Neoplastic pericardial effusion

Incidence of secondary pericardial effusions associated with different etiologies: a comprehensive review of literature

Pericardial effusion is a relatively common complication associated with inflammatory and non-inflammatory diseases. The primary etiology of this condition could be considered when choosing therapeutic options and factors such as effusion size and its hemodynamic consequence. In most cases, small to moderate pericardial effusions can be managed with observation and anti-inflammatory medications unless the effusion develops rapidly. However, in a small proportion of patients, large effusions lead to impaired cardiac filling with hemodynamic compromise and cardiovascular collapse due to cardiac tamponade. The rate at which fluid accumulates is the primary determinant of hemodynamic impact and thus guides the choice of treatment, irrespective of the effusion's size. Severe cases are typically treated with pericardiocentesis with echocardiographic guidance. More aggressive treatments may be necessary for cases due to purulent or malignant etiologies. These cases may require a pericardial window to allow for long-term drainage of the pericardial fluid. This comprehensive review focuses on the epidemiology of pericardial effusion and discusses pathophysiology, diagnostic approaches, and therapeutic options for different causes of secondary pericardial effusions.

Recommendations of the Brazilian Society of Surgical Oncology for the Treatment of Neoplastic Pericardial Effusion

This document presents guidelines to assist surgeons in the diagnosis and management of this condition, emphasizing a multidisciplinary approach. Recommendations described by a group of physicians members of the Brazilian Society of Oncological Surgery regarding the treatment of neoplastic pericardial effusion, developed to guide oncological surgeons, cardiothoracic surgeons and general surgeons in their clinical practice. Members of the Thoracic Neoplasms Committee carried out a literature review and discussion among expert peers to create a guideline that would help in managing this very serious clinical condition in our oncology practice: Neoplastic pericardial effusion.

Pericardial Disease in Patients with Cancer: Clinical Insights on Diagnosis and Treatment

Pericardial disease is increasingly recognized in cancer patients, including acute pericarditis, pericardial effusion, and constrictive pericarditis, often indicating a poor prognosis. Acute pericarditis arises from direct tumor involvement, cancer therapies, and radiotherapy. Immune checkpoint inhibitor (ICI)-related pericarditis, though rare, entails significant mortality risk. Treatment includes NSAIDs, colchicine, and corticosteroids or anti-IL1 drugs in refractory cases. Pericardial effusion is the most frequent manifestation, primarily caused by lung cancer, followed by breast cancer, lymphoma, leukemia, gastrointestinal tumors, and melanoma. Chemotherapy, immunotherapy, and radiotherapy may also cause fluid accumulation in the pericardial space. Symptomatic relief for pericardial effusion may require pericardiocentesis, prolonged catheter drainage, or a pericardial window. Instillation of intrapericardial cytostatic agents may reduce recurrence. Constrictive pericarditis, though less common, often develops from radiotherapy and requires multimodality imaging for diagnosis, with pericardiectomy as the definitive treatment. Primary pericardial tumors are rare, with metastases being more frequent. Patients with cancer and pericardial disease generally have poor survival, emphasizing the need for early detection. A multidisciplinary approach involving hematologists, oncologists, and cardiologists is crucial to tailoring pericardial disease treatment to a patient's clinical status, thereby improving the quality of life and prognosis.

Malignant Pericardial Effusion: A Systematic Review

Background

Malignant pericardial effusion (Eff) is often asymptomatic and has an unknown prevalence, due to its occult presentation. The condition often is identified postmortem on autopsy, and it is associated with a poor prognosis. Given the late presentation of malignant pericardial Effs, a minimal volume of literature has examined the epidemiology, clinical characteristics, and outcomes of these complex patients. We conducted a systematic review to advance present understanding of this condition.

Methods

A search of 4 databases resulted in 41 case reports meeting criteria. Inclusion criteria were being a patient aged > 18 years who presented with pericardial Eff in the setting of malignancy. Intervention was medical and/or surgical therapy, and the outcome was mortality.

Results

For the 41 patients included, the median age was 54 years, and the majority were male patients (58%). Dyspnea was the leading symptom (90%), and cardiac tamponade was present in 78% of cases. Common cancers included lung, gastrointestinal, and renal neoplasms (59%). Pericardiocentesis occurred in 98% of cases, with a median fluid extraction volume of 1000 mL. Death occurred in 44%, primarily due to disease progression and/or metastasis.

Conclusions

This study presents the largest systematic review on malignancy-induced pericardial Effs to date. Notably, solid tumours, and specifically lung adenocarcinomas, are common culprits. Malignant pericardial Effs are often severe, with a majority of patients presenting with cardiac tamponade. Overall, treatment options are limited, and the associated mortality rate is high.

Malignant Pericardial Effusion Presenting as a Sequela of Lung Adenocarcinoma

Pericardial effusion is a collection of fluid in the pericardial sac that can result in symptoms such as shortness of breath, pleuritic chest pain, and/or hemodynamic instability. Malignant pleural effusions are seen in a few cancer patients and are associated with poor prognosis. Here, we present the case of a 65-year-old female with a large malignant pericardial effusion in the setting of advanced-stage lung adenocarcinoma.

Pericardial effusion in oncological patients: current knowledge and principles of management

BACKGROUND

This article provides an up-to-date overview of pericardial effusion in oncological practice and a guidance on its management. Furthermore, it addresses the question of when malignancy should be suspected in case of newly diagnosed pericardial effusion.

MAIN BODY

Cancer-related pericardial effusion is commonly the result of localization of lung and breast cancer, melanoma, or lymphoma to the pericardium via direct invasion, lymphatic dissemination, or hematogenous spread. Several cancer therapies may also cause pericardial effusion, most often during or shortly after administration. Pericardial effusion following radiation therapy may instead develop after years. Other diseases, such as infections, and, rarely, primary tumors of the pericardium complete the spectrum of the possible etiologies of pericardial effusion in oncological patients. The diagnosis of cancer-related pericardial effusion is usually incidental, but cancer accounts for approximately one third of all cardiac tamponades. Drainage, which is mainly attained by pericardiocentesis, is needed when cancer or cancer treatment-related pericardial effusion leads to hemodynamic impairment. Placement of a pericardial catheter for 2-5 days is advised after pericardial fluid removal. In contrast, even a large pericardial effusion should be conservatively managed when the patient is stable, although the best frequency and timing of monitoring by echocardiography in this context are yet to be established. Pericardial effusion secondary to immune checkpoint inhibitors typically responds to corticosteroid therapy. Pericardiocentesis may also be considered to confirm the presence of neoplastic cells in the pericardial fluid, but the yield of cytological examination is low. In case of newly found pericardial effusion in individuals without active cancer and/or recent cancer treatment, a history of malignancy, unremitting or recurrent course, large effusion or presentation with cardiac tamponade, incomplete response to empirical therapy with nonsteroidal anti-inflammatory, and hemorrhagic fluid at pericardiocentesis suggest a neoplastic etiology.

Lung Adenocarcinoma Presenting as Early Cardiac Tamponade: A Case Report

Introduction

Lung cancer remains the most common cause of cancer death in the USA and worldwide despite continued advances in lung cancer screening and treatment. Pericardial effusion (PerF) has been found in up to 50% of postmortem patients with cancer; lung and breast cancers are the most frequent malignancies. Furthermore, it is a sign of poor outcomes with fewer than 5 months of survival. Nevertheless, PErF with or without tamponade as a presentation of lung cancer is uncommon.

Case Presentation

We present a 72-year-old male without medical history who presented with 1 month of cough with white sputum and shortness of breath, progressively worsening, associated with weight loss (20 pounds). Further studies demonstrated early cardiac tamponade secondary to malignancy.

Conclusion

Cardiac tamponade can arise secondarily from various etiologies and have different presentations depending on the cause. In general, it is a slowly developing and clinically silent disease process. Therefore, malignant PerFs can rarely present with hemodynamic instability and be the initial manifestation of an underlying malignancy. Our case review presents a rare case of metastatic lung adenocarcinoma manifesting as early symptomatic cardiac tamponade and as an emergency. The results might be life-threatening if this presentation is not recognized and managed appropriately. Clinicians must be aware of such atypical presentations of thoracic malignancies to take action adequately.

Cardiac Toxicities in Oncology: Elucidating the Dark Box in the Era of Precision Medicine

Despite current advancements in chemotherapy, immunotherapy and targeted treatments, the potential for major adverse cardiovascular events, regardless of previous cardiac history, persists. Scoring systems, such as the Heart Failure Association-International Cardio-Oncology Society (HFA-ICOS) risk assessment tool, can be utilized to evaluate several factors including prior cardiac history, risk factors and cardiac biomarkers to categorize patients into low, moderate, high, and very high-risk groups. Common cardiotoxicity complications include new or worsening left ventricular ejection fraction (LVEF), QT interval prolongation, myocardial ischaemia, hypertension, thromboembolic disease, cardiac device malfunction and valve disease. Baseline electrocardiogram (ECG) and transthoracic echocardiogram (TTE) are routinely performed for all patients commenced on cardiotoxic treatment, while other imaging modalities and biochemical markers have proven useful for monitoring. Management mainly includes early risk stratification and prompt identification of cardiovascular complications, with patient-specific surveillance throughout treatment. A multidisciplinary approach is crucial in determining the relationship between potential treatment benefits and cardiotoxicity, and whether the continuation of treatment is appropriate on a case-by-case basis. Early risk stratification, optimizing the patient's cardiovascular status prior to treatment, and prompt identification of suspected cardiotoxicity are key in significantly reducing risk. This article provides a comprehensive review of the various types of treatment-related cardiotoxicity, offering guidance on identifying high-risk patients, recognizing early signs of cardiotoxicity, and outlining appropriate treatment approaches and follow-up care for such cases.

Impact of multidisciplinary team on the pattern of care for brain metastasis from breast cancer

Purpose

The aim of this study was to explore how a multidisciplinary team (MDT) affects patterns of local or systematic treatment.

Methods

We retrospectively reviewed the data of consecutive patients in the breast cancer with brain metastases (BCBM) database at our institution from January 2011 to April 2021. The patients were divided into an MDT group and a non-MDT group.

Results

A total of 208 patients were analyzed, including 104 each in the MDT and non-MDT groups. After MDT, 56 patients (53.8%) were found to have intracranial "diagnosis upgrade". In the matched population, patients in the MDT group recorded a higher proportion of meningeal metastases (14.4% vs. 4.8%, p = 0.02), symptomatic tumor progression (11.5% vs. 5.8%, p = 0.04), and an increased number of occurrences of brain metastases (BM) progression (p < 0.05). Attending MDT was an independent factor associated with ≥2 courses of intracranial radiotherapy (RT) [odds ratio (OR) 5.4, 95% confidence interval (CI): 2.7-10.9, p < 0.001], novel RT technique use (7.0, 95% CI 3.5-14.0, p < 0.001), and prospective clinical research (OR 5.7, 95% CI 2.4-13.4, p < 0.001).

Conclusion

Patients with complex conditions are often referred for MDT discussions. An MDT may improve the qualities of intracranial RT and systemic therapy, resulting in benefits of overall survival for BC patients after BM. This encourages the idea that treatment recommendations for patients with BMBC should be discussed within an MDT.

Cardiac tamponade

Cardiac tamponade is a medical emergency caused by the progressive accumulation of pericardial fluid (effusion), blood, pus or air in the pericardium, compressing the heart chambers and leading to haemodynamic compromise, circulatory shock, cardiac arrest and death. Pericardial diseases of any aetiology as well as complications of interventional and surgical procedures or chest trauma can cause cardiac tamponade. Tamponade can be precipitated in patients with pericardial effusion by dehydration or exposure to certain medications, particularly vasodilators or intravenous diuretics. Key clinical findings in patients with cardiac tamponade are hypotension, increased jugular venous pressure and distant heart sounds (Beck triad). Dyspnoea can progress to orthopnoea (with no rales on lung auscultation) accompanied by weakness, fatigue, tachycardia and oliguria. In tamponade caused by acute pericarditis, the patient can experience fever and typical chest pain increasing on inspiration and radiating to the trapezius ridge. Generally, cardiac tamponade is a clinical diagnosis that can be confirmed using various imaging modalities, principally echocardiography. Cardiac tamponade is preferably resolved by echocardiography-guided pericardiocentesis. In patients who have recently undergone cardiac surgery and in those with neoplastic infiltration, effusive-constrictive pericarditis, or loculated effusions, fluoroscopic guidance can increase the feasibility and safety of the procedure. Surgical management is indicated in patients with aortic dissection, chest trauma, bleeding or purulent infection that cannot be controlled percutaneously. After pericardiocentesis or pericardiotomy, NSAIDs and colchicine can be considered to prevent recurrence and effusive-constrictive pericarditis.

Extramedullary Acute Myeloid Leukemia Presenting With Pericardial Effusion and Arrhythmias

Acute myeloid leukemia (AML) is a hematologic malignancy that, through clonal transformation, results in abnormal proliferation and accumulation of immature myeloid cells in the bone marrow and blood. It is the most common type of acute leukemia in adults; however, extramedullary relapse is rare, and clinically significant metastasis to the heart with multiple presentations is even more infrequent. We present a case of a patient with AML, who, after successful treatment and remission, was found to have extramedullary metastasis in the form of one pericardial and two intracardiac masses, as well as a large pericardial effusion and conduction abnormalities.

Prevalence, characteristics and mortality of cancer patients undergoing pericardiocentesis in the United States between 2004 and 2017

BACKGROUND

Pericardiocentesis is undertaken in patients with cancer for diagnostic and therapeutic purposes. However, there are limited data on the frequency, characteristics and mortality of patients with different cancers undergoing pericardiocentesis.

METHODS

All hospitalisations of adult cancer patients (≥18 years) in the US National Inpatient Sample between January 2004 and December 2017 were included. The cohort was stratified by discharge code of pericardiocentesis and cancer, using the International Classification of Diseases. The prevalence of pericardiocentesis, patient characteristics, cancer types and in-hospital all-cause mortality were analysed between cancer patients undergoing pericardiocentesis versus not.

RESULTS

A total of 19,773,597 weighted cancer discharges were analysed, out of which 18,847 (0.1%) underwent pericardiocentesis. The most common cancer types amongst the patients receiving pericardiocentesis were lung (51.3%), haematological (15.9%), breast (5.4%), mediastinum/heart (3.2%), gastroesophageal (2.2%) and female genital cancer (1.8%), whilst 'other' cancer types were present in 20.2% patients. Patients undergoing pericardiocentesis had significantly higher mortality (15.6% vs. 4.2%, p < 0.001) compared to their counterparts. The presence of metastatic disease (aOR 2.67 95% CI 1.79-3.97), weight loss (aOR 1.48 95% CI 1.33-1.65) and coagulopathy (aOR 3.22 95% CI 1.63-6.37) were each independently associated with higher mortality in patients who underwent pericardiocentesis.

CONCLUSION

Pericardiocentesis is an infrequent procedure in cancer patients and is most commonly performed in patients with lung, haematological and breast cancer. Cancer patients undergoing pericardiocentesis have increased mortality, irrespective of the underlying cancer type.

The Prognostic Impact of Pericardial Fluid Cytology in Malignant Pericardial Effusion

OBJECTIVE

Malignant pericardial effusion may affect almost 15 of the patients with underlying malignancies which deteriorates the prognosis. The prognostic significance of pericardial fluid cytology is under-represented in previous studies.

METHODS

A total of 73 patients with symptomatic pericardial effusion treated with pericardiocentesis were included in this retrospective analysis. Macroscopic appearance, biochemical features, and cytological findings were obtained. Patients were divided into 3 groups: (i) without malignancy, (ii) with malignancy and negative cytology, and (iii) with malignancy and positive cytology. Survival data were searched via governmental death notification system.

RESULTS

Mean age of the study group was 62 ± 15, and 54% (40) of the patients were female. On the cytological evaluation, 17 patients (23.3%) revealed positive cancer cytology, whereas 56 patients (76.7%) revealed negative cancer cytology. The median follow-up period was 840 days, and 34 patients (46.5%) died during follow-up. The survival rate of Group 3 was found to be significantly worse compared to Groups 1 and 2, no statistical difference was found between Groups 1 and 2 in terms of survival (Group 1 vs. Group 2 P =.078; Group 1 vs. Group 3 P <.001; Group 2 vs. Group 3 P =.041).

CONCLUSION

Cytological evaluation is an important step in patients with malignant pericardial effusion. Positive pericardial fluid cytology indicates a poorer prognosis.

A case series of malignant pericardial effusion

The most common primary malignancies that affect the pericardium are lung cancers. Typically, pericardial involvement stays undiagnosed, with almost 1-20% of all tumor-related autopsies revealing invasion of the pericardium. Pericardial effusions are seldom the first location of metastasis and presentation of a primary malignancy. Malignant pericardial effusions are usually silent, although they cause dyspnea, chest discomfort, arrhythmias, cough, and, in rare cases, pericardial tamponade. In a patient with tamponade, a high index of tumor-related suspicion is crucial to rule out cancer. Emergency pericardiocentesis is indicated based on the clinical presentation, however, the patient frequently has a bad prognosis regardless of whether treatment is administered or not. In this case series, we report five cases of non-small cell lung cancer (NSCLC) with pericardial effusion as an initial presentation.

Diagnosis, treatment, and management of pericardial effusion- review

The hemodynamic stability of the heart and pericardium are maintained by the pericardial fluid of volume ∼10–50 ml. Pericardial effusion is associated with the abnormal accumulation of pericardial fluid in the pericardial cavity. Numerous imaging techniques are utilized to evaluate pericardial effusion including chest X-ray, electrocardiogram, transthoracic echocardiography, computed tomography scan, cardiac magnetic resonance imaging, and pericardiocentesis. Once diagnosed, there are numerous treatment options available for the management of patients with pericardial effusion. These include various invasive and non-invasive strategies such as pericardiocentesis, pericardial window, and sclerosing therapies. In recent times, few studies have been conducted to evaluate the safety and efficacy of each approach in routine clinical practice. In this review, we review the role of different modalities in the diagnosis of pericardial effusion while highlighting existing therapies aimed at the management and treatment of pericardial effusion.

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Numerous imaging techniques are utilized to evaluate pericardial effusion (PE) including chest X-ray, electrocardiogram, transthoracic echocardiography, CT scan, cardiac MRI, and pericardiocentesis.

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Multiple treatment options are available for the management of patients with PE including pericardiocentesis, pericardial window, and sclerosing therapies.

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Recent studies have evaluated the safety and efficacy of various diagnostic and management techniques in routine clinical practice.

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Further research is needed to investigate the optimal diagnostic and treatment options for patients with PE.

Prognostic Value of Pericardial Effusion Size in Patients with Acute Heart Failure

BACKGROUND

Pericardial Effusion (PEf) can occur with Acute Heart Failure (AHF).

OBJECTIVE

To evaluate the effect of PEf size on the prognosis of patients with AHF.

METHODS

According to the maximum size of PEf, all patients were divided into five groups. The primary outcome was in-hospital mortality. The independent effect of PEf size was determined by binary logistic regression analysis. The curve in line with the overall trend was drawn by local weighted regression (Lowess).

RESULTS

We included 192 patients with AHF complicated by PEf. As PEf size increased, in-hospital mortality increased significantly (Group 5 vs. Group 1: 34.8 vs. 8.9% p=0.042). After adjusting for confounders, there was no significant association between PEf groups and in-hospital mortality (Group 5 vs. Group 1: odd ratio (OR), 95% confidence interval (CI): 2.72, 0.41-18.22, p=0.298). However, when PEf size was analysed as a continuous variable, an independent association between increased risk of inhospital mortality and PEf size was observed (OR, 95% CI: 1.08, 1.00-1.16, p=0.037). The Lowess curve showed a positive relationship between PEf size and in-hospital mortality. Furthermore, as PEf groups increased, the length of hospital stay (Group 5 vs. Group 1 median and interquartile range: 16, 14-21 vs. 13, 8-17 days, p<0.001) was significantly prolonged. An association between PEf size with acute kidney injury (AKI) was not observed.

CONCLUSION

The PEf size was independently associated with the increased risk of in-hospital mortality in patients with AHF.

Prognosis and role of clinical and imaging features in patients with malignant pericardial effusion: a single-center study in China

Background

The diagnosis of malignant pericardial effusion (MPE) is often associated with a poor prognosis, but due to the complexity and unspecific nature of MPE patients' clinical manifestations, imaging often performs an essential role in diagnosis and prognosis.

Methods

Patients diagnosed with MPE between 2013 and 2018 at one tumor hospital were included and followed up. The data covered the basic clinical features, imaging findings, treatments and prognosis of patients with MPE, and the factors that may have affected the prognosis were explored.

Results

A total of 216 patients with MPE were included with the median age of 60 years. The most common primary cancer type was lung cancer (73.6%), the most common symptom was dyspnea (62.9%) and the most common abnormal electrocardiogram finding was sinus tachycardia (42.1%). The median survival time of the 216 patients with MPE was 13.7 months. The factors affecting prognosis were echocardiographic fluid signs (HR = 2.37, P = 0.010), electrocardiographic evidence of sinus tachycardia (HR = 1.76, P = 0.006) and echocardiographic evidence of cardiac tamponade (HR = 3.33, P < 0.001).

Conclusions

MPE has complex clinical manifestations and an unsatisfactory prognosis. Echocardiographic fluid signs, electrocardiographic evidence of sinus tachycardia, and echocardiographic evidence of cardiac tamponade are independent risk factors affecting prognosis.

Cardiac inflammation and fibrosis following chemo/radiation therapy: mechanisms and therapeutic agents

The incidence of cardiovascular disorders is one of the most concerns among people who underwent cancer therapy. The heart side effects of cancer therapy may occur during treatment to some years after the end of treatment. Some epidemiological studies confirm that heart diseases are one of the most common reasons for mortality among patients that were received treatment for cancer. Experimental studies and also clinical investigations indicate that inflammatory changes such as pericarditis, myocarditis, and also fibrosis are key mechanisms of cardiac diseases following chemotherapy/radiotherapy. It seems that chronic oxidative stress, massive cell death, and chronic overproduction of pro-inflammatory and pro-fibrosis cytokines are the key mechanisms of cardiovascular diseases following cancer therapy. Furthermore, infiltration of inflammatory cells and upregulation of some enzymes such as NADPH Oxidases are a hallmark of heart diseases after cancer therapy. In the current review, we aim to explain how radiation or chemotherapy can induce inflammatory and fibrosis-related diseases in the heart. We will explain the cellular and molecular mechanisms of cardiac inflammation and fibrosis following chemo/radiation therapy, and then review some adjuvants to reduce the risk of inflammation and fibrosis in the heart.

Thymic cancer: A not-so-indolent cause of pericardial effusion

The incidence of pericardial effusion in the U.S. is roughly 3.4% [1]. While most causes of pericardial effusions are indolent and transient, malignancy is a much more insidious cause that cannot be overlooked. Most cases of documented pericardial effusion secondary to malignancy have been due to mass effect from benign thymic tumors, such as thymomas. Our case highlights a 41-year-old male who presented with a dry cough and epigastric pain, found to have a large pericardial effusion and incidental thymic mass. The mass was biopsied and found to be keratinizing squamous cell carcinoma. This case expands our knowledge base as clinicians that pericardial effusions can be caused by malignant extension of tumors, rather than simply by mass effect of benign tumors.

Fruquintinib beneficial in elderly patient with neoplastic pericardial effusion from rectal cancer: A case report

BACKGROUND

Neoplastic pericardial effusion (NPE) is a rare consequence of rectal cancer and carries a poor prognosis. Optimal management has yet to be determined. Fruquintinib is an oral anti-vascular endothelial growth factor receptor tyrosine kinase inhibitor approved by the China Food and Drug Administration in September 2018 as third-line treatment of metastatic colorectal cancer.

CASE SUMMARY

Herein, we report an elderly patient with NPE from rectal cancer who responded to the use of fruquintinib. In March 2015, a 65-year-old Chinese woman diagnosed with KRAS-mutated adenocarcinoma of the rectum was subjected to proctectomy, adjuvant concurrent chemoradiotherapy, and adjuvant chemotherapy. By October 2018, a mediastinal mass was detected via computed tomography. The growth had invaded parietal pericardium and left hilum, displaying features of rectal adenocarcinoma in a bronchial biopsy. FOLFIRI and FOLFOX chemotherapeutic regimens were administered as first- and second-line treatments. After two cycles of second-line agents, a sizeable pericardial effusion resulting in tamponade was drained by pericardial puncture. Fluid cytology showed cells consistent with rectal adenocarcinoma. Single-agent fruquintinib was initiated on January 3, 2019, as a third-line therapeutic. Ten cycles were delivered before the NPE recurred and other lesions progressed. The recurrence-free interval for NPE was 9.2 mo, attesting to the efficacy of fruquintinib. Ultimately, the patient entered a palliative care unit for best supportive care.

CONCLUSION

Fruquintinib may confer good survival benefit in elderly patients with NPEs due to rectal cancer.

A Case of Stage II Ascending Colon Cancer with Cardiac Tamponade Due to Pericardial Metastasis

Patient: Female, 63-year-old

Final Diagnosis: Cardiac metastasis

Symptoms: Dyspnea

Medication:—

Clinical Procedure: Surgery

Specialty: Oncology

Recurrent pericarditis: an update on diagnosis and management

Recurrent pericarditis is a true challenge for clinicians, especially when the patient becomes unresponsive or not tolerant to conventional treatments. An accurate diagnosis of recurrent pericarditis, possibly supported by advanced imaging tools, is critical to provide timely and appropriate treatment of symptoms and prevention of further episodes. The incessant research on the inflammatory pathways underlying cardiovascular diseases, led recently to the assessment of anti interleukin-1 agents in the setting of recurrent pericarditis. This review will focus on the diagnostic assessment of recurrent pericarditis, along with the most modern therapeutic advances in this field. Bibliographic databases were searched (MEDLINE/PubMed, BioMed Central, the Cochrane Collaboration Database of Randomized Trials, Scopus, ClinicalTrials.gov, EMBASE, Google Scholar) using the terms "recurrent pericarditis" AND "diagnosis" OR "treatment" OR "IL-1" OR "inflammation".

Lung Adenocarcinoma Presenting as Malignant Pericardial Effusion/Tamponade

Lung cancers are the most common primary tumors that involve the pericardium with a prevalence of up to 50%. Usually, pericardial involvement goes undetected with almost 10%-12% found among all cancer related autopsies. Rarely pericardial effusions can be the initial site of metastasis and initial manifestation of a primary tumor. In our case, we report a 57-year-old female presenting with cardiac tamponade and subsequent testing was done which revealed lung adenocarcinoma. Malignant pericardial effusions are often silent, but certain times can present with symptoms of shortness of breath, chest pain, cough, arrhythmias, and rarely as pericardial tamponade. A high index of suspicion is required when a patient presents with tamponade to diagnose malignancy. Emergent pericardiocentesis may be warranted depending on the clinical presentation but quite often, patients tend to have a poor prognosis despite therapy given the extent of disease.

Surgical pericardial drainage procedures have a limited diagnostic sensitivity

Purpose

Cardiothoracic surgeons are frequently called upon to perform surgical pericardial drainage procedures (pericardial window) for pericardial effusions. These procedures have therapeutic value, but the diagnostic value of such procedures is debated. We set out to determine the sensitivity of pericardial drainage to detect the disease when cytology, microbiology, and pathology are evaluated.

Methods

A retrospective chart review of patients who underwent pericardial windows from 1 July 2011 to 1 January 2018 at a single academic institution was conducted. All patients who had undergone a recent trauma or cardiac procedure were excluded. Cytology, microbiology, and pathology were examined. The charts were then carefully reviewed to determine if a clinical diagnosis was reached. Sensitivity was then calculated for all diseases and for those that should have been able to be detected.

Results

One hundred sixty‐two patients who had undergone a pericardial drainage procedure were identified; 49 patients were excluded for recent cardiac procedure or trauma. Of the 113 patients who met our inclusion criteria, 56 patients (49.6%) were female with a mean age of 59.7 ± 15.1 years. A diagnosis based on the pathology, microbiology, or cytology was obtained for 27 patients. The most common pathologies detected were adenocarcinoma (11), bacteremia (9), and small cell lung cancer (3); 56 patients had underlying pathologies that would have been possible to detect with either pathology, microbiology, or cytology. The most common detectable diagnoses were adenocarcinoma (20), bacteremia (12), and lymphoma (7). The most common undetectable diagnoses were idiopathic (17), cardiorenal fluid overload (17), and viral (11). The sensitivity of a pericardial drainage procedure for detecting disease was 0.24 for all cases, and 0.48 when restricted to cases where a detectable disease was present.

Conclusion

Cytology, microbiology, and pathology for pericardial drainage procedures were unable to detect a diagnosis for 76% of all cases and greater than 50% of cases with the theoretically detectable disease. Pericardial drainage procedures have a clear therapeutic value, but they have limited diagnostic utility.

Acute Myeloid Leukemia Presenting as Effusive Constrictive Pericarditis

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AML infrequently causes tamponade and effusive constrictive pericarditis.

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Pericardial cytology has limited sensitivity for malignancy.

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Imaging identifies pericardial effusion and confirms tamponade and constriction.

Platinum sensitive carcinoma of ovary relapsed as pericardial effusion with cardiac tamponade

Epithelial ovarian cancers typically spread by intraperitoneal exfoliation and retroperitoneal lymph nodal involvement along the ovarian vascular supply. Pericardial involvement in ovarian malignancies is very rare with only few cases reported in the literature. Malignancy is the most common cause for pericardial effusion in the western world. In this case report, we present a 58-year-old woman treated for high-grade serous carcinoma of the ovary in 2010, relapsed with pericardial effusion and cardiac tamponade in 2017. Imaging studies revealed gross pericardial effusion. Two-dimensional echocardiogram showed massive pericardial effusion, with cardiac tamponade, New York Heart Association-IV. Pericardiocentesis and pigtail drain was placed under echo guidance. Immunocytochemistry has confirmed the tumour cells to be of the ovarian origin. The patient underwent surgical pericardial window via thoracotomy, followed by paclitaxel and carboplatin-based chemotherapy and olaparib maintenance.

Pericardial effusion in a dog concurrent with carcinoma of unknown primary origin

BACKGROUND

Pericardial effusion (PE) due to secondary metastasis has rarely been reported in dogs.

CASE DESCRIPTION

This case describes clinical signs and further diagnostics regarding metastatic carcinoma of unknown primary origin (CUP) in refractory PE of a dog.

FINDINGS/TREATMENT AND OUTCOME

A nine-year-old, castrated male Shih Tzu dog was referred for evaluation of cough and dyspnea. On presentation, tachypnea, intermittent cough, and muffled heart sounds were noted. Thoracic radiography, electrocardiography, and echocardiography confirmed a PE. No mass lesion was detected at the heart base, aorta, or right atrium (RA). Analysis of the PE showed hemorrhagic cytology, and an idiopathic hemorrhagic PE was tentatively diagnosed. The dog responded to conservative treatment with steroid and diuretics, but the clinical sign recurred. Further evaluation with multi-detector computed tomography (MDCT) was non-diagnostic. The dog died 457 days after initial presentation. Necropsy and histopathology revealed metastatic CUP origin.

CONCLUSION

This case illustrated a rare cause of recurrent PE in dogs.

Swinging heart caused by diffuse large B-cell lymphoma

Pericardial disease is a common complication of solid tumors and occasionally seen in hematologic malignancies. Pericardial effusion, when it occurs, is usually caused by tumor seeding of the pericardium leading to a serous effusion or by mass effect from mediastinal lymphadenopathy blocking drainage of lymphatic ducts. Pericardial disease from non-Hodgkin's lymphoma is uncommon and malignant pericardial effusion is even rarer. Here we present a case of a 31-year-old male with diffuse large B-cell lymphoma who developed cardiac tamponade from a malignant pericardial effusion.

Pericardial Disease Associated with Malignancy

PURPOSE OF REVIEW

Pericardial effusion is commonly associated with malignancy. The goals of treatment should include optimizing symptom relief, minimizing repeat interventions, and restoring as much functional status as possible.

RECENT FINDINGS

Pericardiocentesis should be the first intervention but has high recurrence rates (30-60%). For patients with recurrence, repeat pericardiocentesis is indicated in those with limited expected lifespans. Extended pericardial drainage decreases recurrence to 10-20%. The addition of sclerosing agents decreases recurrence slightly but creates significant pain and can lead to pericardial constriction and therefore has fallen out of favor. Most patients with symptomatic pericardial disease have a short median survival time due to their underlying disease. In patients with a longer life expectancy, surgical drainage offers the lowest recurrence rate. Surgical approach is based on effusion location and clinical condition. Subxiphoid and thoracoscopic approaches lead to similar outcomes. Thoracotomy should be avoided as it increases morbidity without improving outcomes.

Imaging of urgencies and emergencies in the lung cancer patient

Lung cancer patients often experience potentially life-threatening medical urgencies and emergencies, which may be a direct or indirect result of the underlying malignancy. This pictorial review addresses the most common thoracic, neurological and musculoskeletal medical emergencies in lung cancer patients, including superior vena cava syndrome, pulmonary embolism, spontaneous pneumothorax, cardiac tamponade, massive haemoptysis, central airway obstruction, oesophagorespiratory fistula, malignant spinal cord compression, carcinomatous meningitis, cerebral herniation and pathological fracture. Emphasis is placed on imaging findings, the role of different imaging techniques and a brief discussion of epidemiology, pathophysiology and therapeutic options. Since early diagnosis is important for adequate patient management and prognosis, radiologists have a crucial role in recognising and communicating these urgencies and emergencies.

TEACHING POINTS

• Multiplanar multidetector computed tomography is the imaging examination of choice for thoracic urgencies and emergencies. • Magnetic resonance imaging is the imaging modality of choice for investigating central nervous system emergencies. • Urgencies and emergencies can be the initial manifestation of lung cancer. • Radiologists have a crucial role in recognising and in communicating these urgencies/emergencies.

Pericardial effusion and congestive heart failure in a horse with multicentric lymphoma

A 20-year-old Warmblood mare was evaluated for acute-onset tachycardia and a one-week history of lethargy and ventral oedema. Haematology revealed leucocytosis with neutrophilia. Ultrasonographic examination revealed pericardial effusion and cardiac tamponade consistent with right-sided congestive heart failure. Abdominal ultrasonography demonstrated loss of definition of the right kidney and a structure adjacent to the kidney suggestive of a renal neoplasm. A tentative antemortem diagnosis of multicentric neoplasia, most likely lymphoma, was made. The horse was subjected to euthanasia due to a grave prognosis. Postmortem examination and histological evaluation were consistent with lymphoma, including infiltration of the cardiac muscle with neoplastic cells. Although lymphoma has been reported to affect the heart, congestive heart failure due to cardiac and pericardial neoplastic infiltration has not been previously reported as the presenting complaint. This case report describes the diagnostic approach to pericardial effusion and congestive heart failure in a mare with lymphoma.

Genetic contributions to lupus nephritis in a multi-ethnic cohort of systemic lupus erythematous patients

OBJECTIVE

African Americans, East Asians, and Hispanics with systemic lupus erythematous (SLE) are more likely to develop lupus nephritis (LN) than are SLE patients of European descent. The etiology of this difference is not clear, and this study was undertaken to investigate how genetic variants might explain this effect.

METHODS

In this cross-sectional study, 1244 SLE patients from multiethnic case collections were genotyped for 817,810 single-nucleotide polymorphisms (SNPs) across the genome. Continental genetic ancestry was estimated utilizing the program ADMIXTURE. Gene-based testing and pathway analysis was performed within each ethnic group and meta-analyzed across ethnicities. We also performed candidate SNP association tests with SNPs previously established as risk alleles for SLE, LN, and chronic kidney disease (CKD). Association testing and logistic regression models were performed with LN as the outcome, adjusted for continental ancestries, sex, disease duration, and age.

RESULTS

We studied 255 North European, 263 South European, 238 Hispanic, 224 African American and 264 East Asian SLE patients, of whom 606 had LN (48.7%). In genome-wide gene-based and candidate SNP analyses, we found distinct genes, pathways and established risk SNPs associated with LN for each ethnic group. Gene-based analyses showed significant associations between variation in ZNF546 (p = 1.0E-06), TRIM15 (p = 1.0E-06), and TRIMI0 (p = 1.0E-06) and LN among South Europeans, and TTC34 (p = 8.0E-06) was significantly associated with LN among Hispanics. The SNP rs8091180 in NFATC1 was associated with LN (OR 1.43, p = 3.3E-04) in the candidate SNP meta-analysis with the highest OR among African-Americans (OR 2.17, p = 0.0035).

CONCLUSION

Distinct genetic factors are associated with the risk of LN in SLE patients of different ethnicities. CKD risk alleles may play a role in the development of LN in addition to SLE-associated risk variants. These findings may further explain the clinical heterogeneity of LN risk and response to therapy observed between different ethnic groups.

Symptomatic Pericardial Effusion in Hodgkin's Lymphoma: A Rare Occurrence. Case Report and Review of the Literature

Pericardial effusion is observed in approximately 5% of patients with Hodgkin's lymphoma but is rarely symptomatic. We report a case in which a 21-year-old woman with newly diagnosed Hodgkin's lymphoma was found to have symptoms and radiographic evidence of pericardial effusion. Symptomatic pericardial effusion in patients with Hodgkin's lymphoma is extremely rare, with few reports in the literature. The mechanism for the heart and pericardial involvement is reviewed along with a description of the presenting symptoms and differential diagnosis.

Novel echocardiographic prognostic markers for cardiac tamponade in patients with large malignant pericardial effusions: A paradigm shift from flow to tissue imaging

BACKGROUND

With this study, we sought to investigate the prognostic value of echocardiographic tissue imaging markers in predicting tamponade among patients with large malignant pericardial effusion compared to routinely used echocardiographic signs.

METHODS

A total of 96 consecutive patients with large malignant pericardial effusion, not in clinical cardiac tamponade, underwent an echocardiographic examination and were prospectively assessed for 1 month. Clinically evident cardiac tamponade was considered as the study endpoint. The prognostic performance of tricuspid valve annular plane systolic excursion (TAPSE) and peak systolic annular velocity at the lateral margin of the tricuspid valve annulus (S_TV ) was assessed and compared to routinely used imaging signs.

RESULTS

During follow-up, 37 patients (39%) developed clinically evident cardiac tamponade. TAPSE (area under the curve [AUC] 0.958) and S_TV (AUC 0.948) had excellent predictive accuracy for tamponade. Multivariate analysis showed that TAPSE (Hazard ratio [HR] 3.03; 95% CI 1.60-5.73, P=.001) and S_TV (HR 1.17; 95% CI 1.05-1.29, P=.005) remained independent significant predictors of cardiac tamponade. Reclassification analysis and decision curve analysis showed additive prognostic value and adjunct clinical benefit of these markers when added to a recently published triage pericardiocentesis score.

CONCLUSION

Echocardiographic tissue imaging markers such as TAPSE and S_TV are characterized by an excellent prognostic ability for development of cardiac tamponade and better prognostic value compared to routine echocardiographic signs in patients with large malignant pericardial effusion. Incorporating these markers to a recent triage pericardiocentesis score resulted in additional prognostic value and increased clinical benefit.

Cardiovascular Oncologic Emergencies

Oncologic emergencies can present either as a progression of a known cancer or as the initial presentation of a previously undiagnosed cancer. In most of these situations, a very high degree of suspicion is required to allow prompt assessment, diagnosis, and treatment. In this article, we review the presentation and management of cardiovascular oncologic emergencies from primary and metastatic tumors of the heart and complications such as pericardial tamponade, superior vena cava syndrome, and hyperviscosity syndrome. We have included the cardiovascular complications from radiation therapy, chemotherapeutic agents, and biologic agents used in modern cancer treatment.

Prognostic Impact of Minimal Pericardial Effusion in Patients With Advanced Non-small-cell Lung Cancer

INTRODUCTION

Minimal (< 10 mm in thickness) pericardial effusion (PCE) can be incidentally detected by computed tomography at the time of diagnosis in patients with lung cancer. Although malignant PCE is known to be associated with poor prognosis, the impact of minimal PCE on outcome has remained unclear. We therefore examined the prognostic relevance of minimal PCE in patients with advanced non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

We retrospectively analyzed consecutive patients diagnosed with stage IV NSCLC at Kindai University Hospital between April 2009 and March 2015. The patients were classified into 3 groups on the basis of the presence and thickness of PCE: no PCE, minimal (< 10 mm) PCE, and malignant (≥ 10 mm) PCE. The relation between overall survival and PCE status was examined with a Cox proportional hazards model.

RESULTS

The total of 428 enrolled patients included 327 (76.4%) in the no PCE group, 61 (14.3%) in the minimal PCE group, and 40 (9.3%) in the malignant PCE group. Median overall survival was 15.0, 10.1, and 7.6 months in the no PCE, minimal PCE, and malignant PCE groups, respectively, with the survival of patients with minimal PCE thus being intermediate between that of the other 2 groups (P = .003). Multivariable analysis revealed that minimal PCE was independently associated with reduced survival (hazard ratio, 1.46; 95% confidence interval, 1.07-1.96; P = .019).

CONCLUSIONS

The presence of minimal PCE was an independent prognostic factor for reduced survival in patients with advanced NSCLC.

Cytology of Pericardial Effusion due to Malignancy

BACKGROUND

Malignant pericardial effusion occurs in one tenth of all cancers. It is a very serious disorder that is mainly a secondary process due to metastasis because primary neoplasms of the pericardium such as mesotheliomas, sarcomas being exceedingly rare [corrected]. Pericardial effusion specimens are uncommon and to the best of our knowledge the current study is the largest systematic evaluation of pericardial fluid cytology performed to date.

MATERIAL AND METHODS

Pericardial effusion specimens from 145 patients collected over a 25 [corrected] year period were studied by cytology [corrected]. The minimum pericardial fluid volume used for adequate cytologic diagnosis in these patients was more than 60 mL.

RESULTS

Cytological diagnosis revealed malignant pericardial exudates in 100% of the studied patients [corrected].

CONCLUSIONS

Cytology provides an immediate and accurate means of diagnosis. Immunocytology is very important in the diagnostic evaluation.

Echocardiographic approach to cardiac tamponade in critically ill patients

Cardiac tamponade should be considered in a critically ill patient in whom the cause of haemodynamic shock is unclear. When considering tamponade, transthoracic echocardiography plays an essential role and is the initial investigation of choice. Diagnostic sensitivity of transthoracic echocardiography is dependent on image quality, and in some cases a transoesophageal approach may be required to confirm the diagnosis. Knowledge of the pathophysiology and echocardiographic features of cardiac tamponade are essential for the practicing Intensivist. This review presents an approach to the recognition, diagnosis, and treatment of cardiac tamponade in critically ill patients.