Constrictive pericarditis caused by pericardial metastasis from esophageal squamous cell carcinoma: a case report

Abstract

Constrictive pericarditis is a rare condition characterized by clinical signs of right heart failure subsequent to the loss of pericardial compliance. We report a case of constrictive pericarditis due to pericardial metastasis in a patient with a history of esophageal squamous cell carcinoma that had a pathological complete response (pCR) to preoperative chemoradiotherapy. A 66-year-old woman was referred to our division for the treatment of advanced esophageal cancer. Video-assisted thoracoscopic surgery esophagectomy (VATSE) with 3-field lymphadenectomy was performed after neoadjuvant chemoradiotherapy (NAC-CRT). Pathological examination revealed no residual tumor, lymph node metastasis, lymphatic invasion, or vessel invasion. The histological treatment effect of the chemoradiotherapy was pathological complete response (pCR). Five months after surgery, the patient was admitted to a nearby hospital for the treatment of acute pericarditis. However, a month after admission, acute pericarditis progressed to constrictive pericarditis, and she was referred to our hospital for further management. Subsequently, urgent pericardiectomy was performed through a lower half sternotomy incision. After surgery, heart failure improved for a while but worsened again. The patient died 7 days after the surgery. Pathological examination of the resected pericardium revealed evidence of metastasis from squamous cell carcinoma of the esophagus. An autopsy revealed the spread of esophageal cancer to the bilateral pleura, right lung, pericardium, diaphragm, soft tissue surrounding the tracheal bifurcation, and bilateral hilar lymph nodes. Similarly, tumor cells were found in the lymphatic vessels of the pericardium and pleura. Even if pCR is achieved with NAC-CRT, as in our case, esophageal cancer may metastasize and present as constrictive pericarditis within a short period; therefore, careful patient follow-up is essential.

Keywords: Constrictive pericarditis; Esophageal cancer; Pericardial tumor; Squamous cell carcinoma.

Fig. 1

Endoscopic and computed tomography images before chemoradiotherapy. a Endoscopic image before chemoradiotherapy shows an ulcerative esophageal lesion with stenosis. b, c Computed tomography image before chemoradiotherapy shows esophageal wall thickening (arrow head) and lymph node swelling (arrow) around the left and right recurrent nerves

Fig. 2

Endoscopic and computed tomography images after chemoradiotherapy. a Endoscopic image after chemoradiotherapy shows a reduced esophageal lesion. b, c Computed tomography image after chemoradiotherapy shows improvement of esophageal wall thickening (arrow head) and reduced lymph nodes (arrow) around the left and right recurrent nerves

Fig. 3

Computed tomography image a month after admission. The computed tomography image shows a thickened pericardium

Fig. 4

Pathological findings of the resected pericardium. The pericardial tissue shows invasion by squamous cell carcinoma and proliferation of the cancer cells in trabecular, focal, reticular, and solitary patterns. (Hematoxylin and eosin staining. Scale bar = 500 µm)

Fig. 5

Macroscopic and microscopic findings of the heart at autopsy. a Adhesions in the pericardial sac are prominent, and the surface is rough. b Epicardium is thickened and shows invasion by tumor cells, and proliferation of tumor cells is present up to epicardial adipose tissue (hematoxylin and eosin staining). c, d Tumor foci in the lymphatics are indicated by yellow arrow (c: hematoxylin and eosin staining, d: D2-40 immunohistochemistry. Scale bars: 5 cm for a 500 μm for b 100 μm for c 200 μm for d)

Fig. 6

Macroscopic and microscopic findings of the pleura at autopsy. a, b There are many patchy elevations of several mm in size on the chest wall (a) and the pleura (b). c Tumor cells that have proliferated in a trabecular pattern in the pleura (hematoxylin and eosin staining). d Tumor foci in the lymphatics is indicated by yellow arrow (D2-40 immunohistochemistry. Scale bars: 500 μm for c, 50 μm for d)