Case Presentation: A 73 year old male patient was referred to our facility for further evaluation of abnormal cardiac imaging. Patient has no prior history of coronary artery disease, has history of stage I (pT1bN0M0) renal cell carcinoma (RCC) status post right nephrectomy 12 years prior to his presentation. He had no evidence of residual or recurrent disease based on follow up imaging. Patient was seen by his primary care physician for a routine visit and he reported that he had been having episodes of mild left sided non radiating chest pressure for about a month; it was mainly at night while resting and used to resolve on its own.  Patient had no other symptoms and his physical exam was completely normal.  Blood work including CBC, CMP and troponin was within normal limits. EKG showed new T wave inversion in lateral leads, hence underwent transthoracic echocardiogram (TTE) and nuclear pharmacologic stress test. TTE showed an ejection fraction (EF) of 50-55% and regional wall motion abnormalities in the inferior wall as well as a 2 cm X 1.5 cm left ventricular (LV) apical mass versus thrombus. Stress test was positive for inducible ischemia in the inferior wall so he underwent cardiac catheterization that was negative for any obstructive coronary artery disease. However, on left coronary angiography, it was noticed accumulation of contrast in the apex of the heart suggestive of well circumscribed large vascular structure. For further evaluation of the nature of the LV abnormal structure, magnetic resonance imaging (MRI) of the heart showed a solid, avidly enhancing mass at the apex of the LV, with a full-thickness involvement of the adjacent apical lateral and inferior myocardium and based on the morphology of the lesion and the intensity of enhancement, a neoplasm was favored over a thrombus. Patient underwent an open myocardial biopsy that was positive for recurrent RCC. Oncology was consulted as patient was not a candidate for excision given the transmural involvement of the lesion. He was started on salvage chemotherapy with a tyrosine kinase inhibitor, pazopanib 800 mg PO daily. Five months after starting chemotherapy, he underwent repeat MRI of the heart that showed marked reduction of the size of LV apical mass with no enhancement compatible with a favorable response to treatment. Repeat TTE showed reduction of the size of the LV apical mass as well.

Discussion: Cardiac tumors are extremely rare. Primary cardiac tumors are very rare and mostly benign. On the other hand, metastatic disease of the heart is over 20 times more common. The most common secondary tumors of the heart originate from melanoma, leukemia, lung cancer, breast cancer or lymphoma. Cardiac metastasis from RCC occurs by 2 mechanisms either in advanced RCC by direct extension through inferior vena cava or through hematogenous spread in widespread, systemic RCC. However, in the absence of either one, involvement of the heart is extremely uncommon.

Conclusions: Our patient has an isolated left ventricular metastatic lesion from his RCC which is exceedingly rare. On reviewing the literature, the present case report is one of the few cases that describe a similar clinical scenario. We present this interesting case to increase the awareness of health care providers about possibility of having isolated RCC recurrence after many years of initial disease so high degree of suspicion is recommended when we encounter similar situations.