Malignant Pericardial Disease Research Articles

Incidence of immune checkpoint inhibitor induced myocarditis in patients with mesothelioma from a regional tertiary cancer centre covering a patient population of 2.6 million.

e20541 Background: As a large regional tertiary cancer centre with an established cardio-oncology service a high incidence immune checkpoint inhibitor (ICI) induced myocarditis was recognised in mesothelioma patients receiving combination ICIs (cICI). A retrospective analysis of myocarditis in patients with mesothelioma was conducted. The utility of baseline cardiac markers as a prospective stratification tool for the development of ICI induced myocarditis in this patient group was investigated. Methods: A retrospective analysis of 118 patients with mesothelioma treated with ICIs over a 5 year period at the Clatterbridge Cancer Centre, Liverpool, UK. Baseline characteristics, treatment regimen, co-morbidities and the presence of malignant pericardial or cardiac disease were recorded. Baseline cardiac markers (high sensitivity Troponin T (hsTT) and pro-BNP) were recorded for patients initiating ICI treatment from July 2022 when regional baseline testing was introduced. A diagnosis of myocarditis was confirmed by cardiac MRI (n = 6) or clinically by the cardio-oncology team when MRI was clinically unfeasible (n = 1). Statistical analysis was undertaken with Fishers Exact test. Results: 33 patients received cICI treatment with Ipilimumab and Nivolumab, 85 patients received monotherapy ICIs (mICI), 5 as a SACT combination. Myocarditis occurred in 12.1% (n = 4) of patients receiving cICIs vs 3.5% (n = 3) of patients receiving mICIs. The median onset was 57 days with cICI and 245 days with mICI treatment. Baseline (b/l) cardiac assessment was undertaken in 22 patients (66.7%) of those treated with cICIs and 8 patients (9.4%) treated with mICI therapy. An abnormal b/l pro-BNP ( > 500 ng/L) was identified in 5 cICI patients and 1 mICI patient. Those with elevated b/l pro-BNP in the cICI setting all had a significant cardiac association; either an increased incidence of myocarditis (n = 3/5) (p = 0.0065) or pericardial/ invasive cardiac disease (n = 2/5) (p = 0.0433). In the cICI population myocarditis was not seen in patients with a b/l pro-BNP < 500ng/L. Of the 8 mICI patients with b/l cardiac assessment, 1 patient had an elevated pro-BNP which was associated with pericardial extension. Regarding baseline hsTT in the cICI group, the incidence of myocarditis was not increased with mild b/l elevations (14-24 ng/L), however, a moderately elevated level ( > 24ng/L) was associated with an increased incidence of myocarditis (p = 0.0026). Conclusions: In this cohort of patients with mesothelioma there was a high incidence of cICI induced myocarditis. As patients treated with cICIs with abnormal b/l cardiac markers had an increased risk of developing ICI induced myocarditis, b/l cardiac markers could potentially be used to help stratify the risk of ICI induced myocarditis and inform treatment discussions. Further studies are now required.

Pleural and Pericardial Plaques in Asbestos Exposure

Asbestos is a generic term for a group of naturally occurring fibers composed of hydrated magnesium silicate minerals. Transported worldwide to shipyards and factories, it is a material that was widely used in construction, mining, and manufacturing. Exposure to asbestos can cause significant benign and malignant lung, pleural, and pericardial disease. Usually asymptomatic, pleural plaques are the most common radiologic manifestation of asbestos exposure. We report a case of a man who presented with heart failure exacerbation and was incidentally found to have pleural and pericardial plaques from asbestos exposure.

LUNG CANCER WITH CARDIAC COMPLICATIONS

Malignant pericardial disease in the setting of lung cancer portends a grave prognosis. We present a case of malignant pericardial tamponade and subsequent complications. A 61-year-old man presented with acute pericardial tamponade after having undergone a video-assisted left upper lobe

Persistent PR segment change in malignant pericardial disease.

BackgroundElectrocardiographic changes may manifest in patients with pericardial effusions. PR segment changes are frequently overlooked, but when present, can provide diagnostic significance. The diagnostic value of PR segment changes in determining benign versus malignant pericardial disease in cancer patients with pericardial effusions has not been investigated. We aimed to determine the relationship between PR segment changes and malignant pericardial disease in cancer patients presenting with pericardial effusions.MethodsConsecutive patients with active malignancy who underwent surgical subxiphoid pericardial window by a single thoracic surgeon between 2011 and 2014 were included in this study. A total of 104 pre- and post-operative ECGs were reviewed, and PR depression or elevation was defined by deviation of at least 0.5 millivolts from the TP segment using a magnifying glass. Pericardial fluid cytology, flow cytometry and tissue biopsy were evaluated. Baseline characteristics and co-morbidities were compared between cancer patients with benign and malignant pericardial effusions.ResultsA total of 26 patients with active malignancy and pericardial effusion who underwent pericardial window over the study period were included. Eighteen (69 %) patients had isoelectric PR segments, of whom none (0 %) had evidence of malignant pericardial disease (100 % negative predictive value). Eight (31 %) patients had significant ECG findings (PR segment depression in leads II, III and/or aVF as well as PR elevation in aVR/V1), all 8 (100 %) of whom had pathologically confirmed malignant pericardial disease (100 % positive predictive value). PR segment changes in all 8 patients persisted (up to 11 months) on post-operative serial ECGs. The PR segment changes had no relationship to heart rate or the time of atrial-ventricular conduction.ConclusionsIn patients with active cancer presenting with pericardial effusion, the presence of PR segment changes is highly predictive of active malignant pericardial disease. When present, PR changes typically persist on serial ECGs even after pericardial window.

Tuberculous Pericarditis: A Complex Puzzle to Put Together

Tuberculous Pericarditis: A Complex Puzzle to Put Together

Staging of lung cancer CT and PET

Lung cancer is the leading cause of cancer related deaths in the United States with a 5 year survival of only 15%. [1] The International Association for the Study of Lung Cancer (IASLC) issued a 7th edition of the TNM staging system for lung cancer in 2007. [2] It includes several revisions which better align TNM staging with prognosis and in some cases with treatment. There have been revisions in the TNM descriptors. In the T or tumor category, the T1 and T2 categories include now subcategorization of size with new T1a, T1b, T2a and T2b subdescriptors. One of the important changes is that tumors larger than 7 cm are now considered Stage T3 tumors. Stage IV tumors include separate tumor nodules in the same lung but not in the same lobe as the primary lesion which were previously considered metastatic (M1). Stage T4 disease is now downgraded to Stage III when satellite nodules are present in the same lobe as the primary lesion. The presence of malignant pleural effusion, pleural dissemination or pericardial disease is now considered metastatic disease, specifically stage M1a for local intrathoracic disease rather than Stage IV disease [3-5]. Although the IASLC has proposed a new lymph node map there are no changes to the end descriptors in the 7th edition of the TNM staging system [3-5]. Nearly one half of newly diagnosed lung cancers already demonstrate metastases within the lung, brain, liver, and bony structures. Any metastatic disease is automatically designated Stage IV disease and with few exceptions is considered surgically unresectable. The M category is now subcategorized into intra-thoracic metastasis M1a and extra-thoracic metastatic M1b with the former having a better prognosis [4]. Contrast enhanced CT remains the mainstay for staging of lung cancer. However, PET has particular value in nodal staging of lung cancer and also in determining the presence of distant metastatic disease. In a study by Gould et al, the sensitivity of PET CT for metastasis was 85% and the specificity was 95% as compared with a CT sensitivity of 61% and specificity of 79% [6]. PET CT does have a high false positive rate so it cannot replace invasive sampling, but it may be used to direct invasive staging. PET scanning is particularly useful in M staging of non-small cell lung cancer. PET can replace the use of bone scintigraphy and it is now widely used for determination of distant metastasis throughout the body. However, it is limited in the assessment of brain metastases. In the PLUS Trial, 188 patients with potentially resectable non-small cell lung cancer were randomized to either conventional work up or PET CT. Addition of the PET CT to the conventional work up prevented future surgery in 1 out of 5 patients [7].

Lung Cancer Staging Essentials: The New TNM Staging System and Potential Imaging Pitfalls

Lung cancer is the leading cause of cancer-related deaths worldwide, with a dismal 5-year survival rate of 15%. The TNM (tumor-node-metastasis) classification system for lung cancer is a vital guide for determining treatment and prognosis. Despite the importance of accuracy in lung cancer staging, however, correct staging remains a challenging task for many radiologists. The new 7th edition of the TNM classification system features a number of revisions, including subdivision of tumor categories on the basis of size, differentiation between local intrathoracic and distant metastatic disease, recategorization of malignant pleural or pericardial disease from stage III to stage IV, reclassification of separate tumor nodules in the same lung and lobe as the primary tumor from T4 to T3, and reclassification of separate tumor nodules in the same lung but not the same lobe as the primary tumor from M1 to T4. Radiologists must understand the details set forth in the TNM classification system and be familiar with the changes in the 7th edition, which attempts to better correlate disease with prognostic value and treatment strategy. By recognizing the relevant radiologic appearances of lung cancer, understanding the appropriateness of staging disease with the TNM classification system, and being familiar with potential imaging pitfalls, radiologists can make a significant contribution to treatment and outcome in patients with lung cancer.

Reversible Tricuspid Valve Stenosis Due to a Metastatic Dissemination of a Noncardiac Sarcoma

Malignant disease is present in the pericardium of 1.5% to 20.6% of patients dying of malignant diseases as was examined postmortem. We present a case of a 57-year-old man with a history of Hodgkin's disease and a sarcoma of gluteus who presented with tachypnea, generalized weakness, and anasarca for 7 days. The echocardiogram revealed the presence of a significant pericardial thickening and localized pericardial effusion resulting from a tricuspid stenosis. A right anterior thoracotomy was performed, and a pericardiectomy (4 x 4 cm) was done. The histologic examination of the pericardium revealed the presence of a metastatic dissemination from a sarcoma. The cause for the clinical presentation and the treatment of malignant pericardial disease are discussed.

Malignant pericardial effusion treated with IFN alpha 2b

2595 Background: patients with malignant pericardial disease may be asymptomatic or may present with a number of manifestations, pericardial effusion is the more common, pericardial tamponade account for at least 50% of all reported cases that require intervention, overall median survival of patients with MPCE is less than 6 months. Interferon has demonstrated activity in patients with pleural effusion and could be well tolerated in MPCE Objective: to treat patients with MPCE with IFN alpha 2b after pericardiocentesis recurrence. Methods: we administered interferon alpha 2b 10 millions into pericardial cavity, for patients with recurrent MPCE, considering as complete response when the MPCE disappear at least for a month, partial response in the case of disappearing in less than a month, and non response when it did not disappear, the response was evaluated by clinical and radiological findings (CT scan). Results: we treated 56 patients with MPCE since January 1996 to January 2004, 40 women and 16 men, mean age 45 years (range 17–73 y) breast cancer was the most common cause (39 pt); lung cancer (10); cervical cancer (2); LNH (3); primary mediastinal tumors (2). In 20 patients was necessary the administration of INF: 14 with breast cancer, two with lung cancer; three with primary mediastinal tumor; and one with cervical cancer. Four patients received two doses of interferon and in one patient three. We got 13/20 (65%) CR; 2/20 (10%) PR; 5/20 (25%) NR. Toxicity: we did not have any toxicity grade 3 or 4. Conclusions: the administration of IFN alpha 2b should be followed explored as an option for patients with recurrent MPCE. l No significant financial relationships to disclose.

Pericardial disease in the oncology patient.

Malignant pericardial disease is a serious and common problem seen in patients with cancer. It is usually due to metastatic spread of the underlying malignancy or a complication of radiation therapy. The patient may have a mild, subtle presentation, as is often seen in the early stages of pericardial effusion, or may experience dramatic hemodynamic compromise, as is seen with cardiac tamponade and constrictive pericarditis. There are many treatment options available that range from simple drainage to thoracic surgery. It is essential that the treating physician choose a treatment plan in the context of the cancer stage and the patient's prognosis. This article discusses the incidence, pathophysiology, clinical presentation, diagnosis, and treatment options in the various types of malignant pericardial disease.

The Acute Effect of Minocycline on the Pericardium: Experimental and Clinical Findings

To evaluate the acute effect of minocycline on the pericardium in the experimental animal and in the human with malignant pericardial disease. A prospective study in open-chest dogs and in humans. Experimental surgery laboratory, medical school; coronary care unit, university hospital. Twenty-three open-chest dogs were divided into four groups according to the solution injected intrapericardially: (1) minocycline, 5 mg/kg; (2) minocycline, 10 mg/kg; (3) normal saline solution, 100 mL, followed by minocycline, 10 mg/kg; (4) a mixture of 50 mL of the dog's own blood mixed ex vivo with minocycline, 10 mg/kg to evaluate the effect of rising pH of minocycline solution. The extent of myocardial injury is evaluated by measuring ST-T segment deviation in six standard bipolar leads and in three unipolar electrograms recorded over the left ventricular pericardial surface. The pH of the various minocycline solutions is measured. Nine consecutive patients with malignant cardiac tamponade receiving minocycline intrapericardially are evaluated for the appearance of chest pain and ECG changes. Minocycline (5 and 10 mg/kg) caused marked, transient ST-T segment deviation in all dogs, whether or not saline solution was previously injected into the pericardial sac. Prior mixing of minocycline with blood markedly increased the acidic pH of the minocycline solution and significantly reduced the extent of ST-T segment deviation. Four of nine patients had chest pain during minocycline injection. None had ST-T segment changes. Minocycline causes a marked, transient injury to the epicardial-pericardial surface. Our animal and in vitro studies indicate that this acute injury is probably partly related to the acidic pH of the minocycline solution. Our experimental findings suggest that this minocycline-induced injury may be reduced by raising the pH of the solution either ex vivo (eg, by mixing minocycline with previously withdrawn pericardial fluid) or in vivo (eg, by leaving 200 to 300 mL of pericardial fluid prior to minocycline injection). Limited experience in the human with malignant cardiac tamponade indicates that intrapericardial minocycline is usually well tolerated, although severe chest pain may appear.

Ultrasound-guided pigtail catheter drainage of malignant pericardial effusions

Anterior pericardiocentesis was performed under ultrasound guidance using indwelling pigtail catheters in nine patients with malignant pericardial effusions and cardiac tamponade. Symptoms were alleviated in all cases and there were no deaths attributable to the procedure. Catheters remained in place for a median of 24 h (range 8-168 h). Complications were minor: asymptomatic left-sided or bilateral pleural effusions (n = 3), atrial fibrillation (n = 2), transient pericardial pain (n = 1) and erratic drainage (n = 1). Recurrence of the pericardial effusion was limited to a single case and occurred after 5 months of effective palliation. The procedure was successfully repeated with no further recurrence. One patient who went on to surgical fenestration 11 days after pericardiocentesis died 24 h post-operatively. The remaining patients died of the underlying malignant disease without further cardiac complication. Survival following the procedure ranged from 3 to 8 months. Ultrasound-guided pigtail catheter drainage is a minimally invasive, safe and effective method for the palliation of cardiac tamponade in patients with malignant pericardial disease.

Percutaneous balloon pericardiotomy for the treatment of cardiac tamponade and large pericardial effusions: Description of technique and report of the first 50 cases

Objectives. This study describes the technique, clinical characteristics and results of the first 50 patients undergoing percutaneous balloon pericardiotomy as part of a multicenter registry.Background. Percutaneous balloon pericardiotomy involves the use of a percutaneous balloon dilating catheter to create a nonsurgical pericardial window.Methods. Patients eligible for percutaneous balloon pericardiotomy had either cardiac tamponade (n = 36) or a moderate to large pericardial effusion (n = 14). In addition to clinical follow-up, serial echocardiograms and chest X-ray films were obtained.Results. The procedure was considered successful in 46 patients after a mean follow-up period of 3.6 ± 3.3 months. Two patients required an early operation, one for bleeding from a pericardial vessel and one for persistent pericardial catheter drainage. Two patients required a late operation for recurrent tampomde. Minor complications of the procedure included fever in 6 of the first 37 patients (studied before the prophylactic use of antibiotic agents), thoracentesis or chest tube placement in 8 and a small spontaneously resolving pneumothorax in 2. Despite the short-term success of this procedure the long-term progcosis of the 44 patients with malignant pericardial disease remained poor (mean survival time 3.3 ± 3.1 months).Conclusions. Percutaneous balloon pericardiotomy is successful in helping to manage large pericardial effusions, particularly in patients with a malignant condition. It may become the preferred treatment to avoid a more invasive procedure for patients with pericardial effusion and a limited life expectancy.

Pericardial Drainage vs Pericardial `Window'

To the Editor. — The article on nonspecificity of antinuclear antibody (ANA) in pericardial fluid by Leventhal et al1was very helpful for those of us who sometimes puzzle over this test. Although the authors make their main point quite nicely, their case was even more informative than they may have realized. Among many interesting aspects was the conversion in a very short time from a tamponading pericardial effusion to dry constrictive pericarditis, not discussed by the authors. I have seen the same phenomenon in malignant pericardial disease within approximately the same period, ie, 4 weeks. Their patient's S3gallop was typical for constriction, and the pathologic specimen leaves little doubt. Although jugular venous distention was noted, no mention was made of Kussmaul's sign that might well have been present (although necessarily absent in the preceding tamponade). The pulsus paradoxus of 8 mm Hg is not really within

Pulsus Paradoxus, Cardiac Tamponade, and the Pericardial 'Window'

<i>To the Editor</i>.—Leventhal and colleagues' report1 concerning nonspecificity of antinuclear antibody in pericardial fluid was very helpful for those of us who sometimes puzzle over this test. Although the authors make their main point quite nicely, their case was even more informative than they may have realized. Among many interesting aspects was the conversion in a very short time from a tamponading pericardial effusion to "dry" constrictive pericarditis, not discussed by the authors. I have seen the same phenomenon in malignant pericardial disease within approximately the same period—4 weeks. Their patient's S₃gallop was typical for constriction, and the pathologic specimen leaves little doubt. Although jugular venous distention was noted, no mention was made of Kussmaul's sign, which might well have been present (although necessarily absent in the preceding tamponade). The "pulsus paradoxus" of 8 mm Hg is not really within the definition of the term<i>pulsus paradoxus</i>

Pulsus paradoxus, cardiac tamponade, and the pericardial 'window'

To the Editor.—Leventhal and colleagues' report1 concerning nonspecificity of antinuclear antibody in pericardial fluid was very helpful for those of us who sometimes puzzle over this test. Although the authors make their main point quite nicely, their case was even more informative than they may have realized. Among many interesting aspects was the conversion in a very short time from a tamponading pericardial effusion to "dry" constrictive pericarditis, not discussed by the authors. I have seen the same phenomenon in malignant pericardial disease within approximately the same period—4 weeks. Their patient's S3gallop was typical for constriction, and the pathologic specimen leaves little doubt. Although jugular venous distention was noted, no mention was made of Kussmaul's sign, which might well have been present (although necessarily absent in the preceding tamponade). The "pulsus paradoxus" of 8 mm Hg is not really within the definition of the termpulsus paradoxus

Malignant Pericardial Diseases: Diagnosis and Treatment

Malignant pericardial disease is a common neoplastic entity that is often difficult to diagnose and even more difficult to treat successfully. The pathophysiology of malignant percardial disease is reviewed in this article and the various treatment options discussed.

Pericardial effusion in women with breast cancer.

Ninety patients with a history of breast cancer and pericardial effusion detected on echocardiography were identified and divided on a clinical basis into three groups. Group 1 consisted of 20 patients who had progressive metastatic breast cancer and echocardiography performed on a routine basis as a part of a clinical trial involving 38 patients. All 20 had small unexpected effusions, and only one patient developed symptomatic malignant pericardial disease late in her clinical course. Group 2 consisted of 32 patients who were without evidence of metastatic disease at the time of positive echocardiography and the etiology was considered benign in all patients. Six patients required pericardiectomy, five for severe radiation induced pericarditis and one for amyloid. No patient developed proven or suspected malignant pericardial disease. Group 3 comprised 38 patients who had known metastatic disease outside the pericardium at the time of positive echocardiography. Nineteen patients in Group 3 had histologically proven malignant involvement during life or at autopsy, and five more had suspected malignant pericardial disease. Ten patients initially were treated with pericardiectomy and 28 patients were managed with systemic therapy alone (24 patients) or with pericardiocentesis (four patients). Among the 12 patients with malignant effusion treated without surgery, proven local progression of pericardial disease occurred in six, with sudden death in two of those patients. No patient treated initially with surgery suffered progression of her pericardial disease. It was concluded that: small, clinically unsuspected pericardial effusions appear to be relatively common in women with metastatic breast cancer; no patient with clinical pericardial disease confirmed on echocardiography and no evidence of metastatic breast cancer developed malignant pericardial involvement; 50% of patients with known metastatic disease and a clinically apparent pericardial effusion had malignant pericardial disease; and nonsurgical therapy in patients with histologically proven or clinically suspected malignant pericardial effusion was associated with a high incidence of progressive pericardial disease.

Malignant pericardial diseases: Diagnosis and treatment

Pericardial involvement in malignant diseases is fairly common. Usually the various clinical presentations—effusion, tamponade, constriction—occur in patients with known malignancy. Primary malignancy of the pericardium is rare, whereas secondary tumor involvement of the pericardium is more frequently observed. The common secondary solid tumors involving the pericardium are from lung and breast carcinomas; of the nonhematologic malignancies, lymphomas and leukemias are most frequent. A high index of suspicion in patients with malignancy, along with a history, physical examination, x-ray films, ECG, and echocardiography, will often make the diagnosis in a hemodynamically compromised patient. Occasionally, cardiac catheterization and pericardial biopsy are necessary to differentiate malignant pericardial disease from radiation pericarditis and restrictive heart disease. Therapy is dependent on the underlying condition and includes pericardiectomy, chemotherapy to obliterate the pericardial space, and external beam radiotherapy. These therapies are all palliative, but provide months of hemodynamic relief. The underlying prognosis of malignant pericardial disease remains grave.

The Subxiphoid Approach to Pericardial Disease

During the 36-month period from July, 1978, through July, 1981, 25 patients underwent a subxiphoid pericardial window procedure for diagnosis and therapy. Twelve patients were operated on for uremic pericarditis, 6 for malignancy, and 7 for etiological diagnosis of the pericarditis. All 12 patients with renal failure had enlarging effusions, despite aggressive dialysis. Eleven of the 12 are alive, free from recurrence, 3 to 36 months postoperatively. Six patients were operated on for suspected pericardial malignancy with hemodynamic compromise. Histological diagnosis was made from the pericardial tissue in all patients; only 1 patient lived more than 43 days following the procedure. In the group of 7 patients operated on for diagnosis, 4 were thought preoperatively to have tuberculous pericarditis. All 4 were treated with antituberculosis chemotherapy and are asymptomatic, without evidence of calcification, 12 to 31 months postoperatively. This diverse group of patients demonstrates that the subxiphoid pericardial window is an effective approach for relief of uremic effusions and may adequately treat effusive tuberculous pericarditis when combined with multidrug chemotherapy. Patients with suspected malignant pericardial disease and hemodynamic compromise need to be carefully studied before an operative procedure is considered as a means of diagnosis and therapy.