Intracardiac metastasis from known renal cell cancer
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Past of history of renal cell carcinoma, had nephrectomy 3 years ago. She has had metastases to the lung and mediastinum. Recently she complained of exertional dyspnea and shortness of breath. Echo showed 2 cm mass within the right ventricular cavity adherent to the right ventricular wall and the in-ventricular septum. MRI was obtained to differentiate metastases/tumor thrombus from a bland thrombus.
A well circumscribed Intracardiac mass within the right ventriclar cavity adherent to the interventricular septum. The mass shows high signals on native T1 and T2 sequences. There is bright signal on triple IR sequence. On dynamic first-pass perfusion, there is the hereogenous enhancement of the mass, in keeping up with mixed intensities. There is lack of complete nulling of the mass on the delayed Ti 600, post contrast IR sequence, this is constant with true mass rather than a bland thrombus.
Cardiac metastasis is not uncommon, however, the main challenge is to get the correct protocol to be able to diagnose intracardiac metastases with high accuracy. The commonest intracardiac mass is a bland thrombus. The key sequences to diagnose intracardiac metastases or mass versus thrombus are the first pass perfusion as well as the IR post contrast at Ti of 600 ms.
This is a case of renal cell cancer (RCC) that has metastases to the bones, lung, and brain. The intracardiac mass was depicted on echo, which was negative few months ago, the role of MRI is to differentiate metastases from a bland thrombus. There is increased signal on triple IR. On perfusion, there is heterogeneous enhancement the mass, suggestive of mixed intensities, and the presence of some blood products within the mass, which is a common finding with RCC metastases (which are hypervascular). Also, there is lack of complete nulling of the mass on the prolonged IR 600 POST. If there is complete nulling of the mass this would suggest a bland thrombus.