Why does cancer cause pericardial effusion

The treatment of pericarditis is usually as per recommended guidelines [ 13 ]. However, it is to be recognised that many cancer patients may have a predisposition to bleeding due to abnormal blood counts or coagulation abnormalities secondary to their disease or treatment. It can thus be challenging to introduce routine therapy such as non-steroidal anti-inflammatory agents in this context. As a result, there is often a greater and earlier use of other agents, e. Pericarditis can be complicated by pericardial effusions and tamponade and in the long term by constriction discussed below.

Myopericarditis is a condition where there is inflammation involving both the pericardium and the myocardium. Myopericarditis can occur acutely after anthracycline administration [ 15 ]. High-dose cyclophosphamide can cause acute cardiotoxicity manifest as haemorrhagic myopericarditis [ 16 ]. Death has also been reported in this context associated with pericardial effusions and tamponade [ 17 ].

Pre-existing cardiac dysfunction, older age, use of other chemotherapeutic agents and type of cancer e. Renal impairment can increase the risk of cyclophosphamide-related acute myopericarditis [ 19 ].

Diagnosis is through a combination of clinical examination, laboratory tests and cardiac imaging investigations. The troponin levels are elevated reflecting myocardial damage.

However, cardiac biopsies are invasive procedures with a significant degree of procedural risk. The treatment of myopericarditis in this context depends upon the aetiology, i. If it is the former, aggressive treatment of the disease may result in a resolution of cardiac complications.

If it is the latter, different chemotherapeutic regimes may need to be used which may be less effective cancer treatments with the addition of steroids. In clinical practice, the actual aetiology is often determined through a process of elimination.

Any cancer can metastasize to the pericardium resulting in an effusion with the commonest cancers doing so being breast, lung and Hodgkin lymphoma. Pericardial effusions may or may not be associated with pericarditis and may or may not develop acutely.

If they are chronic, they may more often present with a gradually decreasing exercise capacity and an increase in exertional dyspnoea. If the pericardial fluid rapidly accumulates, it may cause cardiac tamponade with acute haemodynamic compromise which requires urgent intervention. Confirmation of the diagnosis is primarily made through echocardiography Fig. Four-chamber echocardiography still demonstrating large global pericardial effusion white arrows.

The treatment of the effusion depends on the acuteness of symptoms as well as the aetiology. In cases of cardiac tamponade, urgent pericardial drainage is required.

In more chronic cases, a decision can be made based on whether the effusion is related to treatment or is malignant. A trial of more intensive chemotherapy or steroids may be undertaken first to determine if this aids effusion resolution.

If not, the treatment varies between pericardiocentesis, prolonged pericardial drainage and surgical approaches. It is important to fully evaluate the pericardial fluid no matter which approach is taken. Fluid should be sent for cytology and flow cytometry and consideration should be made to concomitant pericardial biopsy safer to perform under direct vision in the surgical setting.

Studies have suggested that the surgical treatment of malignant pericardial effusions may offer a more definitive solution to pericardiocentesis [ 27 , 28 ]. Pericardial sclerosis has been carried out with a variety of agents tetracycline, bleomycin, talc etc.

Additionally, a randomised trial showed no statistical difference between this and pericardial drainage in terms of recurrence [ 33 ]. Pericardial sclerosis can also lead to pericardial constriction which is a difficult condition to treat discussed below.

Pericardial constriction is a condition where there is a loss of the normal elasticity of the pericardial sac. In the context of cancer, this can occur as a result of radiation-induced fibrosis or fibrotic change secondary to pericarditis. A variant is effusive-constrictive pericarditis when pericardial constriction is present along with a pericardial effusion with symptoms and signs of the former often being masked until pericardial drainage is performed.

Doppler echocardiography and real-time CMR cines can help in diagnosis. If there remains diagnostic uncertainty, equalisation of left and right ventricular diastolic pressure tracings obtained via cardiac catheterisation reflects increased ventricular interdependence and can clinch the diagnosis. Symptoms are normally progressive and pericardiectomy remains the most effective therapy. Surgical removal of the pericardium is technically challenging and long-term outcomes are mixed [ 34 ].

Outcomes are worse if the pericardial disease was due to radiation therapy [ 35 ]. Pericardial tumours include primary and secondary cancers as well as benign lesions Table 1. Secondary tumours or direct invasion into the pericardium is around times more common. Diagnostically, they can prove a challenge and the definitive diagnosis is often obtained only after pathological analysis of tissue samples.

Imaging can help narrow the list of differentials. Imaging can also guide the surgeon as to the extent of the operation required and as to whether operative removal is feasible in the place e. Positron emission tomography PET scanning can be very helpful in determining whether a particular lesion is active and whether treatment has induced remission.

Relative strengths and weaknesses of different imaging modalities for pericardial tumours. Pericardial cysts mesothelial cysts and lipomas are the commonest benign pericardial masses. Pericardial cysts are commonly located at the right and left anterior cardiophrenic angles and are commonly asymptomatic. Removal may be required if there are compressive symptoms. Pericardial lipomas are similarly asymptomatic in the majority of cases.

If no systemic therapy can control the pericardial effusion, local measures, such as subxiphoid pericardiostomy, with or without intrapericardial instillation of sclerosing or cytotoxic agents, percutaneous balloon pericardiotomy and pericardial window, may be considered. Download the table of contents. Download the first chapter.

Read the first chapter online. This site uses cookies. Some of these cookies are essential, while others help us improve your experience by providing insights into how the site is being used. He was further examined through contrast-enhanced computed tomography CT , which revealed a mass lesion with a mm diameter, extending from the middle lobe of his right lung to the upper mediastinum, lymphadenopathy of the mediastinum and bilateral neck, swelling of bilateral adrenal grands, intraperitoneal dissemination, and slight pericardial effusion.

The patient was treated with four cycles of carboplatin and pemetrexed. Nearly all lesions diminished in size; however, intraperitoneal dissemination worsened. His serum carcinoembryonic antigen CEA level before initiation of nivolumab therapy was After two cycles of nivolumab administration, the tumor size decreased Figures 1C,D , respectively. After four cycles of nivolumab administration, he returned to our hospital with the complaint of dyspnea.

A chest X-ray revealed cardiomegaly, and echocardiography indicated massive pericardial effusion Figures 1E,F , respectively. He was further diagnosed as having cardiac tamponade. Other irAEs, including myocarditis, were not detected. His serum CEA level was decreased He then received pericardiocentesis, and 1, ml of bloody effusion was removed.

Immediately following this procedure, his condition improved. Moreover, cytology revealed adenocarcinoma cells. Despite the fact that nivolumab therapy had not had a positive impact on the pericardial effusion, it had been effective for decreasing the tumor lesions; therefore, the therapy was continued.

Corticosteroid treatment was not administered. After five cycles of nivolumab administration following the pericardiocentesis, the pericardial effusion did not recur Figures 1G,H , respectively ; however, intraperitoneal dissemination worsened again, and nivolumab therapy was discontinued. Subsequently, he was treated with several chemotherapies, such as pemetrexed and bevacizumab, gemcitabine, and bevacizumab, as well as nab -paclitaxel monotherapy; however, the efficacy of these treatment regimens was limited.

Eighteen months after pericardiocentesis, the patient died of lung cancer progression; however, pericardial effusion had not increased. Figure 1. Case 1 A,B Chest X-ray and computed tomography CT before nivolumab administration shows a lung mass from the right mediastinum to the right hilar region. E Chest X-ray after 4 cycles of nivolumab administration shows cardiomegaly. G,H Chest X-ray and CT after pericardiocentesis followed by nivolumab administration shows improvement of cardiomegaly and further tumor regression.

A year-old man with a 25 pack-year smoking history visited our hospital with the chief complaints of productive cough and dyspnea. Subsequently, a massive left pleural effusion was detected on chest X-ray. He was then examined through contrast-enhanced CT, which revealed a massive left pleural effusion, a mass lesion with a mm diameter, in the lower lobe of his left lung, and slight pericardial effusion.

He was treated with four cycles of carboplatin and nab -paclitaxel, and the treatment was effective for all previously detected lesions; however, multiple brain metastases arose. He then received whole brain irradiation, and these new lesions showed reduction. Subsequently, he was treated with three cycles of pemetrexed as a second-line chemotherapy; however, the primary lesion showed regrowth. After two cycles of nivolumab administration, he returned to our hospital with complaints of chest pain and dyspnea.

A chest X-ray revealed cardiomegaly Figure 2D. Massive pericardial effusion was detected by echocardiography as well as by chest CT Figure 2E. Adams HR et al. Cardiac toxicities of antibiotics.

Environ Health Perspect. Download references. The authors did not obtain specific grant funding for this research. The authors declare that they have no competing interests.

You can also search for this author in PubMed Google Scholar. SKi and ZI wrote the manuscript. SH performed the histological examination and was a major contributor to writing the manuscript. SKi and SKo clinically treated the patient. SKo and MS critically reviewed the manuscript and provided significant assistance in writing the manuscript. All authors have read and approved the final version of the manuscript. Correspondence to Zensho Ito. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

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Reprints and Permissions. Kiryu, S. Cancerous pericarditis presenting as cardiac tamponade in a year-old man with pancreatic adenocarcinoma: a case report. J Med Case Reports 14, Download citation. Received : 14 August Accepted : 02 October Published : 07 November Anyone you share the following link with will be able to read this content:.

Sorry, a shareable link is not currently available for this article. Provided by the Springer Nature SharedIt content-sharing initiative. Skip to main content. Search all BMC articles Search. Download PDF. Abstract Introduction Pericardial effusion is a rare complication of pancreatic cancer. Conclusions To our knowledge, pancreatic cancer complicated with cancerous pericarditis has not been previously documented. Introduction Malignant pericardial effusion caused by carcinomatous pericarditis is a complication of advanced malignancy.

Case report A year-old Japanese man was suspected of having pancreatic cancer 3 years previously due to an increase in carbohydrate antigen CA