ST-elevation Due to Primitive Extracardiac Origin. Differential Diagnosis and Review of Literature

Introduction: Vast of cases ST elevation is due to coronary occlusion. Metastatic disease has been identified as a rare case of Acute Myocardial Infarction or artery occlusion. Case Description: This case is about a 65yo man with a diagnose of stage IV Thymic Carcinoma in 2012, with two recurrences and past surgical treatment followed by radiation and chemotherapy. From that time, CPAP addicted for respiratory failure. He went to emergency department with worsening dyspnoea in the last few days. The ECG showed an ST-elevation in DI-aVL and V4-V6 suggesting an Acute Coronary Syndrome (ACS). The emergency coronary angiogram showed no significant coronary artery stenosis. The transthoracic echo revealed a mass infiltrating the left ventricular myocardium with consequent akinesia of lateral and anterior wall. A thoracic CT scan revealed a mass of 17*10*12 cm that infiltrated the myocardium surrounding the left circumflex coronary artery, which was the reason of ST-elevation. Discussion: After multidisciplinary medical evaluation, considering the clinical context and the surgical risk, we dropped to perform any other invasive or bioptic exam. In agreement with the patient and his relatives, the patient was hospitalized Palliative Care Unit. Conclusion: The ECG changes due to metastatic lesions or myocardial infiltration are different from those of an ACS. They are characterized by the persistence of ST-elevation without the typical evolution such as Q waves or T inversion.  In addition, in any patient with history of malignancies, multidisciplinary discussion and multimodality imaging play a key role for the correct diagnosis and management.