Chapter 26: Acute oncology
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Related theory
Malignant pericardial effusions are often undiagnosed in patients with cancer, and some patients with otherwise treatable cancer succumb to undiagnosed pericardial effusion (Rhodes and Manzullo [248]). Metastatic lung or breast cancer causes most effusions but they may also develop from malignant melanoma, leukaemia, lymphoma and where there has been radiation therapy to the chest wall (Higdon and Higdon [108]). Chemotherapies that can cause pericardial effusion include cyclophosphamide, cytarabine, dasatinib, doxorubicin and gemcitabine, along with other cardiotoxic agents (Svoboda [280]). Pericardial effusions, if left untreated, can cause cardiac tamponade which is a life‐threatening oncological emergency. This situation occurs from an excess accumulation of fluid in the pericardial sac. This fluid causes an increase in pressure around the heart and a decrease in blood flow to the heart. The amount of fluid surrounding the heart varies and may range from 50 mL to 1 litre. As excess fluid accumulates it compresses the right ventricle which therefore is unable to fill resulting in a reduction in the amount of blood leaving the left side of the heart (Longmore et al. [152]). Severity is based on the amount of fluid and how rapidly it is accumulating.
Diagnosis
It is important to remember that pericardial effusions may not always be due to the cancer and to ensure that all causes are considered (Lestuzzi [143]). Clinical manifestations of pericardial effusion are highly dependent on the rate of accumulation of fluid in the pericardial sac. Rapid accumulation of pericardial fluid may cause elevated intrapericardial pressures with as little as 80 mL of fluid, while slowly progressing effusions can grow to 2 L without symptoms (Kim et al. [133], Strimel [278]).
Clinical symptoms can include dyspnoea, orthopnoea, fatigue, heart palpitations, dizziness, pulsus paradoxus, tachycardia, distended neck veins with a raised JVP and narrow pulse pressure, and distant heart sounds may be present (Longmore et al. [152], McCurdy and Shanholtz [173], Odor and Bailey [218]). The most common sign of pericardial effusion is pulsus paradoxus (a fall of systolic blood pressure of > 10 mmHg during the inspiratory phase along with a weakening of the pulse), occurring in about 30% of presentations of malignant pericardial effusion (Karam et al. [126]) and 77% of cases of acute tamponade (Karam et al. [126]). In cases caused by malignancy, exertional dyspnoea is the most common presenting symptom, observed in roughly 80% of presentations (Karam et al. [126], Svoboda [280]).
The role of the cancer nurse is to identify an effusion before it progresses to cardiac tamponade (Flounders [79], Magan [158]). Accurate and thorough ongoing assessment of cardiopulmonary and haemodynamic status is necessary to identify early abnormal changes. This should include strict monitoring of vital signs, including assessment for pulsus paradoxus, as well as assessment of level of consciousness, ECG tracings, respiratory status, and skin and temperature changes (Flounders [79]).
Accurate monitoring of intake and output is necessary, including assessment for oedema or oliguria and anuria, as well as measurement of abdominal girth to detect ascites (Schafer [265]). Dyspnoea is the most common sign of pericardial effusion in cancer patients. A chest X‐ray is usually the first diagnostic test requested as this will show an enlarged cardiac silhouette and increase in transverse diameter (water bottle heart) (Karam et al. [126], Peebles et al. [224], Petrofsky [229]).
Echocardiography is the preferred diagnostic study and will enable the clinician to ascertain the impact on cardiac function as findings include low amplitude waveforms and electrical alternans due to swinging heart (Karam et al. [126], Peebles et al. [224], Petrofsky [229]). An ECG is useful to rule out acute pericarditis and will also aid the clinician to ascertain the impact of the perfusion on cardiac function (Troughton et al. [287]). Beck's triad of hypotension, increased JVP and decreased heart sounds is found mostly with a rapidly forming effusion and acute tamponade, but only infrequently in patients with chronic pericardial effusion (Karam et al. [126], Odor and Bailey [218], Strimel [278]). Ewart's sign (bronchial breathing at the left base) is present in large effusions due to compression of the left lower lobe and the patient may also demonstrate signs of cardiac tamponade (Longmore et al. [152], Strimel [278]).
Management
The patient's prognosis from their underlying cancer along with their other co‐morbidities should be taken into consideration when choosing the appropriate treatment of the pericardial effusion (Imazio and Adler [116]). Small asymptomatic effusions may be left alone, and stable patients without evidence of tamponade can be managed with careful monitoring, serial echo studies, avoidance of volume depletion, and therapy aimed at the underlying cause of the pericardial effusion (Odor and Bailey [218], Petrofsky [229]). By understanding the risk factors and goal of management which is the removal of fluid, restoration of hemodynamic functioning and prevention of fluid reaccumulation the nurse can provide emotional support and reassurance (Flounders [79], Magan [158]).
Patients with evidence of tamponade who are hypovolaemic should be given volume resuscitation if systolic BP is below 100 mmHg (Odor and Bailey [218]). In tamponade there is a significant increase in the pericardial pressure, and the central venous pressure must be kept higher than the pericardial pressure in order for the heart to fill. If volume resuscitation results in haemodynamic improvement, such patients may be observed closely without urgent need for pericardiocentesis (Hoit [111]).
In patients with cancer and symptomatic cardiac tamponade with chamber collapse shown on echo, pericardiocentesis is indicated (Kim et al. [133], Odor and Bailey [218]). Fluid samples should be analysed with cytology (Longmore et al. [152], Petrofsky [229]). Systemic anticancer therapy in conjunction with pericardiocentesis has been found to be effective in reducing the recurrence of malignant effusions (Lestuzzi [143], Strimel [278]). If the tumour is chemo‐resistant or refractory to systemic treatment, pleurodesis may be considered as this may prevent the reaccumulation of fluid after the effusion is drained through promotion of the visceral and parietal pericardial layers (Lestuzzi [143]).
