RECURRENT INTRAVASCULAR TUMOR INVASION IN RIGHT ATRIUM: A RARE COMPLICATION OF METASTATIC RENAL CELL CARCINOMA Aniko Nowakowski, Naseeruddin Naseem, Kelsey Berman, Deanna Huffman, Jeffrey Wiese; Tulane University, New Orleans, LA.
Introduction: Cancer associated thrombosis is a feared complication in malignancy. Anticoagulation combats bland thromboses. However, intravascular tumor extension, or tumor thromboses (TT), have tenuous treatment options with limited evidence. TT is most associated with renal cell carcinoma (RCC) (34.6%), commonly invading the renal vein (8-10%) and inferior vena cava (IVC) (4-10%). Very rarely does TT extend above the diaphragm, classifying it as a Mayo Stage IV thrombus, with less than 1% of cases invading the right atrium. Case: A 61-year-old female with hypertension and diabetes mellitus initially presented with groin pain and urinary incontinence. A CT of the abdomen and pelvis revealed a 12cm renal mass with invasion into right hilum and IVC. A echocardiogram showed a large mobile right atrial (RA) mass. A cardiac MRI confirmed a RA TT with retrograde thrombus propagation in the distal IVC into the right common iliac vein. Stage IV RCC diagnosis was ultimately made. Through collaborative multidisciplinary input, extensive surgical resection commenced. This included open right radical nephrectomy with retroperitoneal lymph node dissection, right atriotomy with removal of TT, and resection of the IVC wall and orifice of right renal vein. No
evidence of residual disease was seen on post- surgical imaging. Six months later, she returned with syncope, dyspnea, and tachycardia and imaging revealed bilateral pulmonary emboli (PE) with cardiac strain with initiation of enoxaparin. A CT of the abdomen and pelvis showed new hepatic lesions and a biopsy confirmed metastatic RCC. The patient refused systemic chemotherapy and was briefly lost to follow up. A year later, she returned with dyspnea and a large TT extending into her right atrium as well as worsening pulmonary embolism was discovered. Surgical intervention and suction thrombectomy were deemed too risky. After a goals of care meeting, the patient declined further intervention. She was started on levatinib and everolimus in clinic. 3 weeks later, she returned with dyspnea. Worsening bilateral PE’s with new extensive PE were found in right pulmonary artery. The echocardiogram revealed remaining TT in the IVC with resolution of the right atrial TT, which likely is what embolized into the right pulmonary artery. Discussion: This case illustrates the complexity of managing TT associated with RCC and the rare complication of embolization. Additionally, it highlights the importance of ongoing surveillance and goals of care conversations in advanced cancer.
RET MUTATED NON-SMALL CELL LUNG CANCER (NSCLC) IN ASSOCIATION WITH PATIENTS FROM CENTRAL AMERICA Lily Chen, William J. Gibson, Brian C. Boulmay; Louisiana State University, New Orleans, LA.
Introduction: The rearranged during transfection (RET) gene is on chromosome 10 (10q11.2) and normally encodes a receptor tyrosine kinase that plays a role in the development of the kidney, nervous, and respiratory systems. Aberrant RET gene activation can occur through gene mutations, fusions, or over expression leading to uncontrolled cell growth and malignancy. The RET gene plays a role in the pathogenesis of lymphoma, and mutations are now associated with numerous cancers including lung, thyroid, breast, colon,
prostate, and kidney. Activating RET mutations are estimated to occur in 1-2% of NSCLC cases.
Cases: A 47-year-old nonsmoking man from Honduras presented with a 10 x 9 cm left apical lung mass, diagnosed as T4N3M1 lung adenocarcinoma with a 1.3 x 1.2 cm occipital lobe metastasis. Next generation sequencing (NGS) testing revealed a KIF5B-RET gene fusion. He received radiation to the brain lesion and started selpercatinib. After 21 months, his lung lesion remained stable.
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