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

Successful treatment of extensive-stage small cell lung cancer with concurrent pleural and pericardial effusions: Case report

It is unclear whether pleural/pericardial drainage and pleurodesis/pericardiodesis should be performed before or after initiating chemotherapy in patients with chemotherapy-sensitive small-cell lung cancer. A 76-year-old woman presented to the emergency department with progressive dyspnea on exertion for a week. Chest computed tomography showed a mass shadow anterior to the left upper lobe, bilateral pleural effusions, and a circumferential pericardial effusion surrounding the heart. We diagnosed extensive-stage small-cell lung cancer based on the clinical course and pathological findings. We first performed pleurodesis and pericardial drainage and successfully initiated immune checkpoint inhibitor combined chemotherapy, with improved performance status. This case highlights the importance of aggressive drainage and pleurodesis/pericardiodesis, and suggests that drainage and pleurodesis/pericardiodesis should be considered before systemic chemotherapy in patients with concurrent pericardial or pleural effusions, even in patients with small-cell lung cancer that is sensitive to chemotherapy.

Evaluation and management of cancer patients presenting with acute cardiovascular disease: a Consensus Document of the Acute CardioVascular Care (ACVC) association and the ESC council of Cardio-Oncology-Part 1: acute coronary syndromes and acute pericardial diseases

Advances in treatment, common cardiovascular (CV) risk factors and the ageing of the population have led to an increasing number of cancer patients presenting with acute CV diseases. These events may be related to the cancer itself or the cancer treatment. Acute cardiac care specialists must be aware of these acute CV complications and be able to manage them. This may require an individualized and multidisciplinary approach. We summarize the most common acute CV complications of cytotoxic, targeted, and immune-based therapies. This is followed by a proposal for a multidisciplinary approach where acute cardiologists work close together with the treating oncologists, haematologists, and radiation specialists, especially in situations where immediate therapeutic decisions are needed. In this first part, we further focus on the management of acute coronary syndromes and acute pericardial diseases in patients with cancer.

NLRP3 as Putative Marker of Ipilimumab-Induced Cardiotoxicity in the Presence of Hyperglycemia in Estrogen-Responsive and Triple-Negative Breast Cancer Cells

Hyperglycemia, obesity and metabolic syndrome are negative prognostic factors in breast cancer patients. Immune checkpoint inhibitors (ICIs) have revolutionized cancer treatment, achieving unprecedented efficacy in multiple malignancies. However, ICIs are associated with immune-related adverse events involving cardiotoxicity. We aimed to study if hyperglycemia could affect ipilimumab-induced anticancer efficacy and enhance its cardiotoxicity. Human cardiomyocytes and estrogen-responsive and triple-negative breast cancer cells (MCF-7 and MDA-MB-231 cell lines) were exposed to ipilimumab under high glucose (25 mM); low glucose (5.5 mM); high glucose and co-administration of SGLT-2 inhibitor (empagliflozin); shifting from high glucose to low glucose. Study of cell viability and the expression of new putative biomarkers of cardiotoxicity and resistance to ICIs (NLRP3, MyD88, cytokines) were quantified through ELISA (Cayman Chemical) methods. Hyperglycemia during treatment with ipilimumab increased cardiotoxicity and reduced mortality of breast cancer cells in a manner that is sensitive to NLRP3. Notably, treatment with ipilimumab and empagliflozin under high glucose or shifting from high glucose to low glucose reduced significantly the magnitude of the effects, increasing responsiveness to ipilimumab and reducing cardiotoxicity. To our knowledge, this is the first evidence that hyperglycemia exacerbates ipilimumab-induced cardiotoxicity and decreases its anticancer efficacy in MCF-7 and MDA-MB-231 cells. This study sets the stage for further tests on other breast cancer cell lines and primary cardiomyocytes and for preclinical trials in mice aimed to decrease glucose through nutritional interventions or administration of gliflozines during treatment with ipilimumab.

Update on diagnosis and management of neoplastic pericardial disease

INTRODUCTION

Pericardial neoplasms are uncommon, mostly due to secondary involvement of the pericardium by extracardiac tumors. Clinical presentation is nonspecific, frequently leading to a delayed diagnosis. Moreover, both benign and malignant pericardial tumors may be associated with myocardial infiltration and mechanical compression of cardiac chambers, possibly precipitating clinical conditions. Pericardial tumors are indeed a diagnostic and therapeutic clinical challenge.

AREAS COVERED

This review aims to provide an overview of the main clinical characteristics of pericardial tumors, along with their management in clinical practice.

EXPERT COMMENTARY

Multimodality imaging (echocardiography, chest X-ray, CT, CMR, and PET) enable full characterization of pericardial neoplasms. An individualized strategy should be developed by a multidisciplinary team including cardiologists, oncologists, radiologists, and cardiac surgeons.

Intrapericardial instillation of bleomycin prevents recurrence of malignant pericardial effusions: Series of 46 cases and comprehensive literature review

INTRODUCTION

Malignant pericardial effusion is a severe complication of lung and breast cancer. The median survival is less than 4 months and recurrences occurs in about 40% of cases. Systemic chemotherapy and/or local treatments are necessary, even if there is no consensus.

METHODS

We collected data from patients in our center from 1997 to 2016 who received at least one intrapericardial instillation of bleomycin (60mg). At the same time, we conducted a review of the relevant literature on the subject.

RESULTS

We included 46 patients in the analysis. Median survival was 2.6 months [95% CI: 1.7; 4.7]. Overall survival was 49% [33%; 63%] at 3 months and 28% [15%; 42%] at 6 months. In the lung cancer subgroup, overall survival was 18% [3%; 44%] at 3 months. In the breast cancer subgroup, overall survival was 73% [44%; 89%] at 3 months and 46% [21%; 69%] at 6 months.

DISCUSSION

The best response rates in the literature are obtained with local instillation of bleomycin or cisplatin. Malignant pericardial effusions in breast cancer patients had a better prognosis. This is certainly related to the prognosis of the underlying disease. We have not found an increase in overall survival with intrapericardial chemotherapy injections, but preventing recurrence of malignant pericardial effusions is a benefit in itself, thus avoiding a lethal complication.

Cardiac Tumors

Cardiac tumors (CTs) are extremely rare, with an incidence of approximately 0.02% in autopsy series. Primary tumors of the heart are far less common than metastatic tumors. CTs usually present with any possible clinical combination of heart failure, arrhythmias, or embolism. Echocardiography remains the first diagnostic approach when suspecting a CT which, on the other side, frequently appears unexpectedly during an echocardiographic examination. Yet, cardiac tomography and especially magnetic resonance imaging may offer several adjunctive opportunities in the diagnosis of CTs. Early and exact diagnosis is crucial for the following therapy and outcome of CTs.

Cardiac Interventional Procedures in Cardio-Oncology Patients

Comorbidities specific to the cardio-oncology population contribute to the challenges in the interventional management of patients with cancer and cardiovascular disease (CVD). Patients with cancer have generally been excluded from cardiovascular randomized clinical trials. Endovascular procedures may represent a valid option in patients with cancer with a range of CVDs because of their minimally invasive nature. Patients with cancer are less likely to be treated according to societal guidelines because of perceived high risk. This article presents the specific challenges that interventional cardiologists face when caring for patients with cancer and the modern tools to optimize care.

Pericardial diseases in patients with cancer: contemporary prevalence, management and outcomes

Neoplastic pericardial effusion is a common and serious manifestation of advanced malignancies. Lung and breast carcinoma, haematological malignancies, and gastrointestinal cancer are the most common types of cancer involving the pericardium. Pericardial involvement in neoplasia may arise from several different pathophysiological mechanisms and may be manifested by pericardial effusion with or without tamponade, effusive-constrictive pericarditis and constrictive pericarditis. Management of these patients is a complex multidisciplinary problem, affected by clinical status and prognosis of patients.

Prognostic factors and nomogram for cancer-specific death in non small cell lung cancer with malignant pericardial effusion

Background

The prognosis of lung cancer with malignant pericardial effusion is very terrible owing to the impact of cardiac tamponade. The aim of our study seeks to identify prognostic factors and establish a prognostic nomogram of non small cell lung cancer (NSCLC) with malignant pericardial effusion.

Methods

NSCLC patients with malignant pericardial effusion between 2010 and 2014 are searched from SEER database.Cancer-specific death of these patients are analyzed through the Kaplan–Meier method, Cox proportional hazard model and competing risk model. Prognostic nomogram of cancer-specific death is performed and validated with concordance index (C-index), calibration plots and internal validation population. Propensity score matching is used to evaluate whether chemotherapy affected the survival of study population.

Results

696 eligible NSCLC patients are involved in the study population, with 22.7% of 1-year survival rate and 8.9% of 2-year survival rate. Laterality, AJCC N, AJCC T, and chemotherapy are regarded as independent prognostic factors of cancer-specific death in the Cox proportional hazards model and competing risk model. The C-index of established nomogram is 0.703(95%CI:0.68–0.73) for cancer-specific death in the study population with acceptable calibration, which is significantly higher than classical TNM stage(C-index = 0.56, 95%CI:0.52–0.60). After 1:1 propensity score matching, chemotherapy potentially reduces the risk of cancer-specific death (HR = 0.42 95%CI: 0.31–0.58) of NSCLC with pericardial effusion.

Conclusions

NSCLC with malignant pericardial effusion harbors low overall survival. One prognostic nomogram based on laterality, AJCC N, AJCC T and chemotherapy is developed for cancer-specific death to predict 1-year and 2-year survival rate with good performance.

Neoplastic Pericardial Effusion: A Monocentric Retrospective Study

Background: Neoplastic pericardial effusion (NPE) is a life-threatening condition that can worsen clinical outcome in cancer patients. The optimal management of NPE has yet to be defined because randomized studies are lacking. Objective: We report a retrospective monoinstitutional experience describing characteristics, management and prognostic factors in NPE patients. Design: We reviewed clinical, pathological, and echocardiographic features, therapeutic strategies, and outcome in NPE patients referred to our institute from August 2011 to December 2017. Measurements: Twenty-nine patients with NPE from solid tumors have been identified: 21 lung, 5 breast, and 3 other cancer patients. Results: Median age was 62 years. Most of the patients had Eastern Cooperative Oncology Group (ECOG) performance status (PS) ≥2 (69%) and a symptomatic NPE (69%). In 52% of patients NPE was detected at first diagnosis of metastatic disease, and in 20% of patients pericardium was the only site of metastases. Most of the patients (62%) received systemic therapy, 28% received combined locoregional and systemic therapy, and 10% received locoregional therapy alone. Median overall survival (OS) from NPE diagnosis was 3.9 months. Patients with PS ≥2 had worse OS than patients with better PS <2 (hazard ratio [HR] 3.56, IC 95% 1.19-10.65, p 0.02). Older age, extrapericardial disease, and NPE at progression showed a trend of association with worse OS. Patients treated with locoregional therapy alone showed the shortest median OS (p 0.05). Conclusions: NPE is related to dismal prognosis. Poor PS significantly worsens survival and influences therapeutic approaches. Randomized studies are required to investigate prognostic factors and appropriate clinical management for patients with NPE.

Determinants of Survival After Emergency Intrapericardial Cisplatin Treatment in Cancer Patients with Recurrent Hemodynamic Instability After Pericardiocentesis

BACKGROUND

Pericardial effusion is associated with high mortality in oncology. The etiology of infectious pericarditis and iatrogenic effects of previous radio-/chemotherapy may be always suspected, especially when a subsequent episode is observed.

PATIENTS AND METHODS

The study included 17 hemodynamically-unstable patients with cancer due to recurrent pericardial bloody effusion after previous pericardiocentesis and analyzed survival determinants after intrapericardial chemotherapy with cisplatin.

RESULTS

The mortality rate was not significantly associated with the level of N-terminal pro-B type natriuretic peptide, low hemoglobin (<12 g/dl), elevated white blood cell account (>10⁴/μl), large volume (>1500 ml) and long duration (>8 days) of pericardial drainage, cardiac arrhythmias, positive culture test results nor fever occurring during cisplatin administration. Subsequent systemic anticancer therapy was the strongest factor determining a longer survival (hazard ratio(HR)=0.31, 95% confidence interval(CI)=0.11-0.9; p=0.03).

CONCLUSION

Efficacy of rescue intrapericardial chemotherapy with cisplatin is independent of parameters of hemodynamic instability and levels of inflammatory markers in recurrent pericardial effusion.

The value of the new scoring system for predicting neoplastic pericarditis in the patients with large pericardial effusion

PURPOSE

Early recognition of neoplastic pericarditis (npe) is crucial for the planning of subsequent therapy. The aim of the present study was to construct the scoring system assessing the probability of npe, in the patients requiring pericardial fluid (pf) drainage due to large pericardial effusion.

METHODS

One hundred forty-six patients, 74 males and 72 females, entered the study. Npe based on positive pf cytology and/or pericardial biopsy specimen was recognised in 66 patients, non-npe in 80. Original scoring system was constructed based on parameters with the highest diagnostic value: mediastinal lymphadenopathy on chest CT scan, increased concentration of tumour markers (cytokeratin 19 fragments-Cyfra 21-1 and carcinoembryonic antigen-CEA) in pf, bloody character of pf, signs of imminent cardiac tamponade on echocardiography and tachycardia exceeding 90 beats/min on ECG. Each parameter was scored with positive or negative points depending on the positive and negative predictive values (PPV, NPV).

RESULTS

The area under curve (AUC) for the scoring system was 0.926 (95%CI 0.852-0.963) and it was higher than AUC for Cyfra 21-1 0.789 (95%CI 0.684-0.893) or CEA 0.758 (95%CI 0.652-0.864). The score optimally discriminating between npe and non-npe was 0 points (sensitivity 0.84, specificity 0.91, PPV 0.9, NPV 0.85).

CONCLUSION

Despite chest CT and tumour marker evaluation in pericardial fluid were good discriminators between npe and non-npe, the applied scoring system further improved the predicting of neoplastic disease in the studied population.

Prolonged Drainage and Intrapericardial Bleomycin Administration for Cardiac Tamponade Secondary to Cancer-Related Pericardial Effusion

Malignant pericardial effusion (MPE) is a serious complication of several cancers. The most commonly involved solid tumors are lung and breast cancer. MPE can give rise to the clinical picture of cardiac tamponade, a life threatening condition that needs immediate drainage. While simple pericardiocentesis allows resolution of the symptoms, MPE frequently relapses unless further procedures are performed. Prolonged drainage, talcage with antineoplastic agents, or surgical creation of a pleuro-pericardial window are the most commonly suggested ones. They all result in MPE resolution and high rates of long-term control. Patients suitable for further systemic treatments can have a good prognosis irrespective of the pericardial site of disease. We prospectively enrolled patients with cardiac tamponade treated with prolonged drainage associated with Bleomycin administration. Twenty-two consecutive patients with MPE and associated signs of hemodynamical compromise underwent prolonged drainage and subsequent Bleomycin administration. After injection of 100 mg lidocaine hydrochloride, 10 mg Bleomycin was injected into the pericardial space. The catheter was clumped for 48 h and then reopened. Removal was performed when the drainage volume was <25 mL daily. Twelve patients (54%) achieved complete response and 9 (41%) a partial response. Only 1 (5%) had a treatment failure and underwent a successful surgical procedure. Acute toxicity was of a low degree and occurred in 7 patients (32%). It consisted mainly in thoracic pain and supraventricular arrhythmia. The 1-year pericardial effusion progression-free survival rate was 74.0% (95% confidence interval [CI]: 51.0-97.3). At a median follow-up of 75 months, a pericardial progression was detected in 4 patients (18%). One- and two-year overall survival rates were 33.9% (95% CI: 13.6-54.2) and 14.5% (95% CI: 0.0-29.5), respectively, with lung cancer patients having a shorter survival than breast cancer patients. The worst prognosis, however, was shown in patients not suitable for systemic treatments, irrespective of the site of the primary tumor.Prolonged drainage and intrapericardial Bleomycin is a safe and effective treatment, which should be considered as first choice at least in patients suitable for active systemic treatment.

2015 update on the diagnosis and management of neoplastic pericardial disease

The best approach in diagnosis and treatment of neoplastic pericardial disease has not been defined yet. The authors report the most recent literature about the new diagnostic techniques that are useful to improve the diagnosis. The literature about the therapeutic options is critically reviewed, in order to give suggestions of use to the clinical practice. Pericardial effusion may require urgent drainage; the solid component, however, becomes predominant in some cases. Neoplastic pericardial disease should be assessed following oncologic criteria evaluation of the neoplastic burden; outcome classified as complete or partial response, stable or progressive disease and - in cases with progression - event-free survival. Systemic chemotherapy may be effective in lymphomas and possibly in breast carcinomas. Intrapericardial chemotherapy with systemic chemotherapy is the treatment of choice in lung cancer. Pericardial window with systemic chemotherapy is also effective in preventing the accumulation of large amount of fluid.

The role of early contrast-enhanced chest computed tomography in the aetiological diagnosis of patients presenting with cardiac tamponade or large pericardial effusion

AIMS

The role of chest computed tomography (CT) is not well defined for either diagnosis or management of pericardial disease. The aim of this study was to evaluate the added value of early chest CT in the diagnostic workup for patients presenting with cardiac tamponade or large pericardial effusion of unknown aetiology as the first manifestation of disease.

METHODS AND RESULTS

We performed CT scan on 55 patients with pericardial effusion as defined above, undergoing echo-guided pericardiocentesis. We compared the success rate in making diagnosis and/or staging the underlying disorder of three sequential workups, including, respectively, (i) clinical presentation, inflammatory markers, chest X-ray imaging, (ii) all of the above and pericardial fluid analysis, and (iii) all of the above and chest CT. We were able to make diagnosis in 53 patients (96%): the major cause of effusion was malignancy (38%). Clinical and biochemical data were not able to differentiate non-tumour from tumour patients. CT revealed pathological findings in all patients with malignancy: tumour mass in 15/21 (71%) and pathological lymphadenopathy in the remaining 6 cases. The workup including CT provided a significantly higher diagnostic yield than the other two workups (P < 0.0001), both in the overall population and in the two subgroups of neoplastic (Npl) and non-Npl patients.

CONCLUSION

In all patients with cardiac tamponade or large pericardial effusion, CT was useful either in identifying the underlying disease or in excluding other potential causes of pericardial effusion. We conclude that chest CT is a very useful non-invasive diagnostic tool to identify and stage pericardial diseases.

Sheep (Ovis aries) as a model for cardiovascular surgery and management before, during, and after cardiopulmonary bypass

Because of its similarity to humans in important respects, sheep (Ovis aries) are a common animal model for translational research in cardiovascular surgery. However, some unique aspects of sheep anatomy and physiology present challenges to its use in these complicated experiments. In this review, we discuss relevant anatomy and physiology of sheep and discuss management before, during, and after procedures requiring cardiopulmonary bypass to provide a concise source of information for veterinarians, technicians, and researchers developing and implementing protocols with this model.

Malignant Cardiac Tamponade from Non-Small Cell Lung Cancer: Case Series from the Era of Molecular Targeted Therapy

Cardiac tamponade complicating malignant pericardial effusion from non-small cell lung cancer (NSCLC) is generally associated with extremely poor prognosis. With improved systemic chemotherapy and molecular targeted therapy for NSCLC in recent years, the prognosis of such patients and the value of invasive cardiothoracic surgery in this setting have not been adequately examined. We report outcomes from a contemporary case series of eight patients who presented with malignant cardiac tamponade due to NSCLC to an Australian academic medical institution over an 18 months period. Two cases of cardiac tamponade were de novo presentations of NSCLC and six cases were presentations following previous therapy for NSCLC. The median survival was 4.5 months with a range between 9 days to alive beyond 17 months. The two longest survivors are still receiving active therapy at 17 and 15 months after invasive surgical pericardial window respectively. One survivor had a histological subtype of large cell neuroendocrine carcinoma and the other received targeted therapy for epidermal growth factor receptor mutation. These results support the consideration of active surgical palliation to treating this oncological emergency complicating NSCLC, including the use of urgent drainage, surgical creation of pericardial window followed by appropriate systemic therapy in suitably fit patients.

Pericarditis: pathophysiology, diagnosis, and management

Pericarditis, the most common disease of the pericardium, may be isolated or a manifestation of a systemic disease. The etiology of pericarditis is varied and includes infectious (especially viral and tuberculosis) and noninfectious causes (autoimmune and autoinflammatory diseases, pericardial injury syndromes, and cancer [especially lung cancer, breast cancer, and lymphomas]). Most cases remain idiopathic with a conventional diagnostic evaluation. A targeted etiologic search should be directed to the most common cause on the basis of the patient's clinical background, epidemiologic issues, specific presentations, and high-risk features associated with specific etiologies or complications (fever higher than 38°C, subacute onset, large pericardial effusion, cardiac tamponade, lack of response to NSAIDs). The management of pericardial diseases is largely empiric because of the relative lack of randomized trials. NSAIDs are the mainstay of empiric anti-inflammatory therapy, with the possible addition of colchicine to prevent recurrences.