An unpredictable right atrial mass

Introducere: The most frequent cardiac neoplasias have metastic mechanism, with different pathways of dissemination: hematogenic, through lymphatic system, direct invasion and intracardiac extension via inferior vena cava. The differential diagnosis can be done with primary tumors or a thrombus and need further investigations. In advanced stages, the renal cell carcinoma has venous extension, up to the right side of the heart, with a very poor prognosis in the absence of radical surgical treatment.
Case presentation: We present the case of a 71 year-old patient undergoing immunosuppressive treatment for rheumatoid artritis, who was addressed to our clinic in the context of a fortuity echocardiographic detection of a hiperechogenic tumor mass in the right atrium, considered to be a myxoma. Upon admission, the patient did not show any clinical signs of deep vein thrombosis, nor notable electrocardiographic changes, being symptomatic by reduced exercice tolerance in the last months. The laboratory parameters revealed inflammatory syndrome, anemia, slighly increased level of creatinine and elevated d-dimer levels. The transthoracic echocardiography showed a mass in the right atrium simulating a tumor or a thrombus, without signs of right heart strain and normal left ventricle function. From the subcostal view, the inferior vena cava was markedly dilated, with an image of a thrombus extended into the right atrium. We completed the investigations with abdominal echo and a CT scan. A right kidney tumor which infiltrated the perirenal tissue, extensive tumoral thrombosis into the common femoral veins, right renal vein, across inferior vena cava up to the right atrium, with abdominal adenopathies and small lung metastases were detected. Taking into account the complexity of this case, a multidisciplinary team (cardiovascular surgeon, cardiologist, urologist, nephrologist, oncologist and anesthesiologist) decided to send the patient to the oncology unit. Renal carcinoma with clear cells was identified at the histopathological exam from kidney biopsy tissue and the chemotherapy was initiated.
Conclusions: We have presented a rare case of advanced renal tumor discovered accidentally in a nearly asymptomatic patient in the context of evaluation of a cardiac mass. Favoring of tumor extension due an immunosuppresive status secondary to the treatement of rheumatoid artritis may be considered. We underline the importance of regular health assessment in or-der to detect such tumors in an early stage.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
The Romanian Journal of Cardiology is indexed by:
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)