Pericarditis in malignancy treatment


 * Associate Editor-In-Chief: Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.

Treatment
It is important to assess the life expectancy of the patients before proceeding with the treatment. Patients with advanced malignancy should be treated palliatively with pericardiocentesis to improve their symptoms. While those with better prognosis should be treated more aggressively.

Asymptomatic or minimally symptomatic patients should be treated conservatively with avoidance of volume depletion, antineoplastic therapy and regular followup.

Symptomatic patients should undergo prompt drainage of effusion which could be done either by pericardiocentesis or surgical creation of pericardial window.

Recurrence of pericardial effusion is frequently observed following simple pericardiocentesis. Following approaches are adapted in prevention of reaccumulation: Patients with constrictive pericarditis should be treated with pericardial stripping also known as pericardiectomy provided that the prognosis from the malignancy justifies surgery. It is not recommended in patients with mild constriction and in advanced stages of malignancy due to operative risk of 6-12%.
 * 1) Prolonged pericardiocentesis: Catheter should not be removed until the drainage is <20-30 ml/24 hours. Intermittent catheterization is recommended to maintain catheter patency.
 * 2) Pericardial sclerosis: Obliteration of pericardial cavity using tetracycline, doxycycline, minocycline , bleomycin , or talc.
 * 3) Pericardiotomy: Surgical creation of pericardial window which drains fluid into pleural or peritoneal cavity as fluid accumulates in pericardial sac.In presence of hemodynamic instability, pericardial fluid must be removed first by pericardiocentesis and then proceed with with surgery. To a large extent this avoids further instability or cardiovascular collapse during induction of general anesthesia.

Intrapericardial chemotherapy is another approach in treatment of recurrent effusion. Cisplatin has shown to reduce the incidence of recurrence by up to 93% at 3months and 83% at 6 months followup.