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CASE REPORT
Year : 2015  |  Volume : 25  |  Issue : 4  |  Page : 111-112

Beyond thrombus detection: The role of multimodality imaging approach


1 Department of Cardiology, Humanitas Gavazzeni Hospital, Via M. Gavazzeni 21, 24125 Bergamo, Italy
2 Department of Cardiology, Careggi Hospital, Largo Brambilla 3, Firenze, Italy
3 Department of Radiology, Humanitas Gavazzeni Hospital, Via M. Gavazzeni 21, 24125 Bergamo, Italy

Date of Web Publication22-Dec-2015

Correspondence Address:
Maria Chiara Todaro
Via San Filippo Bianchi, 36 98122 Messina
Italy
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2211-4122.172489

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  Abstract 

We present a very rare case of paraneoplastic syndrome characterized by the unusual coexistence of a left ventricular apical thrombus and pulmonary embolism as the first manifestation of an unrecognized lung adenocarcinoma.

Keywords: Multimodality imaging, paraneoplastic syndrome, thrombus


How to cite this article:
Todaro MC, Sirianni G, Innocenti L, Solazzo A, Zanello A, Piti A. Beyond thrombus detection: The role of multimodality imaging approach. J Cardiovasc Echography 2015;25:111-2

How to cite this URL:
Todaro MC, Sirianni G, Innocenti L, Solazzo A, Zanello A, Piti A. Beyond thrombus detection: The role of multimodality imaging approach. J Cardiovasc Echography [serial online] 2015 [cited 2020 Aug 13];25:111-2. Available from: http://www.jcecho.org/text.asp?2015/25/4/111/172489


  Introduction Top


Multimodality imaging represents the best approach for left ventricular (LV) masses detection. [1],[2]

It is crucial for differential diagnosis among cardiac primary tumors, secondary lesions, and thrombotic masses. Echocardiography, cardiac computer tomography, and cardiac magnetic resonance (CMR) are the main imaging techniques used for this purpose.


  Case report Top


A 51-year-old man was admitted to the Emergency Department for dyspnea at rest.

He presented with stable hemodynamic and oxygenation parameters and an elevated D-dimer (9966 mg/dl) at laboratory tests.

A thoracic cardiac tomography scan was performed, showing a pulmonary embolism of the main right pulmonary artery [Figure 1]a and an intracardiac mass localized in the apical region of the left ventricle [Figure 1]b.
Figure 1: (a and b) A thoracic computer tomography scan shows pulmonary embolism of the main right pulmonary artery and an intracardiac mass. (c) A two-dimensional transthoracic echocardiography, four chamber view, shows a homogeneous mass into the left ventricular apex. (d and e) At cardiac magnetic resonance, the mass showed lower signal intensity at T2-weighted sequences and a dark appearance after early and late gadolinium administration, typical for thrombotic lesions. (f) Late gadolinium enhancement sequences highlight a region of apical fibrosis due to an old myocardial infarction scar

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A two-dimensional trans-thoracic echocardiography showed in four chamber view, an apical akinesia of the left ventricle due to a prior myocardial infarction, with mild global LV dysfunction (ejection fraction 45%) and confirmed the presence of a mobile, homogeneous, echogenic mass, partially adherent to the LV apex [Figure 1]c.

To further characterize the LV mass, a CMR was carried out. The cine CMR sequences demonstrated a "flame-shaped" endocavitary image, localized in the LV apex.

The mass showed lower signal intensity at T2-weighted sequences and a very dark appearance after early and late gadolinium administration [Figure 1]d and e; moreover, late gadolinium enhancement distribution highlighted a region of apical fibrosis due to an old myocardial infarction scar [Figure 1]f. A paraneoplastic syndrome (Trousseau's) was suspected, and a diagnostic work out for lung cancer was carried out, demonstrating an advanced stage lung adenocarcinoma.


  Discussion Top


Thromboembolism is a common complication in patients with malignant disease, representing a major cause of morbidity and mortality in this subset of patients. [3]

Several risk factors for developing venous thrombosis usually coexist in cancer patients including surgery, hospital admissions, and immobilization, the presence of an indwelling central catheter, chemotherapy, use of erythropoiesis-stimulating agents and is possibly related to genetic predisposition. [4] However, the coexistence of LV apical thrombosis and pulmonary embolism is quite unique as the first manifestation of an unrecognized lung adenocarcinoma. Our case highlights two main aspects: The presence of multiple thrombotic masses in the cardiovascular system should lead to the suspicion of a severe prothrombotic state such as metastatic cancer; the widespread use of multimodality imaging techniques has greatly increased the diagnostic accuracy of cardiac masses through a better tissue characterization of lesions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Bugan B, Onar LC. Multimodal imaging approach to intracardiac masses for proper diagnosis, measurement, and definitive surgery. Turk Kardiyol Dern Ars 2013;41:465.  Back to cited text no. 1
    
2.
Kirmani BH, Binukrishnan S, Gosney JR, Pullan DM. Left ventricular apical masses: Distinguishing benign tumours from apical thrombi. Eur J Cardiothorac Surg 2015. pii: ezv098.  Back to cited text no. 2
    
3.
Elyamany G, Alzahrani AM, Bukhary E. Cancer-associated thrombosis: An overview. Clin Med Insights Oncol 2014;8:129-37.  Back to cited text no. 3
    
4.
Villa A, Eshja E, Dallavalle S, Bassi EM, Turco A. Cardiac metastases of melanoma as first manifestation of the disease. J Radiol Case Rep 2014;8:8-15.  Back to cited text no. 4
    


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