ILLUSTRATIVE CASE

An asymptomatic 38-year-old woman collapsed and died while watching television. At autopsy, metastases from malignant melanoma riddled many body parts, especially the heart (image). Black tumor nodules peppered the pericardium and endocardium and replaced much of the myocardiumhence the term, charcoal heart.1,2 There was no evidence of pulmonary thromboemboli, infection, or blood loss. Her sudden death presumably resulted from an arrhythmia. The site of the primary melanoma was never established.

MORE ON METASTATIC MELANOMA OF THE HEART

  • It is found at autopsy in approximately 64 of patients with metastatic melanoma, the highest percentage in any type of malignancy.3
  • Mechanism of spread is hematogenous.2,3
  • Quantity of deposits is far greater than that of any other metastatic malignancy (e.g., one heart weighed 2,450 gm).4
  • Clinical manifestations are often absent or nonspecific, even when the tumor load is huge.3 Nevertheless, in patients with a history of melanoma, telltale developments can include acute pericarditis, rapid increase in cardiac size on chest imaging, pericardial effusion (with or without tamponade), rhythm disturbances, conduction defects, or new-onset heart failure.3
  • Premortem diagnosis is made with imaging evidence of tumor invading the heart2,4 or detection of malignant cells in pericardial fluid.1
  • Therapy is symptomatic and palliative.
  • Cause of death varies: widespread metastases in most; marked involvement of the central nervous system with hemorrhage in some; and cause unclear but sudden in a few.3