Non-small Cell Lung Cancer Initially Presenting with Intracardiac Metastasis
A 64-year-old male was admitted to our hospital with the chief complaints of exertional dyspnea and vague chest discomfort that had developed a few weeks ago. On review of the symptoms, he also complained of fever and cold sweating that began 7 days before admission. He was an active smoker, and he did not have any allergies or familial medical history. The initial vital signs were as follows: blood pressure 100/75 mmHg, pulse rate 86 per minute, temperature 38℃, and a respiration rate of 20 per minute. There was no evidence of cervical lymphadenopathy, and there were no abnormal findings on chest and abdomen examination. Electrocardiography (EKG) showed a complete right bundle branch block (RBBB), and chest X-ray revealed a mass-like lesion in the right lower lung. Transthoracic and transesophageal 2-D echocardiography showed a large mass tightly attached to its akinetic apical wall in the right ventricular chamber (). Computed tomography (CT) and magnetic resonance imaging (MRI) demonstrated a large tumor having involvement of the epicardium and myocardium in the right ventricle, and there was a mass in the right lower lobe of the lung and multiple lymphadenopathies (). The cytologic examination of the percutaneous fine needle aspiration of a lymph node in the anterior mediastinum revealed malignant epithelial cell nests that were strongly suggestive of squamous cell carcinoma (). Subsequent FDG PET confirmed that the intracardiac mass had an abnormally increased FDG uptake, which was strongly suggestive of malignancy (). Although there was no histologic confirmation, we diagnosed the heart mass as intracardiac metastasis by systematically considering these imaging studies. We discussed the treatment options with the patient and his family, such as surgical resection with histologic confirmation for the intracardiac tumor followed by palliative chemotherapy, or whether to perform palliative chemotherapy alone. Thereafter, we administered palliative chemotherapy with the combination of gemcitabine and cisplatin in consideration of the absence of right ventricular outflow obstruction and patient's preference.