case_images: PMC9945526_01
case_images: 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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case_images: F1
case_images: 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).
case_images: 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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case_images: F2
case_images: 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).
case_images: 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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case_images: F3
case_images: 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).
case_images: The levels of (A) hs-TNT and (B) NT-proBNP. Panel (B) were persistently increased, demonstrating decreased cardiac function.
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case_images: F4
case_images: Unfortunately, his cardiac function decreased with increased levels of hs-TNT and NT-proBNP (Figures 4A, B), and without any improvement.