eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Cardiology

Pericardial Effusion, Malignant: Differential Diagnoses & Workup

Author: Poothirikovil Venugopalan, MBBS, MD, FRCP (Glasg), FRCPCH, Consulting Staff, Department of Child Health, University Hospital of Hartlepool, UK
Contributor Information and Disclosures

Updated: Jul 24, 2008

Differential Diagnoses

Bronchogenic Cyst
Hemolytic-Uremic Syndrome
Kawasaki Disease
Pericarditis, Viral
Postpericardiotomy Syndrome

Other Problems to Be Considered

Drug-induced hydralazine, isoniazid, procainamide
Chronic graft-versus-host disease (cGVHD)
Constrictive pericarditis
Purulent pericarditis
Radiation pericarditis
Tuberculous pericarditis
Uremic pericarditis
Hemolytic uremic syndrome after bone marrow transplantation
Posttransplant B-cell lymphoproliferative disorder (PTLD)
Doxorubicin- and daunorubicin-related pericarditis or myocardial dysfunction
Cystic lymphangioma
Effusion possibly related to pre–bone-marrow transplant drug conditioning
Malignant hepatic involvement with portal hypertension
Microvascular tumor spread in lungs with secondary pulmonary hypertension
Pericardial celomic cyst (unilocular)
Pericardial teratoma
Superior venacaval obstruction of any cause
Chylous or lymphatic pericardial effusions with (1) congenital thoracic cystic hygroma with pericardial involvement, (2) following surgery for congenital heart disease complicated by elevated venous pressures or trauma to the thoracic duct, or (3) secondary to obstruction of lymphatic drainage by mediastinal masses

Workup

Laboratory Studies

  • Blood investigations as dictated by the general condition
    • CBC count with platelet count and WBC differential
    • Blood film (smear)
    • Serum chemistry
    • Erythrocyte sedimentation rate (ESR)
    • C-reactive protein (CRP)
    • Blood cultures
  • Markers of specific malignancy may help in following disease progression
    • Serum alpha fetoprotein
    • Serum caner antigen (CA) 125
  • Markers of malignancy in pericardial fluid cells
    • Human telomerase reverse transcriptase (hTERT) mRNA expression may be detected in abnormal cells in body fluids using in situ hybridization (ISH).
    • Molecular genetic studies can also be helpful in the analysis of lymphocyte-rich serous pericardial effusion.
    • Immunocytochemical panel of tests has also been suggested in selected cases.
  • Electrocardiography
    • Changes are nonspecific and may represent the effect of pericardial inflammation on the underlying myocardium.
    • Low voltage QRS complexes (35%) are seen.
    • ST-segment elevation is found.
    • T-wave inversion is seen.
    • Development of arrhythmias (atrial tachycardia, atrial fibrillation, heart block) is observed.
    • Electrical alternans (17%), a beat-to-beat variation in QRS amplitude, occurs with excessive motion of the heart within the fluid-filled pericardial space.

Imaging Studies

  • Chest radiography
    • Chest radiography reveals a varying degree of cardiomegaly, depending on the amount of pericardial fluid and its rate of accumulation.
    • Rapidly accumulating effusion is associated with relatively minimal cardiomegaly.
    • Massive effusions produce a large cardiac shadow, causing the characteristic water-bottle heart or triangular heart with smoothed-out cardiac borders.
    • Pleural effusion, mediastinal widening, hilar mass, or, less commonly, irregular nodular contour of the cardiac silhouette or a bony or parenchymal metastatic deposit may indicate underlying disease.
    • Rarely, pericardial calcification may be evident.
  • Echocardiography
    • Echocardiography is the primary study performed for diagnosis and quantification of the effusion, as well as for guiding needle pericardiocentesis. Echocardiography has a 96% diagnostic accuracy in pericardial effusion.
    • Pericardial fluid gives the appearance of an echo-free space between the epicardial and pericardial reflections. This is evident in both 2-dimensional images and M-mode images.
    • When effusion is minimal, it accumulates posterior to the left ventricle and is more apparent in systole.
    • When effusion is massive, fluid is observed all around the heart and throughout the cardiac cycle.
    • Diastolic ventricular filling is abnormal secondary to cardiac compression.
    • A swinging motion of the heart may be observed within the pericardial cavity, along with abnormalities of septal motion, dilation of the inferior vena cava, and loss of respiratory caval motion.
    • Irregular undulating masses that protrude into the pericardial space, atria, ventricles, or even into the pulmonary arteries are reported.
    • Fetal echocardiography can identify fetal pericardial effusion secondary to fetal pericardial malignancy (most commonly teratoma).
  • CT scanning
    • CT scanning reveals the thickness and density of the pericardium and content of the pericardial space.
    • CT scanning aids in identification of constrictive pericarditis by providing additional information on the status of the vena cava, atria, ventricles, and pleural changes.
    • The minimum amount of pericardial fluid that can be detected by CT scanning is estimated to be 10 mL.
    • CT scanning provides added information regarding the presence and location of space-occupying masses within the pericardium and adjacent mediastinum and lungs.
  • Transesophageal echocardiography (TEE): This provides information regarding the presence and location of space-occupying masses within the pericardium.
  • MRI: MRI provides added information regarding the presence and location of space-occupying masses within the pericardium and adjacent mediastinum and lungs. In addition, this technique is more sensitive in differentiating malignant lesions from benign ones.
  • Radionuclide imaging: This can demonstrate a pericardial effusion in previously undiagnosed pericardial disease.

Procedures

  • Pericardiocentesis
    • This is used to diagnose cause, assess cytology, and treat hemodynamic compromise in the presence of cardiac tamponade.
    • Malignancy may be first suspected from pericardial fluid analysis in as many as 5% of such patients.
    • Catheter drainage technique is commonly used.
    • Ultrasonographic guidance adds to the safety of the procedure but is not a requisite with emergency drainage.
    • Insert a beveled, sharp needle beneath the xiphoid process and angle upward and leftward toward the left shoulder. Sometimes, a pop is felt as the needle is passed into the pericardium.
    • Attempts to withdraw fluid are made with each advance of the needle.
    • If fluid is obtained, remove enough to alleviate tamponade. Even a small amount often provides significant benefit.
    • Process the pericardial fluid for cytology, biochemistry, and culture and sensitivity, including viral and fungal cultures in relevant cases.
    • Exudates differ from transudates by demonstrating higher leukocyte counts, lower glucose, higher protein contents, and higher specific gravity.
    • Cytospin preparations can be stained with Wright-Giemsa stain to identify cellular morphology that, in turn, can be used to test for immunologic markers and for electron microscopy.
    • Complications are myocardial puncture, coronary artery or vein laceration, hemopericardium, laceration of the internal mammary artery, pneumothorax, and liver and aortic injury.
    • In the presence of significant effusion, maintain good hydration and effective filling pressures to help maintain perfusion until pericardiocentesis can be performed.
  • Closed drainage technique
    • Continuous drainage of the pericardial space is accomplished by advancement of a pigtail catheter over a guide wire.
    • This is necessary for patients in whom the effusion reaccumulates rapidly.
  • Pericardioscopy: This can reveal neoplastic effusions by direct observation and by obtaining a biopsy of the pericardium for further analysis.
  • Video-assisted thoracoscopic pericardial fenestration: This is safe and effective for loculated pericardial effusions previously treated by percutaneous drainage maneuvers and patients with concomitant pleural disease.
  • Fetal pericardiocentesis: This has been used in the treatment of pericardial effusion secondary to fetal teratoma.
  • Pericardial biopsy
    • Specimens can be obtained by open pericardiotomy or during thoracotomy (rare). Pericardial biopsy has a sensitivity of approximately 55% for diagnosing malignant involvement; however, together with cytology of the pericardial fluid, pericardial biopsy provides nearly 100% sensitivity.
    • Open pericardial biopsy may be required if initial cytology is negative. Obtaining a larger biopsy specimen by open biopsy should provide a histologic diagnosis in up to 90% of cases. The procedure carries significant risk in patients who are critically ill, but a false-negative diagnosis may occur if the tissue sample is too small.
    • Biopsy specimens are subjected to histologic and immunohistologic evaluations, polymerase chain reaction, or in situ hybridization analysis for microbial DNA and ribonucleic acid.
  • Cardiac catheterization: This is not required for diagnosis of pericardial effusion. Potential indications for cardiac catheterization include the following:
    • Suspected superior venacaval obstruction and pulmonary microvascular tumor (lymphangitic tumor) may occur with malignant cardiac tamponade and contribute to the development of facial edema and jugular venous distension.
    • Cyanosis, hypoxemia, and elevated pulmonary vascular resistance may indicate pulmonary microvascular tumor (lymphangitic tumor). The diagnosis can be established by obtaining a blood sample for cytologic analysis from the pulmonary capillary wedge position using the right heart catheter.

Histologic Findings

  • Malignant pericardial effusion is often hemorrhagic or serosanguineous, but this alone does not differentiate among neoplastic, radiation, or idiopathic causes. Because treatment strategies differ, carrying out a meticulous cytologic examination of the fluid is essential in an attempt to differentiate malignant pericarditis from other causes. False-negative cytology is uncommon in carcinomatous pericarditis but, when it occurs, it may be due to scant cellularity or the presence of obscuring blood. False-negative results are more common with lymphoma and mesothelioma. Chylothorax is most often reported with mediastinal lymphangioma.
  • Detection of malignant cells in effusions is facilitated by the use of immunocytochemistry, using a wide panel of antibodies. BerEP4 and B72.3 appear to be the best markers when both sensitivity and specificity are considered, followed by BG8. Carcinoembryonic antigen (CEA) and CA-125 have a limited role in detection of metastases from gynecologic tumors because of the low sensitivity of CEA and the low specificity of the CA-125.
  • Flow cytometry can also be used to detect DNA diploidy (benign) and aneuploidy (malignant), but the results have not been uniformly convincing. The low sensitivity of flow cytometric DNA analysis does not favor routine use.

More on Pericardial Effusion, Malignant

Overview: Pericardial Effusion, Malignant
Differential Diagnoses & Workup: Pericardial Effusion, Malignant
Treatment & Medication: Pericardial Effusion, Malignant
Follow-up: Pericardial Effusion, Malignant
Multimedia: Pericardial Effusion, Malignant
References
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Further Reading

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Keywords

pericardial effusion, malignant pericardial effusion, dropsy of pericardium, mediastinal mass, nodular tumor deposits, lymphatic spread, diffuse pericardial thickening from tumor infiltration, chronic myelomonocytic leukemia, intrapericardial extramedullary hematopoiesis, preleukemic conditions, blast crisis, chronic myeloid leukemia, obstruction of lymphatic drainage, pericarditis, effusive-constrictive pericarditis, cardiac tamponade, asthma, emphysema, pleural effusion, rhabdomyoma, fibroma, heart failure, fetal hydrops, hydrops fetalis, pericardial mesothelioma, angiosarcoma, liposarcoma, lymphoma, rhabdomyosarcoma, tuberous sclerosis, pheochromocytoma, Kaposi sarcoma, HIV infection, non-Hodgkin lymphoma, neuroblastoma, ganglioneuroblastoma, Wilms tumor, Hodgkin lymphoma, adenocarcinoma, leiomyosarcoma, Burkitt lymphoma

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Contributor Information and Disclosures

Author

Poothirikovil Venugopalan, MBBS, MD, FRCP (Glasg), FRCPCH, Consulting Staff, Department of Child Health, University Hospital of Hartlepool, UK
Poothirikovil Venugopalan, MBBS, MD, FRCP (Glasg), FRCPCH is a member of the following medical societies: British Cardiac Society, Royal College of Paediatrics and Child Health, and Royal College of Physicians and Surgeons of Glasgow
Disclosure: Nothing to disclose.

Medical Editor

Ira H Gessner, MD, Professor Emeritus, Pediatric Cardiology
Ira H Gessner, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, American Pediatric Society, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Hugh D Allen, MD, Professor, Department of Pediatrics, Division of Pediatric Cardiology and Department of Internal Medicine, Ohio State University College of Medicine
Hugh D Allen, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, American Pediatric Society, American Society of Echocardiography, Society for Pediatric Research, Society of Pediatric Echocardiography, and Western Society for Pediatric Research
Disclosure: Nothing to disclose.

CME Editor

Gilbert Herzberg, MD, Assistant Professor, Department of Pediatrics, Section of Pediatric Cardiology, New York Medical College
Gilbert Herzberg, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Chief Editor

Stuart Berger, MD, Professor of Pediatrics, Division of Cardiology, Medical College of Wisconsin; Chief of Pediatric Cardiology, Medical Director of Pediatric Heart Transplant Program, Medical Director of The Heart Center, Children's Hospital of Wisconsin
Stuart Berger, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American College of Chest Physicians, American Heart Association, and Society for Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

 
 
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