Update on diagnosis and management of neoplastic pericardial disease

Multicolor flow cytometry on pericardial effusion for a prompt diagnosis and treatment of hematological malignancies with heart involvement

Background

Malignancies represent 15–50% of total causes of pericardial effusions (PE). Routine analyses recommended to be performed on pericardial fluid include general chemistry, cytology, polymerase chain reaction, and microbiological cultures. Multicolor flow cytometry (FC) is a laboratory test that already proved to be useful in the detection of lymphoproliferative and metastatic malignancies in pleural and peritoneal effusions, but current guidelines do not mention its use on PE to reach a diagnosis.

Methods

Our institutional protocol foresees to routinely perform a multicolor FC analysis on pericardial fluid samples obtained by pericardiocentesis, in addition to other guidelines-recommended analyses. A sample of 15–30 ml is analyzed using a lyse and wash staining method using combination panels of antibodies, allowing to detect specific cellular subpopulations, analyzing tens to hundreds of thousands of cells in few seconds. The present manuscript aims to report our single-center experience with this diagnostic tool in patients presenting with PE requiring pericardiocentesis.

Results

Routine use of multicolor FC on pericardial fluid samples in our institution allowed to reach a definite diagnosis of cardiac lymphomas in two patients presenting with otherwise unexplained severe PE. This resulted in immediate start of combined immunotherapy, with patients’ clinical improvement. At 6 months follow-up both patients are alive and presented a complete disease regression.

Conclusion

Preliminary evidence from routine use of multicolor FC on PE support that this is a promising tool to reach a rapid diagnosis of hematological malignancies with heart involvement, leading to a prompt initiation of targeted therapies.

Chronic pericardial effusion: current concepts and emerging trends

INTRODUCTION

Pericardial effusion (PEF) is a common and challenging pericardial syndrome with a variety of clinical manifestations ranging from asymptomatic, incidentally uncovered small PEFs, to life-threatening cardiac tamponade.

AREAS COVERED

: This review focuses on the pathophysiology, epidemiology, etiology, classification, clinical findings, diagnostic work-up, management and outcome of PEFs. Particular emphasis has been given on the most recent evidence concerning the contribution of imaging for the detection, differential diagnosis and evaluation of the hemodynamic impact of PEFs on the diastolic filling of the heart. Moreover, simplified algorithms for PEF triage and management have been included.

EXPERT OPINION

The management of patients with PEFs is mainly based on four parameters namely hemodynamic impact on diastolic function, elevation of inflammatory markers, presence of a specific underlying condition known to be associated with PEF and finally size and duration of the effusion. Novel data have contributed to change our view towards large, asymptomatic, "idiopathic" PEFs and dictated a rather conservative approach in most cases. It is also stressed that there is a compelling need for additional research, which is essential for tailored treatments aiming at the improvement of quality of life and containment of health care costs.

Is the heart involved or not? The diagnostic value of cardiovascular magnetic resonance imaging in the assessment of non-cardiac malignancies and metastatic cardiac tumours

Cardiovascular magnetic resonance (CMR) is a radiation-free, high-spatial resolution technique which provides dynamic assessment of the heart and pericardial tissue. This is particularly useful for the evaluation and characterisation of non-cardiac tumours close to the pericardium for the exclusion of cardiovascular infiltration, and also for the assessment of the extent of myocardial invasion of cardiac metastases. This information can help make key decisions on further management in oncology multidisciplinary meetings. The CMR evaluation and main types of sequences acquired are detailed in this case series to illustrate the application of CMR in the assessment of non-cardiac malignancies and its importance in guiding management.

Pericarditis and pericardial effusion: one or two distinct diseases?

The main pericardial syndromes include acute and recurrent pericarditis, constrictive pericarditis and chronic pericardial effusion in the absence of overt inflammation. Despite recent advances in pericardial syndromes, certain clinical scenarios depict remarkable peculiarities and their management is often challenging for the clinician. Acute pericarditis is the most common pericardial disease and in most instances is accompanied by pericardial effusion. On the other hand, pericardial effusion may appear as a separate clinical entity occasionally characterized by absence of inflammatory markers elevation. In cases that effusions are accompanied by C-reactive protein (CRP) elevation, the administration of empiric anti-inflammatory treatment as in acute pericarditis, is the guidelines recommended approach. Conversely, the optimal management of patients with pericardial effusions in the absence of clinical or subclinical inflammation (as depicted by CRP levels and cardiac magnetic resonance findings), is not supported by solid evidence. Patients with chronic pericardial effusions should be followed in specialized centers according to tailored timelines, based on the specific clinical scenarios which should take into account etiology, effusion size, disease duration and stability as regards symptoms and effusion volume. Patients should also be advised to seek medical care at any time if symptoms like chest pain, dyspnea and fatigue should appear.

A Clinico-Pathologic Approach to the Differential Diagnosis of Pericardial Tumors

PURPOSE OF REVIEW

Tumors of the pericardium are rare, but a wide variety of congenital, infectious, inflammatory, and neoplastic processes have been reported. Pericardial tumors can be categorized as non-neoplastic or neoplastic. Neoplastic lesions can be further divided into benign or malignant, with malignancies being either primary or secondary (metastatic). Clinical, radiographic, and pathologic features of the most common entities are discussed.

RECENT FINDINGS

Metastatic neoplasms involving the heart and pericardium are far more common than primary pericardial neoplasms. Of primary pericardial malignancies, mesothelioma is the most common; notably, cytology of effusion fluid is relatively insensitive to the diagnosis. The prognosis for most malignancies of the pericardium, primary or secondary, is poor. Increasingly, clinically recognized diseases that involve the pericardium include Erdheim-Chester and IgG4-related disease. This article provides a comprehensive review of the most recent literature to develop a structured framework to the differential diagnosis of pericardial tumors.

Recurrent pericarditis: an update on diagnosis and management

Recurrent pericarditis is a true challenge for clinicians, especially when the patient becomes unresponsive or not tolerant to conventional treatments. An accurate diagnosis of recurrent pericarditis, possibly supported by advanced imaging tools, is critical to provide timely and appropriate treatment of symptoms and prevention of further episodes. The incessant research on the inflammatory pathways underlying cardiovascular diseases, led recently to the assessment of anti interleukin-1 agents in the setting of recurrent pericarditis. This review will focus on the diagnostic assessment of recurrent pericarditis, along with the most modern therapeutic advances in this field. Bibliographic databases were searched (MEDLINE/PubMed, BioMed Central, the Cochrane Collaboration Database of Randomized Trials, Scopus, ClinicalTrials.gov, EMBASE, Google Scholar) using the terms "recurrent pericarditis" AND "diagnosis" OR "treatment" OR "IL-1" OR "inflammation".