CARDIAC TAMPONADE AS A PRESENTATION OF AN ASYMPTOMATIC EXTRACARDIAC MALIGNANCY

Abstract

SESSION TITLE: Medical Student/Resident Lung Cancer Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pericardial tamponade is a life-threatening event secondary to inhibition of passive diastolic filling by rapid accumulation of fluid leading to right atrioventricular diastolic collapse. Patients with pericardial metastasis showing symptoms of cardiac tamponade as the first presenting sign of extracardiac malignancy is very uncommon. CASE PRESENTATION: A 24-year-old female presented to the hospital with progressive dyspnea and lower extremity swelling that started 3 days ago. She had no significant past medical history and was taking no prescription medications. She denied illicit drug use or smoking. There was no family history of malignancy or autoimmune disorder. Her vital signs were: afebrile, blood pressure 90/60 mmHg, heart rate140bpm, respiratory rate 30/min, oxygen saturation 95% on 10 liters of a nonrebreather mask. On physical examination jugular venous distention was 2 cm.Decreased breath sounds on the right hemithorax. Heart sounds were muffled, tachycardia, with a regular rhythm. The patient had 1+ edema bilaterally in the lower extremities. Other exams were unremarkable. CT angiogram of chest found a large right pleural effusion, 2.6 cm pulmonary nodule at right lower lobe,mediastinal lymphadenopathy, and a large pericardial effusion (Fig.1). An echocardiogram showed signs of pericardial tamponade(Fig.2). Cardiology team was consulted and took the patient for an urgent pericardiocentesis with pericardial chest tube placement which drained 650 mL of hemorrhagic fluid. Pulmonology service was consulted for right-sided chest tube placement which drained 600 mL of straw-colored fluid. The patient was then returned to MICU with significantly improvement in vital signs. Pericardial cytology demonstrated malignant cells positive for BerEP4, CK-7, and TTF-1 indicating pulmonary adenocarcinoma, stage 4 given the pericardial tamponade. DISCUSSION: In a young patient without any recent cardiac procedures, history of heart disease or renal failure, other possibilities for hemorrhagic pericardial effusion should be considered such as metastatic cancers including lymphoma, autoimmune disorders, and infectious causes such as tuberculosis and HIV. The treatment of pericardial tamponade in the setting of non-small cell lung cancer is urgent pericardiocentesis, followed by pericardial window if effusion is recurrent. The overall survival in patients with malignant pericardial effusion is dictated by histological type of the underlying malignant process. CONCLUSIONS: Cardiac metastasis is mostly asymptomatic, and pericardium is most common site of metastasis. Pulmonary adenocarcinoma involves lymphatic drainage of the heart and presents with signs of cardiac tamponade even before signs of pulmonary disease. A careful physical exam, imaging, surgical intervention and critical care management were crucial as demonstrated in our case. Reference #1: Fraser, R.S., Viloria, J.B. and Wang, N.-S. (1980), Cardiac tamponade as a presentation of extracardiac malignancy. Cancer, 45: 1697-1704. doi:10.1002/1097-0142(19800401)45:7<1697::AID-CNCR2820450730>3.0.CO;2-J Reference #2: Muir, Keith & Rodger, J. (1994). Cardiac tamponade as the initial presentation of malignancy: Is it as rare as previously supposed?. Postgraduate medical journal. 70. 703-7. 10.1136/pgmj.70.828.703. Reference #3: Bussani R, De-Giorgio F, Abbate A, Silvestri F. Cardiac metastases. J Clin Pathol. 2007;60(1):27-34. doi:10.1136/jcp.2005.035105 DISCLOSURES: No relevant relationships by Kanak Parmar, source=Web Response No relevant relationships by Wasawat Vutthikraivit, source=Web Response