Cardiac Metastasis in Testicular Tumor: An Imaging Challenge

A 29-year-old, previously healthy Caucasian male presented to the emergency department with progressively worsening dyspnea on exertion over the last month period. About 2 weeks prior to presentation, his shortness of breath began to worsen and was brought on even with minimal exertion. He also reported associated symptoms of testicular swelling and abdominal discomfort with severe fatigue, night sweats, fevers, and chills. He denied symptoms of weight loss, chest pain, palpitations, cough, nausea, vomiting, or blood in his stools. Family history was notable for a paternal uncle who had testicular cancer. He was a pack-per-day smoker for 10 years prior to presentation, and he otherwise denied illicit substance or alcohol use. Upon initial presentation, he was hemodynamically stable, however, he was tachypneic on room air. Physical examination was notable for an elevated jugular venous pressure, a firm right testicular swelling and mild abdominal distension with no abdominal tenderness to palpation. He did not have any abnormal heart sounds or lower extremity edema, and lungs were clear to auscultation. Admission electrocardiogram (ECG) was notable for a new complete right bundle branch block. A computed tomography (CT) scan of the abdomen and pelvis showed a heterogeneous liver with small volume ascites and inguinal lymphadenopathy. Subsequent chest CT with contrast showed diffuse lung nodules bilaterally and a right ventricular mass. An echocardiogram showed a left ventricular ejection fraction of 56% with a severely dilated right ventricle (RV) and a 7.4 x 6.0 cm mass infiltrating and obstructing the RV (Figure 1), along with, moderate pericardial effusion and patent foramen ovale. A cardiac magnetic resonance imaging (MRI) re-demonstrated the heterogeneous RV mass (Figure 2). Subsequent testicular ultrasound showed a right testicular mass measuring 1.5 cm in diameter. MRI of the brain showed no evidence of metastasis. Upon admission, he was hemodynamically stable, albeit tachycardic, but within a day he became hypotensive with a rising lactate and liver enzymes concerning for cardiogenic shock. He was intubated and placed on VA-ECMO. During his hospital stay, endomyocardial biopsy of the RV mass showed findings consistent with a metastatic embryonal germ cell tumor. Oncology initiated chemotherapy with cisplatin, etoposide, and bleomycin, subsequently. Cardiothoracic surgery was consulted, however, determined the mass was not resectable.

Figure 1: Transthoracic echocardiogram demonstrating right ventricular mass (red arrow) and pericardial effusion (yellow arrow).

Figure 1

Figure 2: Cardiac MRI demonstrating right ventricular mass.

Figure 2

What is the best imaging modality to evaluate malignant potential in a newly discovered cardiac mass?

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