PMC8602087_01
Diagnostic imaging. Echocardiography (A, B) showed a hypoechoic mass in the left ventricle and the anterolateral right ventricle. Chest CT scan mediastinal window (C, D) with contrast enhancement showed that the heart shadow had increased. A round, soft-tissue mass was observed at the left edge of the Cardiac margin. Multiple lymph node shadows were observed at the left hilum of the lung and mediastinum. The chest CT scan lung window (E, F) showed right pleural effusion and bilateral pneumonia.
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The boundary between the left ventricle wall and the muscular layer was unclear (the upper part reached the level of the main pulmonary artery, and the lower part reached the level of the apex of the heart), and the arterial blood flow signal was detected ( Figures 1A, B ). Multiple lymph node shadows were observed at the left hilum of the lung and mediastinum, and the left coronary artery was wrapped ( Figures 1C, D ). CT scan suggested pneumonia in the upper left lung, multiple lung infections, and right pleural effusion ( Figures 1E, F ). Considering the rarity of the case, a multidisciplinary team discussion was conducted with Ultrasonic Department, Radiology Department, Cardiovascular Department, Otorhinolaryngologic Department, Department of Thoracic Surgery, as well as Oncology Department. Intensive Care Unit (ICU) due to severe pneumonia on October 26, 2020 ( Figure 3D ). In view of the history of bilateral pneumonia according to the chest CT images before the immunotherapy ( Figure 1F ) and sputum culture results, our first consideration was that the patient's death was related to severe bacterial pneumonia, instead of the adverse effects of immunotherapy.
Right paraventricular mass biopsy (200x). The H&E stain (A, B) showed poorly differentiated carcinoma infiltration in fibrous tissue. The immunohistochemical analysis (C-H) showed EGFR (+), CK (+), P63 (+), Ki67 (40%+), PD-L1 (CPS 80%+), and PD-L1 (-).
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The right paraventricular mass biopsy showed poorly differentiated carcinoma infiltration in fibrous tissue ( Figures 2A, B ). Immunohistochemistry showed (EGFR) (+) ( Figure 2C ), CK (+) ( Figure 2D ), P63 (+) ( Figure 2E ), and Ki67 (+40%) ( Figure 2F ), suggesting nonkeratinizing NPC metastasis. The staining of the patient's tumor tissue with Roche SP142 revealed PD-L1 expression by the combined positive score (CPS) 80% staining positive ( Figures 2G, H ).
CT scans before and after treatment and timeline of treatment. Before treatment (A1-A4): The arrows show multiple lymph node shadows at the left hilum of the lung and mediastinum and a round, soft-tissue mass at the left edge of the Cardiac margin. After treatment (B1-B4): The arrows show that the enlarged mediastinal lymph nodes disappeared and myocardial metastasis significantly shrank. Follow-up (C1-C4): myocardial metastasis continuously shrank. Timeline of treatment of the patient (D): The arrow shows the whole process of diagnosis and treatment of the patient.
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On September 8, 2020, the chest CT scan was performed, which revealed a marked shrinkage of myocardial metastasis and the disappearance of enlarged mediastinal lymph nodes, compared with the results on November 1, 2019 ( Figure 3 ). Intensive Care Unit (ICU) due to severe pneumonia on October 26, 2020 ( Figure 3D ). In view of the history of bilateral pneumonia according to the chest CT images before the immunotherapy ( Figure 1F ) and sputum culture results, our first consideration was that the patient's death was related to severe bacterial pneumonia, instead of the adverse effects of immunotherapy.