ARTICLE IN PRESS

doi:10.1510/icvts.2010.232546

Interactive CardioVascular and Thoracic Surgery 11 (2010) 154–161

www.icvts.org

Institutional report - Thoracic oncologic

Effectiveness and prognosis of initial pericardiocentesis in the
primary management of malignant pericardial effusion
Ángel Apodaca-Cruza , Cynthia Villarreal-Garzab , Beatriz Torres-Ávilab, Jorge Torresa, Abelardo Menesesa,
Diana Flores-Estradab, Fernando Lara-Medinab, Óscar Arrietab-d,*
a
Department of Internal Medicine, Instituto Nacional de Cancerologı́a, Mexico City, Mexico
Department of Medical Oncology, Instituto Nacional de Cancerologı́a, Av. San Fernando No. 22, Sección XVI, Deleg. Tlalpan, Mexico City,
b

Mexico 14080, D.F., Mexico

c
Experimental Oncology Laboratory, Instituto Nacional de Cancerologı́a, Mexico City, Mexico
d
Universidad Nacional Autónoma de México (UNAM), Mexico City, Mexico

Received 11 January 2010; received in revised form 28 April 2010; accepted 7 May 2010

Abstract

We retrospectively reviewed the records of 100 patients with malignant disease and symptomatic pericardial effusion initially treated
with pericardiocentesis at the National Cancer Institute of Mexico between 1985 and 2009. We analyzed predictive factors for recurrence
of pericardial effusion by bi- and multivariate analyses. The group comprised 74 women and 26 men. Twenty patients had developed
malignant pericardial effusion at the time of primary cancer diagnosis. Recurrence rate after pericardiocentesis was 33%. Progression-free
survival for pericardial effusion at one year was 59% (range, 47–71%). Median overall survival (OS) after pericardiocentesis was
40.3"7.9 weeks (95% Confidence interval, 24.9–55.7). The sole factor that correlated with increased progression-free survival for
pericardial effusion was the presence of bloody pericardial effusion. For OS, multivariate analysis yielded that female gender and presence
of pericardial effusion at time of primary malignancy diagnosis were associated with higher life expectancy. Initial pericardiocentesis can
provide successful management of patients with a control rate of 67%. In spite of the high effectiveness of the primary management of
pericardial effusion with pericardiocentesis in oncologic patients, it might be considered for initial treatment, especially those with poor
prognosis, leaving pericardial window as a secondary strategy for recurrence.
䊚 2010 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.

Keywords: Malignant pericardial effusion; Pericardiocentesis; Effectiveness; Prognosis

1. Introduction of death from the effusion, many of these patients have

The management of malignant pericardial effusion (MPE)
denotes a complex condition, one that is frequently
encountered. Autopsy studies have revealed malignancy-
associated pericardium involvement with an incidence
between 10 and 20% w1x. MPE is frequently asymptomatic
and usually is detected incidentally. Symptomatic cases,
however, often manifest with cardiac tamponade, which
can rapidly lead to cardiovascular collapse and death unless
promptly treated.
Treatment of MPE must address two concerns: relief of
acute symptoms and the hemodynamic effects of cardiac
tamponade, and prevention of fluid reaccumulation within
the pericardium w2x. However, the best treatment of MPE
remains controversial because there are no definitive,
prospective, and comparative trials that address this topic.
In the presence of malignancy, optimal treatment of MPE
should balance treatment efficacy with life expectancy.
Although timely management may decrease short-term risk
*Corresponding author. Tel.: q52 55 5628-0400 ext. 832; fax: q52 55 5485-
6270.
E-mail address: ogar@servidor.unam.mx (Ó. Arrieta).
䊚 2010 Published by European Association for Cardio-Thoracic Surgery
major comorbidity associated with widespread metastatic
disease, limiting both quality of life and survival even with
optimal management of MPE. In some cases pericardial
effusion might be unrelated with the underlying malignancy
and long-term survival can be expected w3x.
Pericardiocentesis alone is generally not considered to be
a definitive procedure because only 31–38% of effusions
are controlled and reaccumulation frequently occurs within
24–48 h w4x. However, among patients with end-stage dis-
ease, pericardiocentesis is probably the procedure of
choice when effusion recurrence is not a concern, because
it is effective for relieving symptoms and is a less-invasive
procedure. In patients with a higher life expectancy, a
more aggressive and definitive approach may be warranted.
The primary objective of this study was to determine the
effectiveness of initial pericardiocentesis.
In order to determine a better selection of treatment
strategies in MPE, a secondary purpose of this study was to
examine prognostic factors influencing survival in patients
with solid malignant tumors and symptomatic effusion
treated initially with pericardiocentesis. It also reviews the
prognostic factors determined by other authors in their
series of patients.
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Editorial
2. Patients and methods
We retrospectively reviewed all records of 100 patients

New Ideas
diagnosed with malignant disease and symptomatic peri-
cardial effusion at the National Cancer Institute of Mexico
between 1985 and 2009 (48 were reviewed in electronic
records, 30 patients in printed records, and 22 patients in

Progress Report
both electronic and printed records). Diagnosis of MPE was

Work in
considered either clinically (by the presence of pulsus
paradoxus, elevated jugular pressure, tachycardia, and
hypotension) or according to echocardiographic criteria.
Patients developed MPE during or after primary diagnosis
of cancer at any site and all patients had active malignant

Protocol
disease at the time of MPE. Demographic variables, thera-
peutic approach, complications, and clinical outcomes were
recorded. The pericardial effusion-free interval was

Institutional
defined as the time between diagnosis of primary malig-

Report
nancy and MPE.
Initial pericardiocentesis for diagnosis and relief of symp- Fig. 1. Pericardial effusion progression-free survival. CI, confidence
toms was performed in all patients. Electrocardiographic interval.

and standard 2D echocardiographic views were obtained

Article
ESCVS
with commercially available equipment. The site of the
needle puncture was determined by echocardiographic
examination, the ideal site being when the fluid was closest diagnosis was 1 in 24 patients, 2 in 37, and 3 in 39.

Proposal for Bail-

to the transducer and where the needle avoided the heart,
lung and underlying structures. A needle surrounded by
plastic sheet was used. After the pericardial fluid had been
located the steel part of the needle was removed. The
steel needle was never pushed into the right ventricle to
out Procedure
Previously diagnosed malignancies included 50 patients with
breast cancer, 20 non-small cell lung cancer, eight cervical
cancers, six germ cell tumors, three lymphomas, two mel-
anomas and 11 different malignancies. Fifty-three patients
had been previously treated with chemotherapy, and 50

Negative
Results
avoid puncturing it and no ECG trace was ever obtained patients had received previous radiation therapy at the
from the steel part of the needle. In some cases, this was primary tumor.
followed by immunotherapy with interferon alpha-2b. The most common presenting symptoms were dyspnea,
Definitive surgical treatment was conducted only if MPE tachycardia, hypotension, and chest pain. Acute symptom

Follow-up
recurrence was documented and the type of surgical treat- onset was experienced by 57% of patients, while 43% had

Paper
ment routine was performed according to the surgeon’s chronic presentation. In 70 patients, ECG abnormalities
preference. Recurrence of MPE was defined as reaccumu- were revealed, the most frequent alterations being elec-
lation of pericardial fluid manifested by clinical symptoms trical alternation of the QRS complex and low voltage.

and demonstrated by echocardiography and requiring inter-
vention w5x. Patients were followed up until death or time
of last follow-up. Progression-free survival from MPE was
defined as the time between initial pericardial drainage
and recurrence of symptoms that required a secondary
State-of-the-art
Twenty patients had developed MPE at the time of primary
cancer diagnosis. Median interval from diagnosis of primary
malignancy to diagnosis of symptomatic MPE was
14.5 months (range, 0–206).

Best Evidence
intervention, and overall survival (OS) was delineated by

Topic
initial pericardial drainage and death or last follow-up.

3. Statistical analysis
Continuous variables were expressed as mean or median Nomenclature

and standard deviation (S.D.), and categorical variables as

percentage and 95% confidence intervals (95% CI). Median
progression-free survival for MPE and OS were estimated
by Kaplan–Meier method and survival analyses were
assessed by log-rank test. A multivariate model to predict
Historical
Pages

survival among patients with MPE was developed using the

Cox proportional hazards model. A P-0.05 was considered
significant (two-sided tails). All statistical computations
were performed using the SPSS version 14.0 statistical
Communication

software package.
Brief

4. Results
The group comprised 74 women and 26 men (mean age,
47 years; range, 17–82). Performance status at the time of Fig. 2. Overall survival. CI, confidence interval.
Case Report
 ARTICLE IN PRESS
156 Á. Apodaca-Cruz et al. / Interactive CardioVascular and Thoracic Surgery 11 (2010) 154–161

Table 1. Bivariate and multivariate analysis of pre-treatment variables for progression free survival

Variable Bivariate Multivariate

PFS at 1 year (%) 95% CI P-value HR 95% CI P-value

Age (years)
-50 52.7 52.6–70.1 0.9
)50 60.9 42.2–79.5
Gender
Male 68.6 45.1–92.1 0.43
Female 56.7 44.9–68.5
Disease
Breast 56.5 38.9–74.1 0.35
Others 61.5 42.8–77.2
Performance status
1 52.0 28.5–75.5 0.34
2 51.1 33.5–68.7
3 66.5 48.9–84.1
Months between primary cancer diagnosis and pericardial effusion
-14 51.1 31.5–70.7 0.82
)14 57.2 41.5–72.9
Pericardial effusion onset
Acute 56.3 40.6–72.0 0.09 0.6 0.16
Chronic 63.1 44.5–79.7 0.3–1.2
Volume of pericardial drained effusion
-500 62.0 45.3–78.7 0.51
)500 52.7 35.1–70.3
Gross appearance
Serous 40.8 23.2–58.4 0.031 0.46 0.027
Bloody or serosanguineous 68.9 55.2–82.6 0.23–0.91
Cytologic findings
Negative 63.7 48.0–79.4 0.81
Positive 55.1 39.4–76.8
Pericardial effusion at time of primary cancer diagnosis
Yes 51.8 26.3–77.3 0.76
No 55.5 41.8–69.2
Hypotension
No 60.3 44.6–76.0 0.48
Yes 56.3 40.6–72.0
Electrocardiographic abnormalities
No 59.9 40.3–79.5 0.23
Yes 63.6 49.9–77.6
Interferon alpha-2b
No interferon 59.9 46.2–73.6 0.36
Interferon 54.0 32.4–75.6

PFS, progression-free survival; CI, confidence interval; HR, hazard ratio.

The initial pericardial-drainage method for all patients
consisted of pericardiocentesis. The effusion was grossly
bloody in 63 patients, serous in 21, and serosanguinous in
16. In 49 cases, cytology was positive for the presence of
malignancy. Mean MPE volume was 500 ml (range, 15–1700
ml). Intrapericardial instillation of interferon alpha-2b fol-
lowing pericardial drainage was performed in 24 patients.
Minor complications were observed in only eight pericardi-
ocentesis procedures: three cases presented vagal hypoten-
sion and catheter occlusion was noted in five patients.
Recurrence rate after pericardiocentesis was 33% (95% CI,
28.7–37.3). Median recurrence time was not reached. MPE
progression-free survival at one year was 59% (range, 47–
71%) (Fig. 1). Twenty-nine patients required a second thera-
peutic strategy: 16 patients, pericardiocentesis; eight,
pericardial window; and five, indwelling pericardial
catheter.
Median OS was 40.3 weeks wstandard error (S.E.), 7.9x
(95% CI, 24.9–55.7) (Fig. 2). Treatment received after
pericardiocentesis with radio- or chemotherapy prolonged
survival: treatment, 20.3"7.8 (95% CI, 25.0–55.5) vs. no-
treatment, 11.9"5.7 (95% CI, 0.8–22.9) (P-0.001). To
determine if MPE recurrence has a direct effect in OS, we
compared the OS of patients that presented MPE recurrence
vs. those who did not, with a median survival of 38.5 weeks
(95% CI, 25.4–51.6) vs. 47.7 weeks (95% CI, 3.9–99.5),
respectively, (Ps0.796), showing no association.
After bi- and multivariate analyses, the only factor pres-
ent when pericardiocentesis was performed that correlated
with increased progression-free survival of MPE was the
presence of bloody gross appearance (Table 1 and Fig. 3).
For OS, multivariate analysis yielded the following prognos-
tic factors: gender and presence of MPE at time of primary
malignancy diagnosis (Table 2, Figs. 4 and 5).
5. Discussion
In the present study, we retrospectively analyzed 100
patients with MPE who were all consistently treated at our
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Á. Apodaca-Cruz et al. / Interactive CardioVascular and Thoracic Surgery 11 (2010) 154–161 157

Editorial
institution initially with pericardiocentesis. We reported a
control rate as high as 67%, considering that all patients
were primarily submitted to a single procedure, as com-

New Ideas
pared with other series in which pericardiocentesis alone
was not generally considered to be a definitive practice. In
the Mayo Clinic series w6x, they reported a high overall 78%
control rate after treatment of 275 patients with MPE who

Progress Report
were all treated with consecutive pericardiocentesis. How-

Work in
ever, in other series, they have reported a successful initial
pericardiocentesis that ranges only between 10 and 44%
w7 x .
Compared to an initial intervention with pericardial win-

Protocol
dow, which has a control rate as high as 86–92% w7x, an
initial pericardiocentesis has a lower control rate as primary
management of MPE. However, we believe that among

Institutional
oncologic patients who are expected to have a short life

Report
expectancy, an initial pericardiocentesis is the procedure
Fig. 3. Pericardial effusion progression-free survival (PFS) based on gross of choice with an acceptable rate of local control and a
appearance of pericardial effusion. CI, confidence interval; HR, hazard ratio. low rate of complications (2.9%) and mortality (0.7%) w7x.

Article
ESCVS
Table 2. Bivariate and multivariate analyses of pre-treatment variables for overall survival

Proposal for Bail-

out Procedure
Variable Bivariate Multivariate

Median OS"S.E. 95% CI P-value HR 95% CI P-value

Age (years)
-50 42.9"5.0 33.0–52.7 0.71

Negative
Results
)50 31.3"11.5 8.7–53.8
Gender
Male 22.4"10.7 1.4–43.4 0.24 0.386 0.010
Female 47.7"15.8 16.7–78.7 0.19–0.80
Disease

Follow-up
Paper
Breast 31.3"6.1 19.2–43.4 0.31
Other 47.7"18.1 12.3–83.2
Performance status
1 26.6"11.1 4.7–48.4 0.16

State-of-the-art
2 65.4"17.7 30.5–100.3
3 38.7"8.3 22.5–54.9
Months between primary cancer diagnosis and pericardial effusion
-14 40.3"18.9 3.3–7.2 0.68
)14 31.3"8.3 15.0–47.5
Pericardial effusion onset

Best Evidence
Acute 31.1"4.9 21.6–40.7 0.018 0.70 0.2
Chronic 47.7"15.6 17.1–78.4 0.4–1.3

Topic
Volume of pericardial drained effusion (ml)
-500 31.1"5.1 21.2–41.1 0.55
)500 47.7"15.2 18.0–77.4
Gross appearance
Serous 42.8"6.1 30.7–54.9 0.28 Nomenclature
Bloody or serosanguineous 31.1"6.5 18.5–43.7
Cytologic findings
Negative 38.7"18.2 3.1–74.3 0.74
Positive 40.3"8.4 23.9–56.7
Pericardial effusion at time of primary cancer diagnosis
Yes 294.0"53 77.0–286.1 0.09 3.27 0.025
Historical

No 30.6"2.6 25.3–35.7 1.16–9.2

Pages

Hypotension
No 30.6"7.2 16.4–44.7 0.44
Yes 47.7"16.3 15.7–79.6
Electrocardiographic abnormalities
Communication

No 29.7"15.2 0–59.6 0.53

Yes 40.3"10.2 20.3–60.2
Brief

Interferon alpha-2b
No interferon 42.8"8.9 25.5–60.3 0.85
Interferon 31.3"6.5 18.5–44.0

OS, overall survival; S.E., standard error; CI, confidence interval; HR, hazard ratio.
Case Report
 ARTICLE IN PRESS
158 Á. Apodaca-Cruz et al. / Interactive CardioVascular and Thoracic Surgery 11 (2010) 154–161
Fig. 4. Pericardial effusion overall survival (OS) based on gender. CI, confi-
dence interval; HR, hazard ratio.
Fig. 5. Pericardial effusion overall survival (OS) based on pericardial effusion
at time of primary cancer diagnosis. CI, confidence interval; HR, hazard
ratio.
It alleviates symptoms in the majority of cases, and is a
safe, simple, and widely available bedside practice associ-
ated with less morbidity than other approaches. These
malignancies are advanced, and efforts to minimize hospi-
talization, improve quality of life, and diminish costs are
vital.
A secondary objective was to describe the prognostic
factors in the patient with MPE in order to select patients
with a higher life expectancy who might benefit from other
therapeutic strategies from the beginning, in order to
diminish the recurrence rate of effusion reaccumulation.
The sole factor that correlated with increased progression-
free survival of MPE recurrence was the presence of bloody
effusion. This might be explained by the presence of a
higher protein concentration associated with the content
exudate and hemoglobin, as well as an increased number
of platelets that might promote clotting and fibrosis.
For OS, multivariate analysis yielded that feminine gender
and presence of MPE at time of primary malignancy diag-
nosis were associated with higher life expectancy. It has
been reported previously that male gender was indepen-
dently associated with poor prognosis w6x. Although we
expected that differences in gender would be explained by
the higher frequency of breast cancer malignancies, in this
series primary cancer diagnosis was not a prognostic factor
for survival. The presence of pericardial effusion at the
time of primary malignancy diagnosis was associated with
better OS after pericardial drainage probably because these
patients had not been treated previously with chemo- or
radiotherapy. Patients may have an opportunity to achieve
a better condition and longer survival by receiving antican-
cer therapy after pericardial drainage. Similarly, a previous
series reported that development of MPE during chemo-
therapy was associated with poor survival prognosis w8x.
One of the most consistent prognostic factors related with
poor prognosis is positive cytology of the pericardial effu-
sion w3, 6, 9, 10x. However, other studies have demonstrat-
ed that the results of pericardial cytology do not influence
patient survival, similar to our analysis w11x. This might be
explained by the fact that normal cytology does not exclude
the possibility of cancer-related effusion, because a single
pericardial cytology specimen possesses only moderate sen-
sitivity for detection of malignant cells (67–92%) w12x. In
Table 3, we list all trials that evaluate prognostic factors
for recurrence after pericardiocentesis as management of
malignant pericardial effusion.
Some investigators have explored the instillation of a
sclerosant to achieve better pericardial-effusion control
rates. The use of interferon alpha was effectively used to
treat patients with malignant pleural effusion w13x; and
there has been anecdotal success with this approach in
patients with MPE w14, 15x. From October 1996 to December
2000, this institution did a prospective study to evaluate
the use of interferon as a sclerosing agent. After the
analysis of 24 patients, the use of interferon was stopped
because no benefit was demonstrated. Moreover, based on
the results of this study, the use of interferon alpha did
not improve progression-free survival of MPE recurrence,
or OS.
Despite being one of the largest series evaluating the
utility of pericardiocentesis as primary management of MPE
with complete follow-up data, the main limitation of this
study is that clinical data were obtained by retrospective
chart review and that management of recurrent MPE was
not uniform among all patients. In addition, the independ-
ent effect of sclerotherapy with interferon alpha-2b could
not be isolated and evaluated precisely, since in only 24
patients its instillation was added to the primary manage-
ment. Finally, the population size may have allowed some
other significant prognostic factors to remain undetected.
The main contribution of these findings is that all patients
included in this study were initially managed with pericar-
diocentesis as a definitive strategy, and this permits to
deduce conclusions about its effectiveness as primary treat-
ment in patients with MPE. Initial pericardiocentesis can
successfully manage patients, taking the poor prognosis of
these patients into consideration, with only 33% of patients
requiring a second, more aggressive approach. Patients who
should be considered for more invasive approaches are
women and patients diagnosed with MPE at the time of
primary malignancy diagnosis, according to our findings.
 Table 3. Trials that evaluate the use of pericardiocentesis as management of malignant pericardial effusion

Study Center No. of Type of cancer Type of initial Recurrence (%) Poor prognostic factors Unrelated prognostic factors Median survival
Patients intervention (days)

Tsang, et al., Mayo Clinic, USA 275 Lung Pericardiocentesis 22% Gender Effusion size 135
(2000), w6x Breast withywithout Positive-cytology Pericardial fluid color
Hematologic extended catheter Lung cancer Treatment strategies
Others drainage Tamponade presentation
Hemodynamic collapse
presentation

Gornik, et al., Brigham and 219 Lung Fluroscopic-guided NR Cancer-related Gender f420
(2005), w10x Women’s Breast pericardiocentesis Positive cytology Repeat pericardiocentesis
Hospital, USA Hematologic Pericardial surgery
Unknown primary Radiation Hx
Others Age

Yonemori, National Cancer 88 Lung Subxiphoid 16% Performance status Gender f1100
et al., (2007), *w8x Center Hospital, Breast pericardiostomy Presentation with Age
Japan Gastrointestinal Percutaneous tube chemotherapy Type of cancer
Others pericardiostomy Mediastinal lymph node No. metastatic site
enlargement Pleural effusion
Cytologic type Effusion at diagnosis
Effusion initial site of
recurrence
Prior chemotherapy

Wang, et al., Taipei Veterans 82 Lung Several NR Local therapy only Positive cytology 74.5
(2000),* w11x General Hospital, vs. use of systemic Local treatment
Taiwan therapy

Cullinane, City of Hope 63 Lung Surgical pericardial NR Lung cancer Age NR

et al., (2004), w3x National Medical Breast window Pleural effusion Stage
Center, USA Hematology Positive cytology Ejection fraction
ARTICLE IN PRESS

Others Positive histopathology Surgical procedure

Wang, et al., National Taiwan 50 Lung Double balloon 12% Positive cytology Gender f140
(2002), w9x University Breast pericardiotomy High serum calcium Age
Hospital, Taiwan Others Low albuminyglobulin Cardiac tamponade
ratio Immediate or delayed
pericardiotomy
LDH
Á. Apodaca-Cruz et al. / Interactive CardioVascular and Thoracic Surgery 11 (2010) 154–161

Hemoglobin
Platelet count
Time between diagnosis
of malignancy and
effusion
Volume of drained
effusion
Malignancy cell type
159

Communication Pages Topic Paper Results out Procedure Article Report Progress Report
Case Report Nomenclature State-of-the-art Protocol New Ideas Editorial
Brief Historical Best Evidence Follow-up Negative Proposal for Bail- ESCVS Institutional Work in
Table 3. (Continued) 160

Study Center No. of Type of cancer Type of initial Recurrence (%) Poor prognostic factors Unrelated prognostic factors Median survival
Patients intervention (days)

Gross, et al., Hospital do 47 Breast Several 0.02% Pericardial effusion-free Gender f111
(2006),* w2x Cancer, Brazil Lung interval Age
Volume drained Karnofsky
Pericardiocentesis vs. Cardiac tamponade
pericardial window Pleural effusion
Concomitant
chemotherapy
Positive cytology
Positive histopathology

Dequanter, Institut Jules 41 Lung Pericardiocentesis 0.07% Cancer status Age NR

et al., (2008), w5x Bordet, Belgium Breast Surgical pericardial Positive histopathology
Hematology window Volume of effusion
Others

Present study INCAN, Mexico 100 Breast Pericardiocentesis 33% Gender Age f280
Lung Pericardial effusion at Type of cancer
Cervix time of primary cancer Performance status
Germ cell diagnosis Months between primary
Others cancer and effusion
Positive cytology
Effusion onset
Volume of drained
effusion
Gross appearance
Hypotension
EKG abnormalities
Interferon alpha-2b

*Bivariate analysis. NR, Not reported; LDH, lactate dehydrogenase.

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References
w1x Theologides A. Neoplastic cardiac tamponade. Semin Oncol 1978;5:181–
192.
w2x Gross JL, Younes RN, Deheinzelin D, Diniz AL, Silva RA, Haddad FJ.
Surgical management of symptomatic pericardial effusion in patients
with solid malignancies. Ann Surg Oncol 2006;13:1732–1738.
w3x Cullinane CA, Paz IB, Smith D, Carter N, Grannis FW Jr. Prognostic
factors in the surgical management of pericardial effusion in the patient
with concurrent malignancy. Chest 2004;125:1328–1334.
w4x Wilkes JD, Fidias P, Vaickus L, Perez RP. Malignancy-related pericardial
effusion. 127 cases from the Roswell Park Cancer Institute. Cancer
1995;76:1377–1387.
w5x Dequanter D, Lothaire P, Berghmans T, Sculier JP. Severe pericardial
effusion in patients with concurrent malignancy: a retrospective anal-
ysis of prognostic factors influencing survival. Ann Surg Oncol 2008;
15:3268–3271.
w6x Tsang TS, Seward JB, Barnes ME, Bailey KR, Sinak LJ, Urban LH, Hayes
SN. Outcomes of primary and secondary treatment of pericardial
effusion in patients with malignancy. Mayo Clin Proc 2000;75:248–253.
w7x Vaitkus PT, Herrmann HC, LeWinter MM. Treatment of malignant peri-
cardial effusion. J Am Med Assoc 1994;272:59–64.
w8x Yonemori K, Kunitoh H, Tsuta K, Tamura T, Arai Y, Shimada Y, Fujiwara
Y, Sasajima Y, Asamura H. Prognostic factors for malignant pericardial
effusion treated by pericardial drainage in solid-malignancy patients.
Med Oncol 2007;24:425–430.
w9x Wang HJ, Hsu KL, Chiang FT, Tseng CD, Tseng YZ, Liau CS. Technical
and prognostic outcomes of double-balloon pericardiotomy for large
malignancy-related pericardial effusions. Chest 2002;122:893–899.
w10x Gornik HL, Gerhard-Herman M, Beckman JA. Abnormal cytology predicts
poor prognosis in cancer patients with pericardial effusion. J Clin Oncol
2005;23:5211–5216.
w11x Wang PC, Yang KY, Chao JY, Liu JM, Perng RP, Yen SH. Prognostic role
of pericardial fluid cytology in cardiac tamponade associated with non-
small cell lung cancer. Chest 2000;118:744–749.
w12x Meyers DG, Meyers RE, Prendergast TW. The usefulness of diagnostic
tests on pericardial fluid. Chest 1997;111:1213–1221.
w13x Wilkins HE 3rd, Connolly MM, Grays P, Marquez G, Nelson D. Recombi-
nant interferon alpha-2b in the management of malignant pleural
effusions. Chest 1997;111:1597–1599.
w14x Pizzamiglio DRPA. Terapia topico con beta interferon in un caso di
versamento pleuro-pericardico neoplastico. Minerva Med 1991;82:687.
161
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w15x Wilkins HE 3rd, Cacioppo J, Connolly MM, Marquez G, Grays P. Intraper-
icardial interferon in the management of malignant pericardial effusion.
Chest 1998;114:330–331.
New Ideas
eComment: Pericardial sclerosis with cisplatin following pericardio-
centesis. A simple and effective technique for the management of
Progress Report
refractory malignant pericardial effusions
Work in
Authors: Nikolaos Barbetakis, Department of Thoracic Surgery, Theagen-
io Cancer Hospital, Al. Simeonidi 2, Thessaloniki, Greece; Christos Asteriou,
Christos Lafaras, Theodoros Bischiniotis
doi:10.1510/icvts.2010.232546A
We read with great interest the article by Ápodaca-Cruz et al. concerning
Protocol
the effectiveness and prognosis of initial pericardiocentesis in the primary
management of malignant pericardial effusions w1x.
The aim of our brief comment is to highlight the advantages of pericardi-
ocentesis followed by intrapericardial cisplatin administration in patients
Institutional
with neoplastic pericarditis. In our center, we favor pericardiocentesis and
Report
subsequent cisplatin instillation as the method for preventing recurrence of
malignant pericardial effusion, especially in patients with lung cancer. Our
results were documented during a 5-year period study w2, 3x.
Pericardiocentesis followed by intrapericardial administration of cisplatin
is safe and effective in preventing the re-accumulation of malignant peri-
Article
ESCVS
cardial effusion in the majority of oncology patients. In case of recurrence,
the creation of a pleuropericardial window through a mini thoracotomy or a
VATS procedure is the last alternative and is absolutely indicated.
Proposal for Bail-
out Procedure
References
w1x Ápodaca-Cruz A, Villarreal-Garza C, Torres-Ávila B, Torres J, Meneses
A, Flores-Estrada D, Lara-Medina F, Arrieta Ó. Effectiveness and prog-
nosis of initial pericardiocentesis in the primary management of malig-
Negative
nant pericardial effusion. Interact CardioVasc Thorac Surg 2010;11:154–
Results
161.
w2x Bischiniotis T, Lafaras C, Platogiannis D, Moldovan L, Barbetakis N,
Katseas G. Intrapericardial cisplatin administration after pericardiocen-
tesis in patients with lung adenocarcinoma and malignant cardiac
Follow-up
tamponade. Hellenic J Cardiol 2005;46:324–329.
Paper
w3x Barbetakis N, Asteriou C, Papadopoulou F, Bischiniotis T. Pericardiocen-
tesis followed by intrapericardial cisplatin administration in patients
with neoplastic pericarditis. Interact CardioVasc Thorac Surg 2010;
State-of-the-art
10:5–6.
Best Evidence
Topic
Nomenclature
Historical
Pages
Communication
Brief
Case Report