Malignant pericardial effusion

Acute Oncology Guidelines
NHS Lothian

An accumulation of fluid within the pericardial sac leading to an effusion can be a presenting symptom in acute oncology patients. Two thirds of cancer patients have subclinical pericardial effusions with no overt cardiovascular signs or symptoms. 50% of cases initially present with symptoms of cardiac tamponade. Symptoms are often attributed to underlying cancers and are often a pre-terminal event. However, prompt diagnosis and management can achieve significant palliation.

Malignant pericardial effusion pathway

Inform the Acute Oncology Team of the patient's assessment and/or admission as soon as possible. Immediate advice is available from the Acute Oncology Service or the 24 Hour Oncology on call rota. Withhold systemic anti-cancer therapy (SACT), including oral therapy, until you have discussed with the Acute Oncology or Site Specific Team.

Causes

Most malignant pericardial effusions result from direct malignant involvement with the pericardium. Other, rarer causes of effusions in cancer patients include radiation-induced pericarditis or chemotherapy-induced pericarditis associated with agents such as doxorubicin or cyclophosphamide.

Clinical findings

Dyspnoea (majority), fatigue or asthenia may be the initial symptoms. Monitor oxygen saturation and consider arterial blood gases (ABGs).

Other common symptoms include:

  • cough
  • chest pain
  • orthopnoea.

On examination

On examination, findings include:

  • elevated jugular venous pressure (JVP)
  • tachycardia
  • hypotension
  • pulsus paradoxus (an abnormally large decrease in pulse and systolic blood pressure (>20mm Hg) with inspiration)
  • Kussmaul's sign (increased distension of jugular veins with inspiration)

Diagnosis

  • Chest X-ray may show a widened cardiac shadow.
  • Echocardiography shows the size of the effusion and haemodynamic consequence.
  • ECG to investigate small ECG complexes.

Questions

  • Cancer diagnosis/primary disease.
  • Cardinal questions related to breathlessness.

Differential diagnosis

Differential diagnosis would include:

  • chest infection
  • ascending aortic aneurysm
  • pulmonary embolism (PE)
  • due to indwelling intravascular catheter
  • disease progression i.e. consolidation/pleural effusion.

Editorial Information

Last reviewed: 05/01/2024

Next review date: 05/01/2027

Author(s): Edinburgh Cancer Centre.

Version: 1.0

Approved By: Oncology Directorate

Reviewer name(s): Stewart J.

Document Id: Guideline 36