A Swollen Heart in Pregnancy

Abstract

     Thymic carcinoma is a rare malignancy of the anterior mediastinum. Its aggressive course and early metastases portend a poor prognosis. Presentation during pregnancy increases the risk of recurrence, metastases, and maternal death. We describe a case of a healthy, pregnant female with a history of thymoma presenting with cardiopulmonary distress from recurrent pleural and pericardial effusions. The patient responded to serial thoracenteses and pericardiocenteses but extensive work-up remained nondiagnostic. CT thorax revealed an enlarging thymoma with bulky lymphadenopathies. Subsequent pathology re-analysis of the original thymoma biopsy showed pan-cytokeratin, P63, and EBV-positive epithelial tumor cells, similar to our axillary lymph node hematopathology and confirmed the thymoma as the primary malignancy.  Clinicopathologic diagnosis of metastatic thymic carcinoma was finalized through multidisciplinary consensus. The patient responded well to radiation therapy but the mother and fetus died abruptly two weeks later. This case illustrates the diagnostic and therapeutic dilemmas of thymic carcinoma and its devastating consequences during pregnancy. The limited therapies in pregnancy and the sparse evidenced-based-medicine practices all contribute to poor outcomes. Attention to the differential diagnosis of anterior mediastinal tumors in pregnancy, evaluation of patients’ immunocompetency and EBV-status, re-analysis of prior tissue pathology, and early multidisciplinary clinicopathologic diagnosis are all encouraged to expedite therapy and reduce mortality.




doi:10.4021/jmc375w