S Yalcinkaya, A Vural, H Özkan
adenocarcinoma, lung, pericardial tamponade
S Yalcinkaya, A Vural, H Özkan. Lung Adenocarcinoma Causing Pericardial Tamponade. The Internet Journal of Thoracic and Cardiovascular Surgery. 2003 Volume 6 Number 2.
Pericardial tamponade, a life-threatening emergency, is rarely the first presenting symptom in malignancies. We would like to present the case of a fifty-year old male with an adenocarcinoma of the lung whose pericardial tamponade was the presenting symptom, and who, treated with pleuro-pericardial window procedure followed by chemotherapy, survived for 7 months postoperatively.
Pericardial effusion is a common finding in patients with metastatic malignant disease (1,2,3,4,5). Although the leading cause is lung cancer, it can also occur with breast cancer, leukemia and lymphoma (1,3,4,5). Pericardial tamponade in patients with malignancies is rarely seen as an initial presenting symptom (3,4,5). Since it is life-threatening, the symptom requires immediate care. A thorough search through the medical literature available to us revealed eighteen cases of pericardial tamponade due to malignant disease as an initial symptom. We would like to report the nineteenth case.
A fifty-year old male was admitted to the hospital due to progressive shortness of breath, as well as heart palpitations present for the last ten days. After initial therapy for congestive hearth failure, the patient was referred to our hospital. Medical history of the patient included a 35 year history of a pack-a-day cigarette habit until seven months prior to administration, when the patient willingly quitted smoking. He had no past history of cardiac problems. Physical examination revealed congested jugular, shortness of breath, orthopneic posture, and 2+ pitting edema in the lower extremities. His arterial pressure was low (90/60 mm Hg) and the heart beat rate was high (142/min). Prominent low voltage QRS complexes in all derivations were obtained on electrocardiogram (Figure 1).
Routine posteroanterior grid chest roentgenogram revealed a widened cardiac shadow representing pericardiac effusion in the form of a ““water bottle”” (Figure 2).
The patient underwent echocardiographic examination and pericardial effusion was observed (Figures 3A and B).
Two hundred milliliters of bloody fluid were removed by echocardiography guided needle aspiration. Cytological examination revealed malignant pericardial effusion suggestive of metastatic disease. Helical computed tomography sections revealed massive pericardial and left pleural effusions along with a mass lesion in the left lower lung lobe (Figures 4 A and B).
Two days after admittance, a left thoracotomy was performed for pleuro-pericardial window procedure and a biopsy of the left lung mass. Histopathologic examination revealed poorly differentiated adenocarcinoma disseminated to pericardium (Figure 5). Further studies showed no other sites of primary carcinoma besides the lung. Ten days following the operation the patient was referred to a local Oncology Hospital for adjuvant chemotherapy. The patient died 7 months following initial surgery of his malignant disease.
Pericardial effusion is a well known complication of many advanced malignancies such as lung cancer, breast cancer, lymphomas and leukemias (1, 3). The most common reason is lung cancer, and is seen in nearly 40% of all cases (2, 3). In fact, metastasis pericardium due to malignancies has in various extents been found in autopsy series, differing from 1.5 to 21% (2,3). Invasion of adjacent lymph nodes leads to obstruction of lymphatic drainage, and eventually to accumulation of the pericardial fluid (6). Pericardial tamponade as an initial symptom, however, is very rare (1,2,3,4,5, 7). It may occur because of accumulated fluid amounts as low as 150 ml, if the accumulation is rapid. On the other hand, slow accumulation of fluid amounts of as much as 2 liters may not cause tamponade (8).
Pericardial tamponade usually forces the patient to seek help urgently. Due to cardiac relaxation limitations, the patient presents congested jugular veins, tachycardia, arrhythmia, and low voltage criteria on electrocardiograms (1, 3, 7). Shortness of breath occurs frequently and is usually dealt with by either cardiologists or chest physicians. A simple chest x-ray may reveal a widened cardiac shadow, implicating a fluid accumulation within the pericardium (1,2,3, 7, 8). Echocardiography is very helpful in showing the presence of fluid as well as guiding aspiration. Patients with pericardial tamponade should at first be treated with pericardial tapping for urgent relief and cytological diagnosis (2, 3, 9). Only patients with recurrent pericardial effusions or those where aspiration did not help should be considered for surgical intervention (1, 9). Our patient had been admitted to a local hospital for congestive heart failure and was treated as such by a cardiologist. Then he was referred to our hospital where echocardiography was performed, pericardial tamponade was diagnosed and pericardial tapping under echocardiographic guidance was performed. Following symptomatic relief, a CT scan of the chest and total abdomen was planned. According to medical literature a CT is to be planned accordingly (2). Since the patient had a mass lesion in the left lung with pleural effusion and his pericardial effusion recurred, he underwent left thoracotomy for pleuro-pericardial window procedure. This procedure can be performed using several techniques including subxiphoid approach, video assisted thoracic surgery, and thoracotomy. It has been reported that there is no statistically significant difference between the results of a window procedure using subxiphoidal approach and a thoracotomy. The procedure may even be performed using VATS technique combined with a harmonic scalpel (9). We preferred thoracotomy over the subxifoidal route and video assisted thoracic surgery for technical reasons.
Pericardial tamponade implicates advanced disease. The median survival of these patients is reported to be between 7 days and 12 months following initial diagnosis (2, 3, 6, 10). There is growing evidence that chemotherapy might prolong survival in this group of patients (10). We believe that the seven-month survival period of our patient after receiving chemotherapy may support this opinion. Still further prospective clinical studies are needed for such a conclusion.
We believe that it is necessary to consider a possible diagnosis of pericardial tamponade of various causes, even advanced malignancies, in otherwise healthy patients admitted to hospitals with the aforementioned symptoms. Echocardiographic examination and aspiration under its guidance should be preferred as initial therapy. Pleuro-pericardial window procedure should be considered in patients with recurrence as a final step.
Dr. Serhat Yalcinkaya Gögüs Cerrahisi Servisi Yüksek Ihtisas Egitim ve Arastirma Hastanesi Bursa 16330 Turkey. Phone : + 90 224 360 5050 ext 1313 Fax : + 90 224 360 5055 e-mail : firstname.lastname@example.org
The authors wish to thank Ahmet Bayer, M.D., for his effort in histopathologic examination of the specimen and diagnosis, and Ulviye Yalcinkaya, M.D., for her assistance in taking the photomicrographs.