Chest Pain in a Patient With Esophageal Cancer
TZU–TING CHEN and CHING–CHAN LIN
Division of Hematology and Oncology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
A 55-year-old man presented to the emergency room with progressive left retrocardial compressive pain for 2 weeks. The chest pain was relieved while sitting and was exacerbated by lying down. He also had productive cough and dyspnea.
He had a medical history of squamous cell carcinoma of the middle third and lower third of the esophagus with an initial presentation of dysphagia. The clinical stage based on the American Joint Committee on Cancer classification was T4N1M0, stage III. He received concurrent chemoradiotherapy 8 months previously. The bronchial and esophageal stents had been placed because of
tracheoesophageal fistula after concurrent chemoradiotherapy 6 months previously. He underwent palliative fluorouracil-based chemotherapy. A positron emission tomography–computed tomography 2 months previously revealed residual tumor and lymph node metastases in the subcarinal area.
On this presentation, he was afebrile and the pulse oximeter showed a hemoglobin saturation of 97% while breathing ambient air. The physical examination was unremarkable. The breath sounds on both lung sides were clear on auscultation, and the heart sound was normal. The laboratory values were as follows: white blood cell count, 6790/μL (neutrophils, 68%); hemoglobin level, 9.1 g/dL; and platelet count, 321,000/mm3. The electrocardiography disclosed sinus tachycardia and poor R-wave progression. The plain film
radiograph of the chest revealed an air-fluid level in the pericardium (Figure A, arrow). The computed tomography of the chest with contrast showed the collection of air and fluid in bilateral pericardial spaces (Figure B, arrow). Esophagopericardial fistula was seen below the carina (Figure C, arrow). Pneumopericardium secondary to esophageal-pericardium fistula was diagnosed.
Pneumopericardium is a rare etiology of chest pain that is important for differential diagnosis. It can result from a traumatic or nontraumatic cause.1 Pneumopericardium resulting from fistula formation between pericardium and the esophageal cancer is even
more unusual. Prior radiotherapy and direct esophageal injury secondary to pressure necrosis after stent placement had been cited as a predisposing factor for fistula formation.2, 3 A high mortality rate has been described, and most patients die in the first month.2 The
only chance for survival was early surgery or stent placement.3 In one case report, the patient had an esophagopericardial fistula
associated with the placement of the stent; the placement of a second stent was attempted but failed.3 Our patient declined further
