Letters to the Editor

Response to Neoplastic Pericardial Effusion

Refaat MM, Katz WE. Clin Cardiol. 2011;34:593–598.

To the Editor:

We have read with interest the review about neoplastic pericardial effusion by Refaat and Katz, who extensively illustrate the pathophysiology and echocardiographic aspect of the disease.1 About the laboratory investigation, however, we would add some words about the use of tumor markers. Several studies have demonstrated the diagnostic value of carcinoembryonic antigen (CEA), serum cytocheratin 19 fragments (CYFRA 21‐1), neuron‐specific enolase (NSE), and carbohydrate antigens CA 125, CA 15‐3, and CA 19‐9 in serous effusions.2, 3, 4 Specificity is high for the single markers among carcinomas: 80%–100% for CEA, 80%–97% for NSE, and 70%–100% for CYFRA, and the combination of 2 or more tumor markers leads to a higher diagnostic value. Even if the majority of these studies were focused on pleural effusions, which are much more common and easily drained, the same results have been obtained in pericardial effusion.5 Because a pericardial effusion may be the first expression of cancer, and the majority of cases are lung and breast cancer, we suggest routinely checking CEA, which is readily available in every hospital, and possibly CYFRA 21‐1 or NSA in the drained fluid. According to the literature, the cutoff value for CEA is 5 ng/mL and for CYFRA 21‐1 is 90 ng/mL, although in our experience in most cases the values are much higher (above 200 ng/mL). The advantage of the neoplastic markers is that they require a small amount of fluid only, and the results are available in a short time. On the contrary, cytology may be not diagnostic if the amount of fluid is too little or not well preserved. In the case of mesothelioma, the diagnosis may be even more challenging.6, 7, 8, 9

Regarding management, some of us recently published an article that discussed management of malignant pericardial effusion in the course of lung cancer, which is presently by far the most frequent cause of neoplastic pericarditis, comparing 4 different approaches: drainage/sclerosis without any chemotherapy (CT), drainage plus intrapericardial CT alone, systemic CT (with or without drainage), and combined intrapericardial and systemic CT.10 According to our results, combined CT is significantly better in terms of complete cure of local disease and event‐free survival than any other treatment. Even if there was no significant difference among systemic or local CT with regard to event‐free survival, the trend of the response rate would be in favour of local CT. These results confirm previously published data (without comparison among treatment groups) about the effectiveness of local chemotherapy in carcinomas.11, 12, 13, 14 In our experience, the clinical advantage is evident for carcinomas and not for lymphomas.15 This result may be explained by the fact that CT injected into serous effusions allows a higher local concentration and is slowly reabsorbed, as confirmed by pharmacokinetics studies, through the same way (the lymphatic vessels) of carcinoma metastases.16, 17, 18, 19 Pericarditis due to lymphomas, which often spread via blood vessels and are usually very chemosensitive, may show a good response also to systemic CT.