Beyond Thrombus Detection: The Role of Multimodality Imaging Approach.

We present a very rare case of paraneoplastic syndrome characterized by the unusual coexistence of a left ventricular apical thrombus and pulmonary embolism as the first manifestation of an unrecognized lung adenocarcinoma.

INTRODUCTION

Multimodality imaging represents the best approach for left ventricular (LV) masses detection.[12]

It is crucial for differential diagnosis among cardiac primary tumors, secondary lesions, and thrombotic masses. Echocardiography, cardiac computer tomography, and cardiac magnetic resonance (CMR) are the main imaging techniques used for this purpose.

CASE REPORT

A 51-year-old man was admitted to the Emergency Department for dyspnea at rest.

He presented with stable hemodynamic and oxygenation parameters and an elevated D-dimer (9966 mg/dl) at laboratory tests.

A thoracic cardiac tomography scan was performed, showing a pulmonary embolism of the main right pulmonary artery [Figure 1a] and an intracardiac mass localized in the apical region of the left ventricle [Figure 1b].

Figure 1

(a and b) A thoracic computer tomography scan shows pulmonary embolism of the main right pulmonary artery and an intracardiac mass. (c) A two-dimensional transthoracic echocardiography, four chamber view, shows a homogeneous mass into the left ventricular apex. (d and e) At cardiac magnetic resonance, the mass showed lower signal intensity at T2-weighted sequences and a dark appearance after early and late gadolinium administration, typical for thrombotic lesions. (f) Late gadolinium enhancement sequences highlight a region of apical fibrosis due to an old myocardial infarction scar

A two-dimensional trans-thoracic echocardiography showed in four chamber view, an apical akinesia of the left ventricle due to a prior myocardial infarction, with mild global LV dysfunction (ejection fraction 45%) and confirmed the presence of a mobile, homogeneous, echogenic mass, partially adherent to the LV apex [Figure 1c].

To further characterize the LV mass, a CMR was carried out. The cine CMR sequences demonstrated a “flame-shaped” endocavitary image, localized in the LV apex.

The mass showed lower signal intensity at T2-weighted sequences and a very dark appearance after early and late gadolinium administration [Figure 1d and e]; moreover, late gadolinium enhancement distribution highlighted a region of apical fibrosis due to an old myocardial infarction scar [Figure 1f]. A paraneoplastic syndrome (Trousseau's) was suspected, and a diagnostic work out for lung cancer was carried out, demonstrating an advanced stage lung adenocarcinoma.

DISCUSSION

Thromboembolism is a common complication in patients with malignant disease, representing a major cause of morbidity and mortality in this subset of patients.[3]

Several risk factors for developing venous thrombosis usually coexist in cancer patients including surgery, hospital admissions, and immobilization, the presence of an indwelling central catheter, chemotherapy, use of erythropoiesis-stimulating agents and is possibly related to genetic predisposition.[4] However, the coexistence of LV apical thrombosis and pulmonary embolism is quite unique as the first manifestation of an unrecognized lung adenocarcinoma. Our case highlights two main aspects: The presence of multiple thrombotic masses in the cardiovascular system should lead to the suspicion of a severe prothrombotic state such as metastatic cancer; the widespread use of multimodality imaging techniques has greatly increased the diagnostic accuracy of cardiac masses through a better tissue characterization of lesions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.