clinical metastatic cancer to the...

CLINICAL PROGRESS

Metastatic Cancer to the HeartReview of the Literature and Report of 127 Cases

By STANLEY M. HANFLING, M.D.

METASTATIC caneer to the heart as-sumes greater diagnostic and therapeu-

tic importance as the incidence of cancer rises.The condition evidently was first described byBoneti in 1700.1 A report in the English lit-erature appeared in 1822 of a case of testicu-lar cancer with tumor filling the vena eavaand extending to the edge of the Eustachianvalve.2 Subsequent reports described metasta-ses to all parts of the heart from many typesof cancer arising from almost every organ ofthe body.3 8 Characteristically, authors nmen-tioned the paucity or coniplete absence ofsymptoms, often despite extensive involvementof the heart by tumor.The first correct antemortem diagnosis of

cancer in the heart was reported in 1913, butnlot until 1930 did reports of this nature ap-pear in the English literature.9 10 Compara-tively few articles have been written on treat-ment and the effects of treatment on caneermetastatic to the heart."1-'3

PathologyNeoplastic growths may involve any or all

parts of the heart. Most commonly, embolictumor cells reach the heart by a hematogenousroute entering the snialler coronary vesselsfrom which they invade the heart. More un-commonly, fibrin forms on tumor cells freedin the venous system, supporting the furthergrowth of tumor and resulting in a tumorthrombus that may extend into the heart

From the Department of Pathology, New YorkHospital, New York, N.Y.

Dr. Hanfling 's present address is Department ofMedicine, University of California Medical Center,San Francisco 22, Calif.

chambers. Tumors may also reaeh the heartby direct extension from an intrathoracie can-cer. Finally, tumor may reach the heart byretrograde flow through mediastinal andtracheobronchial lymphatic channels. Micro-scopically, the superficial lymph channels ofthe heart may be filled with malignant cells,14a finding known as carcinomatous lymphangi-tis.

Pathologically, heart metastases are usuallysmall, firm, and nodular, microscopically re-sembling the primary lesion. Necrosis is un-common. Leukemia usually causes diffuse andfocal infiltrations radiating around blood ves-sels; in the absence of invasion, leukemic cellsmiay nevertheless be seen in the lumen ofsmaller vessels. Emboli from cancers of dif-ferent origin may also be seen occasionlally inthe lumen of coronary vessels.15

Incidence and Data of Observed CasesThere has been a gradual rise in the inei-

deniee of cardiac metastases, probably becauseof the rising incidence of cancer itself in pa-tients living longer with their disease (table1). The incidence of metastatic cancer to theheart in patienits dying of cancer ranges from1.5 to 13.9 per cent, with a general increasein recent series.

ResultsThe New York Hospital is a private volul-

tary hospital. In the 7-year period, 1947through 1953, 2,652 autopsies were performed.Of these, 694 were deaths from cancer, includ-ing 169 cases of lymphoma, leukemia, andmyeloma. The 127 cases of metastatic cancerto the heart eonstituted an incidence of 4.8

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METASTATIC CANCER TO THE HEART

Table 1Incidence of Metastatic Cancer to the Heart (Collected Series)

Author andreference

Pic and Bret"'1{arrenstei n'Syminers19Morris19Burke4Lym burner'4Helwig"Pollia'Selmitkerl"Scott'Ritchie2HerbutalDimmette2"Prichard'DeLoaeh'Bisel'5Gassmane3

Percentage of heartmetastases

Year Total Cancer Heart Total Cancerreported cases cases metastases cases cases

18911908191719271934193419351936193719391941194219501951195319531955

665551553000

85501000

12,0003570

11,10030004050181543752547

7952

1708

298

327

1450

1082

640455

980340

4124

251995145-9

2919

11839353814613737

217

.29

.17

.17

.61

.90

.24

.531.061.30.87

2.113.45.3

.03

1.5

3.1

4.3)

2.0

10.9

5.58.4

13.912.1

per cent of all autopsies and 18.3 per cent ofdeaths from caneer. Of 525 deaths from vis-ceral and cutaneous cancers (ineluding braintumors), 61 showed gross nietastases to theheart (tables 2, 3, and 4). Of 169 cases oflymphoma, leukemia, and myelonia, 61 showednetastases to the heart, mostly microscopic(table 5).Of the 61 cases of gross metastases to the

heart from viseeral and cutaneous sources,metastases occurred to the pericardium in 36.myocardium and epicardium in 22, and peri-cardium and myocardium in 2. There was Itumor thrombosis. Most patients were in thesixth and seventh decades of life, although theage span was 6 to 83. There were 38 male and23 female patients in this series.Two cases showed no metastases elsewhere;

the heart was involved by direct extension.In a case of retroperitoneal fibroliposarcoma,the coronary arteries were involved by directextension of the tumor. The other was anadrenal cortical careinoma with tumor throin-bosis. All others showed metastatic foci else-where. Of concomitant metastases, lymphnodes, liver, and adrenal glands were each in-volved in over 50 per cent of cases, kidneyin over 33 per cent, pancreas in over 25 percent, and thyroid gland in 16 per cent.


Careinoma of the lung anid breast, lym-phoma, leukemia, and malignant melanon1aspread to the heart with great frequiency, al-though practically all cancers may involvethe heart.23 31-3 Of 74 cases of leukemia inthe present series, the heart was involved in46 per cent (table 5). Malignant melanomaalso has a tendency to in-vade the heart. Biselfound 15 cases of cardiac involvement in 34cases.29

Metastatic cancer to the heart is usually alate manifestationi of cancer and accompaniedby foci elsewhere, although. in rare cases, theheart is the sole imetastatic site.25' 34 In Mostinstanees the tumor is associated with primaryor secondary intrathoracie malignancy. DeLoach found this in 136 of 137 cases.28 Lym-burner14 found it in 88 per cent of his series.In the present series of 61, gross metastaticcancers to the heart, primary or secondarymalignancy occurred in 93 per cent. Polliaand Gogol2' concluded from similar findingsthat "the presence of primary or metastaticcancer of respiratory thoracic tissues shouldsuggest the possibility of involvement of theheart. "

SymptomatologyThe symptomatology of heart metastases is

variable, depending as much or more on loca-

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HANFLING.

Table 2Incidence of Cardiac Metastases from Cancer-(New York Hospital Data 1947-1953)

Table 3Incidence of Pericardtal Metastases from CanecerM(New York Hospital Da!ta 1947-1953)

Num

TotalType

Carcinoma of luntg 93Carcinoma of breast 24C(areinoma of stomnach 49Carcinoma of panereas 27Carcinonia of bladder 32MIalignant melanoma 9Si-te undeteralniied 6Mesothelioma of lung 2Undifferentiated sarcoiia 2

-Neuroblastoma 4Adrenal cortical

careinoma 1Careinioma of jejunum I,Ewing tuaior 1Fibrosarcoma of forearmii 1Retroperitoneal

fibroliposarcoma 1Carcinoma of gallbladdler 5Carcinoma of

extrahepatie duetst aCarcinoma of esophagus 16Carcinoma of kidney I15Careinioma of colon 45Carcinoma of ovary 28Other tumors 158

Total 525

nber of patientsNo. withcardiacinvolve-mentti Perce

8 343 133 343 52 I10

2 11 2

11I1

?ntage

!338L19,3

,iow0o

100100100100

1 10 0

1 20

1

1

I

20

6

74)

40

61 11.6

*Excluding lynmphoma, leukemia ai(lndiveloaua.tGross involvement only.TIncluding cancer of coinmoii bile dlucts.

tion than on size. Extensive involvement may

occur with few or 11o symptoms.Yater proposed a classification of the symp-

tomatology in 1931, dividing the synmptomsinto 2 groups: elinical types suggestive oftumors and types not suggestive (table 6).3

This classificationl does not stress tumor lo-lation that is responsible in large nmeasure forthe symptoms anid signis that develop. Theoutlines in tables 7 through 10 differ in em-

phasis and are suggested as a supplemuenit tothe Yater classification.

Pericardial InvolvementPericardial involvemenlt may occur alone or

may be associated with metastases elsewherein the heart (table 7). Mletastases arise from

Type Total

Carcinoma of lung 93Carcinionia of breast 24Careinoma of pancreas 27Carcinonma of bladder 32)Malignant melanoma 9Carcinoma of esophagus 16CCarcinoma of stomach 49Careinoma of jejunum ICarceiniomna of coloni 4a5Carcinoma of ovary 28Ewing tumor 1

Mesothelionia of lung 2Fibrosarcomia of forearm 1Sarcoma 2Undetermined site 6Other tumors 189

Total 525

Number of patientsNo. with

pericardialinvolve-menttr Pere

17t53

1

111 1I1

1 I

1

110

38

zentage

18-1

1116116

[00

4L0050L0050170

*Excluding lymphoma, leukemia and(l myeloma.fGross involvement only.tIneluding onie case involving myoca rdiuni.§ Involving myocardiunm also.

hematogenous or lymphatic dissemination oftunmor. Initrathoracie growths, usually carci-iionoa of the lung or breast or lymphoina, mayextend directly into the pericardium. Fromthe pericardium, the tumor may invade theepicardium, the myocardiumn, and occasionallythe endocardium.

There are usually no syimptoms of pericar-dial tumor.36 The most conmmon signs of peri-cardial metastases are pericarditis and peri-cardial effusion. The effusion may be serousor bloody. The diagnosis of metastatic peri-cardial tumor has been established in manycases by finding neoplastic cells in aspiratedpericardial fluid.37

Rarely, tumor involvement causes constric-tive pericarditis. Wallace and Logue35 report-ed a case of bronchogenie carcinoma with rightheart failure a prominent symptom. Electro-cardiographic tracings suggested chronic peri-carditis. At necropsy, there was extensiveinfiltration of the pericardium by firm, nodu-lar, tumor tissue which formed a mass 2.5 cm.


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Table 4Incidence of Myocardial (and Ep,icardial) Me-tastases from Cancer" (New York Hospital Data1947-1953)

Type Tota

Careinomna of lunig 93Carcinoma of breast 24Careinoma of stomiiachl 49Malignant melanomna 9Site undeterminied 6Cancer of kidney 15Carcinoma of

extrahepatic ducts 5Carcinoma of bladder 32Mesothelioma of lung 2Neuroblastoma 4Retroperitoneal

fibroliposarcomla 1Sarcoimia 2Careinomiia of gallbladder aOther tumors 278

Total

Number of patientsNo. with

myocardial and epi-cardialinvolve-

'I mentt Per(

5f+333++0

1

1111

1110

1

centage

5136

33933

7

20

509525

10050200

525 24 4.6

*Excluding lymphoma, leukeniia and myeloma.tGross metastases only.tIncludes 1 ease involving pericardium in additioni.

thick, completely encasing the heart. Slater etal.39 reported a case of constrictive pericardi-tis from metastatic breast cancer to the peri-cardium.

Pericarditis also suggests tumor. Smith40reported a case of a patient with malignianitmnelanomia with a pericardial friction rub atthe base of the heart. Along the right borderwas an area of increased density that extendedinto the pulmonary parenchyma. Necropsyrevealed extensive neoplastic infiltration ofthe pericardium. Levy4l diagnosed metastasison the basis of a pericardial friction rub withelectrocardiographic evidence of pericarditisin a patient with bronchogenic carcinoma.The electrocardiogram may be helpful in

demonstrating pericarditis, but as Lambertaand co-workers36 concluded, ". . . the electro-cardiographic changes illustrative of pericar-ditis are minimal in miialignianecv of thepericalrdiumn unless there is suifficientinivolvemlenit. '

Fischer42 mentionied that the introductioll of

Table 5Incidence of Infiltration in the Hear t fromsbLymphoma, Leukemia, and Myelomacz (New YorkHospital Data, 1947-1953)

Number of patientsNo. withinvolve-

Type Total ment Percentage

Leukeiniaf 74 34 46Lymphomas+ 85 27 32Multiple (plasma cell)myeloma 10 0 0Total 169 61 36

*Infiltration mainly microscopic.tIncludes acute and chronic myelogenous, moino-

cytic, and stem-cell leukemia.+Includes Hodgkin 's disease, mnalignant lymphoma

with leukemia, reticulum-cell sarcoma, and folliculartype lymphoma.

Five cases of cancer from visceral or cutaneoussources showed nmieroscopic metastases to the heart.

air into the pericardial sac has been recom-mended as an aid in delineating the presenceor absence of tuimor.

Epicardial and Myocardial InvolvementCancer cells reach the heart most often by

the hematogenous route (table 8). From thenyocardium, tumor mav spread to the peri-cardium and epicardium. Spread to them yocardiunir also occurs from retrogradelymphatic flow through bronchom-iediastina]lymphatic channiiels and from direct extensionifronm pericardial inetastases.

In the past, the low ineidence of canieer tothe heart has beeni explained on the theorythat the heart was not receptive to tumor cells.Prichard27 mentioned the kneading action ofthe muscle, the metabolic peculiarity of stri-ated muscle, alnd the rapid blood flow as fac-tors accounting for the low incidence. Laterauthors considered that the low incidencemore likely was a result of inadequate obser-vation, and Burnett and Shimkin43 concluded,"in tunmours that have spread beyond the lungand liver filters, there is almost an equal like-lihood of the thvroid, the adrenial gland andthe heart to be inivolved with mnetastases.'"Botlh sides of the heart appear to be affecte(dequally.

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HANFLING

Table 6Symptomatology of Heart Metasta.ses-Yater Clas-sification

Clinical types not suggestive of tumor to the heartAbseniee of synmptoms referrable to the lheartSymptoms of cardiac embarrassmeint terrminallySymptoms of congestive heart failureSudden deathSymptoms suggestive of subacute bacterial

endocarditis

Clinical types suggestive of tulmor of the heartHeart blockSymptoms referrable to location of the tunmor

other than heart blockSymptoms of cardiac dysfunction developing with-

out apparent cause in a patient with a know iinmalignant process

Accuniulation of henmorrhagic fluid, pericardial andepleural

Suggestive roentgen observations

tomatic. Symptoms may occur from encroach-ment on the pericardium, endocardium, oreonduction system by infiltration of cancer.In the latter instance, the arrhythnmias or ratechanges provide important clues for antemor-tem diagnosis. Doane and Pressman44 statedthat whenever the right heart is involved, theintervenltricular septum is likely to share inthe process and the conductioni systemn is aptto be embarrassed. Arrhythmias may occur,however, without septal invasion.Tumor nodules in the ventricular muscle

mass usually are asymptomatic and do notproduce any characteristic x-ray, fluoroseopie,or electrocardiographic signs. Atrial flutteror fibrillation may occur although the mech-anism is obscure.Depending on their location, tumors mnay

cause other symptoms and signs. Tumor en-boli occasionally plug a vessel and producecoronary insufficiency, angina peetoris, ormyocardial infaretion. Pilcher45 reported aease characterized by clinical electrocardio-graphic evidence of coronary thrombosis withencroachment or invasion of coronary vesselsby malignant tissue at niecropsy.

Metastases to the heamit imiay affect thle inus-cle sufficienitly to produce congestive failure.Scott anid Garvin23 concluded that the devel-opnment of congestive failure without appareint

Table 7Pericardial Tumor In rolvement

RouteHematogeinousDirect extensiont fromn intrathoracic nieoplasmiiSpread from mnyocardial and epicardial nietastasesRetrograde lymphatic spread fromn tracheal anfd

bronchomediastinal lymphatic chaninelsSymptoms and SignsNo clinical mainifestationsPericarditisPericardial effusion, serous oIr bloodyConstrictive pericarditis

DiagnosisAwareness of presence of intrathoracic nieoplasmnExaminationi of pericardial fluid for mialignant

cellsX-ray general enlargemnent of the heartFluoroscopy fixationi of the right border of the

heartlintroductioni of air inlto the pericardial sac to out-

liine nodulesTherapeutic test-irradiation of pericardium

cause in patiellts with malignanit diseaseraises the possibility of cardiac metastases.MeNamara and associates46 reported cardiacrupture from metastatic caneer in a patientwith rheumatic mitral disease. At necropsy,rupture of the posterior wall of the left atriumwas observed. No other case of cardiae rup-ture froin metastatie caneer has been reported.The electrocardiogram has been of some

help in the diagnosis of metastatic cancer tothe heart. Bisel et al.29 reported that eardiaemetastases may cause T-wave changes, S-Tdeviations, and Q waves. Rosenbaum's group47reported a case of esophageal cancer with per-sistent and pronounced upward displacementof the RS-T segment. Necropsy revealed ex-tensive infiltration of the heart by metastases.Siegel and Young48 reported a case of lympho-sarcoma with inverted T waves and isoelectricS-T segments in all leads. Necropsy revealedtumor in the veentricular wall and interven-tricular septuml. Electrocardiographic changesoccur witb leukemic infiltration usually whenclinical evi(leinee of involvement is presen-t.49Occasionally. the electrocardiogram may bethe first evidenee of nivoceardial infiltrationi.As wTith other eancers to the heart, there are110 diagnostic patterns.

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Table 8Epicardial and Myocardial Involvement

Routte

Hemriatogenous

R e t r o g r a d e f r om lymphatic-bronchomediastinalchannels

Extension fromii pericardial involvenient

Symptoms and SignsNo clinical mlanifestationsChanges in rate or rhythm

Unexplained tachyeardiaAtrial flutterAtrial fibrillationHeart block, complete or inicompleteAtrioventricular rhythmPremature beats

Electrocardiographic changesPersistent RS-t elevationPersistent T-wave inversionBuncdle-branch blocklow-voltage QRS

Sudden death (severe arrlhytlhmia, heart rupture)Congestive heart failureCoronary occlusionAngina pectoris

Diagnosis

Awa reniess

Unexplained arrlhythmia in patients with caneer

Unexplained electrocardiographic changes in pa-

tienits with cancer

The diagnosis of mnetastatic tumor in themyocardium has usually been made when an

arrhythmia develops in a patient with meta-static eancer elsewhere. The first correct ante-mortem diagnosis of myocardial mnetastaseswas reported by Rdsler in 1924.50 The patienthad metastatic cancer and developed a per-

sistent slow and regular cardiac rate of 26 to28 per minute, with an atrial rate of 108. Theauthor ascribed the phenomenon to tunmor in-volvement of the bundle, a diagnosis that was

confirmed at autopsy. In the English litera-ture, Willius and Amberg'0 reported the firstcorrect diagnosis, when incomplete bundle-branch block appeared in a patient with sar-

coma of the femur. Levy4l and Fishberg9 re-

ported patients with bronchogenie carcinioma;eanieer of the heart was suspeeted because ofonset of atrial fibrillationi, the findings were

coonfirmed at autopsy. Schniitker an-d Bailey=2diagonosed a case correctly beeause the "pres-Circulation, Volume XXII, September 1960

Table 9Endocardial Tumor lInvolvement

RouteHematogenous to chambers with direct implantationExtension fromti nmyocardial metastases

Symptoms and SignsNo clinical manifestationsMurmurs of stenosisSudden death

DiagnosisAwareness-development of a murmlurChaniginig mnurmur s witlh positionAngiocardiography

Table 10Chamber Involvemenet-Tumor Thrombosis

RouteRight heart

Inferior rena eava -> right atrium (hyperneph-roma, testicular tumors)

Superior rena eava -- right atrium (careinomuaof lunig)

Left heartPulmoniary vein-s left atrium (carcinoma of

lunig)Symptoms and SignsNo clinical manifestationsMurmurs of stenosisSoft heart sounids of poor qualitySuperior or inferior venia caval syndrome

DiagnosisAngiocardiography

ence of auricular flutter with the suspicioIn ofbronchogenic neoplasmn suggested that theremight be encroachment of tumor growth oiithe right auricle of the heart." Other caseshave been reported by Brick anid GreenfieldiShelburue and Aronison,13 anid Dresdale anldco-workers.32

Endocardial InvolvementNeoplastic implantation on the endocar-

dium is uncommnonl (table 9). Tumor embolireaching the heart chamnbers may implant onthe endocardiumn directly with "subsequentdevelopment in the direction of least resist-aiiee, i.e., out into the cavity and between thenuscular trabeculae. "51Coller and associates52 reported there were

only 9 cases of tumor depositioni oni the enido-cardimnu in the literature, of which 6 were iIm-

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4HANFLING

planted on the valves. He believed a certainamount of valvular dainage was necessary fortunlor implantationi to occur, for it seemedimprobable that tuLmor could implant oin anlintact cusp with smooth surface. The tricuspidvalve or the tricuspid and imitral valves mnay

be involved. Nieholls53 and Blumenthal andPeterson134 reported cases with attachment on

the surface of the right ventricle. MoragueS54reported a case of malignant melanonma im-planting in the region of the conus arteriosus.The growth, large and peduneulated, almostplugged the pulmoiiary orifice conmpletely.Watts55 reported a case in which an intracar-diae imetastasis probably arose by direct im-plantation on the wall of the right atrium.Ragle56 reported a somewhat similar case.

Most of the endocardial growths cause littledisability during life, and, like most meta-static canieer of the heart, are usually an un-

expeeted and incidental autopsy finding.Endocardial metastases muay also mimnic bac-terial enidocarditis.

Chamber Involvement-Tumor ThrombosisTumor muay invade the heart chambers

themselves (table 10) ; tumor cells that infil-trate the lumen of a great vein may initiatethe deposition of fibrin upon them. The fibrin,in turn, serves as a framework for continuedcancer growth. This "symbiosis" produces a

thrombus in which caneer cells are ali integralpart. The tumor thrombosis may extend alongthe vein to the heart chambers, hinderimigblood flow and effeetive cardiac action.Tumor thrombosis of the inferior vena eava

and right atriuni commonly oceurs from can-

eer of the kidney57-58 and testes and occasion-ally the liver,59 whereas growth into the supe-

rior vena eava producing tumor thrombosisto the right atrium oceurs from carcinoma ofthe lung,60 lymphosarcoma, aild caneer of thethyroid gland.6'-62 The left atrium may be in-vaded from extension of tumor thrombosis ofthe pulmonary veins, most comumonily resultinigfro.m careinoma of the lung.13 64 Primnarypulmonary sarcoina and osteogeinie sarcoma

muetastasiziiig to the heart by tum-Lor th-rombo-sis haave also beei reported.

Murmurs typical of stenosis may be causedby an intracardiae tumor and nmay changewith position. Pedunculated tumor masses maycause considerable interferenee with bloodflow through the heart. Linell65 reported acase of a patient with carcinoma of the larynx,with a rapidly deteriorating course. At nee-ropsy, a large antem-lortem clot was found inthe cardiac chambers. Upon removal, a pea-sized papillomatous mass was found project-inlg inlto the heart cavity from the endocardialwall. The author concluded that the patient'sterminal course was precipitated by throm-bus formation promoted by the endocardialtumor. The symptoms and signs of venousand intracardiae involvement are often mini-mal in relation to the extensive involvementseen. Intracardiac involvement may be maskedby superior or inferior vena eaval syndromes.Tumors may cause valvular murmurs prac-tically identical to those of established valvu-lar disease.Tumor thrombosis, like metastatic growths

elsewhere in the heart, may produce suddendeath. Culpepper and Von Haam59 reporteda case of carcinoma of the liver with suddendeath shown to have a tumor thrombosis ofthe inferior venia eava that protruded into theright atrium, which may have caused sudden-death by its ball-valve action. Angiographymay be valuable in delineating the presenceor abselnce of intracardiae tunmor muasses.

Treatment of Metastatic Cancer to the HeartThere have been only a few reports of treat-

ment of metastatic caneer to the heart, butsuccessful, though temporary relief, has beengiven with symptomeatic eancer of the heart.Blotner and Sosmnantm reported a case of leu-kemia with 2 :1 heart block, attributed to leu-kemic infiltration or a leukemic nodule in thebundle of His. X-ray therapy was followed bydisappearance of the block for a number ofdays, with temporary disappearance for asecond tinme after additionmal therapy.

Shelburne and AronIsonl13 reported an in-stanice where a patient with caneer developedheart block with a large pericardial effusion.As a result of deep x-ray therapy, the heart

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block disappeared and the effusion resolvedcompletely without discernible adverse effectson the heart. Hsiung 's group12 treated a pa-tient with metastatic tumor to the heart aindpericardiumn with x-ray and found evidence ofreduction in heart size and disappearance ofthe pericardial effusion. They concluded thatirradiation can also serve as a therapeutic testand substantiate the diagnosis of metastaticcancer to the heart, if the tumor is radioseln-sitive. Digitalis may control the arrhythmiasso produced, but in somie instances,18 it is in-effectual.

SummaryA review of the literature of metastatic

cancer to the heart is presented, and a newclassification offered.

Autopsy data of The New York Hospitalhave been analyzed. In the 7-vear period, 1947to 1953, in 694 deaths from calncer, an over-allincideniee of 18.3 per cent (127 eases) of nme-tastases to the heart was observed. In a groupof 169 cases of lynmphoma, leukemia, and mye-loma, there was an incidence of 36 per cent(61 cases) of metastases to the heart. In theremaining 525 cases, there was an incidenceeof 12.6 per cent (66 cases) of metastases tothe heart. In 61 of these, gross lesions werepresent, an incidence of 11.6 per cent (61cases) of gross metastases to the heart. Thesefigures are comparable to those reported inother series.

Summario in InterlinguaEs presentate un revista del litteratura de eanceres

metastasiate al corde. Un iiove classification es pro-ponite.Le protocollos autoptic del Hospital New York

esseva anialysate. In le eurso del 7 annos ab 1947.usque a 1953, le serie total de 694 ml-ortes ab eancere-revelava un incideintia de 127 casos (i.e. 18,3 procento) de mietastases al corde. In le subgruppo de169 casos de lymphomia, leucemia, e myeloma, iihabeva 61 nmetastases al corde, i.e. un incidentia de36 pro cento. In le remanente 525 casos del serietotal, 66 metastases al corde esseva nlotate, i.e. un

incidentia de 12,6 pro cento. In 61 de iste 66 mneta-stases, i.e. in 11,6 pr o eeato del del serie de 525easos, le lesiones cardiac esseva de importantia miiacro-scopic. Iste cifras e;, comparabile al cifras reportatepro altere series.


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geschwiilste. Prag. nmed. wvchnschr. 18: 121,1893.

2. COATES, B. H.: Case of a singular tumor withinthe vena cava and attached to the Eustachianvalve. Philadelphia J. M. & Phys. Soc. 4: 334,1822.

3. BRICK, I. B., AND GREENFIELD, M.: Reticulumcell sarcoma with cardiac metastasis; reportof two cases with antemortem diagnosis of one.Am. Heart J. 34: 599, 1947.

4. BURKE, E. M.: M-etastatic tumors of heart. Am.J. Cancer 20: 33, 1934.

5. CRISCITIELLO, M., JR.: Case of sarcomatous de-generation of uterine leiomyoma with metas-tases to lungs and heart. Am. J. Cancer 18:919, 1933.

6. LEPLACE, E., AND KARSNER, H. T.: Metastaticsarcoma of heart. Primary sarcoma of femuraind nietastatic sarcomiia of heart. Proe. Path.Soc., Philadelphia 14ns: 106, 1911.

7. NAKADA, J. R.: Primary careinomiia of adreinalswvitlh metastases in skin and iimyocardliiumii. J.Missouri M. A. 27: 367, 1930.

8. NUSBnAUM1, W. D., AND HEYER, F. W.: Carciniomamietastases to heart anid subeutaneous tissues.Am. J. Cancer 24: 831, 1935.

9. FiSHBaRG, A. M.: Auricular fibrillation anid flut-ter inl mietastatic growths of right auricle. Amii.J. M. Se. 180: 629, 1930.

10. WILLIUS, F. A., AND AmBERG, S.: Two cases ofsecondary tumor of heart in children, in oneof which diagnosis was made during life. M.Cliin. North America 13: 1307, 1930.

11. BLOTNER, H., AND SOSMAN, M. C.: X-ray therapyof heart inl patient with leukemia, hleart blockand hypertension; report of case. New Eng-land J. Med. 230: 793, 1944.

12. HSIUNG, S. C., SZUTU, C., HSIEH, C. K., AND LIEU,J. T.: Metastatic tumors of heart; report oftwo cases diagnosed clinically. Chinese M. J.57: 1, 1940.

13. SHELBURNE, S. A., AND ARONSON, H. S.: Tumorsof the heart; report of secondary tumor ofheart involving pericardium and bunidle of Hiswith remission following deep roentgen-raytherapy. Ainn. Int. Med. 14: 728, 1940.

14. LYMBURNER, R. M.: Tunlors of heart; histopath-ological and cliinical study. Caniad. M. A. J. 30:368, 1934.

15. LiSA, J. R., HIRSCHHORN, L., AND HART, C. A.:Tumnors of heart: Report of four cases; reviewof literature. Arch. IJut. Med. 67: 91, 1941.

16. PiC, A., AND BREET, J.: Canceer seconidaire du co-eur. Rev. de mdd. 11: 1322, 1891.

17. KARRENSTEIN: Eim Fall voni Fibroelastomiy-xoimdes Herzes unid Kasuiztisches zur Frage der

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Herzgeschwiilste besoniders der Myxoma. Vir-chow's Arch. f. path. anat. 194: 127, 1908.

18. SYMMERS, D.: The metastasis of tumors: A studyof 298 cases of malignant growth exhibitedamong 5155 autopsies at Bellevue Hospital.Am. J. M. Sc. 154: 223, 1917.

19. MORRIs, L. M.: Metastases to heart from malig-nant tumors. Am. Heart J. 3: 329, 1927.

20. HELWIG, F. C.: Tumors of heart. J. Kansas M.Soc. 36: 265, 1935.

21. POLLIA, J. A., AND GOGOL, L. J.: Some notes onmalignancies of heart. Am. J. Cancer 27: 329,1936.

22. SCHNITKER, M. A., AND BAILEY, 0. T.: Meta-static tumor of the heart a case diagnosedduring life. J.A.M.A. 108: 1787, 1937.

23. SCOTT, R. W., AND GARVIN, 0. F.: Tumors ofthe heart and pericardium. Am. Heart J. 17:431, 1939.

24. RITCHIE, G.: Metastatic tumors of myocardium:Review of 16 cases. Am. J. Path. 17: 483, 1941.

25. HERBUT, P. A., AND MAISEL, A. L.: Secondarytumiors of heart. Arch. Path. 34: 358, 194g.

2'6. DIMMETTE, R. M.: Antemiorteni diagnosis of sec-ondary tunmors of heart; report of four cases.U. S. Armed Forces M. J. 1: 750, 1950.

27. PRICHARD, R. W.: Tunmors of heart; review ofsubject and report of 150 cases. Am. J. Cancer27: 329, 1951.

28. DELOACH, J. F., AND HAYNES, J. N.: Secondarytumors of heart and pericardium; review ofsubject and report of 137 cases. Arch. Int.Med. 91: 224, 1953.

29. BISEL, H. F., WROBLEWSKI, F., AND LADUE, J. S.:Incidence and clinical manifestations of car-diac metastases. J.A.M.A. 153: 712, 1953.

30. GASSMAN, H. S., MEADOWS, S. R., JR., AND BAKER,L. A.: Metastatic tumors of the heart. Am. J.Med. 19: 357, 1955.

31. RAVEN, R. W.: Secondary malignant disease ofheart. Brit. J. Cancer 2: 1, 1948.

32. DIESDALE, 1). T., SPAIN, D., AND PEREZ- IN S, F.:Heart block and leukemic infiltrationi of inter-ventricular septum of heart. Amii. J. M.ed. 6:530, 1949.

33. KIRSCHBAUM, J. D., AND PREV-Ss, F. S.: Leu-kemia; clinical and pathologic stuidy of 1239fatal cases in series of 14,400 aecropsies. Arielb.JIt. Med. 71: 777, 1943.

34. BLUMENTHAL, J. S., AND PETERSON, H. W.: Meta-static careinonma of heart; report of sole metas-tases froull careiiionla of cecum diagniosedI)efore deatlh. Minnesota Med. 30: 860, 1947.

35. YATER, WV. M.: Tulnlors of heart and pericardiumn;pathology, syDmptomiiatology and report of 9eases. Archl. Int. Med. 48: 627, 1931.

3J6. IAMBERTA, F., NAREFF, M. S., AND SCHWAB, J.:Mfetastatic careiniomiia of pericardium. Dis.Clhest 19: 528, 1951.

37. HENINGER, B. R.: Cliinieal aspects of pericardialmetastasis. Alui. Int. Med. 7: 1359, 1934.

38. WALLACE, J. J., AND LOGUE, R. B.: Metastaticcarcinoma as cause of constrictive pericarditis;report of case. Ani. Heart J. 31: 223, 1946.

39. SLATER, S. R., KRooP, I. G., AND ZUCKERMAN, S.:Constrictive pericarditis caused by solitarym-etastatic careiinosis of pericardium and com-plicated by radiation fibrosis of mediastinum.Am. Heart J. 43: 401, 1952.

40. SMITH, D. S.: Neoplastic involvement of theheart-two cases diagnosed before deatlh.J.A.M.A. 109: 1192, 1937.

41. LEVY, T.: Metastatic malignancies involvinigheart. Postgrad. Med. 5: 407, 1949.

42. FISCHER, J. W.: Neoplastic involvement of peri-cardium producing syiidroile of constrictivepericarditis. Am. Heart J. 35: 813, 1948.

43. BI-RNETT, RB. C., AND SHIMKIN, M. B.: Secondarynieoplasms of heart. Arch. Int. Med. 93: 205,1954.

44. DOANE, J. C., AND PRESSMAN, R.: Antemortemdiagnosis of tumors of heart. Alm . J. M. SC.203: 520, 1942.

45. PILCHER, R. B.: Lymlphosarconma invading heart;report of 3 cases with aiutopsy findings. M. J.Australia 2: 366, 1950.

46. MCNAEMARA, W. L., DUCEY, E. F., AND BAKER,L. A.: Cardiac rupture associated with metas-tases to lieart from careinomla of duodeiium.AIu. Heart J. 13: 108, 1937.

47. ROSENBAUM, F., JOHNSTON, F. D., AND ALZAMORA,V. V.: Persistenit displacement of RS-T seg-meat in case of metastatic tumor of heart. Am.Heart J. 27: 667, 1944.

48. SIEGEL, AI. L., AND YOUNG, A. M.: Electrocardio-graphic findings in tumors of heart, with re-port of case. Am. Heart J. 8: 682, 1933.

49. ARoNsoN, S. F., AND LEROY, E.: Electrocar dio-graphic finidings in leukemia. Blood 2: 356,1947.

50. ROSLER, 0. A.: Vier selteiiere Herzbefunde; EinBeitrag zur Herzdiagliostik. Zentralbi. herz. n.gefasskr. 16: 261, 1924.

51. HEKTOEN, L.: Three specimens of tunmors ofheart: Metastatic carcinomatous nodule inmyocardium, imuplantation sarcoma of rightventricle, primnary round cell sarcoma of epi-cardiumn . Med. News, Philadelphia 63: 571,1893.

50. COLLER, F. C., INKLEY, J. J., AND MORAGUES, J.:Neoplastic endocardial implants; report ofcase. Amn. J. Clin. Patlh. 20: 159, 1950.

53. NICHOLLS, A. G.: Secondary careinoma implantedoni endocardium of right ventricle. Cainad. M.A. J. 17: 798, 1927.

54. MORAGUES, V.: Cardiac metastasis from malig-naint miielanoma; report of 4 cases. Am. HeartJ. 18: 579, 1939.

55. WATTS, R. W. E.: Testicular teratoma with e-


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tensive iiitracardiae metastases. Brit. Heart J.9: 175, 1947.

56. RAGLE, H. E.: Implantationi of careinoma cellson endocardium of right auricle; report of case.U. S. Nav. MI. Bull. 28: 613, 1930.

57. JUDD, E. S., AND SCHOOL, A. J.: Thromiibosis atideinbolism resulting fronm renal tumors. J.A.M.A.82: 75, 1924.

58. POLAYES, S. H., AND TAFT, H.: Case of liyper-nephromia with tuinor thrombosis of veiia eavaand heart. Am. J. Path. 7: 63, 1931.

59. CULPEPPER, A. L., AND VON HAAM, E.: Priniarycareinomia of liver with extensive metastasis toright heart anid tumnor-thrombosis of inferiorvena cava. Am. J. Cancer 21: 355, 1934.

60. CRUZ, P. T., AND STAMBAUGH, E. F.: Intracardiaeextension of bronchogenic carcinoma. Dis.Chest 29: 441, 1956.

61. HOLT, W. L., JR.: Extenisioni of mimaligInant tumiiorsof thyroid iiito great veins and right heart.J.A.M.A. 102: 1921, 1934.

62. JACOBI, MA., AND SELTZER, J.: C(ardiac metastasisfrom careinioma of thyroid. Am. Heart J. 12:473, 1936.

63. MCDONALD, W. S., JR., AND HEATHER, J. C.: Neo-plastic inivasioni of pulniioinary veinis andcl leftauriele. J. Patlh. & Bact. 48: 533, 1939.

64. MEAD, C. H.: Metastatic careinoma of heart see-ondary to primary carcinomiia of lungs. J. Tho-racic Surg. 2: 87, 1932.

65. LINELL, E. A.: Ail uiusual cause of deatlh frolmlcanieer. Brit. -M. J. 1: 872, 1922.

66. LAUtRAIN, A. R.: Intracardial tumuor cultur e ofosteogeniic sarcoama w ith fatal tumuor eml-bolisnm:Report of a case. AI11. J. Cliii. PathI. 27: 664,1957.

Austin FlintAustin Flint was born on October 20, 1812, at Petersham, Massachusetts, the fourth

in a succession of a medical ancestry, his father having been a surgeon. He was educatedat Amherst College and graduated at the age of 21 from the Harvard Medical School,where he had been influenced by teachers such as James Jackson, Sr., John C. Warren,and Jacob Bigelow. He praticed medicine in Boston and Northampton and later inBuffalo, and at the age of 32 was called to Chicago as Professor of Medical Theory andPractice at the Rush Medical College. He subsequently occupied iuany ilmlportant posi-tions including professorships at the University of Louisville, Buffalo Medical College,and New Orleans School of Medicine. In 1860 at the age of 48 he became Physician tothe Bellevue Hospital in New York City and Professor of the Principles and Practice ofMedicine. For 8 years he was simultaneously Professor of Pathology and PracticalMedicine in the Long Island College Hospital, until overwork forced hiiii to curtail hisactivities. He was a talented teacher and an ardent student of disease, addressing hisefforts particularly to the refinement of the diagnostic procedures of Auenbrugger andLaennee. His numerous publications were based on voluminous, handwritten memorandawhich are said to have comprised over 16,000 pages. Austin Flint is best rememaberedby the eponym which bears his naine "The Austin Flint Murmnur." This phenomenonwas first noted in 1860 and described in detail in 1862 in the publication "On CardiacMurmurs" that appeared in the American Joutrnal of Medical Sciences.

Austin Flint died on March 13, 1886, at the age of 74, of cerebral apoplexy and wasburied in Boston. His contemporary, Dr. Samuel D. Gross, paid the following tributeto him, "As a diagnostician in diseases of the chest he has few equals. Nor is this factat all surprising when we bear in miind the time and the immense labor which, from anearly period of his professional life, he has devoted to their investigation. I know of noone who is so well entitled as Austin Flint, Sr. to be regarded as the Americain Laennec."-EPITT0,

Circmlation, Volume XXII, September 496Q

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STANLEY M. HANFLINGMetastatic Cancer to the Heart: Review of the Literature and Report of 127 Cases

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