|Year : 2018 | Volume
| Issue : 1 | Page : 20-22
Germ cell tumour presenting as left atrial mass
Anil Ramesh Jawahirani1, Dilip Kshirsagar2, Deepak Jeswani2, Vivek Gupta2
1 Department of Cardiology, Jawaharlal Nehru Medical College, Wardha, Maharashtra, India
2 Department of Critical Care Medicine, Criticare Hospital, Nagpur, Maharashtra, India
|Date of Web Publication||31-Oct-2019|
Dr. Anil Ramesh Jawahirani
Department of Cardiology, Jawaharlal Nehru Medical College, Sawangi, Wardha - 440 003, Maharashtra
Source of Support: None, Conflict of Interest: None
A 33-year-old male presented with dry cough for 6 months and dyspnea on exertion for 3 months for which he was treated symptomatically by nearby physicians. On two-dimensional echocardiography, it revealed large left atrial mass occupying 2/3rd of the left atrium (LA) extending into the left lower pulmonary vein (PV). Then, his computed tomography of the chest was done, which revealed posterior mediastinal mass invading the left upper and lower lobe of the lung through the left main bronchus. The lesion also invaded the LA through the left PV. Biopsy was suggestive of nonseminomatous germ-cell tumor. This case is presented to demonstrate uncommon cardiac manifestations of secondary spread of testicular malignancy.
Keywords: Atrial mass, nonseminomatous germ-cell tumor, posterior mediastinum, pulmonary vein
|How to cite this article:|
Jawahirani AR, Kshirsagar D, Jeswani D, Gupta V. Germ cell tumour presenting as left atrial mass. Arch Cardiovasc Imaging 2018;6:20-2
| Introduction|| |
The cardiac tumors are rare. Secondaries or metastases in the heart are more common than benign tumors. Most often, these tumors start in the lungs, breasts, stomach, kidneys, liver, or colon. Our case of secondaries in the left atrium (LA) due to germ-cell tumor is one of the rare presentations of cardiac tumors reaching LA through the pulmonary vein (PV) not much described in literature.
| Case Report|| |
A 33-year-old male was referred to our center with a history of dry cough for 6 months, chest pain on coughing for 3 months, and dyspnea on exertion NYHA Class II for 3 months which gradually progressed to dyspnea Class III–IV in the past 15 days and palpitations for 15 days.
Detailed history revealed that the patient had developed dry cough 6 months ago for which he consulted a nearby physician. He was treated symptomatically and advised Chest X-ray posteroanterior view, which showed left lower lobe rounded opacity. He was advised to consult chest specialist for the same. The patient did not consult anyone for the next 3 months. After 3 months, dyspnea has progressed to NYHA Class IV level. He now consulted at our center for same complaints. Routine tests were ordered along with computed tomography (CT) of the chest and two-dimensional (2D) echocardiography. 2D echocardiography showed large left atrial mass (approximately 8.1 cm × 2.6 cm) occupying 2/3rd of LA which was extending into the left lower PV. The mass was obstructing the mitral valve creating severe functional mitral stenosis with severe pulmonary hypertension [Figure 1] and [Figure 2].
|Figure 1: Two-dimensional echocardiography showing large mass in the left atrium abutting mitral valve in the parasternal long-axis view|
Click here to view
|Figure 2: Two-dimensional echocardiography showing large mass in the left atrium extending from the pulmonary vein in the subcostal view|
Click here to view
CT of the chest showed large infiltrating posterior mediastinal mass which was invading the left upper and lower lobe of the lung through the left main bronchus. The lesion also invaded the LA through the left PV [Figure 3] and [Figure 4].
|Figure 3: Large well-defined heterogeneously enhancing soft-tissue mass is seen in the left lower lobe basal segments with extension along the inferior pulmonary vein into the left atrium abutting mitral valve in the sagittal image|
Click here to view
|Figure 4: Large well-defined heterogeneously enhancing soft-tissue mass is seen in the left lower lobe basal segments with extension along the inferior pulmonary vein into the left atrium abutting mitral valve in the axial image|
Click here to view
Simultaneously, CT-guided biopsy was performed. Histopathology of biopsy tissue was suggestive of nonseminomatous germ-cell tumor (NSGCT) [Figure 5].
|Figure 5: Biopsy shows nonseminomatous germ-cell tumor comprising lamellated keratin, teratomatous (a, H and E ×40) and yolk sac (b, H and E ×100) component|
Click here to view
Now, a detailed history was again taken when he revealed that he underwent right orchidectomy for immature teratoma 2 years ago. He lost to follow-up at that time with the oncologist.
He was advised chemotherapy by the medical oncologist, but again he refused to undergo further treatment. He lost to follow-up.
| Discussion|| |
Mixed germ-cell tumors are the second-most common testicular germ-cell tumors, accounting for 40%–50% of all primary germ-cell tumors. They usually present with slowly progressive testicular enlargement with or without pain.
However, the presenting manifestation may be due to metastasis in around 10% of patients. Common sites of metastases include the retroperitoneum, posterior mediastinum, supraclavicular lymph node, and pulmonary nodule. Pulmonary metastases are the most common site of visceral organ metastases. Liver, bone, and brain metastases are less common. Metastasis to the heart is rarely reported.
We hereby report a case of NSGCT who presented with widespread metastases to the heart, lungs, and mediastinum.
In the presence of neoplastic disease, pericardial pain, effusion, new heart murmurs, and electrocardiogram changes such as atrial or ventricular arrhythmias and atrioventricular block are suggestive of secondary invasion of the heart. There are few case reports of testicular tumor metastasizing to the heart. Respiratory distress was the presenting feature in a 41-year-old male with testicular mass, which turned out to be seminoma on the histopathological report. He also had intracavitatory mass in both atria causing symptomatic obstruction to blood flow., Our patient also had large infiltrating posterior mediastinal mass which was invading the left upper and lower lobe of the lung through the left main bronchus. The lesion also invaded the LA through the left PV.
Our patient had undergone orchidectomy 2 years ago. After 2 years of quiescent period, he presented with widespread metastasis to the mediastinum and the heart. Fewer than 10% of patients with NSGCT relapse more than 2 years after orchidectomy. Retroperitoneum is the most common site of relapse followed by the lung and other viscera. As relapse is extremely uncommon after 2 years and rare after 5 years, periodic reevaluation should be done and should be performed annually 5th year onward.
Testicular tumors are among the tumors with the best therapy success and the longest survival. Patients have the chance of cure even in the advanced stages. The five-year survival rate is 90% without distant metastases and 60% with distant metastases. Developments in imaging techniques and surgical methods enable curative treatment choices in such patients during metastatic stages. Our patient opted out of further treatment due to financial constraints.
| Conclusion|| |
Any young patient presenting with suspected secondaries in atria should be looked for germ-cell tumor and examined or investigated accordingly. All germ-cell tumors occurring in the testes should be followed up closely in the first 2 years after orchidectomy. Annual checkup is essential to detect the early relapse of germ-cell tumor.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Tickoo SK, Amin MB, Cramer HM, Harik LR, Ulbright TM. The testis, paratesticular structures and male external genitalia. In: Silverberg SG, Delellis RA, Frable WJ, Livolsi VA, Wick MR, editors. Silverberg's Principles and Practice of Surgical Pathology and Cytopathology. 4th
ed. Philadelphia: Churchill Livingstone Elsevier; 2006. p. 1731-89.
Kondagunta V, Motzer RJ, Bosi GJ. Testicular carcinoma. In: Schrier RW, editor. Diseases of the Kidney and Urinary Tract. 8th
ed. Philadelphia: Lippincott Williams & Wilkins; 2007. p. 803-13.
May M, Finkbeiner Y, Gunia S, Seehafer M, Knörig J, Hetzer R. Metastasizing testicular germ-cell tumor with infiltration of the right heart: Indication for primary metastasectomy. Heart Vessels 2006;21:63-5.
Hall RJ, Colley DA, McAllister HA Jr., Frazier OH, O'Rourke RA. Neoplastic heart disease. In: Fuster V, Alexander RW, O'Rourke RA, Robert R, King SB 3rd
, Nash IS, Prystowsky EN. Hurst's The Heart. 11th
ed. USA: McGraw-Hill Publishers; 2004. p. 2081-96.
Jo JC, Lee DH, Kang BW, Lee SS, Sym SJ, Kim MK, et al
. Both-sided intraatrial intracardiac metastases as the initial presentation of testicular seminoma. Jpn J Clin Oncol 2007;37:463-8.
Bosl GJ, Scheinfeld J, Bajorim DF, Motzer RJ, Chaganti RS. Cancer of the testis. In: De Vita VT Jr., Hellman S, Rosenberg SA, editors. Cancer: Principles and Practice of Oncology. Philadelphia: Lippincott Williams & Wilkins; 2005. p. 1269-93.
Gori S, Porrozzi S, Roila F, Gatta G, De Giorgi U, Marangolo M. Germ cell tumours of the testis. Crit Rev Oncol Hematol 2005;53:141-64.
Dickman PW, Hakulinen T, Luostarinen T, Pukkala E, Sankila R, Söderman B, et al.
Survival of cancer patients in Finland 1955-1994. Acta Oncol 1999;38 Suppl 12:1-103.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]