Pericarditis in malignancy approach to treatment
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.
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.
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[1][2]. Following approaches are adapted in prevention of reaccumulation:
- Prolonged pericardiocentesis:[1][3] Catheter should not be removed until the drainage is <20-30 ml/24 hours. Intermittent catheterization is recommended to maintain catheter patency.
- Pericardial sclerosis: Obliteration of pericardial cavity using tetracycline, doxycycline[4], minocycline[5], bleomycin[6], or talc.
- Pericardiotomy: Surgical creation of pericardial window which drains fluid into 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[7].
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%[8][9].
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[10][11].
References
- ↑ 1.0 1.1 Tsang TS, Seward JB, Barnes ME, Bailey KR, Sinak LJ, Urban LH; et al. (2000). "Outcomes of primary and secondary treatment of pericardial effusion in patients with malignancy". Mayo Clin Proc. 75 (3): 248–53. PMID 10725950.
- ↑ Laham RJ, Cohen DJ, Kuntz RE, Baim DS, Lorell BH, Simons M (1996). "Pericardial effusion in patients with cancer: outcome with contemporary management strategies". Heart. 75 (1): 67–71. PMC 484225. PMID 8624876.
- ↑ Allen KB, Faber LP, Warren WH, Shaar CJ (1999). "Pericardial effusion: subxiphoid pericardiostomy versus percutaneous catheter drainage". Ann Thorac Surg. 67 (2): 437–40. PMID 10197666.
- ↑ Liu G, Crump M, Goss PE, Dancey J, Shepherd FA (1996). "Prospective comparison of the sclerosing agents doxycycline and bleomycin for the primary management of malignant pericardial effusion and cardiac tamponade". J Clin Oncol. 14 (12): 3141–7. PMID 8955660.
- ↑ Davis S, Rambotti P, Grignani F (1984). "Intrapericardial tetracycline sclerosis in the treatment of malignant pericardial effusion: an analysis of thirty-three cases". J Clin Oncol. 2 (6): 631–6. PMID 6726303.
- ↑ Kunitoh H, Tamura T, Shibata T, Imai M, Nishiwaki Y, Nishio M; et al. (2009). "A randomised trial of intrapericardial bleomycin for malignant pericardial effusion with lung cancer (JCOG9811)". Br J Cancer. 100 (3): 464–9. doi:10.1038/sj.bjc.6604866. PMC 2658533. PMID 19156149.
- ↑ DeCamp MM, Mentzer SJ, Swanson SJ, Sugarbaker DJ (1997). "Malignant effusive disease of the pleura and pericardium". Chest. 112 (4 Suppl): 291S–295S. PMID 9337306.
- ↑ Ling LH, Oh JK, Schaff HV, Danielson GK, Mahoney DW, Seward JB; et al. (1999). "Constrictive pericarditis in the modern era: evolving clinical spectrum and impact on outcome after pericardiectomy". Circulation. 100 (13): 1380–6. PMID 10500037.
- ↑ DeValeria PA, Baumgartner WA, Casale AS, Greene PS, Cameron DE, Gardner TJ; et al. (1991). "Current indications, risks, and outcome after pericardiectomy". Ann Thorac Surg. 52 (2): 219–24. PMID 1863142.
- ↑ Maisch B, Ristic A, Pankuweit S (2010). "Evaluation and management of pericardial effusion in patients with neoplastic disease". Prog Cardiovasc Dis. 53 (2): 157–63. doi:10.1016/j.pcad.2010.06.003. PMID 20728703.
- ↑ Maisch B, Ristic AD, Pankuweit S, Neubauer A, Moll R (2002). "Neoplastic pericardial effusion. Efficacy and safety of intrapericardial treatment with cisplatin". Eur Heart J. 23 (20): 1625–31. PMID 12323163.