Pericardial Involvement in Cancer

Pericarditis and Cardiac Tamponade in Patients Treated with First and Second Generation Bruton Tyrosine Kinase Inhibitors: An Underappreciated Risk

Introduction

The introduction of Bruton's tyrosine kinase (BTK) inhibitors significantly improved the management of chronic lymphocytic leukemia (CLL). However, BTK carry the risk of cardiotoxicity, which is not only limited to atrial fibrillation. Case Reports. We report three cases of patients on BTK inhibitors who developed acute pericarditis and cardiac tamponade. We report the first patient who developed this complication on treatment with zanubrutinib. This patient's treatment was changed to zanubrutinib due to atrial fibrillation. Shortly after cardioversion, he developed cardiac tamponade and shock. He underwent pericardiocentesis, received treatment for acute pericarditis with steroids and colchicine, and made a full recovery. We also report two further cases, both involving patients treated with ibrutinib. These patients also developed acute pericarditis and cardiac tamponade and required pericardiocentesis. All three patients discontinued BTK therapy following the events.

Conclusions

These three cases highlight the rare but potentially life-threatening risk of cardiac tamponade which can occur even with newer generations of BTK inhibitors. Haemato-oncologists should remain vigilant in patients who report dyspnea or who show sinus tachycardia on routine electrocardiography. Even in the absence of classical clinical signs of tamponade, patients require urgent evaluation with echocardiography and potentially emergency pericardiocentesis.

Asymptomatic Chronic Large Pericardial Effusions: To Drain or to Observe?

Pericardial effusions, especially large ones, have traditionally been regarded with concern by clinicians due to the sometimes unpredictable development of life-threatening cardiac tamponade. In the European Society of Cardiology Guidelines on pericardial diseases, the simplified algorithm for pericardial effusion triage and management recommends pericardial drainage in cases of cardiac tamponade and/or suspicion of bacterial or neoplastic etiology. In the presence of acute pericarditis, empiric anti-inflammatory treatment should be given, while when a specific indication known to be associated with pericardial effusion is found, then treatment of the underlying cause is indicated. Notably, the most challenging subgroup of patients includes those with large, asymptomatic, C-reactive-protein-negative, idiopathic effusions. In the latter subjects, pericardial drainage is proposed in cases of chronic effusions (lasting more than three months). However, this recommendation is based on scant data stemming from small-sized non-randomized studies. Nevertheless, recent evidence in a larger cohort of patients pointed out that a watchful waiting strategy is a safe option in terms of complication-free survival. This review summarizes the contemporary evidence on this challenging topic and provides recommendations for tailoring individual patient treatments.

Home Ultrasound: A Contemporary and Valuable Tool for Palliative Medicine

This narrative review explores the application of point-of-care ultrasound (POCUS) in palliative care and its feasibility in home care settings. POCUS has the potential to streamline diagnostic strategies without patient transfer to the hospital, expedite timely symptomatic relief, and reduce complications from specific palliative interventions. The advent of handheld ultrasound devices has made it an attractive diagnostic and interventional adjunct in acute palliative care. POCUS has gained widespread acceptance as part of routine care in emergency medicine and intensive care, guiding certain procedures and increasing their safety. The modernization and miniaturization of ultrasound equipment have made ultra-portable devices available, allowing for better-quality images at affordable prices. Handheld devices have the potential to revolutionize everyday clinical practice in home-based palliative care, contributing to important bedside clinical decisions. Palliative care patients often require diagnostic examinations in the last months of their lives, with CT being the most frequently performed imaging procedure. However, CT imaging is associated with high costs and burdens, leading to increased suffering and impaired quality of life. Clinical ultrasound, a dialogic imaging modality, offers a safer and more efficient approach to palliative care. POCUS applications, which are cost-effective, non-invasive, and well-tolerated, can be used to improve patient satisfaction and diagnostic understanding. POCUS is a valuable tool in palliative care, improving diagnostic accuracy and reducing the time to diagnosis for various pathologies. It is a standard of care for many procedures and improves patient safety. However, there are limitations to POCUS in palliative care, such as operator-dependent examination variability and limited availability of trained professionals. To overcome these limitations, palliative care physicians should receive mandatory training in POCUS, which can be incorporated into the core curriculum. Additionally, ultrasound teleconsulting can assist less experienced examiners in real-time examinations. The literature on POCUS in palliative care is limited, but research on patient-oriented outcomes is crucial. POCUS should be considered a supplement to good clinical reasoning and regulated radiological evaluations.

Radiation-Induced Pericardial Disease: Mechanisms, Diagnosis, and Treatment

PURPOSE OF REVIEW

We aim to give a concise overview of the different clinical manifestations of both acute and long-term radiotherapy-related pericardial diseases, the underlying pathophysiology as well as the diagnosis and treatment options.

RECENT FINDINGS

Radiotherapy-related pericardial disease is common, but despite radiotherapy being a cornerstone of many cancer treatments, this disease entity is relatively underrepresented in clinical trials, resulting in a paucity of research data on pathophysiology and management. Since the development of innovative cancer treatments, survival has significantly improved. Therefore, the importance of long-term treatment-related side effects increases, most notably cancer treatment-related cardiovascular toxicity. In patients undergoing radiotherapy as a part of their cancer treatment, radiotherapy-related pericardial disease can manifest early (during or shortly after radiotherapy administration) or very late (several years to decades after treatment). This exceptionally long latency period confronts physicians with treatment-related side effects of radiotherapy regimens that may have been abandoned already.

Think Outside the Heart: An Unusual Cause of Large Hemopericardium

Pericardial effusions secondary to tumors are commonly metastatic, originating primarily from the lung, breast, and lymphomas. Pericardial tamponade is a rare oncological emergency warranting early identification and treatment. We describe a 66-year-old male found to have a large bloody pericardial effusion causing tamponade physiology, and multimodality imaging was consistent with intrapericardial malignancy with no identifiable primary source. He was subsequently diagnosed with type B3 thymoma after mediastinal resection.

Main applications of point-of care ultrasound in palliative care

Combined with a physical examination, clinical ultrasound offers a valuable complement that can help guide clinical decision-making. In various medical and surgical specialties, it is increasingly used for diagnostic and therapeutic purposes. Due to recent technological advances, smaller and more affordable ultrasound machines are now being developed for use in home hospice care. The purpose of this paper is to describe how clinical ultrasound may be applied in Palliative Care, where it can be a valuable tool to assist the clinician in making better clinical decisions and to assist in accurately guiding palliative procedures. Furthermore, it can be used to identify unnecessary hospitalizations and prevent them from occurring. Training programs with specific objectives are necessary to implement clinical ultrasound in Palliative Care, as well as defining learning curves and promoting alliances with scientific societies that recognize the teaching, care and research trajectory for accreditation of competencies.

An updated narrative review on the management of the most common oncological and hematological emergencies

Oncological emergencies are defined as an acute life-threatening event in a patient with a tumor occurring as part of their complex treatment regimen or secondarily to their underlying malignancy. These events can occur at any time from the initial diagnosis of their cancer to end-stage disease. These oncological emergencies are broadly classified into four major categories; metabolic, structural, hematological and treatment-related causes; and can be encountered in any clinical setting, ranging from primary care physician and emergency department visits to a variety of subspecialty environments. This study aims to cover an in-depth review of the underlying pathogenesis, clinical presentation, and updated management protocol of most common emergencies belonging to the above-mentioned categories. An all-language literature search was conducted on 15th October 2021 and 10th March 2022, limited to 5 years on PubMed database using the following search strings: oncological emergencies, malignant spinal cord compression, febrile neutropenia, hyperviscosity syndrome, superior vena cava syndrome, immune related adverse events, tumor lysis syndrome, hypercalcemia of malignancy, corrected calcium, malignant pericardial effusion and chemotherapy extravasation.

A Case of a Large Malignant Pericardial Effusion on Computed Tomography Without Electrocardiographic Gating

A 67-year-old female was admitted due to dyspnea. A computed tomography (CT) disclosed a suspicious pulmonary mass and a pericardial effusion. A transthoracic echocardiogram confirmed a large-volume circumferential pericardial effusion. A pericardiocentesis was performed, and the cytological and histochemical studies later confirmed the diagnosis of pulmonary adenocarcinoma. This case report highlights the casualty of having found a cardiac tamponade through a CT not synchronized with an electrocardiogram.

Pericardial Effusion: A Novel Presentation of Aplastic Anemia

Pericardial effusion is defined as the accumulation of fluid between the visceral and parietal pericardium. The underlying etiology varies as any pathology that causes pericarditis or involves the pericardium can cause effusion. In practice, the majority of pericarditis cases are idiopathic, although these are assumed to be secondary to occult viral infection or inflammatory phenomena. Malignancy, particularly the metastatic spread of noncardiac primary tumors, has been implicated as a differential in the diagnosis of pericardial effusion. Though commonly seen in solid malignancies, effusion has been reported in hematologic malignancies such as myelodysplastic syndrome (MDS), acute leukemia, and lymphoma. Nonetheless, pericardial effusions associated with hematologic conditions are extremely rare with only one case report published describing pericardial effusion secondary to immune thrombocytopenia (ITP). We herein report the first documented case, to our knowledge, of pericardial effusion as an initial clinical manifestation of aplastic anemia in a middle-aged male presenting with pancytopenia.

Development and validation a simple scoring system to identify malignant pericardial effusion

Background

Malignant pericardial effusion (MPE) is a serious complication in patients with advanced malignant tumors, which indicates a poor prognosis. However, its clinical manifestations lack specificity, making it challenging to distinguish MPE from benign pericardial effusion (BPE). The aim of this study was to develop and validate a scoring system based on a nomogram to discriminate MPE from BPE through easy-to-obtain clinical parameters.

Methods

In this study, the patients with pericardial effusion who underwent diagnostic pericardiocentesis in Taizhou Hospital of Zhejiang Province from February 2013 to December 2021 were retrospectively analyzed. The eligible patients were divided into a training group (n = 161) and a validation group (n = 66) according to the admission time. The nomogram model was established using the meaningful indicators screened by the least absolute shrinkage and selection operator (LASSO) and multivariate logistic regression. Then, a new scoring system was constructed based on this nomogram model.

Results

The new scoring system included loss of weight (3 points), no fever (4 points), mediastinal lymph node enlargement (2 points), pleural effusion (6 points), effusion adenosine deaminase (ADA≦18U/L) (5 points), effusion lactate dehydrogenase (LDH>1033U/L) (7 points), and effusion carcinoembryonic antigen (CEA>4.9g/mL) (10 points). With the optimal cut-off value was 16 points, the area under the curve (AUC), specificity, sensitivity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (PLR), negative likelihood ratio (NLR) for identifying MPE were 0.974, 95.1%, 91.0%, 85.6%, 96.8%, 10.56 and 0.05, respectively, in the training set and 0.950, 83.3%, 95.2%, 90.9%, 90.9%, 17.50, and 0.18, respectively, in the validation set. The scoring system also showed good diagnostic accuracy in differentiating MPE caused by lung cancer from tuberculous pericardial effusion (TPE) and MPE including atypical cell from BPE.

Conclusion

The new scoring system based on seven easily available variables has good diagnostic value in distinguishing MPE from BPE.

Malignant pericardial effusions: A retrospective look at etiology and prognosis in a tertiary oncological center

PURPOSE

Cancer and the associated treatments are important causes of pericardial effusion. However, the natural history of malignant pericardial effusion is largely unknown, especially in the context of newer cancer treatments. We investigated the causes of pericardial effusions in a tertiary oncology center, with particular focus on the prognosis of malignant effusions in the era of contemporary oncological therapies.

METHOD

We obtained data from electronic medical records. Survival analyses were performed utilizing the Kaplan-Meier method. We performed Cox regression to explore the potential clinical factors associated with survival.

RESULTS

Forty-four patients had pericardial effusion treated with pericardiocentesis during the study period. The mean age was 62-years, and 55% were female. Sixty-eight percent of these patients also had cancer, with approximately half (47%) receiving prior chemotherapy, and a quarter (27%) having had chest radiotherapy. Seventy percent of the patients with active cancer had malignant cells on cytology of pericardial fluid. The median survival of the cohort was 227 days, with malignant effusions having a median survival of 62-days compared to nonmalignant effusions with 1408 days (Logrank statistic 7.4, p-value .007). Malignant cytology was significantly associated with mortality on univariable analysis (HR 2.5, 95% CI 1.2-5.3). Complication rates were low, with no deaths as a direct complication of pericardiocentesis.

CONCLUSION

Malignancy is the most common cause of pericardial effusion in this tertiary medical and oncological center. Abnormal cytology with malignant cells has a poor median survival, despite advances in oncological treatment over the last decade. Pericardiocentesis is a safe procedure for these patients.

Chest Pain in the Cancer Patient

Chest pain is one of the most common presenting symptoms in patients seeking care from a physician. Risk assessment tools and scores have facilitated prompt diagnosis and optimal management in these patients; however, it is unclear as to whether a standardised approach can adequately triage chest pain in cancer patients and survivors. This is of concern because cancer patients are often at an increased risk of cardiovascular mortality and morbidity given the shared risk factors between cancer and cardiovascular disease, compounded by the fact that certain anti-cancer therapies are associated with an increased risk of cardiovascular events that can persist for weeks and even years after treatment. This article describes the underlying mechanisms of the most common causes of chest pain in cancer patients with an emphasis on how their management may differ to that of non-cancer patients with chest pain. It will also highlight the role of the cardio-oncology team, who can aid in identifying cancer therapy-related cardiovascular side-effects and provide optimal multidisciplinary care for these patients.

The Association of Minimally Invasive Surgical Approaches and Mortality in Patients with Malignant Pleuropericarditis—A 10 Year Retrospective Observational Study

Background and Objectives: Malignant neoplasms are common causes of acute pleuropericardial effusion. Pleuropericarditis denotes poor patient prognosis, is associated with shortened average survival time, and represents a surgical emergency. Materials and Methods: We analyzed the impact of two minimally invasive surgical approaches, the type of cancer, and other clinical variables on the mortality of 338 patients with pleuropericarditis admitted to an emergency hospital in Romania between 2009 and 2020. All patients underwent minimally invasive surgeries to prevent the recurrence of the disease and to increase their life expectancy. Log-rank tests were used to check for survival probability differences by surgical approach. We also applied univariate and multivariate Cox proportional hazard models to assess the effect of each covariate. Results: No significant differences were found in the 2-year overall survival rate between patients who underwent the two types of surgery. The multivariate Cox proportional regression model adjusted for relevant covariates showed that age, having lung cancer, and a diagnosis of pericarditis and right pleural effusion increased the mortality risk. The surgical approach was not associated with mortality in these patients. Conclusion: These findings open up avenues for future research to advance the understanding of survival among patients with pleuropericarditis.

Feasibility and safety of CT-aided pericardiocentesis from a subxiphoid anterior approach by using fluoroscopy in patients with chronic pericardial effusions

Background

Pericardiocentesis is an essential procedure for the diagnosis and treatment of pericardial effusions. The purpose of this study was to evaluate the feasibility and safety of a subxiphoid anterior approach using fluoroscopy aided by a sagittal axis chest computed tomography (CT) view in comparison with an ultrasound‐guided apical approach in patients with chronic pericardial effusion.

Methods

Among 72 consecutive patients (68.8 ± 14.4 years old, 52 males) with hemodynamically stable chronic pericardial effusions, a total of 85 procedures were retrospectively analyzed. We divided them into two groups according to the site of the approach for the pericardiocentesis.

Results

A subxiphoid anterior approach (n = 53) was performed guided by fluoroscopy. The sagittal axis view of the chest CT was constructed to determine the puncture angle and direction for the subxiphoid anterior approach. An apical approach (n = 32) was performed by ultrasound guidance. The success rates of the anterior and apical approaches were 98.1% and 93.8%, respectively. There were two cases with cardiac perforations in the apical approach group, while no cases developed perforations in the subxiphoid anterior approach group.

Conclusion

The subxiphoid anterior approach for pericardiocentesis was feasible and safe for managing chronic pericardial effusions. A reconstruction of the sagittal axis view of the chest CT imaging was helpful to identify the direction and depth to access the pericardial space from the subxiphoid puncture site before the pericardiocentesis using the lateral fluoroscopic view.

Prognosis and role of clinical and imaging features in patients with malignant pericardial effusion: a single-center study in China

Background

The diagnosis of malignant pericardial effusion (MPE) is often associated with a poor prognosis, but due to the complexity and unspecific nature of MPE patients' clinical manifestations, imaging often performs an essential role in diagnosis and prognosis.

Methods

Patients diagnosed with MPE between 2013 and 2018 at one tumor hospital were included and followed up. The data covered the basic clinical features, imaging findings, treatments and prognosis of patients with MPE, and the factors that may have affected the prognosis were explored.

Results

A total of 216 patients with MPE were included with the median age of 60 years. The most common primary cancer type was lung cancer (73.6%), the most common symptom was dyspnea (62.9%) and the most common abnormal electrocardiogram finding was sinus tachycardia (42.1%). The median survival time of the 216 patients with MPE was 13.7 months. The factors affecting prognosis were echocardiographic fluid signs (HR = 2.37, P = 0.010), electrocardiographic evidence of sinus tachycardia (HR = 1.76, P = 0.006) and echocardiographic evidence of cardiac tamponade (HR = 3.33, P < 0.001).

Conclusions

MPE has complex clinical manifestations and an unsatisfactory prognosis. Echocardiographic fluid signs, electrocardiographic evidence of sinus tachycardia, and echocardiographic evidence of cardiac tamponade are independent risk factors affecting prognosis.

Mean heart dose-based normal tissue complication probability model for pericardial effusion: a study in oesophageal cancer patients

We investigated the normal tissue complication probability (NTCP) of the incidence of pericardial effusion (PCE) based on the mean heart dose (MHD) in patients with oesophageal cancer treated with definitive chemoradiotherapy. The incidences of PCE in any grade (A-PCE) and symptomatic PCE (S-PCE) were evaluated separately. To identify predictors for PCE, several clinical and dose-volume parameters were analysed using a receiver operating characteristic (ROC) curve and multivariate regression analysis. To validate its clinical applicability, the generated NTCP model was compared to the Lyman–Kutcher–Burman (LKB) model. Among 229 eligible patients, A-PCE and S-PCE were observed in 100 (43.7%) and 18 (7.9%) patients, respectively. MHD showed a preferable area under the curve (AUC) value for S-PCE (AUC = 0.821) and A-PCE (AUC = 0.734). MHD was the only significant predictor for A-PCE; MHD and hypertension were selected as significant factors for S-PCE. The estimated NTCP, using the MHD-based model, showed excellent correspondence to the LKB model in A-PCE and S-PCE. The NTCP curve of A-PCE was gentler than that of S-PCE and had no threshold. The MHD-based NTCP model was simple but comparable to the LKB model for both A-PCE and S-PCE. Therefore, the estimated NTCP may provide clinically useful parameters for predicting PCE.