Effective management of pericardial neoplasia.

M alignant invasion of the pericardium is always serious and, unfortunately, increasingly detected. Once the cell type is identified, physicians have an array of therapeutic options (condensed in Table 1).1 In this issue of CHEST (see page 1412), Dr. Martinoni and colleagues have very carefully followed up their series of patients with various malignancies who were treated successfully with intrapericardial thiotepa. There were no complications from either the therapy or from the pericardiocentesis, which was necessary in every case. Absence of complicated taps may be ascribed both to echocardiographic monitoring and the very large size (749 230 mL [ SD]) of the effusions.2–4 Before pericardiocentesis all patients were quite ill, mainly due to weakness and dyspnea; 56% were in New York Heart Association heart failure class III and 28% in class IV owing to cardiac tamponade in the majority of patients. Thiotepa is both an antineoplastic and a sclerosing agent. Unlike tetracycline, it induces no chest pain, no myelosuppression, and no ECG changes. Of the many intrapericardial therapies, only tetracycline has appeared to have significantly positive effects, at least in the short run, yet it is strictly a sclerosant, suppressing effusions without antineoplastic effects (indeed, indwelling pericardial tubes and catheters can provoke pericardial sclerosis without necessitating chemical sclerotherapy).1 However, thiotepa is almost an ideal agent based on its performance: significant effects on several kinds of malignancy because of its antineoplastic properties, as well as suppression of effusions. In two patients dying on the 22nd and 25th days after the procedure, at autopsy there was no evidence of pericardial effusion. It will be important to learn the results of longterm follow-up in the series by Martinoni and colleagues, since the pericardium itself was effectively treated and all patients were receiving systemic chemotherapy, especially in those with metastatic cancer and particularly certain cancers (eg, breast, lung), in whom survival has been months to a year.1 Perhaps the combination of local effectiveness with systemic antineoplasia will now improve that grim outlook.