Diagnosis, treatment and follow-up of neoplastic pericardial disease in lung cancer

Chiara Lestuzzi, Massimiliano Berretta, Alessandra Bearz, Witold Tomkowski

Research output: Chapter in Book/Report/Conference proceedingChapter

Abstract

Lung cancer is the most frequent cause of neoplastic pericardial effusion. The main path of pericardial metastases is the retrograde lymphatic way. Lymphatic obstruction often leads to a rapid accumulation of a large amount of pericardial fluid, and eventually to cardiac tamponade. Cardiac tamponade is diagnosed on the basis of clinical (engorged jugular veins, pulsus paradoxus) and echocardiographic (right atrial wall collapse, dilated vena cava) findings. Not all the pericardial effusions in lung cancer patients are neoplastic: up to 30% may be due to other causes. To confirm the diagnosis of pericardial metastases the gold standard is the detection of neoplastic cells within the pericardial fluid. Cytological diagnosis is most reliable when a large amount of fresh fluid is available. Immunocytochemistry and cell block analysis in addition to visual analysis of smears may improve the diagnostic power of cytopathologic analysis. In equivocal cases, the dosage of carcinoembryonic antigen (CEA) and serum cytocheratin 19 fragments (CYFRA 21-1) in the pericardial fluid may be very useful both in the diagnosis of neoplastic pericarditis and in the differential diagnosis among different neoplasms. The cut-off value for CEA is 5ng/mL and for CYFRA 21-1 is 90ng/mL. The main advantage of the use of neoplastic markers is that they require a small amount of fluid only and the results are available in a timely manner. As regards the therapeutic approach, several treatments have been proposed: mechanical (extended pericardial drainage, pericardial window, intrapericardial administration of sclerosing agents) or administration of antineoplastic drugs (locally, intravenous or both). The main problem in neoplastic pericarditis is the high rate of recurrence of effusion after drainage. This problem should be considered on the medium to long term period, according to the more prolonged survival of lung cancer patients treated with the new targeted therapies. On the basis of the most recent reports, the combined administration of local (intrapericardial) platinum and systemic antineoplastic therapy gives the highest rate of response and the longest relapse-free survival. Local chemotherapy hasfavourable pharmacokinetics (with high intrapericardial concentration, slow absorption and few systemic effects) and is usually well tolerated even by patients with a poor performance status. The surgical approach (pericardial window) and local radiation therapy may be used in cases of refractory to chemotherapy.

Original languageEnglish
Title of host publicationLung Cancer: A Comprehensive Overview
PublisherNova Science Publishers, Inc.
Pages233-254
Number of pages22
ISBN (Print)9781626184473
Publication statusPublished - May 2013

ASJC Scopus subject areas

  • Biochemistry, Genetics and Molecular Biology(all)
  • Medicine(all)

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