ATRIAL FLUTTER REVEALS THE DIAGNOSIS OF METASTATIC MELANOMA: A CASE REPORT

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Melanoma is the most frequent and severe form of skin cancer. In the United States, it is the fifth most common cancer in men and women, and its incidence increases with age. A diagnosis of cardiac involvement before death is infrequent, with few patients with melanoma presenting with cardiac symptoms. Here, we present a case of metastatic melanoma involving the heart as the first manifestation of the disease. CASE PRESENTATION: A 61-year-old male patient previously healthy presented to the emergency department with weakness. He had tachycardia of 180 beats per minute with normal blood pressure, and his EKG revealed atrial flutter. He was started on IV diltiazem drip, and transthoracic echocardiography demonstrated two distinct hyperechoic masses within the left ventricle. The masses measured 1.2×0.74 cm and 3×1.4 cm, respectively. The right ventricle showed a mass of 1.1×1 cm as well (Panel-A). The masses suggested possible metastatic disease. Chest radiograph showed lung nodules. A chest/abdomen/pelvis CT showed diffuse metastatic disease to the lung, liver, spleen, mesentery, erosive changes in the left scapula with a large left scapular mass, and hypoattenuating masses within the left ventricle (Panel-B, C). The patient had a biopsy from the left shoulder mass and confirmed the diagnosis of metastatic melanoma positive for BRAF V600E (Panel-D). The patient opted for comfort care after the oncology team discussed several treatment options with him. DISCUSSION: The heart's involvement by melanoma is not a common presentation, and it may go undetected. Glancy et al. reviewed autopsies of 70 patients with melanoma and demonstrated that cardiac metastases occurred in up to 65%[1]. In general, cardiac metastasis is unusual and has been described in <10% of melanoma cases. The reason that cardiac metastasis is not common is that most patients lack cardiac symptoms. Few patients present with cardiac symptoms that reveal the diagnosis of metastatic melanoma, like our patient who developed atrial flutter, which was the reason for initiating the workup. The prognosis of melanoma, once it metastasizes, is poor. BRAF gene mutations are found in half of the melanoma cases; therefore, all patients diagnosed with metastatic melanoma should be evaluated for a V600 BRAF mutation[2]. Immunotherapy is also an important systemic treatment modality for metastatic melanoma with a better outcome[3]. CONCLUSIONS: Metastatic melanoma to the heart is not uncommon; however, few patients present with cardiac symptoms that reveal the diagnosis of the disease. REFERENCE #1: Glancy DL, Roberts WC. The heart in malignant melanoma: a study of 70 autopsy cases. The American journal of cardiology. 1968;21(4):555-71.2. Ascierto PA, Kirkwood JM, Grob J-J, Simeone E, Grimaldi AM, Maio M, et al. The role of BRAF V600 mutation in melanoma. Journal of translational medicine. 2012;10(1):1-9.3. Hiniker SM, Reddy SA, Maecker HT, Subrahmanyam PB, Rosenberg-Hasson Y, Swetter SM, et al. A prospective clinical trial combining radiation therapy with systemic immunotherapy in metastatic melanoma. International Journal of Radiation Oncology* Biology* Physics. 2016;96(3):578-88. REFERENCE #2: Ascierto PA, Kirkwood JM, Grob J-J, Simeone E, Grimaldi AM, Maio M, et al. The role of BRAF V600 mutation in melanoma. Journal of translational medicine. 2012;10(1):1-9. REFERENCE #3: Hiniker SM, Reddy SA, Maecker HT, Subrahmanyam PB, Rosenberg-Hasson Y, Swetter SM, et al. A prospective clinical trial combining radiation therapy with systemic immunotherapy in metastatic melanoma. International Journal of Radiation Oncology* Biology* Physics. 2016;96(3):578-88. DISCLOSURES: No relevant relationships by Mostafa Abohelwa, source=Web Response No relevant relationships by Monica Botros, source=Web Response No relevant relationships by Gaspar Del Rio-Pertuz, source=Web Response No relevant relationships by Mohamed Elmassry, source=Web Response No relevant relationships by Peter Khalil, source=Web Response No relevant relationships by Sima Shahbandar, source=Web Response No relevant relationships by Victor Test, source=Web Response