Multimodality Imaging Supports Cardiac Lesion Diagnosis in Patient With Liver Carcinoma: A Case Report

Abstract

Introduction: Nonbacterial thrombotic endocarditis (NBTE) is a rare cardiac manifestation in patients with advanced malignancies of the lungs, pancreas, gynecological system, and gastrointestinal tract. It is often confirmed postmortem by histopathological evidence of sterile platelet-fibrin deposits attached to the endocardium, most often on heart valves. To the best of our knowledge, our case is the first to report multiple heart lesions caused by the systemic effect of cholangiocarcinoma.

Case presentation: We report the case of a 53-year-old male who presented with a stroke; extensive imaging studies, including transthoracic echocardiography (TTE), 2D/3D transesophageal echocardiography (TEE), cardiac multi-slice computed tomography, and cardiac magnetic resonance, found masses on the mitral valve, the aortic valve, and in the right ventricle, with the largest diameter 43 × 11 mm, which led to a diagnosis of NBTE secondary to presumed cholangiocarcinoma. Combining different echocardiography techniques, including TTE and TEE in specific clinical contexts, and training echocardiographers to improve TEE interpretation skills could be the most cost-effective option for early diagnosis, particularly in limited-resource settings, where advanced imaging modalities are not widely applicable.

Conclusions: NBTE can manifest in patients with advanced cancer. A high index of clinical suspicion is of central importance for the diagnosis of NBTE, especially through an identification of the underlying predisposing conditions. A multi-disciplinary approach is crucial for NBTE optimal diagnosis and treatment. As in our patient, multimodality imaging plays a complementary role in clearly defining the nature of cardiac lesions.

Keywords: cardiac magnetic resonance imaging; case report; liver adenocarcinoma; multimodality imaging; nonbacterial thrombotic endocarditis; three‐dimensional transesophageal echocardiography.

FIGURE 1

Extracardiac manifestations. (A) T2 weighted magnetic resonance imaging showing cerebral infarction with hemorrhagic transformation. (B) The same lesion on non‐contrast CT. Abdominal multi‐slice computed tomography (arterial phase) image showing: (C) Hypointense masses in left and right lobes of the liver (yellow arrows) and spleen 535 (white arrow). (D) Hypointense mass in the left kidney.

FIGURE 2

Cardiac masses on different imaging modalities. (A) TTE parasternal long axis view showing aortic valve masses on both cusps (yellow arrow) and a mitral valve mass on the posterior leaflet (white arrow). (B) TEE X‐plane image from the mid‐esophageal position, left: AV long axis view showing aortic valve masses (yellow arrow), and a mitral valve mass on the posterior leaflet (star), and right ventricular mass (white arrow), right: AV short axis view showing cardiac masses on all cusps of the aortic valve (yellow arrow) and right ventricular mass (white arrow). (C) Aortic regurgitation on 2D TTE. (D) 3D TEE enface view showing the mitral valve mass (black arrow) and aortic mass (yellow arrow). (E) Aortic mass (yellow arrow) on 3 cusps of the aortic valve on cardiac MSCT. (F) TTE apical 5 chamber view showing right ventricular mass (yellow arrow) and aortic valve mass (white arrow). (G) CMR image showing aortic mass on cine imaging (arrow). (H) CMR image showing the right ventricular mass (arrow). Ao: Aorta, LA: Left atrium, LCC: Left coronary cusp, LV: Left ventricle, PA: Pulmonary artery, RV: right ventricle, NCC: Non‐coronary cusp, RCC: Right coronary cusp.

FIGURE 3

Fine needle aspiration: Cluster of abnormal cells with enlarged alkaline nuclei and high nucleocytoplasmic ratio (Hematoxylin—Eosin, ×400).

FIGURE 4

Follow‐up TTE and TEE. (A) TEE parasternal long axis view showing aortic valve masses on both cusps (yellow arrow) and mitral valve mass on both leaflets (white arrow). (B) 3D TEE showing right ventricular mass (yellow arrow). (C) TEE X‐plane image from the mid‐esophageal position, left: Long axis view, right: Mitral commissural view showing mitral valve masses on both leaflets (yellow arrows). (D) TEE X‐plane image from the mid‐esophageal position, left: AV long axis view showing cardiac masses on all cusps of aortic valve (yellow arrow) and mitral valve mass on the anterior leaflet (white arrow), right: AV short axis view showing aortic valve masses (yellow arrow). Ao: Aorta, LA: Left atria, LV: Left ventricle, RV right ventricle.

FIGURE 5

Timeline of patient clinical course. (1) Cerebral infarction with hemorrhagic transformation observed on non‐contrast CT. (2) A—TTE parasternal long‐axis view showed masses on both aortic valve cusps (yellow arrow) and a mitral valve mass on the posterior leaflet (white arrow). B—TEE X‐plane imaging from the mid‐esophageal position; left: AV long‐axis view showed aortic valve masses (yellow arrow), a mitral valve mass on the posterior leaflet (star), and a right ventricular mass (white arrow); right: AV short‐axis view showed cardiac masses on all cusps of the aortic valve (yellow arrow) and the right ventricular mass (white arrow). (3) D—3D TEE en face view showed the mitral valve mass (black arrow) and aortic valve masses (yellow arrow). E—Cardiac MSCT revealed aortic masses (yellow arrow) on all three cusps of the aortic valve. F—TTE apical five‐chamber view showed the right ventricular mass (yellow arrow) and the aortic valve masses (white arrow). G—CMR cine imaging showed the aortic masses (arrow). H—CMR showed the right ventricular mass (arrow). (4) Fine needle aspiration. (5) A—Hypointense masses identified in the left and right liver lobes (yellow arrows) and in the spleen (white arrow) during the arterial phase of abdominal MSCT. (6) A—TTE parasternal long‐axis view showed aortic valve masses on both cusps (yellow arrow) and the mitral valve mass on both leaflets (white arrow). B—3D TOE showed the right ventricular mass (yellow arrow). C—TEE X‐plane imaging from the mid‐esophageal position; left: long‐axis view showed mitral valve masses on both leaflets (yellow arrows); right: mitral commissural view also showed mitral valve masses on both leaflets (yellow arrows).