Case Report pISSN 1738-2637 / eISSN 2288-2928 J Korean Soc Radiol 2014;71(5):235-238 http://dx.doi.org/10.3348/jksr.2014.71.5.235
Implantation of Lung Cancer along the Tube Tract after Pericardiotomy for Malignant Pericardial Effusion: A Case Report 악성 심낭삼출액 제거를 위해 시행한 심막절개술 후 튜브경로를 따라 발생한 폐암의 이식성 전이: 증례 보고 Joo Yeon Kim, MD, Dae Hee Han, MD Department of Radiology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
Tube tract implantation metastasis of non-small cell lung cancer is an extremely rare complication of surgical pericardiotomy. We report a case of tube tract seeding along the previous chest tube tract in the subxiphoid region. The subxiphoid tube tract seeding was created during pericardial window operation of a 48-year-old male patient with lung cancer for the drainage of malignant pericardial effusion. Index terms Pericardiotomy Tube Tract Implantation Lung Cancer Malignant Pericardial Effusion
INTRODUCTION
Received April 3, 2014; Accepted August 26, 2014 Corresponding author: Dae Hee Han, MD Department of Radiology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 137-701, Korea. Tel. 82-2-2258-1436 Fax. 82-2-599-6771 E-mail:
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with various chemotherapeutic regiments [Gefitinib (Iress®), May 2012 through November 2012; Pemetrexed (Alimta®)-cisplatin,
Surgical pericardiotomy is an effective method to treat malig-
December 2012 through January 2013; Erlotinib (Tarceva®), May
nant pericardial effusion. Although pericardiotomy is generally
2013 through July 2013]. Chest radiograph taken at the time of
considered safe, it has its risk of complications, including hemo-
admission showed cardiomegaly with a moderate amount of
thorax, arrhythmia, hypotension, or heart failure (1). Metastatic
left-sided pleural effusion. Electrocardiography showed low
tumor seeding along a transient indwelling drainage tube is an
voltage sinus tachycardia (mean, 115/min). Transthoracic echo-
extremely rare complication of pericardiotomy. To our knowl-
cardiography revealed a large amount of pericardial effusion
edge, no such case has ever been reported. We present a case of
causing hemodynamic compromise compatible with cardiac
tumor implantation along the pericardiomtomy tube tract in a
tamponade. The patient underwent a pericardial window opera-
patient with lung cancer.
tion on the day of admission. About 2500 mL of bloody pericardial effusion was drained. Two chest tubes (one via the subxi-
CASE REPORT
phoid region and the other via the lateral chest wall) introduced though separate stab incisions were connected to a suction ma-
A 48-year-old man was admitted to hospital due to dyspnea
chine (Fig. 1A). Both chest tubes were left in place for 5 days.
that had started a few days before. The patient was diagnosed
The pericardial specimen was submitted for histological analysis
with non-small cell lung cancer (adenocarcinoma) in the left
which revealed fibrosis with chronic inflammation and vascular
lower lobe with brain and bone metastases in May 2012, which
proliferation. The pericardial fluid was submitted for cytological
subsequently progressed despite 3 courses of chemotherapy
analysis which revealed metastatic adenocarcinoma. The pa-
Copyrights © 2014 The Korean Society of Radiology
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Implantation of Lung Cancer along the Tube Tract after Pericardiotomy for Malignant Pericardial Effusion
tient’s condition improved considerably after the procedure with
festation in malignancies. Accessible treatment options include
no further complications.
simple drainage and surgical approach, with the primary goal to
Chest CT performed 12 days after the surgery revealed new
relieve symptoms and improve quality of life. In emergency cas-
soft tissue density nodules along the previous chest tube tract in
es, with cardiac tamponade or significant effusion, initial relief
the subxiphoid region (Fig. 1B). Although the nodules were not
could be obtained with percutaneous pericardiocentesis, occa-
biopsied, repeated chest CT performed 1 month later showed a
sionally followed by drainage with indwelling catheter or thorac-
significant increase in nodule size with progression of nodular
ic surgery (pericardiotomy or pericardial window operation) (1).
thickening of pericardium (Fig. 1C). The patient received che-
The most serious complication of pericardiocetesis is injury to
motherapy with a new regimen. Chest CT performed at 3-month
the myocardium or coronary vessels. In addition, pneumotho-
after the pericardial window operation revealed marked regres-
rax, hemothorax, serious arrhythmia, and puncture of the peri-
sion of both the subxiphoid nodules and the pericardial thick-
toneal cavity or abdominal organ can also occur. Chylopericar-
enings (Fig. 1D).
dium and intrapericardial thrombosis have rarely been reported (2). A large echocardiography-based study reported that the incidence of major complications after pericardiocentesis was be-
DISCUSSION
tween 1.3% and 1.6% (3). Tract metastasis is an extremely rare
Malignant pericardial effusion is a common and serious mani-
A
complication of pericardiocentesis or pericardiotomy (4), where-
B
C D Fig. 1. Chest PA taken immediately after pericardial window operation. Two indwelling chest tubes are inserted via subxiphoid (arrows) and intercostal routes, respectively (A). Chest CT obtained 12 days after surgery reveals linear arrayed soft tissue density nodules along the tract of the subxiphoid chest tube (removed) (B). CT obtained 1 month after surgery reveals remarkable interval growth of the seeded nodules and progression of pericardial nodular thickening (C). Post-chemotherapy CT (3 months after surgery) shows marked regression of the seeded nodules and the pericardial thickenings (D).
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Joo Yeon Kim, et al
as catheter-tract metastasis is relatively common (0.5% in three
regions. Therefore, it was very likely that the soft tissue repre-
large series of a combined 374 cases) complication of malignant
sented tumor implantation.
pleural effusion (5). The occurrence of implantation metastasis
In conclusion, we report a case of lung cancer implantation
has been reported in other interventional or surgical proce-
along the previous pericardiotomy tube tract as an extremely
dures, such as fine needle lung biopsy, percutaneous transhepat-
rare complication of malignant pericardial effusion treatment.
ic biliary drainage, percutaneous ethanol injection for the treatment of hepatocellular carcinoma or liver metastasis, and gastrostomy tube insertion and laparoscopy (6, 7). The mechanism of implantation metastasis is uncertain. Possible mechanisms of tumor cell seeding include tumor cell dis-
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J Korean Soc Radiol 2014;71(5):235-238
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Implantation of Lung Cancer along the Tube Tract after Pericardiotomy for Malignant Pericardial Effusion
악성 심낭삼출액 제거를 위해 시행한 심막절개술 후 튜브경로를 따라 발생한 폐암의 이식성 전이: 증례 보고 김주연 · 한대희 배액관 자리를 따라 발생한 이식성 전이는 심막절개술 이후 발생할 수 있는 매우 드문 합병증이다. 우리는 48세 폐암 환 자에서 악성 심낭삼출액에 대한 치료로 심막창형성술을 시행한 이후에 일시적으로 거치한 심낭 배액관 자리를 따라 발생 한 이식성 전이를 보고하고자 한다. 가톨릭대학교 의과대학 서울성모병원 영상의학과
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