A rare presentation of acute heart failure secondary to aggressive uterine leiomyosarcoma metastatic to the myocardium initially diagnosed as hypertrophic obstructive cardiomyopathy

Abstract

Uterine sarcoma is the cause of 3-9% of all uterine malignant neoplasms and has a 2-fold higher incidence in black women as compared to white women. Cellular atypia and abundant mitoses (≥10 per 10 high power fields) as seen in this patient are associated with an increased risk for metastases. Metastases to the heart are infrequently reported with a handful of cases in the literature. We present a case of a 51-year-old woman with aggressively metastatic uterine leiomyosarcoma causing acute heart failure 4 months after initial presentation.

Multimodality Cardiac Imaging Assessment of a Large Metastatic Pericardial Leiomyosarcoma

“… 10 , 11 Four cases were diagnosed by echocardiography, and congestive heart failure was the most common presentation. 3 , 5 , 12 Prior case reports demonstrated that metastatic deposits can be found in various cardiac chambers and valves, but none reported pericardial metastatic involvement by leiomyosarcoma: three cases reported metastatic deposits in the left atrium, 3 , 5 , 6 two involving the right atrium, 7 , 8 two with right ventricular involvement, 11 , 13 two cases demonstrated left ventricular involvement, 12 , 14 and one report each demonstrating mitral 15 and tricuspid valve 9 involvement, respectively. In general, tumors may spread to the heart and pericardium by one of four pathways: (1) retrograde lymphatic extension, (2) hematogenous spread, (3) direct contiguous extension, and (4) transvenous extension.…”

Right ventricular outflow tract obstruction due to a leiomyosarcoma

“…Uterine leiomyosarcomas are rare with an incidence of 0.36 per 100,000 woman-years in the USA, accounting for 3–9% of all uterine malignant neoplasms. [ 1 ] Cardiac metastases from uterine leiomyosarcoma have been infrequently reported with only a handful of cases in literature. [ 1 ] This unique pathology behaves in an unpredictable fashion from the disease progression to presenting symptomatology.…”

“…[ 1 ] Cardiac metastases from uterine leiomyosarcoma have been infrequently reported with only a handful of cases in literature. [ 1 ] This unique pathology behaves in an unpredictable fashion from the disease progression to presenting symptomatology. [ 2 ] In our patient, her cardiac symptoms preceded uterine symptoms, as she was unaware of the primary endometrial leiomyosarcoma lesion.…”

“…Transesophageal echocardiography is considered the best form of imaging due to the superior resolution and the spatial location to the cardiac chambers. [ 1 3 ] Cardiac magnetic resonance imaging (MRI) and CT are also used as noninvasive modalities to assess this cardiac tumor, with MRI being slightly superior as it can help determine the type of tumor. If there is concern for metastatic spread when a primary tumor is established, a positron emission tomography (PET) has also been useful.…”

“…Other invasive modalities include coronary angiography and transvenous biopsy. [ 1 ] When complete resection is feasible, surgical excision can be used to provide symptomatic palliation and alleviate potential acute life-threatening cardiac events. [ 3 4 ] In our patient, surgical removal of the cardiac mass was successful with a resolution of her symptoms.…”