Malignant Pericardial Effusion - Causes, Symptoms, and Treatment

Introduction:

The extra fluid around the heart exerts pressure on the heart and stops it from functioning normally; hence the heart cannot pump sufficient blood to the rest of the body. Dyspnea, also called shortness of breath, and cough, are the main symptoms. This is a life-threatening condition and must be treated immediately.

What Is Pericardial Effusion?

Pericardial effusion is a condition in which extra fluid is collected between the heart and the pericardial sac or pericardium (a pericardium sac surrounds and protects the heart).

This extra fluid causes pressure on the heart and prevents the heart from pumping blood normally. As a result, lymph vessels get blocked, leading to infection.

What Are the Causes of Pericardial Infection?

It is caused by:

1. Cancer or cancer-related treatments.

2. Injuries and infections.

3. In certain autoimmune disorders.

4. Thyroid or kidney problems.

What Are Malignant Pericardial Effusions?

It is a condition in which cancer or cancer-related treatments cause extra fluid to collect around the heart. This extra fluid creates pressure on the heart and prevents the heart from pumping blood normally. As a result, lymph vessels are blocked, causing infection.

Malignant Pericardial Effusion Is Seen in What Type of Cancers?

It is usually seen in:

1. Breast Cancer: Cancer that arises in the breast.

2. Lung Cancer: Cancer that arises in the lungs.

3. Melanoma: Dangerous skin cancer.

4. Leukemia: Cancer of blood-forming tissues like bone marrow and lymphatic system.

5. Lymphoma: Cancer of the lymphatic system.

What Are the Causes of Malignant Pericardial Effusions?

Metastases of the pericardium by cancer cells are the most common reason for developing malignant pericardial effusions. This blocks lymphatic drainage, pericardial fluid, and venous flow. Such blockage can also be seen in primary malignancies of pericardium like pericardium mesothelioma, tumors of myocardium like angiosarcoma, malignant fibrous histiocytosis, and rhabdomyosarcoma.

Metastases of the pericardium can also occur directly through breast, lung, and esophagus carcinomas.

The causes can be categorized into two types: malignant causes and non-malignant causes.

• Malignant Causes: Metastatic spread of cancer, especially of lung, breast, or Hodgkin's lymphoma (lymphatic system cancer).

• Non-malignant Causes:

  1. Trauma: Due to an accident or fall.

  2. Hypothyroidism: Decreased amount of thyroid hormone.

  3. Myocardial Infarction: Also called a heart- attack. Caused by less supply of blood to the heart.

  4. Uremia: Kidneys do not function properly.

  5. Pericarditis: Swelling of the pericardium(a protective sac around the heart).

  6. Intrapericardial Hematomas: Blood accumulates in the pericardial space(around the heart).

  7. Systemic Lupus Erythematosus: Autoimmune disorder.

  8. Postsurgical Pericardiotomy Syndrome: Chest pain.

Certain conditions like AIDS (acquired immunodeficiency syndrome) also cause pericardial effusion.

What Is the Relation Between Pericardial Effusion and Radiotherapy?

Radiation therapy to the chest region can show its effects on the heart. Radiation doses to the chest region exceeding 30 Gy (gray units) show its impact on the heart, resulting in pericarditis and pericardial effusion. Pericardial effusion is mostly seen in people receiving mediastinal radiation for breast cancer and Hodgkin's disease (cancer of the lymphatic system).

Radiotherapy for breast cancer, especially the left breast, can result from cardiac effects like pericardial effusion, coronary artery disease, myopathy, valve dysfunction, and many other abnormalities.

Chemotherapy and Pericardial Effusion: Are They Related?

Chemotherapy drugs such as Doxorubicin and Cyclophosphamide are known to cause pericardial effusions.

What Are the Symptoms of Malignant Pericardial Effusion?

The following are the symptoms:

• Dyspnea: 93 % of the patients with malignant pericardial effusion suffer from dyspnea (shortness of breath).

• Hiccups: Due to pressure on the diaphragm.

• Chest pain.

• Orthopnea: Discomfort while lying on the bed.

• Distention of the upper abdomen caused by downward hepatic distention.

• Pleuritic Pain: Caused by stretching of the pericardium.

• Feeling faint, tired, and weak.

How Could Malignant Pericardial Effusion Be Diagnosed?

1. Chest X-rays: An X-ray for bones and organs inside the chest.

2. Transthoracic echocardiography using parasternal, apical, and subxiphoid views.

3. Echocardiography: Uses sound waves to know blood flow through the heart.

4. ECG (Electrocardiogram): Records electrical signals of the heart.

5. Pericardial Fluid Cytology to Know Malignant Perfusion: Fluid aspiration from pericardial space and examination.

6. Pericardial Biopsy: Analyzing heart tissues.

7. Video Pericardiotomy: Used in studying heart activity.

What Is the Treatment for Pericardial Effusion?

Treatment depends upon the patient's condition and mainly focuses on symptom relief with minimal impact on quality of life. The treatments include:

• Percutaneous Pericardiocentesis: Pericardiocentesis is a process of fluid aspiration from the pericardium surrounding the heart.

• Pericardial Sclerosis: Tetracycline is the most effective sclerosing agent for pericardial effusion. It has a higher success rate. However, this drug is no longer available in the market. Other alternative drugs include:

  1. Doxycycline.

  2. Mitoxantrone.

  3. Bleomycin.

  4. Chromic phosphate.

  5. Docetaxel.

  6. Carboplatin.

  7. Thiotepa.

• Percutaneous Balloon Pericardiotomy: It is a procedure that is carried out to remove excess fluid accumulated surrounding the heart. This is carried out with the help of a long thin tube with a balloon attached, and the fluid is drained out through the tube.

• Pericardiectomy: Surgical removal of the pericardium is called pericardiectomy. A normal pericardium protects the heart, but when it becomes fibrous, it becomes stiff and cannot expand, and the heart cannot fully expand to function properly.

• Pericardiotomy by Thoracotomy or Video-assisted Thoracoscopy: In this, a fiber optic thoracoscope and a high-resolution video camera are carried out in the operation room set up by and monitored by a team of doctors (surgical technician). This has the advantage of early recovery, the safety of patients, and pain control is better. In addition, bleeding is controlled easily, and results in fewer hospital stays.

• Subxiphoid Pericardial Window: It is a surgical procedure used to evaluate the presence of fluid or blood in the pericardial sac. This process is a surgical way to approach the pericardium, giving a direct vision of the pericardium.

• Catheter Drainage: This is advised for the patients if there is a rapid reaccumulation of fluid or a large outflow. This could improve the survival chances of the patient. ECG (echocardiogram) is advised for catheter guidance. Prolonged catheter drainage effectively reduces fluid accumulation, and this could be left for many days until there is no drainage or minimal.

All the procedures mentioned above are complicated and present patients with high risk. Hence the choice of treatment depends on factors like:

• Patient safety and morbidity.

• Short hospital stays in cases of advanced diseases.

• Cost.

• Relief from tamponade (pressure builds up on the heart due to accumulation of fluid around the heart).

• Minimal invasive procedures.

Symptomatic large malignant pericardial effusions are treated by draining the fluid that is collected in the pericardium, But this could not always be the treatment. If there are shorter survival rates, then less conservative approaches and less invasive procedures must be advised to the patient to maintain the quality of life.

If the treatment mainly focuses on managing tamponade, then percutaneous subxiphoid pericardiocentesis is the option.

Conclusion:

Malignant pericardial effusion mostly occurs in the advanced stages of cancer or the last weeks of life. Hence at this time, it is more important to relieve the symptoms and improve the quality and quantity of life than to diagnose the condition.