Effective cardiac radiotherapy relieved life-threatening heart failure caused by advanced small cell lung cancer with cardiac metastasis: a case report

Introduction

Cardiac radiotherapy for radiation-sensitive cardiac tumor seems a reasonable treatment but is rarely used in clinical practice. Only few reports have described experiences in cardiac radiotherapy for cardiac tumors. Cardiac radiotherapy is far from a standard treatment in oncology. We report the first case of small cell lung cancer (SCLC) with life-threatening cardiac metastasis, complicated with both severe heart failure and hepatic failure, and were successfully relieved with cardiac radiotherapy.

Case presentation

A 64-year-old man had left upper lobe SCLC and neck lymph node metastasis, cT1N3M1b, stage IV. He received chemotherapy with etoposide and platinum for six cycles and palliative radiotherapy for better symptomatic control, and achieved partial remission. Two months after completion of six courses of chemotherapy, he developed productive cough, exertional dyspnea, orthopnea, and right upper quadrant pain. On physical examination, the vital signs were stable, and both legs were edematous. Laboratory examination revealed the following results: white blood cell count, 9,550/µL; hemoglobin level, 12.5g/dL; and platelet count, 57,000/µL; elevated serum aminotransferase (AST/ALT) level of 1,174/1,892 U/L; elevated total bilirubin level, 6.6 mg/dL; international normalized ratio, 1.63; elevated lactate dehydrogenase level, 1,271 U/L; blood urea nitrogen level, 55 mg/dL; creatinine level, 1.28 mg/dL; sodium, 118 mEq/L; potassium, 5.5 mEq/L; negative hepatitis A, B, and C markers; creatine kinase level, 112 U/L; troponin I level, 0.25 ng/mL; and B-type natriuretic peptide level, 781.4 pg/mL.

Abdominal sonography revealed no significant liver or biliary lesion. Chest CT revealed pericardial effusion with lobulated epicardial tumor, and progressive tumors in the mediastinum and left pulmonary hilum (Figure 1). Echocardiography revealed moderate pericardial effusion, with epicardial mass encasement all over the heart, and suspected myocardial invasion. The left ventricle ejection fraction was 63%, with constrictive effect on cardiac filling motion (Figure 2).

Figure 1 Chest CT image showing lobulated cardiac mass (arrows) with moderate pericardial effusion (asterisks), and mild bilateral pleural effusions.

Figure 2 Echocardiogram showing significant pericardial effusion (asterisks) and epicardial mass (arrows) encasement all over the heart, with suspected myocardial invasion, especially around the right ventricle.

Severe heart failure due to cardiac metastasis and pericardial effusion, followed by hepatic failure and pre-renal azotemia, was impressed. However, pericardiocentesis was contraindicated because of the high procedural risk, coagulopathy, and initially moderate amount effusion. Chemotherapy was also hampered because of poor liver function and performance status. Therefore, emergent palliative cardiac radiotherapy was given (24 Gy in 8 fractions, Figure 3). His liver function and pre-renal azotemia significantly improved soon after cardiac radiotherapy (Figure 4). Five days later, despite the improving clinical condition and liver functions, echocardiography showed progression of pericardial effusion to massive amount (Figures S1,S2), therefore pericardiocentesis was performed and drained 1,080 mL bloody effusion with cytology confirming SCLC.

Figure 3 The radiation treatment plan for patient with cardiac metastasis from SCLC. The calculated iso-dose distribution was presented. The 100% prescribed dose was shown as red line (24 Gy). SCLC, small cell lung cancer.

Figure 4 Trends of the liver and renal function data. Black arrow, cardiac radiotherapy on days 11–13 and days 16–20 (24 Gy in 8 fractions); dashed arrow, pericardiocentesis 1,080 mL on day 16. ALT, alanine aminotransferase; AST, aspartate aminotransferase; Cre, creatinine.

Figure S1 Echocardiogram revealing bulky cardiac metastasis from small cell lung cancer (18). Available online: http://www.asvide.com/article/view/24502

Figure S2 Explanation for the video. (A) First part (before cardiac radiotherapy): echocardiogram on long axis view, short axis view and 4 chamber view showed significant pericardial effusion and bulky epicardial mass encasement all over the heart, and with myocardial invasion around the right ventricle. The left ventricle ejection fraction was 63%, with constrictive effect on cardiac filling motion; (B) second part (five days after cardiac radiotherapy): echocardiogram 5 days after the beginning of cardiac radiotherapy (7 days after the first echocardiogram) showed progression of pericardial effusion to massive amount. Bulky cardiac metastasis especially around the right heart can be clearly delineated. Then pericardiocentesis was done at this day, and 1080ml bloody effusion was drained out; (C) third part (two weeks after cardiac radiotherapy): echocardiogram showed significant decreased size and thickness of the cardiac mass, and resolution of the pericardial effusion. The constrictive effect on heart chambers resolved and the diastolic function of heart also improved.

His exertional dyspnea and leg edema resolved, and follow-up echocardiography 2 weeks later revealed decreased size of the cardiac mass (Figures 5,S1,S2). He was discharged and lived at home for a short period. One month later, SCLC further progressed, and he expired in the hospice ward.

Figure 5 Echocardiogram 2 weeks after cardiac radiotherapy, showing the decreased size and thickness of the cardiac mass (arrows) and resolution of the pericardial effusion.

Discussion

The cardiac metastasis rate varies in different autopsy series and ranges from 2.7% to 25% in all patients with cancer (1,2). The tumors with the highest tendency of cardiac metastasis are melanoma, carcinomas of the breast and lung, and lymphoma (1). The parts of the heart involved in cardiac metastasis include the pericardium, myocardium, and endocardium, in the order of frequency (1,3).

Only about one-tenth of patients with autopsy-confirmed cardiac metastases presented with significant associated clinical symptoms before their deaths. Most cardiac metastases were small and clinically silent, some of which were masked by symptoms of diffuse tumor diseases (1).

Cardiac radiotherapy is overlooked and rarely used in clinical practice, probably because of the rarity of clinical evident cardiac tumors and for fear of cardiac toxicity from radiation. The first reported case of radiotherapy for cardiac metastasis could be traced back to the 1940s (2). Few case reports and small case series (Table 1) have described various cardiac tumors, and most of which showed symptomatic or image resolution after cardiac radiotherapy (4-13). Despite being unable to cure metastatic cancer, cardiac radiotherapy has beneficial effects on transient local tumor control, symptomatic relief, and may improve life quality.

Table 1 Summary of experiences in cardiac radiotherapy for cardiac tumors in published literature
Full table

Radiotherapy at the thoracic region has been reported to have several potential adverse effects on the heart, including pericarditis, pericardial effusion, coronary artery disease, heart failure, arrhythmia, and valvular disease (14). The risk is associated with the radiation dose, treatment duration, and radiation volume. Most cardiovascular complications are chronic, whereas acute complications of cardiac radiotherapy are uncommon (4-14). Recent literatures report acute cardiac toxicities as early as 1 month after radiation (15,16). Cuculich et al. also demonstrated cardiac radiation for ablation of ventricular tachycardia in five patients, with increased ventricular tachycardia episodes initially, and then became well controlled (17). However, in patients like our case, emergent radiation is still reasonable and necessary to stabilize the life-threatening condition. Therefore, the acute, subacute and chronic cardiac toxicities of radiation are of lesser importance.

Conclusions

In our case, cardiac metastasis from SCLC showed an immediately marked response to cardiac radiotherapy. This palliative treatment effectively relieved multi-organ failure, decreased the cardiac tumor burden, and also improved quality of life. We suggest that cardiac radiotherapy could be an effective and, at least in short-term, safe palliative treatment for radiosensitive malignancy with cardiac metastasis, especially in life-threatening conditions.

Acknowledgements

None.

Footnote

Conflicts of Interest: The authors have no conflicts of interest to declare.

Informed Consent: Written informed consent was obtained from the patient’s relative for publication of this manuscript and any accompanying images

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