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Arch Ophthalmol. 1999;117:1558-1559.

We report a rare occurrence of cardiac metastasis from uveal melanoma.

Report of a Case
A 74-year-old woman had decreased vision in the left eye. On examination, she was found to have a pigmented choroidal lesion in the superior fundus that measured 11 x 11 mm at the base and 6.2 mm in height. The diagnosis was a medium-sized choroidal melanoma (Figure 1). The patient entered the Collaborative Ocular Melanoma Study and received sodium iodide I 125 brachytherapy in October 1987. Eight years and 9 months later, the patient complained of dizziness, was examined, and was found to have a left ventricular mass (Figure 2). She underwent an excisional biopsy, but died the following day of a ruptured myocardium. Microscopic examination of the excised tissue revealed pigmented cells invading the myocardium consistent with metastatic choroidal melanoma (Figure 3).

View larger version (17K): [in this window] [in a new window] Figure 1. Left fundus photograph of a medium-sized choroidal melanoma.

View larger version (31K): [in this window] [in a new window] Figure 2. Echocardiogram showing a left ventricular mass.

View larger version (107K): [in this window] [in a new window] Figure 3. Photomicrograph of the cardiac biopsy. Note the pigmented melanoma cells (arrow) invading the myocardium (hematoxylin-eosin, original magnification x10).

Comment
The metastatic patterns of choroidal melanoma have been well described.^1-3 The most common sites of metastasis are the liver, lung, skin, and bone. Less common sites are the central nervous system, thyroid, breast, ovary, adrenal gland, and contralateral orbit. No reported cardiac metastases of choroidal melanoma were found on a careful review of the literature.

The heart is an uncommon site of metastatic tumor. Explanations for this include the relative avascularity of the endocardium, vigorous kneading action of the myocardium, the rapid blood flow through the heart, and the paucity of lymphatic communications between the heart and surrounding tissues.⁴ In a review by Karwinski and Svendsen⁵ of more than 2800 autopsies on patients with malignant tumors, 130 (5%) of the patients had cardiac metastases. In these 130 cases, the most common primary tumors were lung (46%), cutaneous melanoma (10%), and breast (8%). There were no cases of uveal melanoma. Of the patients with cardiac metastases, most had metastatic disease elsewhere.

It is interesting that cutaneous melanoma has one of the highest rates of cardiac metastases,^4-5 while cardiac metastasis from uveal melanoma is extremely rare. Most cardiac metastases are in the myocardium, which would suggest a blood borne route. The reason for this is unclear. The high rate of cardiac metastasis with cutaneous melanoma may reflect the tumor's propensity toward widespread metastases, or the fact that cutaneous melanoma cells have a higher affinity for cardiac tissue as compared with uveal melanoma cells.

Patients with clinically recognized metastatic choroidal melanoma may also have widespread, asymptomatic, undetected micrometastatic disease. In the absence of an autopsy, such may have existed in this case.

AUTHOR INFORMATION

Richard S. Ruiz, MD; Sherif El-Harazi, MD; Daniel M. Albert, MD, MS; Paul J. Bryar, MD
Madison, Wis

Corresponding author: Daniel M. Albert, MD, MS, Department of Ophthalmology and Visual Sciences, University of Wisconsin–Madison Medical School, F4/336 Clinical Science Center, 600 Highland Ave, Madison, WI 53792-3220 (e-mail: albert{at}eyesee.ophth.wisc.edu).

REFERENCES
1. Rajpal S, Moore R, Karakousis CP. Survival in metastatic ocular melanoma. Cancer. 1983;52:334-336. FULL TEXT | ISI | PUBMED 2. Zimmerman LE, McLean IW. Metastatic disease from untreated uveal melanomas. Am J Ophthalmol. 1979;88:524-534. ISI | PUBMED 3. Char DH. Metastatic choroidal melanoma. Am J Ophthalmol.1978; 86:76-80. 4. Kapoor AS. Cardiac metastasis. In: Kapoor AS, ed. Cancer and the Heart. New York, NY: Springer-Verlag; 1986:76-81. 5. Karwinski B, Svendsen E. Trends in cardiac metastasis. APMIS. 1989;97:1018-1024. ISI | PUBMED

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