CARCINOMA METASTASES TO HEART AND SUBCUTANEOUS TISSUES

WILFORD D. NUSRAUM, M.D. Lancmler. Ohio

F. W. IIEYER, M.D. Nanticokc, Pntnsyluania

Because of the rarity of both cardiac metastases and metastatic deposits in tho skin and subcutaneous tissues, tlie following case is considered worthy of report.

CASE REPORT J. W., a coal miner, aged flfty-three, was admitted to the hospital Sept. 29, 1932,

complaining of pain in the abdomen, loss of appetite, and vomiting. The onset of the illness was given by the patient as a year earlier, when he wtis obliged to give u p work in the mines because of severe pain in the epigastrium and the lower anterior mid chest. He complained of a sense of heavy, constant pressure in the epigastrium and vomiting following meals. At times the vomitus contained bright red blood. Soft and liquid foods were more easily tolerated. There had been a loss of weight of 36 pounds in the past year, the present weight being 118 pounds. A physician was flrst consulted two months before.

The patient had worked in mines regularly for the past twenty-eight years, since his migration from Poland. He had never been ill and knew nothing of his family history. H e was a moderate user of alcohol and tobacco.

The only physical flndings of significance on admission were pain in the upper right abdomen on palpation and muscle rigidity in this area. There was no palpable mass.

No roentgenograms were taken a t this time. The blood count showed: red cells, 6,020,000; hemoglobin 90 per cent; white cells 20,000 (polymorphonuclears 89 per cent; large lymphocytes 1 per cent; eosinophils 1 per cent; small lymphocytes 7 per cent; transitionals 2 per cent). Thc urine gave a n acid reaction and was of amber color; the speciflc gravity was 1.033, and a trace of albumin was present. It was negative f o r sugar, granular casts, pus, and blood cells.

The patient was put to bed, placed on a liquid diet, and given aspirin f o r pain. He improved for a few days, after which the pain recurred. H e was first seen on the authors’ service Nov. 15, 1932, six weeks following admission. He was quite uncomfortable, very cmaciated, and was vomiting regularly after every attempt to take nourishment.

The scalp showed several hard, subcutaneous nodules in the deeper layers, movable with the skin. There was marked gingivitis, and the teeth were poor. I n the neck were many enlarged hard nodcs in both the posterior and anterior regions. The lungs were clear to auscultation and percussion. The heart was not enlarged, and rate and rhythm were normal.

There was a large, hard, tender, palpable mass in the epigastrium, extending from the nipple line on the left side, just beyond the xiphoid process, and down to the um- bilicus. The mass was irregular in sht~pe and seemed quite fixed. There was dullness on percussion. The inguinal nodes were enlarged.

The skin was very rough, due to myriads of subcutaneous nodules, most abundant over the anterior and posterior surfaces of the chest, extending down the arms as f a r as the elbows, involving the face, scalp, and upper abdomen. Only a n occasional nodule was found on the abdomen below the level of the umbilicus. There were many nodules on the legs, extending down to the knees, and in the left axilla and over the back. I n onc area, measuring 5 x 7 inches, over the posterior left chest, 475 nodules were counted,

831

The liver and spleen were not palpable.

832 WILFORD D. NUSBAUM AND F. TV. HEYER

They were attached to the skin and deeper structures, were firm, but not tender, and showed no evidence of ulceration.

The patient stated that the first nodule had appeared about the time of his admission, six weeks previously. He indicated a nodule measuring about half a n inch in diameter in the right lower quadrant of the abdomen, immediatcly below McBurney’s point, as b c h g the first one to be ohservccl. A few days af ter discovering this, hc had noticed n fcw on the anterior left chest. F o r the past month the nodules had increased rapidly in number ancl sizc. Each morning an additional shower would be discovered in some area which had been free the day before.

A tliagnosis of advancwl carcinoma of the stomach with multiple subcutaneous metas-

The blood pressure was 110/80.

P- FIG. 1. SKETCH SHOWINQ DIBTUIBUTION AND SIZE OF SUBCUTANEOUS METABTASEB

tnsrs was mndc. The subcutaneous notlule in the right lower abdomen, the one flrst noticed by the patient, was excised, ancl the pathologist’s report was metastatic cnrcinomii.

A roentgenogram, taken Nov. 20, showed a marked filling defect at the cardiac rnd of the stomach with retention of barium in the lower half of the esophagus after two hours. Roentgenograms of the chest, vertebrae, and long bones showed no evidence of metastases. I t was impossible to ohtain u gastric analysis, because the patient could not swallow the tube.

The blood count a t this time was as follows: red cells 3,900,000; hemoglobin 77 per cent; white cells 16,600 (polymorphonuclears 88 per cent; large lymphocytes 3 per cent; small lymphorytcs 6 per cent; transitionals 3 per cent). The urine showed a heavy t rare of albumin, also hyaline and granular casts. Stools were positive f o r occult blood. The blood Wassermann reaction was negative..

Dysphagia gradually progressed. The patient was given colonic feedings and nlso small amounts of liquids by mouth. The pulse became weak and intermittent, and death occurred Nov. 28, 1932.

The body was five feet, five inches in length, anemic and emaciated; the weight was eighty-three pounds. The scalp and skin, as noted in the physical examination, were very rough due to the presence of multiple subcutaneous nodules (Fig. 1).

Incision was made froin the manuhrium sterni to the symphysis pubis. The flaps were disseeted back, and many hard nodules were found infiltrating through the recti and pectoralis muscles ancl into the subcutaneous tissue. The pleura was studded with nodules, and there were many nodules in the rhest wall. The lungs showed marked anthracosis, but numerous small cut sections revealed no nodules here.

The perieardium was covered with metastatic nodules. Several were found at thc base of the aorta. and in the walls of the left ventricle (Fig. 2), the largest one, a t the

Autopsy was clone by the authors.

METASTASES TO HEABT AND SUBCUTANEOUS TISSUES 833

apex, measuring one inch in diameter. There were also several nodules in the right auricle (Fig. 3).

The peritoneum, mesentery, and a large par t of the small intestine were studded with small nodules, varying in size from one eighth to one half inch in tliamcter. The lower border of the right lohe of the liver was bound down in a mass to the anterior portion of the stomach. The liver was small, weighing only 1200 grams. It was studded with metastatic nodules, ranging in size from one to threc inches in diameter. Practically the entire parenchyma was replaced by these carcinomatous nodules, many of which liad undergone degeneration and were filled with a milky semi-solid suhstance. Projecting into the cavities of these nodules were papillomatous growths of malignant tissue. The

FIQ. 2. MUSCULATURE OF LEFT VENTRICLE, 8HOWINa DISTRIBUTION OF METASTASES

FIO. 3. BISECTED HEABT ~ H o w I N O LARQE METASTATIC GROWTIIS IN "EKE WALL OF THE RIOHT AURICLE

gallbladder was matted down and udherent to thc stomach. It was first thought to contain stones, but on being opened revealed a number of firm, whitish nodules attached to the mueosa.

The stomach was adherent in a dense mass postrriorly to the pancreas and preverte- bra1 tissues. I t was dissected with the esophagus, a large portion of the adherent pancreas, and prevertebral glands. The stomach was markedly deformed, hard, and nodular, practically the entire organ being involved in a carcinomatous mass. There was a n obstruction a t thc esophagcal oriflce (Fig. 4), the lumen permitting only the passage of a probe.

An occasional nodule was found on the kidney capsule hut cut sections of the kidneys showed no parenchymal metastases. Nodules studded, but were confined to, the capsule of the spleen. The bladder and prostate were negative.

834 WILFORD D. NUSBAUM A N D F. W. HEYER

Gross PuthoZogy : Massive carcinoma of the stomach with an obstruction at the esophageal oriflce ; metastases to the pleura, chest wall, pericardium, myoeardium, pan- creas, gallbladder, liver, spleen, kidneys, small intestine, peritoneum, mesentery, and subcutaneous tissues ; marked emaciation and anemia.

B.licroscopic stwdy of the sections showed adenocarcinoma of the stomach (Fig. 6), the pathological picture being reproduced in the metastatic nodules.

DISCVSSION Cardiac metastases are not mentioned in text-books. A review of

medical literature, however, yields a number of authentic cases, with the primary growth located as follows: in the stomach ( l ) , esophagus (2) , mamma (3) , uterus (a), rectum (5), liver (5), vulva (6) , thyroid

Fro. 4. BISE(-TED STOMACH SHOWINO LAWE CARCINOMATOUS MASS WITH ADHERENT PANCREAS

(7), pciiis (5) , skin (8), prostate (9) , bronchi ( lo), gallbladder (5) , kidncy (5), tongue (ll), choroid (12), extremities (12), bones (13), ovary (12), testicle (14), cheek (12), parotid (12), submaxillary gland (15), and pancreas (16). Among the 150 cascs collected, the lungs, esophagus, breast, and stomach were most frequently the primary site. Thcve statist-ics arc of little significance, however, because of the high incidence of primary carcinoma in these organs. It would appear that malignant growth in any site may metastasize to the heart.

The incidence of cardiac metastasis in carcinoma, as computed from autopsy findings, ranges from .02 per cent (Thorel, quoted by Blu- mensohn) in 3,000 autopsies, to 3.15 per cent in 1078 cases (Blumen- sohn, 5). A collection of autopsy series of carcinoma cases gives an incidence of 0.4 per cent. This figure compares favorably with 0.28 per cent as computed by Nicholls (18). Reichelman (quoted by Blu- mensohn), in a large series of cases of carcinoma of the stomach, estimated the frequency of secondary deposits to the heart from that organ as 0.96 per cent.

METASTASES TO HEABT AND SUBCUTANEOUS TISSUES

Secondary Carcinoma Cases Metastases to Heart

Blumensolin (5) .......... 1078.. ................ 34

Willigk (17) ............. 4547 .................. 9 Kohler (18) .............. 9118.. ................ 6 Pic and Bret (5) .......... 170 8 .................. 25 Tliorel (5) ............... 3000 .................. 6

Ely (a) .................. 2101 .................. 7

Bryant (17) .............. 2942 .................. 9 - 24,554 96 (0.4 per cent)

The heart may become involved by direct extension, or by metastasis through the lymph stream or the blood stream. The lymphatic route seems the most common, as is evidenced by the relative frequency of

FIo. 5. PHOTOMICROQBAPH OF P R I M A R Y TUMOR IN THE STOMACH

cardiac involvement in lesions of the esophagus, mediastinum, lungs or pleura, as well as the predominance of secondary deposits on the pericardium. The tracheobronchial lymph nodes drain the pleura, lungs, myocardium and pericardium, making possible retrograde in- vasion from the lungs and pleura. The rapid cardiac vascular flow, and the fact that the coronary arteries come off a t right angles to the axis of the aorta, make remote the probability of foreign matter gaining entrance to these small vessels. Simpson (19), however, reports a case in which carciiioma cells were found in the center of mural and valvular cardiac thrombi, and strands of tumor cells in the lumens of coronary vessels, without metastatic nodules in the heart muscle. One of the

836 WILFORD D. NUSBAUM AND F. W. HEYER

authors has made a similar observation in a case of primary gastric carcinoma.

Little mention is made in the literature of symptoms which would lead a clinician to suspect cardiac metastases. Fishberg (20) reports a case with auricular fibrillation and flutter, in which autopsy showed metastatic growths of the right auricle and widespread metastases in otlier organs. These symptoms are due to the mechanical effects of pressure, disturbance of the cardiac conduction mechanism by changes in muscle fiber!, occlusion of coronary vessels, and the production of multiple emboli, valvular insufficiency, or st enosis by pedunculatcd grafts or free tissue masses in the heart cavity.

Rodenheimer (21 ) calls attention to the following symptoms, which, however, are common to cardiac disease in general: precordial pain, palpitation, sense of oppression, dyspnea, cough, hemoptysis, cyanosis, edema of the extremities, effusions into various serous cavities, giddi- ness, syncope, and attacks of unconsciousness.

Metastases to the skin and subcutaneous tissue are also rare. Kauf- maiin-Wolf (22) after an exhaustive study could collect only 65 case reports. h i 30 per cent of these the primary tumor was in the stomach No cases were included in which the primary growth was located in the breast. Durbeck (23) quotes the following autopsy statistics.

Carrinoma Cases Metastases in Skin Heiinann ................. 20,000 .................. 2 Rodlirk .................. 496 .................. 2 Loepcr and Turpin ........ 2,000 .................. 1 Millrrki .................. 487 .................. 6 Kitain ................... 452 .................. 15 -

23,435 26 (.0117 per ccnt)

We believe, however, that skin metastasis is much more common than the statistics would indicate.

Uhlenbruck aiid Gilardone (24), reviewing the literature in con- nection with a report of a case, added a few cases described as esl~ccially noteworthy because of multiple metastases in the skin. Oldliam and McCfibbon (25) mentioii a case of intrinsic laryngeal carcinoma in which 58 subcutaneous nodules were removed. Loepcr aiid Turpin (36) describe a case of carcinoma of the stomach with 14 metastatic iiodulcs in the skin, one the size of a mandarin orange.

Iiivolvement of the skin and subcutaneous tissues may occur by the lymphatic route, blood stream, direct extension, implantation at operation, and as Furuta (27) states, by nerve paths as a special por- tion of the lymphatic system. Most writers agree that the lymphatic route is the most common mode of extension, except for distant metas- tases, which are no doubt hematogeiious in origin.

Subcutaneous metastases occur most frequently on the abdomen, about the umbilicus, by way of the round ligament and usually secon- dary to carcinomatous nodules in the liver. As with cardiac mettistases, subcutaneous nodules are usually a part of a generalized carcinoma- tosis. I n most of the cases reviewed, metastases were confined to skin

METASTASES TO HEART AND SUBCUTANEOUS TIBSUES 837

on the abdomen, and with the exception of the cases mentioned above, only a few nodules were present.

Metastatic nodules in the skin produce no symptoms unless pressure necrosis occurs ; they are usually small and are discovered by accident. When nodules are present, excision should not be neglected, for the primary tumor may sometimes be determined by a study of the histo- logic picture of the metastatic nodule.

CONCLUSIONS 1. Metastatic carcinoma of the heart and subcutaneous tissues is

2. Metastatic tumors of the heart have never been diagnosed prior

3. Despite large metastatic nodules in the heart, cardiac symptoms

4. Biopsy of a skin nodule is a legitimate and valuable diagnostic

rare, but may occur in cases of carcinomatosis.

to autopsy.

may be absent.

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16. BARTH~LEMY: Note sur deux cas de cancer secondaire du cocur, Bull. SOC. anat. de Paris 54: 551, 1879.

17. BRYANT, C. H.: Primary sarcoma of the heart in a dog, Bull. Johns Hopkins Hosp.

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838 . WILFORD D. NUSBAUM AND F. W. HEYEB

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26. OLDHAM, J. B., AND M ~ I B B O N , J. E. Q.: Multiple subcutaneous metastases from primary intrinsic laryngeal carcinoma, J. Lnryng. & Otol. 47: 633, 1932.

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