PMC9945526_01
The ECG at admission (A) and 4 months prior to admission (B) showed abnormal ST segment elevations in leads V1-V6 and low-voltage QRS complexes in limb leads. Coronary angiography revealed no significant stenosis in the right coronary, left anterior descending, and circumflex coronary arteries (C,D).
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F1
ECG showed sinus tachycardia, ST segment elevation in precordial leads V1-V6, and low-voltage QRS complexes in limb leads (Figure 1A). We performed emergent coronary angiography, but there was no significant stenosis of coronary arteries (Figures 1C, D).
Transthoracic echocardiography (A) revealed massive pericardial effusion and a thickened and hypoechoic mass (red arrow) at the apex of the heart via an apical four-chamber view. Global longitudinal strain (B) showed a significantly decreased absolute value of strain in the area of the anterior and lateral walls of the heart. Routine chest CT at admission (C,D) and contrast-enhanced chest CT after pericardiocentesis (E,F) showed an irregular iso-density mass (yellow arrow) with peripheral exudation in the left lower lobe of the lung panels (C,E) and a myocardial mass (red arrow) located in the left and right ventricular apex emerging with reduced pericardial effusion panel (F).
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F2
On day 2, a transthoracic echocardiogram (TTE) revealed massive pericardial effusion and a 6.5 x 3.1 cm-sized hypoechoic mass at the apex of left ventricular, septal, and right ventricular myocardium associated with hypokinesis and decreased absolute value of global longitudinal strain (Figures 2A, B). Contrast-enhanced chest CT showed scattered irregular iso-density shadow (the largest mass was 67 x 47 mm) with peripheral exudation in the left lower lobe and significant thickness at the ventricular apex with pericardial effusion (Figures 2C-F).
The pericardiac fluid by HE revealed (A) exfoliated tumor cells with (B) CK7 (positive) and (C) Ep-cam (positive). The immunohistochemical analysis of pathologic tissue by percutaneous lung puncture showed (D) CK5/6 (positive), (E) P40 (positive), (F) P63 (positive), and (G) PDL1 (positive).
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F3
The pericardiac fluid contained blood with significantly increased CEA level (>1,000 ng/ml, normal < 5 ng/ml) and exfoliated tumor cells with CK7(+) and Ep-cam(+) (Figures 3A-C). Immunohistochemical analyses showed CK5/6(+), P63(+), P40(+), and PD-L1 (22C3, about 60% +) (Figures 3D-G).
The levels of (A) hs-TNT and (B) NT-proBNP. Panel (B) were persistently increased, demonstrating decreased cardiac function.
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F4
Unfortunately, his cardiac function decreased with increased levels of hs-TNT and NT-proBNP (Figures 4A, B), and without any improvement.