br Case report A year old woman presented to
Case report A 58-year-old woman presented to our hospital with a history of several weeks of chronic dry cough and intermittent shortness of breath. On physical examination, the patient\'s blood pressure was 135/85 mmHg, oral temperature was 37.4 °C, pulse rate was 112/min, and her respiratory rate was 26 breaths/min. A thoracic examination showed disappearance of tympanic percussion and decreased breathing sounds over the left lung. Laboratory testing revealed a white blood cell count of 13.5 × 103/μL (81% neutrophils) and a C-reactive protein (CRP) level of 12.20 mg/dL (reference range, <0.5 mg/dL). Chest roentography revealed blunting of the left costophrenic angle and cardiomegaly. After admission, the patient\'s symptoms worsened, accompanied by intermittent chest tightness. Repeated chest roentography showed globular enlargement of the heart and a cardiac silhouette sign. The electrocardiogram demonstrated widespread concave ST elevation and PR depression throughout the limb leads (I, II, III, aVL, and aVF) and precordial leads (V2–6). In addition, reciprocal ST depression and PR elevation were seen in lead aVR (Fig. 1). Pericarditis was impressed based on the result of EKG study. Subsequent cardiac echography and chest computed tomography (CT) showed massive pericardial effusion with collapse of the right atrium and ventricle. An emergent pericardial window intervention was performed because of the suspicion of cardiac tamponade and pericarditis. During operation, bloody pericardial effusion approximately 500 ml was removed and then some varied sizes of small nodules and increased thickness with uneven surfaces were also observed in some areas of the pericardium. After the operation, the histopathological report on the pericardium specimen indicated that poorly differentiated adenocarcinoma, characterized by pleomorphic tumor ache inhibitors with marked nuclear atypia and hyperchromatism arranged in a glandular or solid nest pattern, infiltrated the pericardial tissue (Fig. 2). Serial tumor markers showed CA-125: 200 U/ml, CEA:8.24 ng/ml, CA 19-9:16.30 U/ml and CA-153: 150 U/ml. Serial immunohistochemistry analysis for markers showed immunoreactivity for cytokeratin 7 (CK 7), cytokeratin 20 (CK 20), and carcinoembryonic antigen. Because of fulminant necrosis of the pathological specimen and no immunoreactivity for other markers such as CDX-2, TTF-1, estrogen receptor, or progesterone receptor, metastatic lesions should be considered based on these results of current studies. Subsequent tumor work-up including abdominal CT revealed two masses with cystic components, 4.7 cm and 4 cm, located at the left and right adnexa, respectively. In addition, some soft tissue nodules were deposited over the omentum and pelvic cavity. Hence, primary ovarian carcinoma with carcinomatosis or krukenberg tumor should be considered into possible different diagnoses. Initially, there were no positive findings after upper and lower gastrointestinal endoscopy. Surgical invention for the ovary lesion is indicated for confirming correct diagnosis despite she presenting poor performance status. However, the histopathological result of ovary showed a metastatic tumor with pleomorphic tumor cells with marked nuclear atypia, eccentric nuclei, and intracellular mucin (Fig. 3). There is no immunoreactivity for marker of PAX-8 expression. Poorly differentiated metastatic adenocarcinoma with focal signet-ring cell differentiation from the gastrointestinal tract was suspected. Subsequent repeated esophagogastroduodenoscopy showed one small ulcerative lesion with peripheral mucosa hypertrophy over the esophagogastric junction, and pathological results revealed a poorly differentiated adenocarcinoma with focal intracytoplasmic mucin production and signet ring formation (Fig. 4). In addition, a strong immunoreaction for the HER2/neu receptor was found in this specimen (immunohistochemistry score: 3+).
Discussion Cardiac metastases, including cardiac parenchymal involvement or pericardium metastases, are not uncommon but they are relatively rare compared to the occurrence of metastasis at other sites. Based on the data given in an epidemiological report, cardiac metastases most commonly arise from pleural mesothelioma (48.4%), melanoma (27.8%), lung adenocarcinoma (21%), undifferentiated carcinomas (19.5%), lung squamous cell carcinoma (18.2%), and breast carcinoma (15.5%). Other origins such as ovarian carcinoma (10.3%), gastric carcinomas (8%), renal carcinomas (7.3%), and pancreatic carcinomas (6.4%) have also been found in autopsy studies.