Conservative management of malignant pericardial effusion

Abstract

The traditional approach to treatment of malignant pericardial effusion has been surgical, with establishment of a pericardial window. Conservative management with local instillation of chemotherapeutic agents and/or focal radiotherapy has received less attention, particularly when solid tumors have been causative. This series of 5 patients with antemortem diagnoses of malignant pericardial disease had predominant pericardial effusion rather than tumor encasement as the basis for tamponade. These 5 patients received initial therapy with local instillation of a chemotherapeutic agent ± radiotherapy. Four of the 5 made complete responses with total disappearance of cardiac symptoms and signs. Two of the responders are dead, 4 and 12 months, respectively, after initial treatment, neither showing significant pericardial fluid at postmortem examination. Two patients are alive and asymptomatic, 40 months and 8 months, respectively, after initial therapy. A literature review of treatment of malignant pericardial effusions discloses longer symptom‐free intervals in patients treated by conservative measures compared to surgical programs utilizing pericardial window accompanied by any combination of other treatment modalities.

Successful treatment of malignant pericardial effusion, using weekly paclitaxel, in a patient with breast cancer

“…[15][16][17][18][19][20] Palliation is the principal aim of treatment for metastatic breast cancer. It is important to establish a therapy that can reduce the toxicity while retaining its clinical activity.…”

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

“…approaches (sclerotherapy, steroids, systemic or local chemotherapy) is 44-100%; however, in most reports diagnosis is not fully defined (patients with cytology negative effusion, possibly inflammatory in origin, are often included) and therapy is aimed to simply prevent recurrent symptomatic PE for a limited period of time (usually 30 days) [4][5][6]. These limitations in comparing the various modalities of treatment have already been addressed by Vaitkus et al [7].…”

Neoplastic pericardial disease: Old and current strategies for diagnosis and management

“…The efficacy criteria, which are necessarily arbitrary, change in different reports and few prospective randomized studies have been published. Moreover, most of the older reports consider an intervention successful if the patient survived for 30 d without recurrence of symptoms or tamponade [56,57] . This approach has two main defects: first, the fixed time of observation (a patient dying for non-cardiac causes without pericardial disease would be considered as "unsuccessfully treated", while one with relapsing tamponade after 32 d would be considered successfully treated); and second, cardiac tamponade depends not only on the entity of pericardial effusion but also on many variables, such as blood volume, right and left ventricular wall thickness and rate of accumulation of pericardial fluid.…”

“…Other chemotherapeutic agents have been used intrapericardially; e.g. nitrogen mustard, mitomycin C, mitoxantrone, 5-fluorouracil, but only case reports or small series have been published, making it impossible to judge the response rates [57,[115][116][117] . Musch et al [118] in 2003, reported 12 complete remissions and 3 partial remissions (small pericardial effusion) among 16 patients (8 bronchial, 7 breast, 1 stomach carcinoma) treated with 10-20 mg of mitoxantrone left in the pericardium for 24 h; the follow-up lasted 28-730 d (mean 6 mo).…”