Unusual mass in the heart
Description
● Introduction / Background
Lung cancer is the most prevalent cause of cancer-related mortality and the second most common disease diagnosed globally. 65 to 70 years old is the median age upon diagnosis. About 85% of cases are non-small cell lung cancer (NSCLC), with adenocarcinoma being the most prevalent subtype.
➣ Risk factors:
Although adenocarcinoma is very common in non-smokers, tobacco use is the biggest risk factor.
➣ Metastasis:
Common locations include the brain, adrenal glands, liver, lungs, and bones. In advanced illness, pericardial and pleural spread is common.
➣ Heart involvement:
It is quite uncommon for metastases to occur inside the left ventricular cavity, and the majority of these instances are asymptomatic.
A unusual occurrence of lung adenocarcinoma spreading to the left ventricular cavity is highlighted in this instance.
● Case Presentation
A 54-year-old woman who does not smoke arrived at the outpatient cardiology department with:
Progressive dyspnoea lasting more than two months
Orthopnea: Getting worse over ten days
Additional symptoms: Significant weight loss and haemoptysis
➣Past history: No significant medical or surgical history.
➣Examination:
SpO₂ 88% on room air, tachypnea
Tachycardia in the sinus
Consistent blood pressure
Cachectic look
➣Initial examinations: Liver, kidney, and blood count tests: Normal
➣Examining
Large heterogeneous mass (8.8 × 4.5 cm) filling the majority of the left ventricular cavity on 2D echocardiography
Otherwise, cardiac chambers are normal.
Excessive pericardial and pleural effusion
➣Analysis of pleural fluid: Exudative cytology shows no cancer cells
➣CT Thorax: The right upper lung lobe's thick-walled cavity
deficiency in the left ventricle's hypodense filling
Bilateral pleural effusion and pericardial
Histopathology (lung biopsy using CT): lung adenocarcinoma, non-small cell lung cancer
EGFR, MET, BRAF, and ALK mutations are negative for next-generation sequencing (NGS).
➣Immunohistochemistry: ROS1 and ALK negative
● Differential Diagnosis
➣Left ventricular thrombus
➣Primary cardiac sarcoma
➣Metastatic tumors (most often from lungs, kidneys, liver, uterus)
● Discussion
➣Epidemiology: Lung cancer is the cause of 30–40% of heart metastases.
Intracavitary left ventricular metastases is very uncommon; pericardial involvement is frequent.
➣Pathogenesis: Haematogenous spread is a common cause of adenocarcinoma metastases.
Genetic alterations include EGFR/ALK rearrangements, K-RAS activation, and p53 mutations.
The prognosis is low survival due to stage IV illness with cardiac involvement.
Advanced lung cancer 5-year survival is less than 10%.
Positive aspects include female sex, early diagnosis, and strong performance.
Poor variables include cachexia, advanced stage, significant weight loss, and negative results for targetable mutations.
➣Treatment difficulties: There is no set protocol for treating intracardiac metastases.
➣Options include immunotherapy (e.g., PD-1 inhibitors like nivolumab), chemotherapy, radiation, targeted treatment, and surgical excision (rarely possible).
Protocol
● Management:
Management began using Gefitinib (EGFR TKI) in an empirical manner.
Supportive treatment includes pleural/pericardial drainage, oxygen supplements, psychiatric counselling, and intense supportive care unit hospitalisation.
● Problems Faced
➣A tumour in the left ventricular cavity, an uncommon symptom associated with lung cancer, was found in the patient.
➣Determining the source of the intracardiac mass and distinguishing between vegetation, tumour, or thrombus presented a clinical difficulty.
➣Cardiovascular compromise (dyspnoea or chest discomfort) and the possibility of embolisation or blood flow restriction were among the symptoms.
● Strategies for Management
➣Diagnostic Approach: To determine the mass's size, shape, and pathology, a multidisciplinary approach using cardiac imaging (echocardiography, CT, and MRI) was used.
➣Medical and Surgical Intervention: Whether the mass was indicative of thrombus, metastatic illness, or another pathology determined how it was managed. In comparable situations, palliative care treatments, surgical excision, chemotherapy, or anticoagulation are options.
➣Support and Monitoring: It's critical to continuously check for haemodynamic instability, heart failure, and embolism symptoms. Plans for interventions are predicated on the underlying disease and patient stability.
● Interventions in Nursing
➣Assessment and Monitoring: To ensure early identification of problems (such as deteriorating heart function or embolic events), nurses conducted routine cardiovascular examinations, monitored for changes in symptoms, and did vital-sign checks.
➣Psychosocial Support: Provided the patient and family with information and emotional support; addressed anxiety brought on by the uncertainty of the diagnosis and prognosis.
➣drug Administration: Maintained clear communication on the drug schedule, watched for adverse effects, and made sure that prescribed medications were delivered accurately and on time.
➣Care Coordination: To ensure smooth care transitions, I helped set up appointments for multidisciplinary consultations and diagnostic work-ups.
➣Education: In order to promote good self-care and timely reporting of new symptoms, nurses provided education to the patient on symptoms to look out for, medication adherence, and the significance of routine follow-up.
Notes
For more information visit https://doi.org/10.1016/j.radcr.2023.04.014
