Nasopharyngeal carcinoma with cardiac tamponade

Nasopharyngeal Carcinoma With Cardiac Tamponade CHUNG-PIN LI, MD, KWAN HWA CHI, MD, JACQUELINE MING LIU, MD, MING-FUNG WU, MD, KUANG Y. CHEN, MD, AND WING-KAI CHAN, MD

(Editorial Comment: The capricious nature of malignant disease continues to amaze me. We have become accustomed to the predictable pattern of cervical metastatic disease. This report is a reminder that some patients with carcinoma of the head and neck will succumb to distant metastasis. These patients may present with a peculiar symptomatology. This case report serves to remind us that the clinical focus on the head and neck does not absolve the head and neck oncologist from his responsibility to evaluate and manage systemic complaints.) Dyspnea in a cancer patient may be caused by many factors, such as lung metastasis, infection, pulmonary embolism, side effects from anticancer treatment, pericardial effusion, and other lung and cardiovascular diseases. The differential diagnosis is important in determining the appropriate management. This is an unusual case of nasopharyngeal carcinoma with cardiac tamponade.

CASE REPORT A 73-year-old man was diagnosed as having a T,N,M, nonkeratinizing squamous cell carcinoma of the nasopharynx in April 1991. Physical examination and computed tomography (CT) scans of the nasopharynx showed a tumor mass in the left nasopharynx and enlarged lymph nodes over the left upper neck. He received definitive radiotherapy with a total dose 70 Gy in 35 fractions, and the tumor disappeared completely. The patient was well until May 1992, when a chest radiograph showed multiple small nodular lesions in both lungs. Abdominal sonography showed bilateral small pleural effusions with a minimal amount of pericardial effusion, multiple

From the Institute of Biomedical Sciences, Academia Sinica; and Cancer Therapy Center, Veterans General Hospital, Taipei, Republic of China. Address reprint requests to Dr Chung-Pin Li, Department of Medicine, Veterans General Hospital, 201, Section 2, Shih-Pai Rd. Taipei, Republic of China. Copyright 0 1994 by ‘W.B. Sknders Company 0196-0709/94/l 504-0014$5.00/O American

Journal

of Otolaryngology,

metastases over both lobes of the liver, and multiple retroperitoneal lymphadenopathy. CT scans of the nasopharynx also showed recurrence of cancer in the left nasopharynx and left upper neck. Chemotherapy with 5-fluorouracil 800 mg/m2/d, cisplatin 20 mg/m’/d, and leucovorin 500 mg/m’/d by continuous infusion for 96 hours was given, but without response. In July 1992, the patient was admitted to the hospital with severe shortness of breath. Physical examination revealed a low-grade fever, tachypnea, and moist rales over both lung fields, but no signs of cardiac tamponade, such as jugular vein engorgement, low blood pressure, pulsus paradoxus, or faint heart sounds. The central venous pressure was 10 cm of water. His chest radiograph showed multiple small nodules with increased interstitial infiltration over both lungs and mild cardiomegaly (Fig 1). Arterial blood gas at 4 L of oxygen per minute via a nasal cannula showed PO, 68.7 mm Hg, Pco, 52.5 mm Hg, HCO, 31 mmol/L, and pH 7.375. Blood chemistry showed blood urea nitrogen (BUN) 31 mg/dL, Cr 1.2 mg/dL, Na 125 mmol/L, K 4.2 mmol/ L, Cl 90 mmol/L, glucose 104 mg/dL, lactate dehydrogenase (LDH) 502 U/L, albumin 3.7 g/dL, aspartate transaminase (AST) 107 U/L, and alanine transaminase (ALT) 38 U/L. Complete blood count showed white blood cell (WBC) 6,800/mm3, Hb 10.6 g/dL, and platelet 115,000/mm3. Sputum cultures and blood cultures showed negative findings. Antibiotics were given to cover the possible lung infection, but no clinical improvement was noted. An echocardiogram was performed and showed a large pericardial effusion with impending cardiac tamponade and two l- x 2-cm nodules in the pericardial space [Fig 2). Pericardiocentesis was arranged, but the patient died suddenly before this procedure could be performed. Autopsy was not performed because of his family’s refusal.

DISCUSSION In approximately 12% of patients who die of carcinoma, metastases to the myocardium, the pericardium, or both are found at autopsy. The tumors that most commonly metastasize to the pericardium are carcinoma of the lung and breast. Together, these two malignancies account for 60% to 75% of all cases of malignant pericardial effusi0n.l Nasopharyngeal carcinoma is rare in the

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Fig 1. Chest radiograph showing multiple nodules and increased interstitial infiltration over both lungs. Mild cardiomegaly was also noted.

western world but common in Southeast Asia, with an incidence of 20 cases per 100,000 people.’ It is potentially curable with radiotherapy, having a 5-year survival rate of 75% for

LI ET AL

patients with T,N,M, stage carcinomaa The incidence of distant metastases is 7.3% in this stage.4 Bone, lung, and liver are the three most common sites of metastases. Other sites of metastasis, including skin, subcutaneous soft tissue, central nervous system, breast, mediastinum, and lymph nodes below clavicles, are less frequent.‘s6 Pericardial involvement as a site of distant metastasis in nasopharyngeal carcinoma is extremely rare. In a review of the literature from 1966 to 1993, only one autopsy case was reported.7 This present report is the first case of nasopharyngeal carcinoma with malignant pericardial effusion and cardiac tamponade diagnosed clinically. Although it was not confirmed by autopsy findings, the presence of multiple metastases associated with pericardial effusion and nodular lesions in the pericardial space were considered sufficient to justify the clinical diagnosis of malignant pericardial effusion from nasopharyngeal cancer in this case.8 The problem of pericardial effusion and cardiac tamponade was further compounded by the coexistent lung metastases and possible pulmonary infection. The diagnosis of cardiac tamponade may sometimes be difficult because the patient may have minimal signs.g However, it is important to be aware of the problem because malignant pericardial effusion with impending cardiac tamponade may become a medical emergency. Urgent treatment can usually be performed with echo-guided pericardiocentesis, pericardiotomy, or pericardiectomy. Early diagnosis and treatment can result in symptomatic relief of dyspnea and restoration of cardiac output. REFERENCES

Fig 2. Echocardiogram showing a large amount of psricardial effusion with impending cardiac tamponade and a 1- x 2-cm hyparechoic nodule in the left pericardial space (another nodule was also present but not shown in this cross-section).

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