Graphical abstract
Key Words: Nonbacterial thrombotic endocarditis, Testicular germ cell tumor, Tricuspid valve, Pulmonic valve, Transthoracic echocardiography
Highlights
-
•
Metastatic TGCT can rarely be complicated by right-sided tumorous-thrombotic NBTE.
-
•
NBTE may include tumorous, thrombotic, inflammatory, or mixed vegetations.
-
•
Tumorous-thrombotic NBTE shows dynamic changes and improvement with medical therapy.
-
•
Prechemotherapy TTE is valuable for detecting and characterizing NBTE.
-
•
A multidisciplinary team approach is recommended for NBTE management.
Introduction
In patients with malignancies, assessment of left ventricular and right ventricular systolic function by transthoracic echocardiography (TTE) before chemotherapy is a guideline-directed practice. Malignant tumors can metastasize to the heart via hematogenous or lymphatic spread or by direct extension, most commonly involving the pericardium and right heart chambers, less frequently the myocardium, and rarely the endocardium.1 Malignancies are also associated with hypercoagulability and may be complicated by deep venous thrombosis, pulmonary embolism (PE), or, rarely, nonbacterial thrombotic endocarditis (NBTE).2 Therefore, TTE is valuable not only for baseline functional assessment but also for the detection of unsuspected metastatic cardiac disease or NBTE.
Detection of right heart masses in a patient with metastatic testicular germ cell tumor (TGCT) poses significant diagnostic and therapeutic challenges and may increase morbidity and mortality.
Case Presentation
A 23-year-old man with no prior medical or family history presented to the emergency department with a 1-month history of a right testicular mass, anorexia, nausea, and 15-pound weight loss. The patient denied infectious or cardiopulmonary symptoms. On examination, findings included lack of fever, tachycardia (112 beats/min), normotension (112/75 mm Hg), and normoxia on room air. With the exception of tachycardia, results of cardiopulmonary examination were normal. A firm, nontender right testicular mass approximately the size of a tennis ball was noted, without peripheral lymphadenopathy or lower extremity edema. The leading diagnosis was a primary testicular tumor.
Scrotal ultrasound revealed a 7-cm heterogeneous mass consistent with malignancy. Computed tomography of the head, chest, abdomen, and pelvis showed no brain metastases but demonstrated multiple pulmonary, mediastinal, hilar, left axillary, and left supraclavicular lesions, as well as extensive retroperitoneal, mesenteric, and omental lymphadenopathy.
Serum tumor markers were markedly elevated: lactate dehydrogenase 7,814 U/L (normal range, 300-670 U/L), α-fetoprotein 16,877 ng/mL (normal range, 2-15 ng/mL), and β-human chorionic gonadotropin 270,000 mIU/mL (normal range, <5 mIU/mL). These findings were consistent with metastatic TGCT.
The patient underwent uncomplicated right radical inguinal orchiectomy. Histopathology confirmed a mixed nonseminomatous TGCT composed of embryonal carcinoma (70%), yolk sac tumor (20%), and teratoma (5%).
Prechemotherapy TTE unexpectedly demonstrated multiple right-sided cardiac masses: (1) a large (3.8 × 2.3 cm), pedunculated, multilobular, irregularly shaped, highly mobile, and hyperechoic mass attached to the atrial side of the anterior tricuspid valve (TV) leaflet tip (Figure 1A and B, Video 1); (2) a smaller (1.7 × 0.6 cm) similar mass on the atrial side of the anterior TV annulus (Figure 1B, Video 1); (3) a large (3.2 × 1.2 cm) similar mass on the posterior right ventricular outflow tract (RVOT; Figure 1C-E, Video 2); and (4) an elongated, highly mobile mass on the right ventricular side of the pulmonic valve (PV; Figure 1E, Video 2).
Figure 1.
Two-dimensional TTE, parasternal long-axis right ventricular inflow mid (A) and late (B) systolic, basal parasternal short-axis early (C) and late (D) systolic, and diastolic (E) views obtained initially, demonstrates a large, pedunculated, multilobular, irregularly shaped, and hyperechoic mass attached to the atrial side of the anterior TV leaflet tip (yellow arrows), a smaller mass with similar characteristics on the atrial side of the anterior TV annulus (orange arrow), a large similar mass on the posterior RVOT (green arrows), and an elongated mass on the right ventricular side of the PV (blue arrow). RA, Right atrium; RV, right ventricle.
The TV and PV leaflets appeared structurally normal, with no evidence of obstruction and trace tricuspid regurgitation (TR) detected by continuous-wave Doppler.
Mild pulmonary hypertension with an estimated right ventricular systolic pressure of 40 to 45 mm Hg, mild right ventricular dilation, and abnormal septal motion consistent with right ventricular pressure overload were present. The left heart and valves were normal.
The echocardiographic features suggested vegetations but could not distinguish among tumorous, thrombotic, inflammatory, and infective etiologies. Regardless of origin, the masses posed a high risk for PE, and surgical or percutaneous extraction was considered. A multidisciplinary team (cardiology, cardiothoracic surgery, urology, infectious disease, and hospital medicine) opted for medical management, recommending (1) blood cultures to exclude infective endocarditis, (2) emergent brain magnetic resonance to rule out metastases, (3) intravenous unfractionated heparin for possible thrombotic vegetations, and (4) oncology consultation for initiation of chemotherapy.
Repeat TTE on hospital day 4 showed a marked decrease in the size of the TV leaflet mass (to 1.3 × 0.5 cm) and TV annular mass (Figure 2A, Video 3), reduction with morphologic change of the RVOT mass (Figure 2B, Video 4), and resolution of the PV mass. TV and PV function, right ventricular size, and right ventricular systolic pressure remained unchanged. Blood cultures remained negative.
Figure 2.
Serial two-dimensional TTE, parasternal long-axis right ventricular inflow systolic (A) and basal parasternal short-axis diastolic (B) views obtained on day 4, demonstrates smaller masses on the anterior TV leaflet (yellow arrow) and annulus, change in the shape of the RVOT mass (green arrows), and resolved PV mass. RA, Right atrium; RV, right ventricle.
Computed tomographic pulmonary angiography on the same day as TTE revealed small PEs in the right upper lobe segmental artery (Figure 3), suggesting that reduction in the intracardiac masses may have resulted from anticoagulation, embolization, or both.
Figure 3.
Computed tomographic pulmonary angiogram, axial display obtained on day 4, demonstrates a small thrombotic filling defect within the segmental right upper lobe pulmonary artery (arrow).
On hospital day 6, cardiovascular magnetic resonance (CMR) with gadolinium confirmed a residual RVOT mass with mild late gadolinium enhancement (Figure 4), suggestive of a tumorous component.
Figure 4.
CMR, axial display at the level of the RVOT, balanced steady-state free precession (A) and late gadolinium enhancement (B) sequence obtained on day 6, demonstrates a thin, curvilinear mass (filling defect; arrows) in the RVOT and extending across the PV with possible mild, associated enhancement (arrows).
Given clinical stability and regression of masses, the patient was transitioned to low–molecular weight heparin (LMWH), appropriate therapy in malignancy-associated thrombosis with similar efficacy and safety as factor Xa inhibitors.3 The patient was discharged in stable condition on hospital day 7.
After 6 weeks of LMWH therapy and two cycles of bleomycin, cisplatin, and etoposide chemotherapy, follow-up TTE showed complete resolution of the TV mass, but reappearance of a larger TV annular mass (1.4 × 1.2 cm; Figure 5A, Video 5) and further reduction of the RVOT mass (0.6 × 0.5 cm; Figure 5B, Video 6).
Figure 5.
Serial two-dimensional TTE, parasternal long-axis right ventricular inflow systolic (A) and basal parasternal short-axis diastolic (B) views obtained after 6 weeks of outpatient anticoagulation and chemotherapy, demonstrates complete resolution of the anterior TV leaflet mass and the appearance of a new, larger TV annulus mass (orange arrows) and a single, smaller, and further morphologically altered RVOT mass extending to the base and right ventricular aspect of the septal TV leaflet (green arrow).
Despite the completion of five chemotherapy cycles, including salvage carboplatin and etoposide, tumor markers remained elevated and imaging continued to show diffuse metastatic disease. The patient’s condition progressively declined, and they ultimately died.
Discussion
TGCTs, comprising seminomas and nonseminomatous tumors, account for approximately 95% of testicular cancers in young men and have an excellent 5-year survival rate of about 95%.4 Radical inguinal orchiectomy with retroperitoneal lymph node resection is recommended for histopathologic staging, identification of micrometastases, risk stratification, and guidance of chemotherapy. Cardiac involvement by TGCT is exceedingly rare and typically involves the right heart chambers5; however, direct valvular involvement has not been well characterized.6
We describe a young patient with metastatic TGCT complicated by large, highly mobile right-sided cardiac masses involving the TV, TV annulus, RVOT, and PV. Initial regression of these masses with anticoagulation, despite a small PE, suggested a thrombotic component, while residual enhancement on CMR indicated possible tumor infiltration. Subsequent reappearance of a TV annular mass during ongoing therapy further supports a mixed tumorous-thrombotic etiology.
A review of the literature identifies three prior reports describing TGCTs with incompletely characterized involvement of the TV. Deck et al.7 reported the case of a 20-year-old patient with mixed TGCT and persistent metastatic disease despite orchiectomy and ongoing chemotherapy. Three years after the initial diagnosis, evaluation of a newly detected heart murmur with TTE revealed multiple mobile masses on the TV with trace TR. Given the patient’s history of inferior vena cava teratoma complicated by PE and multiple recurrences of teratoma, cardiac exploration was pursued. Intraoperatively, multiple firm, lobulated, white masses measuring 0.5 to 1.0 cm in diameter were identified on the TV. Despite preserved TV function and the absence of cardiac symptoms, the valve was replaced with a bioprosthetic prosthesis. Histopathologic examination of the valvular masses was consistent with mature teratoma.
May et al.8 described a 42-year-old man with a yolk sac tumor in whom transesophageal echocardiography (TEE) revealed a large, pedunculated right atrial mass extending from the superior vena cava to the lateral aspect of the TV. Operative findings demonstrated tumor occupying the right atrium and extending proximally into the superior vena cava and distally through the TV into the right ventricle. Following tumor resection, mild to moderate TR was treated using De Vega annuloplasty. However, TV involvement was not well characterized either echocardiographically or surgically.
Liu et al.9 reported a 51-year-old man with nonseminomatous TGCT in whom TTE and surgical findings demonstrated an extensive, apparently contiguous right-sided cardiac mass extending from the superior vena cava to the right atrium, TV, right ventricle, and bilateral pulmonary arteries. As in the prior reports, TV involvement was not well characterized echocardiographically or surgically.
Following orchiectomy, mass excision, anticoagulation, and chemotherapy, all three patients remained clinically stable at 12, 17, and 15 months of follow-up, respectively.
Distinctive features of our case compared with prior reports include (1) detailed echocardiographic characterization of multiple right-sided cardiac masses, (2) involvement of the RVOT and PV, (3) serial changes in the descriptive features of the valvular masses with general overall improvement and lack of worsening regurgitation during therapy; and, most important, (4) the avoidance of high-risk surgical intervention through appropriate medical therapy.
The pathogenesis of NBTE involves endothelial injury, thrombogenesis, inflammation, or combinations thereof. In advanced malignancy, diffuse carcinomatosis and valvular infiltration may also contribute. Thus, NBTE may encompass thrombotic, inflammatory, tumorous, or mixed vegetations.2,10, 11, 12
Libman-Sacks endocarditis, characteristic of systemic lupus erythematosus, represents the inflammatory-thrombotic variant.2,11,13 Purely thrombotic NBTE occurs in primary and secondary hypercoagulable states such as congenital hypercoagulability conditions, primary and secondary antiphospholipid syndrome, or malignancy, including TGCT.12 Most NBTE lesions (>95%) affect left-sided valves; right-sided involvement is rare.
NBTE is often asymptomatic but can manifest with embolic phenomena. Left-sided lesions frequently cause cerebral or systemic emboli, whereas right-sided lesions may lead to PE or, in the presence of a patent foramen ovale, paradoxical embolism. As seen in our case, NBTE in malignancy carries a poor prognosis.
The detection and characterization of cardiac masses depend on the spatial and temporal resolution of imaging modalities and their ability to provide tissue characterization. TTE offers excellent temporal resolution (40-120 frames/s), making it well suited for identifying highly mobile lesions. However, its moderate spatial resolution (1-3 mm) limits the detection of small, deeply located, or posterior valve masses. TEE provides superior spatial resolution (approximately 0.5-1 mm) while maintaining high temporal resolution, allowing reliable visualization of small, mobile, valve-associated lesions. Consequently, TEE is particularly valuable, and often considered the reference standard, for the detection of valve masses, which are typically small and predominate on the left-sided valves. Diagnostic yield may be further enhanced with three-dimensional imaging and contrast agents.
CMR offers good spatial resolution (1-2 mm in plane) and moderate temporal resolution, generally adequate for assessing mass size and anatomic relationships. Its principal strength lies in tissue characterization using multiparametric techniques, including T1- and T2-weighted imaging, parametric mapping, perfusion imaging, and late gadolinium enhancement. However, CMR is less sensitive for detecting small, highly mobile valve lesions. Cardiac computed tomography (CCT) provides the highest spatial resolution (approximately 0.3-0.6 mm) and excels in defining lesion margins, attachment sites, calcification, and perivalvular anatomy, though limited temporal resolution reduces sensitivity for mobile vegetations.
Hybrid imaging with positron emission tomography combined with CCT or CMR provides additional metabolic information and is particularly useful in cases with indeterminate findings or suspected inflammatory, infective, or malignant processes. These techniques also aid in disease staging and assessment of treatment response.
Given that valve-associated masses such as NBTE are often small and highly mobile, a multimodality imaging approach is frequently required. TTE remains an appropriate first-line modality for assessing mass mobility and hemodynamic consequences, particularly for anterior or right-sided valve lesions, as illustrated in the presented case, but may miss small posterior left-sided lesions. TEE offers the highest sensitivity and specificity for detection and morphologic characterization,11,13 while CMR and CCT play complementary roles in tissue characterization, anatomic definition, and evaluation of alternative diagnoses.
In summary, the optimal evaluation of valvular cardiac masses, including NBTE, may rely on multimodal imaging,14 with echocardiography, particularly TEE, as the cornerstone of diagnosis and advanced imaging reserved for problem solving and further characterization. Notably, prospective comparative data among all imaging modalities for NBTE are lacking. Finally, despite these imaging tools, definitive diagnosis will still require surgical histopathology.
Treatment of NBTE depends on the underlying cause. In systemic lupus erythematosus–related NBTE, combined immunosuppressive and antithrombotic therapy with anticoagulant or antiplatelet therapy is beneficial.15 In antiphospholipid syndrome, vitamin K antagonists remain first line; direct oral anticoagulants may increase stroke risk. As illustrated in this case, in malignancy-associated or tumorous-thrombotic NBTE, chemotherapy combined with LMWH or direct oral anticoagulants may be advantageous.
Our case underscores the importance of a multidisciplinary approach in the diagnosis and management of NBTE. In patients with advanced malignancy and NBTE, medical therapy appears beneficial, whereas the risks of surgical intervention may outweigh the potential benefits. Exclusion of infective endocarditis and brain metastases, prompt initiation of anticoagulation, and timely chemotherapy likely prevented further embolic complications and contributed to short-term cardiac stability; however, the patient’s long-term prognosis remained poor because of refractory metastatic disease.
Conclusion
This case illustrates the rare association between metastatic TGCT and right-sided tumorous-thrombotic NBTE, demonstrates the dynamic changes and overall improvement of this type of NBTE with medical therapy, and highlights the value of TTE in its detection and characterization.
Ethics Statement
The authors declare that the work described has been carried out in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki) for experiments involving humans.
Consent Statement
The authors declare that since this was a noninterventional, retrospective, observational study utilizing de-identified data, informed consent was not required from the patient or next of kin under IRB exemption status.
Funding Statement
The authors declare that this report did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Disclosure Statement
The authors report no conflicts of interest.
Acknowledgment
We acknowledge Stacey Bailey, RDMS, for her contribution in obtaining all echocardiographic images.
Footnotes
Supplementary data related to this article can be found at https://doi.org/10.1016/j.case.2025.12.004.
Supplementary Data
Two-dimensional TTE, parasternal long-axis right ventricular inflow view obtained initially, demonstrates a large, highly mobile, pedunculated, multilobular, irregularly shaped, and hyperechoic mass attached to the atrial side of the anterior TV leaflet tip and a smaller mass with similar characteristics on the atrial side of the anterior TV annulus.
Two-dimensional TTE, basal parasternal short-axis view obtained initially, demonstrates a large, highly mobile, pedunculated, multilobular, irregularly shaped, and hyperechoic mass on the posterior RVOT and an elongated mass on the RVOT and right ventricular side of the PV. RA, Right atrium; RV, right ventricle.
Serial two-dimensional TTE, parasternal long-axis right ventricular inflow view obtained on day 4, demonstrates smaller masses on the anterior TV leaflet and annulus.
Serial two-dimensional TTE, basal parasternal short-axis view obtained on day 4, demonstrates smaller TV leaflet mass, change in the shape of the RVOT mass, and resolved PV mass.
Serial two-dimensional TTE, parasternal long-axis right ventricular inflow view obtained after 6 weeks of outpatient anticoagulation and chemotherapy, demonstrates complete resolution of the anterior TV leaflet mass and the appearance of a new, larger TV annulus mass.
Serial two-dimensional TTE, basal parasternal short-axis view obtained after 6 weeks of outpatient anticoagulation and chemotherapy, demonstrates a single, smaller, and further morphologically altered RVOT mass extending to the base and right ventricular aspect of the septal TV leaflet.
References
- 1.Tyebally S., Chen D., Bhattacharyya S., Mughrabi A., Hussain Z., Manisty C., et al. Cardiac tumors. JACC Cardio Oncology State-of-the-Art Review. JACC CardioOncol. 2020;2:293–311. doi: 10.1016/j.jaccao.2020.05.009. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Ahmed O., King N.E., Qureshi M.A., Choudhry A.A., Osama M., Zehner C., et al. Non-bacterial thrombotic endocarditis: a clinical and pathophysiological reappraisal. Eur Heart J. 2025;46:236–249. doi: 10.1093/eurheartj/ehae788. [DOI] [PubMed] [Google Scholar]
- 3.Agnelli G., Becattini C., Meyer G., Muñoz A., Huisman M.V., Connors J.M., et al. Caravaggio Investigators Apixaban for the treatment of venous thromboembolism associated with cancer. N Engl J Med. 2020;382:1599–1607. doi: 10.1056/NEJMoa1915103. [DOI] [PubMed] [Google Scholar]
- 4.Iczkowski K.A. Germ cell neoplasms of the testis: update for 2022. Semin Diagn Pathol. 2023;40:2–21. doi: 10.1053/j.semdp.2022.07.001. [DOI] [PubMed] [Google Scholar]
- 5.Zakhartseva L.M., Zakharova V.P., Shatrova K.M., Chitaeva G.E., Vitovsky R.M. Metastatic cardiac tumors: literature review and own observation of testicular tumor metastasis in the right ventricle of the heart. Exp Oncol. 2018;40:336–342. [PubMed] [Google Scholar]
- 6.Taub C.C., Stainback R.F., Abraham T., Forsha D., Garcia-Sayan E., Jeffrey C Hill J.C., et al. Guidelines for the standardization of adult echocardiography reporting: recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr. 2025;38:735–774. doi: 10.1016/j.echo.2025.06.001. [DOI] [PubMed] [Google Scholar]
- 7.Deck A.J., True L.D., Higano C.S. Tricuspid valve metastasis from testicular carcinoma: a case report and review of the literature. Urology. 2000;56:330. doi: 10.1016/s0090-4295(00)00578-1. [DOI] [PubMed] [Google Scholar]
- 8.May M., Finkbeiner Y., Gunia S., Seehafer M., Knörig J., Hetzer R. Metastasizing testicular germ-cell tumor with infiltration of the right heart: indication for primary metastasectomy. Heart Vessels. 2006;21:63–65. doi: 10.1007/s00380-005-0829-5. [DOI] [PubMed] [Google Scholar]
- 9.Liu J.X., Eftimie B., Mortimer J. Intracardiac metastasis of germ cell tumor complicated by pulmonary hypertension and thrombocytopenia. J Clin Oncol. 2007;25:3547–3549. doi: 10.1200/JCO.2007.12.3562. [DOI] [PubMed] [Google Scholar]
- 10.Itzhaki O., Zadok B., Spectre G., Leader A. Cancer-associated non-bacterial thrombotic endocarditis. Thromb Res. 2022;213(Suppl 1):S127–S132. doi: 10.1016/j.thromres.2021.11.024. [DOI] [PubMed] [Google Scholar]
- 11.Roldan C.A., Tolstrup K., Macias L., Qualls C.R., Charlton G., Sibbitt W.L. Libman-Sacks endocarditis: detection, characterization, and clinical correlates by real time three-dimensional transesophageal echocardiography. J Am Soc Echocardiogr. 2015;28:770–779. doi: 10.1016/j.echo.2015.02.011. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Patriarcheas V., Tsamos G., Vasdeki D., Kotteas E., Kollias A., Nikas D., et al. Antiphospholipid syndrome: a comprehensive clinical review. J Clin Med. 2025;14:733. doi: 10.3390/jcm14030733. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Roldan C.A., Qualls C.R., Sopko K.S., Sibbitt W.L., Jr. Transthoracic versus transesophageal echocardiography for detection of Libman-Sacks endocarditis: a randomized controlled study. J Rheumatol. 2008;35:224–229. [PubMed] [Google Scholar]
- 14.Wu C.M., Bergquist P.J., Srichai M.B. Multimodality imaging in the evaluation of intracardiac masses. Curr Treat Options Cardiovasc Med. 2019;21:55. doi: 10.1007/s11936-019-0756-x. [DOI] [PubMed] [Google Scholar]
- 15.Roldan C.A., Sibbitt W.L., Greene E.R., Qualls C.R., Jung R.E. Libman-Sacks endocarditis and associated cerebrovascular disease: the role of medical therapy. PLoS One. 2021;16 doi: 10.1371/journal.pone.0247052. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Two-dimensional TTE, parasternal long-axis right ventricular inflow view obtained initially, demonstrates a large, highly mobile, pedunculated, multilobular, irregularly shaped, and hyperechoic mass attached to the atrial side of the anterior TV leaflet tip and a smaller mass with similar characteristics on the atrial side of the anterior TV annulus.
Two-dimensional TTE, basal parasternal short-axis view obtained initially, demonstrates a large, highly mobile, pedunculated, multilobular, irregularly shaped, and hyperechoic mass on the posterior RVOT and an elongated mass on the RVOT and right ventricular side of the PV. RA, Right atrium; RV, right ventricle.
Serial two-dimensional TTE, parasternal long-axis right ventricular inflow view obtained on day 4, demonstrates smaller masses on the anterior TV leaflet and annulus.
Serial two-dimensional TTE, basal parasternal short-axis view obtained on day 4, demonstrates smaller TV leaflet mass, change in the shape of the RVOT mass, and resolved PV mass.
Serial two-dimensional TTE, parasternal long-axis right ventricular inflow view obtained after 6 weeks of outpatient anticoagulation and chemotherapy, demonstrates complete resolution of the anterior TV leaflet mass and the appearance of a new, larger TV annulus mass.
Serial two-dimensional TTE, basal parasternal short-axis view obtained after 6 weeks of outpatient anticoagulation and chemotherapy, demonstrates a single, smaller, and further morphologically altered RVOT mass extending to the base and right ventricular aspect of the septal TV leaflet.