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      Recurrent Acute Myocardial Infarction Caused by Intra-cardiac Metastatic Undifferentiated Pleomorphic Sarcoma during Cancer Treatment

      case-report
      , MD 1 , , MD 2 , , MD, PhD 1 ,
      Journal of Cardiovascular Ultrasound
      Korean Society of Echocardiography
      Coronary occlusion, Sarcoma, Cardiac tumor

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          Abstract

          A 54-year-old male visited the emergency room for sudden chest pain. In his previous medical history, he had been diagnosed as left axillary undifferentiated pleomorphic sarcoma two years ago without metastasis in the heart at our hospital (Fig. 1A). Despite surgery, multiple sessions of chemotherapy and radiation therapy, the cancer had proliferated. One year after diagnosis, he had started taking pembrolizumab to target the metastasis of sarcoma. After initiation of pembrolizumab, the patient was hospitalized for sudden cardiac arrest due to acute myocardial infarction (AMI) induced by metastatic sarcoma embolus and an angioplasty had been performed at another hospital a year ago. We performed direct percutaneous coronary intervention due to ST segment elevation myocardial infarction, anterior wall and found the total occlusion of the distal left anterior descending artery (Fig. 1B). We utilized a thromboaspirate suction catheter to suction the area multiple times and obtained mucoid white tissue debris (Fig. 1C). In the final coronary angiography, the coronary flow had been completely restored (Fig. 1D). In his echocardiography six months ago, a huge mass with heterogeneous echogenicity was located in the left atrium and attached to the interatrial septum with a prolapse into the left ventricle (Fig. 2A, Supplementary Movie 1). However, the mass had significantly decreased in size on new echocardiography (Fig. 2B, Supplementary Movie 2). We compared the cytologic and immunohistochemical findings of primary axillary sarcoma with the acquired intracoronary embolus tissue. The embolus tissues were composed of discohesive round sarcoma cells and scattered pleomorphic giant cells, which were diffusely immunoreactive with CD68, a macrophage marker, and vimentin, a representative mesenchymal marker (Fig. 3). These findings confirmed that the pathologic findings of coronary embolus tissues were compatible with the primary axillary undifferentiated pleomorphic sarcoma. Cardiac metastases were present in 25% of consecutive autopsies of patients with soft-tissue sarcoma, which is higher than was recognized clinically, which suggests that most cases are probably missed.1) Metastatic cardiac tumors may induce devastating consequences depending on the cardiac structures involved, so the establishment of appropriate management is very important.2) As in our case, the occurrence of AMI due to cancer embolus in response to treatment was extremely rare.3) Moreover, most cases of the coronary embolization of malignant tumors are confirmed by autopsy study.4) There were a few cases that were histologically confirmed by obtaining tissue in vivo.5) Our case illustrates that recurrent AMI was induced by coronary emboli of intra-cardiac metastatic pleomorphic sarcoma. We obtained embolus tissue in vivo and compared it with the previous primary axillary sarcoma. In the case of malignant tumors in the heart, the mass of a tumor may fall off and embolize during treatment, which can cause AMI or sudden cardiac death. Therefore, we suggest that echocardiography should be considered in cases of malignancy that presents with soft-tissue metastases, because of the condition's highly life-threatening nature and the possibility of soft-tissue dissemination.

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          Most cited references5

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          Eleven cases of cardiac metastases from soft-tissue sarcomas.

          Cardiac metastasis is a highly life-threatening condition because it leads to cardiac failure. However, it is difficult to diagnose because its precise clinical features are unknown. Here, we report 11 cases of cardiac metastasis from soft-tissue sarcoma, and discuss its diagnosis and treatment.
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            Cardiac metastases from soft-tissue sarcomas.

            Cardiac metastases were present in 30 of 120 (25%) consecutive autopsies of patients with soft-tissue sarcoma (STS). Fifty percent of the patients had metastases to the myocardium, while 33% had pericardial metastases and 17% had both. Congestive heart failure was present in ten patients and was commonly caused by diffuse myocardial or restrictive pericardial metastases. Other signs and symptoms of cardiac involvement by STS included chest pain (three patients), arrhythmias (two), conduction block (two), simulation of an atrial myxoma (one), and sudden death (one). Echocardiography was used infrequently, but was diagnostic in 80% of cases in which it was used. We conclude that metastatic STS commonly involves the heart and produces cardiac symptoms.
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              Carcinoma embolization in coronary artery causing myocardial infarction: diagnosis from coronary thromboaspirate.

              A unique case of myocardial infarction due to coronary artery tumor embolism from colonic adenocarcinoma is described. A 79-year-old man with a history of rectal carcinoma with lung metastases 15 years and 9 years before, respectively, was subjected to primary percutaneous coronary intervention for myocardial infarction with aspiration of a thrombus from the occluded artery. The retrieved material contained fragments of adenocarcinoma tissue. To the best of our knowledge, this is the first reported case of adenocarcinoma coronary embolism diagnosed during life from coronary artery aspirate.
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                Author and article information

                Journal
                J Cardiovasc Ultrasound
                J Cardiovasc Ultrasound
                JCU
                Journal of Cardiovascular Ultrasound
                Korean Society of Echocardiography
                1975-4612
                2005-9655
                March 2018
                28 March 2018
                : 26
                : 1
                : 40-42
                Affiliations
                [1 ]Division of Cardiovascular Medicine, Department of Internal Medicine, Dankook University College of Medicine, Dankook University Hospital, Cheonan, Korea.
                [2 ]Department of Pathology, Dankook University College of Medicine, Cheonan, Korea.
                Author notes
                Address for Correspondence: Tae Soo Kang, Division of Cardiovascular Medicine, Department of Internal Medicine, Dankook University College of Medicine, Dankook University Hospital, 201 Manghyang-ro, Dongnam-gu, Cheonan 31116, Korea. Tel: +82-41-550-7690, Fax: +82-41-556-0524, neosoo70@ 123456dankook.ac.kr
                Article
                10.4250/jcu.2018.26.1.40
                5881083
                29629023
                417f8fa1-1719-4f94-85f0-85826d3b9ff3
                Copyright © 2018 Korean Society of Echocardiography

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 10 November 2017
                : 19 January 2018
                : 26 February 2018
                Categories
                Images in Cardiovascular Ultrasound

                Cardiovascular Medicine
                coronary occlusion,sarcoma,cardiac tumor
                Cardiovascular Medicine
                coronary occlusion, sarcoma, cardiac tumor

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