Transcript Case Race
Sat 31st Aug 2013 Session 3 / CR1-7 13:31 – 13:35 HEAPHY 1 & 2 CASE RACE 1 – DIAG Delia DEPHOFF WAIKATO / BAY OF PLENTY ABSTRACT This 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. Rare Metastasis Case Race NZIMRT Annual Conference Hamilton 2013 Delia Dephoff Patient 50 year old Male CT chest abdomen and pelvis Previous Imaging Initial US of right leg showed abnormal mass within anterior musculature in right leg 3 days later MRI right lower leg pre and post contrast large enhancing soft tissue mass, appearance suggestive of a soft tissue sarcoma Previous imaging Next day CT chest, abdo, pelvis for staging. multiple pulmonary nodules concerning for metastases. No additional evidence of metastatic disease elsewhere within the abdomen or pelvis 2 weeks later MRI Brain no evidence of intracranial metastatic disease Then 8 weeks later: Request : CT Chest, Abdo/Pelvis Indication: Metastatic sarcoma (leiomyosarcoma), Baseline CT prior to chemotherapy Leiomyosarcoma Malignant tumour arising from smooth muscle tissue Blood vessels, heart, liver, pancreas, genitourinary and gastrointestinal tracts, retroperitoneum, uterus (most common) and skin (WebMD, 2012) Imaging Protocol: CT CAP Contrast: oral and intravenous Pre-contrast: liver Arterial: chest and liver, Portal venous: abdomen and pelvis Delayed: liver Recons: 5mm axial, sagittal and coronal Windows: lung, mediastinum and abdomen Findings – Abdomen and Pelvis Multiple 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. Adrenal Metastases Often found at autopsy Commonly asymptomatic Detected as one of multiorgan mets (Lam & Lo, 2002) Common site of metastatic desease CT and MRI shows it to be more prevalent than previously thought. Diagnosis is important as invariably influences choice of treatment Melanoma, lung cancer, breast cancer (Goh, 2011) Findings - Thorax “Numerous 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? Findings “A 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.” Cardiac Metastases Occur more frequently than primary tumours Intracavity growth is unusual (more common with a primary tumour) Rarely gain clinical attention Cardiac metastasis symptoms often overlooked because symptoms of disseminated tumor prevail (Reynen, Köckeritz & Strasser, 2004) Cardiac Metastases Secondary may not be as rare as it appears Often undiagnosed and found on post mortem Can be asymptomatic, Symptoms can include: SOB, hypotension, tachycardia, clinical findings suggestive of tamponade Neoplastic pericardial effusions (Bussani, De-Georgio, Abbate & Silvestri, 2007) Summary Cardiac metastases are rarely found Probably occur more often than thought Often go undetected because overshadowed by symptoms from other metastases Sadly this patient passed away earlier this year. References Bussani, 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.2005.035105 Reynen, K., Köckeritz, 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, 2013 Goh, 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 2013 Lam, 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