Case Race

HEAPHY 1 & 2CASE RACE 1 DIAGDelia DEPHOFF

Sat 31st Aug 2013Session 3 / CR1-713:31 13:35WAIKATO / BAY OF PLENTY

ABSTRACTThis case study is of a patient with leimyosarcoma in their lower leg, who had a CT scan which showed a metastasis which is rarely seen. 1Case RaceNZIMRT Annual ConferenceHamilton 2013Delia DephoffRare Metastasis

2Patient50 year oldMaleCT chest abdomen and pelvis3Previous ImagingInitial US of right legshowed abnormal mass within anterior musculature in right leg3 days later MRI right lower leg pre and post contrast large enhancing soft tissue mass, appearance suggestive of a soft tissue sarcoma

4Previous imagingNext day CT chest, abdo, pelvis for staging. multiple pulmonary nodules concerning for metastases. No additional evidence of metastatic disease elsewhere within the abdomen or pelvis2 weeks later MRI Brain no evidence of intracranial metastatic disease

Then 8 weeks later:

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Request : CT Chest, Abdo/PelvisIndication: Metastatic sarcoma (leiomyosarcoma), Baseline CT prior to chemotherapy

6LeiomyosarcomaMalignant tumour arising from smooth muscle tissueBlood vessels, heart, liver, pancreas, genitourinary and gastrointestinal tracts, retroperitoneum, uterus (most common) and skin(WebMD, 2012)7

Imaging Protocol: CT CAPContrast: oral and intravenous Pre-contrast: liverArterial: chest and liver, Portal venous: abdomen and pelvisDelayed: liverRecons: 5mm axial, sagittal and coronalWindows: lung, mediastinum and abdomen

8Findings Abdomen and PelvisMultiple hypoattenuating lesions in liver developed since prior scan consistent with metastases.

A 31mm right adrenal mass is also seen which has developed since the prior examination and is consistent with metastatic disease.9

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11Adrenal MetastasesOften found at autopsyCommonly asymptomaticDetected as one of multiorgan mets(Lam & Lo, 2002)Common site of metastatic deseaseCT and MRI shows it to be more prevalent than previously thought.Diagnosis is important as invariably influences choice of treatmentMelanoma, lung cancer, breast cancer(Goh, 2011)12Findings - ThoraxNumerous pulmonary nodules are seen significantly increased in number and size since prior chest CT. No significant mediastinal lymphadenopathy seen. Left hilar lymphadenopathy is seen. No pleural effusions or pneumothorax are seen.

But what else can be seen?

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15FindingsA 2.2 x 1.8cm enhancing mass is seen in the left ventricle arising from the interventricular septum. This has developed since the prior examination and in this patient with known leiomyosarcoma this most likely represents a metastatic deposit. No pericardial effusion is seen.16Cardiac MetastasesOccur more frequently than primary tumours Intracavity growth is unusual (more common with a primary tumour)Rarely gain clinical attentionCardiac metastasis symptoms often overlooked because symptoms of disseminated tumor prevail(Reynen, Kckeritz & Strasser, 2004)17Cardiac MetastasesSecondary may not be as rare as it appearsOften undiagnosed and found on post mortemCan be asymptomatic, Symptoms can include: SOB, hypotension, tachycardia, clinical findings suggestive of tamponadeNeoplastic pericardial effusions (Bussani, De-Georgio, Abbate & Silvestri, 2007)18SummaryCardiac metastases are rarely foundProbably occur more often than thoughtOften go undetected because overshadowed by symptoms from other metastases

Sadly this patient passed away earlier this year. 19ReferencesBussani, R., De-Georgio, F., Abate, A., & Silvestri, F. (2007). Cardiac metastases. In Journal of Clinical Pathology. January, 60(1): 27-34 doi: 10.1136/jcp.2005.035105Reynen, K., Kckeritz, U., & Strasser, R.H. (2004). Metastases to the heart. In Annals of Oncology 15: 375-381 DOI: 10.1093/annonc/mdh086 downloaded from http://amnoc.oxfordjournals.org May 1, 2013Goh, J. (2011) Imaging in adrenal metastases. In Medscape reference Drugs, diseases and procedures. Downloaded from http://emedicine.medscape.com/article/376585-overview on May 10 2013Lam, K.Y., Lo, C.Y. (2002). Metastatic tumours of the adrenal glands: a 30 year experience in a teaching hospital. In Clinical endocrinology Jan;56(1):95-101. Downloaded from http://www.ncbi.nlm.nih.gov/pubmed/11849252 WebMD (2012). Cancer Health Centre, Leiomyosarcoma, General. Updated May 16 2012. Downloaded July 24th 2013 from http://www.webmed.com/cancer/leiomyosarcoma-general

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