Case report of simultaneous presentation of pulmonary embolism and pericardial effusion following an oncological esophagectomy

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University of Groningen

Case report of simultaneous presentation of pulmonary embolism and pericardial effusion

following an oncological esophagectomy

Jou-Valencia, Daniela; Dijkstra, Frederieke A.

Published in:

International journal of surgery case reports

DOI:

10.1016/j.ijscr.2020.10.090

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Jou-Valencia, D., & Dijkstra, F. A. (2020). Case report of simultaneous presentation of pulmonary embolism

and pericardial effusion following an oncological esophagectomy. International journal of surgery case

reports, 77, 252-255. https://doi.org/10.1016/j.ijscr.2020.10.090

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ContentslistsavailableatScienceDirect

International

Journal

of

Surgery

Case

Reports

jo u r n al hom e p a g e :w w w . c a s e r e p o r t s . c o m

Case

report

of

simultaneous

presentation

of

pulmonary

embolism

and

pericardial

effusion

following

an

oncological

esophagectomy

Daniela

Jou-Valencia

1

_,

_Frederieke

_A.

_Dijkstra

∗

DepartmentofSurgery,UniversityofGroningen,UniversityMedicalCenterGroningen(UMCG),Groningen,theNetherlands

a

r

t

i

c

l

e

i

n

f

o

Articlehistory: Received25August2020 Accepted20October2020 Availableonline28October2020 Keywords: Esophagealcancer Esophagealresection Casereport Pulmonaryembolism Pericardialeffusion

Directoralanticoagulant(DOAC)

a

b

s

t

r

a

c

t

INTRODUCTION:Thisistheﬁrstreportedcaseofsimultaneouspresentationofpulmonaryembolismand pericardialeffusionfollowingesophagectomy.Thiscaseillustratesadiagnosticandtherapeuticchallenge exemplifyingthedifﬁcultiesarisingfromcomplexanticoagulantconsiderationsinesophagealcancer. PATIENTCASE:A72yearoldmaleundergoesanoncologicalesophagealresection.Postoperativelythe patientdevelopspulmonaryembolismforwhichheistreatedwithRivaroxaban.Afterstarting Rivarox-abanthepatientdevelopsalargepericardialeffusion.

DISCUSSION:WesuspectthatthetreatmentofpulmonaryembolismwithRivaroxabanhadacausative roleinthedevelopmentofpericardialeffusion.Basedonliteraturewesuspectthatchemoradiotherapy increasedsusceptibility.

CONCLUSION:Diagnosisandtreatmentofsimultaneouspulmonaryembolismandpericardialeffusion remainsachallenge.SpecialconsiderationshouldbetakenwhenusingRivaroxabaninesophagealcancer patients;thisshouldalwaysbeconductedinconsultationwithacoagulationspecialist.

1. Introduction

Esophageal cancer(EC)isaseriousdiagnosiswithhigh mor-bidityandmortality.Treatmentinvolveschemoradiotherapyand esophagealresection.Thisisacomplexprocedurewithahighrisk ofcomplications[1].

Wepresentacaseofa72-year-oldmalewithprogressivechest pain(CP)andshortnessofbreath(SoB)followinganuncomplicated esophagectomyinaUniversityMedicalCenterintheNetherlands. Thesymptomswereinitiallyattributedtoamassivepulmonary embolism(PE)forwhichRivaroxabanwasstarted.Sixdaysafter,a pericardialeffusion(PcE)wasseenonCTalongsidethePE.

Thisis theﬁrst reportedcase ofthesimultaneous presenta-tionofPEandPcEfollowingesophagectomy.Thiscaseillustratesa diagnosticandtherapeuticchallenges,exemplifyingthedifﬁculties arisingfromcomplexanticoagulantconsiderationsinEC.

ThecaseispresentedaccordingtoSCAREcriteria[2].

2. Presentationofcase

A 72 year-oldCaucasian male(Table1)wasdiagnosed with distalesophagealsquamouscellcarcinoma(cT2N1M0)forwhich

∗ Correspondingauthorat:DepartmentofSurgery,UniversityMedicalCenter Groningen(UMCG),Hanzeplein1,9713GZ,Groningen,theNetherlands.

E-mailaddress:f.a.dijkstra@umcg.nl(F.A.Dijkstra).

1 _Present_address:_Department_of_Surgery,_Medical_Center_Leeuwarden,_Henri Dunantweg2,8934AD,Leeuwarden,TheNetherlands.

he received carboplatin/paclitaxel chemoradiotherapy. After 5 cycles,positronemissiontomographyshowedcompleteresponse to therapy. Due to the aggressive nature of the cancer, an esophagealresectionwasindicated.Twelveweeksafterthelast chemoradiotherapysessionthepatientunderwentarobot-assisted minimally-invasiveesophagectomywithintra-thoracic anastomo-sis.ProcedurewasexecutedbytwoexperiencedupperGIsurgeons. Onpostoperativeday(POD)2thepatientdevelopedSoBandCP. Thiswasinitiallydeemedreﬂectiveofrecentpost-operativestatus, howeveraprogressioninsymptomswarrantedadditional imagin-ing.ACTonPOD6showedbilateralPE(leftbeingsegmental)with infarctionoftherightlowerlobeandbilateralconsolidations sug-gestiveofpneumonia(Fig.2).Therapeuticfraxiparine2dd17600IE andantibioticswereimmediatelyadministered.

OnPOD7thepatientbecameacutelydyspneicrequiring admis-siontotheintensivecarewithacuterespiratoryfailuresecondary toPEandpneumonia.ECGshowedatrialﬂutter.Intheblood,a dou-blingofCRP(350mg/L)withleukocytesof15.50×109_/L_and_stable

hemoglobinwereobserved(Fig.1).Optiﬂowandamiodaronewere started,afterwhichrespiratorystatusimprovedandthearrythmia convertedtosinusrhythm.Thepatientwastransferredbacktothe surgicalwardwherehecontinuedtorecuperate.

OnPOD13thepatientwasswitchedtoRivaroxaban2dd15mg (Fig.1), asthiswasdeemeda bettertreatmentforthe arrhyth-miaandPE.Duetoanxietyquetiapine1dd12.5mg,andlorazepam 1dd10mgwerealsoinitiated.

Despite treatment, symptoms of SoB and CP continued to progress.ElevatedCRPof100mg/Landleukocytesof13.0×109_/L

suggestedthesymptomswereduetothePEandpneumonia.On

https://doi.org/10.1016/j.ijscr.2020.10.090

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D.Jou-Valencia,F.A.Dijkstra InternationalJournalofSurgeryCaseReports77(2020)252–255

Fig.1.Vitalsigns,laboratoryﬁndingsandanticoagulationschemeduringpostoperativeadmission;CRP:C-ReactiveProtein. Addendum1:Clinicalcourse.

POD17ahypotensiveepisode(94/68mmHg)witharegularheart

rateof 96bpmwasobserved.X-thorax showedbilateralpleural

ﬂuidandanenlargedheart.OnCTamassivePcEwasseenwith

pleuralﬂuid,bilateralconsolidations,andmediastinalairpockets

suggestiveofananastomoticleakage(AL)(Fig.2).Atransthoracic

echocardiogramshowedsubstantialpericardialﬂuidwithnosigns ofimminenttamponade.Rivaroxabanwasstopped,andvia pericar-diocentesis1150mLofﬂuidwasaspiratedfromthepericardium.

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Fig.2.ComputedTomographypostoperativeDay6+Day21. Table1 PatientCharacteristics. Baselinecharacteristics Age 72years Gender Male Race Caucasian BMI 2596kg/m2 MedicalHistory

2001 Myocardialinfarction PercutaneousTransluminal

coronaryangioplasty (PTCA)ofcircumﬂexartery 2003/12 PeripheralT-Cell

Non-HodgkinLymphoma Stadium4B:Cervical, mediastinalandinguinal

8xCHOPchemotherapy (after6sessionscomplete remission)

2004/09 RecurrenceT-cell Non-HodgkinLymphoma

DHAP/VIM/DHAPand autologousstemcell transplant.Complete remission. 2016 Coloncarcinoma, pT3N0M0 Lefthemicolectomy 2019/03 Esophagealcancer, cT2N1M0 Neoadjuvant chemoradiotherapy (carboplatin/paclitaxel) Medication

Lorazepam1mgonceaday,atnight Rosuvastatine5mgonceaday

Carbasalatecalcium100mgpowderonceaday Perindopril2mgonceaday

Allergies

None

Intoxications

Smoking Yes,quitin2001 Alcohol Yes,6glassesofalcoholper

week

Drugs Never

SocialContext

Maritalstatus Married

Employment Managerwholesaleglass company:retired

BMI:BodyMassIndex;PTCA:percutaneoustransluminalcoronaryangioplasty; CHOP:combinationchemotherapyusedfortreatmentofnon-HodgkinLymphoma; DHAP/VIM/DHAP:combinationchemotherapyusedfortreatmentofnon-Hodgkin Lymphoma.

Pathologicalassessmentoftheﬂuidshowedbloodwithout

malig-nantcells.Acytogramshowederythrocytes,afewleucocytes,no

bacteria norothermicroorganisms.Therapeutic fraxiparinewas

resumed8hpost-pericardiocentesis.Intravenousantibioticswere

administeredintreatmentofthelungconsolidations.Asmalldefect

at theanastomosiswasgastroscopically conﬁrmed,andtreated

conservativelywithantibioticsandnihilbymouth.

Following pericardiocentesis the CP and SoB symptoms

improved. X-thoraxshowedreduced heartcontoursandpleural

ﬂuid.ECGshowedsinusrhythm.Laboratoryworkupshowed

nor-malizationofinfectionparameters.Thepatientwasobservedfor

another5dayswithoutcomplicationsbeforehewasdischarged

fromhospital.

3. Discussionandconclusion

Thisistheﬁrstreportedcaseofthesimultaneouspresentation

ofPEandPcEfollowingesophagectomy.Thecaseposesdiagnostic

andtherapeuticchallengesarisingfromcomplexanticoagulation

considerations.

TherearefewreportedcasesofPcEfollowingan

esophagec-tomy[3,4].Thisprocedurerequiresthesurgeontoworkinclose proximitytothepericardiuminordertodissectandpreparethe esophagealtissue forresection.Surgicaltraumamayprecipitate thedevelopmentofaPcEshortlyfollowingsurgery.Inourcase, thePcEwasdiagnosedonPOD20,suggestingthatsurgicaltrauma playednodirectroleinitsdevelopment.

AsystematicreviewbyPabbaetal.[5]presents7casesof con-currentPEandPcEincancerpatients,withPcEdeemedsecondary tomalignancybasedoncytologicalﬂuidanalyses.Inourcase, cyto-logicalandpathologyresultsshowednomalignantcells.Another commoncauseofPcEisinfection.Wefoundnoevidenceof ele-vatedwhitebloodcellsormicroorganismsincytology,suggesting analternativecauseofPcE.

Ourpatientreceivedpreoperativechemoradiotherapy.Several observationalstudiesontheincidenceofPcEfollowing chemora-diotherapyforECreportanincidenceof27.7–57.0%withamedian onsetof5.3–12monthsfollowingthelastchemoradiotherapy ses-sion[6,7].Inourcase,thePcEwasdiagnosedapproximately15 weeksafterthelastchemoradiotherapysession,suggestingthat thechemoradiotherapymayhaveplayedaroleinthedevelopment ofPcE.

Consideringthetimeline,SoBandCPsymptomsworsenedone dayafterthestartofRivaroxaban.Atthistime,weseea down-wardtrend inhemoglobinlevels-possiblyindicating anactive bleed.Thefactthatthepatientdidnotdevelopacardiac tampon-adedespitehavingalmost1200mLofbloodinthepericardium, suggeststhatthebloodaccumulatedslowly.Togetherthisdraws suspiciontowardsRivaroxabanasthePcE-cause.Acaseseriesby Cinellietal.(2019)[8]presentsthreecasesofdirectoral antico-agulant(DOAC)-inducedPcEinoncologicpatients.Allthreecases showedmalignantcellsinﬂuidcytology,suggestingthatthismay haveplayedacausativeroleratherthanRivaroxaban.

Thecurrent standard of treatmentfor PEis therapeutic low molecular weight heparin (LMWH). Studies within the gen-eral population presented DOACs as an appropriate, patient friendly alternative to LMWH for the treatment of Venous Thromboembolism (VTE). Although encouraging, these studies underrepresentedoncologicpatients[9].Tworecentrandomized controlledtrialslookedattheeffectivenessofDOACscomparedto LMWHforthetreatmentofVTEincancerpatients[10,11].They showedadecreasedincidenceofrecurrentVTE,withanincreased riskofbleedingamongsttheDOACgroup.Thisriskwas primar-ilyobservedinuppergastrointestinalmalignancies,withemphasis onesophagealandgastriccancer. Withintheesophagealgroup, bleedingwasonlynotedin unresectedesophagealtumors.This

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D.Jou-Valencia,F.A.Dijkstra InternationalJournalofSurgeryCaseReports77(2020)252–255

suggeststhatthebleedinginthispatientgroupmainlyinvolved

tumourtissue.However,duetothelimitednumberofECpatients

inthesestudies,furtherresearchisnecessarybeforeﬁrm

conclu-sionscanbeformulated.Specialattentionshouldbegiventothe

uptakeofDOACsinECpatients.Studieslookingattheeffectsof

bariatricsurgeryandgastrointestinalresectionsonDOACuptake

haveshownaninadequateabsorptionofthedrugresultingin

sub-optimalanticoagulation[12].Thisissuggestiveofasimilarproblem

amongstesophagectomypatients.

Lastly,RivaroxabanisasubstrateoftheP-gpefﬂuxtransporter, andismetabolizedviaCYP3A.Medicationsinteractionswiththese systemscancausechangesinmedicationconcentrations[13]. Que-tiapine,theantipsychoticwhichourpatientreceived,actsasaP-gp andCYP3Ainhibitor.Bothinteractionscanresultinanincreased plasma concentrationofRivaroxaban and increasingtherisk of bleeding,andpotentiallyplayingaroleinthedevelopmentofPcE inourpatient.

Inconclusion,thiscaseillustratesthediagnosticchallengesof SoBandCPinpost-esophagectomypatients,aswellasthe difﬁcul-tiesarisingfromcomplexanticoagulantconsiderationsinEC.There isconﬂictingevidenceregardingthesafetyofRivaroxabaninEC patients,withnoevidenceofitsuptakefollowinganesophageal resection.InourpatientcasewesuspectthatthetreatmentofPE withRivaroxabanhadacausativeroleinthedevelopmentofPcE andbasedonliteraturewealsosuspectthatchemoradiotherapy increasedsusceptibility.Basedoncurrentliteratureandthiscase studywebelievethattheuseofRivaroxabaninECpatientsshould alwaysbeconductedinconsultationwithacoagulationspecialist. DeclarationofCompetingInterest

Theauthorsreportnodeclarationsofinterest. Funding

None. Ethicalapproval

Notapplicable.Informedconsentfrompatientobtained. Consent

Informedconsentfrompatientobtained. Registrationofresearchstudies

Casestudy:Notapplicable. Guarantor

Theﬁrstand lastauthor(DanielaJou-ValenciaMDa,1,_*;

Fred-eriekeA.DijkstraMDa₎_accept_full_{responsibility}_for_the_study_and

guaranteeit’saccuracy. Provenanceandpeerreview

Notcommissioned,externallypeer-reviewed.

CRediTauthorshipcontributionstatement

DanielaJou-Valencia:Conceptualization,Datacuration, Writ-ing-originaldraft.FrederiekeA.Dijkstra:Supervision,Writing -review&editing.

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