Pericardial Effusions in People with Cancer

A pericardial effusion is the buildup of fluid within the pericardium, the layer of tissues that lines the heart. A pericardial effusion may develop slowly (chronic pericardial effusion) and cause few symptoms. Instead, if it develops rapidly (acute pericardial effusion), it often causes life-threatening symptoms and is a medical emergency. When enough fluid builds up in this area and severely limits the motion of the heart, the condition is known as cardiac tamponade.

A pericardial effusion may occur for many reasons (some of these are listed below) but are far too common in people with lung cancer. They occur in up to 21 percent of people with cancer and are usually associated with a poor prognosis, but prompt recognition and diagnosis provide the opportunity for palliative care. The mortality rate has decreased substantially in the past few decades due prompt diagnosis and management. In roughly two-thirds of people, the effusion does not cause any obvious 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)
• Lightheadedness
• Chest pain
• A 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 lung cancer, delaying the diagnosis.

There are many causes of pericardial effusions. Some of these include:

• Infections
• Autoimmune conditions (such as with rheumatoid arthritis)
• Cancers (both those that spread to the pericardium from other regions of the body and those that begin in the pericardium)
• Kidney failure
• Inflammation (including pericarditis)
• Chest surgery
• Heart attacks
• Medications

Some of the medications that may cause pericardial effusions include:

• The chemotherapy medications Adriamycin (doxorubicin) and Cytoxan (cyclophosphamide)
• The tuberculosis drug Isoniazid
• The seizure medication Dilantin (phenytoin)
• The medication Rogaine (minoxidil) used for male pattern baldness and high blood pressure

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 roughly half of people undergoing radiation therapy for lung cancer developing some degree of an infusion. Adjuvant chemotherapy appears to increase this risk.

In about 50 percent of people with cancer who have a pericardial effusion, the pericardial effusion is the first sign and leads to the diagnosis of the cancer.

The treatment of pericardial effusions is two-fold. First, the pericardial effusion needs to be treated, often emergently if it is compressing the heart. Secondly, the cause of the pericardial effusion needs to be addressed.

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 cancer, management of the cancer will vary depending on the extent of the cancer (see below).

Treatments to resolve a pericardial effusion may include:

• Pericardiocentesis
• Inserting a shunt (often into the abdomen to continually drain the fluid)
• Balloon pericardiotomy
• Pericardiectomy (removing the pericardium) via either thoracoscopic or open surgery

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 fairly poor regardless of the treatment chosen.

Treatment can vary depending on how extensive the cancer is. 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 and treatment is palliative: done for comfort reasons but not with an attempt to cure cancer.

The prognosis of a pericardial effusion depends largely on the cause. With infections, inflammatory disease, or kidney disease that can be managed, the prognosis may be very good.

With lung cancer, the development of a pericardial effusion is a poor prognostic sign, even with very small effusions.

A third of people who have cancer metastases to the pericardium will die from pericardial tamponade.