Neoplastic pericarditis as the initial manifestation of a papillary thyroid carcinoma
A 49-year-old female, who was a heavy smoker, but with negligible previous medical history, was admitted to a hospital due to stridor, dyspnea, cough, and hoarseness. Physical examination revealed no pathological signs, blood tests were normal, and the patient was treated with corticosteroids without a definite diagnosis. Ten days later, she developed epigastric pain that radiated to the left scapula and the left supraclavicular fossa. She was admitted to a hospital, where an echocardiogram and a chest CT scan revealed the presence of pericardial effusion (). During her hospitalization, she developed cardiac tamponade, for which she urgently underwent pericardiocentesis. Blind biopsies were taken from the pericardium and the upper lobe of the left lung, which showed malignant cells forming papillae and invading lymphatic and blood vessels (). However, it was not possible to identify the primary origin of the neoplasm, despite the thorough investigation with abdominal CT scan and technetium-99m-MDP bone scan. In addition, blood tests were normal, apart from the values of CEA (20.6 ng/mL (normal value: <4.7 ng/mL)) and CA-125 (341.4 IU/mL (normal value: <34 IU/mL)). The patient received one cycle of chemotherapy with carboplatin 5AUC, docetaxel 60 mg/m2, and bevacizumab 5 mg/kg for a neoplasm of unknown primary origin, which improved her symptoms.\nAfterwards, she was admitted to our department for further investigation and treatment. The physical examination revealed a palpable nodule of the right lobe of the thyroid gland, and the ultrasound demonstrated diffuse heterogeneity of the same lobe. Nevertheless, the ultrasound failed to reveal any specific suspicious area, and the serum concentration of thyroglobulin was normal (17.7 ng/mL (normal value: <78 ng/mL)). The cytological examination after a blind fine-needle aspiration biopsy of the right lobe of the thyroid gland revealed the presence of a papillary thyroid carcinoma. Subsequently, a cervical MRI was performed, demonstrating extensive lymphadenopathy. The patient underwent total thyroidectomy and bilateral lymph node dissection. The histological examination verified the presence of a stage IVC (T3N1bM1) papillary carcinoma with high-grade (grade III) malignancy and sporadic anaplastic changes, lymphovascular and perineural invasion, and metastatic infiltration of the cervical lymph nodes (). A reexamination of the pericardial fluid from the pericardiocentesis revealed the expression of thyroglobulin by the malignant cells. An I131 scan was also performed, but without demonstrating abnormal I131 uptake. The patient's treatment was continued with the use of the same chemotherapy regimen for a total of six cycles without any major adverse events and with excellent tolerance.\nAfter the completion of chemotherapy, a FDG-PET scan was performed with negative results. Afterwards, the follow-up was based on physical examination, blood tests, and imaging examinations. Unfortunately, the disease relapsed six months later with a very aggressive clinical course due to lung metastases and cardiac tamponade. It was not possible to administer any anticancer treatment at that time, and she passed away due to respiratory and cardiac failure.