Management of malignant pericardial effusion and tamponade

THE OPTIMAL management of neoplastic cardiac tamponade has been controversial, with ardent proponents of pericardiocentesis (with or without sclerotherapy),^1-3surgical decompression,^4-8and radiation therapy^9-11as primary therapeutic modalities. In the eight years since this oncologic emergency was last reviewed in this journal,¹²several informative therapeutic trials have been reported that warrant a reappraisal of the recommended interventions for this condition.

Epidemiology

Although neoplastic involvement of the heart is commonly regarded as a rare condition, a compilation of autopsy series suggests that 3.4% (642/19130) of general autopsies^13-18and 11.6% (1280/11078) of cancer autopsies^13-21demonstrate cardiac metastatic disease. Of 770 cases of cardiac metastases for which adequate information was reported, 533 (69.2%) had involvement of the pericardium.^13-16,19,21The majority of cases were clinically insignificant; however, 29% of such patients developed symptoms referable to pericardial metastases and 16% developed cardiac tamponade.²²Pericardial lesions were either