SESSION TYPE: Cardiovascular Student/Resident Case Report Posters I
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Symptomatic cardiac masses are rare. The differential diagnosis includes primary cardiac neoplasms, metastases and thrombi. Most often, cardiac neoplasms are discovered incidentally.
CASE PRESENTATION: A 74 year old man presented with dyspnea on exertion, fatigue, fevers, night sweats and weight loss. History was significant for renal cell carcinoma with right nephrectomy 8 years previously and bladder cancer treated with local chemotherapy. Heart rate was 103 bpm. There was a grade 2/6 harsh holosystolic murmur loudest at the left upper sternal border. A third heart sound was audible at the left sternal border. S1 was normal. S2 was split with inspiration and there was increased intensity of P2. The PMI was non-displaced and there was no RV heave. Jugular venous pressure was elevated at 10 cm of water. Lung exam was unremarkable. A transthoracic echocardiogram revealed a 32x 32 mm mass in the right ventricular outflow tract creating a 24 mmHg systolic gradient. Chest CT without contrast due to underlying renal disease revealed a 49x 25x 38 mm cavitary mass in the superior aspect of the left lower lobe abutting the chest wall as well as mediastinal and hilar adenopathy. CT-guided left lung mass biopsy revealed squamous cell carcinoma.. PET scan was consistent with uptake in the cavitated lung mass and presumed metastatic left hilar and mediastinal lymphadenopathy and a large very intensely FDG avid cardiac mass. Echocardiographically -guided RV biopsy revealed metastatic squamous cell carcinoma. Palliative chemotherapy was offered for stage IV lung cancer; however, the patient declined and entered hospice.
DISCUSSION: Peripheral lung masses do not typically cause dyspnea and as a result are often diagnosed at an advanced stage. In our patient, right ventricular outflow tract obstruction leading to dyspnea on exertion ultimately led to his diagnosis. Patients with malignancy are at high risk for thromboembolic events. Evaluation of the RV mass was necessary to exclude thrombus and further characterize the stage of this patient’s squamous cell carcinoma. The CT PET effectively excluded thrombus. Given the intensely FDG avid cardiac mass biopsy was pursued as the mass may have represented a second primary which would alter therapy recommendations.
CONCLUSIONS: Although one-quarter of lung cancer patients present with dyspnea the mechanism of dyspnea in our patient is quite unusual. Cardiac tumors most often represent metastases, the majority of which are from lung or breast cancers.
DISCLOSURE: The following authors have nothing to disclose: Rachel Le, Garvan Kane
No Product/Research Disclosure InformationMayo Clinic, Rochester, MN