Seminoma with extensive metastases to the right atrium

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Journal of the New Zealand Medical Association, 23-June-2006, Vol 119 No 1236

Constantin Marcu, Kristen Andresen, Richard Salzano, Thomas Donohue

A 43-year-old Caucasian male presented with mild dyspnoea on exertion 2 years after treatment for stage IB testicular seminoma. Chest radiography demonstrated multiple, bilateral lung nodules. Computed tomographic (CT) imaging showed pulmonary nodules and a filling defect, measuring 5×4 cm, in the right atrium extending through the atrial wall into the anterior mediastinum (Figure 1AB).

Figure 1AB. Chest computed tomographic (CT) scan with intravenous contrast. A: Transverse plane at the level of the ascending aorta. Hypodense mass-tumour (arrow) outside the ascending aorta. B: Four-chamber view of the heart. Tumour (arrow) inside the right atrial (RA) cavity.

PA=pulmonary artery; RA=right atrium; Ao=aorta.

No periaortic or intrathoracic adenopathy was demonstrated. Percutaneous lung nodule biopsy was nondiagnostic. Mediastinotomy under cardiopulmonary bypass was planned because of concerns of possible right ventricular inflow obstruction from the right atrial mass. Presurgical coronary angiography demonstrated normal coronary arteries and a large “tumour blush” in the region of the right atrium (Figure 1CD).

Figure 1CD. Right coronary angiogram. Right coronary artery in a 30-degree right anterior oblique (panel C) and left anterior oblique projection (panel D), with “contrast blush” indicating the presence of a highly vascular structure (tumour) in the right atrial region (arrowhead).

An intraoperative transoesophageal echocardiogram (TOE) showed a mobile echogenic structure in the right atrium extending through the atrial wall, into the mediastinum (Figure 2ABC).

The specimen was excised from the anterior mediastinum and recurrent seminoma was confirmed on pathology. Surgical debulking was not indicated, and chemotherapy with cisplatin, bleomycin, and etoposide was started. After one course of chemotherapy, a follow-up TOE revealed a ~50% reduction in the right atrial mass size without further evidence of extracardiac extension (Figure 3ABC).

The patient will undergo three additional courses of the same chemotherapy regimen.

Figure 2ABC. Transoesophageal echocardiogram. A: Four-chamber view with tumour inside the right atrium (arrow). B: Right atrium with an irregular mobile echogenic structure representing tumour (arrow). Tricuspid valve (arrowhead). C: Short axis view of the aorta and right atrium. Tumour inside the right atrial cavity and spreading through the atrial wall (white and black arrows) anterior to the aorta.

LA=left atrium; RV=right ventricle; RA=right atrium; Ao=aorta.

Figure 3ABC. Transoesophageal echocardiogram after one course of chemotherapy. A: Four-chamber view with remnant tumour (arrow); B: Right atrium (RA) containing the tumour; C: Short axis view of the aorta (Ao) and right atrium with tumour decreased in size and without extracardiac extension (white and black arrows).

RV=right ventricle; RA=right atrium; LA=left atrium;. Ao=aorta.

Author information: Constantin B Marcu, Consultant Cardiologist, Vrije University Medical Center, Amsterdam, The Netherlands; Kristen M Andresen, Consultant Cardiologist, Hospital of Saint Raphael – Yale University, New Haven, CT, USA; Richard Salzano, Consultant Cardiothoracic Surgeon, Hospital of Saint Raphael – Yale University, New Haven, CT, USA; Thomas J Donohue, Consultant Cardiologist, Hospital of Saint Raphael – Yale University, New Haven, CT, USA

Correspondence: Constantin B Marcu, MD, Vrije University Medical Center, Department of Cardiology 6D 120, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands. Fax: +31 20 4442446; email: bogmarcu@pol.net