Evaluation and management of pericardial effusion in patients with neoplastic disease

The incidence and extent of pericardial involvement in neoplastic disease varies. In a considerable number of patients with breast or lung cancer or with mediastinal lymphoma, in addition to direct involvement by the tumor, radiation therapy as well as systemic tumor treatment can also lead to pericardial effusion. In addition, in immunosuppressed tumor patients, pericardial effusion can also arise from viral, bacterial, and autoimmune causes. To distinguish between these 3 different conditions leading to pericardial effusion, the diagnosis should be based on pericardiocentesis followed by fluid analysis for cytology and biomarkers, on epicardial and pericardial biopsy facilitated by flexible pericardioscopy with analysis of specimens by conventional histology and molecular biology techniques for viral and microbial aetiology. We collected prospectively but analyzed retrospectively 357 patients undergoing pericardiocentesis from 1988 to 2008 and identified 68 patients who had cancer-related pericardial effusion. With these methods, 42 patients demonstrated malignant effusion, 15 patients had radiation-induced pericardial, effusion, and in 11 patients without radiation therapy, the effusion could be attributed to either viral infection in 5 cases or to an autoimmune process in the remaining 6 patients. Consequently, intrapericardial treatment could be tailored for each cohort: neoplastic effusion was treated with intrapericardial cisplatin (single instillation of 30 mg/m(2) per 24 hours); in addition to the tumor-specific systemic chemotherapy, intrapericardial triamcinolone acetate (Volon A) was given in a dose of 500 mg/m(2) in the patients with autoimmune and radiation-induced effusion. Saline rinsing and intrapericardial sclerosing treatment were the treatment of choice in viral pericardial effusion. Oral colchicine treatment (2-3 x 0.5 mg) was given in all patients for at least 3 months. Recurrence of pericardial effusion was prevented for at least 3 months in more than 85% of patients. This differential diagnostic approach and the results of treatment were compared with published series.