Cardiac metastasis of malignant melanoma: a case report
A 42-year-old Caucasian woman, who had lived in Africa for 3 years, presented herself in the Emergency Department. She reported shortness of breath on mild exertion during the last few weeks, a swollen face, abdominal pain and oedema in the legs.\nHer medical history disclosed a malignant melanoma on the right shoulder 4 years earlier. The tumour had a Breslow thickness of 5 mm (Clark level 5 with satellite lesions) and was radically excised and consequently re-excised with a margin of 2 cm. During re-excision a sentinel node procedure was performed without metastasis. An enlarged lymph node was noticed at the right side of the neck during follow-up, which contained melanoma cells at cytological examination. Since no dissemination could be demonstrated elsewhere, a lymph node dissection of the right neck (level 2a, 3, 4 and 5) was performed 11 months after the first excision. One lymph node tested positive for metastatic melanoma. She had been free of symptoms since the dissection.\nPhysical examination of the lungs was unremarkable. Heart sounds were muffled, without murmurs. Extremities showed a normal arterial circulation; however, both ankles demonstrated oedema. There were no signs of ascites or splenohepatomegaly. The most remarkable laboratory examinations were a haemoglobin level of 6.2 mmol/l (normal: 7.5–10.0 mmol/l), thrombocyte count of 59 × 109/l (normal: 150–400 × 109/l) and lactate dehydrogenase level of 1,393 U/l (normal: <450 U/l).\nAbdominal ultrasonography showed a mass in the right lower abdomen, ascites, three masses in the liver and lymphadenopathy around the portal vein. CT of neck and thorax revealed a large inhomogeneously enhancing mass within the right cardiac atrium measuring 7.5 × 6.5 cm (Fig. ). The mass protruded into the right ventricle and into the superior caval vein and showed signs of vascularisation. There was a large amount of pericardial and pleural effusion. CT of the abdomen demonstrated a mass in the right ovary and confirmed the other abnormalities demonstrated on ultrasound. It was concluded that the patient was suffering from metastases of the melanoma or from a primary gynaecological neoplasm. Diagnostic biopsy of the right adnex confirmed metastatic melanoma.\nDue to cardiac tamponade, ultrasound-guided pericardial drainage was performed and resulted in evacuation of 700 cc of clear yellow fluid. Immunohistochemistry showed the presence of macrophages; however, malignant cells were not found. After drainage, ECG-triggered magnetic resonance imaging (MRI) of the heart was performed to characterise the cardiac mass. The intra-atrial mass showed a relatively high signal intensity on the T1 weighted black-blood images and after the injection of gadolinium contrast agent, the intra-atrial mass showed inhomogeneous enhancement. There was a large amount of pleural effusion but no residual pericardial effusion (Fig. ) The MRI image was highly suggestive for intracardial metastasis of the melanoma due to melanotic signal intensity on T1-weigthed images.\nBoth surgery and systemic chemotherapy were considered not achievable due to the severe, worsening, condition of this patient. Therefore, palliative sedation was started and patient died 23 days after initial presentation. Autopsy was not performed.