Asymptomatic right ventricle cavity obliteration due to metastatic oral squamous cell carcinoma.

Background: Oral squamous cell carcinoma (SCC) with cardiac metastasis is a rare antemortem finding. A case demonstrating significant right ventricular (RV) cavity obliteration due to metastatic SCC in an asymptomatic patient is presented. Case Summary: A 46-year-old gentleman underwent routine preoperative electrocardiogram which raised concern of possible anterior and inferior ST elevation (Image 1A). Clinically he had no chest pain but a 2-week history of night sweats, anorexia and weight loss. This was on a background of meta-static floor of mouth SCC treated with neoadjuvant carboplatin/paclitaxel chemotherapy and wide local excision of the floor of the mouth, subtotal glossectomy, segmental mandibulectomy, left sided selective lymph node dissection, and right modified radical neck dissection. Histopathology revealed T4aN2cM0 locally advanced SCC. Clinical examination was unremarkable except for a JVP with a prominent 'a' wave and a pericardial friction rub. Investigations revealed a normal Troponin (<0.04 ng/ml). CT Pulmonary Angiogram demonstrated a large pericardial effusion, a large filling defect (49x45mm) within the RV, multiple enlarged mediastinal and anterior pericardial lymph nodes. Several lung nodules were found bilaterally (largest 14x17mm). FDG-PET scan demonstrated an intensely avid mass involving the myocardium, the interventricular septum and floor of the ventricle (Image 1D). Nodular FDG avid pericardial disease and bilateral pulmonary metastases were noted in addition to uptake in the subcutaneous soft tissues anterior to the left oropharynx (SUV max 6). Urgent transtho-racic echocardiogram revealed moderate right ventricular (RV) dilation, with a large lobulated echodense mass invading the RV free wall, occupying most of the RV cavity (Image 1B & C). Estimated RV systolic pressure was 32 mmHg. A moderate circumferential pericardial effusion was detected, measuring 25 mm in diameter posteriorly with no tamponade physiology. Management: A pres