Ovarian Malignancy Presenting as Multiple Intracardiac Masses
A 38-year-old woman with no significant previous illness presented with progressive breathlessness and abdominal distension of 6 months’ duration. Examination noted tachycardia, a blood pressure level of 100/60 mm Hg, an elevated jugular venous pressure to the angle of the mandible, a middiastolic heart sound, dullness at both lung bases, and hepatomegaly. Chest x-ray confirmed cardiomegaly and bilateral pleural effusions. Echocardiography demonstrated 6 intracardiac masses, 3 in the left atrium, 2 in the right atrium, and 1 in the apex of the right ventricle. There was obstruction to both the right and left ventricular inflows. Abdominal ultrasound revealed a small 3×2.5-cm left ovarian mass and pelvic ascites consistent with an ovarian malignancy. Whole-body computed tomography scanning noted 2 localized pleural masses but no further secondary deposits. The clinical assessment was of a primary ovarian malignancy with secondary spread to the heart and pleura. The cardiac tumors were large, well-circumscribed, and severely obstructing ventricular inflow; therefore, it was decided that they should be resected before initiation of a cisplatin-based chemotherapy regimen. Contrast-enhanced cardiac magnetic resonance imaging was performed (Figure 1) before surgery. The gross pathology and representative histology specimens are shown in Figure 2. Histological examination disclosed a sarcomatoid tumor, which demonstrated strong positivity with a cytokeratin immunostain. The appearances were consistent with a metastatic, malignant, mixed mullerian tumor. After an initial response to chemotherapy, the patient’s pelvic and cardiac diseases progressed rapidly, and she died within 3 months of the initial diagnosis.
The online-only Data Supplement can be found at http://circ.ahajournals.org/cgi/content/full/113/10/e399/DC1.