This report illustrates the case of a young patient with locally advanced endocervical adenocarcinoma, FIGO stage IIA1, that was recommended to treatment with concurrent chemoradiotherapy and presented TTS followed by cardiorespiratory arrest induced during brachytherapy.
TTS is clinically an acute myocardial infarction-like cardiomyopathy without a culprit coronary artery lesion.3 Approximately 80–90% of cases occur in postmenopausal women and classically TTS has been linked to emotional stress due to excessive release of catecholamines as mechanism of response.1,9,10 Although the patient in this case outwardly displayed very little anxiety about her diagnosis and treatment approach, it is possible that she felt a heightened degree of internal emotional stress that may have contributed to the development of TTS. It is also possible that she presented some degree of pain during applicator removal at the end of the third brachytherapy session, due to anesthesia superficialization, that triggered a cardiomyopathy induced by the release of several inflammatory cytokines and metabolites related to this physical distress. Of note, a small vaginal laceration was observed after the applicator removal.
The relationship between malignancy and TTS is particularly interesting from an epidemiologic, mechanistic and outcome standpoint as both malignancy and chemotherapy have been associated with TTS.11 The overall long-term mortality of TTS patients with malignant disease is significantly increased and the prevalence of cancer in patients with TTS is high, considerably exceeding that in the normal population.12 One of the hypothesis is that cancer and TTS share similar triggering mechanisms, which consist in activation of the sympathetic nervous system.8,13 Therefore, TTS patients with cancer should be considered a high-risk subgroup with respect to their increased mortality rate.
Endothelial dysfunction in epicardial and microvascular coronary arteries occurs frequently in patients with cancer, especially during and after systemic chemotherapy or radiotherapy of the heart region, which might be a predisposing factor for developing TTS.1,3,14 Mediastinal radiotherapy can induce heart disease, such as coronary obstruction, stenosis or regurgitation due to valvular fibrosis, cardiomyopathy and pericardial constriction and inflammation.15 However, so far there is limited data on TTS induced by radiotherapy and no reports on brachytherapy-induced cardiomyopathy. In fact, brachytherapy by itself is painless. However, applicators placement and removal may present only mild discomfort or severe pain according to the different procedures (molds, intracavitary procedures, interstitial implants), and the use of sedation or anesthesia is accordingly indicated. TTS in the context of intracavitary gynecological brachytherapy procedure, not the radiation delivery, could have been triggered by the unweighted pain experienced by our patient during applicator removal. This case may represent a warning for intracavitary gynecological brachytherapy procedures, since in many facilities in our country it is performed only with sedation, or even without any sedation or analgesia.
Although most patients with TTS experience complete cardiac function recovery, the risk of complications is similar to that in patients with acute coronary syndrome.13 Patients who survive an acute episode typically recover systolic function within one to four weeks.1,3 Our patient recovered the systolic function within two weeks.