Cardiac metastasis from a renal cell carcinoma without contiguous vena caval involvement, Azin Alizadeasl, Feridoun Noohi, Farnoosh Larti, Saeid Hosseini, Majid Maleki Archives of Cardiovascular Imaging 2017 5(2):30-31 Tumors that involve the heart are more likely to represent metastatic disease than do primary cardiac neoplasms. Cardiac metastases from a renal cell carcinoma are rare and would be unique when there is no contiguous vena caval involvement such as the case that will be described here.

Introduction

Renal cell carcinoma (RCC) accounts for 2%–3% of all adult malignancies and is the third most frequent urological malignancy after prostate and bladder cancer. Approximately one-third of the patients present with metastatic disease at diagnosis. In addition, 30% of all other patients develop metastases at a later stage of their disease.^[1] The most common sites of RCC metastases are the bone, liver, brain, lymphatic system, and lung. Cardiac metastases are rare, and a small number of cases have been published in the literature.^[2] The most common mechanism of cardiac metastases is the extension of a tumor column to the vena cava as a luminal mass, with growth along the caval wall into the right heart chambers. Other possible mechanisms are that tumor cells from the kidney may disseminate to the heart either by retrograde lymphatic or lymphohematogenous spread through the thoracic duct into the superior vena cava, or by the hematogenous spread of embolic cells.^[3],[4] In this report, we describe a case of a huge right heart metastasis from RCC in the absence of vena caval involvement.

Case Report

A 43-year-old man referred to our hospital for the evaluation of a cardiac mass. Three years earlier, he had undergone right nephrectomy because of RCC. No written document about the surgery report or the postoperative chemotherapy regimen was available. He was asymptomatic after the surgery until 2 months before his last medical contact. Two months before his referral to us, he developed nonspecific pain in the right hip and underwent a thorough evaluation for bone and lung metastases, which was negative. Accidentally, however, in his thoracic chest computed tomography, a large mass was diagnosed in the right atrium and the right ventricle (RV) with no evidence of a tumor in the inferior vena cava (IVC) or the renal veins. Transthoracic and transesophageal echocardiographic examinations were done, and a large multilobulated mass (10 cm × 6 cm) was seen in the RV. The mass originated from the right atrial appendage and crossed the tricuspid valve with no functional stenosis. The protrusion of the mass into the pulmonic valve during systole was also evident [Videos 1 and 2]. RV myocardial involvement as tissue infiltration and increased RV free wall thickness with evidence of mild RV systolic dysfunction were also noted. As shown in [Figure 1], there was no intraluminal mass in the IVC. The patient did not have any other site of metastases, so he was scheduled for the surgery. [Figure 2] shows the resected intracardiac tumor. After the surgery, due to the tumoral infiltration of the RV free wall, severe RV systolic dysfunction complicated the disease course, and unfortunately, the patient died despite extracorporeal membrane oxygenation (ECMO) implantation. The pathology report confirmed the metastatic RCC.

Figure 1: No tumoral involvement of the inferior vena cava in transesophageal echocardiography Click here to view

Figure 2: (a) Three-dimensional echocardiographic view of 60° with a large mass that filled the right atrium, right ventricular inflow and outflow so similar to excited tumor, (b) Resected right-sided intracardiac tumor Click here to view

[Figure 2] depicts the resected intracardiac tumor (in comparison with a three-dimensional echocardiographic view of the mass).

Conclusions

Cardiac tumors are mainly metastatic and not primary cardiac tumors. Malignant melanoma, leukemia, lymphoma, lung, esophageal, and breast cancers are tumors that have more cardiac invasion.^[1] Cardiac metastases from RCC are not common and mainly occur in two ways: the extension of RCC into the renal vein and the IVC in 5%–15% of patients and into the right atrium in about 1% of patients, and hematologic metastasis to the heart, which occurs in 10%–20% of patients with systemic RCC involvement. However, in the absence of either direct vena caval extension or systemic disease, the involvement of the heart is rare.^[3],[4],[5]

In our case, 3 years after a successful nephrectomy, a large right atrial and RV mass without evidence of IVC involvement or any metastases were detected. Because of severe RV dysfunction and despite the implantation of ECMO, our patient did not survive.

The case emphasizes the importance of cardiac assessment in patients with a history of RCC and underscores the fact that metastasis to the heart can happen without evidence of systemic disease or vena caval involvement.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 

References

1.	Cheng AS. Cardiac metastasis from a renal cell carcinoma. Int J Clin Pract 2003;57:437-8.
2.	Atik FA, Navia JL, Krishnamurthi V, Singh G, Shiota T, Pitas G, et al. Solitary massive right ventricular metastasis of renal cell carcinoma without inferior vena cava or right atrium involvement. J Card Surg 2006;21:304-6.
3.	Ohba K, Miyata Y, Mitsunari K, Matsuo T, Mochizuki Y, Sakai H, et al. Left atrial metastasis of renal cell carcinoma: A case report and review of the literature. BMC Res Notes 2014;7:520.
4.	Bouzouita A, Ben Slama MR, Mohamed MO, Larbi H, Selmi S, Cherif M, et al. Cardiac metastasis of renal cell carcinoma, a rare location. Prog Urol 2011;21:492-4.
5.	Alghamdi A, Tam J. Cardiac metastasis from a renal cell carcinoma. Can J Cardiol 2006;22:1231-2.