論文ID: CJ-22-0059
A 69-year-old man was referred to Yamaguchi University Hospital for implantation of an Ommaya reservoir for a metastatic brain tumor of lung adenocarcinoma (Figure A). On admission, echocardiography showed a small amount of hemodynamically irrelevant pericardial effusion (Figure B). Nine days later, the patient suddenly developed dyspnea with perspiration. Computed tomography and echocardiography revealed cardiac tamponade due to an increase in pericardial effusion (Figure B,C; Supplementary Movie). Although urgent pericardiocentesis achieved transient hemodynamic stabilization, the patient died the next day from multiple organ failure. The bloody fluid obtained by pericardiocentesis was composed of cancer cells (Figure D). Postmortem analysis yielded no evidence of direct invasion of the peri- or endocardium (Figure E). Microscopic evaluation showed vascular invasion of cancer cells in the epicardium of the left ventricle (Figure F). Interestingly, immunohistochemical analysis revealed that the vascular endothelial cells were CD34 positive (Figure G,H) and podoplanin negative (Figure I), indicating venous, but not lymphatic, invasion.
(A) Brain magnetic resonance imaging. (B,C) Echocardiography (B) and computed tomography (C) on admission and on Day 9. (D) Cytology of the pericardial effusion (Papanicolaou stain). (E) Gross examination of the heart. (F) Microscopic examination of the epicardial side of the left ventricle (hematoxylin and eosin stain; original magnification ×100). Arrowheads indicate vascular invasion. (G,H) Immunohistochemical analysis for CD34 (original magnification ×20 [G] and ×100 [H]). Arrowheads indicate positive vessels. (I) Immunohistochemical analysis for podoplanin (original magnification ×20). Arrowheads indicate podoplanin-negative vessels.
The clinical course was unique because progression of malignant cardiac tamponade is typically subacute or chronic. The rapid progression could have originated from the microscopic venous invasion that inhibited effusion drainage. Of the different invasive pathways, venous invasion accounts for the lowest proportion of cases of pericardial invasion and is usually categorized as invasion via macroscopic veins. This report is the first of a case of malignant cardiac tamponade due to microscopic venous invasion without evidence of macroscopic venous invasion or direct invasion.
None.
M.Y. is a member of Circulation Journal’s Editorial Team.
Informed consent was obtained from a bereaved family to report a date of the present case.
Supplementary Movie. Echocardiography.
Please find supplementary file(s);
http://dx.doi.org/10.1253/circj.CJ-22-0059
