THE TUMOR PLOP WHO CRIED WOLF: A CASE OF METASTATIC CARDIAC ANGIOSARCOMA

Abstract

SESSION TITLE: Monday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Cardiac sarcomas are extremely rare, primary malignant tumors arising from the heart or great vessels. Due to their complex nature and infrequency, there is often a delay in diagnosis and thus, a dismal prognosis. Here, we review the case of a patient who presented with a constellation of symptoms that, over many weeks, led to the final diagnosis of metastatic cardiac angiosarcoma. CASE PRESENTATION: Our patient is a 63 year-old female with history of type 2 diabetes. She was undergoing an outpatient workup for multiple myeloma and was found to have worsening anemia, renal function and hip pain, secondary to a pathologic ischial fracture. On initial presentation, her chief complaint was progressive dyspnea. Physical exam was notable for tachypnea and tachycardia, and she was found to have an elevated D-dimer. CT angiogram of her chest was negative for pulmonary embolism, however, revealed a large left atrial mass with possible extension into the ventricle and bilateral pleural effusions. The multi-lobulated mass measured approximately 3 x 4 cm on echocardiogram. Secondary metastasis to the heart or primary benign myxoma was initially suspected. Further study with cardiac MRI determined that the mass was centered over the ostium of the left inferior pulmonary vein and covered in thrombus, thus favoring the diagnosis of sarcoma. Biopsy of the pathologic hip fracture was also consistent with metastatic sarcoma. Upon further staging, she was noted to have several abdominal soft tissue nodules, scattered lytic bony lesions, and a filling defect within the proximal jejunum. Initial treatment consisted of diuresis, steroids, bisphosphonates, as well as Lovenox for the associated thrombus. Later, she developed sharp abdominal discomfort and was found to have jejunal intussusception. EGD revealed an adjacent duodenal ulcer and biopsy with immunohistochemical studies was consistent with metastatic cardiac angiosarcoma. Given the location and size of the atrial tumor, surgical resection was not an option. The patient was started on a trial of olaratumab, typically used in soft-tissue sarcomas, and doxorubicin with possible future palliative radiation. Over the next six months, after multiple admissions with various complications and worsening pain, she elected to pursue hospice care. She passed away peacefully at home, approximately one year after her initial presentation. DISCUSSION: This case illustrates a complex case of metastatic cardiac angiosarcoma. Given the late presentation with distant metastasis to various sites within the abdomen and bone, it serves as an example of the devastating effects this rare form of cancer can have. CONCLUSIONS: The complex location of the mass and its paroxysmal extension through the mitral valve into the left ventricle likely caused transient mitral regurgitation and pulmonary hypertension, which likely caused her initial dyspnea on presentation. Reference #1: Patel SD, Peterson A, Bartczak A, et al. Primary cardiac angiosarcoma - a review. Med Sci Monit. 2014;20:103-9. Published 2014 Jan 23. https://doi.org/10.12659/MSM.889875 DISCLOSURES: No relevant relationships by Logan Rhea, source=Web Response