Cancer-Related Pneumopericardium: A Case Report and Literature Review

Abstract

Pneumopericardium is a relatively rare entity mostly described in the literature as a result of causes such as penetrating/blunt trauma and iatrogenic causes during cardiothoracic procedures. We are presenting a case of pneumopericardium as a complication of progressed gastroesophageal junction tumor along with a literature review of all cancer-related pneumopericardium cases reported in the last decade. We present the case of a 65-year-old male with a past medical history significant for locally advanced gastroesophageal junction adenocarcinoma who presented to the hospital with complaints of shortness of breath and fever. A chest X-ray showed an intact esophageal stent along with radiolucency around the cardiac silhouette which suggested pneumopericardium. Computed tomography scan of the chest confirmed the presence of pneumopericardium in posterior pericardium with foci of gas above the esophageal stent likely to be communicating with the pericardium. An echocardiogram was obtained which showed no signs of tamponade. Given the advanced nature of the disease we applied a conservative management given that the pneumopericardium was deemed to be small with no tamponade. Goals of care were discussed with the patient and his family and the patient opted for comfort care measures. This case report prompted us to perform an extensive literature review of cancer-related pneumopericardium from 2008 to 2019. We found 11 cases where it was reported secondary to malignancies of different kinds. Our aim is to compile a review for clinicians to view varied presentations and better direct therapy dependent on the individual case and clinical presentation in patients with cancerrelated pneumopericardium. Moreover, although pneumopericardium is rare, it should be considered in differential diagnosis in patients presenting with shortness of breath or chest pain especially with cancers involving the cardiothoracic region.

Pneumopericardium after Pericardiocentesis: An Underlying Tracheopericardial Fistula

“…It has also been described spontaneously (1) and as a rare complication of pericardiocentesis (3)(4). A recent case series brought light to cancer-related pneumopericadium, and identified 11 reported cases in the literature, 10 of which were in adult males and occurred as a result of a fistulous communication with the esophagus or bronchus (5). To our knowledge, this is the first reported case of pneumopericardium as a result of a fistulous communication with the distal trachea, in this case, manifesting after pericardiocentesis.…”

Cardiac tamponade due to advanced gastric cancer: case report and review

“…Three cases had received treatment with radiotherapy [ 20 , 21 ], and one had chemotherapy [ 22 ]. Tang et al suggest that treatment with radiotherapy could be a predisposing factor for the formation of a gastro-pericardial fistula [ 20 ].…”

“…The tumor topography in most of the cases (5 patients) was at the anterior wall of the gastric fundus, immediately below the diaphragm. In only one report the lesion was at the gastroesophageal junction [ 22 ].…”

“…Therefore, the level of evidence of this rare condition is low, consisting mostly on case reports and expert opinions. In this bibliographic review, comfort measures were established in two patients [ 21 , 22 ], in two cases treatment was performed by percutaneous pericardial drainage, pericardiocentesis [ 16 , 20 ] and radical surgical treatment were performed in two patients [ 19 , 23 ]. One of these patients underwent a thoracotomy approach, gastro-diaphragmatic release and closure of the fistula; with a poor post-operative evolution, dying after 4 days [ 23 ].…”

Delayed pneumopericardium after total gastrectomy

“…Hirani et al described pneumopericardium in 11 patients with different types of malignant diseases. 3 Treatment was mainly dependent on the hemodynamic compromise and underlying cause.…”