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CASE REPORT
Year : 2020  |  Volume : 9  |  Issue : 8  |  Page : 4460-4462  

Left atrial metastasis of a Wilms' tumor: A rare occurrence


1 Department of Pathology, SMS Medical College and Hospital, Jaipur, Rajasthan, India
2 Department of Cardiology, Noble Care Hospital, Sikar, Rajasthan, India

Date of Submission18-May-2020
Date of Decision19-Jun-2020
Date of Acceptance04-Jul-2020
Date of Web Publication25-Aug-2020

Correspondence Address:
Dr. Manish Ruhela
Department of Cardiology, Noble Care Hospital, Sikar, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfmpc.jfmpc_908_20

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  Abstract 


Isolated involvement of the left atrium by metastasis of malignant tumors is extremely rare. Here, we report a rare case of a 6-year-old male child with left atrial metastasis of Wilms' tumor detected in transthoracic 2 D echocardiography 3 years after nephrectomy. Intra atrial extension of Wilms' tumor occurs in only about 1–3% cases and its isolated metastasis to left heart in the absence of vena cava extension is extremely rare, so we present a unique case.

Keywords: Left atrium, metastasis, Wilms' tumor


How to cite this article:
Sahu I, Ruhela M, Ola RK. Left atrial metastasis of a Wilms' tumor: A rare occurrence. J Family Med Prim Care 2020;9:4460-2

How to cite this URL:
Sahu I, Ruhela M, Ola RK. Left atrial metastasis of a Wilms' tumor: A rare occurrence. J Family Med Prim Care [serial online] 2020 [cited 2020 Sep 23];9:4460-2. Available from: http://www.jfmpc.com/text.asp?2020/9/8/4460/293117




  Introduction Top


Wilms' tumor or nephroblastoma most commonly occur between the age of 2 and 5 years and are the second most common abdominal tumor in children secondary to neuroblastoma.[1]

Intravascular extension of Wilms' tumor is a well-recognized phenomenon. Vena caval extension occurs in 4–8% of cases and occasionally reach to the right atrium in about 1 to 3% of cases.[2],[3]

To the best of our knowledge, only a few reported cases of metastatic extension of Wilms' tumor in the left atrium are known. Here, we report a rare case of metastasis of Wilms' tumor to left atrium in a 6-year-old male child in absence of vena caval extension.


  Case History Top


A 6-year-old male child presented with complaints of gradually progressive dyspnea and easy fatigability since last month. The patient had a past history of right nephrectomy 3 years back for removal of Wilms' tumor. He received multiple cycles of radiotherapy and chemotherapy.

On examination, his vitals were stable. Bilateral breath sounds were normal and his heart sounds were normal with a low pitched early diastolic murmur heard. Per abdomen examination revealed no organomegaly. Laboratory investigations showed normal hemogram, renal, and liver functions. Chest X-ray, ultrasonogram (USG) abdomen, and inferior vena cava Doppler showed no abnormality.

Transthoracic 2 D echocardiography (TTE) revealed a large 48 × 32 mm homogenous mass attached to left lateral wall of left atrium via a narrow stalk and protruding into left ventricle through the mitral valve during each diastole [Figure 1] and [Figure 2]. Tricuspid valve showed moderate regurgitation with severe pulmonary hypertension. TEE showed a large 50 × 24 mm homogenous mass extending from the left lateral wall of the left atrium with a narrow stalk of about 10 mm. No interatrial septal defect was seen.
Figure 1: Transthoracic echocardiography (TTE) showing LA mass attached to the left lateral wall of the left atrium with stalk

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Figure 2: Transthoracic echocardiography (TTE) showing LA mass protruding into to left ventricle through the mitral valve

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The patient was referred to a cardio thoracic surgery department for further management. The team of cardiac surgeons removed the left atrial mass by median sternotomy and mass biopsy was taken.

Histopathological examination of resected mass was found to be consistent with the histology of Wilms' tumor. Microscopic examination [Figure 3] showed malignant small round cells (blastomatous cells) with immunohistochemical positivity for WT 1 and vimentin and negative for myogenin.
Figure 3: Blastemal (blue) cells (a) seen along with epithelial component (abortive tubules) (b) in the fibrous stroma (100x H and E): Triphasic histology of Wilm's tumor

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  Discussion Top


Wilms' tumor is curable in the majority of patients. More than 90% of patients survive 4 years after the diagnosis.[1] Metastatic tumors of the heart are 20 to 40 times more common than primary tumors. Melanoma, leukemia, lymphoma lung, and breast cancers metastasize to heart with the highest frequency.

Metastasis to heart involves the pericardium, myocardium, and endocardium in decreasing frequency.[4] Metastatic tumors can reach the heart or its chambers by various routes including hematogenous, lymphatic spread, or by direct invasion.[5] Wilms' tumor metastasis to heart mainly occurs through the lumen of inferior vena cava and occasionally involves the right atrium.

The involvement of the heart in the absence of direct caval extension is extremely rare. Isolated left atrial involvement is exceedingly rare and that is what makes this case unique.


  Conclusion Top


Patients of post-operative Wilm's tumor who presented with dyspnea, primary physician have to evaluate for any possibility of cardiac extension. Isolated left atrial metastasis of Wilms' tumor in the absence of inferior vena cava extension is exceedingly rare phenomenon. TTE is a simple imaging modality to detect space-occupying lesions of the heart.

Key Messages: Isolated left atrial metastasis of Wilms' tumor in the absence of inferior vena cava extension is exceedingly rare phenomenon. Transthoracic echocardiography is a simple imaging modality to detect space-occupying lesions of the heart.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hay WW Jr, Hayward AR, Levin MJ, Sandheimer JM. Currentpaediatric Diagnosis and Treatment. 14th ed. Norwalk, CT: Appleton & Lange; 1999. p. 787-9.  Back to cited text no. 1
    
2.
Lall A, Pritchard-Jones K, Walker J, Hutton C, Stevens S, Azmy A, et al. Wilms' tumor with intracaval thrombus in the UK Children's Cancer Study Group UKW3 trial. J Pediatr Surg 2006;41:382-7.  Back to cited text no. 2
    
3.
Abdullah Y, Karpelowsky J, Davidson A, Thomas J, Brooks A, Hewitson J, et al. Management of nine cases of Wilms' tumor with intra-cardiac extension —A single centre experience. J Pediatr Surg 2003;48:394-9.  Back to cited text no. 3
    
4.
Patane J, Flum DR, Mcginn JT Jr, Tyras DH. Surgical approachfor renal cell carcinoma metastatic to the left atrium. Ann Thorac Surg 1996;62:891-2.  Back to cited text no. 4
    
5.
Reardon MJ, Smythe WR. Cardiac neoplasms. In: Cohn LH, Edmunds LH Jr, editors. Cardiac Surgery in the Adult. 2nd ed. New York: McGraw Hill; 2003. p. 1373-400.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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