Neoplastic pericarditis as the initial manifestation of a papillary thyroid carcinoma


Full Terms & Conditions of access and use can be found at
https://www.tandfonline.com/action/journalInformation?journalCode=iups20

Upsala Journal of Medical Sciences

ISSN: 0300-9734 (Print) 2000-1967 (Online) Journal homepage: https://www.tandfonline.com/loi/iups20

Neoplastic pericarditis as the initial manifestation
of a papillary thyroid carcinoma

Nikolaos Tsoukalas, Ioannis D. Kostakis, Stamatina Demiri, Georgios
Koumakis, Vasileios Barbounis, Kalypso Barbati & Anna Efremidis

To cite this article: Nikolaos Tsoukalas, Ioannis D. Kostakis, Stamatina Demiri, Georgios
Koumakis, Vasileios Barbounis, Kalypso Barbati & Anna Efremidis (2013) Neoplastic pericarditis as
the initial manifestation of a papillary thyroid carcinoma, Upsala Journal of Medical Sciences, 118:3,
196-198, DOI: 10.3109/03009734.2013.801541

To link to this article:  https://doi.org/10.3109/03009734.2013.801541

© Informa Healthcare

Published online: 23 May 2013.

Submit your article to this journal 

Article views: 437

View related articles 

Citing articles: 2 View citing articles 

https://www.tandfonline.com/action/journalInformation?journalCode=iups20
https://www.tandfonline.com/loi/iups20
https://www.tandfonline.com/action/showCitFormats?doi=10.3109/03009734.2013.801541
https://doi.org/10.3109/03009734.2013.801541
https://www.tandfonline.com/action/authorSubmission?journalCode=iups20&show=instructions
https://www.tandfonline.com/action/authorSubmission?journalCode=iups20&show=instructions
https://www.tandfonline.com/doi/mlt/10.3109/03009734.2013.801541
https://www.tandfonline.com/doi/mlt/10.3109/03009734.2013.801541
https://www.tandfonline.com/doi/citedby/10.3109/03009734.2013.801541#tabModule
https://www.tandfonline.com/doi/citedby/10.3109/03009734.2013.801541#tabModule


Upsala Journal of Medical Sciences. 2013; 118: 196–198

CASE REPORT

Neoplastic pericarditis as the initial manifestation of a
papillary thyroid carcinoma

NIKOLAOS TSOUKALAS1,3, IOANNIS D. KOSTAKIS2, STAMATINA DEMIRI3,
GEORGIOS KOUMAKIS3, VASILEIOS BARBOUNIS3, KALYPSO BARBATI4 &
ANNA EFREMIDIS3

1Department of Medical Oncology, ‘401’ General Military Hospital, Athens, Greece, 2Second Department of Propedeutic
Surgery, ‘Laiko’ General Hospital, National and Kapodistrian University of Athens, Medical School, Athens,
Greece, 3Second Department of Medical Oncology, ‘Agios Savvas’ Anticancer Hospital, Athens, Greece, and
4Department of Pathology, Hellenic Red Cross Hospital ‘Korgialeneio-Benakeio’, Athens, Greece

Abstract
Neoplastic pericarditis represents approximately 5%–7% of the cases with acute pericarditis and is rarely the initial manifestation
of malignancy. The most common cause is lung cancer, followed by breast cancer, lymphomas, leukemia, and esophageal
cancer. Neoplastic pericardial disease is extremely rare in thyroid cancer, especially as the first manifestation. Here, we present a
papillary thyroid carcinoma that was manifested with pericarditis and cardiac tamponade in a 49-year-old female.

Key words: Cardiac tamponade, neoplastic pericarditis, pericardial effusion, thyroid cancer

Introduction

Neoplastic pericarditis represents approximately 5%–7%
of the cases with acute pericarditis (1-4). Theoretically,
any malignant tumor may cause pericarditis/pericardial
effusion (1,2) through direct extension or metastasis
via lymphatic or blood vessels into the pericardium
(3,5). However, the most common malignancy causing
pericarditis/pericardial effusion is lung cancer, followed
by breast cancer, lymphomas, leukemia, and esoph-
ageal cancer. Primary neoplasms of the pericardium,
such as mesothelioma, are very rare (1-3,5). Only few
cases of neoplastic pericarditis in patients with thyroid
cancer have been reported in the literature. Here, we
present a case of papillary thyroid carcinoma that was
manifested with pericarditis and cardiac tamponade.

Case report

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 patho-
logical 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
(Figure 1). 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 (Figure 2A). 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

Correspondence: Nikolaos Tsoukalas, MD, MSc, Medical Oncologist, Department of Medical Oncology, ‘401’ General Military Hospital, 10-12 Gennimata N.
Street, 11524 Ampelokipi, Athens, Greece. Fax: +30 2107494095. E-mail: tsoukn@yahoo.gr

(Received 16 March 2013; accepted 29 April 2013)

ISSN 0300-9734 print/ISSN 2000-1967 online � 2013 Informa Healthcare
DOI: 10.3109/03009734.2013.801541

http://informahealthcare.com/journal/ups
mailto:tsoukn@yahoo.gr


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.
Afterwards, 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 dem-
onstrated diffuse heterogeneity of the same lobe.
Nevertheless, the ultrasound failed to reveal any spe-
cific 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 lymph-
adenopathy. The patient underwent total thyroidec-
tomy 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 ana-
plastic changes, lymphovascular and perineural inva-
sion, and metastatic infiltration of the cervical lymph
nodes (Figure 2B). A reexamination of the pericardial
fluid from the pericardiocentesis revealed the expres-
sion 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.
After 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 possi-
ble to administer any anticancer treatment at that
time, and she passed away due to respiratory and
cardiac failure.

Discussion

As mentioned previously, approximately 5%–7% of
pericardial effusions have a malignant origin (1-4).
Most patients with neoplastic pericardial disease have
an already diagnosed malignancy (3). Acute pericar-
ditis or pericardial effusion is the initial manifestation
of malignancy in about 4% of the cases with pericar-
dial disease (1,3), but this percentage rises to approx-
imately 20% in large, symptomatic effusions without
obvious origin (1,5), as in our case. Risk factors for
malignant etiology are cardiac tamponade at presen-
tation, as in our case, recurrent or incessant pericar-
ditis, no response to non-steroidal anti-inflammatory
drugs, and a history of malignancy (1-3). Cytological
examination of pericardial fluid or pericardial biopsy
is required for a diagnosis to be made (1-3,5).
However, pericardial effusion is detected in only

A B

Figure 2. Histological images with malignant cells from the papillary thyroid carcinoma. A: Biopsy of the pericardium (hematoxylin and eosin
stain, 100�); B: Histological examination of the thyroid gland (hematoxylin and eosin stain, 200�).

Figure 1. Chest CT scan in which the pericardial effusion is
revealed.

Thyroid cancer presented with neoplastic pericarditis 197



12%–25% of patients with metastasis to the pericar-
dium, but cardiac tamponade, which developed in our
patient, is relatively rare among them (5).
Neoplastic pericardial disease is extremely rare in

thyroid cancer, especially as the initial manifestation.
Several cases have been reported in the literature
(6-16). Neoplastic pericarditis (6,9), massive pericar-
dial effusion (13), or cardiac tamponade (7,8,10,12,16)
have been reported as the first manifestation of a
previously occult thyroid cancer. On the other hand,
malignant pericardial effusion (14,15) or cardiac tam-
ponade (11) have also been diagnosed in patients with
already diagnosed thyroid cancer. Most cases have
pertained to papillary carcinoma (7,9-11,14-16), as in
our patient, whereas a follicular (13) and a mucin-
producing carcinoma (8) have also been described as
causes of neoplastic pericardial disease.

Conclusions

Neoplastic pericardial disease is most commonly
caused by lung cancer, followed by breast cancer,
lymphomas, leukemia, and esophageal cancer
(1-3,5), and is rarely the first manifestation of malig-
nancy (1,3). However, thyroid cancer, and especially
papillary carcinoma, should be included in the dif-
ferential diagnosis of pericarditis/pericardial effusion.

Declaration of interest: The authors report no
conflicts of interest. The authors alone are responsible
for the content and writing of the paper.

References

1. Imazio M, Brucato A, Derosa FG, Lestuzzi C, Bombana E,
Scipione F, et al. Aetiological diagnosis in acute and recurrent
pericarditis: when and how. J Cardiovasc Med (Hagerstown).
2009;10:217–30.

2. Imazio M, Spodick DH, Brucato A, Trinchero R, Markel G,
Adler Y. Diagnostic issues in the clinical management of
pericarditis. Int J Clin Pract. 2010;64:1384–92.

3. Imazio M, Brucato A, Mayosi BM, Derosa FG, Lestuzzi C,
Macor A, et al. Medical therapy of pericardial diseases: part II:
Noninfectious pericarditis, pericardial effusion and constric-
tivepericarditis. J Cardiovasc Med (Hagerstown). 2010;11:
785–94.

4. Azam S, Hoit BD. Treatment of pericardial disease. Cardio-
vasc Ther. 2011;29:308–14.

5. Refaat MM, Katz WE. Neoplastic pericardial effusion. Clin
Cardiol. 2011;34:593–8.

6. Nissimov R, Machtey I, Salomon M. Thyroid carcinoma with
pericardial involvement simulating rheumatic heart disease.
Harefuah. 1973;84:83–7.

7. Haskell RJ, French WJ. Cardiac tamponade as the initial
presentation of malignancy. Chest. 1985;88:70–3.

8. Motoba Y, Fujita J, Miura A, Sakurai T, Ishikawa K,
Kawai C, et al. A case of mucin-producing adenocarcinoma
of the thyroid presented with cardiac tamponade as an
initial manifestation. Nihon Naika Gakkai Zasshi. 1985;74:
1283–8.

9. Jancić-Zguricas M, Janković R. Occult papillary carcinoma of
the thyroid gland revealed by cancer pericarditis. Pathol Res
Pract. 1986;181:761–6.

10. Kovacs CS, Nguyen GK, Mullen JC, Crockford PM. Cardiac
tamponade as the initial presentation of papillary thyroid
carcinoma. Can J Cardiol. 1994;10:279–81.

11. Puigfel M, Falces C, Castellá M, Roig E. [Metastatic cardiac
tamponade in a patient with papillary carcinoma of the
thyroid]. Med Clin (Barc). 1996;107:197–8.

12. de la Gándara I, Espinosa E, Gómez Cerezo J, Feliu J,
Garcia Girón C. Pericardial tamponade as the first
manifestation of adenocarcinoma. Acta Oncol. 1997;36:
429–31.

13. Chiewvit S, Pusuwan P, Chiewvit P, Pleehachinda R,
Attanatho V, Mongkharuk J. Metastatic follicular carcinoma
of thyroid to pericardium. J Med Assoc Thai. 1998;81:
799–802.

14. Fukuda A, Saito T, Imai M, Ishii K, Miwa K. Metastatic
cardiac papillary originating from the thyroid in both ventricles
with a mobile right ventricular pedunculated tumor. Jpn Circ
J. 2000;64:890–2.

15. Ignjatović M, Stanić V. [Multiple intrathoracic compression
syndrome of thyroid etiology]. Vojnosanit Pregl. 2000;57:
709–16.

16. González Valverde FM, Gómez Ramos MJ, Moltó
Aguado M, Balsalobre MD, Menarguez F, Mauri F, et al.
Pericardial tamponade as initial presentation of papillary
thyroid carcinoma. Eur J Surg Oncol. 2005;31:205–7.

198 N. Tsoukalas et al.

www.ncbi.nlm.nih.gov/pubmed/19262208?dopt=Abstract
www.ncbi.nlm.nih.gov/pubmed/19262208?dopt=Abstract
www.ncbi.nlm.nih.gov/pubmed/20487049?dopt=Abstract
www.ncbi.nlm.nih.gov/pubmed/20487049?dopt=Abstract
www.ncbi.nlm.nih.gov/pubmed/20925146?dopt=Abstract
www.ncbi.nlm.nih.gov/pubmed/20925146?dopt=Abstract
www.ncbi.nlm.nih.gov/pubmed/20925146?dopt=Abstract
www.ncbi.nlm.nih.gov/pubmed/20406240?dopt=Abstract
www.ncbi.nlm.nih.gov/pubmed/21928406?dopt=Abstract
www.ncbi.nlm.nih.gov/pubmed/4704618?dopt=Abstract
www.ncbi.nlm.nih.gov/pubmed/4704618?dopt=Abstract
www.ncbi.nlm.nih.gov/pubmed/4006558?dopt=Abstract
www.ncbi.nlm.nih.gov/pubmed/4006558?dopt=Abstract
www.ncbi.nlm.nih.gov/pubmed/3001207?dopt=Abstract
www.ncbi.nlm.nih.gov/pubmed/3001207?dopt=Abstract
www.ncbi.nlm.nih.gov/pubmed/3001207?dopt=Abstract
www.ncbi.nlm.nih.gov/pubmed/3562345?dopt=Abstract
www.ncbi.nlm.nih.gov/pubmed/3562345?dopt=Abstract
www.ncbi.nlm.nih.gov/pubmed/8143231?dopt=Abstract
www.ncbi.nlm.nih.gov/pubmed/8143231?dopt=Abstract
www.ncbi.nlm.nih.gov/pubmed/8143231?dopt=Abstract
www.ncbi.nlm.nih.gov/pubmed/8758680?dopt=Abstract
www.ncbi.nlm.nih.gov/pubmed/8758680?dopt=Abstract
www.ncbi.nlm.nih.gov/pubmed/8758680?dopt=Abstract
www.ncbi.nlm.nih.gov/pubmed/9247105?dopt=Abstract
www.ncbi.nlm.nih.gov/pubmed/9247105?dopt=Abstract
www.ncbi.nlm.nih.gov/pubmed/9803073?dopt=Abstract
www.ncbi.nlm.nih.gov/pubmed/9803073?dopt=Abstract
www.ncbi.nlm.nih.gov/pubmed/11110437?dopt=Abstract
www.ncbi.nlm.nih.gov/pubmed/11110437?dopt=Abstract
www.ncbi.nlm.nih.gov/pubmed/11110437?dopt=Abstract
www.ncbi.nlm.nih.gov/pubmed/11332365?dopt=Abstract
www.ncbi.nlm.nih.gov/pubmed/11332365?dopt=Abstract
www.ncbi.nlm.nih.gov/pubmed/15698739?dopt=Abstract
www.ncbi.nlm.nih.gov/pubmed/15698739?dopt=Abstract

	Abstract
	Introduction
	Case report
	Discussion
	Conclusions
	Declaration of interest
	References