Asymptomatic Cardiac Metastasis in a Diagnosed Case of Squamous Cell Carcinoma of the Middle Third of Esophagus.

A lady walks in with complaints of dysphagia mostly to solids to begin with and gradually progressive to liquids requiring naso-gastric tube feeding, with history of vomiting after taking food and weight loss of 20kilograms over 2months. Upper gastrointestinal endoscopy showed an ulceroproliferative growth starting at 28cms from the central incisor and extending upto 36 cms with luminal compromise. Biopsy from the lesion was found to be moderately differentiated squamous cell carcinoma. As part of metastatic work-up a PET-CT (Figure 1 shows lesion in the left ventricle) was done which revealed a metabolically active lesion involving the lower third of esophagus and a metabolically active lesion in the wall of the left ventricle which was the only site of metastatic diseae(Figure 2. Maximum intensity projection). Further investigations were done for characterisation of the cardiac lesion. 2-D Echo cardiography was done and was normal with an ejection fraction of 60%. A cardiac MRI was done which showed a soft tissue mass in the wall of the left ventricle which was isointense with normal myocardium and hyperintense on double inversion recovery sequence which measured 3.2 x 3 cms with post contrast enhancement. She was planned for palliative radiotherapy. A total dose of 30Gy in 10 fractions over 2 weeks was delivered. She tolerated the treatment well with Grade I mucositis (as per RTOG grading) and on follow-up after 4 weeks she had 40% relief in dysphagia and could take semi-solid food with little difficulty.