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| __NOTOC__ | | __NOTOC__ |
| | {{Pericarditis in malignancy}} |
| {{Pericarditis}} | | {{Pericarditis}} |
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| {{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. |
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| ==Overview== | | ==[[Pericarditis in malignancy overview|Overview]]== |
| 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>.
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| Malignancy related pericardial disease can manifest as [[pericarditis]], [[pericardial effusion]], [[cardiac tamponade]] or [[pericardial constriction]].
| | ==[[Pericarditis in malignancy epidemiology and demographics|Epidemiology and demographics]]== |
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| ==Epidemiology and demographics== | | ==[[Pericarditis in malignancy natural history|Natural history, prognosis and complications]]== |
| 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>.
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| [[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. | | ==[[Pericarditis in malignancy pathophysiology|Pathophysiology]]== |
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| [[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. | | ==[[Pericarditis in malignancy causes|Causes]]== |
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| 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>
| | ==[[Pericarditis differential diagnosis|Differentiating Pericarditis in malignancy from other Diseases]]== |
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| ===Sex===
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| 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>
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| ==Natural history, prognosis and complications== | |
| 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>.
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| 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>.
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| 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.
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| ==Pathophysiology==
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| 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]].
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| [[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>.
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| ==Etiology== | |
| #Pericardial [[mesothelioma]]
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| #[[Fibrosarcoma]]
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| #[[Wilms tumor]]
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| #[[Hodgkin lymphoma]]
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| #Primary mediastinal (thymic) [[B-cell lymphoma]]
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| #[[Adenocarcinoma]]
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| #[[Angiosarcoma]]
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| #[[Sarcomas]]
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| #[[Non-Hodgkin lymphoma]]
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| #[[Liposarcoma]]
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| #[[Pheochromocytoma]]
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| #[[Lymphoma]]
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| #Malignant pericardial [[teratoma]]
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| #[[Rhabdomyosarcoma]] with [[tuberous sclerosis]]
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| #[[Pheochromocytoma]]
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| #[[Neuroblastoma]]
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| #Ganglioneuroblastoma
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| #Leiomyosarcomas
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| #Liposarcomas
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| #High-grade sarcomas
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| #[[Burkitt lymphoma]]
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| #[[Kaposi sarcoma]] and primary cardiac lymphoma in association with [[human immunodeficiency virus]] ([[HIV]]) infection
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| #Intrapericardial teratoma in the fetus and neonate
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| ==Diagnosis== | | ==Diagnosis== |
| ===History and symptoms===
| | [[Pericarditis in malignancy history and symptoms|History and symptoms]] | [[Pericarditis in malignancy physical examination|Physical examination]] | [[Pericarditis in malignancy electrocardiogram|Electrocardiogram]] | [[Pericarditis in malignancy chest x ray|Chest X-ray]] | [[Pericarditis in malignancy echocardiography or ultrasound|Echocardiography]] | [[Pericarditis MRI|MIR]] | [[Pericarditis CT|CT]] | [[Pericarditis in malignancy cardiac catheterization|Cardiac Catheterization]] | [[Pericarditis laboratory studies|Lab Studies]] |
| In addition to malignancy specific presentation, patients may present with the following symptoms due to pericardial involvement:
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| *[[Fever]]
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| *[[Chest pain]] that improves on leaning forward and worsens on inspiration
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| *[[Breathlessness]]
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| *[[Orthopnoea]]
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| *[[Dizziness]]
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| *[[Palpitation]]
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| *[[Malaise]]
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| *[[Ankle edema]]
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| *[[Weight loss]]
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| Many patients may be asymptomatic and pericardial involvement may be detected incidentally on chest x-ray or on [[autopsy]].
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| ===Physical examination===
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| [[Cachexia]], weight loss and other organ-system specific abnormalities secondary to malignancy.
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| '''Vitals:''' [[Tachycardia]], [[pulsus paradoxus]] and [[hypotension]](in [[cardiac tamponade]])
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| '''Neck:''' [[Jugular venous distension]] with a prominent Y descent and [[Kussmaul's sign]]
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| '''Chest:''' Pericardial knock, [[pericardial rub]] and distant [[heart sounds]]
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| '''Abdomen:''' [[Hepatomegaly]], [[ascites]]
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| '''Extremities:''' [[Ankle edema]]
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| ===Electrocardiography===
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| *Characteristic ST elevations with PR depression may be noted in all leads in presence of [[pericarditis]].
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| *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.
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| *Constrictive pericarditis may present with ECG changes consistent with [[atrial fibrillation]].
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| [[Image:Alternans.jpg|500px|left|thumb|Electrical alternans in cardiac tamponade]]
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| <br clear="left"/>
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| ===Chest X-ray===
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| Enlarged cardiac silhouette may be noted in pericardial effusion. Pericardial calcifications may be noted in constrictive pericarditis
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| [[Image:Pericardial calcification.jpg|400px|left|thumb|Pericardial calcification]] | |
| <br clear="left"/>
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| ===Echocardiography===
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| Echocardiography facilitates in visualizing the fluid accumulation within the pericardial cavity. Pericardial or myocardial tumors if present can also be noted.
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| Echocardiogram demonstrating '''Pericardial effusion''' and '''Myocardial tumor'''
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| <youtube v=sGTttwrx2xw/>
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| ===MRI and CT===
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| 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.
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| ===Pericardiocentesis===
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| 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>.
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| ===Pericardial biopsy===
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| 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%.
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| ===Cardiac catheterization===
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| *'''[[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.
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| *'''[[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.
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| *'''[[Effusive constrictive pericarditis]]:''' Cardiac tamponade findings are noted initially. Findings of constrictive pericarditis are unmasked following [[pericardiocentesis]].
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| ==Treatment==
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| 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.
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| Asymptomatic or minimally symptomatic patients should be treated conservatively with avoidance of volume depletion, antineoplastic therapy and regular followup.
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| Symptomatic patients should undergo prompt drainage of effusion which could be done either by [[pericardiocentesis]] or surgical creation of [[pericardial window]].
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| 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:
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| #'''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.
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| #'''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.
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| #'''[[Pericardiotomy]]:''' Surgical creation of pericardial window which drains fluid into [[pleural cavity|pleural]] or [[peritoneal cavity]] as fluid accumulates in pericardial sac.In presence of hemodynamic instability, pericardial fluid must be removed first by pericardiocentesis and then proceed with with surgery. To a large extent this avoids further instability or cardiovascular collapse during induction of general anesthesia<ref name="pmid9337306">{{cite journal| author=DeCamp MM, Mentzer SJ, Swanson SJ, Sugarbaker DJ| title=Malignant effusive disease of the pleura and pericardium. | journal=Chest | year= 1997 | volume= 112 | issue= 4 Suppl | pages= 291S-295S | pmid=9337306 | doi= | pmc= | url= }} </ref>.
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| 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>.
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| '''Intrapericardial chemotherapy''' is another approach in treatment of recurrent effusion. [[Cisplatin]] has shown to reduce the incidence of recurrence by up to 93% at 3months and 83% at 6 months followup<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="pmid12323163">{{cite journal| author=Maisch B, Ristić AD, Pankuweit S, Neubauer A, Moll R| title=Neoplastic pericardial effusion. Efficacy and safety of intrapericardial treatment with cisplatin. | journal=Eur Heart J | year= 2002 | volume= 23 | issue= 20 | pages= 1625-31 | pmid=12323163 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12323163 }} </ref>.
| | ==[[Pericarditis in malignancy treatment|Treatment]]== |
| | [[Pericardiocentesis]] | [[Pericardial window]] |
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| ==References== | | ==References== |