| Number 10-26: Metastatic Malignant Melanoma Presenting as Incidental Cardiac Mass: CMR Diagnosis |
Number 10-26: Metastatic Malignant Melanoma Presenting as Incidental Cardiac Mass: CMR DiagnosisCase from: Ketheswaram Caruppannan, Robert W.W. Biederman, Gregory Smith, Vikas K. Rathi. Institute: Center for Cardiovascular MRI, Division of Cardiology, Allegheny General, Hospital, 320 E North Avenue, Pittsburgh, PA-15212, USA. Clinical history: A 74-year old white male with history of coronary artery disease with previous CABG and chronic renal failure on hemodialysis, presented to our institution after a spontaneous fall while lawn mowing. He did not sustain head injury. He also had a history of colonic melanoma diagnosed on screening colonoscopy and had undergone resection 2 years ago.
Figure 1 Figure 2
The admission non-contrast head CT showed a large right temporal mass with hemorrhagic changes and severe vasogenic edema (Figure 1). His screening non-gated, contrast-enhanced CT of the chest and abdomen showed multiple peritoneal metastases, a small thoracic subcutaneous nodule and a right middle lobe mass (Figure 2).
Figure 3
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A transthoracic echocardiogram (TTE) confirmed a large sessile mass (2.4 x 2.1cm) attached to the interatrial septum and posterior wall of the right atrium with independent mobility. These features appeared similar to that of an atrial myxoma (Movies 1 & 2).
Figure 4
CMR Findings: Breath-hold T1 weighted images (Figure 4 - four-chamber view) show a well defined, hyperintense (similar signal characteristics to fat) right atrial mass, suggestive of short T1 relaxation, due to the presence of melanin or hemorrhage.
Figure 5
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T2-weighted, triple inversion recovery images with fat saturation (Figures 5 & 6) show a hyperintense lesion, due to increased proton density, suggestive of a tumor.
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Steady state free precession cine images (SSFP) show the isointense mobile mass lesion in the right atrium (Movies 3 & 4). No contrast was given due to renal failure and low GFR. Based on the T1 and T2 weighted characteristics of this lesion (see Table 1), the mass is most likely a metastatic melanoma [1,2].
Table 1
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Conclusion: The patient underwent and Intra Cardiac Echo (ICE) - guided biopsy of the lesion (Movie 5).
Figure 7
The immuno-histochemical staining of the mass revealed diffuse positive staining for S-100 (Figure 7B), strong focal to diffuse staining for melan-A (Figure 7A), focal staining for HMB-45 (Figure 7C) and positive staining for MiTF (Figure 7D), all supportive of metastatic malignant melanoma. Perspective: Metastatic melanoma has an unpredictable biological behavior and is the most common metastatic malignancy to the heart [3]. Due to hematogenous spread, the cardiac metastasis is most commonly intramyocardial and multifocal but there are reports of pericardial, valvular and endocardial involvement. References: COTW handling editor: Monica Deac Re: Number 10-26: Metastatic Malignant Melanoma Presenting a [quote="drflett"]I have to say from the CMR pictures alone, melanoma would not have immediately sprung to mind so this is a good learning point for me ......quote]ChiaraThat was why I qualified it with the above - from... On: 02/06/2011 By: drflett Read more? Re: Number 10-26: Metastatic Malignant Melanoma Presenting a well done, nicely presented at the SCMR best case of the week sesion.interseting about melanin being a T1 shortening agentlink here to your charcoal heart http://www.jcmr-online.com/content/10/1/37 ... On: 02/04/2011 By: moon Read more? Re: Number 10-26: Metastatic Malignant Melanoma Presenting a Did not know that this case generated so much discussion. Ok...here are few thoughts of my own. 1. Although it was known from CT that there a right atrial mass most likely an melanoma metastasis but other etiologies... On: 02/02/2011 By: vikasrathi Read more? Re: Number 10-26: Metastatic Malignant Melanoma Presenting a Totally agree with you Andy. However, bear in mind that from the hx we knew he had a colonic melanoma for which he underwent resection. So I guess this is a big hint. ... On: 01/27/2011 By: chiarabd Read more? Re: Number 10-26: Metastatic Malignant Melanoma Presenting a I have to say from the CMR pictures alone, melanoma would not have immediately sprung to mind so this is a good learning point for me (having not seen melanoma in the heart before). I think my report would have... On: 01/26/2011 By: drflett Read more? Re: Number 10-26: Metastatic Malignant Melanoma Presenting a Would be interesting to get Vikas's opinion on this. He is the senior author for this case. Vikas- any thoughts? ... On: 01/25/2011 By: chiarabd Read more? Re: Number 10-26: Metastatic Malignant Melanoma Presenting a Great case, but as is often the case, one wonders whether CMR really changed the overall management or prognosis in this patient with metastatic disease... ... On: 01/25/2011 By: gvorobiof Read more? Re: Number 10-26: Metastatic Malignant Melanoma Presenting a The right atrial mass was initially an incidental finding on the non-gated contrast enhanced chest CT that the patient underwent for screening. Wasnt CT enough to tissue characterise this mass and differentiate between myxoma, metastatic melanoma or thrombus? Why... On: 01/24/2011 By: chiarabd Read more? Re: Number 10-26: Metastatic Malignant Melanoma Presenting a This is a very nice case on the role of CMR for non invasive tissue characterisation of a right atrial cardiac mass. This case was indeed one of the best 5 cases published this year. ... On: 01/24/2011 By: chiarabd Read more? Re: Number 10-26: Metastatic Malignant Melanoma Presenting a This was our 100th case published! ... On: 01/24/2011 By: chiarabd Read more?
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