A 58-year-old woman comes to the emergency department due to dyspnea and chest discomfort over the past 2 weeks. The patient was diagnosed with left breast cancer 2 years ago and underwent surgery but refused chemotherapy and radiotherapy due to potential adverse effects. Blood pressure is 110/70 mm Hg, and pulse is 110/min and regular. Chest x-ray reveals an enlarged cardiac shadow. Echocardiography confirms a large pericardial effusion. The patient undergoes pericardiocentesis with removal of 700 mL of serosanguinous fluid. Cytologic examination of the fluid shows malignant cells consistent with metastatic breast cancer. What is the best next step in management of this patient's pericardial effusion?
Malignant pericardial effusion | |
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Clinical features |
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Treatment |
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CXR = chest x-ray; GI = gastrointestinal. | |
This patient with a history of breast cancer has developed a large, malignant pericardial effusion (MPE) with associated dyspnea, chest discomfort, and tachycardia. Malignancy is a common cause of pericardial effusion, which may be the initial clinical manifestation of recurrence, as in this patient. Common tumor types associated with MPE include breast cancer, lung cancer, and lymphoma.
Subacute accumulation of pericardial fluid (eg, over weeks) gives the pericardium time to progressively stretch; therefore, a large fluid volume (eg, 700 mL) may accumulate. Patients often experience only nonspecific symptoms (eg, dyspnea, chest discomfort) until enough fluid (typically 1-2 L) accumulates to increase intrapericardial pressure and compromise cardiac function (ie, cardiac tamponade).
Management of MPE consists of the following:
Acute drainage: Pericardiocentesis is performed to relieve patient symptoms, treat early signs of cardiac compromise (eg, tachycardia), and/or obtain fluid for cytologic evaluation.
Prevention of reaccumulation: A means for prolonged pericardial drainage is recommended because fluid reaccumulates frequently (eg, up to 60% of cases). This is typically achieved either through the creation of a pericardial window (surgical removal of part of the pericardium to allow pericardial fluid to drain into the pleural or peritoneal cavity) or through prolonged pericardial catheter drainage.
(Choices A, B, and D) Combination therapy with colchicine and nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, indomethacin) is commonly used to treat viral or idiopathic acute pericarditis, which can sometimes cause pericardial effusion. Glucocorticoids (eg, prednisone) may be used when NSAIDs are contraindicated or initial therapy fails. Such therapies, which reduce pericardial inflammation, are less effective for malignant effusion, which typically requires prolonged drainage to prevent recurrence, as well as treatment of the underlying malignancy (eg, chemotherapy).
(Choice E) After further workup to determine the extent of metastatic spread, systemic chemotherapy may be indicated to treat or palliate this patient's metastatic breast cancer. Other than lymphoma, which may respond rapidly, any benefit of chemotherapy on malignant spread to the pericardium will likely take weeks or months to take effect; in the meantime, a definitive method of prolonged drainage is needed.
Educational objective:
Malignant pericardial effusions are often large and prone to recurrence. In addition to acute management with pericardiocentesis, they often require prevention of reaccumulation, either via a pericardial window or prolonged catheter drainage.