Gastropleural Fistula Caused by Peritoneal Carcinomatosis in Metastatic Ovarian Cancer: A Case Report and Review of Literature

In April 2015, a 59-year old woman was referred to the Oncological Department after onset of dyspnea, tachycardia, polypnea and cachexia. In 2004, she had a diagnosis of well-differentiated serum-papillary ovarian adenocarcinoma stage IIIc based on the International Federation of Gynecology and Obstetrics (FIGO) classification. The patient was not eligible for surgery and was prescribed chemotherapy with carboplatin and paclitaxel (a total of six cycles). During followup, a complete radiological and serological response was observed. In 2008, a blood test reported an increased level of serum CA125 and computed tomography (CT) imaging demonstrated progression of the disease represented by ascites and peritoneal carcinomatosis. From November 2008 to March 2015 the patient received multiple rounds of chemotherapy due to disease progression. In February 2015, liposomal doxorubicin was administered as salvage therapy. At the time of clinical evaluation, a left lung mobility reduction with decrease ipsilateral vesicular murmur and basal right crackles were detected. Moreover, blood test demonstrated a leucocytosis neutrophil with (20.8x10 9 /l leucocytes with 18.2x10 9 /l of neutrophils) and increased C-reactive protein level (199 mg/L). A chest X-ray showed massive left pneumothorax with mediastinal traction (Figure 1A) and a pleural drain was placed. Emission of abundant blackish liquid was observed. Chest Xray revealed persistent massive pleural effusion (Figure 1B) without any improvement in clinical symptoms. A thoracic CT scan showed a large fistula between posterior-lateral gastric wall and left pleura (Figure 2). The patient’s clinical condition did not allow surgical intervention and antibiotic therapy was prescribed (ceftriaxone and metronidazole). During hospitalization the patient was apyretic, with negative blood cultures, but clinical deterioration was observed with bronchial congestion, dyspnea and respiratory distress. The patient died seventeen days after the diagnosis of gastric wall and left pleura fistula.