma of the breast. Cardiac metastasis secondary to thyroid carcinoma is very uncommon. Among the thyroid malignancies, anaplastic carcinoma is the most aggressive and metastases to the heart has rarely been described in the literature. We report a case of a 60-year-old female with right ventricular outflow tract obstruction secondary to anaplastic carcinoma of the thyroid. An extensive literature search till date was unfruitful in finding a similar case. Thus, we focus the importance of regular echocardiography screening for all cases of thyroid malignancy, especially anaplastic carcinoma for recognizing cardiac involvement antemortem rather than postmortem.
Keywords: Anaplastic carcinoma thyroid, cardiac metastases in thyroid malignancy, right ventricular outflow obstruction in anaplastic carcinoma thyroid, right ventricular outflow tract obstruction
|How to cite this article:|
Sudhakar RM, Sneha S, Tom D, Lakshmi R. Cardiac metastasis and right ventricular outflow tract obstruction in anaplastic carcinoma of the thyroid. Med J DY Patil Univ 2015;8:502-4
|How to cite this URL:|
Sudhakar RM, Sneha S, Tom D, Lakshmi R. Cardiac metastasis and right ventricular outflow tract obstruction in anaplastic carcinoma of the thyroid. Med J DY Patil Univ [serial online] 2015 [cited 2021 Jan 22];8:502-4. Available from: https://www.mjdrdypu.org/text.asp?2015/8/4/502/160809
| Introduction|| |
Cardiac metastasis secondary to thyroid carcinoma is very uncommon. Among the thyroid malignancies, anaplastic carcinoma metastasizing to heart has rarely been described in the literature. Common sites of cardiac metastasis include pericardium and epicardium with endocardium, myocardium and cardiac chambers being less frequently involved. We report a case of right ventricular outflow tract (RVOT) obstruction secondary to anaplastic carcinoma of the thyroid. An extensive literature search did not show a similar previous published case.
We focus the importance of regular echocardiography screening for all cases of systemic malignancy for ruling out cardiac involvement.
| Case Report|| |
A 60-year-old female detected to have hypertension and bronchial asthma, presented with swelling in the neck since 20 years that increased in size over time. Examination findings were suggestive of multi nodular goiter. In view of her symptoms of dysphagia and hoarseness of voice, she underwent right hemithyroidectomy.
After surgery, the patient received external radiotherapy to the bed of the thyroid gland with delivery of 200 cGy twice daily over 17 days (total dose 3600 cGy) as biopsy revealed the diagnosis of anaplastic thyroid carcinoma [Figure 1] and [Figure 2] showing histopathology of anaplastic carcinoma thyroid].
One-month later, patient presented with dyspnea and pedal edema. She was dyspneic even at rest (New York Heart Association grade IV). Abdominal distension and facial puffiness were not identified. On arrival to the emergency room, she was hemodynamically stable. Systemic examination was unremarkable except for pedal edema. Chest auscultation revealed no rales. Jugular venous pulse was not elevated.
|Figure 1: H and E stained section of left lobe of thyroid under magnification of 4× showing cellular encapsulated neoplasm composed of micro and few normo follicles lined by hurthle cells characterised by abundant eosinophilic cytoplasm, anisonucleosis, vesicular nuclei surrounded by stroma showing congested vessels and lymphoplasmacytic infi ltrate. Capsule is irregularly thickened without any invasion|
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|Figure 2: H and E stained section of postthyroidectomy specimen under 40× magnifi cation depicting pleomorphic, rhabdoid, polygonal malignant cells in syncitial sheets and dyscohesive clusters|
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Routine investigations were in normal limits except an elevated erythrocyte sedimentation rate of 83.
Biopsy report of the thyroidectomy specimen confirmed anaplastic carcinoma of the thyroid.
Electrocardiography (ECG) on preoperative cardiac evaluation was normal, but 1-month later showed nonspecific ST-T wave changes.
Normal echocardiography preoperatively, however demonstrated an irregular well defined mass extending into the RVOT during the subsequent presentation [Figure 3] shows Echocardiography picture of mass in the RVOT and [Figure 4] shows the RVOT gradient].
|Figure 3: Echocardiography picture showing dilated right atrium and right ventricle with a well circumscribed mass measuring 3.7 cm × 5.9 cm on right ventricular free wall extending upto the tricuspid valve|
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|Figure 4: Echocardiography picture showing tricuspid regurgitation gradient of approximately 78 mmhg suggesting high right ventricular pressures (severe pulmonary artery hypertension) secondary to right ventricular outfl ow tract obstruction|
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As there was severe obstruction to the RVOT, a surgical excision was planned.
Patient had a rapid downhill course and finally succumbed.
Autopsy done, with the permission of the family, confirmed the metastatic nature of the RVOT mass, primary being the anaplastic carcinoma of the thyroid.
| Discussion|| |
Although cardiac metastasis is more frequent than primary tumors, reported incidence of the absolute number is low. They are usually found in association with the terminal stage of the malignant disease with total body metastasis and usually diagnosed at autopsy. Cardiac metastases are common secondary to malignant melanoma, carcinoma of the lung, lymphoma, and carcinoma of the breast.  Among the thyroid malignancies, anaplastic thyroid carcinoma has been well known to be aggressive, bearing a grave prognosis, with a mean survival of 6 months. The most common sites of metastasis from anaplastic thyroid carcinoma have been shown to be lung and bone. Giuffrida and Gharib  reported three cases of anaplastic thyroid carcinoma with metastasis to the left ventricle, cardiac chamber and myocardium. However in our case RVOT was involved which has not been previously described in the literature.
A number of theories have been advanced to explain the route of involvement of the heart by metastatic carcinoma. Metastases may reach the heart via the lymphatic  or hematogenous route,  or by direct or transvenous extension. Lymphatic spread tends to give rise to pericardial metastases; hematogenous spread preferentially gives rise to myocardial metastases. Only rarely are endocardial tumor deposits found. Common sites of cardiac metastasis include pericardium and epicardium with endocardium, myocardium and cardiac chambers being less frequently involved.  The right side of the heart is more commonly involved than the left. 
The clinical diagnosis of metastatic carcinoma to the heart is difficult because there are no early symptoms. Since the clinical picture is chiefly dominated by generalized tumor spread, cardiac metastases usually remain clinically silent, particularly as the vast majority of cardiac metastases are small. Frequently, cardiac involvement is not noticed until after death. Cardiac metastasis may be suspected in patients with new onset heart failure, pericardial effusion or arrhythmias. 
There are no physical signs or laboratory examinations to detect cardiac metastasis. Electrocardiographic recordings are usually nonspecific but may document possible ventricular or supraventricular arrhythmias, or conduction defects. Frequently, only nonspecific ST-T changes may be found on ECG. The method of choice to detect cardiac metastases and their complications, however, is two-dimensional echocardiography. Cardiac metastasis has been shown to have a dismal prognosis. Thus, simple noninvasive routine echocardiography as a part of metastatic work up in thyroid malignancy can help in early diagnosis of metastasis rather than at autopsy.
| Acknowledgment|| |
We acknowledge the patient for providing us material to publish. We would like to thank Dr. Nitin Kansal for active participation and being a part in the diagnosis
| References|| |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]