C63-53 Pre-syncope as a Presenting Complaint for Pulmonary Involvement of Renal Cell Carcinoma

Intro Pre-syncope can be a benign symptom or an ominous sign of significant underlying disease. This case presents a patient with one episode of pre-syncope who was subsequently found to have extensive tumor burden from renal cell carcinoma involving the lung parenchyma, saddle pulmonary embolus, and involvement of the renal vein and inferior vena cava. Case A 59-year-old gentleman with a history of diabetes who presented with pre-syncope. On initial examination, the patient was intermittently tachycardic. EKG revealed sinus tachycardia. CTA revealed multiple pulmonary emboli including saddle embolus of the left pulmonary artery, multiple pleural-based masses and lung nodules, and a necrotic-appearing left sided retroperitoneal mass measuring 11 x 9cm. Echocardiogram revealed a LVEF of 60% without right ventricular dysfunction. RVSP across the tricuspid valve was read at 25 mmHg. Additionally, two masses were discovered in the right atrium and inferior vena cava. Tissue biopsy of the retroperitoneal mass confirmed clear cell renal carcinoma. The patient remained asymptomatic during his hospitalization. Discussion Though pre-syncope is a common presenting complaint for a pulmonary embolism, the etiology is generally lower limb deep vein thrombosis. Renal cell carcinoma is classically described as a triad of hematuria, flank pain, and palpable mass, however the majority of patients (>90%) do not present with these symptoms.1 Accordingly, around 25% of patients present with advanced disease including regional and metastatic disease burden, commonly to the lung parenchyma and pleura. Though the disease process, when advanced, extends into the renal vein and IVC with some frequency, very few cases have been reported of cardiac invasion of tumor from the IVC and renal vein.2-5 In these cases, patients often present with symptoms including pain, weight loss, syncope, and/or severe dyspnea. In the case of our patient, the absence of severe symptoms makes this a unique presentation.