Letters to the Editor
Pneumomediastinum and Pneumopericardium in a Patient With Squamous Cell Lung Cancer
Neumomediastino y neumopericardio en un paciente con cáncer de pulmón espinocelular
Jan Kara
, Sarka Klimesova, Norbert Pauk
Corresponding author
Department of Pneumology and Thoracic Surgery, Third Faculty of Medicine, Charles University, University Hospital Na Bulovce, Praga, Czech Republic
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We report the case of a 55-year-old man with lung cancer complicated by pneumomediastinum and pneumopericardium. The patient was admitted with a 3-month history of dyspnea (Day 1). Computed tomography (CT) was performed and disease staging was established as cT4N3M0, although the tumor was not confirmed by histopathology. Pericardial and tracheal invasion were observed, causing tracheomediastinal fistula, pneumomediastinum (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), and pneumopericardium. No distant metastases were observed. Bronchoscopy showed significant tumor stenosis on the trachea, approximately 6<span class="elsevierStyleHsp" style=""></span>cm below the glottis. Samples could not be obtained and the procedure had to be terminated prematurely due to dyspnea.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">The invasive bronchology team was consulted, but the conclusion was that bronchological intervention was impossible – at that time Y stents were not yet available in the hospital. The patient's condition deteriorated rapidly and he died on Day 10. Autopsy revealed squamous cell lung cancer with direct invasion of the pericardium and trachea, forming a tracheomediastinal fistula, pneumohydropericardium, left lung pneumonia (not present at the time of performing the CT). No distant metastases were observed, so stage pT4 and pM0 was confirmed (no information on N3 lymph node invasion was provided).</p><p id="par0015" class="elsevierStylePara elsevierViewall">Only 4 cases of spontaneous pneumomediastinum in patients with primary lung cancer have been described.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">1–4</span></a> In 2 of them, the clinical situation deteriorated rapidly until death,<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">1,2</span></a> 1 patient recovered,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a> and clinical progress was not reported in the fourth case.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a> Histological types were large cell carcinoma,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> small cell carcinoma<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">2,3</span></a> and undifferentiated carcinoma.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">There are 2 explanations for poor clinical progress in the cases discussed. Tracheomediastinal fistula carries a high risk for acute mediastinitis and possible development of tension pneumomediastinum. This, like tension pneumothorax, can rapidly be fatal.</p><p id="par0025" class="elsevierStylePara elsevierViewall">We have identified 2 risk factors for the development of pneumomediastinum, both of which were presented by our case: direct tumor invasion of the trachea or the proximal ends of the main bronchi that can cause a leak to the mediastinum and raised airway pressure, occurring, for example, with intense cough or tracheal stenosis. Fistula formation does not appear to be associated with any specific histological type. Recommended treatment is symptomatic and includes high-flow oxygen therapy, analgesics and antibiotics. Preventive measures include treatment of the underlying cause of cough, if present, and endoscopic treatment of stenosis of the large airways. Tension pneumomediastinum is treated with decompression (incision or drainage).</p><p id="par0030" class="elsevierStylePara elsevierViewall">To our knowledge, this is the first report of simultaneous spontaneous pneumomediastinum and spontaneous pneumopericardium in a patient with primary lung cancer. Our hypothesis is that, in this specific case, spontaneous pneumomediastinum was due to 2 circumstances: infiltration of the trachea (providing a less resistant area for fistula formation), and tracheal stenosis 6<span class="elsevierStyleHsp" style=""></span>cm below the glottis (requiring a significantly greater change in intrathoracic pressure to maintain normal respiratory volume). Rapidly progressing respiratory failure was probably due to tracheal stenosis and pneumonia, rather than to spontaneous pneumomediastinum or spontaneous pneumopericardium.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Kara J, Klimesova S, Pauk N. Neumomediastino y neumopericardio en un paciente con cáncer de pulmón espinocelular. Arch Bronconeumol. 2015;51:249–250.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 996 "Ancho" => 1000 "Tamanyo" => 106913 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chest computed tomography showing large tumor in the right lung with direct mediastinal invasion and pneumomediastinum (arrow) anterior to the heart.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0025" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Spontaneous pneumomediastinum and subcutaneous emphysema: an uncommon complication of lung cancer" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J. 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Walker" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Respir Med" "fecha" => "1995" "volumen" => "89" "paginaInicial" => "385" "paginaFinal" => "386" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7638377" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15792129/0000005100000005/v2_201504270531/S157921291500049X/v2_201504270531/en/main.assets" "Apartado" => array:4 [ "identificador" => "14576" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Letters to the editor" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/15792129/0000005100000005/v2_201504270531/S157921291500049X/v2_201504270531/en/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S157921291500049X?idApp=UINPBA00003Z" ]
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| 2017 December | 27 | 8 | 35 |
| 2017 November | 22 | 5 | 27 |
| 2017 October | 21 | 5 | 26 |
| 2017 September | 27 | 4 | 31 |
| 2017 August | 24 | 9 | 33 |
| 2017 July | 21 | 4 | 25 |
| 2017 June | 29 | 15 | 44 |
| 2017 May | 26 | 4 | 30 |
| 2017 April | 21 | 7 | 28 |
| 2017 March | 14 | 7 | 21 |
| 2017 February | 15 | 7 | 22 |
| 2017 January | 15 | 2 | 17 |
| 2016 December | 31 | 4 | 35 |
| 2016 November | 43 | 10 | 53 |
| 2016 October | 52 | 18 | 70 |
| 2016 September | 34 | 8 | 42 |
| 2016 August | 48 | 8 | 56 |
| 2016 July | 26 | 10 | 36 |
| 2016 March | 3 | 0 | 3 |
| 2016 February | 1 | 0 | 1 |
| 2015 December | 3 | 0 | 3 |
| 2015 October | 30 | 3 | 33 |
| 2015 September | 30 | 10 | 40 |
| 2015 August | 49 | 27 | 76 |
| 2015 July | 4 | 2 | 6 |
| 2015 June | 1 | 0 | 1 |
| 2015 April | 2 | 0 | 2 |
Show all
