thymic carcinoma is an aggressive anterior mediastinal malignancy that can cause severe chest pain , although its incidence is rare .
echocardiography is useful for assessing chest pain in the emergency room , but the diagnosis of an extracardiac mass can be missed .
the purpose of this report is to describe the validation of echocardiography for accessing an extracardiac mass that presented with chest pain .
an 80-year - old male visited the emergency room for sharp chest pain that had lasted for 1 month .
he had a history of inferior wall myocardial infarction and percutaneous coronary intervention on the proximal - middle right coronary artery 2 years ago .
on the physical examination , his temperature was 36.6 , his blood pressure was 100/60 mmhg , and his pulse was 81 beats / min .
laboratory examinations showed that the levels of ck - mb , troponin - i , and brain natriuretic peptide were not significantly elevated ( 2.8 ng / ml , 0.05 ng / ml , and 143 ng / ml , respectively ) .
electrocardiography revealed atrial fibrillation with q - waves in lead ii , iii , and avf .
emergent coronary angiography was performed because of his history of previous myocardial infarction , but mild in - stent restenosis of the proximal right coronary artery and no new lesions of significant coronary artery stenosis for chest pain were shown .
two - dimensional transthoracic echocardiography showed akinesia of the basal inferior wall , but no newly detected regional wall motion abnormality .
this extracardiac mass was located in the upper anterior mediastinal area and showed vascularity by color doppler imaging ( fig . 2c ) .
the right ventricle was slightly compressed by this mass , but there was no detectable pericardial effusion .
the previous echocardiography 1 year ago had shown no echogenic mass in the extracardiac area ( fig .
a huge anterior mediastinal mass was enhanced heterogeneously and directly invaded the sternal cartilage , costal cartilage , aortic arch , and pulmonary artery ( fig .
these ct findings were suggestive of a thymic carcinoma , and the severe chest pain of this patient was due to the huge anterior mediastinal mass with bone invasion .
histological findings by sonography - guided fine - needle aspiration demonstrated that the great majority of cells had tumoral necrosis and a very small number of cells had a high nucleus to cytoplasm ratio with hyperchromatin .
these findings represented malignancy of the thymus ; however , it was impossible to classify the subtype of tumor because of severe necrosis ( fig . 5 ) .
the patient was referred to an oncologist for further management of the left anterior mediastinal mass .
however , further specific tests were refused . according to the clinical presentation , the anterior mediastinal mass with invasiveness , and ptosis and muscle weakness ,
however , palliative radiotherapy was discontinued because the patient complained of significant anorexia and weakness .
only 15% to 20% of patients with acute chest pain actually have acute coronary syndrome.1,2 to discriminate patients with acute coronary syndrome from patients with non - cardiac chest pain is an immediate challenge to the primary clinician , especially in patients with a history of myocardial infarction and percutaneous coronary intervention
. the accuracy and efficiency of the differential diagnosis of acute chest pain can be improved by combining various approaches based on vigilant history taking , electrocardiography , biochemical markers , and imaging modalities such as echocardiography , coronary computerized tomography , and coronary angiography . because transthoracic echocardiography is widely available , with bedside utility and high sensitivity and negative predictive value in patients with acute chest pain for ischemia
therefore , after ruling out life - threatening conditions , it is necessary to consider other possible causes . especially when chest pain is sharp and lasts for hours , it is frequently suspicious that the chest pain originates from a musculoskeletal cause .
when a mediastinal mass such as a thymic carcinoma invades the chest wall , pleura , or heart , patients frequently present with chest pain.3 our case illustrates several considerations in the initial evaluation of chest pain .
first , chest ct was needed more than emergent coronary angiography because of the characteristics of the chest pain , which was sharp and had lasted for a month .
although a few cases of thymic cyst and malignancy have been documented,4 - 7 there has been no report that echocardiography detected an extracardiac mediastinal mass in the course of evaluating chest pain .
thymic carcinoma is a heterogeneous group of aggressive and epithelial malignancies , and its incidence is rare .
most patients present with cough , dyspnea , or chest pain . while these symptoms are being evaluated , the malignancy is often incidentally detected by chest radiographs or ct scan.3 when an anterior mediastinal mass shows the presence of an irregular contour , necrotic or cystic component , heterogeneous enhancement , lymphadenopathy , and great vessel invasion on a ct scan , the mass is likely to be a thymic carcinoma.8 mediastinal tumors , including thymoma , thymic carcinoma , and seminoma have been incidentally detected by thallium-201 ( tl 201 ) imaging.9 considering that the mediastinal mass is adjacent to the cardiac chamber , echocardiography can evaluate a mediastinal mass like a ct scan or tl 201 uptake . the mediastinal mass can distort or partially displace one or more cardiac chambers , and an anterior mediastinal mass can compress the right heart chamber , which can be shown by echocardiography.5 it has been reported that thymic cancer was detected by echocardiography presenting as cardiac tamponade or supra vena cava ( svc )
echocardiography is useful for the evaluation of chest pain in emergency circumstances and can detect a mediastinal mass because mediastinal masses are just adjacent to the heart ; however , the diagnosis of an extracardiac mass can be missed .
therefore , it is important to look outside the heart in addition to the heart itself in the assessment of chest pain .
 we report a case of thymic carcinoma that was initially detected by echocardiography in an 80-year - old male who visited the emergency room for chest pain and had a history of myocardial infarction and percutaneous coronary intervention . 
 transthoracic echocardiography showed a huge extracardiac mass that was located in the anterior mediastinum and was diagnosed as a thymic carcinoma by biopsy . 
INTRODUCTION
CASE REPORT
DISCUSSION