A case series of malignant pericardial effusion

Background

Malignant pericardial effusions are most commonly associated with a metastatic process from a solid tumour such as the lung, breast or haematological spread.¹ Primary cardiac tumours are rare with an incidence of 0.02%.² Pericardial tumours are even rarer, accounting for 6.7%–12.8% of all primary cardiac tumours.3, 4 This case series reports three patients presenting with malignant pericardial effusion. Two of the cases were found to have a rare form of primary pericardial tumours. The third case presented with a metastatic form of pericardial effusion of an unknown primary.

Case summary

Case 1 (Fig 1): A 49-year-old man attended hospital for pleuritic chest pain and breathlessness 4 weeks post-Covid vaccination, diagnosed as pericarditis. He represented significant pericardial effusion requiring emergency drainage. Pericardial fluid was deeply haemorrhagic, but cytology did not show any malignant cells. Subsequently, he underwent a CT thorax, abdomen, pelvis, and a cardiac MRI that confirmed a round 1.5 × 1.2 cm mass in the right atrium. There was no evidence of metastasis. For concerns of the inoperability of the tumour and its extent, he underwent a right VATS biopsy of the mass. The histology reported malignant biphasic mesothelioma. Pericardial mesothelioma typically carries a poor prognosis and consequently the patient died.

Fig 1.

Case 1: CMR revealed a large mass (6 × 3 cm) with irregular margins that appeared to originate from the pericardium and compressing the right atrium.

Case 2 (Fig 2): A 43-year-old man presented with a 3-week history of cough, malaise and raised inflammatory markers. A CT thorax and abdomen confirmed a moderate-sized pericardial effusion predominantly accumulated in the posterior pericardial cavity measuring 4.5 cm. There was also associated pericardial wall thickening and enhancement with heterogeneous attenuation in the pericardial fluid suggestive of an exudative picture. He was treated for acute pericarditis and referred for a pericardial window but was unfortunately unsuccessful due to the dense adhesions and organising pericarditis. Soon after, he found an improvement in his symptoms and returned to work. A few months later, he presented with shortness of breath and a repeat CT scan showed a large, heterogeneous enhancing lesion seen in the posterior pericardium compressing on the left atrium and ventricle. Mild pericardial effusion was only noted. Cardiac MRI was performed that showed a large 14 × 10 cm oval mass in the pericardium compressing the left atrium. The tissue characterisation was suggestive of sarcoma. A CT-guided biopsy was successfully performed and confirmed the diagnosis of spindle cell sarcoma.

Fig 2.

Case 2: CMR revealed heterogeneous increased signal intensity on T2 weighted image.

Case 3: A 78-year-old man was admitted with a collapse. He was found to have a significant global effusion with features of cardiac tamponade; hence emergency drainage was conducted. Pericardial fluid was also hemorrhagic. The histology confirmed the diagnosis of metastatic adenocarcinoma. Unfortunately, further investigations could not be done as the patient died soon after.

Conclusion

These cases illustrate the importance of having a high suspicion of malignancy in the acute presentation of pericardial disease with cardiac tamponade, unexplained haemorrhagic pericardial fluid and unresolved or recurrent course.