Thoracoscopic Pericardiectomy for Malignant Pericardial Effusion

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Frederic W. Grannis jr. MD Notes for a presentation to the Methodist Hospital Cardiology Conference July 1992

Thoracoscopy has been performed for almost one hundred years, but had minimal utility other than as a diagnostic tool for pleural diseases. New technology borrowed from gynecologic and general surgeons now allows the thoracic surgeon to perform traditional pericardial resection without thoracotomy.

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Technique

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The patient is anesthetized and intubated with a double lumen ET tube for right sided thoracoscopy and with a Uni-vent tube for left sided thoracoscopy. The position of the tube is checked by the surgeon using a pediatric bronchoscope, with the patient supine and again after he is turned into the lateral decubitus position. Proper positioning of the tube is essential as adequate surgical exposure cannot be achieved unless the lung is completely collapsed. Ordinarily patients will tolerate collapse of one lung without problems, but if there is concomitant pulmonary disease, desaturation and cardiopulmonary decompensation can occur during one lung anesthesia. In this instance, the procedure can be carried out during short periods of pulmonary collapse with intermittent reinflation.

Left thoracoscopy is preferable, as a more complete resection can be carried out. If the left pleura is obliterated a pericardiectomy can be achieved on the right side.If the patient is hemodynamically unstable, secondary to tamponade, a preliminary pericardiocentesis under thoracoscopic control can be done with the patient in the supine position, before turning.

The pleural cavity, in the mid-axillary line in a lower interspace, is entered under direct vision, to avoid pulmonary injury, in case of adhesions. A working cannula is then placed, the thoracoscope is passed, and the chest cavity is examined completely. Cannulas with leak-proof diaphragms are not strictly necessary as in laparotomy, for the lung will stay collapsed unless suction is applied to the chest cavity. Positive pressure insufflation of CO2 is not necessary. A cannula is useful in keeping blood off the tip of the thoracoscope to avoid blurring of the image.

Two further small intercostal incisions are made, as needed, usually one anterior and one posterior to the telescope. The telescope is connected to a television camera and the surgical field is visualized on a television monitor.

The thoracoscope is controlled by an assistant while the surgeon resects a generous portion of pericardium anterior or posterior to the phrenic nerve, using specially constructed instruments passed through the intercostal incisions. The tensely distended pericardium is difficult to grasp, and so it must either be stabbed and cut with sharp scissors or grasped by forceps and cut, after decompression by pericardiocentesis. Partial pericardiectomy can then be performed with scissors and electrocautery. The extent of pericardiectomy that can be achieved through the thoracoscope is limited in comparison to that possible via thoracotomy, but adequate drainage of the pericardium can be attained and the advantages to the patient outweigh this limitation. Chest tubes are brought out through two of the intercostal incisions and left in place for two or three days.

The following paragraphs describe a personal series of 4 cases of pericardial effusions in patients with advanced malignant disease treated by partial pericardiectomy, performed without thoracotomy, using thoracoscopic techniques.

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CASE PRESENTATIONS

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CASE #1

L.M. a 60 year old male 90 pack/year smoker presented with shortness of breath. In December 1990 a T3N2 unresectable squamous cell bronchogenic carcinoma in the right middle lobe was biopsied. There was an partial response to three courses of cis-platinum and etoposide and 6600 rads of radiation therapy.

On 11/23/91 he experienced chest pain and shortness of breath. A pericardial friction rub was heard. Hypertrophic pulmonary osteoarthropathy was noted on exam. Pulsus paradoxus of 15 mm./Hg. was found. A large right hilar mass was seen on chest roentgenogram. A pericardial effusion was demonstrated with echocardiography. Despite treatment with indomethacin and later, pericardiocentesis, the effusion recurred.

On 12/9/91 the patient was bronchoscoped and found to have obstruction of the right middle and lower lobes. A double lumen endotracheal tube was then positioned in the distal left main bronchus. The patient was placed in the right lateral decubitus position and thoracoscopy performed. Arterial saturation dropped rapidly each time that the left lung was deflated. During multiple short periods of such deflation a 4 by 4 cm. pericardial window was created anterior to the right phrenic nerve. Pathologic examination revealed no evidence of malignancy in the resected pericardium or in the pericardial fluid.

Partial relief of dyspnea was attained. Multiple bone metastases resulted in the patients demise 4 months later.

CASE #2

C.W. a 55 year old woman presented with shortness of breath and anemia. In March 1988 breast adenocarcinoma was treated with modified radical mastectomy, CMF chemotherapy and tamoxifen. Diffuse bone metastases were treated with multiple different chemotherapeutic regimens starting in 7/90. On 3/19/92 she was admitted to City of Hope National Medical with bilateral pleural effusions, a large pericardial effusion and anemia. Left thoracentesis of 400 cc. resulted in syncope. An echocardiogram demonstrated a large pericardial effusion with right ventricular collapse in diastole suggesting tamponade. On 3/21/92 a pericardiocentesis yielded 350 cc of bloody fluid. Cardiac output increased from 3.5 to 7.0 l./min..

On 3/23/92 under general anesthesia a Univent tube was placed and the endobronchial blocker positioned endoscopically in the distal left main bronchus. The patient was placed in the right lateral decubitus position and thoracoscopic partial pericardiectomy was performed removing a 4x4 cm. piece of pericardium. Malignant infiltration of pericardial lymphatics were found on pathologic examination.

The patient was alive and free of tamponade three months later. There was progression of bone metastases and symptomatic hypercalcemia.

CASE #3

J.T., a 61 year old woman presented with progressive shortness of breath and back pain. In 1978 adenocarcinoma of the breast was treated with mastectomy. On admission, a large right pleural effusion was tapped and adenocarcinoma demonstrated. Chest tube thoracostomy and intrapleural bleomycin therapy were only partially successful in controling pleural effusion. Pulmonary function studies ( Total lung capacity=2.88 l.,VC=1.62 l., FEV1=1.07 l./sec.) demonstrated a combined moderate restrictive and mild obstructive defect. Echocardiography showed a large pericardial effusion and early tamponade. There were also mass lesions in the mediastinum, lung, liver and bone. On 5/4/92 left thoracoscopy and partial pericardiectomy posterior to the phrenic nerve was performed using intermittent inflation of the left lung necessitated by desaturation. No metastatic tumor could be demonstrated in the pathologic specimens.

Three months post-op the patient is doing well and is being treated with B-MAC chemotherapy protocol.

Case #4:

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DISCUSSION

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Pericardial effusion in patients with malignant disease is almost always due to the cancer but it is important to remember that other causes of effusion are occasionally present. Probably the most common non-neoplastic etiology is associated with radiation therapy. These patients can have long term survival after pericardiectomy.l

Malignant pericardial effusion is usually associated with metastasis to mediastinal lymph nodes and therefore the most common neoplasms causing effusion are lung, breast, lymphoma, leukemia and melanoma in that approximate order.

Effusion usually occurs in a patient with advanced malignancy clinically apparent. It can occasionally represent the initial presentation of a malignancy.

It is difficult to make definitive statements about treatment of malignant pericardial effusions. There are only a few series with large enough numbers to approach statistical significance. No series of cases with proper experimental controls exists. Comparison of different series can be difficult because there is so much variation in prognosis depending on the cell type of the primary and on the stage of the tumor as well as the general health of the patients. Certain generalizations can be made.

Untreated patients usually die within 2 weeks.

Patients treated with pericardiocentesis alone can have long term palliation, but rapid reaccumulation of fluid and recurrence of tamponade is the usual course of events.Patients with malignant pericardial effusion usually die within one year of diagnosis, with the one exception of malignant lymphoma where patients can live for many years with effective chemotherapy. Lung cancer carries a much shorter survival than does breast cancer.

Cannulation of the pericardium by pericardiocentesis and Seldinger technique with drainage and later sclerosis with tetracycline or treatment with antineoplastic agents has recieved increasing interest over the past few years and is felt to be the best treatment in some review articles. It has the disadvantages that it carries the risk of pericardiocentesis, is painful for the patient and can result in recurrence. A further problem is that tetracycline is no longer produced in the US.

Surgical resection of pericardium can provide reasonable palliation by removal of the threat of tamponade. Recurrence can occur when only a pericardial window is performed, presumably when fibrosis causes closure of the window. We have seen pericardial constriction develop secondary to tumor growth months after a pericardial window resection. Sub-total pericardiectomy gives freedom from recurrence but the incision and operative morbidity are larger.

Pericardiectomy requires a major thoracotomy incision. Surprisingly, the mortality of this proceedure in my hands has been zero to date, but the patient does have significant morbidity. Finally there is obligatory time lost during hospitalization, expense, discomfort and disability secondary to the thoracotomy incision. All of these factors cut into the quality of the limited duration of life left to the patient.

In my experience with approximately 25 cases, the average survival is 4-6 months. The only survival over one year is a patient alive at 5 years post-op with a lymphoma of the heart.

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