Chronic myelomonocytic leukemia primarily presenting as life-threatening pericardial effusion, Eldoret, Kenya: A case report

Key Clinical Message

Chronic myelomonocytic leukemia, a rare case of hematological malignancy mainly affects the elderly and may present with life threatening pericardial effusion as an initial manifestation. High index of suspicion is hence key for early management.

Abstract

We present a case of an 81-year-old African male who presented with progressive cough, respiratory distress and bilateral lower limb swelling, and was diagnosed with life-threatening pericardial effusion resulting from chronic myelomonocytic leukemia following complete blood count, peripheral blood film, bone marrow aspirate with trephine biopsy, and flow cytometry studies.

Successful Management of Malignant Pericarditis Using Nivolumab for Metastatic Esophageal Squamous Cell Carcinoma

Esophageal cancer is a malignant disease with a poor prognosis and is one of the most common causes of cardiac metastasis. Malignant pericarditis may cause the repetitive accumulation of pericardial effusion, which can occasionally pose a clinical challenge. We herein report a case of malignant pericarditis in a patient with metastatic esophageal squamous cell carcinoma with cardiac tamponade, which was successfully managed with single pericardial drainage and systemic nivolumab monotherapy. This is the first case report to suggest that systemic therapy with nivolumab is a promising option for the management of malignant pericarditis.

Pericardial effusion in oncological patients: current knowledge and principles of management

BACKGROUND

This article provides an up-to-date overview of pericardial effusion in oncological practice and a guidance on its management. Furthermore, it addresses the question of when malignancy should be suspected in case of newly diagnosed pericardial effusion.

MAIN BODY

Cancer-related pericardial effusion is commonly the result of localization of lung and breast cancer, melanoma, or lymphoma to the pericardium via direct invasion, lymphatic dissemination, or hematogenous spread. Several cancer therapies may also cause pericardial effusion, most often during or shortly after administration. Pericardial effusion following radiation therapy may instead develop after years. Other diseases, such as infections, and, rarely, primary tumors of the pericardium complete the spectrum of the possible etiologies of pericardial effusion in oncological patients. The diagnosis of cancer-related pericardial effusion is usually incidental, but cancer accounts for approximately one third of all cardiac tamponades. Drainage, which is mainly attained by pericardiocentesis, is needed when cancer or cancer treatment-related pericardial effusion leads to hemodynamic impairment. Placement of a pericardial catheter for 2-5 days is advised after pericardial fluid removal. In contrast, even a large pericardial effusion should be conservatively managed when the patient is stable, although the best frequency and timing of monitoring by echocardiography in this context are yet to be established. Pericardial effusion secondary to immune checkpoint inhibitors typically responds to corticosteroid therapy. Pericardiocentesis may also be considered to confirm the presence of neoplastic cells in the pericardial fluid, but the yield of cytological examination is low. In case of newly found pericardial effusion in individuals without active cancer and/or recent cancer treatment, a history of malignancy, unremitting or recurrent course, large effusion or presentation with cardiac tamponade, incomplete response to empirical therapy with nonsteroidal anti-inflammatory, and hemorrhagic fluid at pericardiocentesis suggest a neoplastic etiology.

The BALTO Registry: Long-term results of percutaneous BALloon pericardioTomy in oncological patients

OBJECTIVES

The aim of this study was to analyze the efficacy and safety of percutaneous balloon pericardiotomy (PBP) in oncological patients who present with a malignant pericardial effusion (MPE).

BACKGROUND

The use of PBP as a treatment for MPE is not standardized due to the limited evidence. Furthermore, the performance of a second PBP for a recurrence after a first procedure is controversial.

METHODS

The BALTO Registry (BALloon pericardioTomy in Oncological patients) is a prospective, single-center, observational registry that includes consecutive PBP performed for MPE from October 2007 to February 2022. Clinical and procedural, characteristics, as well as clinical outcome were analyzed.

RESULTS

Seventy-six PBP were performed in 61 patients (65% female). Mean age was of 66.4 ± 11.2 years. In 15 cases, a second PBP procedure was performed due to recurrence despite the first PBP. The procedure could be performed effectively in all cases with only two serious complications. Ninety-five percent of cases were discharged alive from the hospital. During a median follow-up of 6.3 months (interquartile range [IQR], 0.9-10.8), MPE recurred in 24.5% cases although no recurrences were reported after the second procedure. No evidence of malignant pleural effusion developed on follow-up. The median overall survival time was 5.8 months (IQR, 0.8-10.2) and the time to recurrence after the first PBP was 2.4 months (IQR, 0.7-4.5).

CONCLUSIONS

PBP is a safe and effective treatment for MPE. It could be considered an acceptable therapy in most MPE, even in those who recur after a first procedure.

In-hospital adverse events and recurrence in hospitalized patients with acute pericarditis

BACKGROUND

Acute pericarditis occasionally requires invasive treatment, and may recur after discharge. However, there are no studies on acute pericarditis in Japan, and its clinical characteristics and prognosis are unknown.

METHODS

This was a single-center, retrospective cohort study of clinical characteristics, invasive procedures, mortality, and recurrence in patients with acute pericarditis hospitalized from 2010 to 2022. The primary in-hospital outcome was adverse events (AEs), a composite of all-cause mortality and cardiac tamponade. The primary outcome in the long-term analysis was hospitalization for recurrent pericarditis.

RESULTS

The median age of all 65 patients was 65.0 years [interquartile range (IQR), 48.0-76.0 years], and 49 (75.3 %) were male. The etiology of acute pericarditis was idiopathic in 55 patients (84.6 %), collagenous in 5 (7.6 %), bacterial in 1 (1.5 %), malignant in 3 (4.6 %), and related to previous open-heart surgery in 1 (1.5 %). Of the 8 patients (12.3 %) with in-hospital AE, 1 (1.5 %) died during hospitalization and 7 (10.8 %) developed cardiac tamponade. Patients with AE were less likely to have chest pain (p = 0.011) but were more likely to have symptoms lasting 72 h after treatment (p = 0.006), heart failure (p < 0.001), and higher levels of C-reactive protein (p = 0.040) and B-type natriuretic peptide (p = 0.032). All patients complicated with cardiac tamponade were treated with pericardial drainage or pericardiotomy. We analyzed 57 patients for recurrent pericarditis after excluding 8 patients: 1 with in-hospital death, 3 with malignant pericarditis, 1 with bacterial pericarditis, and 3 lost to follow-up. During a median follow-up of 2.5 years (IQR 1.3-3.0 years), 6 patients (10.5 %) had recurrences requiring hospitalization. The recurrence rate of pericarditis was not associated with colchicine treatment or aspirin dose or titration.

CONCLUSIONS

In acute pericarditis requiring hospitalization, in-hospital AE and recurrence were each observed in >10 % of patients. Further large studies on treatment are warranted.

A Rare First Presentation of Hodgkin's Lymphoma: Symptomatic Pericardial Effusion

Symptomatic pericardial effusion occurring as the initial manifestation of Hodgkin's lymphoma is exceedingly uncommon, and there are limited documented instances in the available literature. Pericardial effusion can present various differential diagnoses, and among these, malignancy is an important yet less frequently encountered cause. A heightened level of suspicion is crucial for establishing an accurate diagnosis, particularly when the patient's clinical course deviates from the anticipated trajectory. Through this case, we aim to emphasize the significance of considering lymphoproliferative diseases as a pertinent possibility in the differential diagnosis of pericardial effusion. Additionally, we underscore the importance of promptly reaching a diagnosis, as it can help prevent severe complications and enhance the patient's prognosis.

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.

Effects of intrapericardial administration after catheter drainage on malignant pericardial effusion in non-small cell lung cancer: A real-world study

BACKGROUND

Malignant pericardial effusion (MPE) is a serious complication of cancer that can be potentially deadly. It usually occurs in advanced or terminal stages of the disease, and as a result, patients with MPE often have a poor prognosis. There is a limited amount of research available that directly compares the effectiveness and safety of intrapericardial drug administration following pericardial drainage versus catheter drainage alone in non-small cell lung cancer (NSCLC) patients who have MPE.

METHODS

We retrospectively included 86 patients with NSCLC with MPE at Zhejiang Cancer Hospital. Survival and recurrence estimates were determined with the Kaplan-Meier method.

RESULTS

We divided the 86 patients with NSCLC into two groups: a pericardial drainage group (34 out of 86, 39.5%) and an intrapericardial administration group (52 out of 86, 60.5%). The response rates were 70.6% and 76.9% (p = 0.510), respectively. The median OS was 132.0 and 234.0 days (p = 0.579), respectively. The median time to recurrent drainage was 43.0 and 104.0 days (p = 0.170), respectively. The incidence of adverse events (AEs) was 44.1% and 61.5% (p = 0.113), respectively. The most frequent AEs were pain (27.9%) and fever (24.4%). Additionally, two patients in the intrapericardial administration group died of cardiac arrest.

CONCLUSIONS

Compared with catheter drainage alone, intrapericardial medication infusion during catheter drainage did not have significantly different effects. AEs require close monitoring and management.

Acute Oncologic Complications: Clinical-Therapeutic Management in Critical Care and Emergency Departments

Introduction. It is now known that cancer is a major public health problem; on the other hand, it is less known, or rather, often underestimated, that a significant percentage of cancer patients will experience a cancer-related emergency. These conditions, depending on the severity, may require treatment in intensive care or in the emergency departments. In addition, it is not uncommon for a tumor pathology to manifest itself directly, in the first instance, with a related emergency. The emergency unit proves to be a fundamental and central unit in the management of cancer patients. Many cancer cases are diagnosed in the first instance as a result of symptoms that lead the patient's admittance into the emergency room. Materials and Methods. This narrative review aims to analyze the impact of acute oncological cases in the emergency setting and the role of the emergency physician in their management. A search was conducted over the period January 1981-April 2023 using the main scientific platforms, including PubMed, Scopus, Medline, Embase and Google scholar, and 156 papers were analyzed. Results. To probe into the main oncological emergencies and their management in increasingly overcrowded emergency departments, we analyzed the following acute pathologies: neurological emergencies, metabolic and endocrinological emergencies, vascular emergencies, malignant effusions, neutropenic fever and anemia. Discussion/Conclusions. Our analysis found that a redefinition of the emergency department connected with the treatment of oncology patients is necessary, considering not only the treatment of the oncological disease in the strict sense, but also the comorbidities, the oncological emergencies and the palliative care setting. The need to redesign an emergency department that is able to manage acute oncological cases and end of life appears clear, especially when this turns out to be related to severe effects that cannot be managed at home with integrated home care. In conclusion, a redefinition of the paradigm appears mandatory, such as the integration between the various specialists belonging to oncological medicine and the emergency department. Therefore, our work aims to provide what can be a handbook to detect, diagnose and treat oncological emergencies, hoping for patient management in a multidisciplinary perspective, which could also lead to the regular presence of an oncologist in the emergency room.

Cardiac tamponade

Cardiac tamponade is a medical emergency caused by the progressive accumulation of pericardial fluid (effusion), blood, pus or air in the pericardium, compressing the heart chambers and leading to haemodynamic compromise, circulatory shock, cardiac arrest and death. Pericardial diseases of any aetiology as well as complications of interventional and surgical procedures or chest trauma can cause cardiac tamponade. Tamponade can be precipitated in patients with pericardial effusion by dehydration or exposure to certain medications, particularly vasodilators or intravenous diuretics. Key clinical findings in patients with cardiac tamponade are hypotension, increased jugular venous pressure and distant heart sounds (Beck triad). Dyspnoea can progress to orthopnoea (with no rales on lung auscultation) accompanied by weakness, fatigue, tachycardia and oliguria. In tamponade caused by acute pericarditis, the patient can experience fever and typical chest pain increasing on inspiration and radiating to the trapezius ridge. Generally, cardiac tamponade is a clinical diagnosis that can be confirmed using various imaging modalities, principally echocardiography. Cardiac tamponade is preferably resolved by echocardiography-guided pericardiocentesis. In patients who have recently undergone cardiac surgery and in those with neoplastic infiltration, effusive-constrictive pericarditis, or loculated effusions, fluoroscopic guidance can increase the feasibility and safety of the procedure. Surgical management is indicated in patients with aortic dissection, chest trauma, bleeding or purulent infection that cannot be controlled percutaneously. After pericardiocentesis or pericardiotomy, NSAIDs and colchicine can be considered to prevent recurrence and effusive-constrictive pericarditis.

Continuous drainage for the treatment of gastric cancer with pericardial metastasis and cardiac tamponade: A case report

Key Clinical Message

Signet-ring cell gastric carcinomas presenting as pericardial effusion early in diagnosis are rare and associated with high mortality and a poor prognosis. There are two interesting aspects of this case: primary gastric carcinoma presenting as cardiac tamponade and the metastatic behavior of gastric signet-ring cell carcinoma.

Abstract

This report describes an 83-year-old man diagnosed to have cardiac tamponade due to massive pericardial effusion. A cytological analysis of the pericardial effusion disclosed adenocarcinoma. The patient was treated with continuous pericardial drainage and the amount of pericardial effusion decreased.

Malignant Pericardial Effusion due to Colorectal Cancer in a Young Man

A 28-year-old man presented with sudden-onset right lower quadrant abdominal pain and shortness of breath at rest. On examination, he had tachycardia with distant heart sounds and right lower quadrant tenderness. A computed tomography scan showed segmental thickening of the proximal ascending colon and ileum with proximal cecal distension. Echocardiogram confirmed large pericardial effusion with impending tamponade. Video-assisted thoracoscopic surgery was performed for pericardial fluid drainage from a pericardial window. The mediastinal lymph node biopsy revealed metastatic adenocarcinoma cells. A colonoscopy showed a large polypoidal mass in the ascending colon with biopsy confirming poorly differentiated adenocarcinoma, thereby suggesting a possible lymphatic or hematogenous spread without liver or lung involvement.

Fixed right ventricular collapse: A loculated pericardial effusion due to metastatic pulmonary adenocarcinoma

Pericardial effusions can occur as either circumferential or loculated when referencing their anatomic distribution in the pericardium. These effusions can result from multiple different etiologies, including malignancy, infection, trauma, connective tissue disease, acute pericarditis drug induced, or idiopathic. Loculated pericardial effusions can be difficult to manage. Even small loculated effusions can result in hemodynamic compromise. Oftentimes in the acute setting, point of care ultrasound can be used to evaluate pericardial effusions directly at the bedside. We present a case of a malignant loculated pericardial effusion and offer insight into management and clinical evaluation using point of care ultrasound.

Diagnosis, treatment, and management of pericardial effusion- review

The hemodynamic stability of the heart and pericardium are maintained by the pericardial fluid of volume ∼10–50 ml. Pericardial effusion is associated with the abnormal accumulation of pericardial fluid in the pericardial cavity. Numerous imaging techniques are utilized to evaluate pericardial effusion including chest X-ray, electrocardiogram, transthoracic echocardiography, computed tomography scan, cardiac magnetic resonance imaging, and pericardiocentesis. Once diagnosed, there are numerous treatment options available for the management of patients with pericardial effusion. These include various invasive and non-invasive strategies such as pericardiocentesis, pericardial window, and sclerosing therapies. In recent times, few studies have been conducted to evaluate the safety and efficacy of each approach in routine clinical practice. In this review, we review the role of different modalities in the diagnosis of pericardial effusion while highlighting existing therapies aimed at the management and treatment of pericardial effusion.

•

Numerous imaging techniques are utilized to evaluate pericardial effusion (PE) including chest X-ray, electrocardiogram, transthoracic echocardiography, CT scan, cardiac MRI, and pericardiocentesis.

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Multiple treatment options are available for the management of patients with PE including pericardiocentesis, pericardial window, and sclerosing therapies.

•

Recent studies have evaluated the safety and efficacy of various diagnostic and management techniques in routine clinical practice.

•

Further research is needed to investigate the optimal diagnostic and treatment options for patients with PE.

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.

Malignant cardiac tamponade: safety and efficacy of intrapericardial bleomycin instillation

BACKGROUND

Malignant cardiac tamponade is a life-threatening condition that requires prompt treatment and effective management to prevent recurrence. This paper describes safety and efficacy outcomes after intrapericardial instillation of bleomycin as well as possible predictors of survival.

METHODS

We performed a 10-year retrospective, single-center study to evaluate the safety and efficacy of intrapericardial instillation of bleomycin in patients with suspected malignant cardiac tamponade.

RESULTS

Intrapericardial instillation of bleomycin was performed in 31 cancer patients (9 men, 22 women) presenting with cardiac tamponade. Non-fatal complications occurred in 3 patients and relapse occurred in 1 patient. Overall survival was less than 10% at the end of the study. Median survival was 104 days (95% CI, 0-251 days). Survival was compared between different groups (defined by primary tumor, type of tumor, TNM stage and results of cytological analysis) with median survival being considerably higher when oncologic therapy was altered afterwards.

CONCLUSIONS

The use of intrapericardial bleomycin instillation following pericardiocentesis for malignant cardiac tamponade is a safe procedure with a high success rate. Survival rates depend on further oncological treatment options available.

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.

Massive pericardial effusion as the first manifestation of childhood non-Hodgkin's lymphoma: A case report

Although one of the serious manifestations of advanced malignancies is pericardial involvement, pericardial involvement of lymphoma is extremely rare. We present a case of a 6-year-old girl arriving at the hospital with dyspnea and pleuritic chest pain, which is eventually diagnosed with massive pericardial effusion due to mediastinal non-Hodgkin lymphoma.

Malignant pericardial effusion as a primary manifestation of metastatic colon cancer: a case report

Background

Pericardial neoplastic involvement is rarely related to primary tumors of the pericardium and is most often caused by spread from other primary sites, such as lung and breast carcinomas, hematological malignancies (lymphoma and leukemia), and melanoma. Although pericardial metastasis from infradiaphragmatic tumors (such as colon cancers) are rare and poorly described in literature, any neoplasm has the potential to metastasize to the pericardium and heart by either contiguity, lymphatic, or hematological spread.

Case presentation

A 44-year-old previously healthy male Causasian patient had a sudden onset of dyspnea and wheezing. During investigation with echocardiogram, computed tomography and repeated pericardiocentesis, the cause of malignant pericardial effusion was confirmed as primary manifestation of metastatic colon cancer. The patient was treated with appropriate chemotherapy and presented satisfactory disease control.

Conclusions

This report emphasizes the importance of considering the diagnostic hypothesis of occult neoplasia in a patient with pericardial effusion.

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.

Cardiac tamponade as the first presentation of thymoma: A case report during COVID-19 pandemic

We report a case of neoplastic cardiac tamponade, a life-threatening condition, as the initial presentation of an anterior mediastinal malignancy. A 69-year-old gentleman with no known history of malignancy presented to the emergency department with shortness of breath, reduced effort tolerance and chronic cough. Clinically, he was not in distress but tachycardic. He was subjected to echocardiography which revealed large pericardial effusion with tamponade effect. Pericardiocentesis drained 1.5 L of haemoserous fluid. CECT thorax, abdomen and pelvis revealed an anterior mediastinal mass with intrathoracic extension complicated with mass effect onto the right atrium and mediastinal vessels. Ultrasound-guided biopsy histopathology examination revealed thymoma. Due to locally advanced disease, tumour resection was not possible, and patient was referred to oncology team for chemoradiotherapy. We report this case study not only due to the rarity of the case but also to highlight its diagnostic challenge due to the COVID-19 pandemic.

Cardiac Tamponade as a Manifestation of Clear Cell Renal Cell Carcinoma

Some solid cancers (such as lung, breast, and esophageal cancer, and melanoma) can lead to pericardial effusion by metastatic spread, potentially provoking hemodynamic instability. Detection by echocardiography is therefore essential. Pericardiocentesis can help restore cardiac function and provide fluid for establishing an etiology through cytological, microbiological, and cellularity analysis. A 60-year-old woman with metabolic syndrome and obesity hypoventilation syndrome presented to the emergency department with dyspnea at rest. A chest X-ray showed cardiomegaly and massive left pleural effusion. Ultrasound findings were pericardial effusion with signs of cardiac tamponade. We performed pericardiocentesis, extracting 1000 mL of exudate, and thoracentesis, which confirmed the diagnosis of lymphocytic exudative effusion. A CAT (computerized tomography) scan of the chest, abdomen, and pelvis revealed a left kidney mass. A biopsy of the mass confirmed the diagnosis of clear cell renal cell carcinoma and a pleural biopsy revealed metastatic involvement. This report describes a rare presentation of cardiac tamponade due to clear cell renal cell carcinoma and discusses the pathogenesis, mechanisms, and prognosis of this condition.

Impact of pericardial fluid glucose level and computed tomography attenuation values on diagnosis of malignancy-related pericardial effusion

Background

We evaluated malignancy according to the characteristics of pericardial fluid in symptomatic Japanese patients undergoing pericardiocentesis and computed tomography (CT).

Methods

This was a retrospective, single-center, observational study of 125 symptomatic patients undergoing pericardiocentesis. The patients were classified into two groups: a malignancy group and a non-malignancy group, according to the primary disease and cytology of the pericardial effusion (PE). We compared the pericardial fluid sample and CT measurements between both groups.

Results

All patients were diagnosed as having exudative PE by Light’s criteria. PE with malignant cells was demonstrated in 76.8% of the malignancy group patients. Pericardial to serum lactate dehydrogenase (LDH) ratio > 0.6, as one of Light’s criteria, was associated with malignancy (p = 0.017). Lower serum brain natriuretic peptide (BNP) concentration was also associated with malignancy (BNP: 126.9 ± 89.8 pg/ml vs 409.2 ± 97.7 pg/ml, malignancy vs non-malignancy groups, respectively; p = 0.037). A significant difference was observed in pericardial fluid glucose level between the malignancy and non-malignancy groups (pericardial fluid glucose: 78.24 ± 48.29 mg/dl vs 98.41 ± 44.85, respectively; p = 0.048). Moreover, CT attenuation values (Hounsfield units (HU)) tended to be higher in the malignancy group vs the non-malignancy group (22.7 [interquartile range (IQR), 17.4–26.0] vs 17.4 [IQR, 13.7–26.4], respectively; p = 0.08). The sensitivity and specificity of pericardial fluid glucose level ≤ 70 mg/dl and CT attenuation values > 20 HU were 40.9% and 89.6%, respectively, in the malignancy group. The positive- and negative predictive values of pericardial fluid glucose level ≤ 70 mg/dl and CT attenuation values > 20 HU were 85.7% and 50.0%, respectively, in the malignancy group. Pericardial fluid glucose level ≤ 70 mg/dl and CT attenuation values > 20 HU were cutoff values associated with malignancy (p = 0.012).

Conclusions

Lower pericardial fluid glucose level with higher CT attenuation values may suggest malignancy-related PE.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02091-6.

Pericardial Involvement in Cancer

Despite the monumental advances in the diagnoses and therapeutics of malignancy, several cancer patients have presented with pericardial involvement, including acute pericarditis, constrictive pericarditis, and pericardial effusion. Multiple factors can contribute to acute pericarditis, including direct metastasis to the heart, pericardial hemorrhage, infections due to immunosuppression, and cancer therapies that include chemotherapy, immunotherapy, and radiation. Pericardial effusion, either due to cancer invasion or cancer treatment, is one of the most common incidental findings in cancer patients, which significantly worsens morbidity and mortality. If left untreated, pericardial effusion is known to cause complications such as pericardial tamponade. Constrictive pericarditis can be due to radiation exposure, chemotherapy, or is a sequela of a previous episode of acute pericarditis. In conclusion, early detection, prompt treatment, and understanding of pericardial diseases are necessary to help improve the quality of life of cancer patients, and we aim to summarize the knowledge of pericardial involvement in patients with cancer.

Pericardial Effusions in Patients With Cancer: Anesthetic Management and Survival Outcomes

OBJECTIVES

The objective of this study was to describe practice patterns of anesthetic management during pericardial window creation.

DESIGN

Retrospective observational cohort study.

SETTING

Single tertiary cancer center.

PARTICIPANTS

A total of 150 patients treated for cancer between 2011 and 2015 were included in the study.

MEASUREMENTS AND MAIN RESULTS

The primary objective was to evaluate anesthetic management in pericardial window creation. Secondary outcomes were 30-day mortality and overall survival after pericardial window creation. Thirty-day mortality was 19.3%, and median survival was 5.84 months. Higher American Society of Anesthesiologists (ASA) physical status of patients was associated with preinduction arterial line placement (51% ASA 3 v 79% ASA 4; p = 0.002) and use of etomidate for anesthetic induction (34% ASA 3 v 60% ASA 4; p = 0.003). However, there was no association between anesthetic management and presence of tamponade in these patients. Cardiac aspirate volume (per 10 mL: odds ratio [OR], 1.02 [95% CI, 1.0-1.04]; p = 0.026) and intraoperative arrhythmia (atrial fibrillation: OR, 6.76 [95% CI, 1.2-37.49]; p = 0.029; sinus tachycardia: OR, 4.59 [95% CI, 1.25-16.90]; p = 0.022) were associated independently with increased 30-day mortality. High initial heart rate (per 10 beats per minute: hazard ratio [HR], 1.18 [95% CI, 1.05-1.33]; p = 0.005) in the operating room and intraoperative sinus tachycardia (HR, 1.86 [95% CI, 1.15-3.03]; p = 0.012) were associated independently with worse overall survival.

CONCLUSION

Risk of death after pericardial window creation remains high in patients with cancer. Variations in anesthetic management did not affect survival in oncologic patients with pericardial effusions.

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.

Fluorodeoxyglucose positron emission tomography/computed tomography identifying pericardial metastasis from early-stage p16-positive oropharyngeal cancer

Pericardial metastasis from HPV-positive oropharyngeal squamous cell carcinoma (OPSCC) without local recurrence is extremely rare. We report about a 69-year-old man exhibiting pericardial metastasis on positron emission tomography/computed tomography (PET/CT). There are currently no reports on the use of PET/CT in patients with pericardial metastasis from p16-positive OPSCCs.

Surgical treatment of cardiac tamponade developed in two patients with terminal stage lung cancer

Introduction: Although tamponade due to pericardial effusion that develops in advanced stage lung cancer is rare, it is a life-threatening complication. Case report: 59 and 72 years old 2 female patients diagnosed with cardiac tamponade were hospitalized in Cardiology Clinic of Balækesir State Hospital. Massive pericardial effusion that caused diastolic collapse of right ventricle was detected in their echocardiographies. Inoperable lung cancer was diagnosed as a result of bronchoscopy performed due to pathologies observed in their radiograms. Despite repeated pericardiocentesis, fluid continued to accumulate rapidly. Hence, pericardioperitoneal window was formed through subxiphoid route to obtain continuous drainage in both patients. Significant pericardial effusion didn't develop in echocardiographies in the 2nd and the 6th-month post-operative follow-ups. Conclusion: Subxiphoid pericardioperitoneal window is a simple, safe and effective surgical procedure. It may be performed in some patients with malignant tamponade

Effusion and coin shadow: is there a relation? A case report

Background

Malignant pericardial effusion is a common consequence of various types of cancer. The diagnosis of cardiac tamponade in malignant effusion may be challenging, as the typical echocardiographic signs are not met. Patients with cancer can present with cardiac tamponade in form of tachycardia (rather that hypotension) that improves after pericardiocentesis.

Case summary

A 70-year-old female patient presented to the emergency department with rapid development of shortness of breath over a week. Her past medical history included oesophageal carcinoma 1 year before presentation. This was complicated by dysphagia for which the patient underwent oesophageal stenting 5 months before admission. On admission, the patient was in respiratory distress, tachycardia; however, she was normotensive. Echocardiography revealed massive circumferential pericardial effusion. Apart from significant respiratory variation in mitral and tricuspid inflow, the echocardiographic features of tamponade were absent. We discuss on how we applied European Society of Cardiology guidelines in order to calculate the pericardiocentesis score and make a firm management plan. Despite that the patient was normotensive, the pericardiocentesis score was 13.5, so urgent pericardiocentesis was done followed by immediate improvement.

Discussion

This case demonstrates that oncology patients can present with tamponade in the form of tachycardia rather than hypotension as the slow course of effusion formation allows the body to compensate by increasing the heart rate and peripheral vascular resistance, thus maintaining the blood pressure. The application of ‘pericardiocentesis score’ is very helpful in such patients. Score equal or greater than 6 necessitates urgent pericardiocentesis even if the blood pressure is normal.

Endometrial carcinoma complicated by malignant pericardial effusion: A case report on the therapeutic regimen

RATIONALE

High-stage endometrial carcinoma is an aggressive tumor with a high propensity for distant spread. However, metastases to the pericardium are rare in gynecological cancer, and are usually fatal.

PATIENT CONCERNS

A 69-year-old woman was diagnosed with endometrial carcinoma with pericardium metastasis. The symptoms at presentation were panic and shortness of breath.

DIAGNOSES

The cytologic examination of pericardial fluid obtained by pericardiocentesis confirmed metastasis.

INTERVENTIONS

In addition to cisplatin instilled into the pericardial space, for systemic chemotherapy, we chose that gemcitabine and lobaplatin regimen be preferred.

OUTCOMES

The patient has been participating in telephone follow-up for 8 months and has generally remained in a good condition.

LESSONS

Endometrial carcinoma can have pericardial metastases. When this happens, we recommend ultrasound-guided pericardial puncture and the pericardial injection of cisplatin, in combination with systemic chemotherapy that consists of gemcitabine and lobaplatin.

Outcome and Pathological Characteristics of Primary Malignant Cardiac Tumors

The literature on malignant cardiac tumors is relatively limited because they are rare, especially among the Chinese population. We analyzed 14 patients diagnosed with malignant cardiac tumors in Fuwai Hospital and present the results of surgical treatments on the tumors. The mean age at tumor diagnosis was 47 years in a male-dominated cohort. There was a high frequency of pericardial effusion and coronary artery involvement in our group. We compared the survival times of patients who received different treatments and found that surgery improved prognosis of tumors, especially for patients who underwent orthotopic heart transplantation.

Management of neoplastic pericardial disease

At present, there is no accurate and effective method for treating neoplastic pericardial effusion. This study analyzed the current literature on the treatment of neoplastic pericardial effusion to provide advice and guidance for clinical treatment. Surgical treatments include pericardial puncture, extension of catheter drainage, pericardial window, and surgical pericardiotomy. Each surgical procedure has a corresponding indication, and the best treatment is selected according to the patient's specific conditions. Systemic chemotherapy is effective in lymphoma and small cell lung cancer that are sensitive to chemotherapeutic drugs. Although pericardial injection of drugs is effective for pericardial tamponade and recurrent pericardial effusion, these methods can only temporarily relieve symptoms and cannot prolong the life of patients. In recent years, immunotherapy, especially adoptive immunotherapy, has achieved good results in the treatment of neoplastic pericardial effusion, thus providing a novel treatment option for neoplastic pericardial effusion.

Serum BNP levels are associated with malignant pericardial effusion

Introduction

The development of malignant pericardial effusion indicates a poor prognosis and is the leading cause of cardiac tamponade. The objectives of the study were to examine the levels of BNP in traumatic, malignant and non-malignant pericardial effusion etiologies, and to assess the value of serum and pericardial fluid BNP levels in the prognosis of malignant pericardial effusion.

Methods

A of 56 patients with clinical and echocardiographic diagnosis of pre-tamponade or tamponade who required pericardiocentesis were included in the study. BNP levels were assessed in the serum and within the pericardial fluid. The diagnostic value of BNP levels in discriminating between malignant and non- malignant etiology of pericardial effusion was examined using a receiver-operating characteristic (ROC).

Results

Pericardial fluid BNP levels were similar across all etiology groups. In patients with malignant etiology, the amount of pericardial fluid was high and their serum BNP levels were relatively low. BNP levels were strong predictors of malignant pericardial effusion, and the cut-off point of BNP ≤ 250 pg/ml demonstrated the highest sensitivity (90.0%) for malignant etiology.

Conclusions

Low serum BNP levels were significantly associated with malignancy in patients undergoing pericardiocentesis for pericardial effusions. Serum BNP levels <250 pg/ml may trigger more extensive diagnostic testing for malignant pericardial effusion in patients with small pericardial effusion who are not considered for pericardiocentesis due to small effusion, in whom the etiology is unclear.

A contemporary look at pericardiocentesis

Percutaneous drainage is the default strategy for evacuating a pericardial effusion. A pericardiocentesis can be necessary or required in a wide variety of clinical settings ranging from urgent tamponade to relieve in iatrogenic hemorrhagic effusions in the electrophysiology or catheterization room, to planned diagnostic procedures in patients with suspected or known malignancy or infections. With the help of several procedural improvements over the past decades, echocardiography and fluoroscopy-guided percutaneous pericardiocentesis has become the standard intervention for evacuating pericardial effusions, as well as an essential tool in the diagnostic work-up of an unexplained pericardial effusion. When performed by skilled physicians assisted by appropriate imaging it is a very safe procedure, and provided that an indwelling catheter is placed, it is also very effective with an acceptably low risk of recurrences. In this review, the indications and standard techniques for pericardiocentesis are discussed, as well as their consequences for patients with iatrogenic and malignant effusions.

Acute Pericarditis and Cancer Risk: A Matched Cohort Study Using Linked UK Primary and Secondary Care Data

Background We aimed to examine whether acute pericarditis is an indicator of undetected cancer and identify patient-level factors associated with high cancer risk among patients presenting with pericarditis. Methods and Results A population-based matched cohort study was conducted using primary care data from the UK Clinical Practice Research Datalink linked to Hospital Episode Statistics. Patients with acute pericarditis (n=6530) were matched to a comparison cohort (n=26 111) on age, sex, calendar time, and general practice. We estimated cumulative cancer incidences, and calculated hazard ratios using Cox regression. Effect modification by patients' characteristics and lifestyle factors was examined, and we fitted a parsimonious model to evaluate absolute excess risk of later cancer among pericarditis patients by key patient-level factors. We identified 728 and 1379 incidents of cancer among pericarditis patients and the comparison cohort (median follow-up, 2.8 and 3.5 years). Pericarditis was associated with an elevated subsequent risk of any cancer (hazard ratio=3.03; 95% confidence interval, 2.74-3.36). The association was particularly pronounced 0 to 3 months after pericarditis (hazard ratio=23.56; 95% confidence interval, 18.00-30.83), but a more-modest association remained thereafter (hazard ratio=1.95; 95% confidence interval, 1.48-2.57 after 3-12 months, and hazard ratio=1.40; 95% confidence interval, 1.21-1.62 after >12 month). Older individuals hospitalized with pericarditis and with combinations of obesity and smoking were at the highest excess risk of having a cancer diagnosis 3 to 12 months later, reaching 4.8%. Conclusions Occult cancers may be going undiagnosed during the acute episode of pericarditis. Patients presenting with pericarditis and combinations of older age, obesity, smoking, and a need for hospitalization might warrant targeted investigations for cancer.

Echocardiographic characteristics of primary malignant pericardial mesothelioma and outcomes analysis: a retrospective study

Background

Little is known about the echocardiographic characteristics of primary malignant pericardial mesothelioma (PPM) due to its rarity. The aim of this study was to explore the sex-specific echocardiographic patterns of PPM and risk factors for in-hospital mortality.

Methods

A retrospective information retrieval was conducted for cases of PPM reported from China during 1981 and 2015. The diagnosis was made by histopathological examinations and only cases with echocardiographic descriptions were included. Data on the clinical and echocardiographic findings were collected. Difference in clinical, sex-specific echocardiographic characteristics and findings across different time periods were assessed. Logistic regression analysis was performed to explore echocardiographic risk factors for in-hospital mortality.

Results

A total of 64 patients with PPM were included, with a mean age of 39.2 ± 15.6 years and minor male dominance (40, 62.5%). The most common echocardiographic presentations were pericardial effusion (55, 85.9%), pericardial masses (36.4%) and thickening (17.3%), respectively. The positive rate of pericardiocentesis was only 20.9%. Six patients (15.4%) died among 39 cases reporting in-hospital outcome. Logistics analysis identified no clinical or echocardiographic parameters associated with in-hospital mortality (all P > 0.05).

Conclusions

The echocardiographic signs of PPM are basically nonspecific with massive pericardial effusion as the most common sign, although no echocardiographic gender differences or association with in-hospital mortality could be identified.

Etiology and Long-Term Outcome of Patients Undergoing Pericardiocentesis

Background

Pericardial effusions can be caused by a variety of disorders. The frequency of the underlying diseases varies with patient population; therefore, previously reported series are not necessarily representative of other populations. Our purpose was to examine the etiology of pericardial effusions and the survival of patients requiring pericardiocentesis at a tertiary center.

Methods and Results

We performed a retrospective observational study of 269 consecutive patients who underwent percutaneous pericardiocentesis at our university hospital between 2006 and 2016 and had prospective follow‐up for up to 10 years. The most frequent etiologies were idiopathic (26%), malignancy (25%), and iatrogenicity (20%), whereas bacterial causes were very rare. The most frequent malignancies originated from the lung (53%) or breast (18%). A new cancer was diagnosed with malignant pericardial effusion as the presenting complaint for 9% of patients, whereas the pericardium was the first metastatic site of a known malignancy in 4% of patients. Survival was significantly poorer in malignancy‐related versus non–malignancy‐related effusions (P<0.001) and in cytology‐positive versus cytology‐negative effusions in the overall cohort (P<0.001). Among cancer‐only patients, however, there was no significant difference in long‐term survival between cytology‐positive and ‐negative effusions.

Conclusions

In this contemporary tertiary‐center cohort, pericardial effusions often represent the primary instance of a new malignancy, underscoring the importance of cytological analyses of noniatrogenic effusions in patients without known cancer, as survival is significantly worse. In cancer patients, however, the presence of pericardial malignant cytology does not appear to affect outcome significantly.

Pericarditis as a Marker of Occult Cancer and a Prognostic Factor for Cancer Mortality

BACKGROUND

Pericarditis may be a serious complication of malignancy. Its significance as a first symptom of occult cancer and as a prognostic factor for cancer survival is unknown.

METHODS

Using Danish medical databases, we conducted a nationwide cohort study of all patients with a first-time diagnosis of pericarditis during 1994 to 2013. We excluded patients with previous cancer and followed up the remaining patients for subsequent cancer diagnosis until November 30, 2013. We calculated risks and standardized incidence ratios of cancer for patients with pericarditis compared with the general population. We assessed whether pericarditis predicts cancer survival by the Kaplan-Meier method and Cox regression using a matched comparison cohort of cancer patients without pericarditis.

RESULTS

Among 13 759 patients with acute pericarditis, 1550 subsequently were diagnosed with cancer during follow-up. The overall cancer standardized incidence ratio was 1.5 (95% confidence interval [CI], 1.4-1.5), driven predominantly by increased rates of lung, kidney, and bladder cancer, lymphoma, leukemia, and unspecified metastatic cancer. The <3-month cancer risk among patients with pericarditis was 2.7%, and the standardized incidence ratio was 12.4 (95% CI, 11.2-13.7). The 3- to <12-month standardized incidence ratio of cancer was 1.5 (95% CI, 1.2-1.7), subsequently decreasing to 1.1 (95% CI, 1.0-1.2). Three-month survival after the cancer diagnosis was 80% and 86% among those with and without pericarditis, respectively, and the hazard ratio was 1.5 (95% CI, 1.3-1.8). One-year survival was 65% and 70%, respectively, corresponding to a 3- to <12-month hazard ratio of 1.3 (95% CI, 1.1-1.5).

CONCLUSIONS

Pericarditis may be a marker of occult cancer and augurs increased mortality after a cancer diagnosis.

Prognostic Impact of Minimal Pericardial Effusion in Patients With Advanced Non-small-cell Lung Cancer

INTRODUCTION

Minimal (< 10 mm in thickness) pericardial effusion (PCE) can be incidentally detected by computed tomography at the time of diagnosis in patients with lung cancer. Although malignant PCE is known to be associated with poor prognosis, the impact of minimal PCE on outcome has remained unclear. We therefore examined the prognostic relevance of minimal PCE in patients with advanced non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

We retrospectively analyzed consecutive patients diagnosed with stage IV NSCLC at Kindai University Hospital between April 2009 and March 2015. The patients were classified into 3 groups on the basis of the presence and thickness of PCE: no PCE, minimal (< 10 mm) PCE, and malignant (≥ 10 mm) PCE. The relation between overall survival and PCE status was examined with a Cox proportional hazards model.

RESULTS

The total of 428 enrolled patients included 327 (76.4%) in the no PCE group, 61 (14.3%) in the minimal PCE group, and 40 (9.3%) in the malignant PCE group. Median overall survival was 15.0, 10.1, and 7.6 months in the no PCE, minimal PCE, and malignant PCE groups, respectively, with the survival of patients with minimal PCE thus being intermediate between that of the other 2 groups (P = .003). Multivariable analysis revealed that minimal PCE was independently associated with reduced survival (hazard ratio, 1.46; 95% confidence interval, 1.07-1.96; P = .019).

CONCLUSIONS

The presence of minimal PCE was an independent prognostic factor for reduced survival in patients with advanced NSCLC.

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.

Pulmonary Manifestations of Solid Non-Pulmonary Malignancies

The lungs are a common site of metastatic disease. Pulmonary metastases develop due to local blood flow and cellular or biochemical properties of tumor cells. Metastases develop from any type of malignancy and may occur via hematogenous, lymphatic, aerogenous, and/or direct spread. Metastatic disease may present with symptoms indistinguishable from primary lung cancer, including dyspnea, hemoptysis, and chest pain. Radiographically, these may present as parenchymal lung disease, mediastinal lymphadenopathy, airway obstruction, or pleural and vascular disease. No part of the thorax is spared from metastatic potential. This review highlights complications of non-pulmonary solid malignancies based on sites of anatomic metastases.