Cardiac Masses - Cases

1351560 - Sarcomatoid renal cell carcinoma presenting with cardiac metastasis: Complications and management of a rare cardiac mass

Saturday, January 28, 2023

10:44 AM – 10:50 AM

Location: Sandpiper

Presenting Author(s)

JT

Jeffrey Triska, MD

Resident Physician
Baylor College of Medicine, Texas, United States

Primary Author(s)

JT

Jeffrey Triska, MD

Resident Physician
Baylor College of Medicine, Texas, United States

Co-Author(s)

NP

Nicolas Palaskas, MD

Assistant Professor
The University of Texas MD Anderson Cancer Center
Houston, Texas, United States
IH

Ihab Hamzeh, MD

Associate Professor
The University of Texas MD Anderson Cancer Center, United States
CI

Cesar Iliescu, MD

Professor
The University of Texas MD Anderson Cancer Center, United States
AD

Anita Deswal, MD

Chair
The University of Texas MD Anderson Cancer Center, United States
Shaden Khalaf, MD

Assistant Professor
University of Texas M.D. Anderson Cancer Center
Houston, Texas, United States

Description of Clinical Presentation: A 55-year-old female with a history of a transient ischemic attack presented with pleuritic chest pain. An ECG showed new-onset atrial fibrillation with rapid ventricular response. An echocardiogram (ECHO) revealed an apical left ventricular (LV) mass with a moderate pericardial effusion concerning for metastatic disease. Cardiovascular magnetic resonance imaging (CMR) confirmed two LV masses extending into the pericardium and invading the inferomedial papillary muscle (Image 1 C-E). A biopsy of a paraspinal soft tissue mass revealed sarcomatoid renal cell carcinoma (RCC).

Diagnostic Techniques and Their Most Important Findings: The patient underwent pericardiocentesis due to a rapidly enlarging pericardial effusion on ECHO despite treatment with anti-inflammatory agents. Hemorrhagic fluid without malignant cells was identified in the pericardial fluid. She was initiated on dual-immune checkpoint inhibitor therapy with nivolumab and ipilimumab with good clinical response including resolution of the antero-apical mass (Image 1A-B) and no recurrence of pericardial effusion.

The sarcomatoid variant of RCC, which comprises around 5% of RCC cases, is aggressive and often presents with metastatic disease [1]. While cardiac metastasis is rare, it often leads to cardiovascular complications [2]. Cardiac tumors pose several diagnostic dilemmas along with therapeutic challenges.

Arrhythmias are common; as in this case in which the patient presented with new onset atrial fibrillation with rapid ventricular rates [3]. Presence of pericardial effusion should heighten readers' concern for pericardial masses on ECHO, especially if there is exaggerated apical trabeculation or papillary muscles as compared to prior studies. CMR is essential in diagnosis and monitoring of these patients due to its excellent tissue characterization, wide field of view, and excellent spatial resolution.

Learning Points from this Case: • Cardiac metastasis may lead to cardiovascular complications that challenge management.
• The presence of a pericardial effusion should heighten readers’ concern for pericardial masses.
• CMR is essential in diagnosis and monitoring of patients with cardiac tumors.
• Management of cardiac tumors requires a tailored, multidisciplinary approach.