Abstract Body (Do not enter title and authors here): Background
Melanoma frequently spreads hematogenously, yet cardiac metastases remain under-
recognized and carry high mortality. Early identification and coordinated cardio-oncology
management may improve functional outcomes.

Case
A 59-year-old woman underwent resection of CDK4-positive, BRAF/KIT/NRAS-negative
cutaneous melanoma of the left thigh and foot. Four months later, an 18F-FDG PET-CT (figure 1)
revealed disseminated disease with intense pericardial uptake. Cardiac MRI (figure 2) showed a
3.3 cm right-ventricular (RV) free-wall mass and a 1.1 cm left-ventricular (LV) apical lesion;
transthoracic echocardiography (TTE) (figure 3) confirmed mass location with preserved
biventricular function.

Decision-Making/Intervention
A heart–oncology team initiated nivolumab + ipilimumab (4 × q3 wk, every 3 weeks) followed
by maintenance nivolumab. Therapy induced widespread metabolic remission and LV mass
resolution but paradoxical RV-mass enlargement, causing exertional dyspnea, orthopnea, and
edema. After coronary angiography excluded ischemia, the patient underwent RV debulking
with resection of two large tumors, multiple implants, and a right-atrial thrombus; intra-
operative transesophageal echocardiography (TEE) confirmed tricuspid-valve integrity.
Outcome
Pathology verified metastatic melanoma. Post-operative TTE showed complete RV mass
removal and normalized filling; symptoms resolved, and the patient resumed maintenance
immunotherapy. At 5-month follow-up, she remained New York Heart Association (NYHA) class
I with no residual tumor on imaging.

Conclusion
Multimodal imaging unmasked occult biventricular melanoma, guided immunotherapy, and
informed the timing of palliative-to-therapeutic surgical debulking. Early multidisciplinary
engagement facilitated hemodynamic recovery and durable oncologic control, offering a
pragmatic framework for managing cardiac metastases in the era of checkpoint inhibitors.