Sarcoma - Metastases to the Heart

Although heart metastases are identified in 25% of people who die of cancer, detection and diagnoses of heart metastases in living patients are surprisingly low (1% of pediatric sarcoma patients). We wanted to share this information because although most cancer patients feel as if they are having frequent tests and imaging to look for new signs of cancer, cardiac metastases are commonly missed when standard studies only include conventional CT, MRI, and PET scans.

Tumors in the heart can come from neighboring lung metastases that travel up through the lung vessels in to the heart, direct extension from metastases in the lung, or from mets that arrive from the bloodstream.

If you have a met to the heart, you want to have it surgically removed as soon as safely possible because it can become deadly whether your cancer responds well to treatment or not. If the tumor invades the heart, then it can cause the heart to stop pumping well; but other causes of mischief include obstructing blood flow into or out of the heart, or breaking off and forming metastases to other parts of the body like the brain.

We wanted to post about heart metastases because we found out about them only because our dd was on a Phase I / II trial that required an ECHO.  The mass was seen on ECHO - and although it was about the size of a golf ball, it didn't block any of the valves - and there were no changes in EKG or abnormal sounds that the cardiologist could hear. The important point is your doctor should have a high index of suspicion to find these - and the screening study is likely to be an ECHO. We had been watching our dd's lung mets - and thought these were still fairly far (1-2 cm) from the main pulmonary vessels by chest CT - but when we didn't know is that they can sneak into small pulmonary veins that aren't well seen on chest CTs (the resolution is too small) and travel into the heart. On Chest CT the heart is bright white - so intracardiac tumors can't be seen.

Recently we heard that young woman with cardiac tumors seemed to be responding to a promising clinical trials medication, but she unexpectedly died. The problem with medical treatments and cardiac tumors is that even when a cancer responds to treatment, a tumor in the heart can be just as deadly.

Our dd had open heart surgery a few weeks ago and the tumor was removed. The surgery was surprisingly quick (13 minutes on cardiac bypass) and her recovery was quick too (discharged on the 3rd day of after the operation). She was able to be back at school in less than 2 weeks and required no pain medication by then. Her recovery was much quicker than when she had a thoracotomy. As tough as it is to face difficult news such as a heart metastasis, the earlier diagnosis the better - and surgery can be effective.

Metastases to the heart
Management of intraatrial lung tumors
Cardiac metastases in soft tissue sarcomas

CureASPS.org - Resources and Discussion Forum for Alveolar Soft Part Sarcoma

CureASPS.org is the definite site for information about Alveolar Soft Part Sarcoma on the Web. Look their library of resources for recent articles about new clinical trials drugs and new surgical and minimally invasive treatments for this cancer.

Alveolar soft part sarcoma is an early metastasizing cancer that affects mostly children and young adults. No definite cure is known, but many promising therapies have been discovered and some 15+ year survivors are members of the CureASPS.org community.

Additional Minimally-Invasive Options for Sarcoma - Cryoablation and RFA

Another quick update for those of you with metastatic sarcoma.

Our daughter is 2 years out from laser surgery on on the right, and 1 year out from laser surgery on the left. Some small nodules have appeared in the intervening times - this is a difficult aspect of determining the timing of metastasectomy and probably why so many people have to have repeated lung surgeries. Because metastasectomies seem to slow the progress of disease there is always a difficulty determining when to operate - you want to operate to slow the disease, but you don't want to operate too early because new mets appear and then you have to operate again. A second surgery is always more difficult than the first - because of scarring from the previous surgery that may make the procedure longer (need to release the adhesions) and also the greater difficulty feeling for the mets. Usually the mets will have to be larger for a second surgery, but if you wait too long, the mets may also become inoperable.

We are currently considering cryoablation at least on one side. There was a small nodule missed on our daughter's surgery on the left, and that nodule has been slowly increasing over the past year. The main danger of these tumors is if they press on a major airway. Also it adds to the overall tumor burden which may make it more difficult for patients to respond to medications. One of the world's experts is Dr. Peter Littrup: http://www.karmanos.org/app.asp?id=1117

The best candidates for cryoablation are those with fewer rather than many lung mets. It is best for the mets to be smaller than 3 cm for a complete ablation, although potentially if something regrows, it can be ablated again. We were told the reason multiple tumors aren't done is that when the lung recovers from the ablation, revascularization in the area could make the other tumors grow more quickly. It seems that it makes more sense that metastatsectomy comes first to reduce the numbers of multiple tumors, and then for additional tumors that either got missed or appear, they can be removed by cryoablation. At least one sarcoma doc told us that because lung blood vessels are terminal - they don't tend to form distal metastases...that means they are unlikely to 'break off' and go to other parts of the body.

Usually these procedures are covered by insurance, but they may require pre-authorization. Radiofrequency ablation or RFA can also be performed for lung, but from what I've read, it can be harder to perform because the burn zone can't be easily visualized by CT (by cryoablation you can see the 'ice ball') and the great vessels can pull away the heat. RFA is a great option for liver mets though (http://www.medicinenet.com/radiofrequency_ablation/article.htm).

Whether a met or group of mets can be treated by cryoablation completely depends upon the appearance of the scan (the doctor will look at size and location etc.), so scans need to be sent to the doctor who is considering ablation. Usually the procedure takes about an hour or less, no ICU time afterward, small incision, and home the next day. No flying for 1 week due to the risk of pneumothorax. The most common complication is a pneumothorax, especially if a patient hasn't had a prior surgery before.

Hope that helps!