Between the Devil and the Deep Sea—The Cardiac Conundrum: Report of a Contiguous Cavo-Atrial Tumor Thrombus in NSGCT Testis

Testicular cancer is notorious for its myriad presentations. In this case report, we present a 28-year-old gentleman diagnosed with metastatic non-seminomatous germ cell tumor (NSGCT). After receiving neoadjuvant chemotherapy, he was found to have a large paracaval conglomerate nodal mass infiltrating the inferior vena cava (IVC), with a contiguous thrombus extending from the vena cava to the right atrium. The pre-operative imaging was ambiguous, with the cavo-atrial thrombus appearing to float within the vascular lumen at some places and infiltrating the caval wall at others. Hence, arrangements were made for cardiopulmonary bypass, sternotomy, and vascular surgeon backup. Intraoperatively, the vena cava was palpated in its entirety up to the mediastinum, and the thrombus was found to be freely floating. Hence, the thrombus was milked out in its entirety from the right atrium up to the vena cava, and the paracaval mass was resected en bloc with the tumor thrombus. The IVC was reconstructed with a Dacron graft. A review of the literature revealed no previously documented cases of contiguous cavo-atrial tumor thrombus. Approaching cases requires an assessment of the nature of the thrombus and the need to prepare for the worst. It is worth remembering that going the extra mile concerning obtaining a complete tumor clearance is worth it in NSGCTs, given the highly gratifying outcomes.