2015 update on the diagnosis and management of neoplastic pericardial disease

Abstract

The best approach in diagnosis and treatment of neoplastic pericardial disease has not been defined yet. The authors report the most recent literature about the new diagnostic techniques that are useful to improve the diagnosis. The literature about the therapeutic options is critically reviewed, in order to give suggestions of use to the clinical practice. Pericardial effusion may require urgent drainage; the solid component, however, becomes predominant in some cases. Neoplastic pericardial disease should be assessed following oncologic criteria evaluation of the neoplastic burden; outcome classified as complete or partial response, stable or progressive disease and – in cases with progression – event-free survival. Systemic chemotherapy may be effective in lymphomas and possibly in breast carcinomas. Intrapericardial chemotherapy with systemic chemotherapy is the treatment of choice in lung cancer. Pericardial window with systemic chemotherapy is also effective in preventing the accumulation of large amount of fluid.

Keywords:

• malignant pericardial effusion
• neoplastic pericardial disease
• neoplastic pericarditis
• pericardial metastases

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Neoplastic pericardial disease is rather frequent in cancer patients, but not all the pericardial effusions and masses are neoplastic.

• Hemodynamic impairment, either due to cardiac tamponade or to constrictive pericarditis is not infrequent, and symptoms may appear abruptly.

• The diagnosis of neoplastic pericardial disease may be challenging and may require an integrated evaluation of clinical, imaging and pathology.

• Percutaneous pericardial drainage is mandatory in case of cardiac tamponade to relieve symptoms, and suggested in large effusion to define the diagnosis; without any additional intervention, the rate of relapse is high.

• To prevent relapsing symptomatic effusion systemic chemotherapy is generally suggested. In patients with solid cancers, possibly local interventions should be added.

• The response to the treatments should be based not only on symptoms, but rather on objective evaluation of the pericardial neoplastic burden, and classified following the oncologic criteria: complete response, partial response, stable disease, progressive disease. In progressive disease, the overall survival, the time to progression and the event-free survival should be considered.

• Platinum is the most widely used intrapericardial chemotherapy. It is the first choice in lung cancer, and has proven to be very effective also in other solid tumors, as breast cancer. Thiotepa has been successfully used in breast cancer, but is less effective in lung cancer. Paclitaxel is a promising new drug to be employed.

• The overall survival depends by the type of primary tumor, the presence of other metastatic sites and the type of treatment: mesothelioma and lung cancer patients have the worst prognosis; breast cancer patients have a better prognosis; leukemia and lymphoma patients have the best prognosis and may achieve a complete recovery lasting many years even with systemic chemotherapy only.

• In lung cancer and other solid tumors, the use of combined local and systemic chemotherapy increases both the local control of disease and the overall survival.

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