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Pericardiocentesis Versus Pericardiotomy for Malignant Pericardial Effusion: a Retrospective Comparison

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Pericardiocentesis Versus Pericardiotomy for Malignant Pericardial Effusion: a Retrospective Comparison MALIGNANT PERICARDIAL EFFUSION, Labbé et al. ORIGINAL ARTICLE Pericardiocentesis versus pericardiotomy for malignant pericardial effusion: a retrospective comparison C. Labbé MD,* L. Tremblay MD,* and Y. Lacasse MD MSc* ABSTRACT Background Treatment of malignant pericardial effusion remains controversial, because no randomized controlled trials have been conducted to determine the best approach, and results of retrospective studies have been inconsistent. The objective of the present study was to compare pericardiocentesis and pericardiotomy with respect to efficacy for preventing recurrence, and to determine, for those two procedures, diagnostic yields, complication rates, and effects on survival. We also aimed to identify clinical and procedural factors that could predict effusion recurrence. Methods We retrospectively assessed 61 patients who underwent a procedure for treatment of a malignant pericardial effusion at the Institut universitaire de cardiologie et de pneumologie de Québec between February 2004 and September 2013. Results Pericardiocentesis was performed in 42 patients, and pericardiotomy, in 19 patients. The effusion recurrence rate was significantly higher in patients treated with pericardiocentesis than with pericardiotomy (31.0% vs. 5.3%, p = 0.046). The diagnostic yield of the procedures was not significantly different (92.9% vs. 86.7%, p = 0.6). The overall rate of complications was similar in the two groups, as was the median overall survival (2.4 months vs. 2.6 months, p = 0.5). In univariate analyses, the procedure type was the only predictor of recurrence that approached statistical significance. Age, sex, type of cancer, presence of effusion at the time of cancer diagnosis, prior chest irradiation, tamponade upon presentation, and total volume of fluid removed did not influence the recurrence rate. Conclusions Compared with pericardiocentesis, pericardiotomy had higher success rate in preventing recurrence of malignant pericardial effusion, with similar diagnostic yields, complication rates, and overall survival. Key Words Malignant pericardial effusion, pericardiocentesis, pericardiotomy, recurrence, complications, diagnostic yield, survival Curr Oncol. 2015 Dec;22(6):412-416 www.current-oncology.com INTRODUCTION toxicity, and opportunistic infections related to immuno- suppressive therapies3. Despite treatment, median overall Malignant pericardial effusion is a common problem in survival in patients with malignant pericardial effusion is oncology, and the primary tumour that most frequently reported to be in the range of 2–4 months and is influenced involves the pericardium is lung cancer1. Patients are often mainly by the nature of the underlying malignancy, lung asymptomatic, but they can also present with cardiorespi- cancer being a poor prognostic factor4. ratory symptoms (for example, dyspnea, cough, chest pain), For patients with advanced cancer involving the clinical signs (tachycardia, for instance), echocardio- pericardium, the goals of treatment should be to use a graphic features of right heart compromise, and possibly minimally invasive procedure with a good safety profile life-threatening cardiac tamponade requiring emergency to achieve symptom relief, improvement in quality of life, drainage2. Malignancies can involve the pericardium by and prevention of recurrence. Several approaches can be four mechanisms: direct extension or metastatic spread via used to treat malignant pericardial effusion, but no ran- lymphatics or blood, chemotherapeutic toxicity, radiation domized controlled trials have been conducted to compare Correspondence to: Catherine Labbé, Centre de Pneumologie, Institut universitaire de cardiologie et de pneumologie de Québec, 2725 chemin Ste-Foy, Québec, Québec G1V 4G5. E-mail: [email protected] n DOI: http://dx.doi.org/10.3747/co.22.2698 412 Current Oncology, Vol. 22, No. 6, December 2015 © 2015 Multimed Inc. MALIGNANT PERICARDIAL EFFUSION, Labbé et al. their risk–benefit ratio; no “gold standard” has been estab- Statistical Analysis lished; and practices differ widely. Many authors believe Descriptive statistics (proportions, means, standard devi- that treatment must be individualized according to the ations, and ranges) are used to describe the study popu- patient’s condition and tumour type, and to the success lation. Clinical characteristics of the patients treated with rates and risks of the various options, local availability, pericardiocentesis and those treated with pericardiotomy and expertise5. were compared using chi-square tests for dichotomous One consensus is that cardiac tamponade is a clear variables and unpaired t-tests for continuous variables. indication for urgent pericardiocentesis. For effusions We used univariate analyses to test the influence of each without tamponade, guidelines from the European Soci- baseline clinical characteristic and treatment (that is, ety of Cardiology state that pericardiocentesis can relieve pericardiocentesis or pericardiotomy) on risk of recur- symptoms and establish diagnosis, and that systemic rence. Fine–Gray Cox models were constructed to account antineoplastic treatment and intrapericardial instillation for death as a competing risk event for recurrence14. For of a cytostatic or sclerosing agent can prevent recurrence6. both groups, Kaplan–Meier estimates were used to con- Subxiphoid pericardiotomy is indicated when pericar- struct survival curves, and the log-rank test was used for diocentesis cannot be performed. Extended catheter between-group comparisons. In all analyses, statistical drainage after pericardiocentesis, percutaneous balloon significance (p value) was set at the 0.05 level. pericardiotomy, and various other surgical approaches are also possible options to prevent recurrence. They have RESULTS been compared, with inconsistent results, in many retro- spective studies7–11. Recently, a retrospective analysis in Patients 88 patients showed that, compared with surgical pericar- Of the 61 patients included in the study, 42 (69%) were diotomy, pericardiocentesis with extended drainage had treated with pericardiocentesis, and 19 (31%) underwent the same diagnostic yield, the same recurrence rate, and pericardiotomy (7 by the subxiphoid approach, 5 by per- fewer complications12; and a systematic review including cutaneous balloon procedure, 4 by left mini-thoracotomy, 1399 patients concluded that surgical drainage is superior 1 by left video-assisted thoracic surgery, 1 by laparoscopy, to nonsurgical approaches in terms of symptom relief, and 1 by sternotomy). Most of the patients (n = 52, 85%) had effusion recurrence, and morbidity13. lung cancer (46 adenocarcinomas, 2 squamous cell cancers, The objective of our study was to compare pericardio- 2 small-cell lung cancers, 2 non-small-cell lung cancers centesis with pericardiotomy in respect of their efficacy for not otherwise specified). Other diagnoses included breast preventing recurrence in patients with malignant pericar- cancer in 5 patients, and single cases of mesothelioma, dial effusion, and to determine the diagnostic yields, com- uterine cancer, bladder cancer, and adenocarcinoma of plication rates, and effect on survival of the two procedures. unknown origin. We also aimed to identify clinical and procedural factors Table i shows the baseline characteristics of the pa- that could predict effusion recurrence. tients. The only significant difference was that the pericar- diocentesis group contained a higher proportion of patients METHODS with pulmonary neoplasms. Almost all the patients treated with pericardiocentesis underwent prolonged drainage, Patients with the pericardial catheter left in place for at least 24 We retrospectively reviewed the medical records of all hours and up to 7 days, until drainage stopped. Only 1 patients who underwent a procedure for malignant peri- patient underwent local sclerotherapy with bleomycin. cardial effusion at the Institut universitaire de cardiologie et de pneumologie de Québec between February 2004 Clinical Outcomes and September 2013. The study was carried out with the The overall rate of pericardial effusion recurrence was approval of the institute’s ethics committee review board 23%, and the rate was significantly different in the two (CÉR 21060). The study population was divided into two groups (31.0% pericardiocentesis vs. 5.3% pericardiotomy, groups, and patients treated with pericardiocentesis under p = 0.046; Table ii). In the univariate analyses, procedure local anesthesia and ultrasound guidance were compared type was the only predictor of recurrence that approached with patients who underwent surgical or percutaneous the level of statistical significance (hazard ratio: 0.154; balloon pericardiotomy. Because this study was retrospec- p = 0.08). Age, sex, type of cancer, presence of effusion tive, the choice of the therapeutic intervention was at the at the time of cancer diagnosis, prior chest irradiation, treating physician’s discretion. tamponade on presentation, and total volume of fluid removed had no influence on the recurrence rate. The Data Extraction mean interval between the procedure and effusion re- The medical records of the patients were searched for currence was 90 days. Of the 13 patients with recurrence patient age and sex, type of cancer, presence of pericar- after pericardiocentesis, 9 were subsequently treated with dial effusion at the time of cancer diagnosis, prior chest pericardiotomy, 3 underwent repeat pericardiocentesis, irradiation, tamponade upon
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