Abubakar, S

Ali, S M

Khan, A

Malik, I

English

eCommons@AKU

eCommons@AKUSection of Internal Medicine Department of MedicineJanuary 1991Management of malignant pericardial effusion withtetracycline induced pericardiodesisS AbubakarAga Khan UniversityI MalikAga Khan UniversityS M. AliAga Khan UniversityA KhanAga Khan UniversityFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_med_intern_medRecommended CitationAbubakar, S., Malik, I., Ali, S. M., Khan, A. (1991). Management of malignant pericardial effusion with tetracycline inducedpericardiodesis. Journal of Pakistan Medical Association, 41(1), 20-22.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_med_intern_med/74MANAGEMENT OF MAUGNANT PERICARIMALEFFUSION WITH TETRACYCLINE INDUCEDPERICARDIODESISPages with reference to book, From 20 To 22 Saleem Abubakar ( Departments of Medicine, The Aga Khan University Medical College, Karachi-74800. ) Imtiaz Malik, Ata Khan ( Departments of Medicine, The Aga Khan University Medical College, Karachi-74800. ) Sohaila Mohsin Ali ( Departments of Surgery, The Aga Khan University Medical College, Karachi-74800. ) Clinically evident cardiac involvement due to malignancy is uncommonly encountered. In autopsyseries, however, involvement of the heart has been observed in 5.1% of the patients with advancedcancer. Pericardium is most frequently involved. Pericardial involvement usually presents as pericardialeffusion. Depending upon the rapidity of the process, pericardial effusion may remain asymptomatic onone hand or present with life- threatening cardiac tamponade on the other. Patients presenting withcardiac tamponade require immediate pericardiocentesis which affords rapid relief ofsymptoms. Longterm management of these cases, however, is difficult and controversial. We recently had two patientspresenting with symptomatic pericardial effusion who after pericardiocentesis underwent tetracyclineinduced pericardiodesis. On follow-up neither has recurrence of the pericardial effusion.CASE REPORTS Case 1A 42 years old male was admitted with acute onset of dyspnea. He had history of cough with whitishexpectora¬tion and occasional hemoptysis. Chest x-ray, done 6 weeks ago, showed a large right hilarmass. A transbronchial biopsy performed elsewhere showed poorly differentiated carcinoma. He hadtwenty pack year history of smoking. On examination he was afebrile with respiratory rate of 39/minand pulse rate of 150 /min. He had marked clubbing, distended neck veins, distant heart sounds anddecreased chest wall expansion with bilateral wheezing. Haemogram showed neutrophilic leucocytosis.Electrolytes and renal functions were normal. ECG had no abnormality. X-ray chest showed globularcardiomegaly and a right hilar mass. Echocardiogram confirmed the clinical suspicion of a largepericardial effusion. On pericardiocentesis, 1.5 L of bloody fluid was removed and drainage tube wasleft in the pericardial space. Cytologic analysis of the fluid confirmed malignancy, most likely large cellcarcinoma. Once catheter drainage decreased, 1.5 g of tetracycline was instilled into the pericardialcavity. Catheter was clamped for 4 hours. After unclamping, fluid was drained and catheter was pulledout next day. Patient tolerated the procedure well and was discharged after two days. Follow-up in theoncology clinic revealed a rapid increase in the size of the hilar mass. He was treated withchemotherapy but did not respond and died after six weeks of follow-up. During this time period, hehad no clinical or radiologic recurrence of the pericardial effusion.Case 2A 45 years old female was brought to the emergency room in shock. She bad a history of vomiting andhaema¬temesis for the past 2 days and chest pain for the last 6 months. X-ray chest showed a roundopacity in the right mid zone and she was being treated with anti-TB drugs. On examination,extremities were cold and clammy, respiratory rate was 40/mm, pulse was rabid and feeble and BP wasunrecordable. Her neck veins were distended and heart sounds were muffled. Investigations revealedleucocytosis, high anion-gap, metabolic acidosis, slightly raised creatinine and normal liver profile.ECG had low voltage. X-ray chest showed massive cardiomegaly with a right mid-zone opacity.Echocardiogram confirmed the presence of pericardial effusion. Immediate pericar-diocentesis wasperformed with removal of 500 ml of bloody fluid followed by creation of a pericardial window and adrainage tube was left in the pericardial cavity. Fluid was cytologically positive for large cellcarcinoma. Pericardial biopsy confirmed metastatic large cell cancer with strong positivity for estrogenreceptors. Pericardiodesis was per¬formed with 1.5 g of tetracycline followed by removal of thecatheter. Although her breast examination was normal, due to estrogen receptor positivity, she wasstarted on Tamo¬xifen. Presently she has been followed for the last 8 weeks in the oncology clinicwithout any recurrence of the pericar¬dial effusion. Lung opacity remains unchanged. Patient is fullyfunctional.DISCUSSION Involvement of the heart with cancer occurs in 5.1 % of all patients with advanced cancer at the time ofautopsy. In approximately two-thirds of these cases, it remains undiagnosed during life. Pericardium ismost commonly involved, solely so in 45% of the cases1. It usually manifests as pericardial effusion.Malignant pericardial effusion is due to carcinomas of lung or breast in 75% of the cases, rest maybedue to leukemias, lymphomas, melanoma, sarcoma and G.I. tumours. Thirty five percent of patientswith lung cancer2 and 25% of those with breast cancer3 may have pericardial involvement at autopsy.Symptomatic pericardial effusion however occurs uncommonly and is usually a pre-terminal event.Malignant pericardial effusion develops due to the obstruction of lymphatic and venous drainage by thetumour cells. Development of symptoms depends upon the rate of accumulation of fluid, volume offluid and function of the underlying heart. A slowly developing symptomatic pericardial effusion maymimic congestive cardiac failure due to other causes. Rapidly developing effusion may present withacute dyspnea, chest pain, hypotension, jugular venous distension, distant heart sounds, pericardial ruband cardiomegaly. Congestive hepatomegaly, ascites and leg edema may also be present. Presence ofpulsusparadoxus is highly suggestive of cardiac tamponade. Chest x-ray is very helpful in making thediagnosis and ECG may show low voltage, tachycardia and arrhythmias. However, echocardiographyremains the most valuable tool for the demonstration and quantitation of the pericardial effusion. It issimple, sensitive, non-invasive and can be performed at the bed side. Immediate management ofsymptomatic pericardial effusion is by echocardiographically guided pericardiocentesis. It has a highyield, complication rate is low and provides rapid symptomatic relief. Fluid is mostly exudative, bloodyand cytologically positive in majority of the cases. Pericardiocentesis with indwelling catheter drainageis frequently effective in controlling pericardial effusions for short time periods4, but relapses occurafter pericardiocentesis alone and surgical procedures may become necessary3. Radiotherapy was onceused very frequently for the long term management of these cases5 but is now mostly reserved for casesof refractory pericardial effusions in patients with lymphomas. Surgical procedures for the managementof malignant pericardial effusion include the creation of draining pericardial window6 orpericardiectomy7. These procedures are very effective, and also provide the histologic diagnosis buthave higher complication rate including secondary infection (40%) and atelectasis with pleural effusion(35%). These procedures are usually reserved for the patients who are refractory to other measures.Instillation of sclerosing agents into the pericardial space to decrease the relapse of pericardial effusionhas been reported in many studies. Although other agents (bleomycin, thiotepa, quinacrine, nitrogenmustard, vinbiastine etc) 8,9 have also been used, tetracycline appears to be most effective and leasttoxic10,11. Tetracycline instillation has been reported to be effective in preventing a recurrence ofpericardial effusion for a mean of 120 days in 75% of the patients. Our patients, after initial drainage,underwent pericardiodesis with 1.5g of tetracycline. The procedure was very well tolerated and nocomplications were observed. One patient has died after six weeks, other is alive at 8 weeks, bothwithout recurrence of pericardial effusion. We conclude that the induction of pericardial sclerosis byinstillation of tetracycline into the pericardial space maybe a safe and effective method for controllingmalignant pericardial effusions.REFERENCES 1. Skhvatsabaju, L.V. Secondary malignant lesions of the heart and pericardium in neoplastic disease.Oncology, 1986; 43: 103.2. Shenkai,T.,Tomenagu, K., Sajjo, N., etal. The incidence of cardiac metastases in primaiy lung cancerand the management of malignant pericardial effusion. J. Clin. Oncol., 1982; 12: 23.3. Buck, M., Ingle, J.N., Guiliani, E.R., Gordon, J.R.and Therneau, T.M. Pericardial effusion in womenwith breast cancer. Cancer, 1987; 60: 263.4. Flannery, E.P., Gregoratos, 0. and Corder, M.P. Pericardial effusions in patients with malignantdiseases. Arch. Intern. Med., 1975; 135: 976.5. Cham,W., Freiman, A.H., Carstens, P.H.B. and Chu, F.C.H. Radiation therapy of cardiac andpericardial metastases. Ther. Radiol., 1975; 114: 701.6. Fredriksen, R.T., Cohen, L.S. and Mullins, ç.B. Pericardial windows or pericardiocentesis forpericardial effusions. Am. Heart J., 1971; 82:158.7. Morton, D.L., Kagan, A.R., Roberts, W.E., et al. Pericardiectomy for radiation - induced pericarditiswith effusion. Ann. Thorac. Surg., 1969; 8: 195.8. Terpinning, M., Orringer, M., Wheeler, R. and Bull, F.E. Interpericardial nitrogen mustard withcatheter drainage for the treatment of malignant effusions. Proc. Am. Assoc. Cancer Res., 1979; 20:286.9. Primrose, W.R., Clee, M.D. and Johnston, RN. Malignant pericardial effusion managed withVinbiastine. Clin. Oncol., 1983; 9:67.10. Davis, S., Sharma, S.M., Blumberg, E.D. and Kim, C.S. In. trapericardial tetracycline for themanagement of cardiac tamponade secondary to malignant pericardial effusion. N. Engl. J. Med., 1978;299: 1113.11. Shephard, F.A., Ginsherg, J.S., Evans, W.R., et al. Tetracycline sclerosis in the management ofmalignant pericardial effusion. J.Clin. Oncol., 1985; 3: 1678.

Management of malignant pericardial effusion with tetracycline induced pericardiodesis

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Management of malignant pericardial effusion with tetracycline induced pericardiodesis

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