Neoplastic Pericardial Disease Research Articles

Management of neoplastic pericardial disease.

At present, there is no accurate and effective method for treating neoplastic pericardial effusion. This study analyzed the current literature on the treatment of neoplastic pericardial effusion to provide advice and guidance for clinical treatment. Surgical treatments include pericardial puncture, extension of catheter drainage, pericardial window, and surgical pericardiotomy. Each surgical procedure has acorresponding indication, and the best treatment is selected according to the patient's specific conditions. Systemic chemotherapy is effective in lymphoma and small cell lung cancer that are sensitive to chemotherapeutic drugs. Although pericardial injection of drugs is effective for pericardial tamponade and recurrent pericardial effusion, these methods can only temporarily relieve symptoms and cannot prolong the life of patients. In recent years, immunotherapy, especially adoptive immunotherapy, has achieved good results in the treatment of neoplastic pericardial effusion, thus providing anovel treatment option for neoplastic pericardial effusion.

Acute haemorrhagic tamponade in cancer patients receiving direct oral anticoagulant: case series.

The use of direct oral anticoagulants (DOACs) is on the rise in the general population. However, data related to the safety of DOACs in patients with malignancy are limited. In this brief report, we present a series of three cases of haemorrhagic pericardial effusions and tamponade in patients receiving DOACs while undergoing cancer therapy. These three cases were all observed within a period of 6 weeks at a single institution and occurred shortly after the initiation of anticoagulation with one of the DOACs. Two of these patients had evidence of neoplastic pericardial process and were being treated with immunotherapy. The third patient was receiving targeted cancer therapy with a drug known to be associated with increased bleeding risks. Haemorrhagic pericarditis may represent a unique type of DOACs-related complications in subgroups of cancer patients with neoplastic pericardial disease and/or complex pharmacodynamics drug–drug interaction. The purpose of this report is to raise awareness of the lack of conclusive safety data of DOACs in certain cancer patients and to remind clinical providers of the National Comprehensive Cancer Network guidelines recommending against their use in patients with malignancy on the basis of limited safety data in patients undergoing cancer therapies.

Neoplastic pericarditis as the initial manifestation of a papillary thyroid carcinoma

Neoplastic pericarditis represents approximately 5%–7% of the cases with acute pericarditis and is rarely the initial manifestation of malignancy. The most common cause is lung cancer, followed by breast cancer, lymphomas, leukemia, and esophageal cancer. Neoplastic pericardial disease is extremely rare in thyroid cancer, especially as the first manifestation. Here, we present a papillary thyroid carcinoma that was manifested with pericarditis and cardiac tamponade in a 49-year-old female.

Evaluation and management of pericarditis

Pericarditis may be caused by infectious or noninfectious noxa. Most cases are labeled as ‘idiopathic’ because the traditional diagnostic approach often fails to identify the etiology. Most important causes are presumed to be viruses in countries with a low prevalence of tuberculosis and tuberculosis in developing countries. Noninfectious pericarditis mainly includes autoimmune systemic diseases, post-pericardiotomy syndromes and neoplastic pericardial disease. Treatment should be targeted to the cause, but remains empirical with NSAIDs and the possible adjunct of colchicine in idiopathic cases. Corticosteroids use should be limited to patients with NSAID contraindications/intolerance or failure, and rarely for specific conditions (i.e., pregnancy and systemic autoimmune diseases). Recurrences are the most common complication, but the overall prognosis is related to the etiology, usually benign in idiopathic pericarditis.

Neoplastic pericardial disease in lung cancer: Impact on outcomes of different treatment strategies. A multicenter study

BackgroundLocal (intrapericardial) chemotherapy has been reported to be useful for the treatment of neoplastic pericardial disease, but it has never been compared to systemic chemotherapy, a combination of the two and simple pericardial drainage or sclerosis. MethodsWe analyzed the clinical and echocardiographic data of 119 patients, suffering of neoplastic pericarditis due to lung cancer (97 with non-small-cell), comparing the outcomes of four different treatment strategies (extended catheter drainage/sclerosis, systemic chemotherapy, local chemotherapy, and combined – local plus systemic – chemotherapy) at the last available follow-up or at the change of therapy after a treatment failure. The outcomes (based on semiquantitative evaluation of pericardial disease) were classified as complete, partial, no response and progressing disease. ResultsA complete response was achieved in 37/53 of patients with combined, in 12/22 with local, in 5/27 with systemic chemotherapy, respectively, and in 4/17 after drainage/sclerosis (p<0.001). Overall response was achieved in 51/53 with combined, 18/22 and 16/27 with local or systemic chemotherapy, respectively, and in 5/17 with drainage/sclerosis only (p<0.001). Survival was significantly better after combined chemotherapy (p<0.001) and 12/53 patients (23%) in this subgroup survived more than 1 year. The overall response rate was higher with intrapericardial cisplatinum than with other agents (98% vs 80%, χ2=7.69, p<0.01). ConclusionsLocal chemotherapy, alone or with systemic chemotherapy, is effective in treating pericardial metastases from lung carcinoma, leading to a good control of pericardial effusion in 92% of cases, and to complete disappearance of effusion and masses in 65%. Combined therapy is significantly better than any other treatment. Pericardiocentesis and intrapericardial chemotherapy should be used whenever possible in lung cancer neoplastic pericardial disease, not only in case of tamponade.

Medical therapy of pericardial diseases

The treatment of pericardial diseases is largely empirical because of the relative lack of randomized trials compared with other cardiovascular diseases. The main forms of pericardial diseases that can be encountered in the clinical setting include acute and recurrent pericarditis, pericardial effusion with or without cardiac tamponade, and constrictive pericarditis. Medical treatment should be targeted at the cause of the disease as much as possible. However, the cause of pericardial diseases may be varied and depends on the prevalence of specific diseases (especially tuberculosis). The search for an etiology is often inconclusive, and most cases are classified as idiopathic in developed countries where tuberculosis is relatively rare, whereas a tuberculous etiology is often presumed in developing countries where tuberculosis is endemic. The aim of the present article is to review current medical therapy for pericardial diseases, highlighting recent significant advances in clinical research, ongoing challenges and unmet needs. Following a probabilistic approach, the most common causes are considered (idiopathic, viral, tuberculous, purulent, connective tissue diseases and neoplastic pericardial disease). In this article, the therapy of idiopathic and more common forms of infectious pericarditis (viral and bacterial) is reviewed.

Controversial Issues in the Management of Pericardial Diseases

The management of pericardial diseases is largely empirical because of the relative lack of randomized trials. The first published guidelines1,2 are a first attempt to organize current knowledge. At present, no specific guidelines have been issued by the American Heart Association and American College of Cardiology. After a literature review including a Medline search with the MeSH terms “pericarditis” and “pericardium,” we identified the following controversial issues related mainly to the management of pericarditis and pericardial effusion: (1) etiological search and hospitalization; (2) role of pericardiocentesis, pericardial biopsy, and pericardioscopy; (3) myopericarditis; (4) use of corticosteroids, nonsteroidal antiinflammatory drugs (NSAIDs), and colchicine; (5) management of refractory cases and long-term outcome; (6) role of pericardiectomy, pericardial window, and other interventional techniques; and (7) management of chronic idiopathic pericardial effusion. At the end of each issue, key points are summarized. Management of most cases is done by general practitioners or different healthcare specialists and does not require specific expertise; nevertheless, incessant and recurrent cases and specific forms (eg, tuberculous pericarditis, neoplastic pericardial disease, autoimmune conditions) require cooperation among specialties (eg, cardiology, infectious diseases, rheumatology, oncology). Specific interventional techniques (eg, pericardioscopy) and pericardiectomy should be performed in referral centers. ### Pericarditis Although the clinical diagnosis of pericarditis is relatively simple (Tables 1 and 2⇓),1–13 establishing the cause may be more difficult. A major controversy in “pericardiology” is the role of an extensive etiologic search and hospital admission for all patients with pericarditis or pericardial effusion.1–8 The causes of pericarditis are varied (Table 3),9 and the clinician should identify causes that require targeted therapies. The epidemiological background is essential to develop a rational cost-effective management program3,4,15,16; the approach may be different for research, when we attempt to reduce the number of “idiopathic” cases. In developed countries, idiopathic …

Neoplastic pericardial disease: Old and current strategies for diagnosis and management.

The prevalence of neoplastic pericardial diseases has changed over time and varies according to diagnostic methods. The diagnostic factor is usually the detection of neoplastic cells within the pericardial fluid or in specimens of pericardium, but the diagnosis may be difficult. Accurate sampling and cytopreparatory techniques, together with ancillary studies, including immunohistochemical tests and neoplastic marker dosage, are essential to obtain a reliable diagnosis. The goals of treatment may be simply to relieve symptoms (cardiac tamponade or dyspnea), to prevent recurrent effusion for a long-term symptomatic benefit, or to treat the local neoplastic disease with the aim of prolonging survival. Immediate relief of symptoms may be obtained with percutaneous drainage or with a surgical approach. For long term prevention of recurrences, various approaches have been proposed: extended drainage, pericardial window (surgical or percutaneous balloon pericardiostomy), sclerosing local therapy, local and/or systemic chemotherapy or radiation therapy (RT) (external or with intrapericardial radionuclides). The outcomes of various therapeutic approaches vary for different tumor types. Lymphoma and leukemias can be successfully treated with systemic chemotherapy; for solid tumors, percutaneous drainage and the use of systemic and/or local sclerosing and antineoplastic therapy seems to offer the best chance of success. The use of "pure" sclerosing agents has been replaced by agents with both sclerosing and antineoplastic activity (bleomycin or thiotepa), which seems to be quite effective in breast cancer, at least when associated with systemic chemotherapy. Local chemotherapy with platinum, mitoxantrone and other agents may lead to good local control of the disease, but the addition of systemic chemotherapy is probably relevant in order to prolong survival. The surgical approach (creation of a pericardial window, even with the mini-invasive method of balloon pericardiostomy) and RT may be useful in recurring effusions or in cases that are refractory to other therapeutic approaches.

Aetiologic diagnosis of pericardial disease: worthy efforts may not be applied in the appropriate directionThe opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.

The aetiologic diagnosis of pericardial disease has something of a paradox. On the one hand, the precise aetiology of many, perhaps most, instances of pericarditis remains an enigma in individual patients. Fortunately, for management purposes, such precise diagnosis is virtually irrelevant in most cases, as spontaneous cure is the rule in such patients; however, in a few patients, it may prove crucial. On the other hand, because of the poor specificity of many clinical findings, patients needing aetiologically guided intervention may remain unnoticed until too late. Not rarely, when concomitant disease does not point at a likely aetiological association, the only means of assessing if pericardial disease is due to specific mechanisms requiring individual therapy is to examine the pericardial fluid or tissue. If often poorly acknowledged as such, the challenge has always been to know in which patients the study of pericardial fluid or tissue is likely to be rewarding in terms of discovering specific, treatable disease. The key issue in acute pericardial disease is whether or when investigation of pericardial fluid or tissue in search of the aetiologic diagnosis is warranted for clinical purposes. To do too many invasive investigations would amount to a number of irrelevant or inconclusive findings in patients who will otherwise spontaneously recover (i.e. those with viral infection or with the classically called acute idiopathic pericarditis, no matter what its aetiologic or pathogenetic mechanisms are), whereas failing to investigate pericardial fluid or tissue in patients with purulent, tuberculous, or neoplastic pericardial disease would represent missing the opportunity to cure or alleviate serious disease. Algorithms have been proposed for guidance in … *Corresponding author. Tel: +34 93 274 6070; fax: +34 93 274 6063. E-mail address : jsoler{at}vhebron.net

Neoplastic pericardial disease. Analysis of 26 patients.

To characterize patients with neoplastic pericardial disease diagnosed by clinical presentation, complementary test findings, and the histological type of tumor. Twenty-six patients with neoplastic pericardial disease were retrospectively analyzed. Clinical manifestations and abnormalities in chest roentgenograms and electrocardiograms were frequent, but were not specific. Most patients underwent surgery. There was a high positivity of the pericardial biopsy when associated with the cytological analysis of the pericardial liquid used to determine the histological type of the tumor, particularly when the procedure was performed with the aid of pericardioscopy. The correct diagnosis of neoplastic pericardial disease involves suspicious but nonspecific findings during clinical examination and in screen tests. The suspicious findings must be confirmed through more invasive diagnostic approaches, in particular pericardioscopy with biopsy and cytological study.

Pericardiectomy in dogs: 22 cases (1978–1994)

Objective To determine long-term outcome of dogs with neoplastic and nonneoplastic pericardial disease that undergo pericardiectomy. Design Retrospective study. Animals 22 dogs. Procedure Dogs that underwent pericardiectomy and in which the diagnosis had been confirmed histologically were included. Data collected from each record included signalment, history, clinical signs, results of diagnostic evaluations, operative management, postoperative complications, histologic diagnosis, and outcome. Dogs were grouped on the basis of underlying cause of pericardial disease (neoplastic vs nonneoplastic), and survival times were determined by means of Kaplan-Meier analyses. Results 9 dogs had neoplastic pericardial disease (chemodectoma, 4; hemangiosarcoma, 2; malignant mesothelioma, 2; lymphoblastic lymphoma, 1). Thirteen dogs had nonneoplastic pericardial disease (benign idiopathic pericarditis, 10; lymphocytic-plasmacytic pericarditis, 2; osseous metaplasia of unknown cause, 1). Thoracic radiography and echocardiography were the most specific methods for diagnosis of pericardial effusion. Pleural effusion was the most common postoperative complication (8/22 dogs). Prevalence of postoperative complications was not associated with underlying cause of pericardial disease, surgical approach, or surgical procedure (subtotal vs total pericardiectomy). Median survival time of dogs with neoplastic disease (52 days) was significantly shorter than median survival time of dogs with nonneoplastic disease (792 days). Dogs that developed pleural effusion &gt; 30 days after pericardiectomy had a poor prognosis for survival. Clinical Implications Radiography and echocardiography are useful for diagnosis of pericardial effusion in dogs. Dogs with neoplastic pericardial disease have a significantly shorter survival time than do dogs with nonneoplastic pericardial disease. (J Am Vet Med Assoc 1997;211:736–740)

MR EVALUATION OF THE PERICARDIUM AND CARDIAC MALIGNANCIES

The pericardium and cardiac malignancies are well visualized on MR imaging because of the superb contrast resolution and multiplanar capability of the technique. This article highlights some of the clinical uses of MR imaging in evaluating the pericardium and cardiac lesions and provides comparison with echocardiography and CT scan. Specific diseases that are described include pericardial effusion, constrictive pericarditis, neoplastic pericardial disease, congenital abnormalities of the pericardium, benign, malignant and metastatic cardiac tumors, and paracardiac masses. This article discusses the impact of newer MR techniques such as cine MR imaging on the assessment of pericardial disease and cardiac lesions.

MR Evaluation of the Pericardium

The pericardium is well visualized on magnetic resonance imaging (MRI) because of the superb contrast resolution and multiplanar capability of the technique. This article highlights some of the clinical uses of MRI in evaluating the pericardium and provides comparison with echocardiography and computed tomography (CT) scan. Specific pericardial diseases that are described include pericardial effusion, constrictive pericarditis, neoplastic pericardial disease, congenital abnormalities of the pericardium, and paracardiac masses. The value of MRI in differentiating constrictive pericarditis from restrictive cardiomyopathy is emphasized. The article discusses the impact of newer MRI techniques such as cine MRI on the assessment of pericardial disease.

Pericardial diseases, with a focus on etiology, pathogenesis, pathophysiology, new diagnostic imaging methods, and treatment

Recent advances in the study of pericardial disorders have opened new diagnostic windows to the heart through the pericardial sac, with the development of pericardioscopy and thoracoscopy. Specific diagnosis of inflammatory, postinflammatory, autoreactive, or neoplastic pericardial disease can now be made by epicardial and pericardial biopsy and by cytologic analysis of the pericardial fluid. In perimyocarditis, optically guided epicardial biopsy gives more disease-specific results than does endomyocardial biopsy in the same patients. For viral and tuberculous pericarditis, molecular techniques such as polymerase chain reaction and in situ hybridization are available. Immunologic characterization of lymphocytic cells and antibodies demonstrates increased reactivity in viral, autoimmune, and neoplastic disorders of the heart. Doppler echocardiographic features in tamponade are reviewed thoroughly. Advantages and problems of pericardectomy in constrictive disease are noted, and finally, a pragmatic clinical and scientific approach for improved diagnosis of pericardial diseases is outlined.

COMPUTED TOMOGRAPHY IN THE DIAGNOSIS OF PERICARDIAL HEART DISEASE

To evaluate the use of computed tomography (CT) in the diagnosis of pericardial heart disease, 53 patients were prospectively studied by computed tomography of the chest and cardiac ultrasound. A diagnostic-quality CT study was done for all patients; a technically satisfactory ultrasound examination was not possible in six patients. Of 47 patients in whom both chest scans and satisfactory ultrasound studies were obtained, computed tomography showed pericardial thickening not shown by ultrasound in five patients. Estimated size of pericardial effusion was the same for both computed tomography and ultrasound. Computed tomography provided quantifiable evaluation of the composition of pericardial fluid in seven patients with either hemopericardium or purulent pericarditis. Neoplastic pericardial heart disease was detected by CT scan in four of the 53 patients. Computed tomography of the chest provides a sensitive evaluation of the pericardium and quality of pericardial effusion, and is a valuable adjunct in patients in whom cardiac ultrasound is technically unsatisfactory.