Shariff
N, Karthik S, Sissons MCJ, Li Kam Wa E
(sn,
ks, lkwe) Department of Respiratory Medicine, Victoria Hospital, Blackpool, UK
(smcj) Department of Pathology, Victoria Hospital, Blackpool, UK
Corresponding author: Dr. Nasir Shariff, Department of Respiratory Medicine, Victoria Hospital, Blackpool FY3 8NR
e-mail – nasirshariff@rediffmail.com
SMJ 2006 51(1): 57
Abbreviations
PSA
– Prostate specific antigen,
Keywords or phrases
adenocarcinoma
prostate, cardiac tamponade, massive pericardial effusion
Cardiac
tamponade is a potentially life-threatening condition that is not uncommon in
the oncology setting. Massive pericardial effusion occurring due to metastatic
prostatic carcinoma is very rare and only a handful of cases have been reported
in literature till date. We report one such case, review literature and stress
on keeping this rare diagnosis as one of cause of breathlessness in patients
with prostate cancer.
Case Report
A 62-year-old male patient with a known diagnosis of hormone resistant prostatic carcinoma (Gleason score 8) for two years was admitted with breathlessness of 4 months and central chest pain of a week duration. He also suffered with severe chronic obstructive airway disease and was on Prednisolone, Seretide inhaler and Terbutaline and Ipratropium nebulisers for this. Physical examination revealed a pulse rate of 90/min, respiratory rate of 24/min, and blood pressure of 96/60mmHg. There was pitting pedal oedema, and raised jugular venous pressure. Respiratory examination revealed bilateral wheezes. Cardiac and abdominal examinations were normal.
Laboratory studies included a normal renal and liver functions tests but for slightly elevated urea levels (Urea 7.9mmol/L). Complete blood counts showed: white cells count 13.9 ´ 109/L (90% neutrophils). Serum prostate specific antigen level was 100ng/ml. Chest roentgenogram showed marked enlargement of the cardiac silhouette with congested lungs. Electrocardiography showed low voltage complexes with incomplete right bundle branch block. Echocardiography revealed 6cm heterogeneous pericardial effusion with right atrial collapse and right ventricular wall inversion.
Urgent pericardiocentesis was performed and 1600 ml of hemorrhagic fluid was drained. Cytology samples of the pericardial fluid were positive for malignant cells consistent with primary from the prostate. After the removal of the drain there was rapid re-accumulation of the fluid in a week with recurrence of his symptoms. A CT scan of the chest done at this time revealed significant mediastinal lymphadenopathy and pericardial effusion. He underwent mini thoracotomy with pericardial window 5 weeks after his presentation. A tense pericardial effusion was noted. Biopsy of the pericardium revealed metastatic adenocarcinoma, which stained positive for prostate specific antigen and prostatic alkaline phosphatase (fig 1 & 2).
He improved and remained stable subsequently, and was discharged home 2 months after admission. Six weeks later, he was readmitted with acute exacerbation of his chronic obstructive pulmonary disease. Evaluation for further re-accumulation of pericardial effusion was negative. He was treated with antibiotics, bronchodilators and non-invasive ventilation. He passed away 3 weeks after his second admission.
Discussion
Cardiac tamponade is a potentially life-threatening condition that is not uncommon in the oncology setting. The most common malignancies causing cardiac tamponade are lung cancer in the men and breast or uterine in the women.[1] Though prostatic cancer is the most common cancer diagnosed in men, massive pericardial effusion occurring due to metastatic prostatic carcinoma is very rare and only a handful of cases have been reported in English literature till date.[2,3,4,5]
In a review by DeCamp et al. it was noted that pericardial effusion in patients with malignancy could result from direct malignant or metastatic involvement of parietal pericardium or epicardium with or without frank myocardial invasion. Pre-existing mediastinal disease or prior radiotherapy may contribute to pericardial effusions because the lymphatic drainage necessary for pericardial fluid homeostasis has been obstructed.[6] Management of cardiac tamponade in patients with malignancy involves pericardiocentesis as initial treatment followed by therapies to prevent its recurrence. Prevention of recurrences may be achieved by intrapericardial instillation of sclerosing, cytotoxic agents, immunomodulators or surgical drainage procedures. Intrapericardial treatment tailored to the type of the tumour indicates that administration of cisplatin is most effective in secondary lung cancer and intrapericardial instillation of thiotepa was more effective in breast cancer pericardial metastases. Radiation therapy is very effective in controlling malignant pericardial effusion in patients with radiosensitive tumours such as lymphomas and leukemias.[7] In a study by Laham et al. on pericardial effusion in patients with cancer, it is suggested that surgical pericardial windows or possibly percutaneous balloon pericardiotomy to be considered as initial treatment to avoid recurrence.[8]
The patient in the current case report had been diagnosed with carcinoma of prostate about 2 yrs previously. Hormonal therapy had been tried but since there was no response it had been stop previously. Having identified cardiac tamponade the patient was initially managed by pericardiocentesis with improvement of his symptoms and performance status. Going by the reported case of successful treatment [5] of hormone resistant prostatic carcinoma with pericardiocentesis and intrapericardial methylprednisolone and cisplatin, followed by a course of intravenous docetaxel; chemotherapy was initially considered in our patient to avoid recurrence of the effusion but not given as he had advanced chronic obstructive pulmonary disease and a poor general condition. He was taken up for creating a pericardial window. This also allowed us to obtain a piece of the pericardium that confirmed the diagnosis.
In
conclusion we stress that though prostatic cancer is a common malignancy, its
metastasis to the pericardium producing symptoms of tamponade is rare but should
be considered as a possible cause of breathlessness in these patients.
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