Unsuspected malignant pericardial effusion causing cardiac tamponade. Rapid diagnosis by computed tomography

Evaluation of the Pericardium with CT and MR

The pericardium plays an important role in optimizing cardiac motion and chamber pressures and serves as a barrier to pathology. In addition to pericardial anatomy and function, this review article covers a variety of pericardial conditions, with mention of potential pitfalls encountered during interpretation of diagnostic imaging. Normal and abnormal appearance of pericardium on CT and MR imaging is emphasized, including dynamic imaging correlates of pericardial pathophysiology.

Pericardiocentesis in patients with and without incipient cardiac tamponade due to pericardial effusion. An easy and safe bedside approach

Fourteen patients with pericardial effusion of various origins underwent pericardiocentesis on 16 occasions. Incipient cardiac tamponade was present on 19 occasions in 12 patients. Pericardiocentesis was carried out bedside under sterile conditions by a trained cardiologist. In case of impaired central circulation, drainage was sufficient to stabilize the clinical condition haemodynamically, and no adverse events occurred during pericardiocentesis. Fenestration of the parietal pericardium was necessary in 5 patients because of rapid regeneration of the fluid and in one patient due to pyopericardium with cardiac constriction. Pericardiocentesis is recommended in incipient cardiac tamponade. In the hands of experienced cardiologists the drainage procedure can be carried out safely without sophisticated equipment.

Malignancies involving the pericardium

Malignancies rarely arise from the pericardium. Mesothelioma, the most common of these, is usually unresectable and almost always incurable. Malignancies may secondarily involve the pericardium by direct extension. Carcinoma of the lung and malignant thymoma with limited direct invasion of the pericardium both can undergo complete and potentially curative resections, but adjuvant therapy is usually indicated. More frequently, malignancies involve the pericardium by a process of retrograde lymphangitic spread or hematogenous dissemination. These patients present with a symptomatic pericardial effusion and occasionally pericardial tamponade. Subxiphoid pericardiostomy and drainage is a safe procedure that provides effective and durable symptomatic relief in these terminally ill patients. More aggressive open procedures should be reserved for loculated or recurrent pericardial effusions.

Case report: malignant pericardial effusion as the initial manifestation of malignancy

Although malignant pericardial effusion is a common complication of malignancy, it is rarely the initial manifestation. A case of a nonsmoking 36-year-old woman who had pericardial tamponade due to malignant pericardial effusion as the initial manifestation of malignancy is presented. Case reports of patients with malignant pericardial effusion as the initial manifestation of malignancy published since 1974 are reviewed. The clinical presentation, histology, and survival of these patients is compared with those cases published prior to 1974. Survival of patients with primary malignancy in the lung who present with malignant pericardial effusion has not improved.

Symptomatic pericardial effusion in lung cancer patients: the role of fluid cytology

During the years 1975-1988, twenty lung cancer patients with symptomatic pericardial effusion were treated conservatively at our center. Echocardiography demonstrated small pericardial effusion in 2 patients, medium size effusion in 3 patients and large amount of fluid in 15 patients. Fifteen patients developed cardiac tamponade; in three of these patients, this was the presenting manifestation of lung cancer. Pericardiocentesis resulted in prompt, though temporary, symptomatic relief in all patients. Fluid cytology demonstrated suspected malignant cells in 2 patients and malignant cells in 13 patients. Based on cytology, the diagnosis of adenocarcinoma was established in six patients, small cell carcinoma in three patients, and epidermoid carcinoma in one patient. All patients were dead within 9 months from the time of diagnosis of pericardial effusion; 17 died within less than 3 months. It is concluded that pericardial effusion in lung cancer is indicative of rapid tumor progression and short survival. Fluid cytology provides an immediate and accurate means of diagnosis.

Cardiac tamponade as the initial presentation of malignancy

We describe a series of five patients who had cardiac tamponade at the time of initial presentation as a result of extracardiac malignancy. Three cases had adenocarcinoma and two had squamous cell carcinoma. The diagnosis of bronchogenic carcinoma was established after appropriate investigations in three cases. One patient possibly had a primary malignancy of the gastro-intestinal tract. The relevant literature is reviewed.

Successful management of malignant pericardial effusion in metastatic squamous cell carcinoma of the uterine cervix

Malignant pericardial effusion secondary to pericardial metastases from gynecological malignancies represents an infrequent but potentially life threatening problem. A patient with recurrent squamous cell carcinoma of the cervix causing symptomatic pericardial effusion is presented, and the incidence, mechanism, pathophysiology, treatment, and outcomes of malignant pericardial effusion in patients with gynecologic malignancies are reviewed. This case represents only the fourth reported patient with metastatic carcinoma of the cervix in whom the diagnosis of malignant pericardial effusion was made antemortem, and is the longest survivor of treatment. Gratifying results, in terms of improved quality and length of survival, can be obtained in what is often perceived as a preterminal complication. Recommendations for management are presented, stressing radiation therapy and other local measures following initial pericardiocentesis.

Ovarian adenocarcinoma complicated by malignant pericarditis

Neoplastic pericarditis is a rare complication of gynecologic malignancies. However, as illustrated in the case presented, the physician involved in the care of patients with cancer should be aware of this possible life-threatening complication. The case report is followed by a brief review of the pertinent clinical, pathophysiologic, and therapeutic aspects of this condition.