Chronic Massive Pericardial Effusion Following Roentgen Therapy for Carcinoma of the Breast

Abstract

Chronic pericardial effusion following a single massive dose of x-rays appears to be extremely rare. We have not been able to find any reported case in an extensive search of the literature. The effects of irradiation on the heart and its coverings have been discussed by Leach (13) in a recent study of 85 cases and by Leucutia (14) in an editorial. These authors have reviewed the essential clinical and experimental findings. Leucutia states: “For the present, we can safely make the premise that no damage is being done to the heart itself by the various methods of irradiation as currently used in roentgen therapy.” While this generalization may normally be valid, complications arising from injudicious therapy must always be kept in mind. These possibilities may be explored with the aid of animal experiments and answered more fully by carefully recording observations of the effects of the rays on the patient. Close correlation of the clinical observations with the pathological findings is essential in cases in which doses massive enough to produce lesions of some magnitude have been administered. Thus will the appropriate critical tolerance dose which will not produce damaging changes be discovered. We had the opportunity of observing the effects of a single massive dose of x-rays given in such a way that the minimum of tissue lay between the incident beam and the heart. The position and the body build (short and obese) of the patient brought the heart and its coverings to within 2 or 3 cm. of the measured surface treated. A short preoperative course was given, consisting of three treatments totaling 600 r (in air) to a circular field, 25 cm. in diameter, on the anterior left chest. The posterior axilla was treated with a single 300 r exposure to a 15-cm. circular field. At the time of operation a single dose, thought to be 3,000 r (in air), was directed to a 12 × 14-cm. area through the open wound. Review of the original treatment record leads us to believe that the exposure at the surface of the chest wall (flayed) may have been 3,600 r (in air). Estimating scattering and absorption, the tissue dose in the pericardium where it lay closest to the surface—2 to 3 cm.—may have reached 3,800 r. This tissue dose of 3,800 r given in one session is probably equal to a tissue dose of 7,600 r delivered in ten minutes over a ten-day period (Pack and Quimby, 16). Added to this single massive dose was a certain amount of radiation from the preoperative course (which undoubtedly included the left half of the cardiac area), an increment of perhaps 650 tissue roentgens in four days, or a total estimated tissue dose of 8,250 r in a period of nine days. Case Report On Aug. 22, 1939, a plump Korean woman of 53 years entered San Francisco Hospital complaining of masses in the left breast and axilla of one month's duration. The mass in the upper outer quadrant of the left breast measured 7 cm. in diameter and was attached to the skin and deep tissues.