In the two autopsy series with 255 and 100 ovarian cancer patients, the incidence of pericardium as distant metastasis site was 2.4% and 4% respectively (1). The cardiac metastases most commonly involves pericard-ium (70%) followed by myocardium (32%) and epicardium (5%) (1). Ovarian malignancy either usually remains locoregionally conﬁned or metastasizes by direct extension to surrounding pelvic organs or via transperitoneal dissemination of detached malignant cells (1). Less commonly, metastases through hemato-genous or lymphatic pathways may occur to pelvic and/or para-aortic lymph nodes, pleura (33%), liver (26%), and lung (15%) and rarely, heart (2.4–4%) and have a poor prognosis (1, 5).
Clinical presentation of malignant pleural effusion remains variable with non-speciﬁc symptoms such as dyspnea on exertion and rest (most common), chest pain, cough, orthopnea, and fatigue (8). Physical examination may reveal Beck’s triad in acute cases (tachycardia, hypotension and muffled heart sounds), elevated jugular venous pressure, pulsus paradoxus, peripheral edema, and cyanosis (3, 8). In a study done by Fatema et al. on 260 patients having malignancy-related pericardial effusion, 81% of patients had shortness of breath, while the pulsus paradoxus and pericardial tamponade were seen in 22% and 5 % patients, respectively (7). Con-sistent with the above features, our patient presented with vague generalized symptoms as well as classic signs of cardiac tamponade such as tachycardia, tach-ypnea, hypotension and jugular venous distension.
Various multidimensional non-invasive investiga-tions are available for the timely and correct diagnosis of malignant pericardial effusion. Chest X-ray usually shows widening of the cardiac silhouette with clear lungs (the "water bottle'" sign) while ECG may be normal or show low QRS voltage in the limb leads due to impaired transmission across the pericardial fluid, nonspecific ST- or T-wave changes, atrial ﬁbrillation, ventricular tachycardia and in some cases, complete atrioventricular block (2,3,8). In the setting of larger pericardial effusions and tamponade, ECG typically shows electrical alternans (variation in the amplitude of P wave and QRS complexes with each successive beat) possibly due to swinging heart within a large pericardial effusion. However, due to the low sensitivity of ECG in diagnosing pericardial effusions, ECHO remains a "gold standard" investigation probably due to its high sensi-tivity and speciﬁcity, lack of ionizing radiations, and its ability in determining the presence, size, location, and hemodynamic effect of pericardial effusion (3, 8). Clas-sical ECHO findings are the diastolic collapse of the right atrium or ventricle with respiratory doppler var-iation in transvalvular flow. In the absence of classical diagnostic ﬁndings, clinically symptomatic patients should undergo Pericardiocentesis (3).
Usually, pericardiocentesis is performed by aspirating the pericardial fluid through the subxiphoid approach. After the procedure, the pericardial fluid samples are immediately sent for centrifugation and cytological diagnosis, culture, biochemical tests, or stored at 2-8°C (best at 4˚C) if the delay is anticipated, to avoid cellular degeneration (4). Confirmation of malignant pericardial effusion necessitates the detection of malignant adeno-carcinoma cells within the pericardial fluid but it may be difficult either due to hyperplastic or reactive mesothe-lial cells mimicking adenocarcinoma cells. Therefore, in cytology-negative samples, or whenever the diagnosis is equivocal, the dosage of tumor markers, such as carcino-embryonic antigen (CEA), neuron-specific enolase (NS-E), serum cytokeratin 19 fragments (CYFRA 21-1), and carbohydrate antigens CA 125, CA 15-3 and CA 19-9, in the effusion may be helpful (4). However, these tumor markers must be used cautiously because of their ill-defined cut-off values and variable sensitivity. Never-theless, specificity is high for some markers and tumors (among carcinomas: 80%-100% for CEA, 80%-97% for NSE and CYFRA), and the combination of two or more tumor markers leads to a higher diagnostic value (4).
Management of malignant pericardial effusion prim-arily focuses on immediately relieving the symptoms (cardiac tamponade or dyspnea), to prevent recurrent effusion for a long-term symptomatic benefit, or to treat the local neoplastic disease for prolonged survival.(3, 4) In terminally ill patients, therapeutic approach should be directed towards control of symptoms while in all other patients who have a chance of surviving at least a few months, the goals should be to obtain complete and stable control of effusion as long as possible, and to try to improve survival as well.
Treatment modalities of malignant pericardial effusion includes pericardiocentesis (lifesaving but recurrence rate up to 40%), pericardial sclerosis, systemic chemotherapy, radiotherapy, and surgical treatment depending upon various factors such as the presence of hemodynamic compromise, the general medical condition of a patient, expertise available at a particular institution, and the extent and histological features of the tumor (7-9).
Cardiac tamponade due to malignant pericardial effusion is a potentially fatal medical emergency rarely seen in ovarian carcinoma patients. Its prompt evalu-ation, timely correct diagnosis, and management will help many patients in surviving without recurrence for several months or even years.
None declared by Authors.
None declared by Authors
Conflicts of Interest
The author declared no conflict of interest.