Germ cell tumour presenting as left atrial mass
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/ACVI.ACVI_3_19
Keywords: Atrial mass, nonseminomatous germ-cell tumor, posterior mediastinum, pulmonary vein
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.
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].
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].
Simultaneously, CT-guided biopsy was performed. Histopathology of biopsy tissue was suggestive of nonseminomatous germ-cell tumor (NSGCT) [Figure 5].
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.
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.[1] 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.[2] Metastasis to the heart is rarely reported.[3] 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.[4] 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.[3],[5] 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.[6] 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.[7] The five-year survival rate is 90% without distant metastases and 60% with distant metastases.[8] 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.
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 Nil. Conflicts of interest There are no conflicts of interest.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
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