Neoplastic pericardial disease
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Neoplastic pericardial disease, neoplastic pericardial involvement or neoplastic pericarditis refers to a pericardial infiltration by tumor cells usually associated with a variably sized pericardial effusion and is a form of non-infectious pericarditis. It needs to be differentiated from other causes of pericardial effusions.
Neoplastic pericardial involvement is one possible cause of pericardial effusion or pericarditis with an estimated frequency of 5-10% alongside other causes as idiopathic pericarditis, radiation or chemotherapy-induced pericarditis and others 1-3. Primary pericardial tumors are rare. Secondary involvement of other neoplasms as lung cancer, breast cancer, lymphomas or leukaemias are more common 1.
Pericardial involvement in neoplastic disease is associated with a variably sized pericardial effusion in about 12-25%.
Clinical features of pericardial involvement in neoplastic disease include dyspnea and reduced exercise intolerance, pericarditic chest pain, fatigue and possible pericardial friction rub. Often there will be a known underlying malignancy. However, malignant pericardial effusion might also occur as an initial presentation of malignant disease 1-3.
Possible changes in electrocardiogram include widespread ST-segment elevation and PR-segment depression as seen in pericarditis.
Complications of pericardial involvement in neoplastic disease include the following 1:
Pericardial involvement in neoplastic disease is characterized by tumor infiltration of the pericardium and/or pericardial effusion often associated with high monocyte count.
Causes pericardial involvement in neoplastic disease includes the following 1,4,5:
- primary tumors of the pericardium or the heart (rare)
- secondary pericardial involvement (direct invasion, metastases, venous extension)
Imaging forms an integral part of the diagnosis of pericardial involvement in neoplastic disease. One of the main imaging features is a variable-sized pericardial effusion which will be apparent on different imaging modalities. Other imaging features include variable pericardial thickening or direct tumor growth.
Echocardiography is a first-line imaging modality in the diagnosis and monitoring of pericardial effusions and pericarditis. It can also identify complications as cardiac tamponade or pericardial constriction and can be used to guide pericardiocentesis 1,4,5.
CT is a standard imaging modality in the staging of malignancy. In addition, it can depict pericardial effusion which might be heterogeneous, pericarditis as well as direct tumor growth or deposits 1,4,5.
MRI cannot only detect and visualize pericardial effusion and pericarditis but can also characterize any underlying tumor or neoplastic involvement. Besides, cardiac MRI can detect hemorrhagic effusion. Imaging Finding includes the following 4,5:
- pericardial adhesions
- pericardial thickening and nodular changes
- pericardial edema and enhancement
- pericardial (pseudo)mass or tumor deposits
- T1: variable, hyperintense if blood is present
- T2: heterogeneous high signal intensity
- STIR/PDFS: high signal intensity
- T1C+(Gd): variable enhancement
Demonstration of FDG-uptake in the pericardium by PET or PET-CT in patients with cancer or lymphoma indicates pericardial involvement and can aid in the diagnosis as well as in monitoring therapy.
The radiological report should contain a description of the following:
- pericardial effusion, pericardial thickening, pericardial enhancement
- presence of pericardial hemorrhage
- location and size of tumor deposits
- cardiac volumes and measurements
- ventricular wall motion abnormalities
- myocardial involvement or signs of myocarditis
Treatment and prognosis
Pericardial involvement of neoplastic disease features a high rate of recurrence of 40-70%. Management involves the following 1,4:
- systemic tumor therapy as a baseline
- pericardiocentesis for securing/establishing the diagnosis and symptom relief
- extended pericardial drainage
- intrapericardial administration of cytostatic and/or sclerosing agents to prevent recurrences
Radiation therapy can control pericardial effusion in lymphomas and leukaemias 1. Percutaneous balloon pericardiotomy or pericardial window creation can be considered in large pericardial effusions to relieve symptoms.
Complications of intrapericardial treatment include the following 1:
- chest pain
- atrial arrhythmias
Complications of radiation therapy include 1:
- radiation-induced pericarditis
Pericardial involvement in neoplastic disease can mimic the appearance of other types of pericardial effusions 1,4:
- radiotherapy-induced pericarditis
- pericarditis due to chemotherapeutic toxicity
- pericarditis due to opportunistic infections
- tuberculous pericarditis
- purulent pericarditis
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