Pleural and pericardial effusions in cancer patients

Video-assisted thoracoscopic management of primary pericardial Hodgkin's lymphoma

Primary pericardial Hodgkin's disease is extremely rare, increasingly so in the decades of modern imaging. We illustrate one of these atypical presentations, with absent mediastinal lymphadenectomy and with pericardial effusion successfully managed by video-assisted thorascopic surgery (VATS).

Pleural fluid cytology: immunocytochemistry usage patterns and significance of nondefinitive diagnoses

There has been little study of how pleural fluids are interpreted in actual practice, including the use of immunocytochemistry and nondefinitive diagnoses. Pleural fluid reports (n = 1,330) from 1991-1997 and the University of Iowa cancer database were retrospectively reviewed to determine the cytologic diagnosis, requisition form history, patient survival, and use of immunocytochemistry. Nondefinitive diagnoses were made in 11.3% of cases. Immunocytochemistry was used in 2.6% of cases and aided in making a definitive diagnosis in 71.9% of cases. For patients with a clinical suspicion of malignancy, the percentages of patients who had a nondefinitive, benign, and malignant diagnosis and died of disease were 81.6%, 94.0%, and 90.6%, respectively. In conclusion, if patients had a history of malignancy and a clinical suspicion of recurrence, patient survival was dismal, regardless of the cytologic diagnosis. Immunocytochemistry was used sparsely but often aided in making a definitive diagnosis.

Metastases that interfere with circulation

OBJECTIVES

To review the nursing implications of select circulatory problems caused by metastatic cancer.

DATA SOURCES

Journal articles, research studies, and book chapters relating to circulatory problems associated with metastatic disease.

CONCLUSIONS

During the metastatic process, tumor cells can interfere with circulation. As a result, circulatory impairments can range from life threatening to manifestations that may alter a person's quality of life.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses have a responsibility to seek current knowledge about therapeutic and supportive care for persons experiencing circulatory alterations. Collaboration with colleagues can facilitate patient care in these clinical situations. Patient education can be supportive and may enhance optimal outcomes.

Malignant pericardial effusion in breast cancer: terminal event or treatable complication?

BACKGROUND

Few data are available on malignant pericardial effusion (MPCE) in breast cancer. We identify the patient prone to develop MPCE describe the result of surgical management, and try to identify a subgroup of patients who do not benefit from surgical management.

METHOD

We performed an audit of our policy of active search for MPCE in breast cancer patients and its treatment by subxiphoid pericardial fenestration.

RESULT

Nineteen patients with MPCE had a mean of 3.2 other sites of recurrence: 17 had pleural recurrence. Six patients had exertional dyspnea and 13 had dyspnea at rest; three needed emergency pericardiocentesis. An average of 740 ml of fluid was recovered; cytology was diagnostic in 11 cases and histopathology in 10 cases. At discharge, six patients had no dyspnea and six had exertional dyspnea. Of 10 patients who did not receive systemic treatment, eight died within 30 days. Nine patients who received systemic treatment had an average survival of 8.3 months.

CONCLUSIONS

Patients with pleural recurrence presenting with dyspnea should be evaluated for the presence of a MPCE. Subxiphoid pericardial fenestration is the treatment of choice. Patients who will not receive systemic treatment should be managed conservatively.

Malignancy-related pericardial effusion. 127 cases from the Roswell Park Cancer Institute

BACKGROUND

Malignancy-related pericardial effusions may represent a terminal event in patients with therapeutically unresponsive disease. However, select patients with malignancies sensitive to available therapies may achieve significant improvement in palliation and long term survival with prompt recognition and appropriate intervention.

METHODS

From 1968 to 1994, 150 invasive procedures were performed for the treatment or diagnosis of pericardial effusion in 127 patients with underlying malignancies. These cases were reviewed retrospectively to best identify the clinical features, appropriate diagnostic workup, and optimal therapy for this complication of malignancy.

RESULTS

Dyspnea (81%) and an abnormal pulsus paradoxus (32%) were the most common symptoms. Echocardiography had a 96% diagnostic accuracy. Cytology and pericardial biopsy had sensitivities of 90% and 56%, respectively. Fifty-five percent of all effusions were malignant comprising 71% of adenocarcinomas of the lung, breast, esophagus, and unknown primary site. In 57 patients, a malignant effusion could not be determined, and no definitive etiology could be established for 74% of these effusions. Radiation-induced, infectious, and hemorrhagic pericarditis each were identified in fewer than 5% of cases.

CONCLUSIONS

Subxyphoid pericardiotomy proved to be a safe and effective intervention that successfully relieved pericardial effusions in 99% of cases with recurrence and reoperation rates of 9% and 7%, respectively. Survival most closely was related to the extent of disease and its inherent chemo-/radiosensitivity, with 72% of the patients who survived longer than 1 year having breast cancer, leukemia, or lymphoma.

Cardiac tamponade as the initial manifestation of primary pericardial mesothelioma

Although cardiac tamponade is a known complication of malignancy, it is rarely the initial manifestation. We report a 46-year-old male who presented with malignant cardiac tamponade 6 months prior to the definitive diagnosis of primary pericardial mesothelioma. A thorough literature search has not revealed a similar care.

Management and prevention of thromboembolic events in patients with cancer-related hypercoagulable states: a risky business

OBJECTIVE

To determine the optimal strategy for managing and preventing thromboembolic events in malignancy-associated hypercoagulable states.

DESIGN

A Markov-based decision and cost-effectiveness analysis was performed. The authors explicitly considered consequences of embolic and bleeding events, filter complications, and cancer-related excess mortality. Data were drawn from the current literature. The main outcome measure for each strategy was the quality-adjusted life expectancy and the total average variable costs.

SUBJECTS

Patients with advanced malignancies prone to develop thromboembolic events, patients with acute proximal deep venous thrombosis (DVT), and patients who have survived a first episode of pulmonary embolism (PE).

INTERVENTIONS

The authors considered three different interventions: 1) OBSERVATION, in which neither anticoagulant therapy nor filter placement is pursued, 2) ANTICOAGULATION, in which long-term anticoagulant therapy is started immediately, and 3) VENA CAVAL FILTER.

MAIN RESULTS

Vena caval filter was the preferred strategy for every malignancy studied, yielding an 11% gain in quality-adjusted life expectancy, compared with observation, for patients with acute DVT, and an 18% gain for patients having survived a PE. Anticoagulant therapy yielded gains of 9% and 16%, respectively. Compared with anticoagulant therapy, filter was less costly due to the avoidance of additional expenses incurred by bleeding events. Prophylactic therapy was the least effective of the three strategies examined.

CONCLUSIONS

Vena caval filter placement and long-term anticoagulation therapy yield similar outcomes in the setting of cancer-related hypercoagulable states. However, filter insertion is less expensive than anticoagulation. Given the short life expectancy and morbidity of patients with end-stage malignancy, patient preferences for health states must be considered in the decision-making process. If active treatment is pursued, vena caval filter should be used as a primary therapy. Prophylactic therapy is not warranted in any circumstance.

Malignant pericardial effusion in endometrial adenocarcinoma

A case of endometrial adenocarcinoma in a 62-year-old woman with malignant pericardial effusion is presented. The patient underwent a total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic node dissection, and paraaortic node biopsy. Postoperatively, she was placed on a combination chemotherapy regimen of cisplatin, doxorubicin, and cyclophosphamide. The patient developed cardiac tamponade during the course of chemotherapy. Although we first suspected cardiotoxic effect of doxorubicin, cytologic examination revealed adenocarcinoma cells in the pericardial fluid. A review of the literature revealed no other cases of cardiac metastasis from endometrial carcinoma diagnosed during life.

Malignant pleural effusions

Pleural effusions are common in cancer patients, developing either from the malignant condition or from unrelated causes, such as congestive heart failure, pulmonary infarction, or infection. Diagnosis of malignant pleural effusion rests on demonstration of the presence of malignant cells in the pleural fluid or pleural biopsy specimen. Treatment is usually aimed at relief of symptoms rather than at the underlying malignancy. Specific therapeutic measures include thoracentesis, chest tube drainage, pleurodesis with chemicals or biologic agents, radiation and systemic chemotherapy, surgical pleurodesis, and pleuroperitoneal shunt. These should be supplemented by ancillary measures to maintain fluid and nutritional balance and prevent complications.