Late metastatic recurrence of renal cell carcinoma in the heart and mediastinum: A case report and review of literature

Cardiac metastasis from renal cell carcinoma (RCC) without involvement of inferior vena cava is extremely rare. Late recurrence in the heart, defined as recurrence more than 10 years after nephrectomy for primary RCC, is even more infrequent. We present a case of a patient who had late metastasis of RCC to the right ventricle 12 years after nephrectomy for primary disease. A 78-year-old man with a history of clear cell RCC (AJCC pathological stage: pT3, pNX, pMX) status post nephrectomy in 2008 presented with progressive dyspnea and unintentional 13 lb weight loss over the past 3 months. A chest x-ray revealed tracheal deviation, and a subsequent CT scan of the neck and chest revealed a large mass in the upper mediastinum and a filling defect within the apex of the right ventricle (RV). TTE revealed an RV apical mass measuring 3.0 x 2.5 cm without RV outflow tract obstruction, which was confirmed with cardiac MRI. Cardiac catheterization was unrevealing. PET scan revealed minimal metabolic activity involving the mediastinal mass and right ventricular mass without abnormal uptake elsewhere. The patient underwent RV tumor resection with pericardial patch placement. Postoperative pathology confirmed metastatic disease from a clear cell RCC. The accepted treatment for late isolated metastatic recurrence of RCC is wide local excision with histological free margins. Immunotherapy and/or molecularly targeted therapy may be considered as adjuvant treatment or alternative to surgery for unresectable tumors. Solitary metastases, a long disease-free interval, and complete excision of the tumor confer a good prognosis. Late cardiac metastasis presents a unique disease course in RCC. Presentation is usually non-specific and requires a high index of suspicion for diagnosis. Long-term surveillance based on risk stratification may aid in prompt diagnosis and timely intervention in such cases.