Clinical vignette

A pathological mobile mass in the right heart found on echocardiography: Just a thrombus or a manifestation of a neoplastic disease?

Katarzyna Kurnicka1Tomasz Cader2Martyna Kuryła1Dominika Dąbrowska1Katarzyna Ślubowska3Piotr Pruszczyk1
١Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warszawa, Poland
٢Students› Scientific Association by Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warszawa, Poland
٣Department of Transplantation Medicine, Nephrology and Internal Medicine, Medical University of Warsaw, Warszawa, Poland

Correspondence to:

Katarzyna Kurnicka, MD, PhD,

Department of Internal Medicine and Cardiology,

Medical University of Warsaw,

Lindleya 4, 02–005, Warszawa, Poland

phone: +48 22 502 1144,

e-mail: kkurnicka@yahoo.pl

Copyright by the Author(s), 2022

DOI: 10.33963/KP.a2022.0216

Received: August 20, 2022

Accepted: September 7, 2022

Early publication date: September 15, 2022

Pathological mobile masses in the right heart (RH) can be found on transthoracic echocardiography (TTE) in patients with a suspected or confirmed pulmonary embolism (PE), but they are often detected incidentally.

We present three patients with additional mobile masses in the RH detected using TTE, with completely different final diagnoses.

In the first patient, a 61-year-old male with a history of exertional dyspnea and PE confirmed in CT pulmonary angiography, a “wormlike echo” in the right atrium (RA) (Figure 1A) was detected, corresponding to a thrombus from the venous system, which disappeared following anticoagulation. Importantly, the image of the inferior vena cava (IVC) was normal.

Figure 1. Two-dimensional transthoracic echocardiography in patients with mobile pathological masses found in the right heart. A. Mobile thrombus in the right atrium (the arrow) in a patient with a pulmonary embolism; four-chamber view. B. Mobile pathological mass in the right atrium (the arrow) in a patient with renal cell carcinoma; four-chamber view. C. The inferior vena cava filled with pathological mass (renal cell carcinoma) entering the right atrium (the arrows, top panel); venous flow limitation visible in the color Doppler assessment (the arrow, bottom panel); subcostal view. D. Mobile pathological mass in the right heart (the arrows) in a patient with endometrial stromal sarcoma; four-chamber view. E. Additional mass (stromal sarcoma) in the inferior vena cava (the arrow); subcostal view. F. Stromal sarcoma surgically removed; part of a tumor visible in the right heart on echocardiography (the arrow)
Abbreviations: IVC, inferior vena cava; RA, right atrium; RV, right ventricle

In the second patient, a 69-year-old male with a low-grade fever for several weeks and suspected endocarditis, we also found a mobile mass in the RA (Figure 1B), but it was more echogenic, oblong, emerging from the lumen of the IVC, and disturbing the blood flow (Figure 1C, Supplementary material, Video S1, S2). In this case, abdominal CT and postoperative examination confirmed clear cell type renal cell carcinoma (RCC) in an advanced stage.

In the third patient, a 54-year-old female with worsening exercise tolerance and suspected PE, TTE showed an irregular mass with a “soft” structure that moved from the RA into the right ventricle in diastole (Figure 1D). It was visible in the long segment of the IVC (Figure 1E), similarly to the previous patient. She underwent extensive surgery, and the histopathological examination showed stromal sarcoma originating from the reproductive organ (Figure 1F).

In the case of pathological mobile mass in the RH, especially in the RA, the differential diagnosis should include a thrombus, vegetation, or a primary and metastatic tumor [1, 2]. Mobile RH thrombi are detected in approximately 4% of unselected patients with PE (and even in 18% of PE patients in the Intensive Care Units) and are associated with high early mortality in the case of right ventricular dysfunction [3]. Right heart vegetations are usually associated with the tricuspid valve.

Approximately 15%–20% of myxomas are tumors originating from the RA, pedunculated, and partially mobile [1].

Primary malignant tumor angiosarcoma, predominantly occurring in the RA (80%), is usually large, not very mobile, and frequently infiltrates adjacent structures [2].

However, the most common cardiac neoplasms are metastases, the frequency of which can be as high as even 18% [1, 2]. Due to transvenous extension of neoplasms, including RCC, hepatocellular carcinoma, and certain types of gynecological neoplasms, careful evaluation of the IVC during TTE is recommended to detect the source of the abnormal mass [2].

RCC can extend through the renal vein into the IVC as a tumor-thrombus formation in several percent of patients, while it reaches the heart in 1% of cases. If the tumor is large, it can even lead to symptoms of RH failure [4].

Endometrial stromal sarcoma is a rare malignant gynecological tumor that infiltrates the IVC and also spreads to the RH, which significantly worsens the prognosis [5].

As is known, tumor invasion is also possible through the superior vena cava.

Additional mobile masses in the RH, detected by TTE may be the first manifestation of neoplastic disease and often require CMR and CT examination to make the proper final diagnosis [2]. A promptly initiated therapy will have a major impact on the patient’s long-term prognosis.

Supplementary material

Supplementary material is available at https://journals.viamedica.pl/kardiologia_polska.

Article information

Conflict of interest: None declared.

Funding: None.

Open access: This article is available in open access under Creative Common Attribution-Non-Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0) license, allowing to download articles and share them with others as long as they credit the authors and the publisher, but without permission to change them in any way or use them commercially. For commercial use, please contact the journal office at kardiologiapolska@ptkardio.pl.

REFERENCES

  1. L’Angiocola PD, Donati R. Cardiac masses in echocardiography: A pragmatic review. J Cardiovasc Echogr. 2020; 30(1): 514, doi: 10.4103/jcecho.jcecho_2_20, indexed in Pubmed: 32766100.
  2. Pradella S, Grazzini G, Letteriello M, et al. Masses in right side of the heart: spectrum of imaging findings. Acta Biomed. 2020; 91(8-S): 6070, doi: 10.23750/abm.v91i8-S.9940, indexed in Pubmed: 32945280.
  3. Koć M, Kostrubiec M, Elikowski W, et al. Outcome of patients with right heart thrombi: the Right Heart Thrombi European Registry. Eur Respir J. 2016; 47(3): 869875, doi: 10.1183/13993003.00819-2015, indexed in Pubmed: 26797032.
  4. Canpolat U, Aytemir K. Unexpected cause of acute right heart failure: renal cell carcinoma and tumour thrombus. Kardiol Pol. 2013; 71(12): 1327, doi: 10.5603/KP.2013.0339, indexed in Pubmed: 24399599.
  5. Tadic M, Belyavskiy E, Cuspidi C, et al. Right heart masses in a patient with endometrial stromal sarcoma. J Clin Ultrasound. 2020; 48(2): 117120, doi: 10.1002/jcu.22732, indexed in Pubmed: 31074021.

Regulations

Important: This website uses cookies. More >>

The cookies allow us to identify your computer and find out details about your last visit. They remembering whether you've visited the site before, so that you remain logged in - or to help us work out how many new website visitors we get each month. Most internet browsers accept cookies automatically, but you can change the settings of your browser to erase cookies or prevent automatic acceptance if you prefer.

By VM Media Group sp. z o.o., ul. Świętokrzyska 73 , 80–180 Gdańsk, Poland

phone:+48 58 320 94 94, fax:+48 58 320 94 60, e-mail: viamedica@viamedica.pl