Pericarditis in malignancy: Difference between revisions

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__NOTOC__
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{{Pericarditis}}
{{Pericarditis in malignancy}}
'''For patient information click [[Pericarditis (patient information)|here]]'''
 
'''To go back to the main page on Pericarditis, click [[Pericarditis|here]].'''


{{CMG}}; '''Associate Editor-In-Chief:''' [[Varun Kumar]], M.B.B.S.; [[Lakshmi Gopalakrishnan]], M.B.B.S.
{{CMG}}; '''Associate Editor-In-Chief:''' [[Varun Kumar]], M.B.B.S.; [[Lakshmi Gopalakrishnan]], M.B.B.S.


==Overview==
{{SK}} Neoplastic pericarditis; malignant pericarditis
Many malignant neoplasms such as [[lung cancer]], [[breast cancer]], [[esophageal cancer]], [[lymphomas]], [[melanomas]], [[kaposi's sarcoma]] and [[leukemia]]s may metastasize to [[pericardium]] causing [[pericarditis]], [[pericardial effusion|effusion]], [[cardiac tamponade]] and [[pericardial constriction]]. Malignant pericardial effusion is seen in approximately 50-60% of patients presenting with pericardial effusion who have history of malignancy<ref name="pmid16051963">{{cite journal| author=Gornik HL, Gerhard-Herman M, Beckman JA| title=Abnormal cytology predicts poor prognosis in cancer patients with pericardial effusion. | journal=J Clin Oncol | year= 2005 | volume= 23 | issue= 22 | pages= 5211-6 | pmid=16051963 | doi=10.1200/JCO.2005.00.745 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16051963  }} </ref><ref name="pmid10554845">{{cite journal| author=Porte HL, Janecki-Delebecq TJ, Finzi L, Métois DG, Millaire A, Wurtz AJ| title=Pericardoscopy for primary management of pericardial effusion in cancer patients. | journal=Eur J Cardiothorac Surg | year= 1999 | volume= 16 | issue= 3 | pages= 287-91 | pmid=10554845 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10554845  }} </ref>. Among patients presenting with [[pericarditis]] or [[pericardial effusion]] with no history of malignancy, undiagnosed underlying malignancy was detected in 4-7%<ref name="pmid4050698">{{cite journal| author=Permanyer-Miralda G, Sagristá-Sauleda J, Soler-Soler J| title=Primary acute pericardial disease: a prospective series of 231 consecutive patients. | journal=Am J Cardiol | year= 1985 | volume= 56 | issue= 10 | pages= 623-30 | pmid=4050698 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4050698  }} </ref><ref name="pmid17502574">{{cite journal| author=Imazio M, Cecchi E, Demichelis B, Ierna S, Demarie D, Ghisio A et al.| title=Indicators of poor prognosis of acute pericarditis. | journal=Circulation | year= 2007 | volume= 115 | issue= 21 | pages= 2739-44 | pmid=17502574 | doi=10.1161/CIRCULATIONAHA.106.662114 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17502574  }} </ref><ref name="pmid15904655">{{cite journal| author=Imazio M, Demichelis B, Parrini I, Favro E, Beqaraj F, Cecchi E et al.| title=Relation of acute pericardial disease to malignancy. | journal=Am J Cardiol | year= 2005 | volume= 95 | issue= 11 | pages= 1393-4 | pmid=15904655 | doi=10.1016/j.amjcard.2005.01.094 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15904655  }} </ref>.
==[[Pericarditis in malignancy overview|Overview]]==
 
Malignancy related pericardial disease can manifest as [[pericarditis]], [[pericardial effusion]], [[cardiac tamponade]] or [[pericardial constriction]].
 
==Epidemiology and demographics==
In developed countries malignancy is the leading cause of [[cardiac tamponade]] secondary to [[pericardial effusion]]. Malignant pericardial effusion is seen in approximately 50-60% of patients presenting with pericardial effusion who have history of malignancy<ref name="pmid16051963">{{cite journal| author=Gornik HL, Gerhard-Herman M, Beckman JA| title=Abnormal cytology predicts poor prognosis in cancer patients with pericardial effusion. | journal=J Clin Oncol | year= 2005 | volume= 23 | issue= 22 | pages= 5211-6 | pmid=16051963 | doi=10.1200/JCO.2005.00.745 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16051963  }} </ref><ref name="pmid10554845">{{cite journal| author=Porte HL, Janecki-Delebecq TJ, Finzi L, Métois DG, Millaire A, Wurtz AJ| title=Pericardoscopy for primary management of pericardial effusion in cancer patients. | journal=Eur J Cardiothorac Surg | year= 1999 | volume= 16 | issue= 3 | pages= 287-91 | pmid=10554845 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10554845  }} </ref>. Among patients presenting with [[pericarditis]] or [[pericardial effusion]] with no history of malignancy, undiagnosed underlying malignancy was detected in 4-7%<ref name="pmid4050698">{{cite journal| author=Permanyer-Miralda G, Sagristá-Sauleda J, Soler-Soler J| title=Primary acute pericardial disease: a prospective series of 231 consecutive patients. | journal=Am J Cardiol | year= 1985 | volume= 56 | issue= 10 | pages= 623-30 | pmid=4050698 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4050698  }} </ref><ref name="pmid17502574">{{cite journal| author=Imazio M, Cecchi E, Demichelis B, Ierna S, Demarie D, Ghisio A et al.| title=Indicators of poor prognosis of acute pericarditis. | journal=Circulation | year= 2007 | volume= 115 | issue= 21 | pages= 2739-44 | pmid=17502574 | doi=10.1161/CIRCULATIONAHA.106.662114 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17502574  }} </ref><ref name="pmid15904655">{{cite journal| author=Imazio M, Demichelis B, Parrini I, Favro E, Beqaraj F, Cecchi E et al.| title=Relation of acute pericardial disease to malignancy. | journal=Am J Cardiol | year= 2005 | volume= 95 | issue= 11 | pages= 1393-4 | pmid=15904655 | doi=10.1016/j.amjcard.2005.01.094 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15904655  }} </ref>.
 
[[Lung carcinoma|Carcinoma of the lung]] is the most common cause for pericardial effusion in malignancy accounting for approximately 40%. Another 40% of cases could be due to [[breast carcinoma]] and [[lymphomas]]. Carcinoma of GI tract, [[melanoma]], [[sarcomas]], and other neoplastic diseases are less common.
 
[[Kaposi sarcoma]] and lymphomas associated with [[HIV]] were other neoplastic causes of pericardial effusion which accounted for 5% and 7% respectively<ref name="pmid10047635">{{cite journal| author=Chen Y, Brennessel D, Walters J, Johnson M, Rosner F, Raza M| title=Human immunodeficiency virus-associated pericardial effusion: report of 40 cases and review of the literature. | journal=Am Heart J | year= 1999 | volume= 137 | issue= 3 | pages= 516-21 | pmid=10047635 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10047635  }} </ref> in one study and 15% together<ref name="pmid12934767">{{cite journal| author=Gowda RM, Khan IA, Mehta NJ, Gowda MR, Sacchi TJ, Vasavada BC| title=Cardiac tamponade in patients with human immunodeficiency virus disease. | journal=Angiology | year= 2003 | volume= 54 | issue= 4 | pages= 469-74 | pmid=12934767 | doi= | pmc= | url= }} </ref> in another series. However, with the use of [[antiretroviral agent]]s, the incidence of Kaposi carcinoma and subsequent pericardial effusion has considerably decreased.
 
In regions where [[tuberculosis]] is not highly prevalent, malignancy may be the most common cause of a hemorrhagic effusion<ref name="pmid20728703">{{cite journal| author=Maisch B, Ristic A, Pankuweit S| title=Evaluation and management of pericardial effusion in patients with neoplastic disease. | journal=Prog Cardiovasc Dis | year= 2010 | volume= 53 | issue= 2 | pages= 157-63 | pmid=20728703 | doi=10.1016/j.pcad.2010.06.003 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20728703  }} </ref><ref name="pmid10593777">{{cite journal| author=Atar S, Chiu J, Forrester JS, Siegel RJ| title=Bloody pericardial effusion in patients with cardiac tamponade: is the cause cancerous, tuberculous, or iatrogenic in the 1990s? | journal=Chest | year= 1999 | volume= 116 | issue= 6 | pages= 1564-9 | pmid=10593777 | doi= | pmc= | url= }} </ref>
 
===Sex===
Higher incidence of the pericardial effusion related to malignancy is observed among males with ratio of 7:3 as reported in a series<ref name="pmid8632279">{{cite journal| author=Medary I, Steinherz LJ, Aronson DC, La Quaglia MP| title=Cardiac tamponade in the pediatric oncology population: treatment by percutaneous catheter drainage. | journal=J Pediatr Surg | year= 1996 | volume= 31 | issue= 1 | pages= 197-9; discussion 199-200 | pmid=8632279 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8632279  }} </ref>


==Natural history, prognosis and complications==
==[[Pericarditis in malignancy pathophysiology|Pathophysiology]]==
Gaurded prognosis associated with malignancies is worsened by [[pericardial effusion]] and [[cardiac tamponade]]. Children may have poor prognosis and thus, prompt detection and treatment of cardiac tamponade improves survival<ref name="pmid16523053">{{cite journal| author=Ben-Horin S, Bank I, Guetta V, Livneh A| title=Large symptomatic pericardial effusion as the presentation of unrecognized cancer: a study in 173 consecutive patients undergoing pericardiocentesis. | journal=Medicine (Baltimore) | year= 2006 | volume= 85 | issue= 1 | pages= 49-53 | pmid=16523053 | doi=10.1097/01.md.0000199556.69588.8e | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16523053  }} </ref><ref name="pmid16719168">{{cite journal| author=Bień E, Stefanowicz J, Aleszewicz-Baranowska J, Połczyńska K, Szołkiewicz A, Stachowicz-Stencel T et al.| title=[Cardio-vascular disorders at the time of diagnosis of malignant solid tumours in children--own experiences]. | journal=Med Wieku Rozwoj | year= 2005 | volume= 9 | issue= 3 Pt 2 | pages= 551-9 | pmid=16719168 | doi= | pmc= | url= }} </ref>.


Patients rarely present with cardiac tamponade as their first presentation. [[Superior vena cava syndrome]] may occur in few secondary to either coexisting tumor or rapid accumulation of pericardial effusion<ref name="pmid19956024">{{cite journal| author=Tsai MH, Yang CP, Chung HT, Shih LY| title=Acute myeloid leukemia in a young girl presenting with mediastinal granulocytic sarcoma invading pericardium and causing superior vena cava syndrome. | journal=J Pediatr Hematol Oncol | year= 2009 | volume= 31 | issue= 12 | pages= 980-2 | pmid=19956024 | doi=10.1097/MPH.0b013e3181b86ff3 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19956024  }} </ref>.
==[[Pericarditis in malignancy causes|Causes]]==


Prognosis of symptomatic malignant pericardial disease is grave with a short life expectancy of 2-4 months<ref name="pmid10725950">{{cite journal| author=Tsang TS, Seward JB, Barnes ME, Bailey KR, Sinak LJ, Urban LH et al.| title=Outcomes of primary and secondary treatment of pericardial effusion in patients with malignancy. | journal=Mayo Clin Proc | year= 2000 | volume= 75 | issue= 3 | pages= 248-53 | pmid=10725950 | doi= | pmc= | url= }} </ref><ref name="pmid17028771">{{cite journal| author=Gross JL, Younes RN, Deheinzelin D, Diniz AL, Silva RA, Haddad FJ| title=Surgical management of symptomatic pericardial effusion in patients with solid malignancies. | journal=Ann Surg Oncol | year= 2006 | volume= 13 | issue= 12 | pages= 1732-8 | pmid=17028771 | doi=10.1245/s10434-006-9073-1 | pmc= | url= }} </ref><ref name="pmid15078742">{{cite journal| author=Cullinane CA, Paz IB, Smith D, Carter N, Grannis FW| title=Prognostic factors in the surgical management of pericardial effusion in the patient with concurrent malignancy. | journal=Chest | year= 2004 | volume= 125 | issue= 4 | pages= 1328-34 | pmid=15078742 | doi= | pmc= | url= }} </ref><ref name="pmid18648881">{{cite journal| author=Dequanter D, Lothaire P, Berghmans T, Sculier JP| title=Severe pericardial effusion in patients with concurrent malignancy: a retrospective analysis of prognostic factors influencing survival. | journal=Ann Surg Oncol | year= 2008 | volume= 15 | issue= 11 | pages= 3268-71 | pmid=18648881 | doi=10.1245/s10434-008-0059-z | pmc= | url= }} </ref>. While the patients with hematologic<ref name="pmid12853529">{{cite journal| author=Dosios T, Theakos N, Angouras D, Asimacopoulos P| title=Risk factors affecting the survival of patients with pericardial effusion submitted to subxiphoid pericardiostomy. | journal=Chest | year= 2003 | volume= 124 | issue= 1 | pages= 242-6 | pmid=12853529 | doi= | pmc= | url= }} </ref> or breast cancer<ref name="pmid9386714">{{cite journal| author=Girardi LN, Ginsberg RJ, Burt ME| title=Pericardiocentesis and intrapericardial sclerosis: effective therapy for malignant pericardial effusions. | journal=Ann Thorac Surg | year= 1997 | volume= 64 | issue= 5 | pages= 1422-7; discussion 1427-8 | pmid=9386714 | doi=10.1016/S0003-4975(97)00992-2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9386714  }} </ref>, or those in whom malignant cells are not present in pericardium<ref name="pmid18329349">{{cite journal| author=Neragi-Miandoab S, Linden PA, Ducko CT, Bueno R, Richards WG, Sugarbaker DJ et al.| title=VATS pericardiotomy for patients with known malignancy and pericardial effusion: survival and prognosis of positive cytology and metastatic involvement of the pericardium: a case control study. | journal=Int J Surg | year= 2008 | volume= 6 | issue= 2 | pages= 110-4 | pmid=18329349 | doi=10.1016/j.ijsu.2007.12.005 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18329349  }} </ref> have better prognosis in comparison to those with solid tumors, lung cancer<ref name="pmid11480719">{{cite journal| author=García-Riego A, Cuiñas C, Vilanova JJ| title=Malignant pericardial effusion. | journal=Acta Cytol | year= 2001 | volume= 45 | issue= 4 | pages= 561-6 | pmid=11480719 | doi= | pmc= | url= }} </ref>, etc.
==[[Pericarditis differential diagnosis|Differentiating Pericarditis in malignancy from other Diseases]]==


==Pathophysiology==
==[[Pericarditis in malignancy epidemiology and demographics|Epidemiology and Demographics]]==
Pericardium may be involved by direct local spread from neoplasms such as [[breast carcinoma|breast]] and [[lung carcinoma]]s or by metastatic spread via blood stream and lymphatics as in [[melanomas]], [[lymphomas]] and [[leukemias]].


[[Pericardial effusion]] in such situations may occur either secondary to pericardial inflammation or obstruction of lymphatic drainage by enlarged [[mediastinal nodes]]<ref name="pmid15120056">{{cite journal| author=Maisch B, Seferović PM, Ristić AD, Erbel R, Rienmüller R, Adler Y et al.| title=Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task force on the diagnosis and management of pericardial diseases of the European society of cardiology. | journal=Eur Heart J | year= 2004 | volume= 25 | issue= 7 | pages= 587-610 | pmid=15120056 | doi=10.1016/j.ehj.2004.02.002 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15120056  }} </ref><ref name="pmid16523053">{{cite journal| author=Ben-Horin S, Bank I, Guetta V, Livneh A| title=Large symptomatic pericardial effusion as the presentation of unrecognized cancer: a study in 173 consecutive patients undergoing pericardiocentesis. | journal=Medicine (Baltimore) | year= 2006 | volume= 85 | issue= 1 | pages= 49-53 | pmid=16523053 | doi=10.1097/01.md.0000199556.69588.8e | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16523053  }} </ref><ref name="pmid15904655">{{cite journal| author=Imazio M, Demichelis B, Parrini I, Favro E, Beqaraj F, Cecchi E et al.| title=Relation of acute pericardial disease to malignancy. | journal=Am J Cardiol | year= 2005 | volume= 95 | issue= 11 | pages= 1393-4 | pmid=15904655 | doi=10.1016/j.amjcard.2005.01.094 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15904655  }} </ref>.
==[[Pericarditis in malignancy natural history|Natural History, Complications and Prognosis]]==
 
==Etiology==
#Pericardial [[mesothelioma]]
#[[Fibrosarcoma]]
#[[Wilms tumor]]
#[[Hodgkin lymphoma]]
#Primary mediastinal (thymic) [[B-cell lymphoma]]
#[[Adenocarcinoma]]
#[[Angiosarcoma]]
#[[Sarcomas]]
#[[Non-Hodgkin lymphoma]]
#[[Liposarcoma]]
#[[Pheochromocytoma]]
#[[Lymphoma]]
#Malignant pericardial [[teratoma]]
#[[Rhabdomyosarcoma]] with [[tuberous sclerosis]]
#[[Pheochromocytoma]]
#[[Neuroblastoma]]
#Ganglioneuroblastoma
#Leiomyosarcomas
#Liposarcomas
#High-grade sarcomas
#[[Burkitt lymphoma]]
#[[Kaposi sarcoma]] and primary cardiac lymphoma in association with [[human immunodeficiency virus]] ([[HIV]]) infection
#Intrapericardial teratoma in the fetus and neonate


==Diagnosis==
==Diagnosis==
===History and symptoms===
[[Pericarditis in malignancy history and symptoms|History and Symptoms]] | [[Pericarditis in malignancy physical examination|Physical Examination]] | [[Pericarditis laboratory studies|Laboratory Findings]] | [[Pericarditis in malignancy electrocardiogram|Electrocardiogram]] | [[Pericarditis in malignancy chest x ray|Chest X Ray]] | [[Pericarditis CT|CT]] | [[Pericarditis MRI|MRI]] | [[Pericarditis in malignancy echocardiography or ultrasound|Echocardiography]] | [[Pericarditis in malignancy cardiac catheterization|Cardiac Catheterization]]
In addition to malignancy specific presentation, patients may present with the following symptoms due to pericardial involvement:
*[[Fever]]
*[[Chest pain]] that improves on leaning forward and worsens on inspiration
*[[Breathlessness]]
*[[Orthopnoea]]
*[[Dizziness]]
*[[Palpitation]]
*[[Malaise]]
*[[Ankle edema]]
*[[Weight loss]]
 
Many patients may be asymptomatic and pericardial involvement may be detected incidentally on chest x-ray or on [[autopsy]].
 
===Physical examination===
[[Cachexia]], weight loss and other organ-system specific abnormalities secondary to malignancy.
 
'''Vitals:''' [[Tachycardia]], [[pulsus paradoxus]] and [[hypotension]](in [[cardiac tamponade]])
 
'''Neck:''' [[Jugular venous distension]] with a prominent Y descent and [[Kussmaul's sign]]
 
'''Chest:''' Pericardial knock, [[pericardial rub]] and distant [[heart sounds]]
 
'''Abdomen:''' [[Hepatomegaly]], [[ascites]]
 
'''Extremities:''' [[Ankle edema]]
 
===Electrocardiography===
*Characteristic ST elevations with PR depression may be noted in all leads in presence of [[pericarditis]].
*In case of [[pericardial effusion]] or [[cardiac tamponade]], micro-voltage with [[electical alternans]] may be observed which could be due to swinging motion of heart in pool of pericardial fluid.
*Constrictive pericarditis may present with ECG changes consistent with [[atrial fibrillation]].
 
[[Image:Alternans.jpg|500px|left|thumb|Electrical alternans in cardiac tamponade]]
<br clear="left"/>
 
===Chest X-ray===
Enlarged cardiac silhouette may be noted in pericardial effusion. Pericardial calcifications may be noted in constrictive pericarditis
[[Image:Pericardial calcification.jpg|400px|left|thumb|Pericardial calcification]]
<br clear="left"/>
 
===Echocardiography===
Echocardiography facilitates in visualizing the fluid accumulation within the pericardial cavity. Pericardial or myocardial tumors if present can also be noted.
 
Echocardiogram demonstrating '''Pericardial effusion''' and '''Myocardial tumor'''
<youtube v=sGTttwrx2xw/>
 
===MRI and CT===
MRI and CT of chest and abdomen helps us in visualizing the presence of tumor/malignancy and the degree of metastasis to other parts of the body in addition to pericardial involvement. They are superior to echocardiography<ref name="pmid7622713">{{cite journal| author=Bellon RJ, Wright WH, Unger EC| title=CT-guided pericardial drainage catheter placement with subsequent pericardial sclerosis. | journal=J Comput Assist Tomogr | year= 1995 | volume= 19 | issue= 4 | pages= 672-3 | pmid=7622713 | doi= | pmc= | url= }} </ref> in terms of providing information about whether an effusion is hemorrhagic or loculated and also in differentiating hematoma from tumor.
 
===Pericardiocentesis===
Pericardial fluid should be aspirated and tested for presence of malignant cells and tumor markers particularly in patients with hemorrhagic effusion without preceding trauma<ref name="pmid10593777">{{cite journal| author=Atar S, Chiu J, Forrester JS, Siegel RJ| title=Bloody pericardial effusion in patients with cardiac tamponade: is the cause cancerous, tuberculous, or iatrogenic in the 1990s? | journal=Chest | year= 1999 | volume= 116 | issue= 6 | pages= 1564-9 | pmid=10593777 | doi= | pmc= | url= }} </ref>. However, hemorrhagic pericarditis in developing countries could be due to [[tuberculosis]]. Sensitivity of [[cytology|cytological]] analysis of pericardial fluid for malignant cells were 67%<ref name="pmid2028688">{{cite journal| author=Wiener HG, Kristensen IB, Haubek A, Kristensen B, Baandrup U| title=The diagnostic value of pericardial cytology. An analysis of 95 cases. | journal=Acta Cytol | year= 1991 | volume= 35 | issue= 2 | pages= 149-53 | pmid=2028688 | doi= | pmc= | url= }} </ref>, 75%<ref name="pmid10554845">{{cite journal| author=Porte HL, Janecki-Delebecq TJ, Finzi L, Métois DG, Millaire A, Wurtz AJ| title=Pericardoscopy for primary management of pericardial effusion in cancer patients. | journal=Eur J Cardiothorac Surg | year= 1999 | volume= 16 | issue= 3 | pages= 287-91 | pmid=10554845 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10554845  }} </ref> and 92%<ref name="pmid9149572">{{cite journal| author=Meyers DG, Meyers RE, Prendergast TW| title=The usefulness of diagnostic tests on pericardial fluid. | journal=Chest | year= 1997 | volume= 111 | issue= 5 | pages= 1213-21 | pmid=9149572 | doi= | pmc= | url= }} </ref> in different studies with specificity of 100%. [[Immunohistochemistry]] can be used to distinguish between the malignant cells and their possible origin<ref name="pmid12508174">{{cite journal| author=Gong Y, Sun X, Michael CW, Attal S, Williamson BA, Bedrossian CW| title=Immunocytochemistry of serous effusion specimens: a comparison of ThinPrep vs cell block. | journal=Diagn Cytopathol | year= 2003 | volume= 28 | issue= 1 | pages= 1-5 | pmid=12508174 | doi=10.1002/dc.10219 | pmc= | url= }} </ref><ref name="pmid9068950">{{cite journal| author=Mayall F, Heryet A, Manga D, Kriegeskotten A| title=p53 immunostaining is a highly specific and moderately sensitive marker of malignancy in serous fluid cytology. | journal=Cytopathology | year= 1997 | volume= 8 | issue= 1 | pages= 9-12 | pmid=9068950 | doi= | pmc= | url= }} </ref>.
 
===Pericardial biopsy===
Negative cytology should be followed with by pericardial biopsy performed via a subxiphoid or transthoracic [[pericardiostomy]] or by [[pericardioscopy]]. The pericardioscopy which helps in direct visualization of pericardium and collecting biopsy sample, has a good sensitivity of 97%<ref name="pmid10554845">{{cite journal| author=Porte HL, Janecki-Delebecq TJ, Finzi L, Métois DG, Millaire A, Wurtz AJ| title=Pericardoscopy for primary management of pericardial effusion in cancer patients. | journal=Eur J Cardiothorac Surg | year= 1999 | volume= 16 | issue= 3 | pages= 287-91 | pmid=10554845 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10554845  }} </ref><ref name="pmid8840855">{{cite journal| author=Nugue O, Millaire A, Porte H, de Groote P, Guimier P, Wurtz A et al.| title=Pericardioscopy in the etiologic diagnosis of pericardial effusion in 141 consecutive patients. | journal=Circulation | year= 1996 | volume= 94 | issue= 7 | pages= 1635-41 | pmid=8840855 | doi= | pmc= | url= }} </ref> when compared to blind biopsy which has a low sensitivity of 55-65%.
 
===Cardiac catheterization===
*'''[[Cardiac tamponade]]:''' There is equalization of pressures in all four chambers of heart. The right atrial pressure equals the right ventricular end diastolic pressure equals the pulmonary artery diastolic pressure.
*'''[[Constrictive pericarditis]]:''' Equalization of elevated right atrial and pulmonary artery wedge pressures may be noted with a diastolic dip and plateau in the right ventricular tracing.
*'''[[Effusive constrictive pericarditis]]:''' Cardiac tamponade findings are noted initially. Findings of constrictive pericarditis are unmasked following [[pericardiocentesis]].


==Treatment==
==Treatment==
It is important to assess the life expectancy of the patients before proceeding with the treatment. Patients with advanced malignancy should be treated palliatively with [[pericardiocentesis]] to improve their symptoms. While those with better prognosis should be treated more aggressively.
[[Pericarditis in malignancy approach to treatment|Approach to Treatment]] | [[Pericarditis treatment|Medical Therapy]] | [[Pericardiocentesis]] | [[Pericardial window|Pericardial Window]] | [[Pericardial stripping|Pericardial Stripping]]
 
Asymptomatic or minimally symptomatic patients should be treated conservatively with avoidance of volume depletion, antineoplastic therapy and regular followup.
 
Symptomatic patients should undergo prompt drainage of effusion which could be done either by [[pericardiocentesis]] or surgical creation of [[pericardial window]].


Recurrence of pericardial effusion is frequently observed following simple pericardiocentesis<ref name="pmid10725950">{{cite journal| author=Tsang TS, Seward JB, Barnes ME, Bailey KR, Sinak LJ, Urban LH et al.| title=Outcomes of primary and secondary treatment of pericardial effusion in patients with malignancy. | journal=Mayo Clin Proc | year= 2000 | volume= 75 | issue= 3 | pages= 248-53 | pmid=10725950 | doi= | pmc= | url= }} </ref><ref name="pmid8624876">{{cite journal| author=Laham RJ, Cohen DJ, Kuntz RE, Baim DS, Lorell BH, Simons M| title=Pericardial effusion in patients with cancer: outcome with contemporary management strategies. | journal=Heart | year= 1996 | volume= 75 | issue= 1 | pages= 67-71 | pmid=8624876 | doi= | pmc=PMC484225 | url= }} </ref>. Following approaches are adapted in prevention of reaccumulation:
==Case Studies==
#'''Prolonged pericardiocentesis:'''<ref name="pmid10725950">{{cite journal| author=Tsang TS, Seward JB, Barnes ME, Bailey KR, Sinak LJ, Urban LH et al.| title=Outcomes of primary and secondary treatment of pericardial effusion in patients with malignancy. | journal=Mayo Clin Proc | year= 2000 | volume= 75 | issue= 3 | pages= 248-53 | pmid=10725950 | doi= | pmc= | url= }} </ref><ref name="pmid10197666">{{cite journal| author=Allen KB, Faber LP, Warren WH, Shaar CJ| title=Pericardial effusion: subxiphoid pericardiostomy versus percutaneous catheter drainage. | journal=Ann Thorac Surg | year= 1999 | volume= 67 | issue= 2 | pages= 437-40 | pmid=10197666 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10197666  }} </ref> Catheter should not be removed until the drainage is <20-30 ml/24 hours. Intermittent catheterization is recommended to maintain catheter patency.
[[Pericarditis in malignancy case study one|Case #1]]
#'''Pericardial sclerosis:''' Obliteration of pericardial cavity using [[tetracycline]], [[doxycycline]]<ref name="pmid8955660">{{cite journal| author=Liu G, Crump M, Goss PE, Dancey J, Shepherd FA| title=Prospective comparison of the sclerosing agents doxycycline and bleomycin for the primary management of malignant pericardial effusion and cardiac tamponade. | journal=J Clin Oncol | year= 1996 | volume= 14 | issue= 12 | pages= 3141-7 | pmid=8955660 | doi= | pmc= | url= }} </ref>, [[minocycline]]<ref name="pmid6726303">{{cite journal| author=Davis S, Rambotti P, Grignani F| title=Intrapericardial tetracycline sclerosis in the treatment of malignant pericardial effusion: an analysis of thirty-three cases. | journal=J Clin Oncol | year= 1984 | volume= 2 | issue= 6 | pages= 631-6 | pmid=6726303 | doi= | pmc= | url= }} </ref>, [[bleomycin]]<ref name="pmid19156149">{{cite journal| author=Kunitoh H, Tamura T, Shibata T, Imai M, Nishiwaki Y, Nishio M et al.| title=A randomised trial of intrapericardial bleomycin for malignant pericardial effusion with lung cancer (JCOG9811). | journal=Br J Cancer | year= 2009 | volume= 100 | issue= 3 | pages= 464-9 | pmid=19156149 | doi=10.1038/sj.bjc.6604866 | pmc=PMC2658533 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19156149  }} </ref>, or talc.
#'''[[Pericardiotomy]]:''' Surgical creation of pericardial window which drains fluid into [[pleural cavity|pleural]] or [[peritoneal cavity]] as fluid accumulates in pericardial sac.
Patients with [[constrictive pericarditis]] should be treated with pericardial stripping also known as [[pericardiectomy]] provided that the prognosis from the malignancy justifies surgery. It is not recommended in patients with mild constriction and in advanced stages of malignancy due to operative risk of 6-12%<ref name="pmid10500037">{{cite journal| author=Ling LH, Oh JK, Schaff HV, Danielson GK, Mahoney DW, Seward JB et al.| title=Constrictive pericarditis in the modern era: evolving clinical spectrum and impact on outcome after pericardiectomy. | journal=Circulation | year= 1999 | volume= 100 | issue= 13 | pages= 1380-6 | pmid=10500037 | doi= | pmc= | url= }} </ref><ref name="pmid1863142">{{cite journal| author=DeValeria PA, Baumgartner WA, Casale AS, Greene PS, Cameron DE, Gardner TJ et al.| title=Current indications, risks, and outcome after pericardiectomy. | journal=Ann Thorac Surg | year= 1991 | volume= 52 | issue= 2 | pages= 219-24 | pmid=1863142 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1863142  }} </ref>.
 
==References==
{{reflist|2}}


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Latest revision as of 15:05, 27 November 2017