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(Circulation. 2007;115:e320-e321.)
© 2007 American Heart Association, Inc.

Images in Cardiovascular Medicine

Infarction-Like Electrocardiographic Changes Due to a Myocardial Metastasis From a Primary Lung Cancer

Panagiotis Samaras, MD^*; Frank Stenner-Liewen, MD^*; Stefan Bauer, MD; Gerhard W. Goerres, MD; Lotta von Boehmer, MD; Nina Kotrubczik, MD; Rolf Jenni, MD; Christoph Renner, MD; Alexander Knuth, MD

From the Departments of Oncology (P.S., F.S.-L., S.B., L.v.B., N.K., C.R., A.K.), Radiology (G.W.G.), and Cardiology (R.J.), University Hospital Zurich, Zurich, Switzerland.

Correspondence to Panagiotis Samaras, MD, University Hospital Zurich, Department of Oncology, Ramistrasse 100, 8091 Zurich, Switzerland. E-mail Panagiotis.Samaras{at}usz.ch

A 69-year-old man (a heavy smoker) presented with chest pain and dyspnea that he had experienced for several days. The initial ECG revealed ST-segment elevations in the leads V2 through V5, suggesting an acute myocardial infarction (Figure 1A). Laboratory tests showed normal levels of creatine kinase and troponin T, but an elevated pro-brain natriuretic peptide (1895 ng/L; normal value for adult males is <227 ng/L). Chest radiography revealed a tumorous mass in the right upper lobe. A computed tomography scan demonstrated a lung tumor occluding the right main bronchus. In addition, a 3.7-cm, hypodense lesion was seen in the apical near-right ventricular myocardium, consistent with a metastasis (Figure 1A). Echocardiography confirmed a right ventricular mass filling the apex and one third of the right ventricle (Figure 2). Left ventricular function was unimpaired. The biplane ejection fraction was 65% (fractional shortening: 47%; left ventricular end-diastolic volume: 132 mL; left ventricular end-systolic volume: 29 mL; interventricular septum: 1.2 cm, akinetic; left ventricular posterior wall: 1.1 cm, contraction normal).

View larger version (125K): [in this window] [in a new window]   Figure 1. Metastatic growth and ECG changes. A, At diagnosis in January 2006, the myocardial metastasis had a diameter of 3.7 cm (arrow). ST-segment elevations were seen in chest leads V2 to V5. B, Three months later, in April 2006, the metastasis was 7 cm (arrow). The ST-segment elevations in leads V2 to V4 were more pronounced than in the initial ECG, and new elevations in V1 and V6 indicated growth of the metastasis.

View larger version (111K): [in this window] [in a new window]   Figure 2. The apical 4-chamber plane showed a right ventricular mass that was 5x3 cm in size (arrow). Left ventricular function was unimpaired, with a biplane ejection fraction of 65%.

By transbronchial biopsy, a squamous cell carcinoma was diagnosed. The respiratory symptoms resolved after an Ultraflex stent had been placed in the right main bronchus.

Three months after onset of chemotherapy with carboplatin and gemcitabine, the patient’s cancer progressed, with growth of the myocardial metastasis. In ECG, more pronounced ST-segment elevations and new elevations in leads V1 and V6 were detected (Figure 1B).

Chest pain and infarction-like ECG changes were associated with tumor in this case. Usually, myocardial metastases remain clinically unapparent and are only discovered at autopsy. Although acute myocardial infarction is the most frequent cause of ST-segment elevations, the possibility of a myocardial metastasis should be considered when electrocardiographic changes are seen in patients with malignancies.

	Acknowledgments

 
Disclosures

None.

	Footnotes

 
*The first 2 authors contributed equally to this work.

The online-only Data Supplement, consisting of a movie, is available with this article at http://circ.ahajournals.org/cgi/content/full/115/10/e320/DC1.

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Circulation 2007 115: 1177. [Full Text]

This Article Full Text (PDF) Data Supplement Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Samaras, P. Articles by Knuth, A. Search for Related Content PubMed PubMed Citation Articles by Samaras, P. Articles by Knuth, A. Related Collections Electrocardiology CT and MRI Echocardiography Acute myocardial infarction Related Article