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Number 10-13: Cardiac Metastases of the Renal Cell Carcinoma Diagnosed by CMR
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Number 10-13: Cardiac Metastases of the Renal Cell Carcinoma Diagnosed by CMR

Case from: Patterson B, Peterson J, Shifrin R, Schmalfuss C, Cooper G.
University of Florida, Gainesville, FL, USA

Clinical history: A 59 year old male presented with pleuritic chest pain and was initially diagnosed with bilateral pulmonary emboli. Four months later he developed painless hematuria. This was subsequently found to be caused by a left renal mass which invaded and partially occluded the left renal vein and inferior vena cava (Image 1, red arrows). The mass extended to the level of liver, but not to the level of right atrium.

 

 

 

Image 1, CT Abdomen

 

Transthoracic and transesophageal echocardiograms revealed an infiltrating right ventricular mass.

 

 

     

                                          

Transthoracic Echocardiogram                                         Transesophageal Echocardiogram

 

Cardiac MRI: CMR was performed to evaluate the extent of cardiac mass and inferior vena cava involvement. On the scout images, the left renal mass was visualized invading and occluding the left renal vein and inferior vena cava on coronal and sagittal views (Images 2 & 3, red arrows). SSFP cine images demonstrates right atrial and right ventricular enlargement as well as a large, invasive, inhomogeneous, lobular, exophitic, RV mass, invading the anterior right ventricular wall. A second small mobile mass is present in the right ventricular outflow tract (SSFP Movie 1 and 2). The mass perfuses with gadolinium first pass perfusion (Movie 3) and has patchy late gadolinium enhancement (LGE) (Image 4, red arrow). The T1 and T2 4-chamber views without and with fat saturation did not demonstrate fat within the mass (not shown).

 

   

Image 2                                                    Image 3

 

   

SSFP Movie 1                                       SSFP Movie 2

 

                     

(Movie 3) First Pass Perfusion                                Image 4

 

Perspective: Renal cell carcinoma typically presents with painless hematuria and flank mass. Prognosis depends on tumor staging and presence of metastases. Cardiac metastasis of renal cell cancer is not uncommon. There are two common modes of cardiac metastasis: contigous extension through the renal vein and inferior vena cava into the right heart chambers and metastasis by diffuse systemic spread (1, 2). Although contigous extension from the inferior vena cava is common, direct distant metastasis are not uncommon (3, 4). Transthoracic echocardiography is the first diagnostic tool in the assessment of patients with suspected cardiac metastasis of renal cell carcinoma. CMR compliments the echocardiography and the CT with its wider field of view and the ability to characterize tissue (2). CMR should be used to localize the extent of primary tumor within the inferior vena cava and in the cardiac chambers. CMR's unique tissue characterization qualities can differentiate between tumor and thrombus. The malignant nature of the tumor is suggested by local invasion of the myocardial wall, gadolinium perfusion, late gadolinium enhancement and the absence of fat within the mass. All these characteristics also separate this mass from being a thrombus. Identification of myocardial infiltration by CMR can also help plan surgical resection of the cardiac metastases.

The discussions set forth in this case confirm the use of CMR for complete evaluation of the cardiac mass thus avoiding invasive additional testing such as transesophageal echocardiogram which did not add much information to the results already obtained by transthoracic study. The use of CMR for complete evaluation of cardiac and paracardiac masses are in line with the recommendations set forth in appropriateness criteria by American College of Cardiology and concensus report of European Society of Cardiology (5,6)

 

Reference:

1. Rathi VK (2006). Cardiac and paracardiac masses. Textbook of Cardiovascular Magnetic Resonance. Pages 299-326. Informa healthcare. ISBN: 0-8247-5841-2.

2. Deetjen A, Conradj Get al: Cardiac metastasis of a renal cell adenocarcinoma investigated by cardiac magnetic resonance imaging.  Clin Res Card. 95; 9: sep 2006:492-495.

3. Aburto J, Bruckner BA, Blackmon SH, Beyer EA, Reardon MJ. Renal cell carcinoma, metastatic to the left ventricle.  Tex Heart Inst J. 2009;36(1):48-9.

4. Pala S, Erkol A, Kahveci G. Massive right atrial metastasis from renal cell carcinoma without inferior vena cava involvement. Turk Kardiyol Dern Ars. 2009 Jul;37(5):358.

5. Hendel RC et al. ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 appropriateness criteria for cardiac computed tomography and cardiac magnetic resonance imaging: J Am Col Cardiol. 2006 Oct 3;48(7):1475-97.

6. Pennell DJ, Sechtem UP, Higgins CB, et al. Clinical indications for cardiovascular magnetic resonance (CMR): Consensus Panel report. Eur Heart J 2004;25:1940-65.

 

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COTW handling editor: Vikas K. Rathi

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