Quick Fire Cases
Leyla Musayeva, MD
Radiologist, Cardiovascular imaging specialist
Central Clinic Hospital, Azerbaijan
Leyla Musayeva, MD
Radiologist, Cardiovascular imaging specialist
Central Clinic Hospital, Azerbaijan
Yunus Afandiyev, PhD
Head of Radiology department, radiologist
N. Tusi memorial clinic, Azerbaijan
Nargiz Mushtagzadeh, MD
Cardiologist, Cardiovascular imaging specialist
Central Clinic Hospital, Azerbaijan
Aytan Nasibova, MD
Cardiologist, cardiovascular imaging specialist
Central Clinic Hospital, Azerbaijan
Rauf Samadov, MD
Cardiologist
Republican Diagnostic Center, Azerbaijan
Oqtay Musayev, MD
Interventional cardiologist
Central Clinic Hospital, Azerbaijan
Anakhanim Safarova, MD
Cardiologist
Central Clinic Hospital, Azerbaijan
Firdovsi Ibrahimov, PhD
Head of the cardiology department, interventional cardiologist
Central Clinic Hospital, Azerbaijan
Sarah Bahaa Nasser, MD
Cardiologist
Dar AI Fouad Hospital, Egypt
Tamar Bigvava, MD
Tbilisi Heart and Vascular Clinic, Georgia
A 46-year-old female patient with a history of chest pain and a suspected small hamartoma in the basal left lung presented with recurrent chest pain. Two months earlier, she had experienced ST depression on a stress test but had declined coronary angiography at that time. One month before the current admission, she developed deep venous thrombosis (DVT) in both legs, resulting in near-total popliteal obliteration on one side, treated successfully with anticoagulant therapy. The patient decided to undergo further evaluation for her chest pain to exclude pulmonary emboly (PE) and to control suspected hamartoma.
Diagnostic Techniques and Their Most Important Findings:
A CT scan of the chest with PE protocol revealed a small thrombus in the right lower segmental pulmonary artery, small loculated pleural effusion on the right, left basal mass suggestive of a possible Hampton's hump-like infarct or a malignancy as lymphoma manifestation or lung cancer. Additional findings included mediastinal and left hilar lymphadenopathy and enlarged retroperitoneal lymph nodes. On CT-angiography images was seen a soft tissue dense mass in the right ventricle (RV) not known before and on further assessment by echocardiography was suspected to be a thrombus. Thrombolytic therapy was started again with no size reduction of RV mass in 2 months. A cardiac MRI (CMR) supported the presence of RV mass. A pathological irregular shaped mobile mass was observed in the right ventricle with dimensions 21 x 17 x 11 mm. The mass was found to be located close to the posterior leaflet of the tricuspid valve and connection with the papillary muscle chords in the RV free and inferior walls was suspected. Black blood T2, T1 and T2 Fs signals of the mass were isointense to the myocardium. In the early contrast phase (EGE), active accumulation of contrast material was not noticeable, later on delayed enhancement images a minimal peripheral hyperintensity was seen. The RV mass was described on MR as a suspected marantic thrombus/vegetations, although echocardiography raised the possibility of a myxoma. The patient refused suggested minithoracotomy surgery for cardiac mass removal. A biopsy from the mediastinal lymph node confirmed non-small cell carcinoma (NSCLC) and was ROS1-positive. 8FDG-PET/CT was done for lung cancer staging and showed no pathologic radiotracer uptake on RV mass which supports diagnosis of nonbacterial thrombotic endocarditis.
As a patient has metastatic cancer, the treatment with proteinkinase inhibitors for ROS1-positive NSCLC was started. On control thoracic CT images with contrast enhancement 9 months after treatment there were described a resorption of lymphadenopathy, reduction of size of lung tumor and total regression of RV mass. On control CMR RV mass was not seen. The regression of RV mass after targeting cancer treatment supports the suspected by CMR marantic thrombus.
Learning Points from this Case:
This case illustrates the complexity of evaluation and management of thrombotic and neoplastic conditions, particularly in a patient with coexisting cardiovascular and oncological issues and the important role of CMR in differentiation between tumors and thrombi. The presence of RV mass, likely a marantic thrombus associated with NSCLC, highlights the need for multimodality imaging and careful evaluation of cardiac masses in cancer patients. Clinicians should maintain a high index of suspicion for malignancy-related thromboembolic events and be prepared to use multidisciplinary approaches for diagnosis and management.
