PMC8349103_01
Chest CT images of the patient before surgery. (A) Contrast-enhanced CT images of the chest at the initial visit. A bifurcated, multinodular mass with a maximum diameter of 60 mm and coarse internal calcification in the anterior mediastinum (arrows) was noted. (B) The anterior mass rapidly progressed one month after the first visit.
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Chest computed tomography (CT) showed a bifurcated, multinodular mass having a maximum diameter of 6.0 cm with coarse internal calcification in the anterior mediastinum (Fig. 1A). The surrounding anterior mediastinal adipose tissue was opacified, and a right pleural effusion was also present (Fig. 1A). One month later, although his chest pain had disappeared, a follow-up CT revealed progression of the anterior mediastinal mass (Fig. 1B).
Pathological examination of the tumor. (A) (B) Hematoxylin and eosin staining. (C) Elastica van Gieson staining showed numerous venous invasions of tumor cells. (D) CAM5.2 staining, (E) AE1AE3 staining, (F) c-kit staining. Magnification: (A),(B),(D),(E),(F) x 400, (C) x 100.
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Histologically, there was diffuse proliferation of epithelioid tumor with high N/C ratio and hyperchromatic nuclei (Fig. 2A). Spindle-shaped tumor cells were also seen (Fig. 2B). Elastica van Gieson staining showed numerous venous invasions (Fig. 2C). Tumor cells were positive for an epithelial marker, CAM5.2 (Fig. 2D), and partially positive for AE1AE3 (Fig. 2E), but negative for thymic carcinoma markers (CD5 and c-kit) (Fig. 2F), lymphocytic markers (CD3, CD20, CD30), mesothelial markers (D2-40 and calretinin), and melanocytic markers (HMB45 and melanA).
Chest CT and X-ray images before and after lenvatinib treatment. (A) Chest CT and X-ray images (A) before and (B) 28 days after lenvatinib treatment.
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CT revealed progression of pulmonary metastasis and pleural dissemination (Fig. 3A). Considering his medical conditions (chronic heart failure: 43% ejection fraction, paroxysmal atrial fibrillation, and chronic kidney disease: creatinine clearance rate of 45 mL/min), he was initiated with 14 mg of lenvatinib orally once daily, as first-line chemotherapy (Fig. 4). On day 28 at the outpatient clinic, a follow-up chest CT (Fig. 3B) revealed a partial shrinkage of multiple lung metastases and pleural dissemination evaluated as a stable disease (SD).
Clinical course of the patient. The patient was initiated with 14 mg of lenvatinib. On day 3 after lenvatinib initiation, he was treated with candesartan, followed by candesartan and amlodipine due to developing hypertension. On day 5 after lenvatinib initiation, he developed fatigue (grade 3) and exacerbation of chronic heart failure. On day 6, lenvatinib was transiently discontinued. He was initiated with eplerenone and furosemide. On day 8, he responded well to the diuretics and his symptoms improved. He was then restarted with 10 mg of lenvatinib, suspending administration of the drug on weekends. On day 12, he developed persistent atrial fibrillation and was treated with bepridil. On day 13, the lenvatinib dose was increased to 14 mg. He was discharged on day 21. On day 28 at the outpatient clinic, a follow-up chest CT revealed a partial shrinkage of multiple lung metastases and pleural dissemination. He has been treated with lenvatinib since then.
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CT revealed progression of pulmonary metastasis and pleural dissemination (Fig. 3A). Considering his medical conditions (chronic heart failure: 43% ejection fraction, paroxysmal atrial fibrillation, and chronic kidney disease: creatinine clearance rate of 45 mL/min), he was initiated with 14 mg of lenvatinib orally once daily, as first-line chemotherapy (Fig. 4). He was referred to the Department of Cardiovascular Medicine and was initiated with eplerenone and furosemide (Fig. 4).