Cervical cancer is the second most common malignancy worldwide in women and the third most common cause of cancer death in developing countries. This type of cancer spreads mainly to the lung, the bone, and the brain; however, the pericardium is an unusual site of invasion, which is associated with a poor prognosis. We present a case of a 35-year-old woman with six months of leg edema and abnormal uterine bleeding. During the initial evaluation, cardiac tamponade and a bilateral pleural effusion were found. A left supraclavicular lymphadenopathy was identified on physical examination, while gynecological examination and MRI were irrelevant. Initial cytology of the pericardial fluid showed a poorly differentiated carcinoma, and a cervical biopsy revealed a squamous cell invasive carcinoma. Chemotherapy was started with carboplatin and paclitaxel, but no clinical improvement was noted and the patient died 46 days after arrival. Cardiac tamponade in a young female patient is a harbinger to widen the differential diagnosis to include not only infectious, cardiac, or metabolic etiology but also oncological causes since this will allow appropriate treatment.
Pericardial metastasis is an unusual manifestation of cervical cancer, generally identified at autopsy [
A 35-year-old woman arrived at the emergency department because of rest dyspnea and a 6-month history of lower extremity edema. She had a 3-month history of intermittent abnormal vaginal bleeding. On initial evaluation, the patient was hypoxemic with an oxygen saturation of 80% with room air. Relevant clinical signs were tachycardia and hypotension, decreased heart sounds, and a left supraclavicular lymphadenopathy. A chest X-ray showed a widening of the cardiac silhouette with a bilateral pleural effusion (Figure
Chest X-ray.
Pericardiocentesis was performed and a total of 500 mL of bloody secretion was drained with symptomatic improvement. Pleural fluid was obtained by thoracocentesis, and cytology was positive for a poorly differentiated carcinoma (Figure
(a) Pleural and pericardial fluid cytology (10x) shows mesothelial cells with hyperplasia; the second population of cells are malignant squamous epithelial cells. (b) Pleural and pericardial fluid cytology (40x). A close-up of mesothelial cells; a group of malignant squamous cells is seen in the lower part of the image.
An excisional biopsy of the left supraclavicular lymphadenopathy was positive for metastatic squamous cell carcinoma. The cervical biopsy reported a squamous cell carcinoma associated with an intraepithelial high-grade lesion (Figures
(a) Cervical biopsy, 5x, invasive nonkeratinized squamous cell; (b) intercellular bridge, nuclear hyperchromia, macronucleolus, and atypical mitosis, 40x; and (c) cervical cytology with invasive squamous cell carcinoma.
Immunochemistry, P63(+); immunophenotype for malignant squamous cells.
Chemotherapy was begun with carboplatin and paclitaxel. Despite the treatment received during her hospitalization, she again presented a pericardial and pleural effusion with subsequent hemodynamic instability and respiratory failure. Due to the fact that in our center there is no experience in applying intrapericardial sclerotherapy, it was offered to repeat pericardiocentesis; however, this intervention was refused. The patient died 46 days after the initial presentation.
Cervical cancer is the second most common cancer diagnosed in women worldwide and the third cause of cancer death in developing countries [
The most common causes of pericardial effusion with or without tamponade are infections (
Maisch et al. analyzed 357 pericardial effusion samples from 1988 to 2008 and identified 68 patients with cancer-associated pericardial effusion. In 42 patients, a malignant pericardial effusion was noted; in 15 patients, it was induced by radiation; in 11, by viral disease; and in 6, with an autoimmune process. From the cancer-associated pericardial effusion, it was found that 52.4% was from lung cancer, 19% breast cancer, 4.8% Hodgkin’s lymphoma, 4.8% colon cancer, 2.4% mesothelioma and esophageal cancer, and 14.2% was of unknown origin undifferentiated cancer [
Pericardial effusion as a clinical presentation can be acute (trauma, aortic rupture, and iatrogenic), subacute (uremia or idiopathic), or chronic (constrictive or adhesive). The clinical features are dyspnea, pleuritic pain, cough, fatigue, and syncope. Cardiac tamponade causes hypotension, tachycardia, and decreased heart sounds (Beck triad). The paradoxical pulse is reported as the most sensitive sign (82%) to diagnose cardiac tamponade, followed by tachycardia and elevated jugular venous pressure with a sensitivity of 77% and 76%, respectively [
Pericardiocentesis is a diagnostic and therapeutic procedure. The drainage of the pericardial fluid is assessed daily. The inserted catheter is removed when drainage is less than 30 mL/day. Such a procedure has a greater risk of major complication (1.2%) such as ventricle laceration, pneumothorax, ventricular tachycardia, and bacteremia. In patients with cancer, the risk of recurrence is about 90% [
Table
Reported cases of cervical cancer with pericardial effusion and cardiac tamponade.
Author (year) | Age at initial presentation (years) | Time from diagnosis to pericardial effusion | FIGO clinical stage (initial) | Previous treatment | Presence of cardiac tamponade | Treatment after diagnosis of pericardial effusion | Overall survival |
---|---|---|---|---|---|---|---|
Charles et al. (1997) [ |
46 | 24 months | IIIB | RT, hysterectomy+BSO | Yes | Pericardial window, CT, doxorubicin | 8 months |
Rieke and Kapp (1988) [ |
49 | 23 months | IIA | Hysterectomy+BSO, RT | No | Pericardiocentesis, RT | 9 months |
Rudoff et al. (1989) [ |
27 | 21 months | IIIB | RT | Yes | Pericardiocentesis, anterior pericardiectomy, cisplatinum | Not reported |
Nelson and Rose (1993) [ |
51 | 5 days | IV | None | Yes | Pericardiocentesis/CT cisplatin+RT | 4 months |
61 | 3 months | IIIB | RT | Yes | Pericardiocentesis, instillation of tetracycline, CT cisplatin, bleomycin, methotrexate alternating with cisplatin and 5FU | 12 months | |
Kountz et al. (1993) [ |
28 | 10 months | IIB | RT/CT | No/mass in right ventricle | Not specified | 3 months |
Jamshed et al. (1996) [ |
57 | 32 months | IB | Hysterectomy, RT | Yes | Pericardiocentesis, pericardial window, RT | 5 months |
Lemus et al. (1998) [ |
53 | 24 months | IB | RT, hysterectomy+BSO+superior vaginectomy | No/interventricular septum mass | RT | 1 month |
49 | 12 months | IVB | RT | No/mass in right ventricle | CT 5FU+cisplatin | 7 months | |
Senzaki et al. (1999) [ |
28 | 16 months | Hysterectomy, RT/CT | No/mass in right ventricle | Pericardiocentesis+intrapericardial cisplatinum | 1 month | |
Kim et al. (2008) [ |
64 | 6 months | IB | CT carboplatin+paclitaxel+concurrent RT pre- and posthysterectomy | No/right atrium mass | 5-fluorouracil+cisplatin+RT | 12 months |
Kim et al. (2011) [ |
52 | 6 months | IVB | 3 cycles of 5FU, cisplatin+concurrent RT | Yes | Pericardiocentesis | 1 month |
Azria et al. (2011) [ |
54 | Initial presentation (cervical adenocarcinoma) | IVB | None | Yes | Pericardiocentesis, pericardial window, carboplatin+paclitaxel | 33 days |
Ore et al. (2013) [ |
5th decade | 9 months | IVB | RT, CT topotecan+cisplatin | Yes | Pericardiocentesis, pericardial window | 26 days |
Kalra et al. (2014) [ |
56 | 6 months | IIIB | Carboplatin+paclitaxel+RT | Yes | CT not specified+RT | Not reported |
Ramegowda et al. (2015) [ |
50 | 23 months | IIIB | RT, brachytherapy | Yes | No treatment | 4 months |
Tsuchida et al. (2016) [ |
78 | 15 months | IIIB | RT | No/mass in right ventricle | No treatment | 1 month |
FIGO: International Federation of Gynecology and Obstetrics; CT: chemotherapy; RT: radiotherapy; BSO: bilateral salpingo-oophorectomy; 5FU: 5-fluorouracil.
Within the initial approach of a young woman presenting with cardiac tamponade, an etiology must be identified and cancer should be considered as a possible cause. A correct workup is required to achieve a timely diagnosis, in order to grant the patient the best possible outcome.
The authors declare that there is no conflict of interest regarding the publication of this paper.