Soft-tissue sarcomas, a heterogeneous family of malignancies arising from connective tissues such as muscle, fat, and blood vessels, are known to have a comparatively high propensity for spreading to the heart via the bloodstream. Yet cardiac involvement often remains clinically silent until the tumor reaches a critical size or occupies a strategically damaging location. In this patient, four years after an initial diagnosis treated with surgery, radiotherapy, and chemotherapy, the first warning signs were progressive shortness of breath and intermittent chest pain over several weeks. He had no prior cardiovascular history, which made the eventual findings all the more consequential. On examination he was hemodynamically stable, with a heart rate of 88 beats per minute, blood pressure of 128 over 76 millimeters of mercury, and oxygen saturation of 94 percent on room air. A soft systolic murmur was heard at the apex of the heart, and breath sounds were diminished over the right lower lung field, hinting at pathology within the chest rather than a primary cardiac disorder.

The diagnostic journey began with the simplest tools. An electrocardiogram showed sinus rhythm with nonspecific ST-T changes, findings that are easy to dismiss but consistent with myocardial stress. A chest X-ray revealed an enlarged cardiac silhouette and a mass in the right lung, prompting the team to proceed to transthoracic echocardiography. That ultrasound-based study proved pivotal. It demonstrated mild-to-moderate left ventricular systolic dysfunction, with the heart’s ejection fraction reduced to between 40 and 45 percent, meaning the main pumping chamber was operating well below its normal capacity of roughly 55 to 70 percent. The chambers and valves were otherwise structurally normal apart from mild mitral and tricuspid regurgitation, minor backflows of blood through the valves that often accompany altered cardiac loading conditions.

The echocardiogram’s decisive finding was a large, heterogeneous mass measuring approximately 2.7 by 3.2 centimeters within the left atrium, the chamber that receives oxygenated blood from the lungs before passing it to the left ventricle. Critically, the mass was intruding upon the right pulmonary veins, the vessels that deliver blood from the right lung into the atrium. This anatomical relationship explained much of the patient’s symptomatology: by obstructing pulmonary venous return, the tumor reduced the filling of the left ventricle, compounding the ventricle’s already weakened pumping function and contributing to breathlessness and chest discomfort. A slightly elevated pulmonary artery pressure was also noted, plausibly a secondary response to the underlying lung pathology and the left-sided hemodynamic burden.

To define the mass’s full extent and tissue characteristics, the clinicians turned to cardiac magnetic resonance imaging, the gold standard for characterizing cardiac masses. The CMR scans, acquired using steady-state free precession sequences, confirmed a far larger lesion than the echocardiogram alone suggested: a mass of 120 by 95 millimeters extending from the right lung into the left atrium through the pulmonary vein. The tissue was heterogeneous, showing mild perfusion and enhancement after contrast administration, a pattern typical of metastatic tumors and one that helps distinguish viable tumor from avascular structures such as thrombus. The imaging also revealed multiple metastatic nodules scattered through the left lung, painting a picture of widespread disease.

CMR added functional detail that proved equally important. The right ventricle, the chamber that pumps blood to the lungs, showed mildly reduced function with a right ventricular ejection fraction of 43 percent, although the chamber itself remained of normal size, indicating that some compensatory reserve persisted. The scans also detected a localized increase in T1 signal within the myocardium, the heart muscle itself, a finding the authors interpreted as possible chemotherapy-induced cardiomyopathy, a well-recognized late toxicity in patients treated with cardiotoxic agents. Trivial aortic insufficiency was also noted. Together these observations underscored that the patient’s heart was being assaulted on multiple fronts: by direct tumor invasion, by obstruction of venous return, and by the residual cardiac cost of his earlier cancer therapy.

A computed tomography scan of the chest completed the multimodal picture, confirming multiple pulmonary metastases with the dominant right-sided lesion extending directly into the left atrium. The concordance of findings across echocardiography, CMR, and CT was essential, because the differential diagnosis of a cardiac mass is broad and consequential. The clinicians systematically considered primary cardiac tumors such as atrial myxoma, the most common benign tumor of the left atrium, which can appear heterogeneous on imaging but typically does not invade surrounding structures, and rhabdomyosarcoma, a rare primary malignancy. They also weighed lung cancer metastasis, intracardiac thrombus, which lacks enhancement on CMR, infective endocarditis with its vegetations, cardiac sarcoidosis, fatty tumors such as lipoma and liposarcoma, hemangioma, and pericardial cysts. The patient’s sarcoma history, combined with the invasive growth pattern and enhancement characteristics on CMR, strongly favored metastatic disease, and the diagnosis was supported by clinical progression.

With the disease too extensive for surgical resection, the case was referred to a multidisciplinary tumor board comprising oncologists, cardiologists, and radiologists. The panel opted for palliative chemotherapy combined with targeted radiation therapy aimed at symptomatic relief. The outcome was encouraging: the patient experienced reduced dyspnea and chest pain, and follow-up imaging and clinical assessments documented improved cardiac function. This response aligns with recent evidence suggesting that continued antitumor therapy can improve survival even in patients with cardiac metastases, a population once considered to have uniformly dismal prospects. The authors emphasize that the positive trajectory followed directly from early detection and coordinated, multidisciplinary management rather than from any single intervention.

The broader lessons of the case extend beyond this single patient. Cardiac metastasis is rare but increasingly recognized as advances in imaging and cancer therapy extend survival long enough for late complications to emerge. Symptoms such as progressive breathlessness and chest pain in a patient with a known malignancy, particularly one of the sarcoma family, should prompt a low threshold for cardiac evaluation rather than attribution to more common causes. Transthoracic echocardiography remains the accessible first-line test, but its field of view can underestimate tumor extent, as it did here, where CMR revealed a mass several times larger than the initial measurement. The integration of multiple modalities, each contributing complementary anatomical, tissue-characterization, and functional information, was pivotal in establishing the diagnosis, mapping the disease, and steering therapy. As the authors conclude, early recognition and a coordinated multidisciplinary strategy remain essential to improving outcomes, even when metastatic disease is extensive, and the case stands as a testament to how modern cardiac imaging can turn a diagnostic dilemma into an actionable treatment plan.

Subject of Research: Cardiac metastasis from soft-tissue sarcoma diagnosed with multimodal imaging

Article Title: Metastatic Soft Tissue Sarcoma With Cardiac Involvement: A Case Study on the Role of Multimodal Imaging in Diagnosis and Management

Article References: Alizadehasl, A., Akhavan, S., Jebelli, S. F. H., najmabadi, A. F., Marzbali, N. A., Yousefimoghaddam, F., Haghazali, M., & Rafiei, S. (2026). Metastatic Soft Tissue Sarcoma With Cardiac Involvement: A Case Study on the Role of Multimodal Imaging in Diagnosis and Management. Clinical Case Reports, 14(9), Article e72112. https://doi.org/10.1002/ccr3.72112

Image Credits: AI Generated

DOI: 10.1002/ccr3.72112

Keywords: cardiac metastasis, soft-tissue sarcoma, echocardiography, cardiac MRI, computed tomography, left atrial mass, pulmonary veins, multidisciplinary care, palliative chemotherapy, case report, oncology, heart failure

The story began in 2021, when the man, previously healthy, presented with testicular pain and swelling. Scrotal ultrasonography revealed a solid intratesticular mass, and he underwent a radical orchiectomy, the surgical removal of the affected testicle. Histopathological examination confirmed a mixed germ cell tumor composed of roughly 70 percent post-pubertal type yolk sac tumor and 30 percent teratoma. Critically, the tumor was still confined to the testis, with no lymphovascular invasion and no involvement of the spermatic cord, placing it in the favorable pT1 category. His preoperative alpha-fetoprotein, a key tumor marker for yolk sac tumor, was elevated at 200 ng/mL, while beta-human chorionic gonadotropin and lactate dehydrogenase were normal.

At that point, the standard of care was clear: adjuvant chemotherapy after orchiectomy substantially reduces the risk of relapse in patients with this tumor profile. The patient declined. He also declined the recommended staging workup and did not return for regular follow-up visits. According to the case report, his repeated refusals stemmed from a combination of financial constraints, limited health literacy and educational background, and fear of chemotherapy-related toxicity. Those decisions, the authors suggest, likely allowed early hematogenous dissemination of tumor cells and may have contributed to the chemoresistance that emerged later in his disease course.

Roughly twelve months after the orchiectomy, the man returned to care with cough, shortness of breath, and episodes of coughing up blood. Contrast-enhanced computed tomography of the chest revealed multiple pulmonary metastases, including a large 80 by 57 millimeter solid mass with central necrosis in the left upper lobe, an adjacent 36 by 28 millimeter lesion, and a 42 by 26 millimeter cavitary lesion in the left lower lobe. A 15 by 12 millimeter mediastinal mass sat adjacent to the main pulmonary artery. Notably, cardiac evaluation at that time was unremarkable, with no pleural or pericardial effusion, a detail that underscores how quietly intracardiac disease can later develop. He received four cycles of bleomycin, etoposide, and cisplatin, the standard first-line BEP regimen, and responded well, with resolution of his hemoptysis and shrinkage of the lung lesions.

The reprieve did not last. During follow-up in 2024, serial monitoring showed a rising alpha-fetoprotein level accompanied by radiologic progression of the pulmonary metastases. Once again, the patient declined systemic therapy. A few months later he developed numbness and tingling in the fingers of his right hand, and brain magnetic resonance imaging revealed a metastatic lesion in the left temporoparietal lobe. For the third time during his illness, he declined recommended treatment. Approximately a year after the initial marker rise, he presented with a decreased level of consciousness, a neurological emergency. Repeat brain MRI showed a large left temporoparietal mass with significant perilesional edema and mass effect causing midline shift, the dangerous displacement of brain structures across the cranial midline that signals impending herniation.

Surgeons performed an emergency decompressive craniectomy, removing part of the skull to relieve intracranial pressure. Histopathology of the resected tissue confirmed metastatic yolk sac tumor, showing the characteristic reticular and microcystic architecture with prominent Schiller-Duval bodies, the pathognomonic finger-like structures of this tumor type, set within a loose mesenchymal-like stroma. About a month after surgery, the patient began four cycles of TIP chemotherapy, a salvage regimen combining paclitaxel, ifosfamide, and cisplatin, completed over approximately two months. TIP is a well-established option for relapsed or cisplatin-resistant non-seminomatous germ cell tumors, and in this case it helped stabilize the central nervous system disease when combined with subsequent whole-brain radiotherapy.

What came next was the most unusual chapter of the case. Approximately one month after completing TIP chemotherapy, follow-up chest CT revealed a persistent dominant pulmonary mass with stable dimensions. The patient underwent thoracotomy for surgical resection of that mass. During the operation, surgeons identified a separate, discrete metastatic deposit measuring 50 by 50 by 25 millimeters in the right atrium of the heart, anatomically discontinuous from the pulmonary lesion. It, too, was surgically excised. The precise route of hematogenous spread to the right atrium, potentially via the systemic venous circulation, could not be definitively established from the available operative and pathological documentation. Histopathology confirmed yolk sac tumor involvement of the atrial tissue, matching the morphology seen in the pulmonary and cerebral resections.

Cardiac metastasis from testicular non-seminomatous germ cell tumors is exceedingly rare, reported in fewer than one percent of cases, with most evidence drawn from autopsy series and scattered case reports. When it does occur, it typically involves the right side of the heart and carries life-threatening risks including intracardiac obstruction and tumor embolism, in which fragments of tumor break loose and block blood vessels in the lungs. The literature suggests that aggressive surgical resection can be beneficial when feasible, but overall survival in such cases remains suboptimal because complete disease control with chemotherapy alone is difficult to achieve. This case demonstrates that, even in heavily pretreated patients with disease in multiple organs, thoracotomy with resection of cardiac lesions can be accomplished safely in selected individuals.

The treatment sequence continued to build. About one month after the thoracotomy, the patient received whole-brain radiotherapy at a total dose of 30 Gy to consolidate control of the CNS disease. Then, approximately one month after completing radiotherapy, his oncologists initiated maintenance therapy with oxaliplatin and bevacizumab, a combination drawn from a published Phase II clinical trial regimen for refractory germ cell tumors. Bevacizumab is a monoclonal antibody that blocks vascular endothelial growth factor, starving tumors of their blood supply, while oxaliplatin is a platinum chemotherapy agent that offers a mechanism of action distinct from the cisplatin used in his earlier regimens. The rationale was to hold the disease in check after maximal cytoreduction through surgery and radiotherapy.

At the time of the report, the patient had been on maintenance therapy for approximately six months and clinically stable for roughly eight months after the thoracotomy. Serum alpha-fetoprotein levels, the most reliable biochemical fingerprint of residual yolk sac tumor, have remained stable without significant elevation. He reports no new neurological or cardiopulmonary symptoms, and his general condition is stable, with no biochemical evidence of overt disease progression. The authors caution that longer-term follow-up will be necessary to determine the durability of this response, and they acknowledge limitations, including the absence of complete serial tumor marker data that would have allowed formal risk stratification under the international consensus classification, a gap that itself reflects the patient’s repeated loss to follow-up, and the lack of detailed intraoperative documentation of the atrial resection technique.

Beyond its rarity, the case carries several lessons that the authors emphasize for practicing clinicians. New neurological or cardiopulmonary symptoms in a patient with a history of non-seminomatous germ cell tumor should prompt a high index of suspicion for metastasis at atypical sites, including the brain and heart. Multimodal therapy, combining chemotherapy, radiotherapy, and surgery, remains critical for disease control in aggressive or unusually metastatic cases. Salvage regimens such as TIP can produce meaningful responses even in chemotherapy-resistant disease, and urgent neurosurgical intervention can be lifesaving when brain metastases cause mass effect. Maintenance therapy with oxaliplatin and bevacizumab may offer benefit in selected patients with chemoresistant tumors. Finally, the case stands as a stark reminder that adherence to recommended treatment and close surveillance are not optional extras in testicular cancer care; in this patient’s trajectory, each interval of refused therapy preceded a stepwise escalation in the difficulty and danger of his disease, and only an extraordinary coordinated effort across neurosurgery, thoracic surgery, oncology, and radiotherapy brought it back under control.

Subject of Research: A case report of intracardiac, brain, and pulmonary metastases from a testicular yolk sac tumor managed with multimodal treatment.

Article Title: Intracardiac Metastasis From a Testicular Yolk Sac Tumor With Brain and Pulmonary Involvement: A Multimodality Management Case Report

Article References: Intracardiac Metastasis From a Testicular Yolk Sac Tumor With Brain and Pulmonary Involvement: A Multimodality Management Case Report. (n.d.). https://doi.org/10.1002/ccr3.73528

Image Credits: AI Generated

DOI: 10.1002/ccr3.73528

Keywords: testicular cancer, yolk sac tumor, non-seminomatous germ cell tumor, cardiac metastasis, brain metastasis, pulmonary metastases, BEP chemotherapy, TIP salvage chemotherapy, decompressive craniectomy, whole-brain radiotherapy, bevacizumab, case report