The heart is not too noble to host a metastatic tumor! A right ventricle metastasis of a transitional cell carcinoma of the bladder

An 85-year-old woman was admitted to the hospital with a one-week history of fatigue and progressive dyspnoea. In the prior months she had lost a considerable amount of weight (10 kg). The general practitioner diagnosed a urinary tract infection. On physical examination we found rapid irregular heart tones without any murmurs, some crackles in the lungs and oedema in the lower extremities. The ECG showed atrial fibrillation with a ventricular response of 160 beats/min, with a normal QRS duration and ST segments. Laboratory tests showed a BNP of 1130 ng/l (normal <100 ng/l) and a CRP of 160 mg/l (normal <7 mg/l). Urine analysis was positive for erythrocytes and leukocytes, which confirmed the diagnosis of urinary tract infection. Chest X-ray showed cardiomegaly (cor-thorax ratio = 0.8), bilateral intrapulmonary consolidation, left-sided pleural effusion and a mass in the lung close to the left hilus. CT-thorax showed bilateral intrapulmonary consolidation in the lower lung fields, pericardial and pleural effusion and a 5 cm cyst in the lung, left and ventral of the mediastinum close to the left hilus (Fig. 1). Transthoracic echocardiography showed a non-dilated, normal functioning left and right ventricle with thickened pericardium and pericardial effusion (10 mm). Remarkable was a mass in the free wall of the right ventricular outflow tract, with a long intracardial mobile structure reaching up to the pulmonary valve (Fig. 2). Despite optimal medical therapy the patient died of respiratory insufficiency 1 day later, before a definite diagnosis was made.

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