Cancer Lung Cancer Pericardial Effusions in People With Cancer By Lynne Eldridge, MD facebook Lynne Eldrige, MD, is a lung cancer physician, patient advocate, and award-winning author of "Avoiding Cancer One Day at a Time." Learn about our editorial process Lynne Eldridge, MD Medically reviewed by Medically reviewed by Doru Paul, MD on November 01, 2019 Doru Paul, MD, is board-certified in internal medicine, medical oncology, and hematology. Learn about our Medical Review Board Doru Paul, MD Updated on March 31, 2020 Print A pericardial effusion is defined as the buildup of fluid within the pericardium, the layer of tissues that line the heart. If it develops rapidly, however, an acute pericardial effusion often causes life-threatening symptoms and is a medical emergency. When enough fluid builds up in the pericardial space it can severely limit the motion of the heart, a condition known as cardiac tamponade. Sinhyu / Getty Images The test of choice for making the diagnosis is an echocardiogram, but a high index of suspicion is important in finding the effusion early. Thought to be a poor prognostic sign in the past, the mortality rate has decreased substantially in the past few decades due prompt diagnosis and management. Pericardial effusions can be acute or chronic (present for at least 3 months). Ordinarily, there is 15 ml to 50 ml of fluid present in the pericardial space (1 tsp equals 5 ml), but large effusions may contain up to 2 liters of fluid. Symptoms If you have a pericardial effusion that is small and developed slowly, you may only know of its presence due to findings on an X-ray or CT scan. In contrast, if the pericardial effusion is large, or if it develops rapidly it can cause symptoms including: Shortness of breath (especially with lying down and often worse with inspiration)Lightheadedness and fainting (syncope)Chest pain, more commonly felt on the left side than the rightPalpitationsA rapid heart rate (since the heart is restricted and cannot beat as forcefully, heart rate increases to maintain the same blood flow to tissues) Unfortunately, symptoms of a pericardial effusion can mimic those of the condition that often results in these effusions (such as lung cancer or metastatic breast cancer), delaying the diagnosis. It can also mimic heart disease. Causes There are many causes of pericardial effusions, and even if a person has cancer these conditions may be the culprit. Some of these include: Infections, including viral infections, bacterial infections (including tuberculosis), fungal infections, and parasitic infections. Viral infections are most common, especially Cocksackie A and B, HIV, hepatitis viruses, cytomegalovirus (CMV), and echoviruses.Autoimmune conditions (such as with rheumatoid arthritis and lupus)Cancers (both those that spread to the pericardium from other regions of the body such as lung cancer, breast cancer, sarcomas, and lymphomas, and those that begin in the pericardium, such as pericardial mesothelioma)Current or previous radiation therapy to the chest for lung cancer, breast cancer, esophageal cancer, lymphomas, and othersChemotherapyKidney failureHypothyroidism (usually when severe)Inflammation (including pericarditis)Chest surgery (including surgery for heart disease or lung cancer)Heart attacksMedications Medications Some of the medications that may cause pericardial effusions include: The chemotherapy medications Adriamycin (doxorubicin) and Cytoxan (cyclophosphamide)The tuberculosis drug IsoniazidThe seizure medication Dilantin (phenytoin)The medication Rogaine (minoxidil) used for male pattern baldness and high blood pressure Pericardial Effusions With Cancer Pericardial effusions may occur with any type of cancer, but the most common include lung cancer, breast cancer, and lymphomas. With lung cancer, pericardial effusions are very common, with many people undergoing radiation therapy for lung cancer developing some degree of an effusion. Adjuvant chemotherapy (chemotherapy given after surgery) appears to increase this risk this risk as well. Diagnosis The diagnosis of a pericardial effusion begins with a careful history and physical exam, combined with a high index of suspicion in people who have cancer. Physical Exam Physical examination may suggest the presence of a pericardial effusion, but is not diagnostic alone. Breath sounds may be decreased, usually due to a concurrent pleural effusion. The classic triad of findings includes low blood pressure (hypotension), enlargement or bulging of veins in the neck (jugular venous distention), and muffled heart sounds. A pericardial friction rub (a high pitched scratching sound over the heart) may also be heard. Lab Tests Laboratory tests cannot diagnose a pericardial effusion but may be helpful in detecting some of the underlying causes, such as viral cultures, TB tests, and inflammatory markers. An EKG may show ST elevation in most leads. Imaging In general, imaging tests alone cannot make a diagnosis of a pericardial effusion, but may suggest that one is present. On a chest X-ray, a radiologist may see an enlarged cardiac shadow known as the "water-bottle sign." A pericardial fat stripe may also be seen. CT and MRI are sometimes done, and may be helpful along with an echocardiogram in defining pericardial effusions found on the anterior side of the heart, or when pockets of fluids (a loculated effusion) are present. Echocardiogram An echocardiogram, or ultrasound of the heart is the test of choice for diagnosing a pericardial effusion, and there are several variations of this test that may be used (including 2-D echo, M-mode echo, doppler echo, transesophageal echo, and/or intracardiac echo). Differential Diagnosis Some of the conditions that can mimic a pericardial effusion include: Acute pericarditisConstrictive pericarditisPulmonary edema (cardiogenic)Pulmonary embolismHeart attacks Treatments The treatment of pericardial effusions is two-fold. First, the pericardial effusion needs to be treated, often on an emergency basis if it is compressing the heart. Secondly, the cause of the pericardial effusion needs to be addressed. Treatment of the Underlying Cause With infections, antibiotics or antiviral medications will be needed. With inflammation, anti-inflammatory medications or steroids may be used. If the effusion is due to medications, the drug is usually stopped and alternative medications used when possible. With heart failure, medications to treat the conditions, such as diuretics, may be used. With cancer, management of the cancer will vary depending on the extent of the cancer (see below). Treatments Specifically for the Effusion Treatments to resolve a pericardial effusion may include: Pericardiocentesis: In a pericardiocentesis, a long, thin needle is inserted through the skin and into the pericardial sac (usually with ultrasound guidance) to withdraw the fluid.Inserting a shunt (from the pericardial effusion into the abdomen to continually drain the fluid) is often needed as these effusion often recur after they are drained.Balloon pericardiotomyPericardiectomy (removing the pericardium) via either thoracoscopic or open surgery. A pericardial window (subxyphoid pericardiectomy) is a procedure in which a section ("window") of pericardial tissue is removed so that fluid can no longer accumulate in the pericardial sac. If the effusion is large or symptomatic, a procedure known as video-assisted thoracoscopic (VATS) pericardiectomy may be performed. For people who have pericardial effusions due to benign causes (such as an infection) the prognosis with this procedure is good. Given the reasons behind the development of pericardial effusions in people with cancer, the prognosis is guarded regardless of the treatment chosen. That said, with better treatments now available for many advanced cancers, managing the effusion while beginning treatment to control the underlying cancer is likely to improve the prognosis. Treatment of the Cancer Treatment can vary depending on the extend of the cancer. In some cases, chemotherapy and radiation therapy have reduced a pericardial effusion so that surgery can later be successful. Most of the time, however, a pericardial effusion is associated with other areas of cancer metastases (metastatic cancer) and systemic (whole-body) treatments such as chemotherapy, targeted therapy, and/or immunotherapy are the best options. Prognosis The prognosis of a pericardial effusion depends largely on the underlying cause. With infections, inflammatory disease, or kidney disease that can be managed, the prognosis may be very good, and it's important to remember that people who have cancer also develop these conditions. In the past, the prognosis for a pericardial effusion was poor, with up to a third of people with metastases to the pericardium dying from pericardial tamponade. Better treatment options for metastatic cancer as well as prompt treatment of a developing pericardial effusion are critical to improve survival. A Word From Verywell A pericardial effusion may be mild and temporary with conditions such as some viral infections, but can be serious and a poor prognostic sign for people living with cancer. That said, there are a number of methods that can be used to resolve an effusion to improve symptoms and prevent complications when diagnosed promptly. If you or a loved one have cancer and develop a pericardial effusion, ask a lot of questions and be your own advocate. The treatment and prognosis of cancers, even lung cancer, is improving, and much of what you may have heard or read about metastatic cancer and pericardial effusions may not only be very disheartening, but inaccurate. Since it's challenging for even oncologists who specialize in one type of cancer to stay abreast of the latest treatment options, strongly consider getting an opinion at a large cancer center such as a National Cancer Institute designated cancer center. Even in the elderly, newer treatments are available that are much better tolerated, and performance status (how someone functions day to day) is more important than chronological age. How to Advocate for Yourself as a Cancer Patient Was this page helpful? Thanks for your feedback! Limiting processed foods and red meats can help ward off cancer risk. These recipes focus on antioxidant-rich foods to better protect you and your loved ones. Sign up and get your guide! Sign Up You're in! Thank you, {{form.email}}, for signing up. There was an error. Please try again. What are your concerns? Other Inaccurate Hard to Understand Submit Article Sources Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy. Cleveland Clinic. Pericardial Effusion. UT Southwestern Medical Center. Pericardial Effusion. Additional Reading Ghosh, A., Crake, T., Manisty, C., and M. Westwood. Pericardial Disease in Cancer Patients. Current Options in Cardiovascular Medicine. 2018. 20(7):60. doi:10.1007/s11936-018-0654-7 Kato, R., Hayashi, H., Chiba, Y. et al. Prognostic Impact of Minimal Pericardial Effusion in Patients With Advanced Non-Small-Cell Lung Cancer. Clinical Lung Cancer. 2017 May 10. doi:10.1016/j.cllc.2017.05.011 Mizukami, Y., Ueda, N., Adachi, H., Arikura, J., and K. Kondo. Long-Term Outcomes after Video-Assisted Thoracoscopic Pericardiectomy for Pericardial Effusion. Annals of Thoracic and Cardiovascular Surgery. 2017 August 9. doi:10.5761/atcs.oa.17-00046 National Cancer Institute. Cardiopulmonary Syndromes (PDQ): Health Professional Version. Ning, M., Tang, L., Gomez, D. et al. Incidence and Predictors of Pericardial Effusion After Chemoradiation Therapy for Locally Advanced Non-Small Cell Lung Cancer. International Journal of Radiation Oncology, Biology, and Physics. 2017. 99(1):70-79. doi:10.1016/j.ijrobp.2017.05.022