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Cardiac Masses in a Patient With Pancreatic Adenocarcinoma and a History of Breast Carcinoma

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 64-year-old woman with borderline resectable pancreatic adenocarcinoma and a history of hormone receptor–positive left-sided breast cancer (treated with lumpectomy and radiation in 2014) was transferred to our hospital for management of a displaced percutaneous hepatobiliary drain. She was diagnosed as having pancreatic adenocarcinoma in September 2019 after developing right upper quadrant pain and jaundice, which prompted imaging and a subsequent endoscopic biopsy of a pancreatic head mass. She established oncologic care in Kentucky and received 1 dose of gemcitabine plus nanoparticle albumin-bound (nab)–paclitaxel in early October 2019. Her posttreatment course was complicated by elevated levels of transaminases, significant fatigue, and an infusion port thrombosis. Her infusion port (right sided) was subsequently removed, and she was given 1.5 mg/kg of enoxaparin daily for anticoagulation.

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D. Apical left ventricular thrombus

Cardiac magnetic resonance imaging revealed subtle late gadolinium enhancement of the left ventricular apex with an associated 1.3 × 0.6-cm multilobulated mass (Figure 2). The mass appeared avascular on perfusion imaging and did not enhance on late gadolinium contrast imaging. These findings are most consistent with thrombus.1 Echocardiography can be useful in the evaluation of cardiac masses. Features such as echodensity, mobility, location, and echocardiographic contrast enhancement can help distinguish thrombi from tumors. However, cardiac magnetic resonance imaging remains the optimal test for distinguishing between these 2 entities, largely because of superior tissue characterization. Given the late gadolinium enhancement of the apical myocardium, endomyocardial fibrosis, a rare form of restrictive cardiomyopathy in developed countries, was considered as a possible etiology for the thrombus. Hypercoagulability from her pancreatic cancer was also considered a contributing factor.2 Pancreatic adenocarcinoma creates a prothrombotic state through multiple mechanisms, including increased tissue factor expression, increased thrombin-dependent platelet aggregation, and decreased levels of anticoagulants (antithrombin III, protein C, and protein S) relative to procoagulants.3 Although venous thromboembolic phenomena are more common in patients with pancreatic adenocarcinoma, arterial thrombi and cardiac thrombi have been described in existing literature.4

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Article Information

Corresponding Author: Satya Das, MD, Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, 2220 Pierce Ave, Nashville, TN 37232 (satya.das@vumc.org).

Published Online: April 23, 2020. doi:10.1001/jamaoncol.2020.0086

Conflict of Interest Disclosures: Dr Das has received honorarium from Targeted Oncology, Medsphere, and Clarivate Analytics. No other disclosures were reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
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