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Cardiac Tamponade as an Initial Manifestation of Cervical Cancer

Cardiac Tamponade as an Initial Manifestation of Cervical Cancer Hindawi Case Reports in Oncological Medicine Volume 2019, Article ID 7524797, 5 pages https://doi.org/10.1155/2019/7524797 Case Report 1 2 Yuridia Evangelina Rodríguez-Rosales, Carlos Eduardo Salazar-Mejía , 2 2 2 Blanca Angélica Soto-Martínez, David Hernández-Barajas , Oscar Vidal-Gutiérrez, and Gabriela Sofia Gómez-Macías Universidad Autónoma de Nuevo Leon, Facultad de Medicina y Hospital Universitario “Dr. José Eleuterio González”, Department of Internal Medicine, Av. Madero y Gonzalitos s/n, Colonia Mitras Centro, Monterrey, Nuevo Leon, C.P. 64460, Mexico Universidad Autónoma de Nuevo Leon, Facultad de Medicina y Hospital Universitario “Dr. José Eleuterio González”, Centro Universitario Contra el Cáncer, Av. Madero y Gonzalitos s/n, Colonia Mitras Centro, Monterrey, Nuevo Leon, C.P. 64460, Mexico Universidad Autónoma de Nuevo Leon, Facultad de Medicina y Hospital Universitario “Dr. José Eleuterio González”, Department of Pathology, Av. Madero y Gonzalitos s/n, Colonia Mitras Centro, Monterrey, Nuevo Leon, C.P. 64460, Mexico Correspondence should be addressed to Carlos Eduardo Salazar-Mejía; drsalazarmejia@gmail.com Received 9 October 2018; Accepted 5 December 2018; Published 9 January 2019 Academic Editor: Raffaele Palmirotta Copyright © 2019 Yuridia Evangelina Rodríguez-Rosales et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 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. 1. Introduction 2. Case Report Pericardial metastasis is an unusual manifestation of cervical A 35-year-old woman arrived at the emergency department cancer, generally identified at autopsy [1]. Symptomatic peri- because of rest dyspnea and a 6-month history of lower cardial effusion and cardiac tamponade are usually described extremity edema. She had a 3-month history of intermittent in the scenario of recurrent disease after previous treatment abnormal vaginal bleeding. On initial evaluation, the patient with chemotherapy and/or radiotherapy, with very few cases was hypoxemic with an oxygen saturation of 80% with room reporting these entities as an initial presentation of cervical air. Relevant clinical signs were tachycardia and hypotension, cancer [2]. Herein, we present a case of cardiac tamponade decreased heart sounds, and a left supraclavicular lymphade- as an initial manifestation of a squamous cell carcinoma of nopathy. A chest X-ray showed a widening of the cardiac sil- the cervix. houette with a bilateral pleural effusion (Figure 1). 2 Case Reports in Oncological Medicine (a) Figure 1: Chest X-ray. Pericardiocentesis was performed and a total of 500 mL of bloody secretion was drained with symptomatic improve- ment. Pleural fluid was obtained by thoracocentesis, and cytology was positive for a poorly differentiated carcinoma (Figure 2). An excisional biopsy of the left supraclavicular lymph- adenopathy was positive for metastatic squamous cell car- cinoma. The cervical biopsy reported a squamous cell carcinoma associated with an intraepithelial high-grade lesion (Figures 3 and 4). CA-125 was 335.5 IU/mL and a simple and contrasted pelvic MRI demonstrated a uterine (b) and cervical absence of tumoral mass; however, peritoneal carcinomatosis was present. Figure 2: (a) Pleural and pericardial fluid cytology (10x) shows mesothelial cells with hyperplasia; the second population of cells Chemotherapy was begun with carboplatin and paclitaxel. are malignant squamous epithelial cells. (b) Pleural and pericardial Despite the treatment received during her hospitalization, she fluid cytology (40x). A close-up of mesothelial cells; a group of again presented a pericardial and pleural effusion with subse- malignant squamous cells is seen in the lower part of the image. quent 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 peri- ovary hyperstimulation); or drugs (cyclophosphamide, doxo- cardiocentesis; however, this intervention was refused. The rubicin, gemcitabine, cytarabine, fludarabine, docetaxel, iso- patient died 46 days after the initial presentation. niazid, hydralazine, and phenytoin) [1, 13]. Maisch et al. analyzed 357 pericardial effusion samples from 1988 to 2008 and identified 68 patients with cancer- 3. Discussion associated pericardial effusion. In 42 patients, a malignant pericardial effusion was noted; in 15 patients, it was induced Cervical cancer is the second most common cancer diag- nosed in women worldwide and the third cause of cancer by radiation; in 11, by viral disease; and in 6, with an autoim- death in developing countries [1, 3, 4]. The main sites for mune process. From the cancer-associated pericardial effu- metastasis are the lung, the bone, and the brain [2]. Metasta- sion, it was found that 52.4% was from lung cancer, 19% sis to the pericardial sac is an unusual manifestation. It has a breast cancer, 4.8% Hodgkin’s lymphoma, 4.8% colon cancer, 2.4% mesothelioma and esophageal cancer, and 14.2% was of reported incidence of 1.2-7% [2, 5, 6], conferring a poor prognosis with an overall survival of 2 to 5 months from unknown origin undifferentiated cancer [14]. diagnosis [2], with the majority of cases discovered at Pericardial effusion as a clinical presentation can be acute autopsy [7–10]. To our knowledge, this is the first case of car- (trauma, aortic rupture, and iatrogenic), subacute (uremia or diac tamponade as the initial presentation of a squamous cell idiopathic), or chronic (constrictive or adhesive). The clinical carcinoma of the cervix. features are dyspnea, pleuritic pain, cough, fatigue, and syn- The most common causes of pericardial effusion with or cope. Cardiac tamponade causes hypotension, tachycardia, without tamponade are infections (Coxsackievirus, VEB, and decreased heart sounds (Beck triad). The paradoxical CMV, and M. tuberculosis); autoimmune diseases; cancer pulse is reported as the most sensitive sign (82%) to diagnose from lymphatic or hematogenous dissemination (metasta- cardiac tamponade, followed by tachycardia and elevated sis: melanoma (50%), lung (30%), breast (12%), and lym- jugular venous pressure with a sensitivity of 77% and 76%, phoma (12%)) [5, 9, 11, 12]; cardiac diseases (Dressler respectively [1, 5, 13]. From the initial evaluation, the widen- syndrome, myocarditis, and aortic dissection aneurysm); ing of the cardiac silhouette can be associated with the “water trauma; metabolic diseases (hypothyroidism, uremia, and bottle sign” and the concomitant bilateral pleural effusion. Case Reports in Oncological Medicine 3 (a) (b) (c) Figure 3: (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. Figure 4: Immunochemistry, P63(+); immunophenotype for malignant squamous cells. The EKG demonstrates low-voltage QRS and nonspecific pericardial sclerosis with chemotherapeutic agents such as cisplatin, bleomycin, or tetracycline [12]. T wave and ST segment changes. A transthoracic echocar- diogram helps assess size, location, and hemodynamic Table 1 summarizes the reported literature regarding cer- physiology [1]. vical cancer associated with pericardial effusion and cardiac Pericardiocentesis is a diagnostic and therapeutic proce- tamponade. The mean age for diagnosis was 52 years. Car- dure. The drainage of the pericardial fluid is assessed daily. diac tamponade was reported with pericardial effusion 6.2 The inserted catheter is removed when drainage is less than months after the initial diagnosis and mostly in patients with 30 mL/day. Such a procedure has a greater risk of major previous treatment. Pericardial tamponade was detected in complication (1.2%) such as ventricle laceration, pneumo- one patient 5 days after cervical cancer diagnosis with an thorax, ventricular tachycardia, and bacteremia. In patients overall survival of 4 months after pericardiocentesis [9]. with cancer, the risk of recurrence is about 90% [1, 13]. Also, Azria et al., in 2011, published a similar case of a There are many treatment options for pericardial effusion 54-year-old woman who initially presented cardiac tampo- recurrence such as the use of an indwelling catheter with nade, which was posteriorly associated with metastatic an efficacy of 70-90%, a pericardial window with drainage cervical adenocarcinoma and who died 33 days after its to the pleural or peritoneal cavity (recurrence of 5-15%), or diagnosis [20]. 4 Case Reports in Oncological Medicine Table 1: Reported cases of cervical cancer with pericardial effusion and cardiac tamponade. FIGO Age at initial Time from clinical Presence of cardiac Overall Author (year) presentation diagnosis to Previous treatment Treatment after diagnosis of pericardial effusion stage tamponade survival (years) pericardial effusion (initial) Charles et al. 46 24 months IIIB RT, hysterectomy+BSO Yes Pericardial window, CT, doxorubicin 8 months (1997) [15] Rieke and 49 23 months IIA Hysterectomy+BSO, RT No Pericardiocentesis, RT 9 months Kapp (1988) [5] Rudoff et al. Pericardiocentesis, anterior pericardiectomy, 27 21 months IIIB RT Yes Not reported (1989) [16] cisplatinum 51 5 days IV None Yes Pericardiocentesis/CT cisplatin+RT 4 months Nelson and Pericardiocentesis, instillation of tetracycline, CT Rose (1993) [9] 61 3 months IIIB RT Yes cisplatin, bleomycin, methotrexate alternating 12 months with cisplatin and 5FU Kountz et al. No/mass in right 28 10 months IIB RT/CT Not specified 3 months (1993) [17] ventricle Jamshed et al. 57 32 months IB Hysterectomy, RT Yes Pericardiocentesis, pericardial window, RT 5 months (1996) [6] RT, hysterectomy+BSO No/interventricular 53 24 months IB RT 1 month +superior vaginectomy septum mass Lemus et al. (1998) [10] No/mass in right 49 12 months IVB RT CT 5FU+cisplatin 7 months ventricle Senzaki et al. No/mass in right 28 16 months Hysterectomy, RT/CT Pericardiocentesis+intrapericardial cisplatinum 1 month (1999) [18] ventricle CT carboplatin+paclitaxel Kim et al. No/right atrium 64 6 months IB +concurrent RT pre- and 5-fluorouracil+cisplatin+RT 12 months (2008) [19] mass posthysterectomy Kim et al. 3 cycles of 5FU, cisplatin 52 6 months IVB Yes Pericardiocentesis 1 month (2011) [1] +concurrent RT Initial presentation Azria et al. Pericardiocentesis, pericardial window, 54 (cervical IVB None Yes 33 days (2011) [20] carboplatin+paclitaxel adenocarcinoma) Ore et al. 5th decade 9 months IVB RT, CT topotecan+cisplatin Yes Pericardiocentesis, pericardial window 26 days (2013) [21] Kalra et al. 56 6 months IIIB Carboplatin+paclitaxel+RT Yes CT not specified+RT Not reported (2014) [2] Ramegowda 50 23 months IIIB RT, brachytherapy Yes No treatment 4 months et al. (2015) [11] Tsuchida et al. No/mass in right 78 15 months IIIB RT No treatment 1 month (2016) [22] ventricle FIGO: International Federation of Gynecology and Obstetrics; CT: chemotherapy; RT: radiotherapy; BSO: bilateral salpingo-oophorectomy; 5FU: 5-fluorouracil. Case Reports in Oncological Medicine 5 [14] B. Maisch, A. Ristic, and S. Pankuweit, “Evaluation and man- Within the initial approach of a young woman presenting agement of pericardial effusion in patients with neoplastic dis- with cardiac tamponade, an etiology must be identified and ease,” Progress in Cardiovascular Diseases, vol. 53, no. 2, cancer should be considered as a possible cause. A correct pp. 157–163, 2010. workup is required to achieve a timely diagnosis, in order [15] E. H. Charles, J. Condori, and S. Sall, “Metastasis to the to grant the patient the best possible outcome. pericardium from squamous cell carcinoma of the cervix,” American Journal of Obstetrics & Gynecology, vol. 129, no. 3, Conflicts of Interest pp. 349–351, 1977. [16] J. Rudoff, R. Percy, G. Benrubi, and M. L. Ostrowski, “Recur- The authors declare that there is no conflict of interest rent squamous cell carcinoma of the cervix presenting as car- regarding the publication of this paper. diac tamponade: case report and subject review,” Gynecologic Oncology, vol. 34, no. 2, pp. 226–231, 1989. References [17] D. S. Kountz, “Isolated cardiac metastasis from cervical carci- noma: presentation as acute anteroseptal myocardial infarc- [1] M. H. Kim, T. H. Lee, C. J. Lee, H. Y. Kim, W. G. Kim, and tion,” Southern Medical Journal, vol. 86, no. 2, pp. 228–230, S. H. Kim, “Malignant pericardial effusion in carcinoma of the uterine cervix,” Korean Journal of Obstetrics & Gynecology, [18] H. Senzaki, Y. Uemura, D. Yamamoto et al., “Right intraven- vol. 54, no. 4, pp. 214–217, 2011. tricular metastasis of squamous cell carcinoma of the uterine [2] R. Kalra, R. Pawar, A. Chandna, and R. Panwar, “Metastatic cervix: an autopsy case and literature review,” Pathology Inter- pericardial effusion secondary to squamous cell carcinoma of national, vol. 49, no. 5, pp. 447–452, 1999. uterine cervix: a rare case report,” International Journal of [19] H. S. Kim, N. H. Park, and S. B. Kang, “Rare metastases of Healthcare and Biomedical Research, vol. 2, no. 4, pp. 80–82, recurrent cervical cancer to the pericardium and abdominal muscle,” Archives of Gynecology and Obstetrics, vol. 278, [3] C. Marth, F. Landoni, S. Mahner et al., “Cervical cancer: no. 5, pp. 479–482, 2008. ESMO Clinical Practice Guidelines for diagnosis, treatment [20] E. Azria, M. Dufeu, P. Fernandez, F. Walker, and D. Luton, and follow-up,” Annals of Oncology, vol. 28, Supplement 4, “Cervical adenocarcinoma presenting as a cardiac tamponade pp. iv72–iv83, 2017. in a 57-year-old woman: a case report,” Journal of Medical [4] P. Petignat and M. Roy, “Diagnosis and management of cervi- Case Reports, vol. 5, no. 1, 2011. cal cancer,” BMJ, vol. 335, no. 7623, pp. 765–768, 2007. [21] R. M. Ore, B. G. Reed, and C. A. Leath III, “Malignant pericar- [5] J. W. Rieke and D. S. Kapp, “Successful management of malig- dial effusion and pericardial tumor involvement secondary to nant pericardial effusion in metastatic squamous cell carci- cervical cancer,” Military Medicine, vol. 178, no. 1, pp. e130– noma of the uterine cervix,” Gynecologic Oncology, vol. 31, e132, 2013. no. 2, pp. 338–351, 1988. [22] K. Tsuchida, T. Oike, T. Ohtsuka et al., “Solitary cardiac [6] A. Jamshed, Y. Khafaga, G. el-Husseiny, A. J. Gray, and metastasis of uterine cervical cancer with antemortem diagno- M. Manji, “Pericardial metastasis in carcinoma of the uterine sis: a case report and literature review,” Oncology Letters, cervix,” Gynecologic Oncology, vol. 61, no. 3, pp. 451–453, vol. 11, no. 5, pp. 3337–3341, 2016. [7] W. B. Lockwood and W. L. Broghamer, “The changing preva- lence of secondary cardiac neoplasms as related to cancer ther- apy,” Cancer, vol. 45, no. 10, pp. 2659–2662, 1980. [8] D. Dequanter, P. Lothaire, T. Berghmans, and J. P. Sculier, “Severe pericardial effusion in patients with concurrent malig- nancy: a retrospective analysis of prognostic factors influenc- ing survival,” Annals of Surgical Oncology, vol. 15, no. 11, pp. 3268–3271, 2008. [9] B. E. Nelson and P. G. Rose, “Malignant pericardial effusion from squamous cell cancer of the cervix,” Journal of Surgical Oncology, vol. 52, no. 3, pp. 203–206, 1993. [10] J. F. Lemus, G. Abdulhay, C. Sobolewski, and V. R. Risch, “Cardiac metastasis from carcinoma of the cervix: report of two cases,” Gynecologic Oncology, vol. 69, no. 3, pp. 264–268, [11] K. S. Ramegowda, N. Agrawal, P. Bhatt, and C. N. Manjunath, “Cardiac metastases from a gynecological malignancy present- ing with tamponade: a rare and potentially life threatening medical emergency,” Journal of Indian College of Cardiology, vol. 5, no. 1, pp. 86–89, 2015. [12] K. Reynen, U. Köckeritz, and R. H. Strasser, “Metastases to the heart,” Annals of Oncology, vol. 15, no. 3, pp. 375–381, 2004. [13] M. Petrofsky, “Management of malignant pericardial effu- sion,” Journal of the Advanced Practitioner in Oncology, vol. 5, no. 4, pp. 281–289, 2014. 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Abstract

Hindawi Case Reports in Oncological Medicine Volume 2019, Article ID 7524797, 5 pages https://doi.org/10.1155/2019/7524797 Case Report 1 2 Yuridia Evangelina Rodríguez-Rosales, Carlos Eduardo Salazar-Mejía , 2 2 2 Blanca Angélica Soto-Martínez, David Hernández-Barajas , Oscar Vidal-Gutiérrez, and Gabriela Sofia Gómez-Macías Universidad Autónoma de Nuevo Leon, Facultad de Medicina y Hospital Universitario “Dr. José Eleuterio González”, Department of Internal Medicine, Av. Madero y Gonzalitos s/n, Colonia Mitras Centro, Monterrey, Nuevo Leon, C.P. 64460, Mexico Universidad Autónoma de Nuevo Leon, Facultad de Medicina y Hospital Universitario “Dr. José Eleuterio González”, Centro Universitario Contra el Cáncer, Av. Madero y Gonzalitos s/n, Colonia Mitras Centro, Monterrey, Nuevo Leon, C.P. 64460, Mexico Universidad Autónoma de Nuevo Leon, Facultad de Medicina y Hospital Universitario “Dr. José Eleuterio González”, Department of Pathology, Av. Madero y Gonzalitos s/n, Colonia Mitras Centro, Monterrey, Nuevo Leon, C.P. 64460, Mexico Correspondence should be addressed to Carlos Eduardo Salazar-Mejía; drsalazarmejia@gmail.com Received 9 October 2018; Accepted 5 December 2018; Published 9 January 2019 Academic Editor: Raffaele Palmirotta Copyright © 2019 Yuridia Evangelina Rodríguez-Rosales et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 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. 1. Introduction 2. Case Report Pericardial metastasis is an unusual manifestation of cervical A 35-year-old woman arrived at the emergency department cancer, generally identified at autopsy [1]. Symptomatic peri- because of rest dyspnea and a 6-month history of lower cardial effusion and cardiac tamponade are usually described extremity edema. She had a 3-month history of intermittent in the scenario of recurrent disease after previous treatment abnormal vaginal bleeding. On initial evaluation, the patient with chemotherapy and/or radiotherapy, with very few cases was hypoxemic with an oxygen saturation of 80% with room reporting these entities as an initial presentation of cervical air. Relevant clinical signs were tachycardia and hypotension, cancer [2]. Herein, we present a case of cardiac tamponade decreased heart sounds, and a left supraclavicular lymphade- as an initial manifestation of a squamous cell carcinoma of nopathy. A chest X-ray showed a widening of the cardiac sil- the cervix. houette with a bilateral pleural effusion (Figure 1). 2 Case Reports in Oncological Medicine (a) Figure 1: Chest X-ray. Pericardiocentesis was performed and a total of 500 mL of bloody secretion was drained with symptomatic improve- ment. Pleural fluid was obtained by thoracocentesis, and cytology was positive for a poorly differentiated carcinoma (Figure 2). An excisional biopsy of the left supraclavicular lymph- adenopathy was positive for metastatic squamous cell car- cinoma. The cervical biopsy reported a squamous cell carcinoma associated with an intraepithelial high-grade lesion (Figures 3 and 4). CA-125 was 335.5 IU/mL and a simple and contrasted pelvic MRI demonstrated a uterine (b) and cervical absence of tumoral mass; however, peritoneal carcinomatosis was present. Figure 2: (a) Pleural and pericardial fluid cytology (10x) shows mesothelial cells with hyperplasia; the second population of cells Chemotherapy was begun with carboplatin and paclitaxel. are malignant squamous epithelial cells. (b) Pleural and pericardial Despite the treatment received during her hospitalization, she fluid cytology (40x). A close-up of mesothelial cells; a group of again presented a pericardial and pleural effusion with subse- malignant squamous cells is seen in the lower part of the image. quent 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 peri- ovary hyperstimulation); or drugs (cyclophosphamide, doxo- cardiocentesis; however, this intervention was refused. The rubicin, gemcitabine, cytarabine, fludarabine, docetaxel, iso- patient died 46 days after the initial presentation. niazid, hydralazine, and phenytoin) [1, 13]. Maisch et al. analyzed 357 pericardial effusion samples from 1988 to 2008 and identified 68 patients with cancer- 3. Discussion associated pericardial effusion. In 42 patients, a malignant pericardial effusion was noted; in 15 patients, it was induced Cervical cancer is the second most common cancer diag- nosed in women worldwide and the third cause of cancer by radiation; in 11, by viral disease; and in 6, with an autoim- death in developing countries [1, 3, 4]. The main sites for mune process. From the cancer-associated pericardial effu- metastasis are the lung, the bone, and the brain [2]. Metasta- sion, it was found that 52.4% was from lung cancer, 19% sis to the pericardial sac is an unusual manifestation. It has a breast cancer, 4.8% Hodgkin’s lymphoma, 4.8% colon cancer, 2.4% mesothelioma and esophageal cancer, and 14.2% was of reported incidence of 1.2-7% [2, 5, 6], conferring a poor prognosis with an overall survival of 2 to 5 months from unknown origin undifferentiated cancer [14]. diagnosis [2], with the majority of cases discovered at Pericardial effusion as a clinical presentation can be acute autopsy [7–10]. To our knowledge, this is the first case of car- (trauma, aortic rupture, and iatrogenic), subacute (uremia or diac tamponade as the initial presentation of a squamous cell idiopathic), or chronic (constrictive or adhesive). The clinical carcinoma of the cervix. features are dyspnea, pleuritic pain, cough, fatigue, and syn- The most common causes of pericardial effusion with or cope. Cardiac tamponade causes hypotension, tachycardia, without tamponade are infections (Coxsackievirus, VEB, and decreased heart sounds (Beck triad). The paradoxical CMV, and M. tuberculosis); autoimmune diseases; cancer pulse is reported as the most sensitive sign (82%) to diagnose from lymphatic or hematogenous dissemination (metasta- cardiac tamponade, followed by tachycardia and elevated sis: melanoma (50%), lung (30%), breast (12%), and lym- jugular venous pressure with a sensitivity of 77% and 76%, phoma (12%)) [5, 9, 11, 12]; cardiac diseases (Dressler respectively [1, 5, 13]. From the initial evaluation, the widen- syndrome, myocarditis, and aortic dissection aneurysm); ing of the cardiac silhouette can be associated with the “water trauma; metabolic diseases (hypothyroidism, uremia, and bottle sign” and the concomitant bilateral pleural effusion. Case Reports in Oncological Medicine 3 (a) (b) (c) Figure 3: (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. Figure 4: Immunochemistry, P63(+); immunophenotype for malignant squamous cells. The EKG demonstrates low-voltage QRS and nonspecific pericardial sclerosis with chemotherapeutic agents such as cisplatin, bleomycin, or tetracycline [12]. T wave and ST segment changes. A transthoracic echocar- diogram helps assess size, location, and hemodynamic Table 1 summarizes the reported literature regarding cer- physiology [1]. vical cancer associated with pericardial effusion and cardiac Pericardiocentesis is a diagnostic and therapeutic proce- tamponade. The mean age for diagnosis was 52 years. Car- dure. The drainage of the pericardial fluid is assessed daily. diac tamponade was reported with pericardial effusion 6.2 The inserted catheter is removed when drainage is less than months after the initial diagnosis and mostly in patients with 30 mL/day. Such a procedure has a greater risk of major previous treatment. Pericardial tamponade was detected in complication (1.2%) such as ventricle laceration, pneumo- one patient 5 days after cervical cancer diagnosis with an thorax, ventricular tachycardia, and bacteremia. In patients overall survival of 4 months after pericardiocentesis [9]. with cancer, the risk of recurrence is about 90% [1, 13]. Also, Azria et al., in 2011, published a similar case of a There are many treatment options for pericardial effusion 54-year-old woman who initially presented cardiac tampo- recurrence such as the use of an indwelling catheter with nade, which was posteriorly associated with metastatic an efficacy of 70-90%, a pericardial window with drainage cervical adenocarcinoma and who died 33 days after its to the pleural or peritoneal cavity (recurrence of 5-15%), or diagnosis [20]. 4 Case Reports in Oncological Medicine Table 1: Reported cases of cervical cancer with pericardial effusion and cardiac tamponade. FIGO Age at initial Time from clinical Presence of cardiac Overall Author (year) presentation diagnosis to Previous treatment Treatment after diagnosis of pericardial effusion stage tamponade survival (years) pericardial effusion (initial) Charles et al. 46 24 months IIIB RT, hysterectomy+BSO Yes Pericardial window, CT, doxorubicin 8 months (1997) [15] Rieke and 49 23 months IIA Hysterectomy+BSO, RT No Pericardiocentesis, RT 9 months Kapp (1988) [5] Rudoff et al. Pericardiocentesis, anterior pericardiectomy, 27 21 months IIIB RT Yes Not reported (1989) [16] cisplatinum 51 5 days IV None Yes Pericardiocentesis/CT cisplatin+RT 4 months Nelson and Pericardiocentesis, instillation of tetracycline, CT Rose (1993) [9] 61 3 months IIIB RT Yes cisplatin, bleomycin, methotrexate alternating 12 months with cisplatin and 5FU Kountz et al. No/mass in right 28 10 months IIB RT/CT Not specified 3 months (1993) [17] ventricle Jamshed et al. 57 32 months IB Hysterectomy, RT Yes Pericardiocentesis, pericardial window, RT 5 months (1996) [6] RT, hysterectomy+BSO No/interventricular 53 24 months IB RT 1 month +superior vaginectomy septum mass Lemus et al. (1998) [10] No/mass in right 49 12 months IVB RT CT 5FU+cisplatin 7 months ventricle Senzaki et al. No/mass in right 28 16 months Hysterectomy, RT/CT Pericardiocentesis+intrapericardial cisplatinum 1 month (1999) [18] ventricle CT carboplatin+paclitaxel Kim et al. No/right atrium 64 6 months IB +concurrent RT pre- and 5-fluorouracil+cisplatin+RT 12 months (2008) [19] mass posthysterectomy Kim et al. 3 cycles of 5FU, cisplatin 52 6 months IVB Yes Pericardiocentesis 1 month (2011) [1] +concurrent RT Initial presentation Azria et al. Pericardiocentesis, pericardial window, 54 (cervical IVB None Yes 33 days (2011) [20] carboplatin+paclitaxel adenocarcinoma) Ore et al. 5th decade 9 months IVB RT, CT topotecan+cisplatin Yes Pericardiocentesis, pericardial window 26 days (2013) [21] Kalra et al. 56 6 months IIIB Carboplatin+paclitaxel+RT Yes CT not specified+RT Not reported (2014) [2] Ramegowda 50 23 months IIIB RT, brachytherapy Yes No treatment 4 months et al. (2015) [11] Tsuchida et al. No/mass in right 78 15 months IIIB RT No treatment 1 month (2016) [22] ventricle FIGO: International Federation of Gynecology and Obstetrics; CT: chemotherapy; RT: radiotherapy; BSO: bilateral salpingo-oophorectomy; 5FU: 5-fluorouracil. Case Reports in Oncological Medicine 5 [14] B. Maisch, A. Ristic, and S. 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