European Journal of Internal Medicine 15 (2004) 318 – 320 www.elsevier.com/locate/ejim
Malignant pericardial effusion and cardiac tamponade as a late complication of endometrial carcinoma Jacob Kogana,*, Boris Golzmana, Svetlana Turkota, David Ben-Dorb, Tatiana Charkowskyc, Shmuel Orena a
Department of Internal Medicine A, Barziali Medical Center, Histadrut St., Ashkelon, 78306, Israel b Pathology Department, Barziali Medical Center, Histadrut St., Ashkelon, 78306, Israel c Department of Clinical Oncology, Barziali Medical Center, Histadrut St., Ashkelon, 78306, Israel Received 13 October 2003; received in revised form 29 January 2004; accepted 5 February 2004
Abstract Malignant pericardial effusion, as a complication of gynecological cancer, is a rare occurrence. A review of the literature reveals only four cases of malignant pericardial effusion from endometrial carcinoma diagnosed during life. All of them were followed by cardiac tamponade a short time after being diagnosed and were associated with extensive myometrial invasion and multiple metastases. We describe a case of malignant pericardial effusion and cardiac tamponade due to recurrence of endometrial carcinoma characterized by the long period from diagnosis to clinical evidence of pericardial involvement. The causes of long-term disease-free interval are discussed. D 2004 Elsevier B.V. All rights reserved. Keywords: Malignant pericardial effusion; Cardiac tamponade; Endometrial carcinoma
2. Case report
Cardiac metastasis from gynecological malignancy is rare. A review of the literature revealed only four cases of malignant pericardial effusion from endometrial carcinoma diagnosed during life (two of them from papillary serous carcinoma) [1,2]. All of them associated with advanced disease with extensive local invasion and distant metastases. Time from diagnosis to pericardial involvement did not exceed 2 years. We report a case of malignant pericardial effusion with cardiac tamponade 8 years after hysterectomy, oophorectomy and radiotherapy for papillary serous endometrial carcinoma.
A 69-year-old woman was admitted to our hospital with a history of cough and worsening dyspnea over 1 month. She had been diagnosed with poorly differentiated papillary serous endometrial carcinoma (T2AN0M0 FIGO Stage IIA) 8 years earlier. The patient had undergone total abdominal hysterectomy, bilateral salpingo-oophorectomy. Postoperatively, the patient underwent whole pelvic irradiation 4500 cGy and two applications of brachytherapy to vaginal stump at 2000 cGy each. Follow-up for 8 years showed no evidence of recurrence. On examination, the patient was in good general condition with mild dyspnea and jugular venous distension. The patient’s blood pressure was 119/90 mmHg and pulse was 104. Dullness and inspiratory rales were found in the lower lobe of the right lung and diminished heart sounds were heard. Cardiomegaly and small right pleural effusion was present in chest X-ray (Fig. 1).
* Corresponding author. Tel.: +972 8 6745688; fax: +972 8 6745689. E-mail address: [email protected]
(J. Kogan). 0953-6205/$ - see front matter D 2004 Elsevier B.V. All rights reserved. doi:10.1016/j.ejim.2004.02.005
J. Kogan et al. / European Journal of Internal Medicine 15 (2004) 318–320
Fig. 1. Chest X-ray at presentation with cardiomegaly and pleural effusion.
On the second day of hospitalization, severe dyspnea developed and paradoxical pulse was demonstrated. Echocardiogram confirmed the presence of a large amount of pericardial effusion with compression of the right atrium. A thoracoscopic pericardial window was performed with drainage of 1900 ml of hemorrhagic fluid. A left thoracic drain was inserted and remained in place for 4 days. Pericardial biopsy confirmed metastatic serous papillary carcinoma consistent with previous endometrial tumor (Fig. 2). The procedure was followed by symptomatic improvement. Gynecologic examination showed no pathologic findings. No evidence of lymphadenopathy was found in CT scan of the abdomen, pelvis and chest. A follow-up echocardiogram showed only minimal pericardial effusion. The patient was discharged after 17 days.
3. Discussion The pericardium is a common target for neoplastic involvement in advanced cancer (8.4% of all cancers by autopsy in one study) , but this complication is not
commonly found in departments of internal medicine. The major etiological factors of malignant pericardial infusion include lung cancer, breast cancer, lymphoma and leukemia. A retrospective review from the Mayo Clinic  demonstrated the experience of 275 patients with malignant disease who underwent pericardiocenteses for symptomatic or hemodynamically important pericardial effusions. Lung, breast and hematologic cancers account for 38%, 23% and 18%, respectively, of all underlying malignant disease, respectively. The remaining 21% of the effusions were secondary to adenocarcinoma of an unknown primary source, thymoma, ovarian carcinoma, mesothelioma, testicular carcinoma, osteogenic sarcoma and gastrointestinal and genitourinary tract malignancy. Malignant pericardial effusion as a complication of gynecological cancers is a rare occurrence. Most of the cases were complications of ovarian carcinoma . A review of the literature revealed only four cases of malignant pericardial effusion from endometrial carcinoma; all of them followed by cardiac tamponade. The first case was described in 1988; the patient developed cardiac tamponade soon after undergoing hysterectomy during the course of chemotherapy. In the other cases, cardiac tamponade occurred 8 months, 12 months and 24 months after hysterectomy and bilateral salpingo-oophorectomy [1,2]. Two of the cases were due to papillary serous carcinoma. This carcinoma is a distinct histologic type of endometrial cancer which accounts for approximately 5% of all endometrial cancer and is associated with a high relapse rate and poor prognosis. Myometrial invasion and lymphatic or vascular channel involvement were frequent. The vaginal apex was the most common site of recurrences. Other extrauterine sites include lymph nodes, lungs and liver . We describe another case of malignant pericardial effusion and cardiac tamponade due to recurrence of uterine papillary serous carcinoma. The risk of recurrent endometrial carcinoma is greatest within the first 3 years of diagnosis as 75–95% of recurrences develop within this
Fig. 2. (A) Biopsy from endometrial tumor 8 years before admission. (B) Cytologic examination from pericardial biopsy. Both pictures confirm poorly differentiated papillary serous endometrial carcinoma.
J. Kogan et al. / European Journal of Internal Medicine 15 (2004) 318–320
period . Our case is characterized by the long period from diagnosis to clinical evidence of pericardial involvement. Prognostic factors of recurrences and short survival include age over 60 years, surgical stage III or IV, presence of lymph–vascular space invasion, myometrial invasion greater than 50% and histology (recurrences were more frequent among papillary serous carcinoma) . Two of these factors were present in our patient—age and histology—but early stage without myometrial and lymphatic invasion most probably affected the long-term disease-free interval. In another case report of cardiac tamponade due to metastatic uterine papillary serous carcinoma, the patient presented with extensive myometrial invasion, extension to the serosa and involvement of the upper endocervical region . Two years after treatment, extrauterine recurrence presented with pericardial effusion, extensive myometrial invasion and extensive ascites. In our case, no evidence of local recurrence or any other extrauterine recurrence was demonstrated. Consensus on optimal management of neoplastic pericardial disease has not been achieved. Large pericardial effusion with tamponade requires removal of the fluid by catheter pericardiocentensis or surgical pericardectomy. Intrapericardial injection of sclerosing agents, cytotoxic and immunosuppressive drugs and cardiac radiation may be discussed. In our patient, thoracoscopic pericardial window was performed, the fluid was drained and the procedure was well tolerated.
Treatment with carboplatin–paclitaxel begun. For 3 months after undergoing the thoracoscopic operation, patient was in generally good condition; however, afterwards, rapid deterioration occurred and the patient died from massive malignant invasion of the lungs.
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