metastatic cardiac involvement is reported in the literature highly variable , ranging from 2.3 to 18.3% in different reported studies .
tumors can spread to the heart through direct extension of extra cardiac neoplasm , by bloodstream or lymphatic system diffusion and by intracavitary invasion through both the superior and inferior vena cava or pulmonary vessels .
lung cancer is one of the most common metastatic neoplasms to the heart , usually associated with malignant pericardial effusion .
the presence of cardiac involvement is often only accidentally detected , prognosis is poor and therapeutic options limited .
non - invasive imaging methods are available for evaluation of suspected cardiovascular complications of malignancy .
in may 2012 , a 52-year - old caucasian woman , with no significant past cardiovascular history and risk factors , was admitted to the department of medical oncology because a computed tomography ( ct ) scan , performed 1 month ago for worsening cough and fever , revealed a heterologous neoformation occluding the bronchial branch of the upper lobe , with extension at the parietal pleura , involvement of periaortic and precarenal lymph nodes , and another hypodense formation of about 2 cm with hyperdense rib in correspondence of the right supraspinatus muscle .
bronchoscopy also , with bioptic sample of the mass , confirmed the diagnosis of bronchial spinocellular carcinoma , p63 + , thyroid transcription factor-1 ( ttf-1 ) . on physical examination , were found two painful and non - mobile swellings localized in the right forearm and in the right scapula compatible with repetitive lesions , but not appreciable superficial pathological lymph nodes .
the overall clinical condition of the patient were discrete and karnofsky performance status ( kps ) of 80/90 .
this clinical aspect refers to advanced clinical stage iv ( ct3 , cn2 , and m1 ) with a poor prognosis , therefore the patient was not considered candidable for surgery , but it was considered appropriate to perform a chemotherapy scheme with carboplatin area under the time - concentration curve ( auc ) 6 g1 + paclitaxel 175 mg / m g1 , every 21 days , and , in reason of the symptoms , also a radiotherapy treatment . in june , after the second cycle of chemotherapy treatment , the patient was admitted to emergency care unit for syncope associated with sphincters incontinence and nosebleed .
electrocardiographic examination ( ecg ) revealed a sustained ventricular tachycardia ( vt ) ; the sinus rhythm was restored firstly with electrical shock of 150 j and then with amyodarone intra - venous infusion .
the patient was discharge with clopidrogrel 75 mg / day , ramipril 5 mg / day , and bisoprololo 2.5 mg / day .
a ct evaluation showed a progression of the disease with infiltration of the chest wall , mediastinal pleura and heart chambers [ figure 1 ] .
it was decide to administer a second line of chemotherapy scheme with vinorelbine 25 mg / mq g1 , g8 , and g15 every 21 days , started in july .
the arrows show the infiltration of left ventricular lateral wall and apex after 1 week of beginning the treatment , the patient presents chest pain and she was referred to the cardiology department . at clinical examination
she was eupnoic , with a normal physical examination ; ecg revealed sinus tachycardia but with st segment elevation in leads di and avl [ figure 2a ] and poor progression of r wave in leads v1-v4 [ figure 2b ] .
two- and three - dimensional transthoracic echocardiography ( 2d/3d tte ) showed myocardial involvement with infiltration of the anterolateral left ventricular ( lv ) wall [ figure 2c ] by the side of mass extending from the epicardial to the endocardial layer , with apical hypokinesia and reduction of the lv ejection fraction ( lvef , 45% ) ; 3d global longitudinal strain [ figure 2d ] , obtained from the triplane cine - loops using the automated functional imaging ( afi ) modality , was reduced ( average 11.9% ) especially at posterior wall ; there was mild mitral insufficiency , but was absent pericardial effusion .
( a and b ) electrocardiographic examination ( ecg ) : st segment elevation in di and avl leads ( arrows ) and r - wave poor progression v1-v4 leads .
( c ) two- and three - dimensional transthoracic echocardiography ( 2d/3d tte ) : anterolateral left ventricular wall and apex infiltration .
( d ) a lesser 3d global longitudinal strain at posterior ( post ) , lateral ( lat ) , and aterior ( ant ) wall under the impression of acute coronary syndrome we initially intent to perform emergency coronary angiography .
however , the cardio - oncology team resolved to not perform the invasive cardiac procedure or coronary ct in view of the progressive decline in global performance status , of the serially followed cardiac enzyme levels within their normal range and also because the coronary ct do not take advantages for diagnostic approach in this clinical contest , the patient was already exposed to elevated ionizing radiation and , in order to evaluate the progression of disease , she could be exposed to other radiation .
it was decide to start the third - line of erlotinib , an oral epidermal growth factor receptor tyrosine kinase inhibitor ( egfr - tki),150 mg / die , reduced to 100 mg daily after 1 month because of severe skin toxicity .
three months from the beginning of erlotinib , the ecg revealed a sinus rhythm with depth of negative t wave in leads di and avl [ figure 3a ] and poor progression of r wave in leads v1 and v3 [ figure 3b ] , but without st elevation . at this time 2d/3d - tte showed a mild regression of the lv lateral wall infiltration [ figure 3c ] and a slightly improvement of lvef ( 50% ) .
global and regional strain [ figure 3d ] increased ( average 14.6% ) ; the akinesia of the ventricular wall was unchanged .
a ct scan showed partial remission of the primary lung lesion , of intracavitary and intramyocardial mass and an assessment of the size and morphology of the cardiac chambers [ figure 4 ] .
we subsequently performed egfr mutation analysis that showed single - point substitution mutation l858r in exon 21 , specific types of activating mutations that confer sensitivity to egfr - tkis .
( a and b ) negative t wave in di and avl leads ( arrows ) , but without st elevation and r - wave poor progression v1-v3 leads .
( c ) 2d/3d tte : mild regression of the left ventricle lateral wall infiltration .
( d ) recovery of 3d global longitudinal strain thorax ct scan at 3 months from the beginning of chemotherapy .
lung cancer is one of the most common metastatic neoplasms to the heart , usually associated with malignant pericardial effusion .
clinical manifestations are extremely variable ; some common presentations of cardiac metastases include atrial and ventricular tachyarrhythmia or premature beats , conduction disorders and blocks , syncope and sudden death as result of lv metastatic infiltration causing episodes of vt or lv outflow tract dynamic obstruction , myocardial dysfunction , angina pectoris , and myocardial infarction as result of coronary embolism , but also of invasion or compression of a coronary artery . when a cardiac metastasis is diagnosed antemortem , signs and symptoms of the primary cancer are usually the presenting features , the presence of cardiac involvement is often only accidentally detected , prognosis is poor , and therapeutic options limited .
our patient also exhibited findings suggestive of myocardial ischemia with a previous episode of vt , but without pericardial effusion .
the explanations for the ecg findings are the probably occlusion of the circumflex epicardial artery by the neoplasm infiltration , tumor microembolization occluding minor branches of myocardial vessels , expression of myocardial lesions currents , or coronary artery disease ( cad ) causing myocardial infarction .
we could not exclude the presence of cad because the patient did not undergo coronary angiography mainly for ethical reasons .
however , considering the clinical context and the temporal duration of ecg alterations , the presence of cad was very unlikely . according to lim , previous vt episode
might also be related to focal myocardial ischemia , but we rather think that it is mainly due to spatial heterogeneity of refractoriness or localized conduction delay caused by direct invasion mass . after treatment with erlotinib , the patient showed a significant clinical improvement and we observed a reduction in lung carcinoma and myocardial involvement .
we conclude that the noninvasive strategy in this context was more suitable for patient s quality life .
noninvasive imaging methods are useful for evaluation of suspected cardiovascular complications of malignancy and to guide proper management of these patients .
 a 52-year - old woman with a lung carcinoma metastatic to bone was admitted to the cardiology department for acute chest pain after 1 week of the oncologic therapy . 
 electrocardiographic examination ( ecg ) revealed ischemic picture with st - t wave abnormalities in di and avl leads and poor progression of r wave in v1-v4 leads . 
 two- and three - dimensional transthoracic echocardiography ( 2d/3d tte ) showed myocardial involvement with infiltration of the anterolateral left ventricular ( lv ) wall from the epicardial to the endocardial layer , apical hypokinesia , lv ejection fraction ( lvef ) and global 3d longitudinal strain reduction , but was absent pericardial effusion . 
 three months from the beginning of erlotinib , the patient showed a significant reduction in myocardial involvement with no ecg - st elevation . 
 echo showed a mild regression of the wall infiltration and a slightly improvement of lvef and strain . 
 a computed tomography ( ct ) scan showed partial remission of the primary lung lesion , intracavitary and intramyocardial mass . 
INTRODUCTION
CASE HISTORY
DISCUSSION