Case presentation
A 57-year-old female patient detected masses on the tricuspid valve’s ventricular surface by transthoracic echocardiography(TTE). The patient had a medical history of squamous carcinoma of the cervix(SCC) one year ago when the TTE was no abnormality. On physical examination, vital signs were stable with a blood pressure of 100/64 mmHg, a heart rate of 79 b.p.m, and a respiratory rate of 18 per minute. Laboratory examination proved mild anemia. It slightly elevated the counts of C-reactive protein(CRP), erythrocyte sedimentation rate(ESR), D-dimer (turbidimetry), and fibrinogen degradation products(FDP). Transthoracic echocardiography showed a mobile mass on the tricuspid ventricular surface protruding into the pulmonary valve during systole (Fig 1A, marks) and many neoplasms attaching the tricuspid valve and its chordae tendineae(Fig 1B, arrow). The imaging showed no sign of pulmonary emboli. Considering the high risk of the lump falling off, the patient underwent a one-stage operation through median sternotomy to establish cardiopulmonary bypass. A honeycomb mass (Fig 1C, arrows) was attached to the anterior tricuspid valve with a dimension of about 33mm×18mm. Moreover, many small groups were attached to the ventricular surface of the tricuspid valve and its chordae tendineae. All masses and part of the chordae tendineae were removed and reconstructed. Histopathology revealed SCC (Fig 1D, E). The enhanced positron emission tomography-computed tomography(PET-CT) showed increased glucose metabolism in the lymph nodes on the left side of the abdominal aorta and behind the foot of the left diaphragm(Fig 1F, arrows). It was supposed to originate from cervical squamous cell carcinoma recurrence and distant metastasis. Furthermore, the TTE found no abnormality (Fig 2A), electrocardiogram, and PET-CT(Fig 2 B, arrows) after the operation on the heart. The patient recovered successfully postoperative course. However, the postoperative patients did not receive regular chemotherapy. One month after the procedure, the color Doppler Echocardiography showed normality in color Doppler Echocardiography(Fig 2C, arrow).
Three months after discharge, the patient has admitted again because he found a mass in the left neck with a dimension of about 22mm×30mm, which was hard, with poor mobility, and no tenderness. Color Doppler ultrasonography of cervical lymph nodes revealed hypoechoic nodules in the left neck, considering lymph node growth and structural abnormalities. The 64-slice Spiral Computed Tomography of the chest showed left supraclavicular fossa and axillary multiple lymph nodes with partial enlargement. The patient underwent left cervical mass resection. The pathological examination showed metastatic squamous cell carcinoma of lymph nodes (Fig 2D, arrow) and tumor thrombus (Fig 2E, arrow). After the operation, the patient was successfully discharged from the hospital but still did not receive traditional chemotherapy. Next, the TTE revealed a mass attached to the tricuspid valve with a dimension of about 28.1mm×18.2mm(Fig 2F, arrow). There is no noticeable change in examining the 64-slice Spiral Computed Tomography of the chest and electrocardiogram compared with last time. According to the current condition of the patients, the short-term effect after the operation is not ideal, and the progress of the patient’s condition still needs further follow-up.