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 in around two-thirds of people, but 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 sometimes the first symptom that a cancer is present. In the setting of cancer they are often 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.

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 the condition that often result in these effusions (such as 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 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.

Lab Tests

Laboratory tests cannot diagnose a pericardial effusion but may be helpful in detecting some of the underlying causes.

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) is 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.

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.

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 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 needle is inserted into the pericardial sac (usually with ultrasound guidance), and fluid is withdrawn
• Inserting a shunt (from the pericardial effusion 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 of the Cancer

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.

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.