Lung Cancer |

Adenocarcinoma of the Lung Presenting as Tamponade FREE TO VIEW

Justin Goralnik, MD; Lawrence Giove, MD; Evan Nadler, MD
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Internal Medicine, University of Connecticut, Farmington, CT

Chest. 2014;146(4_MeetingAbstracts):664A. doi:10.1378/chest.1992480
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SESSION TITLE: Cancer Student/Resident Case Report Posters II

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Malignant pericardial effusion causing tamponade is an uncommon initial presentation of lung carcinoma. Among patients presenting with pericardial effusion without known malignancy, the likelihood of finding previously undiagnosed cancer is between 4 to 7 percent.

CASE PRESENTATION: A 45-year-old male, Chinese immigrant, former smoker, engineer by profession, presenting with complaints of weakness and dyspnea on exertion for one week. Patient first noticed symptoms while hiking with his family, but attributed it to a flu vaccine he received two days prior. While at work he became increasingly short of breath and went to the emergency room. On exam the patient was anxious without acute distress. Blood pressure was 102/71, pulse 120, respirations 23, and oxygen saturation 96% on room air. Neck veins were not distended. Chest exam was clear bilaterally with decreased sounds at the right base. Cardiovascular exam noted tachycardia, regular rhythm, and distant heart sounds. The remainder of the exam was unremarkable. EKG demonstrated sinus tachycardia and electrical alternans. Chest radiograph showed an enlarged cardiac shadow. CT scan of the chest showed a large pericardial effusion and bilateral pleural effusions. A bedside echo demonstrated a large pericardial effusion with tamponade physiology. The patient underwent emergent pericardiocentesis with catheter placement and pericardial window. Cytologyof the fluid revealed adenocarcinoma with staining positive for CK7, CEA, Napsin, and TTF-1, consistent with lung origin. Subsequent supraclavicular node biopsy confirmed metastatic adenocarcinoma of a lung primary. As an outpatient he had a PET CT and MRI. PET scan was significant for an FDG avid nodule in the right middle lobe consistent with primary lung carcinoma with extensive spread to the abdomen. MRI brain had no evidence of metastatic disease.

DISCUSSION: Lung cancer is the most common cancer worldwide, with an estimated 1,600,000 new cases and 1,380,000 deaths in 2008. Lung cancer generally metastasizes to the liver, bone, and brain, but any organ can be involved. Typically lung cancer will present with local symptoms including cough, pain, and hemoptysis. Obstructive phenomenon is also common and includes pneumonia and atelectasis.

CONCLUSIONS: The occurrence of tamponade as the presenting manifestation of an extracardiac malignancy is rare. In patients presenting with pericardial effusion, pericardiocentesis is vital to provide relief of symptoms and determine the etiology of the fluid, especially in those with risk factors for malignancy. Cytologic examination of the fluid with flow cytometry provides an immediate and accurate means of diagnosis. In general, pericardial effusion in the setting of primary lung cancer tends to be indicative of rapid tumor progression and shorter survival.

Reference #1: Cardiac tamponade as a presentation of extracardiac malignancy, Richard S. Fraser MD, Juan B. Viloria MD, Cancer, June 28, 2006

DISCLOSURE: The following authors have nothing to disclose: Justin Goralnik, Lawrence Giove, Evan Nadler

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