Heavy smoker means lung tumor?

Clinical History

Heavy smoker admitted to the emergency service for increasing dyspnea, fatigue and progressive weight-loss. No relevant prior history

Imaging Findings

A chest radiography was performed, showing a suspicious opacity at the middle-low pulmonary region (figure 1) and a Computed Tomography (CT) scan was suggested. CT revealed a pre-vascular para-cardiac solid mass of 10,5x6 cm, extended cranio-caudally for 9 cm, with not homogenous enhancement post iodine contrast administration (figure 2). Since the lesion did not present distinct limits with the near cardiovascular structures, a cardiac Magnetic Resonance (MR) was requested. Cardiac MR study was performed with electrocardiographic and respiratory trigger. MR demonstrated an intra-pericardial polilobulated mass, leaning on the antero-lateral left ventricle wall (figure 3) and determining right deviation of heart axis. The lesion was isointense in T1 weighted sequences (figure 4) and slightly hyperintense in T2 weighted sequences to myocardium (figure5) with early enhancement during Gadolinium contrast injection (figure 6). The boundaries of the lesion were not clearly defined especially at cardiac apex level where myocardial infiltration was not excluded. Pericardial effusion was present. A CT guided cardiac biopsy was performed; histology showed high grade undifferentiated pleomorphic sarcoma, with no specific immunohistochemical markers.

Discussion

The overall frequency of cardiac tumors is low (0,002-0,3%) and the majority of them is benign. Primary cardiac malignancies are very rare: angiosarcoma is the commonest of adulthood whereas rhabdomyosarcoma is more prevalent in childhood. Cardiac MR imaging is an established technique in the evaluation of cardiac tumors, because it permits a multiplanar localization and assessment of involvement and functional impact of the lesion. Moreover cardiac MR allows to tissue characterization, despite the limit of demonstrating calcium, being adequate for most intra-cavity lesions. Undifferentiated sarcomas are sarcomas with no specific histologic markers and they are the 2^nd most common primary malignancy with a prevalence of 24-37,5%. Sarcomas are tumors of the adulthood, manifesting typically in the fifties with symptoms of dyspnea, chest pain and weight-loss. The 80% of tumors arises in the left atrium, although they can involve other cardiac chambers, valves and pericardium. MR descriptions are rare, but sarcomas generally appear as isointense irregular mass infiltrating the myocardium. The tumor can have a heterogeneous appearance on T1 weighted images with areas of intermediate and low signal reflecting tumor tissue and necrosis and hyperintense appearance on T2 weighted images. The enhancement is heterogeneous, sometimes with marked surface enhancement. Tumor infiltration of myocardium may appear as thickening and irregularity. The tumor may also manifest it-self as a hemorrhagic mass replacing the pericardium, similar to angiosarcoma.

Differential Diagnosis List

Final Diagnosis

Undifferentiated pleomorphic sarcoma.

URL:	https://eurorad.org/case/5937
DOI:	10.1594/EURORAD/CASE.5937
ISSN:	1563-4086