General Information about Malignant Pericardial Effusions
Causes of Malignant Pericardial Effusions
Diagnosis of Malignant Pericardial Effusion
Managing Malignant Pericardial Effusions

General Information about Malignant Pericardial Effusions

Pericardial effusion is an increased amount of fluid inside the pericardium, the thin layer of tissue that forms a sac surrounding the heart. The excess fluid causes pressure on the heart, which prevents it from pumping blood normally. Lymph vessels may also be blocked, and bacterial or viral infections often develop. If fluid builds up very quickly, a condition called cardiac tamponade may occur, in which the pressure on the heart becomes life-threatening and must be treated promptly.

Pericardial effusions may be malignant or nonmalignant. Malignant pericardial effusions are caused by cancer that begins in the pericardium or the heart muscle, or by cancer that has spread there from the lung, esophagus, thymus, or lymph system. Malignant pericardial effusions are commonly caused by lung cancer in males and breast cancer in females. Nonmalignant causes include infection of the pericardium, heart attack, underactive thyroid gland, lupus, injury, surgery, and AIDS. Infection of the pericardium is a possible side effect of radiation therapy or chemotherapy.

The following symptoms may be caused by malignant pericardial effusions:

• Dyspnea.
• Cough.
• Chest pain.
• Difficulty breathing while lying flat.
• Swelling in the upper abdomen.
• Hiccups.
• Extreme tiredness and weakness.

Because pericardial effusions usually occur in advanced cancer or in the last few weeks of life, extensive diagnostic testing may be less important than relief of symptoms. The following tests and procedure may be used to diagnose pericardial effusion:

• Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.



• Echocardiography: A procedure in which high-energy sound waves (ultrasound) are bounced off internal tissues or organs of the chest. The echoes form a picture of the heart's position, motion of the walls, and internal parts such as the valves.



• Electrocardiogram (EKG or ECG): A recording of the heart's electrical activity to evaluate its rate and rhythm. A number of small pads (electrodes) are placed on the patient’s chest, arms, and legs, and are connected by wires to the electrocardiograph machine. Heart activity is then recorded as a line graph on paper. Electrical activity that is faster or slower than normal may be a sign of heart disease or damage.



• Pericardiocentesis: The removal of fluid from the pericardium using a needle inserted through the chest wall. The physician may use an echocardiogram to view the movement of the needle inside the chest. This procedure can be used to drain fluid from an effusion and reduce pressure on the heart. To diagnose malignant pericardial effusion, the fluid is examined under a microscope to check for cancer cells. The fluid may also be checked for signs of infection.

Large malignant pericardial effusions are managed by draining the fluid, unless the goals of therapy are to use a less invasive approach that may improve quality of life but not help the patient live longer. The goals of therapy depend on a number of factors, including the following:

• The patient's prognosis.
• The cost, risks, and invasiveness of treatment.
• Whether treatment will relieve symptoms and improve the patient's quality of life.
• Whether treatment will shorten the patient's hospital stay.

Treatment options include the following:

• Pericardiocentesis

  (See Diagnosis of Malignant Pericardial Effusion.) In some patients, fluid may again collect in the pericardium after pericardiocentesis. A catheter may be inserted and left in place to allow continued drainage. This procedure may be used for patients with advanced cancer instead of more invasive surgery.




• Pericardial sclerosis

  A procedure to close the pericardium so fluid cannot collect in the cavity. Fluid is first removed by pericardiocentesis. A drug or chemical that causes the pericardium to close is then injected through a catheter into the pericardial space. Three or more treatments may be needed to completely close the pericardium.




• Pericardotomy

  A surgical incision is made in the chest and then in the pericardium to insert a drainage tube. This increases the quantity of fluid that can be drained from the pericardium.




• Pericardiectomy

  Surgery to remove part of the pericardium. This may be done when there are chronic infections of the pericardium or to drain fluid quickly when cardiac tamponade occurs. This surgery is also called pericardial window.




• Balloon pericardiostomy

  A catheter with a balloon tip is inserted through the chest and into the pericardium. The balloon is then inflated to enlarge the pericardial opening and allow fluid to drain into the pleural cavity. This may be used when an effusion has recurred (come back) after pericardiocentesis or as an alternative to more invasive surgery.

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