Malignant pericardial effusion: Current diagnosis and treatment

Ranjit K. Chaudhary, Smith Giri, Ranjan Pathak, Sumit Dahal, Vijaya R Bhatt

Research output: Chapter in Book/Report/Conference proceedingChapter

Abstract

Pericardium is a common site for neoplastic involvement that occursdue to direct local invasion by malignancy or metastatic spread via thelymphatics or bloodstream. Malignant involvement of the pericardium oroccasionally treatment of malignancy can cause pericardial effusion.Pericardial effusion can be asymptomatic or cause chest discomfort,dyspnea, tachycardia, hypotension and cardiogenic shock, with increasingamount of fluid. Electrocardiogram, chest x-ray, echocardiography andcardiac catheterization can all aid in diagnosis of pericardial effusion butpericardial fluid and biopsy with histologic and cytologic analysis isrequired for diagnosis on underlying malignancy.Prognosis for patients with malignant pericardial effusion isprimarily dictated by the underlying disease. Since outcome is usuallypoor, goal of treatment is palliation of symptoms and prevention ofrecurrence of effusion. Pericardiocentesis is useful for prevention andtreatment of cardiac tamponade but inadequate in itself because of a highrate of recurrence even when followed by extended tube drainage.Pericardial sclerosis has good success rate but high rate of complicationssuch as arrhythmias and pericardial constriction. This makes it lesspreferred option than pericardial drainage, however, it may be useful forthose, who are unfit for any surgical intervention. Cisplatin andtetracycline are most widely used sclerosing agents. Confirmed malignantpericardial effusion can be treated with relatively high doses ofintrapericardial chemotherapy with minimal systemic side effects but thedisease is restricted to only pericardium on a rare occasion. Indisseminated malignancy, intrapericardial chemotherapy can improvesymptoms of a hemodynamically significant effusion but other moreeffective and inexpensive treatment modalities may also be available.Surgical treatment appears to result in better clinical outcome butselection of healthier patients may be confounding the results. Pericardialfenestration is the most commonly performed surgical procedure thatemploys subxiphoid, video-assisted thoracic surgery (VATS) and minithoracotomyapproaches. This has an overall success rate of 93%,recurrence rate of 6% and perioperative complication rate of 4%.Subxiphoid approach can be performed under local anesthesia and doesnot require single-lung ventilation procedure unlike during VATS.Pericardiectomy is performed using VATS and is the second mostcommonly performed surgical procedure with almost 100% success ratebut with a perioperative complication rate of up to 10%. Pericardioperitonealshunt as a treatment of malignant pericardial effusion has beenreported as a safe and effective treatment but the small study populationmandates further confirmatory studies. Percutaneous balloonpericardiotomy has good outcome, can be performed under localanesthesia and allows early discharge. It is useful in poor surgicalcandidates but has higher complications (up to 32%), which include a riskof pleural effusion, fever and pneumothorax. Outcomes tend to be betterin the high-volume centers.In conclusion, there is a paucity of high-quality studies and a lack oftherapeutic options with significant impact on survival of patients withmalignant pericardial effusion. Safe, cost effective and durable palliativetreatment as well as treatment strategies that can prolong survivalmeaningfully are needed

Original languageEnglish (US)
Title of host publicationCardiac Tamponade
Subtitle of host publicationEpidemiology, Causes and Management
PublisherNova Science Publishers, Inc.
Pages91-112
Number of pages22
ISBN (Electronic)9781634828123
ISBN (Print)9781634827874
StatePublished - Jan 1 2015

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Pericardial Effusion
Video-Assisted Thoracic Surgery
Pericardium
Therapeutics
Drainage
Neoplasms
Thorax
One-Lung Ventilation
Pericardiocentesis
Pericardiectomy
Sclerosing Solutions
Recurrence
Drug Therapy
Cardiac Tamponade
Cardiogenic Shock
Sclerosis
Pneumothorax
Local Anesthesia
Pleural Effusion
Constriction

Keywords

  • Cytology
  • Intrapericardial chemotherapy
  • Malignant pericardial effusion
  • Percutaneous balloon pericardiectomy
  • Pericardial sclerosis
  • Pericardial window
  • Pericardial-peritoneal shunt
  • Pericardiectomy
  • Pericardiocentesis
  • Video-assisted thoracoscopic surgery

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Chaudhary, R. K., Giri, S., Pathak, R., Dahal, S., & Bhatt, V. R. (2015). Malignant pericardial effusion: Current diagnosis and treatment. In Cardiac Tamponade: Epidemiology, Causes and Management (pp. 91-112). Nova Science Publishers, Inc..

Malignant pericardial effusion : Current diagnosis and treatment. / Chaudhary, Ranjit K.; Giri, Smith; Pathak, Ranjan; Dahal, Sumit; Bhatt, Vijaya R.

Cardiac Tamponade: Epidemiology, Causes and Management. Nova Science Publishers, Inc., 2015. p. 91-112.

Research output: Chapter in Book/Report/Conference proceedingChapter

Chaudhary, RK, Giri, S, Pathak, R, Dahal, S & Bhatt, VR 2015, Malignant pericardial effusion: Current diagnosis and treatment. in Cardiac Tamponade: Epidemiology, Causes and Management. Nova Science Publishers, Inc., pp. 91-112.
Chaudhary RK, Giri S, Pathak R, Dahal S, Bhatt VR. Malignant pericardial effusion: Current diagnosis and treatment. In Cardiac Tamponade: Epidemiology, Causes and Management. Nova Science Publishers, Inc. 2015. p. 91-112
Chaudhary, Ranjit K. ; Giri, Smith ; Pathak, Ranjan ; Dahal, Sumit ; Bhatt, Vijaya R. / Malignant pericardial effusion : Current diagnosis and treatment. Cardiac Tamponade: Epidemiology, Causes and Management. Nova Science Publishers, Inc., 2015. pp. 91-112
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N2 - Pericardium is a common site for neoplastic involvement that occursdue to direct local invasion by malignancy or metastatic spread via thelymphatics or bloodstream. Malignant involvement of the pericardium oroccasionally treatment of malignancy can cause pericardial effusion.Pericardial effusion can be asymptomatic or cause chest discomfort,dyspnea, tachycardia, hypotension and cardiogenic shock, with increasingamount of fluid. Electrocardiogram, chest x-ray, echocardiography andcardiac catheterization can all aid in diagnosis of pericardial effusion butpericardial fluid and biopsy with histologic and cytologic analysis isrequired for diagnosis on underlying malignancy.Prognosis for patients with malignant pericardial effusion isprimarily dictated by the underlying disease. Since outcome is usuallypoor, goal of treatment is palliation of symptoms and prevention ofrecurrence of effusion. Pericardiocentesis is useful for prevention andtreatment of cardiac tamponade but inadequate in itself because of a highrate of recurrence even when followed by extended tube drainage.Pericardial sclerosis has good success rate but high rate of complicationssuch as arrhythmias and pericardial constriction. This makes it lesspreferred option than pericardial drainage, however, it may be useful forthose, who are unfit for any surgical intervention. Cisplatin andtetracycline are most widely used sclerosing agents. Confirmed malignantpericardial effusion can be treated with relatively high doses ofintrapericardial chemotherapy with minimal systemic side effects but thedisease is restricted to only pericardium on a rare occasion. Indisseminated malignancy, intrapericardial chemotherapy can improvesymptoms of a hemodynamically significant effusion but other moreeffective and inexpensive treatment modalities may also be available.Surgical treatment appears to result in better clinical outcome butselection of healthier patients may be confounding the results. Pericardialfenestration is the most commonly performed surgical procedure thatemploys subxiphoid, video-assisted thoracic surgery (VATS) and minithoracotomyapproaches. This has an overall success rate of 93%,recurrence rate of 6% and perioperative complication rate of 4%.Subxiphoid approach can be performed under local anesthesia and doesnot require single-lung ventilation procedure unlike during VATS.Pericardiectomy is performed using VATS and is the second mostcommonly performed surgical procedure with almost 100% success ratebut with a perioperative complication rate of up to 10%. Pericardioperitonealshunt as a treatment of malignant pericardial effusion has beenreported as a safe and effective treatment but the small study populationmandates further confirmatory studies. Percutaneous balloonpericardiotomy has good outcome, can be performed under localanesthesia and allows early discharge. It is useful in poor surgicalcandidates but has higher complications (up to 32%), which include a riskof pleural effusion, fever and pneumothorax. Outcomes tend to be betterin the high-volume centers.In conclusion, there is a paucity of high-quality studies and a lack oftherapeutic options with significant impact on survival of patients withmalignant pericardial effusion. Safe, cost effective and durable palliativetreatment as well as treatment strategies that can prolong survivalmeaningfully are needed

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KW - Percutaneous balloon pericardiectomy

KW - Pericardial sclerosis

KW - Pericardial window

KW - Pericardial-peritoneal shunt

KW - Pericardiectomy

KW - Pericardiocentesis

KW - Video-assisted thoracoscopic surgery

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