Forensic Sci Med Pathol (2015) 11:127–129 DOI 10.1007/s12024-014-9614-z
IMAGES IN FORENSICS
Sudden death due to cardiac tamponade from malignant pericardial involvement by metastatic lung cancer Robert Cassady • Joseph A. Prahlow
Accepted: 8 September 2014 / Published online: 19 October 2014 Ó Springer Science+Business Media New York 2014
Case report After being ill with an ‘‘upper respiratory infection’’ for approximately 2 weeks duration, a 45-year-old black female called 911 due to vomiting and diarrhea of 2 days duration and then new onset of shortness of breath. When paramedics arrived at her home she was conscious, but upon transferring her to the stretcher, she had more trouble breathing and became unresponsive. Emergency advanced cardiac life support measures were immediately initiated, and she was transported to a local Emergency Department (ED). Upon arrival at the hospital, her Glasgow Coma Scale was 3 and cardiac monitoring showed pulseless electrical activity. Emergent chest X-ray revealed a somewhat enlarged heart and a possible right-sided pleural effusion, but no evidence of masses or lymphadenopathy (Fig. 1). A head CT and an enzyme immunoassay screen for influenza were negative. Resuscitation efforts were continued for a time but without success. The patient died in the ED approximately 25 min after arrival, without a known explanation for death. As such, the case was referred to the coroner’s office for further investigation. Death investigation revealed that the patient had been treated at a health clinic for a productive cough, chest pain, sore throat, and generalized achiness of 3 days duration 4 days prior to death. She was given a Z-Pak and Robitussin AC for a possible upper respiratory infection
and bronchitis. The only available past medical history was benign hypertension; the patient had a history of smoking. A coroner’s autopsy was performed on the day of death. Upon removal of the anterior chest plate with exposure of the pericardial cavity, a hemorrhagic infiltrative process was found that extensively involved the epicardium and pericardium, with 500 mL of liquid blood within the pericardial cavity (Figs. 2, 3). Subsequent examination of the lungs revealed a 3 9 3 9 2 cm subpleural mass within the upper medial aspect of the lower lobe of the right lung (Fig. 4). There were focal white nodules on the left pleural surface and onto the left hemidiaphragm as large as 1 cm, as well as pulmonary hilar lymphadenopathy. Microscopically, the primary lung tumor was an adenocarcinoma with areas of squamous differentiation, with extensive metastases involving the epicardium/pericardium, lymph nodes, mediastinal soft tissues, and spleen. The lungs were also emphysematous. Other notable findings included atherosclerosis of the aorta, mild to severe atherosclerosis in the coronary arteries, and nephroarteriolosclerosis. Based on the autopsy findings, the cause of death was cardiac tamponade due to hemopericardium related to diffuse involvement of the epicardium and pericardium by adenocarcinoma of the lung. The manner of death was natural.
Discussion R. Cassady J. A. Prahlow Indiana University School of Medicine-South Bend, South Bend, IN, USA J. A. Prahlow (&) South Bend Medical Foundation, 530 N. Lafayette Blvd., South Bend, IN 46601, USA e-mail: [email protected]
Adenocarcinoma of the lung is the most common lung cancer in the United States [1]. Furthermore it accounts for the majority of lung cancers in women and in non-smokers [2]. Black women in the United States have the highest incidence of lung cancer among women world-wide [1]. Although this cancer has been increasingly found in
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Forensic Sci Med Pathol (2015) 11:127–129
Fig. 1 Chest radiograph on presentation in the Emergency Department, showing an ‘‘enlarged heart,’’ but no obvious masses
Fig. 3 The posterior epicardial surface of the heart, demonstrating a markedly irregularly-roughened surface
Fig. 2 Opened pericardial sac at autopsy, after removal of most of the 500 mL of blood that filled the cavity. Note the irregular, roughened epicardial, and pericardial surfaces
younger age cohorts [3], only 3.4 % of lung cancer in general is found in patients aged 45–49 [4]. Metastatic disease of the pericardium and epicardium is a common complication of cancer [5], with involvement of the pericardium in 1 out of 20 cancer cases in one study [6].
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Fig. 4 A cross section through the lower lobe of the right lung, showing a 3 cm mass lesion (arrow) that, on microscopic examination, was a primary adenocarcinoma of the lung
Pericardial effusions and cardiac tamponade are common presentations of such involvement. In fact, malignancy is the most common cause of pericardial effusion in the Western world [7]. Lung cancer is the most common primary source for pericardial metastasis [5], and Kim et al.
Forensic Sci Med Pathol (2015) 11:127–129
[8] showed that adenocarcinoma was the most common pulmonary subtype. Although the majority of malignant effusions occur in patients with known underlying cancer, Atar et al. [9] showed that hemorrhagic effusion was the presenting sign of malignancy in only 2 % of patients. In a different study, 6 % of 231 cases of either acute pericarditis or tamponade were initial presentations of malignancy [10]. Another study of 450 patients with acute pericardial disease showed that 7.3 % were from undiagnosed malignancy [11]. Malignant pericardial effusion is a very poor prognostic factor with approximately 86 % of patients dying within the first year and a third within the first month [5]. Although the long-term prognosis is poor, the initial manifestation of pericardial involvement in patients with cancer is usually subacute [12]. Although adenocarcinoma of the lung and malignant pericardial effusion are relatively common in the clinical setting, sudden death as the initial presentation is reasonably rare. Forensic pathologists are well-aware of the fact that sudden death may be the initial presentation of an underlying malignancy, but even within a medical examiner/coroner population of decedents, a minority of cases where death is due to malignancy involve an initial diagnosis of cancer at autopsy. Said et al. [13] showed in an autopsy study that of 271 cancers that were the definitive cause of death only 17 % were initially diagnosed at autopsy. The presented case is notable as an example of sudden death related to cardiac tamponade secondary to malignant pericardial involvement by a metastatic adenocarcinoma of the lung, which was first diagnosed at autopsy. The case highlights the importance of considering undiagnosed lung cancer as a cause of common symptoms in at risk populations, and as a cause of malignant cardiac effusion and possible cardiac arrest, for primary care and emergency care providers. For forensic pathologists, the case serves as an example of the impressive destructive capability of malignant neoplasms.
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References 1. Lortet-Tieulent J, Soerjomataram I, Ferlay J, Rutherford M, Weiderpass E, Bray F. International trends in lung cancer incidence by histological subtype: adenocarcinoma stabilizing in men but still increasing in women. Lung Cancer. 2014;84(1):13–22. 2. Courad S, Zalcman G, Milleron B, Morin F, Souquet PJ. Lung cancer in never smokers—a review. Eur J Cancer. 2012;48(9): 1299–311. 3. Charloux A, Quoix E, Wolkove N, Small D, Pauli G, Kreisman H. The increasing incidence of lung adenocarcinoma: reality or artifact? A review of the epidemiology of lung adenocarcinoma. Int J Epidemiol. 1997;26(1):14–23. 4. SEER Cancer statistics review 1975–2011. National Cancer Institute. 2014. http://seer.cancer.gov/csr/1975_2011/browse_csr. php?sectionSEL=15&pageSEL=sect_15_table.11.html. Accessed 5 Aug 2014. 5. Burazor I, Imazio M, Markel G, Adler Y. Malignant pericardial effusion. Cardiology. 2013;124:224–32. 6. Maisch B, Ristic A, Pankuweit S. Evaluation and management of pericardial effusion in patients with neoplastic disease. Prog Cardiovasc Dis. 2010;53(2):157–63. 7. Refaat MM, Katz WE. Neoplastic pericardial effusion. Clin Cardiol. 2011;34(10):593–8. 8. Kim SH, Kwak MH, Park S, Kim H, Lee HS, Kim MS, et al. Clinical characteristics of malignant pericardial effusion associated with recurrence and survival. Cancer Res Treat Off J Korean Cancer Assoc. 2010;42(4):210–6. 9. Atar S, Chiu J, Forrester JS, Siegel RJ. Bloody pericardial effusion in patients with cardiac tamponade: is the cause cancerous, tuberculous, or iatrogenic in the 1990s? Chest. 1999;116:1564–9. 10. Permanyer-Miralda G, Sagrista-Sauleda J, Soler-Soler J. Primary acute pericardial disease: a prospective series of 231 consecutive patients. Am J Cardiol. 1985;56(10):623–30. 11. Imazio M, Demichelis B, Parrini I, Favro E, Beqaraj F, Cecchi E, et al. Relation of acute pericardial disease to malignancy. Am J Cardiol. 2005;95(11):1393–4. 12. Borlaug B, DeCamp M. Pericardial disease associated with malignancy. UpToDate. 2014. http://www.uptodate.com/contents/ pericardial-disease-associated-with-malignancy. Accessed 20 Sept 2014. 13. Said SM, Hahn J, Koops S, Puschel K. How reliable are our cancer statistics? Cancer cases in Hamburg’s autopsy material. Dtsch Med Wochenschr. 2007;132(40):2067–70.
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IMAGES IN FORENSICS
Sudden death due to cardiac tamponade from malignant pericardial involvement by metastatic lung cancer Robert Cassady • Joseph A. Prahlow
Accepted: 8 September 2014 / Published online: 19 October 2014 Ó Springer Science+Business Media New York 2014
Case report After being ill with an ‘‘upper respiratory infection’’ for approximately 2 weeks duration, a 45-year-old black female called 911 due to vomiting and diarrhea of 2 days duration and then new onset of shortness of breath. When paramedics arrived at her home she was conscious, but upon transferring her to the stretcher, she had more trouble breathing and became unresponsive. Emergency advanced cardiac life support measures were immediately initiated, and she was transported to a local Emergency Department (ED). Upon arrival at the hospital, her Glasgow Coma Scale was 3 and cardiac monitoring showed pulseless electrical activity. Emergent chest X-ray revealed a somewhat enlarged heart and a possible right-sided pleural effusion, but no evidence of masses or lymphadenopathy (Fig. 1). A head CT and an enzyme immunoassay screen for influenza were negative. Resuscitation efforts were continued for a time but without success. The patient died in the ED approximately 25 min after arrival, without a known explanation for death. As such, the case was referred to the coroner’s office for further investigation. Death investigation revealed that the patient had been treated at a health clinic for a productive cough, chest pain, sore throat, and generalized achiness of 3 days duration 4 days prior to death. She was given a Z-Pak and Robitussin AC for a possible upper respiratory infection
and bronchitis. The only available past medical history was benign hypertension; the patient had a history of smoking. A coroner’s autopsy was performed on the day of death. Upon removal of the anterior chest plate with exposure of the pericardial cavity, a hemorrhagic infiltrative process was found that extensively involved the epicardium and pericardium, with 500 mL of liquid blood within the pericardial cavity (Figs. 2, 3). Subsequent examination of the lungs revealed a 3 9 3 9 2 cm subpleural mass within the upper medial aspect of the lower lobe of the right lung (Fig. 4). There were focal white nodules on the left pleural surface and onto the left hemidiaphragm as large as 1 cm, as well as pulmonary hilar lymphadenopathy. Microscopically, the primary lung tumor was an adenocarcinoma with areas of squamous differentiation, with extensive metastases involving the epicardium/pericardium, lymph nodes, mediastinal soft tissues, and spleen. The lungs were also emphysematous. Other notable findings included atherosclerosis of the aorta, mild to severe atherosclerosis in the coronary arteries, and nephroarteriolosclerosis. Based on the autopsy findings, the cause of death was cardiac tamponade due to hemopericardium related to diffuse involvement of the epicardium and pericardium by adenocarcinoma of the lung. The manner of death was natural.
Discussion R. Cassady J. A. Prahlow Indiana University School of Medicine-South Bend, South Bend, IN, USA J. A. Prahlow (&) South Bend Medical Foundation, 530 N. Lafayette Blvd., South Bend, IN 46601, USA e-mail: [email protected]
Adenocarcinoma of the lung is the most common lung cancer in the United States [1]. Furthermore it accounts for the majority of lung cancers in women and in non-smokers [2]. Black women in the United States have the highest incidence of lung cancer among women world-wide [1]. Although this cancer has been increasingly found in
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Forensic Sci Med Pathol (2015) 11:127–129
Fig. 1 Chest radiograph on presentation in the Emergency Department, showing an ‘‘enlarged heart,’’ but no obvious masses
Fig. 3 The posterior epicardial surface of the heart, demonstrating a markedly irregularly-roughened surface
Fig. 2 Opened pericardial sac at autopsy, after removal of most of the 500 mL of blood that filled the cavity. Note the irregular, roughened epicardial, and pericardial surfaces
younger age cohorts [3], only 3.4 % of lung cancer in general is found in patients aged 45–49 [4]. Metastatic disease of the pericardium and epicardium is a common complication of cancer [5], with involvement of the pericardium in 1 out of 20 cancer cases in one study [6].
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Fig. 4 A cross section through the lower lobe of the right lung, showing a 3 cm mass lesion (arrow) that, on microscopic examination, was a primary adenocarcinoma of the lung
Pericardial effusions and cardiac tamponade are common presentations of such involvement. In fact, malignancy is the most common cause of pericardial effusion in the Western world [7]. Lung cancer is the most common primary source for pericardial metastasis [5], and Kim et al.
Forensic Sci Med Pathol (2015) 11:127–129
[8] showed that adenocarcinoma was the most common pulmonary subtype. Although the majority of malignant effusions occur in patients with known underlying cancer, Atar et al. [9] showed that hemorrhagic effusion was the presenting sign of malignancy in only 2 % of patients. In a different study, 6 % of 231 cases of either acute pericarditis or tamponade were initial presentations of malignancy [10]. Another study of 450 patients with acute pericardial disease showed that 7.3 % were from undiagnosed malignancy [11]. Malignant pericardial effusion is a very poor prognostic factor with approximately 86 % of patients dying within the first year and a third within the first month [5]. Although the long-term prognosis is poor, the initial manifestation of pericardial involvement in patients with cancer is usually subacute [12]. Although adenocarcinoma of the lung and malignant pericardial effusion are relatively common in the clinical setting, sudden death as the initial presentation is reasonably rare. Forensic pathologists are well-aware of the fact that sudden death may be the initial presentation of an underlying malignancy, but even within a medical examiner/coroner population of decedents, a minority of cases where death is due to malignancy involve an initial diagnosis of cancer at autopsy. Said et al. [13] showed in an autopsy study that of 271 cancers that were the definitive cause of death only 17 % were initially diagnosed at autopsy. The presented case is notable as an example of sudden death related to cardiac tamponade secondary to malignant pericardial involvement by a metastatic adenocarcinoma of the lung, which was first diagnosed at autopsy. The case highlights the importance of considering undiagnosed lung cancer as a cause of common symptoms in at risk populations, and as a cause of malignant cardiac effusion and possible cardiac arrest, for primary care and emergency care providers. For forensic pathologists, the case serves as an example of the impressive destructive capability of malignant neoplasms.
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References 1. Lortet-Tieulent J, Soerjomataram I, Ferlay J, Rutherford M, Weiderpass E, Bray F. International trends in lung cancer incidence by histological subtype: adenocarcinoma stabilizing in men but still increasing in women. Lung Cancer. 2014;84(1):13–22. 2. Courad S, Zalcman G, Milleron B, Morin F, Souquet PJ. Lung cancer in never smokers—a review. Eur J Cancer. 2012;48(9): 1299–311. 3. Charloux A, Quoix E, Wolkove N, Small D, Pauli G, Kreisman H. The increasing incidence of lung adenocarcinoma: reality or artifact? A review of the epidemiology of lung adenocarcinoma. Int J Epidemiol. 1997;26(1):14–23. 4. SEER Cancer statistics review 1975–2011. National Cancer Institute. 2014. http://seer.cancer.gov/csr/1975_2011/browse_csr. php?sectionSEL=15&pageSEL=sect_15_table.11.html. Accessed 5 Aug 2014. 5. Burazor I, Imazio M, Markel G, Adler Y. Malignant pericardial effusion. Cardiology. 2013;124:224–32. 6. Maisch B, Ristic A, Pankuweit S. Evaluation and management of pericardial effusion in patients with neoplastic disease. Prog Cardiovasc Dis. 2010;53(2):157–63. 7. Refaat MM, Katz WE. Neoplastic pericardial effusion. Clin Cardiol. 2011;34(10):593–8. 8. Kim SH, Kwak MH, Park S, Kim H, Lee HS, Kim MS, et al. Clinical characteristics of malignant pericardial effusion associated with recurrence and survival. Cancer Res Treat Off J Korean Cancer Assoc. 2010;42(4):210–6. 9. Atar S, Chiu J, Forrester JS, Siegel RJ. Bloody pericardial effusion in patients with cardiac tamponade: is the cause cancerous, tuberculous, or iatrogenic in the 1990s? Chest. 1999;116:1564–9. 10. Permanyer-Miralda G, Sagrista-Sauleda J, Soler-Soler J. Primary acute pericardial disease: a prospective series of 231 consecutive patients. Am J Cardiol. 1985;56(10):623–30. 11. Imazio M, Demichelis B, Parrini I, Favro E, Beqaraj F, Cecchi E, et al. Relation of acute pericardial disease to malignancy. Am J Cardiol. 2005;95(11):1393–4. 12. Borlaug B, DeCamp M. Pericardial disease associated with malignancy. UpToDate. 2014. http://www.uptodate.com/contents/ pericardial-disease-associated-with-malignancy. Accessed 20 Sept 2014. 13. Said SM, Hahn J, Koops S, Puschel K. How reliable are our cancer statistics? Cancer cases in Hamburg’s autopsy material. Dtsch Med Wochenschr. 2007;132(40):2067–70.
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