Chameleonic appearance of caseous calcification of the mitral valve – still a problem for its appropriate management

Figure 1. Echocardiographic study: (A) Apical four-chamber view – echo-dense tumor mass at the level of the posterior mitral ring; (B) Parasternal short axis view

Figure 2. MRI study: (A) Cine sequence, telediastolic four-chamber view – the tumor can be seen very well at the level of the mitral valve; (B) T1 sequence, mitral valve short axis view. MRI: Magnetic resonance imaging

Figure 3. Intraoperative appearance of the posterior mitral valve with a roundish irregular homogeneous mass with a firm consistency

Figure 4. The macroscopic aspect suggesting a so-called “toothpaste tumor”, or caseous calcification (right), compared to the rest of the posterior mitral valve (left)

Figure 5. Fibrosis and fibro-hyaline alteration of the mitral valve (GS trichrome staining, ×100).

Figure 6. Fibrous connective tissue with myxoid areas of the mitral valve (GS trichrome staining, ×100).

Figure 7. Dystrophic calcification, fibrinoid necrosis (chronic ulceration) and chronic inflammatory infiltrate of the mitral valve (HE staining, ×40).

Figure 8. Mitral valve with areas of dystrophic calcifications and abundant inflammatory infiltrate (HE staining, ×100).

Figure 9. Tumor area with an abundant inflammatory infiltrate consisting mainly of T-lymphocytes (Immuno-staining with anti-CD3 antibody, ×200). CD3: Cluster of differentiation 3

Figure 10. Mitral valve area infiltrated with numerous macrophages (Immunostaining with anti-CD68 antibody, ×200). CD68: Cluster of differentiation 68

Figure 11. Mitral valve area with an abundant inflammatory infiltrate, but with a small number of B-lymphocytes (Immunostaining with anti-CD20 antibody, ×200). CD20: Cluster of differentiation 20

Figure 12. Image of tumor tissue with few mast cells present in the inflammatory infiltrate (Immunostaining with anti-tryptase antibody, ×200)