A 75-year-old Japanese male was admitted to our hospital complaining of lumbago, which had persisted for one month. He was an ex-smoker, and had type II diabetes, hypertension and ileus. Chest computed tomography (CT) revealed a 37-mm diameter mass lesion in the left lower lobe of his lung. The histological diagnosis of the transbronchial biopsy specimen was adenocarcinoma (fig. 1a). We diagnosed the patient to have lung cancer with multiple bone metastases, brain metastasis, and liver metastasis (cT2aN0M1b, stage IV). After the patient provided informed consent, we analyzed the specimen obtained from the TBLB for EGFR mutations. The analysis identified an 18-base pair deletion in exon 19 (fig. 1b). The patient was treated with cisplatin and pemetrexed as a first-line chemotherapy; however, after one cycle of the treatment, he developed paralysis of his left leg, and this symptom was rapidly progressive. Therefore, an emergency operation was performed for posterior lumbar interbody fusion. As second-line chemotherapy, the patient was started on 150 mg/day erlotinib. One month later, the size of both the primary lesion and the bone metastases were found to have decreased.
Three months later, he developed dyspnea at rest and edema. Furthermore, he had severe dyspnea and orthopnea, with a resting heart rate of 160-170 beats/min and a blood pressure of 63/43 mm Hg. His temperature was 36.8 C, and his arterial oxygen saturation was 88.0% on room air. A physical examination revealed distant heart sounds and a significantly distended internal jugular vein to the jaw level. An electrocardiogram revealed sinus tachycardia and borderline low-voltage QRS complexes. Chest radiographs showed cardiomegaly with an increased cardiothoracic ratio and bilateral pleural effusion (fig. 2a). A CT scan of the chest revealed a large pericardial effusion (fig. 2b). An emergency echocardiogram confirmed the presence of a large pericardial effusion, together with evidence of diastolic collapse of the right artrium, ventricle and left atrium, consistent with cardiac tamponade (fig. 2c).
The patient underwent pericardiocentesis of 520 ml of malignant sanguineous fluid, and placement of a pericardial drain, while having removed 1,100 ml of sanguineous fluid, in which adenocarcinoma was detected (fig. 3a). EGFR mutation analysis was performed in this pericardial effusion, and both the 18-base pair deletion in exon 19 and a second mutation, T790M in exon 20, were detected (fig. 3b and c). The patient temporarily recovered from the state of shock and survived for one month after drainage. He could not undergo further chemotherapy because his general condition had worsened. He died due to progressive disease five months after the original diagnosis. No autopsy was performed.