SESSION TYPE: Cardiovascular Case Report Posters
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Hypoxemia with cor pulmonale in patients with malignancy has a broad differential.
CASE PRESENTATION: An 83-year-old white female presented to the Pulmonary clinic with five days of progressive dyspnea. She was three weeks status post mastectomy for high-grade invasive ductal carcinoma with sarcomatoid features. (Fig 1) Exam revealed tachycardia with a blood pressure 130/65 mmHg, a room air saturation of 85% and a new III/VI systolic murmur. Electrocardiogram revealed a new incomplete right bundle branch block. Computed tomography angiography (CTA) demonstrated a large, 5.5 cm enhancing mass/thrombus arising from the basal aspect of the right ventricle (RV) and by extension nearly occluding the main pulmonary artery. (Fig 2) Innumerable new, bilateral, noncalcified, pulmonary nodules were seen without evidence of segmental or sub-segmental filling defects. Trans-thoracic echocardiogram confirmed a mass in the RV, moderate tricuspid regurgitation (TR) and depressed RV function with an estimated RV systolic pressure of 70 mmHg. CT guided biopsy of a lung nodule demonstrated metastatic poorly differentiated adenocarcinoma morphologically consistent with known primary.
DISCUSSION: This patient has an intermediate probability for pulmonary embolism per Wells Criteria and Geneva scores. However, the absence of segmental and sub-segmental thrombus on CTA makes this diagnosis highly unlikely. Pulmonary tumor embolism is recognized as an uncommon cause of cor pulmonale in cancer patients. Metastatic disease may present in the lungs as some combination of large, proximal emboli, generalized lymphatic dissemination, or microscopic vascular occlusion. CTA is typically non-diagnostic in patients with tumor emboli. Ventilation-perfusion scan and pulmonary artery cytology have a greater diagnostic utility. Twenty-nine cases of tumor emboli due to breast cancer have been reported.(1) Primary intracavitary cardiac tumors are exceedingly rare (incidence of 0.001%-0.03%) while metastatic lesions are more common.(2) However there is only one prior report of metastatic breast carcinoma resulting in an intracardiac mass with associated right ventricle outflow tract (RVOT) obstruction.(3)
CONCLUSIONS: We present a case of breast carcinoma metastatic to the right ventricle, crossing the pulmonary valve with near occlusion of the pulmonary artery. We propose that hematogenous spread of the breast malignancy accounts for the formation of the large intracavitary mass. This is the second reported case of an intra-ventricular breast metastasis causing RVOT obstruction and acute cor pulmonale.
1) Roberts KE, et al. Pulmonary Tumor Embolism: A Review of the Literature. Am J Med. 2003;115:228-232.
2) Butany J, et al. Cardiac tumours: Diagnosis and management. Lancet Oncol. 2005;6:219-228.
3) Labib SB, et al. Obstruction of right ventricular outflow tract caused by intracavitary metastatic disease: Analysis of 14 cases. J Am Coll Cardiol. 1992;19:1664-1668.
DISCLOSURE: The following authors have nothing to disclose: Leslie Wilke, Marcia Henderson, Shannon Ward, William Petersen
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