Treatment of malignant pericardial effusion

To discuss the diagnosis and treatment of malignant pericardial effusion and focus on quantitating the success and complication rates of the many treatment modalities and updating recent advances in the field.

English-language publications were identified by a computerized search (MEDLINE) of these key words: cancer, tumor, malignancy, pericardium, and pericardial effusion. This computerized search was supplemented by a manual search of the bibliographies of original research articles and textbooks.

Studies were included if the outcome of patients undergoing treatment for malignant pericardial effusion was reported separately from the outcome of patients with other causes of pericardial effusions. Studies that only reported the combined results of patients with malignant and nonmalignant effusions were excluded.

To determine success rates for the various treatment modalities, we examined freedom from symptomatic recurrence of pericardial effusion requiring reintervention as the key end point. Where appropriate, we also examined procedural mortality rates.

Initial relief of symptoms is achieved in most cases with percutaneous pericardiocentesis that, with echocardiographic guidance, can be performed with low morbidity and mortality. In many cases, drainage for several days with an indwelling catheter alleviates the effusion without subsequent recurrence. Systemic antitumor therapy with chemotherapy or radiation therapy is effective in controlling malignant effusions in cases of sensitive tumors such as lymphomas, leukemias, and breast cancer. Local sclerotherapy with tetracycline hydrochloride or bleomycin sulfate is also effective and associated with low morbidity. Sclerotherapy with other agents or radionuclides offers no advantages. Of the several surgical options, subxiphoid pericardiotomy has the advantage of low morbidity and mortality, can often be performed under local anesthesia, and is highly effective in preventing recurrence. Percutaneous balloon pericardiotomy has recently been described. This intervention is performed with local anesthesia, is effective in preventing reaccumulation, and has a low morbidity.

Treatment of malignant pericardial effusions must be individualized with consideration given to the patient's condition and tumor type, the success rates and risks of the various modalities, and local availability and expertise.