Excerpt

A 79-year-old woman was referred for cardiac evaluation because of decreasing physical performance. She had been treated for melanoma and papillary thyroid carcinoma respectively 16 and 11 months ago. Transthoracic echocardiography (TTE) demonstrated a large (17 × 30 mm) well-demarcated tumour located on the posterior mitral valve annulus with peripheral calcifications and central echolucent areas (Fig. 1A, arrow). Transoesophageal echocardiography (TEE) confirmed TTE-findings and excluded significant distortion of the mitral valve apparatus (Fig. 1B, arrow). The mass was also visible on chest X-ray (Fig. 1C, red dots). Cardiac computed tomography (CCT) revealed a high-density lesion (Fig. 1D) with no metabolic activity on positron emission tomography-CT (Fig. 1E, red dots). Subsequent cardiac magnetic resonance imaging (MRI) showed low-signal lesions on T1- and T2-weighted images without enhancement after gadolinium administration (Fig. 1F, G, arrowheads) which definitively established caseous calcification of the mitral annulus (CCMA). A conservative attitude was decided. Four months later, however, she was admitted with confusion and trouble of speech. MRI of the brain revealed multiple cerebellar and bilateral cerebral infarction zones (Fig. 1H, I, asterisks). TEE highlighted “voidance” of the CCMA into the left atrium (Fig. 1J, arrow) and CCT confirmed disappearance of caseous content with only a calcified rim remaining (Fig. 1K). …