Presentations

Abstract

Introduction: Cardiac metastases are rare and associated with poor prognosis. We report a case of bladder cancer with associated cardiac metastasis; moreover, the abnormal cardiac mass presented as the initial finding.

Case Information: A 63-year-old male with a past medical history of ulcerative colitis and benign prostate hyperplasia presented with shortness of breath. The patient denied history of tobacco use. CTA was significant for small to moderate burden of pulmonary emboli in the right lower lobe, hilar and mediastinal lymphadenopathy, and a right middle lobe pulmonary nodule. An Echo revealed a 5.7 cm x 1.4 cm echogenicity in the right ventricular outflow tract, crossing the pulmonic valve. Ejection fraction was 58% and no other abnormalities were noted. After initiation of anticoagulation, he developed a lower gastrointestinal bleed, that required transfer to a tertiary care center. A colonoscopy was performed with findings of ulcers in the rectosigmoid colon and quiescent ulcerative colitis. A cardiac MRI was obtained and confirmed an enhancing right ventricular mass, concerning for malignancy. CT of the abdomen and pelvis demonstrated extensive retroperitoneal lymphadenopathy, and irregular prostate mass invading the bladder and rectum. The patient underwent radiology-guided retroperitoneal lymph node biopsy, and pathology resulted in squamous cell carcinoma. Cardiothoracic surgery and cardiology were consulted regarding the RV mass; there was no intention for surgical procedure. Cystoscopy with prostate biopsy was conducted, and pathology resulted in invasive urothelial carcinoma with predominant squamous differentiation. The cardiac mass was presumed to be metastatic urothelial carcinoma. Oncology started systemic chemotherapy and palliative pelvic radiation. However, the hospital course was prolonged and included multiple complications; the cardiac mass remained stable but metastatic tumor burden continued to rapidly progress throughout the abdomen and pelvis. Ultimately, the patient chose comfort measures and passed away in the hospital.

Discussion/Clinical Findings: This was a rare presentation of a cardiac metastasis of urothelial carcinoma. Urothelial cancer has been reported to metastasize to the heart; a review of 20 cases in literature resulted in 68% of urothelial cancer metastases in the heart were located in the right ventricle. Unfortunately, such presentation is indicative of advanced disease and outcomes are typically poor.

Conclusion: In conclusion, cardiac metastases can have unusual origins that are not always apparent. This case demonstrates the importance of a broad differential and thorough evaluation of patients presenting with an unexpected mass in the heart.