Myocardial metastasis from ZEB1- and TWIST-positive spindle cell carcinoma of the esophagus: A case report

Our plain-English summary of Myocardial metastasis from ZEB1- and TWIST-positive spindle cell carcinoma of the esophagus: A case report, by Y. Shibata, H. Ohmura, K. Komatsu, et al (World Journal of Gastroenterology, 2024).

The study

• Authors: Y. Shibata, H. Ohmura, K. Komatsu, K. Sagara, A. Matsuyama, R. Nakano, E. Baba
• Journal: World Journal of Gastroenterology
• Published: 2024;30(11):1636-1643
• Type of article: Case report
• Cited by: 4 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Metastatic cardiac tumors are known to occur more frequently than primary cardiac tumors, however, they often remain asymptomatic and are commonly discovered on autopsy. Malignant tumors with a relatively high frequency of cardiac metastasis include mesothelioma, melanoma, lung cancer, and breast cancer, whereas reports of esophageal cancer with cardiac metastasis are rare.

Case Summary: The case of a 60-year-old man who complained of dysphagia is presented. Upper gastrointestinal endoscopy showed a submucosal tumor-like elevated lesion in the esophagus causing stenosis. Contrast-enhanced computed tomography showed left atrial compression due to the esophageal tumor, multiple liver and lung metastases, and a left pleural effusion. Pathological examination of a biopsy specimen from the esophageal tumor showed spindle-shaped cells, raising suspicion of esophageal sarcoma. The disease progressed rapidly, and systemic chemotherapy was deemed necessary, however, due to his poor general condition, administration of cytotoxic agents was considered difficult. Given his high Combined Positive Score, nivolumab was administered, however, the patient soon died from the disease. The autopsy confirmed spindle cell carcinoma (SCC) of the esophagus and cardiac metastasis with similar histological features. Cancer stem cell markers, ZEB1 and TWIST, were positive in both the primary tumor and the cardiac metastasis.

Conclusion: To the best of our knowledge, there have been no prior reports of cardiac metastasis of esophageal SCC. This case highlights our experience with a patient with esophageal SCC who progressed rapidly and died from the disease, with the autopsy examination showing cardiac metastasis.

©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.

In plain English

This is a case report from Japan about one 60-year-old man with spindle cell carcinoma, a rare esophageal cancer. It does not study asbestos. The patient had difficulty swallowing and left chest pain. CT showed multiple liver and lung metastases and fluid around the left lung. The case text says CT showed the tumor invading the left atrium, but the CT figure caption describes compression, heart ultrasound found no invasion, and the authors later stated direct invasion was absent. Biopsies showed spindle-shaped cells, which raised suspicion of sarcoma. The patient was too weak for systemic chemotherapy; with a Combined Positive Score of 10 or higher, nivolumab immunotherapy was started. The patient died the same day. The autopsy diagnosed spindle cell squamous cell carcinoma of the esophagus. It found heart-muscle metastases, including a 15 mm by 12 mm left ventricle nodule, microscopically similar to the esophageal tumor. Both the esophageal tumor and heart metastasis tested positive for ZEB1 and TWIST. Death was ascribed to tumor metastases in many organs. The authors concluded this was the first reported heart-muscle metastasis from this tumor type.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Case report (single patient, including autopsy findings)
• Who was studied: One 60-year-old man admitted to a hospital in Fukuoka, Japan, with difficulty swallowing and left chest pain
• Main results:
  • On contrast-enhanced CT, the patient had multiple liver and lung metastases and a left pleural effusion. The case text also describes the esophageal tumor as invading the left atrium.
  • The CT figure caption describes the esophageal tumor as compressing the left atrium, rather than invading it.
  • Cardiac ultrasound showed a tumorous lesion behind the left atrium but no invasion into the heart and no tumor within the heart muscle.
  • The patient's first biopsy showed spindle cells that were positive for the marker vimentin and negative for epithelial markers. This led to suspicion of esophageal sarcoma.
  • The patient's programmed death-ligand 1 Combined Positive Score was 10 or higher.
  • Systemic chemotherapy was considered but judged infeasible because of the patient's poor general condition.
  • On the day nivolumab was given, the patient lost consciousness, then had respiratory and cardiac arrest and died.
  • At autopsy, the patient was diagnosed with spindle cell squamous cell carcinoma arising from esophageal squamous cell carcinoma.
  • The autopsy found a 15 mm by 12 mm nodule in the left ventricular lateral wall, plus microscopic metastases in other parts of the heart wall and septum.
  • Under the microscope, the primary esophageal tumor and the metastases showed no major difference.
  • The cancer stem cell markers ZEB1 and TWIST were positive in both the primary esophageal tumor and the heart metastasis.
  • Death was ascribed to tumor metastases in many organs. Respiratory failure from the pleural effusion was considered a possible contributing cause.
  • The authors stated that direct invasion and pericardial metastasis were absent, so they presumed the heart-muscle metastasis spread through the blood.
  • In the authors' view, the heart-muscle metastasis did not appear to cause symptoms or affect the outcome.
• The authors' conclusion: The authors concluded that this was the first reported case of heart-muscle metastasis from ZEB1- and TWIST-positive esophageal spindle cell carcinoma, and that the report characterizes its immunohistochemical profile.
• Limitations the authors state:
  • The authors noted that death on the day nivolumab was given raises the possibility of a drug-related event. They argued the autopsy findings support cancer as the cause.
  • The patient died before any response to treatment could be assessed.
  • Only a small part of the tumor showed the epithelial marker AE1/AE3. The authors said this suggests a definitive diagnosis was difficult to make from a biopsy.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Lung cancer, Throat and laryngeal cancer.

Medical terms in this study, explained in our Lexicon: Metastasis, Spindle Cell, Carcinoma, Autopsy, Mesothelioma, Lung Cancer, Esophageal Cancer, Dysphagia.

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