Cardiac Involvement in Sarcomatoid Renal Cell Carcinoma

Pulmonary emboli (PE) in malignancy are usually related to hypercoagulability; however, in rare situations, direct tumor emboli are the etiology of pulmonary embolism. We present here a case of a 68-year-old male with known stage IV sarcomatoid renal cell carcinoma who came to the emergency department (ED) complaining of shortness of breath. A CT scan was done that showed bilateral segmental PE and a cardiac mass in the right ventricle that was consistent with known renal cell carcinoma. He was started on anticoagulation with low molecular weight heparin; six months later, he presented to the ED with worsening shortness of breath, and repeat CT showed an increased clot burden in the pulmonary arteries with new right ventricular (RV) strain on CT despite anticoagulation. A decision was made to go for cardiac MRI to check if the cardiac metastasis could be removed as it was thought to be the source of embolization. Cardiac MRI showed cardiac metastasis near the RV outflow tract. Unfortunately, before surgical planning, he was admitted with fatal intra-abdominal bleeding from the tumor, and passed away despite angiographic embolization and resuscitation. PE from renal cell carcinoma are sometimes tumor emboli rather than related to hypercoagulability, and this sometimes needs a different intervention compared to ordinary pulmonary embolism management, as shown in this case.