Endocardial Invasion of Lung Cancer Undiagnosable before Autopsy
A 59-year-old male patient presented with left chest discomfort on admission. His blood pressure was 86/54 mm Hg, with a pulse rate of 107 beats per minute and a body temperature of 35.7°C. His medical history included encephalitis in childhood and his smoking history was 20 cigarettes per day for 40 years.\nA physical examination showed an anemic and edematous face with weak respiratory sounds in the left lung. The patient had elevated C-reactive protein, leukocytes, and calcium levels, and decreased hemoglobin and potassium. Cancer markers such as carcinogenic antigen, neuron-specific enolase, squamous cell carcinoma, and cytokeratin-19 fragment were all elevated. The calcium level was 12.6 mg/dl. His parathyroid hormone-related protein (PTHrP) level was elevated to 20.2 pmol/l (normal range: 0–1.1), and intact parathyroid hormone (PTH) was 2 pg/ml (normal range: 10–65).\nThoracic radiography showed cardiomegaly and computed tomography showed a left lung mass with invasion of the heart and pleural effusion (fig. ). Magnetic resonance imaging (MRI) revealed a large mass surrounding the heart (fig. ), and gallium-68 imaging showed positive accumulation in the region surrounding the heart (fig. ). No malignant diagnoses were possible upon frequent cytology of his sputum and pleural effusion. Bronchoscopy proved impossible due to the critical risk to life. The patient died from congestive heart failure with anoxia 38 days after admission. An autopsy revealed tumoral mass occlusion in the left main bronchus and tumoral invasion of the left atrium, left ventricle, and aorta.