Spiked helmet sign in a patient with cardiac metastasis

A 52-year-old male presented with low-grade fever and persistent chest pain 3 months following resection of a penile squamous cell carcinoma (postoperative pathological stage T3N2M0). Electrocardiogram revealed ST-segment elevation with an upward shift starting before the onset of QRS complexes in the V1 and V2 leads (Figure 1A). Echocardiography demonstrated a hypoechoic mass of ∼44 × 43 mm in the apical region of the right ventricular apex and a moderate pericardial effusion (Figure 1B). Cardiac magnetic resonance imaging revealed a mass of 49 × 34 mm in the right ventricular apex extending to the interventricular septum and pericardium, with associated pericardial thickening and haemopericardium, and left ventricular ejection fraction decline to 42% (Figure 1C–E). The positron emission tomography showed abnormal uptake of fluorodeoxyglucose in the areas of right ventricular apex, interventricular septum, diffusely thickened pericardium, and mediastinal lymph nodes station 5 (Figure 1F). Pericardiocentesis revealed turbid reddish pericardial fluid with significantly elevated tumour markers: carcinoembryonic antigen 25.85 ng/mL, carbohydrate antigen 19-9 201.52 U/mL, cancer antigen 125 229.46 U/mL, and cytokeratin 19 fragment 23.8 ng/mL. Multiple-panel image illustrating the following: (A) Electrocardiogram showing ST-segment elevation with an upward shift starting before the onset of QRS complexes in the V1 and V2 leads (arrow), complete right bundle branch block, ST-segment elevation (0.10–0.25 mV) in V1–V6, I, and aVL leads; (B) echocardiogram demonstrating a hypoechoic mass of ∼44 × 43 mm at the right ventricular apex (arrow), with moderate pericardial effusion; (C) cine image demonstrating a mass (49 × 34 mm, arrow) in the right ventricular apex extending to the interventricular septum and pericardium, with heterogeneous hyperintensity on T1- and T2-weighted sequences; (D) late gadolinium enhancement cardiac magnetic resonance imaging showing heterogeneous enhancement (arrow) within the mass during first-pass perfusion post-gadolinium administration; (E) diffusion-weighted imaging demonstrating high signal (arrow); (F) positron emission tomography scans showing abnormal uptake of fluorodeoxyglucose in the areas of right ventricular apex, interventricular septum, thickened pericardium, and mediastinal lymph nodes station 5. A clinical diagnosis of cardiac metastasis with ‘Spiked helmet sign’ was made after a multidisciplinary discussion. The family of the patient declined further aggressive anti-tumour therap. His condition deteriorated, culminating in cardiac arrest and death despite resuscitative efforts. Jianliang Yin (Data curation [equal], Resources [equal], Writing—original draft [equal], Writing—review & editing [equal]), Xianqing Hu [Resources (equal)], Wenbin Zhang [Methodology (equal)], and Ya Li (Data curation [equal], Methodology [equal], Writing—original draft [equal], Writing—review & editing [equal]) Consent: The authors confirm that written informed consent for publication of this case and associated images was obtained from the patient’s next of kin in accordance with the COPE guidelines. None declared. The data underlying this article are available from the corresponding author upon reasonable request.