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© 2001 American Society for Clinical Oncology
Diagnostic Dilemmas in OncologyCase 3. Pericardial Effusion After Esophageal RadiationRoswell Park Cancer Institute, Buffalo, NY A 78-year-old man was treated at our institution for locally advanced distal esophageal adenocarcinoma with suspicious periesophageal and celiac adenopathy. He received definitive chemotherapy and radiotherapy consisting of fluorouracil, cisplatin, and 59.4 Gy in 1.8-Gy fractions using a multiple field technique and three-dimensional treatment planning. Posttreatment evaluation included upper endoscopy, which revealed no residual gross tumor, and esophageal biopsy, which revealed no evidence of malignancy. A computed tomography scan taken 1 month after completion of radiation therapy demonstrated a pericardial effusion and small bilateral pleural effusions (Fig 1). Approximately 6 months after the completion of radiation therapy, the patient presented with shortness of breath, cough, and jugular venous distension. An ECG suggested pericardial effusion (Fig 2, which shows atrial arrhythmia and low QRS voltage in the precordial leads), and an echocardiogram revealed tamponade with diastolic collapse. Computed tomography imaging revealed worsening of the pericardial and pleural effusions (Fig 3). The patient subsequently underwent pericardiocentesis, bilateral pleurocentesis, bilateral pleurodesis, and pericardial window placement with pericardial biopsy. Cytologic analysis of pleural and pericardial fluid revealed lymphocytes and reactive mesothelial cells. Pathology studies of pericardial biopsy samples revealed reactive mesothelial hyperplasia and focal chronic inflammation but no evidence of malignancy. The patient’s symptoms improved with pericardial window placement and bilateral pleurodesis.
Review of the literature indicates benign pericardial effusion after radiation therapy to be a rare event, with only sporadic case reports. Cases have been documented after radiation therapy for breast cancer, lung cancer, Hodgkin’s disease, and esophageal cancer.1-10 Self-limited, asymptomatic, small pericardial effusions may occur in as many as 30% of patients treated with mediastinal radiation; symptomatic effusions are less common. Total doses greater than 41 Gy and daily fractionation in excess of 1.8 to 2 Gy have been associated with increased effusion incidence. Worsening of clinical severity with dose has also been proposed.5,8,9 However, these responses have not been seen by others.6 Radiation-induced obstruction of cardiac and mediastinal lymphatic channels has been proposed as a possible etiology of radiation-induced pericardial effusions.6 Although most patients with esophageal cancer who are not surgical candidates will receive combined-modality treatment with chemotherapy and external-beam radiation therapy, the etiologic role of chemotherapy remains uncertain. Pericardial effusion in patients treated with radiation for esophageal cancer therefore may have a nonmalignant cause whose mechanism is not well understood. Such effusions may develop within only a few weeks after treatment without any signs or symptoms and progress over several months with worsening signs and symptoms that require intervention. REFERENCES 1. Ikaheimo MJ, Niemela KO, Linnaluoto MM, et al: Early cardiac changes related to radiation therapy. Am J Cardiol 56: 943-946, 1985[Medline] 2. Green B, Zornoza J, Ricks JP: Eccentric pericardial effusion after radiation therapy of left breast carcinoma. Am J Roentgenol 128: 27-30, 1977[Abstract]
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Carey RW, Sawicka JM, Choi NC: Cytologically negative pericardial effusion complicating combined modality therapy for localized small-cell carcinoma of the lung. J Clin Oncol 5: 818-824, 1987
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Totterman KJ, Pesonen E, Siltanen P: Radiation-related chronic heart disease. Chest 83: 875-878, 1983 5. Kurtz B, Maisch B, Voss AC: Etiology of pericardial effusion following radiation therapy of Hodgkin’s disease. Strahlentherapie 157: 571-575, 1981[Medline] 6. Byhardt R, Brace K, Ruckdeschel J, et al: Dose and treatment factors in radiation-related pericardial effusion associated with the mantle technique for Hodgkin’s disease. Cancer 35: 795-802, 1975[Medline] 7. Cwikiel M, Albertsson M, Hambraeus G: Acute and delayed effects of radiotherapy in patients with oesophageal squamous cell carcinoma treated with chemotherapy, surgery and pre- and postoperative radiotherapy. Acta Oncol 33: 49-53, 1994[Medline] 8. Martel MK, Sahijdak WM, Ten Haken RK, et al: Fraction size and dose parameters related to the incidence of pericardial effusions. Int J Radiat Oncol Biol Phys 40: 155-161, 1998[Medline] 9. Cosset JM, Henry-Amar M, Pellae-Cosset B, et al: Pericarditis and myocardial infarctions after Hodgkin’s disease therapy. Int J Radiat Oncol Biol Phys 21: 447-449, 1991[Medline] 10. Stewart JR, Fajardo LF, Gillette SM, et al: Radiation injury to the heart. Int J Radiat Oncol Biol Phys 31: 1205-1211, 1995[Medline] This article has been cited by other articles:
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Copyright © 2001 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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