The Pearl Necklace around the Heart: Cardiac Metastases from Oral Squamous Cell Carcinoma

Cardiac metastases are rare manifestations of advanced malignancy but can produce dramatic imaging findings with significant clinical implications.[1-3] We present the case of a 56-year-old female with carcinoma of the right lateral tongue who was admitted with cough, weakness, and progressive breathlessness. Echocardiography revealed preserved left ventricular systolic function with Grade I diastolic dysfunction. The right atrium and ventricle were dilated, with moderate tricuspid regurgitation, pulmonary hypertension, and an infiltrative mass extending into the right ventricular cavity and pulmonary trunk [Figure 1a and Videos 1 and 2]. These findings suggested malignant infiltration of the right heart and great vessels.[4]Figure 1: Imaging findings of pericardial metastases from oral squamous cell carcinoma. (a) Echocardiogram (four-chamber view) showing the right atrium and ventricle dilatation with an infiltrative mass (yellow arrow). (b) Contrast-enhanced computed tomography (CT) of the chest showing round peripherally enhancing necrotic nodular lesions all around the heart and great vessels (yellow stars), also in the right atrioventricular groove (blue arrow), along with a nonenhancing hypodense clot in the right ventricle (red arrow). (c) Fluorodeoxyglucose positron emission tomography–CT scan depicting intense uptake in pericardial and mediastinal deposits encasing the cardiac chambers, pulmonary trunk, and aortic root, with intraluminal extension into the right ventricle and pulmonary artery (blue arrows). (d) Sagittal CT view showing encasement of the cardiac chambers and pulmonary trunk with necrotic deposits (yellow arrows and black arrow) {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1:","caption":"Echocardiography shows preserved left ventricular systolic function with an infiltrative mass involving the right ventricular cavity and pulmonary trunk, with a superimposed clot in the right ventricular outflow tract.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_mvhzzy43"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 2:","caption":"Apical four-chamber echocardiography shows a heterogeneous, relatively immobile mass occupying the dilated right ventricle with extension toward the RV outflow tract, consistent with malignant right heart involvement with superimposed thrombus.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_4975968n"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Contrast-enhanced computed tomography (CT) of the chest demonstrated multiple necrotic nodular lesions involving the pericardium and pericardial space, producing filling defects within the right ventricular cavity and outflow tract, with intraluminal extension, along with a hypodense, nonenhancing filling defect consistent with clot formation. Similar necrotic deposits were also noted along the pleura, with mediastinal and axillary nodal involvement [Video 3]. A particularly striking feature was the continuous, curvilinear distribution of pericardial deposits, giving an appearance like a “pearl necklace around the heart” [Figure 1b and d]. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 3:","caption":"Contrast-enhanced CT showing the encasement of the heart and great vessels by necrotic nodules, intraluminal invasion into the right ventricle and outflow tract along with non-enhancing hypodense clot formation in the right ventricle. Similar necrotic subpleural, mediastinal and axillary deposits.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_v40lll93"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Fluorodeoxyglucose (FDG) positron emission tomography (PET)-CT confirmed the extent and metabolic activity of the disease [Video 4]. The pericardial and mediastinal deposits showed intense uptake, encasing the cardiac chambers, the pulmonary trunk, and the aortic root, with intraluminal extension into the right ventricle and the pulmonary artery [Figure 1c]. Subpleural lung nodules and necrotic axillary nodes were also metabolically active [Video 4]. Notably, there was no evidence of local recurrence at the primary tongue site, underscoring the aggressive distant spread of disease.[2,4] {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 4:","caption":"FDG PET-CT demonstrating hypermetabolic activity of pericardial, pleural and mediastinal deposits with intense uptake.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_96t800ur"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Pleural fluid cytology provided pathological confirmation, revealing malignant squamous cells in a neutrophil-rich inflammatory background. Cell block demonstrated single malignant cells, and immunohistochemistry for p63 was positive, consistent with metastatic squamous cell carcinoma. The patient underwent therapeutic pleural tapping and supportive therapy with oxygen, antibiotics, and symptomatic management. She stabilized clinically and was discharged for outpatient follow-up. This case illustrates the rare phenomenon of extensive cardiac metastases from a primary oral malignancy. While the pericardium is not an unusual site for secondary deposits, the unique, pearl-necklace-like configuration of encasing necrotic lesions around the heart is a rare and memorable imaging feature.[1-3] It emphasizes the critical role of multimodality imaging, with echocardiography as the first diagnostic tool and CT and PET-CT providing exquisite detail of morphology and extent. Cytology and immunohistochemistry further establish the malignant nature of the effusion, underscoring the importance of clinical–radiological–pathological correlation.[4,5] Differential diagnoses for infiltrative pericardial and intracardiac masses associated with filling defects include primary cardiac neoplasms (such as angiosarcoma), cardiac lymphoma, metastatic melanoma, infective endocarditis with vegetations, and bland or tumor thrombus in the setting of malignancy. However, in a known case of carcinoma of the tongue, the constellation of imaging findings – multiple necrotic pericardial nodules forming a curvilinear encasement of the heart, intense FDG uptake on PET-CT, and associated pleural and nodal metastases – together with cytological confirmation of malignant squamous cells, favors metastatic disease over these alternative considerations.[1,2,5] Such unusual visual patterns enrich our understanding of metastatic spread and serve as powerful teaching images. Recognizing them may help clinicians and radiologists alike to suspect cardiac involvement earlier, tailor management, and appreciate the diverse manifestations of advanced squamous cell carcinoma.[1,3,5] Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published, and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed. Authors’ contributions Dr Ruchita analyzed and interpreted the radiology images as well as contributed to preparing the manuscript. Dr Priya helped in interpreting the scan and making appropriate modifications. Both authors have approved the manuscript. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.