Snake-like hypermobile masses in three chambers of the heart: very unusual metastasis of squamous cell carcinoma

Introduction

Metastatic disease of the heart is rare, with an incidence of 1.23% depending on the autopsy series [1]. Metastasis can occur in various ways: through the lymph system, direct extension, and hematogenous or intracavitary dissemination by direct extension via the caval or pulmonary veins. Cardiac metastases mostly involve the pericardium and with lower incidence the epicardium or the myocardium. However, only 5% of tumors affect the endocardium [2]. Pericardial invasion usually occurs through lymphatic propagation, while endocardial involvement mainly results from hematogenous dissemination [2]. This rare form of metastasis leading to intracavitary, endocardial, or valvular metastatic deposits mainly occurs in the right chambers and is only rarely seen in the left chambers. This is attributed to the filtering role of the pulmonary circulation and the slower flow in the right chambers [3].
We report a very rare case of squamous cell carcinoma-detected snake-like hypermobile metastatic intracardiac masses in three chambers of the heart from an unknown primary origin.

Case report

At 8 years after coronary artery bypass graft surgery a 53-year-old man was admitted to the emergency room with sudden onset of dysarthria and left hemiparesis. His blood pressure was 130/70 mm Hg, and the pulse was regular with no pulsus paradoxus. Cardiac examination was normal except for a systolic ejection murmur. There was no marked jugular venous distention or edema of the extremities. Radial and dorsal pedis arteries were symmetrically palpable. Neurological examination revealed disturbance of consciousness, dysarthria, and left hemiparesis. Electrocardiography was normal except for the rare premature atrial contractions, and chest X-ray findings were in the normal ranges. His erythrocyte sedimentation rate was high (56 mm/h), but other laboratory data were in the normal ranges. Head magnetic resonance imaging (MRI) revealed multiple hyperintense lesions on the bilateral cerebral hemisphere. A low-molecular-weight heparin, enoxaparin was started. On the fourth day after he began to improve, gained his consciousness and was able to talk again, recurrent transient ischemic attacks (TIA) began to occur, causing transient loss of consciousness. For evaluation of the embolic source, we performed transthoracic echocardiography. Two-dimensional echocardiography showed highly mobile, snake-like structures with a slightly higher echodensity as...


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