Occult infiltrating bi-ventricular papillary renal cell carcinoma metastasis found during coronary artery bypass graft surgery

Abstract

E54Cite as: Can Urol Assoc J 2012;6(2):e54-56. http://dx.doi.org/10.5489/cuaj.11144 AbstractMetastatic papillary renal cell carcinoma (RCC) to the heart has never been reported. We report the case of a 73-year-old patient with papillary RCC metastatic to the left and right ventricles, found during a triple vessel coronary artery bypass graft surgery. IntroductionMetastatic tumour involvement of the heart from clear cell renal cell carcinoma (RCC) has been previously reported. [1][2][3][4] However, cardiac metastasis from papillary RCC has not yet been described. Papillary (or chromophilic) RCC, which accounts for 7% to 14% of adult renal neoplasms, is associated with a better prognosis than clear cell RCC. 5 We describe a patient diagnosed with papillary RCC found to have occult infiltrating bi-ventricular metastases discovered during triple vessel coronary artery bypass graft surgery (CABG). Case reportA 73-year-old man with a history of chronic obstructive pulmonary disease and hypertension was evaluated for rightsided abdominal pain, weight loss and anemia. Physical exam revealed a palpable right sided abdominal mass. Abdominal computed tomography (CT) revealed a 9 × 7 cm cystic mass arising from the right kidney suspicious for cystic RCC. Additional staging workup was negative for metastatic disease. In anticipation of operative exploration, preoperative electrocardiogram was performed and showed ST segment depression in the anterior and septal leads. This was followed up by a nuclear stress test which was positive for a reversible perfusion defect. Left heart catheterization showed severe stenosis in the distal left main coronary artery, along with three-vessel coronary artery disease. Echocardiography demonstrated normal ventricular systolic function.The patient was taken to the operating room for triple vessel CABG with a left internal mammary to left anterior descending coronary artery, a saphenous vein to the posterior descending artery branch of the right coronary artery, and a saphenous vein to the obtuse marginal branch of the circumflex coronary artery. During the operation, there were two 2 × 2 cm epicardial masses infiltrating into the myocardium: one on the right ventricle near the proximal segment of the coronary sinus and the other on the left ventricular wall near the apex. These were biopsied and sent for pathologic examination (Fig. 1a). The patient had an uneventful postoperative course and was discharged. After being discussed at a multidisciplinary tumour board, the patient underwent an open right radical nephrectomy without any complications and the final pathology (Fig. 1b) revealed papillary RCC type II (T2a, N0, M1). The patient underwent systemic chemotherapy with sunitinib and is doing well at the 8-month follow-up. DiscussionCardiac metastases from clear cell RCC are rare. A large autopsy study of 11 432 patients showed 264 cases of cardiac metastases, of which only 3 (1.1%) were renal in origin. 5Metastatic tumours may reach the heart hematogenously, via lymphatic spread, or direc...