Embolic Stroke as a Result of an Intracardiac Metastatic Lung Cancer.

SESSION TITLE: Cancer Student/Resident Case Report Posters IIISESSION TYPE: Medical Student/Resident Case ReportPRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PMINTRODUCTION: Metastatic cardiac tumors are relatively uncommon, and are generally seen with highly disseminated disease. We present a case of a patient with an embolic stroke secondary to a metastatic left ventricular (LV) mass from an undiagnosed adenocarcinoma of the lung.

CASE PRESENTATION: A 69 year old female with no significant past medical history presented with acute onset right hemiparesis and slurring of speech. On admission patient was found in respiratory failure and shock requiring endotracheal intubation and vasopressors. Head computed tomography (CT) angiogram reported multiple areas of lucency involving the posterior aspect of the right corona radiata and the external capsule, reflecting sites of infarction with no evidence of intracranial hemorrhage. Due to high risk of hemorrhagic conversion therapy with tissue plasminogen activator (TPA) was deferred. On day 2 of admission head CT showed multiple new small ischemic infarcts of the left basal ganglia and left anterior temporal lobe. Echocardiogram revealed a normal LV ejection fraction and a ~1x1x2cm pedunculated mass originating from the left ventricle anteroapex. Bubble study was negative for patent foramen ovale. Furthermore, chest CT revealed occlusion of the left mainstem bronchus with complete opacification of the left hemithorax by a large left-sided pleural effusion. Chest tube was placed, draining 2 litters of exudative serous fluid. Intravenous heparin was started to prevent further embolic events. Bronchoscopy was performed recording no visible endobronchial lesions. Initial cytology from bronchoalveolar lavage was negative for malignancy; however cytology from pleural effusion showed malignant cells positive for Cytokeratin 7, TTF-1, Moc-31 and EGFR overexpression. These findings were consistent with primary adenocarcinoma of the lung. Ultimately patient was extubated and discharged home on oral anticoagulation with plans to start outpatient chemotherapy.DISCUSSION: Metastatic disease to the heart is a rare finding; however large autopsy studies showed intracardiac metastases in up to 15% of patients with lung cancer. Remarkably, these metastases are clinically silent, especially when obscured by the symptoms of the disseminated tumor disease. Clinical manifestations can result from involvement of the pericardium causing pericardial effusion; and when intracavitary, they can cause heart failure or embolization to distal organs. In our case an embolic stroke secondary to a metastatic intracardiac mass makes this initial presentation of adenocarcinoma of the lung a very unique scenario.

CONCLUSIONS: Our case serves as an important reminder that lung cancer can present in very diverse ways and that sometimes there is more history behind an ischemic stroke.Reference #1: Majano-Lainez RA, Cardiac tumors: a current clinical and pathological perspective. Crit Rev Oncog 1997;8:293-303. Reference #2: Fiala W. Heart metastasis of malignant tumors. Schweiz Med Wochenschr 1982;112:1497-501.

DISCLOSURE: The following authors have nothing to disclose: Narjust Perez-Florez, Yulanka Castro, Sean SadikotNo Product/Research Disclosure Information.