PMC3573823_01
a Pathological findings. The tissue obtained by transbronchial biopsy revealed poorly differentiated adenocarcinoma. b A representation of the direct DNA sequencing for PCR products including the deletions in exon 19 of the EGFR. The deletion ranged from codon 747 to 753, including 18 base pairs of nucleotides (TAAGAGAAGCAACATCTC). The black vertical bars indicate deletion sites.
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F1
The histological diagnosis of the transbronchial biopsy specimen was adenocarcinoma (fig. 1a). The analysis identified an 18-base pair deletion in exon 19 (fig. 1b).
a A chest radiograph showing an enlarged cardiac silhouette with diffuse vascular congestion, indicating cardiac tamponade. b A chest CT scan demonstrating pericardial effusion with cardiac tamponade. c An echocardiogram (four-chamber view) showing a large circumferential pericardial effusion (PE) with diastolic collapse of three chambers of the right atrium (RA), the right ventricle (RV), and the left atrium (LA).
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F2
Chest radiographs showed cardiomegaly with an increased cardiothoracic ratio and bilateral pleural effusion (fig. 2a). A CT scan of the chest revealed a large pericardial effusion (fig. 2b). An emergency echocardiogram confirmed the presence of a large pericardial effusion, together with evidence of diastolic collapse of the right artrium, ventricle and left atrium, consistent with cardiac tamponade (fig. 2c).
a Cytological preparation from the pericardial effusion showing pleomorphic nuclei and prominent nucleoli, consistent with adenocarcinoma, similar to the specimen obtained from the primary lesion. b We performed a mutational analysis of the exon 19 deletion with DNA from the pericardial effusion. The presence of the exon 19 deletion was confirmed by a common fragment analysis using polymerase chain reaction (PCR). The PCR products were analyzed on an ABI PRISM instrument. The two shorter segments, of 154.7 and 136.9, respectively, showed a deletion mutation. c The T790M mutation was detected by the Cycleave real-time quantitative PCR technique with a T790M-specific probe and a wild-type probe. Each Ct point of the wild-type and mutant sequence was 29.58 and 34.86 cycles.
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F3
The patient underwent pericardiocentesis of 520 ml of malignant sanguineous fluid, and placement of a pericardial drain, while having removed 1,100 ml of sanguineous fluid, in which adenocarcinoma was detected (fig. 3a). T790M in exon 20, were detected (fig. 3b and c). The patient temporarily recovered from the state of shock and survived for one month after drainage.