International Journal of Cardiology 173 (2014) e35–e37
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Contrast-enhancing right atrial thrombus in cancer patient Pietro Pugliatti a,⁎, Rocco Donato b, Gianluca Di Bella a, Scipione Carerj a, Salvatore Patanè c a b c
Clinical and Experimental Department of Medicine and Pharmacology, University of Messina, Italy Department of Radiological Sciences, University of Messina, Italy Cardiologia Ospedale San Vincenzo, Taormina (Me) Azienda Sanitaria Provinciale di Messina, Contrada Sirina, 98039 Taormina, Messina, Italy
a r t i c l e
i n f o
Article history: Received 4 March 2014 Accepted 9 March 2014 Available online 15 March 2014 Keywords: Echocardiography Right atrial mass Cardiac magnetic resonance
The progress in cancer knowledge and treatment has led to a new frontier: the cardio-oncology [1–11]. Cancer patients can benefit from an open dialogue between both cardiologists and oncologists [1] for the optimal effective patient care. Increasing evidence suggests that the role of IE antibiotic prophylaxis remains a dark side of the cardio-oncology prevention [12,13] as well as the role of the thromboembolism prophylaxis [14–24]. The increased thromboembolism risk in cancer patients [19,20] is influenced by the type of cancer, its stage and histology, the presence of thrombophilia, concomitant and previous treatments, metastatic-stage malignancy [25], vascular catheter presence [15], and paraneoplastic hypercoagulability [17,18,20,25]. Patient-, cancer-, and treatment-related factors should be taken under consideration in the assessment of individual venous thromboembolism risk [25]. We present a case of a right atrial mass in a 57-year-old Italian woman. She reported a history of diabetes mellitus, a history of smoking, a sotalol treatment and a lymphoma chemotherapy treatment. Echocardiographic evaluation revealed a right atrial mass (Fig. 1) [26,27]. The discovery of a mass in the right atrium obliges the clinician to perform a broad differential diagnosis among a tumour, vegetations on the tricuspid valve, an atrial thrombus and Chiari network [26]. Cardiac magnetic resonance [27,28] identified right atrial mass as an atrial thrombus
⁎ Corresponding author at: Unità Operativa Complessa di Cardiologia, Azienda Ospedaliera Universitaria Policlinico “G. Martino” di Messina, Via Consolare Valeria N 1, 98125 Messina, Italy. Tel./fax: +39 0902213531. E-mail address: [email protected] (P. Pugliatti).
http://dx.doi.org/10.1016/j.ijcard.2014.03.043 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
originated from the superior vena cava. Also this case focuses attention on increased thromboembolism risk in cancer patients and on the importance of the thromboembolism prophylaxis. Acknowledgements The authors of this manuscript have certified that they adhere to the statement of ethical publishing as appears in International Journal of Cardiology. Author contributions: Pietro Pugliatti and Salvatore Patanè wrote the work; Pietro Pugliatti and Scipione Carerj prepared Fig. 1 and its legend and they also prepared the references; Rocco Donato and Gianluca di Bella prepared Fig. 2 and its legend. References [1] Patanè S. A dark side of the cardio-oncology: the bacterial endocarditis prophylaxis. Int J Cardiol Jun 14 2012;157(3):448–9. [2] Conti E, Romiti A, Musumeci MB, et al. Arterial thrombotic events and acute coronary syndromes with cancer drugs: are growth factors the missed link?: what both cardiologist and oncologist should know about novel angiogenesis inhibitors. Int J Cardiol Sep 10 2013;167(6):2421–9. [3] Rateesh S, Luis SA, Luis CR, Hughes B, Nicolae M. Myocardial infarction secondary to 5-fluorouracil: not an absolute contraindication to rechallenge? Int J Cardiol Mar 15 2014;172(2):e331–3. [4] Kurisu S, Iwasaki T, Ishibashi K, Mitsuba N, Dohi Y, Kihara Y. Comparison of treatment and outcome of acute myocardial infarction between cancer patients and non-cancer patients. Int J Cardiol Sep 1 2013;167(5):2335–7. [5] Scott JM, Jones LW, Hornsby WE, et al. Cancer therapy-induced autonomic dysfunction in early breast cancer: implications for aerobic exercise training. Int J Cardiol Feb 1 2014;171(2):e50–1. [6] Claridge S, Chakrabarti A, Greaves K, Boos CJ. Successful use of Trastuzumab following cardiac resynchronisation therapy. Int J Cardiol Jun 20 2013;166(2):e33–4. [7] Lotrionte M, Palazzoni G, Abbate A, et al. Cardiotoxicity of a non-pegylated liposomal doxorubicin-based regimen versus an epirubicin-based regimen for breast cancer: the LITE (Liposomal doxorubicin-Investigational chemotherapy-Tissue doppler imaging Evaluation) randomized pilot study. Int J Cardiol Aug 10 2013;167(3):1055–7. [8] Kaya MG, Ozkan M, Gunebakmaz O, et al. Protective effects of nebivolol against anthracycline-induced cardiomyopathy: a randomized control study. Int J Cardiol Sep 1 2013;167(5):2306–10. [9] Wang KL, Liu CJ, Chao TF, et al. Long-term use of angiotensin II receptor blockers and risk of cancer: a population-based cohort analysis. Int J Cardiol Sep 1 2013;167(5):2162–6. [10] Patanè S, Marte F, Sturiale M, Dattilo G. ST-segment elevation and diminution of prostate-specific antigen in a patient with coronary spasm and without significant coronary stenoses. Int J Cardiol Apr 14 2011;148(2):e31–3. [11] Pugliatti P, Donato R, Grimaldi P, et al. Extrinsic pulmonary stenosis in primary mediastinal B-cellular lymphoma. J Clin Ultrasound Jan 22 2014. http://dx.doi.org/ 10.1002/jcu.22133. [12] Patanè S. Is there a need for bacterial endocarditis prophylaxis in patients undergoing urological procedures? J Cardiovasc Transl Res 2014 Feb 25.
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P. Pugliatti et al. / International Journal of Cardiology 173 (2014) e35–e37
Fig. 1. Echocardiographic evaluation revealed a right atrial mass.
[13] Patanè S. Is there a need for bacterial endocarditis prophylaxis in patients undergoing gastrointestinal endoscopy? J Cardiovasc Transl Res 2014 Feb 25. [14] Pugliatti P, De Gregorio C, Patanè S. The chance finding of echocardiographic complications of infective endocarditis. Int J Cardiol Nov 29 2012;161(3):e50–1. [15] Hu YF, Liu CJ, Chang PM, et al. Incident thromboembolism and heart failure associated with new-onset atrial fibrillation in cancer patients. Int J Cardiol May 10 2013;165(2):355–7. [16] Chopra V, Anand S, Hickner A, et al. Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and metaanalysis. Lancet Jul 27 2013;382(9889):311–25. [17] Busch A, Tschernitz S, Thurner A, Kellersmann R, Lorenz U. Fatal paraneoplastic embolisms in both circulations in a patient with poorly differentiated neuroendocrine tumour. Case Rep Vasc Med 2013;2013:739427.
[18] Lee YG, Kim I, Lee E, et al. Risk factors and prognostic impact of venous thromboembolism in Asian patients with non-small cell lung cancer. Thromb Haemost Jan 30 2014;111(6). [19] Budaj-Fidecka A, Kurzyna M, Fijałkowska A, et al. ZATPOL Registry Investigators. Inhospital major bleeding predicts mortality in patients with pulmonary embolism: an analysis of ZATPOL Registry data. Int J Cardiol Oct 9 2013;168(4):3543–9. [20] Larsen AC, Dabrowski T, Frøkjaer JB, et al. Prevalence of venous thromboembolism at diagnosis of upper gastrointestinal cancer. Br J Surg Feb 2014;101(3):246–53. [21] Tanasanvimon S, Garg N, Viswanathan C, et al. High prevalence of recurrent thrombosis in subsets of cancer patients with isolated gonadal vein thrombosis: a single center retrospective study. Thromb Res Feb 2014;133(2):154–7. [22] Burbury K. Haemostatic challenges in the cancer patient: focus on the perioperative period. Best Pract Res Clin Anaesthesiol Dec 2013;27(4):493–511.
Fig. 2. Right atrium thrombi (white asterisks) show a typical hypointense appearance on steady state gradient echo sequence (panels B and C) and on the early images acquired postcontrast administration (panel D, white asterisk) and hypointense appearance on T1-weighted sequence. The white arrow heads in panels A, C, D show the continuation of the thrombus in the superior vena cava (SVC). The white arrow in panel b shows the coexistence of aortic regurgitation. Panel A: T1-weighted magnetic resonance imaging in coronal plane. Panel B: Steady state gradient echo sequence in coronal plane. Panel C: Steady state gradient echo sequence in right two chamber view. Panel D: Contrast-enhanced magnetic resonance imaging (MRI) in right two chamber view. Typically, intracardiac thrombi remain hypointense after contrast injection [27].
P. Pugliatti et al. / International Journal of Cardiology 173 (2014) e35–e37 [23] Christensen TD, Vad H, Pedersen S, et al. Venous thromboembolism in patients undergoing operations for lung cancer: a systematic review. Ann Thorac Surg Feb 2014;97(2):394–400. [24] Shah DR, Dholakia S, Shah RR. Effect of tyrosine kinase inhibitors on wound healing and tissue repair: implications for surgery in cancer patients. Drug Saf Mar 14 2014;37(3):135–49. [25] Streiff MB. Managing breast cancer in the older patient. Clin Adv Hematol Oncol Jun 2013;11(6):349–57.
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[26] Patanè S, Anfuso C, Marte F, Minutoli F, Di Bella G, Coglitore S. An unusual presentation of a right atrial Chiari network. Int J Cardiol Feb 6 2009;132(1): e28–30. [27] Öksüz F, Akyel A, Örnek E, Kurtul A, Murat SN. Catastrophic result of a huge right atrial mass. Int J Cardiol Jan 10 2013;162(2):e31. [28] Donato R, Ganame J, Bogaert J. Contrast-enhancing left ventricular apical thrombus. Eur Heart J Aug 2009;30(16):1977.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Contrast-enhancing right atrial thrombus in cancer patient Pietro Pugliatti a,⁎, Rocco Donato b, Gianluca Di Bella a, Scipione Carerj a, Salvatore Patanè c a b c
Clinical and Experimental Department of Medicine and Pharmacology, University of Messina, Italy Department of Radiological Sciences, University of Messina, Italy Cardiologia Ospedale San Vincenzo, Taormina (Me) Azienda Sanitaria Provinciale di Messina, Contrada Sirina, 98039 Taormina, Messina, Italy
a r t i c l e
i n f o
Article history: Received 4 March 2014 Accepted 9 March 2014 Available online 15 March 2014 Keywords: Echocardiography Right atrial mass Cardiac magnetic resonance
The progress in cancer knowledge and treatment has led to a new frontier: the cardio-oncology [1–11]. Cancer patients can benefit from an open dialogue between both cardiologists and oncologists [1] for the optimal effective patient care. Increasing evidence suggests that the role of IE antibiotic prophylaxis remains a dark side of the cardio-oncology prevention [12,13] as well as the role of the thromboembolism prophylaxis [14–24]. The increased thromboembolism risk in cancer patients [19,20] is influenced by the type of cancer, its stage and histology, the presence of thrombophilia, concomitant and previous treatments, metastatic-stage malignancy [25], vascular catheter presence [15], and paraneoplastic hypercoagulability [17,18,20,25]. Patient-, cancer-, and treatment-related factors should be taken under consideration in the assessment of individual venous thromboembolism risk [25]. We present a case of a right atrial mass in a 57-year-old Italian woman. She reported a history of diabetes mellitus, a history of smoking, a sotalol treatment and a lymphoma chemotherapy treatment. Echocardiographic evaluation revealed a right atrial mass (Fig. 1) [26,27]. The discovery of a mass in the right atrium obliges the clinician to perform a broad differential diagnosis among a tumour, vegetations on the tricuspid valve, an atrial thrombus and Chiari network [26]. Cardiac magnetic resonance [27,28] identified right atrial mass as an atrial thrombus
⁎ Corresponding author at: Unità Operativa Complessa di Cardiologia, Azienda Ospedaliera Universitaria Policlinico “G. Martino” di Messina, Via Consolare Valeria N 1, 98125 Messina, Italy. Tel./fax: +39 0902213531. E-mail address: [email protected] (P. Pugliatti).
http://dx.doi.org/10.1016/j.ijcard.2014.03.043 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
originated from the superior vena cava. Also this case focuses attention on increased thromboembolism risk in cancer patients and on the importance of the thromboembolism prophylaxis. Acknowledgements The authors of this manuscript have certified that they adhere to the statement of ethical publishing as appears in International Journal of Cardiology. Author contributions: Pietro Pugliatti and Salvatore Patanè wrote the work; Pietro Pugliatti and Scipione Carerj prepared Fig. 1 and its legend and they also prepared the references; Rocco Donato and Gianluca di Bella prepared Fig. 2 and its legend. References [1] Patanè S. A dark side of the cardio-oncology: the bacterial endocarditis prophylaxis. Int J Cardiol Jun 14 2012;157(3):448–9. [2] Conti E, Romiti A, Musumeci MB, et al. Arterial thrombotic events and acute coronary syndromes with cancer drugs: are growth factors the missed link?: what both cardiologist and oncologist should know about novel angiogenesis inhibitors. Int J Cardiol Sep 10 2013;167(6):2421–9. [3] Rateesh S, Luis SA, Luis CR, Hughes B, Nicolae M. Myocardial infarction secondary to 5-fluorouracil: not an absolute contraindication to rechallenge? Int J Cardiol Mar 15 2014;172(2):e331–3. [4] Kurisu S, Iwasaki T, Ishibashi K, Mitsuba N, Dohi Y, Kihara Y. Comparison of treatment and outcome of acute myocardial infarction between cancer patients and non-cancer patients. Int J Cardiol Sep 1 2013;167(5):2335–7. [5] Scott JM, Jones LW, Hornsby WE, et al. Cancer therapy-induced autonomic dysfunction in early breast cancer: implications for aerobic exercise training. Int J Cardiol Feb 1 2014;171(2):e50–1. [6] Claridge S, Chakrabarti A, Greaves K, Boos CJ. Successful use of Trastuzumab following cardiac resynchronisation therapy. Int J Cardiol Jun 20 2013;166(2):e33–4. [7] Lotrionte M, Palazzoni G, Abbate A, et al. Cardiotoxicity of a non-pegylated liposomal doxorubicin-based regimen versus an epirubicin-based regimen for breast cancer: the LITE (Liposomal doxorubicin-Investigational chemotherapy-Tissue doppler imaging Evaluation) randomized pilot study. Int J Cardiol Aug 10 2013;167(3):1055–7. [8] Kaya MG, Ozkan M, Gunebakmaz O, et al. Protective effects of nebivolol against anthracycline-induced cardiomyopathy: a randomized control study. Int J Cardiol Sep 1 2013;167(5):2306–10. [9] Wang KL, Liu CJ, Chao TF, et al. Long-term use of angiotensin II receptor blockers and risk of cancer: a population-based cohort analysis. Int J Cardiol Sep 1 2013;167(5):2162–6. [10] Patanè S, Marte F, Sturiale M, Dattilo G. ST-segment elevation and diminution of prostate-specific antigen in a patient with coronary spasm and without significant coronary stenoses. Int J Cardiol Apr 14 2011;148(2):e31–3. [11] Pugliatti P, Donato R, Grimaldi P, et al. Extrinsic pulmonary stenosis in primary mediastinal B-cellular lymphoma. J Clin Ultrasound Jan 22 2014. http://dx.doi.org/ 10.1002/jcu.22133. [12] Patanè S. Is there a need for bacterial endocarditis prophylaxis in patients undergoing urological procedures? J Cardiovasc Transl Res 2014 Feb 25.
e36
P. Pugliatti et al. / International Journal of Cardiology 173 (2014) e35–e37
Fig. 1. Echocardiographic evaluation revealed a right atrial mass.
[13] Patanè S. Is there a need for bacterial endocarditis prophylaxis in patients undergoing gastrointestinal endoscopy? J Cardiovasc Transl Res 2014 Feb 25. [14] Pugliatti P, De Gregorio C, Patanè S. The chance finding of echocardiographic complications of infective endocarditis. Int J Cardiol Nov 29 2012;161(3):e50–1. [15] Hu YF, Liu CJ, Chang PM, et al. Incident thromboembolism and heart failure associated with new-onset atrial fibrillation in cancer patients. Int J Cardiol May 10 2013;165(2):355–7. [16] Chopra V, Anand S, Hickner A, et al. Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and metaanalysis. Lancet Jul 27 2013;382(9889):311–25. [17] Busch A, Tschernitz S, Thurner A, Kellersmann R, Lorenz U. Fatal paraneoplastic embolisms in both circulations in a patient with poorly differentiated neuroendocrine tumour. Case Rep Vasc Med 2013;2013:739427.
[18] Lee YG, Kim I, Lee E, et al. Risk factors and prognostic impact of venous thromboembolism in Asian patients with non-small cell lung cancer. Thromb Haemost Jan 30 2014;111(6). [19] Budaj-Fidecka A, Kurzyna M, Fijałkowska A, et al. ZATPOL Registry Investigators. Inhospital major bleeding predicts mortality in patients with pulmonary embolism: an analysis of ZATPOL Registry data. Int J Cardiol Oct 9 2013;168(4):3543–9. [20] Larsen AC, Dabrowski T, Frøkjaer JB, et al. Prevalence of venous thromboembolism at diagnosis of upper gastrointestinal cancer. Br J Surg Feb 2014;101(3):246–53. [21] Tanasanvimon S, Garg N, Viswanathan C, et al. High prevalence of recurrent thrombosis in subsets of cancer patients with isolated gonadal vein thrombosis: a single center retrospective study. Thromb Res Feb 2014;133(2):154–7. [22] Burbury K. Haemostatic challenges in the cancer patient: focus on the perioperative period. Best Pract Res Clin Anaesthesiol Dec 2013;27(4):493–511.
Fig. 2. Right atrium thrombi (white asterisks) show a typical hypointense appearance on steady state gradient echo sequence (panels B and C) and on the early images acquired postcontrast administration (panel D, white asterisk) and hypointense appearance on T1-weighted sequence. The white arrow heads in panels A, C, D show the continuation of the thrombus in the superior vena cava (SVC). The white arrow in panel b shows the coexistence of aortic regurgitation. Panel A: T1-weighted magnetic resonance imaging in coronal plane. Panel B: Steady state gradient echo sequence in coronal plane. Panel C: Steady state gradient echo sequence in right two chamber view. Panel D: Contrast-enhanced magnetic resonance imaging (MRI) in right two chamber view. Typically, intracardiac thrombi remain hypointense after contrast injection [27].
P. Pugliatti et al. / International Journal of Cardiology 173 (2014) e35–e37 [23] Christensen TD, Vad H, Pedersen S, et al. Venous thromboembolism in patients undergoing operations for lung cancer: a systematic review. Ann Thorac Surg Feb 2014;97(2):394–400. [24] Shah DR, Dholakia S, Shah RR. Effect of tyrosine kinase inhibitors on wound healing and tissue repair: implications for surgery in cancer patients. Drug Saf Mar 14 2014;37(3):135–49. [25] Streiff MB. Managing breast cancer in the older patient. Clin Adv Hematol Oncol Jun 2013;11(6):349–57.
e37
[26] Patanè S, Anfuso C, Marte F, Minutoli F, Di Bella G, Coglitore S. An unusual presentation of a right atrial Chiari network. Int J Cardiol Feb 6 2009;132(1): e28–30. [27] Öksüz F, Akyel A, Örnek E, Kurtul A, Murat SN. Catastrophic result of a huge right atrial mass. Int J Cardiol Jan 10 2013;162(2):e31. [28] Donato R, Ganame J, Bogaert J. Contrast-enhancing left ventricular apical thrombus. Eur Heart J Aug 2009;30(16):1977.
