SHARE @ Advocate Health - Midwest - Scientific Day: Testicular Embryonal Carcinoma Presenting as Right Ventricular Outflow Tract Obstruction – A Case Report
 

Affiliations

Aurora St. Luke's Medical Center

Abstract

Introduction/Background:

The most common etiologies of intracardiac masses include myxoma, fibroelastoma, sarcoma, endocarditis, and metastatic tumors. Cardiac masses of testicular origin are rare. These are commonly found due to respiratory distress, cerebrovascular event, or severe anemia. Given the dynamic nature of these masses, our case supports the need for repeat cardiac imaging to prevent embolization.

Description:

A 37-year-old male with a noncontributory history presented with shortness of breath and right leg pain. He was diagnosed with intracardiac mass in the setting of suspected testicular cancer. A grade 4/6 systolic murmur at the left upper sternal border was appreciated. Imaging showed a right testicular mass, retroperitoneal lymphadenopathy, DVT, PE, and a right ventricular (RV) filling defect. Cardiac MRI displayed a 6.5 cm mass in the right ventricle causing outflow tract obstruction. A lymph node biopsy showed embryonal carcinoma, likely testicular in origin. His shortness of breath was attributed to PE and obstructive RV mass. He was anticoagulated and started on chemotherapy. Surgical intervention was deferred due to the likelihood that the RV mass would respond to chemotherapy. Two weeks later, he returned with worsening right leg pain after apixaban was held for 48 hours for chemotherapy port placement. Repeat imaging showed increasing mobile RV mass prolapsing through the pulmonic valve and advancing DVT. Percutaneous removal of the thrombus using expression thrombectomy catheter was considered. However, since the mass was directly below the tricuspid valve, he underwent surgical open approach embolectomy through the right atrium. Pathology showed atypical endothelial cells which stained positive for cytokeratin, a diagnostic marker for embryonal carcinoma metastases.

Discussion:

In young, healthy individuals, the presence of a RV mass and VTE should raise concern for malignancy. Holding anticoagulation may increase the risk of thromboembolism and should be limited. Clinicians must consider whether to pursue chemotherapy, percutaneous intervention, or surgical intervention accounting for risk factors, comorbidities, and decompensation. Increased mobility, location, and size of the mass may necessitate an expedited surgical approach over less invasive options. Close follow-up with repeat ECHO or cardiac MRI may improve outcomes by monitoring mobility to help prevent embolization. Future studies to determine the appropriate interval for imaging of intracardiac masses are needed.

Presentation Notes

Presented at Scientific Day; May 21, 2025; Park Ridge, IL.

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May 21st, 11:41 AM May 21st, 1:15 PM

Testicular Embryonal Carcinoma Presenting as Right Ventricular Outflow Tract Obstruction – A Case Report

Introduction/Background:

The most common etiologies of intracardiac masses include myxoma, fibroelastoma, sarcoma, endocarditis, and metastatic tumors. Cardiac masses of testicular origin are rare. These are commonly found due to respiratory distress, cerebrovascular event, or severe anemia. Given the dynamic nature of these masses, our case supports the need for repeat cardiac imaging to prevent embolization.

Description:

A 37-year-old male with a noncontributory history presented with shortness of breath and right leg pain. He was diagnosed with intracardiac mass in the setting of suspected testicular cancer. A grade 4/6 systolic murmur at the left upper sternal border was appreciated. Imaging showed a right testicular mass, retroperitoneal lymphadenopathy, DVT, PE, and a right ventricular (RV) filling defect. Cardiac MRI displayed a 6.5 cm mass in the right ventricle causing outflow tract obstruction. A lymph node biopsy showed embryonal carcinoma, likely testicular in origin. His shortness of breath was attributed to PE and obstructive RV mass. He was anticoagulated and started on chemotherapy. Surgical intervention was deferred due to the likelihood that the RV mass would respond to chemotherapy. Two weeks later, he returned with worsening right leg pain after apixaban was held for 48 hours for chemotherapy port placement. Repeat imaging showed increasing mobile RV mass prolapsing through the pulmonic valve and advancing DVT. Percutaneous removal of the thrombus using expression thrombectomy catheter was considered. However, since the mass was directly below the tricuspid valve, he underwent surgical open approach embolectomy through the right atrium. Pathology showed atypical endothelial cells which stained positive for cytokeratin, a diagnostic marker for embryonal carcinoma metastases.

Discussion:

In young, healthy individuals, the presence of a RV mass and VTE should raise concern for malignancy. Holding anticoagulation may increase the risk of thromboembolism and should be limited. Clinicians must consider whether to pursue chemotherapy, percutaneous intervention, or surgical intervention accounting for risk factors, comorbidities, and decompensation. Increased mobility, location, and size of the mass may necessitate an expedited surgical approach over less invasive options. Close follow-up with repeat ECHO or cardiac MRI may improve outcomes by monitoring mobility to help prevent embolization. Future studies to determine the appropriate interval for imaging of intracardiac masses are needed.

 

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