Sunteți pe pagina 1din 6

Cardiopulmonar y Imaging Original Research

Sun et al. CT of Pericardial Effusion Cardiopulmonary Imaging Original Research

CT Findings in Patients With Pericardial Effusion: Differentiation of Malignant and Benign Disease
Joo Sung Sun1 Kyung Joo Park Doo Kyoung Kang
Sun JS, Park KJ, Kang DK

OBJECTIVE. This study was designed to validate the usefulness of a CT finding of abnormal pericardial thickening and to investigate the value of associated thoracic changes in predicting the presence of malignant pericardial effusion. MATERIALS AND METHODS. Seventy-four consecutively registered patients with pericardial effusion detected with transthoracic echocardiography were included in the study. The patients fulfilled the following criteria: undergoing pericardial fluid cytologic examination or pericardial tissue biopsy and undergoing chest CT examination less than 30 days after pericardial fluid or tissue examination. CT images were reviewed for the presence of pericardial thickening, the pattern of pericardial thickening, and the presence of pleural effusion and mediastinal lymph node enlargement. RESULTS. Twenty-eight cases of malignant and 46 cases of benign pericardial effusion were identified. Mean pericardial thickening was greater in association with malignant disease (7.25 2.91 mm) than with benign disease (4.11 1.39 mm) ( p < 0.05). Abnormal pericardial thickening ( p < 0.05) and mediastinal lymph node enlargement ( p < 0.001) were statistically significant findings of malignant pericardial effusion. The sensitivity of abnormal pericardial thickening was 42.9% and that of mediastinal lymph node enlargement was 60.7%. CONCLUSION. CT findings of irregular pericardial thickening and mediastinal lymphadenopathy have the potential to be reliably specific findings suggesting the presence of malignant pericardial effusion. It would be useful, however, to obtain pericardial fluid or tissue for causebased management of pericardial effusion, especially in patients with malignant disease. ericardial effusion, a common clinical finding, is provoked by a variety of infectious and noninfectious processes. The primary aim in treating patients with symptomatic pericardial effusion is relief of the symptoms, although secondary aims should include determination of the cause of the effusion and prevention of recurrence [1]. Pericardial effusion develops as transudate (hydropericardium), exudate, pus (pyopericardium), blood (hemopericardium), or a mixture of these substances. The presence of a large pericardial effusion generally suggests the patient has more serious disease and is commonly associated with neoplasia, hypercholesterolemia, uremic pericarditis, myxoedema, and parasitosis [2]. Development of techniques of sampling and analyzing pericardial fluid and tissue has improved the etiologic classification of the disease and increased the likelihood of identifying a specific cause, reducing the number of idiopathic cases [3, 4].

Keywords: CT, heart, neoplasm, pericarditis, pericardium, secondary pericardial effusion DOI:10.2214/AJR.09.2599 Received February 18, 2009; accepted after revision November 21, 2009.
1

All authors: Department of Radiology, Ajou University School of Medicine, San 5, Wonchon-dong, Yeongtonggu, Suwon 443721, Republic of Korea. Address correspondence to K. J. Park (kjpark@ajou.ac.kr).

WEB This is a Web exclusive article. AJR 2010; 194:W489W494 0361803X/10/1946W489 American Roentgen Ray Society

Management of pericarditis consists of nonsteroidal antiinflammatory drugs, systemic corticosteroid therapy, and pericardiocentesis based on the specific cause of pericarditis. Whenever possible, treatment of patients with pericardial effusion should be aimed at managing the underlying cause [5]. The prognosis of pericardial effusion is closely related to the underlying cause and is especially poor among patients with malignant disease. Therefore, pericardial effusion continues to be a serious problem for patients with malignant disease. Echocardiography is an excellent initial imaging tool for evaluating the pericardium, particularly pericardial effusion, but it can be limited by the intrinsic properties of the technique, such as small or limited field of view, occasionally poor acoustic windows, and problems related to anatomic factors, such as severe emphysema [6]. Moreover, echocardiography cannot be used to evaluate associated abnormalities in the mediastinum, lungs, and adjacent struc-

AJR:194, June 2010

W489

Sun et al. tures. Cross-sectional imaging techniques such as CT, however, can display the detailed anatomic features of the entire pericardium more clearly than can echocardiography, and CT has been found to be an excellent tool for detecting pericardial effusion and disease [6, 7]. In addition, associated thoracic changes can be evaluated because of the larger field of view inherent in CT. Previous reports [610] have suggested that malignant pericardial effusion and tuberculous pericardial effusion may be associated with nodular or uneven pericardial thickening. To the best of our knowledge, however, the diagnostic performance of CT in differentiating malignant and benign pericardial effusion has not been fully elucidated in the clinical literature. The aim of this study was to validate the usefulness of a CT finding of abnormal pericardial thickening in the diagnosis of malignant pericardial effusion and to investigate the value of other associated thoracic changes in predicting the occurrence of malignant pericardial effusion. Materials and Methods Study Sample
The institutional review board of our hospital approved this study. Patient consent was waived for this retrospective study. During the period May 2003 to May 2007, 74 consecutively registered patients with pericardial effusion were included from a population of inpatients of an 1,100-bed tertiary referral university hospital. The patients fulfilled the following criteria: underwent trans thoracic echocardiography that showed pericardial fluid accumulation; underwent pericardial fluid cytologic examination or pericardial tissue biopsy with echocardiographic or thoracoscopic guidance; underwent chest CT less than 30 days after pericardial fluid or tissue examination; and did not have an obvious bulky pericardial mass lesion. The criteria for benign pericardial effusion were an initially normal finding at pericardial tissue examination or cytologic examination of pericardial fluid and no recurrence of pericardial effusion during at least 1 year of clinical and radiologic follow-up. The criterion for tuberculous pericarditis was the finding of tubercle bacilli in a stained smear or culture of pericardial fluid or the finding of tubercle bacilli or caseating granuloma during histologic examination of the pericardium [11]. patients were given 100 mL of nonionic contrast material (iopamidol, Iopamiro 300, Bracco; or iopromide, Ultravist 300, Bayer Schering Pharma) injected IV with a mechanical automated injector. The scan parameters for the Sensation 16 CT unit were as follows: collimation, 16 1.5 mm; tube rotation time, 0.5 second; pitch, 1.5; 200 effective mAs; 120 kV. Image data were reconstructed at a slice thickness setting of 4 mm with a 4-mm reconstruction increment. The scan parameters for the Brilliance 16 CT unit were as follows: collimation, 16 0.75 mm; tube rotation time, 0.5 second; pitch, 0.938; 200 effective mAs; 120 kV. Image data were reconstructed with a lung filter kernel at a slice thickness of 4 mm with a 4-mm reconstruction increment. The single-detector CT scan parameters were as follows: section thickness, 5 mm; collimation, 5 mm; pitch, 1.6; table speed, 8 mm/s; 150200 mAs; 120 kV. Images were viewed with a PACS with standard lung windows (level, 600 to 700 HU; width, 1,0001,500 HU) and mediastinal windows (level, 20 HU; width, 400 HU).

TABLE 1: Clinical Features of Patients (n = 74)


Characteristic Age (y) Mean Range Sex Men Women Symptom Dyspnea Chest pain Underlying malignant disease Malignant pericardial effusion Benign pericardial effusion Tuberculous pericardial effusion Pleural effusion Pericardial fluid cytology Pericardial tissue examination 41 (55.4) 33 (44.6) 53 (71.6) 41 (55.4) 20 (27.0) 42 (56.8) 28 (37.8) 46 (62.2) 9 (12.2) 52 (70.3) 71 (95.9) 21 (28.4) 54 2382 Value

Image Interpretation
Two experienced chest radiologists (17 and 6 years of experience in interpretation of clinical chest CT scans) analyzed the CT findings, and decisions were reached by consensus. The radiologists were blinded to the pathologic results and to the presence of an underlying malignant tumor. CT images were reviewed in terms of determining the presence of pericardial thickening, the pattern of pericardial thickening (irregular or smooth), and the presence of pleural effusion and mediastinal lymph node enlargement (greater than 10 mm in the shortest dimension). Abnormal pericardial thickening was classified as irregular or smooth. Nodular or uneven thickening of the pericardium was recorded as irregular thickening, and localized or generalized pericardial thickening without a discrete nodule or irregularity was considered smooth pericardial thickening. Pericardial thickness was measured with electronic calipers after magnification of a region of interest at the most thickened area as visualized on the PACS monitor. On the basis of findings in previous studies [7, 1214], we regarded a pericardial thickness greater than 3 mm as abnormal pericardial thickening.

NoteExcept for age, values are number of patients with percentages in parentheses.

pare mean levels of abnormal pericardial thickening between benign and malignant pericardial effusion. Receiver operating characteristics curve analysis was performed to determine a cutoff value of pericardial thickness for differentiating benign from malignant pericardial disease.

Statistical Analysis
The chi-square test or Fishers exact test was used to evaluate the significance of CT findings such as smooth or irregular thickening and the presence of associated pleural effusion or mediastinal node enlargement in predicting the presence of benign or malignant pericardial effusion. The independent Students t test was used to com-

CT Examination
Sixty-two patients were examined with a 16MDCT scanner (Sensation 16, Siemens Healthcare; or Brilliance 16, Philips Healthcare), and 12 patients were examined with a single-detector CT scanner (HiSpeed Advantage, GE Healthcare). All

Results Clinical Features The patient data are presented in Table 1. The study included 74 patients (41 men, 33 women; mean age, 54 years; range, 2382 years). Forty-two of the patients had underlying malignant disease: 23 had lung cancer (21, nonsmall cell lung cancer; two, small cell lung cancer), six had breast cancer, two had lymphoma, one had stomach cancer, two had thymic carcinoma, and eight had other malignant diseases. Among the 74 patients, 28 cases of malignant pericardial effusion and 46 cases of benign pericardial effusion were identified. Twenty-eight cases of malignant pericardial effusion (37.8%) were identified after tissue biopsy (two cases), cytologic examination (28 cases), or both. The underlying malignant diseases in the 28 cases of malignant pericardial effusion were as follows: 17 cases of lung cancer (15, nonsmall cell lung cancer; two, small cell lung cancer), three cases of breast cancer, two cases of lymphoma, and six cases of other malignant diseases.

W490

AJR:194, June 2010

CT of Pericardial Effusion
Fig. 1 Pericardial effusion without pericardial thickening. A, 67-year-old woman with tuberculous pericarditis. Contrast-enhanced axial CT scan shows pericardial effusion (black arrows ) without pericardial thickening (white arrows ). B, 50-year-old man with nonsmall cell lung cancer. Contrast-enhanced axial CT scan shows pericardial effusion (black arrows ) without pericardial thickening (white arrows ). Arrowheads indicate hematogenous metastatic nodules. Pericardium is evident between low-density pericardial effusion and pericardial fat.

A The causes of the 46 benign pericardial effusions were as follows: 23 unknown causes, nine tuberculosis, six pneumonia, four radiation induced, two systemic lupus erythematosus, one myocardial infarctionrelated, and one polymyositis. A total of 46 cases of benign pericardial effusion (62.2%) were identified after tissue biopsy (19 cases), cytologic examination (43 cases), or both. Among these 46 cases of benign pericardial effusion, 14 cases were identified in patients in whom malignant disease was found after an initial negative result of pericardial fluid cytologic examination (11 cases) or tissue biopsy (three cases) with no recurrence of pericardial effusion in more than 1 year of clinical and radiologic follow-up. Nine of the 46 patients with benign pericardial effusion (19.6%) had tuberculous pericarditis confirmed with pericardial tissue examination (six patients), cytologic examination of pericardial fluid (five patients), or both. Differentiation of Malignant and Benign Pericardial Effusion There was no pericardial thickening in 15 cases of malignant pericardial effusion and 35 cases of benign pericardial effusion (Fig. 1). A total of 24 cases of abnormal pericardial thickening were identified. Thirteen cases (46.4%, 13/28) were associated with malignant pericardial effusion, and 11 cases (23.9%, 11/46) were associated with benign pericardial effusion. The data on these cases are presented in Table 2. The mean SD thickness of malignant pericardial thickening (7.25 2.91 mm) was greater than that of benign thickening (4.11 1.39 mm) ( p = 0.02). Receiver operating characteristics curve analysis showed the cutoff pericardial thickness for differentiating benign from malignant disease was 4.09 mm. The area under the receiver operating characteristics curve was 0.867 (Fig. 2), revealing the test as moderately accurate [15]. The 14 cases of malignant pericardial thickening included 10 cases of irregular pericardial thickening (8.21 2.61 mm) and three cases of smooth pericardial thickening (4.04 0.34 mm) (Fig. 3). The 11 cases of benign pericardial thickening included 10 cases of smooth pericardial thickening (3.8 0.8 mm) (Fig. 3) and one case of irregular pericardial thickening (thickness, 7.64 mm). Abnormal pericardial thickening, either smooth or irregular, was a statistically significant finding of malignant pericardial effusion ( p = 0.044). Furthermore, irregular pericardial thickening only was a more powerful indicator for discriminating malignant from benign pericardial effusion ( p < 0.001). Smooth pericardial thickening alone, however, was not a statistically significant finding ( p > 0.05). Among 11 cases of irregular pericardial thickening, 10 cases (35.7%, 10/28) were associated with malignant pericardial effusion (Fig. 4), and one case was associated with benign (tuberculous) pericardial effusion (2.2%, 1/46) TABLE 2: Data on Pericardial Thickening
Malignant Benign Pericardial Pericardial Effusion Effusion (n = 28) (n = 46) 15 (53.6) 13 (46.4) 3 (23.1) 10 (76.9) 17 (60.7) 22 (78.6) 35 (76.1) 11 (23.9) 10 (90.9) 1 (9.1) 3 (6.5) 30 (65.2)

B (Fig. 4). The sensitivity and specificity of abnormal pericardial thickening in prediction of the presence of malignant pericardial disease were 46.4% and 76.1% (Table 3). There was no statistical difference between cases of malignant (22/28, 78.6%) and benign (30/46, 65.2%) pericardial effusion with respect to presence of pleural effusion. Abnormal Pericardial Thickening and Benign Pericardial Effusion Among 11 cases of benign pericardial thickening, seven cases of pericardial thickening (63.6%, six cases of smooth and one case of irregular thickening) were associated with tuberculous pericarditis, and four cases of pericardial thickening (36.4%, all smooth thickening) were associated with nontuberculous pericarditis (two idiopathic cases, one radiation-induced case, and one case related

100 80 Sensitivity 60 40 20 0 0 20 40 60 80 100 Specificity 100

Finding Pericardial thickening Absent Present Smooth Irregular Mediastinal lymph node Pleural effusion

NoteData are number of cases with percentages in parentheses.

Fig. 2 Graph shows receiver operating characteristics curve of abnormal pericardial thickening. Solid line indicates receiver operating characteristics curve of abnormal pericardial thickening (AUC = 0.867); dashed line, chance diagonal; square on curve, ideal point with highest accuracy.

AJR:194, June 2010

W491

Sun et al.
Fig. 3 Pericardial effusion with smooth pericardial thickening. A, 43-year-old woman with nonsmall cell lung cancer. Contrast-enhanced axial CT scan shows pericardial effusion (black arrows ) with smooth pericardial thickening (white arrows ). B, 42-year-old man with tuberculous pericarditis. Contrast-enhanced axial CT scan shows generalized smooth pericardial thickening (arrows ) and pleural effusion (arrowhead ).

A to myocardial infarction). There was only one case of irregular benign pericardial thickening, and it was associated with a case of tuberculous pericarditis. Mediastinal Lymph Node Enlargement Mediastinal lymph node enlargement was found in 17 cases of malignant pericardial effusion and three cases of benign pericardial effusion. Lower paratracheal (15 cases, 88.2%), subcarinal (12 cases, 70.6%), and upper paratracheal lymph nodes (10 cases, 58.8%) were identified in cases of malignant pericardial effusion. In benign pericardial effusion, lower paratracheal (three cases, 100%), subcarinal (two cases, 66.7%), and aortopulmonary win-

B dow nodes (two cases, 66.7%) were found. Mediastinal lymph node enlargement (Fig. 4) was a significant finding of malignant pericardial effusion (60.7% [17/28] for malignant pericardial effusion, 6.5% [3/46] for benign pericardial effusion; p < 0.05). Furthermore, for 42 patients with malignant disease, mediastinal lymph node enlargement was a significant finding of malignant pericardial effusion (60.7% [17/28] for malignant pericardial effusion, 7% [1/14] for benign pericardial effusion; p < 0.05). The sensitivity and specificity of mediastinal lymph node enlargement in prediction of the presence of malignant pericardial disease were 60.7% (17/28) and 93.5% (43/46) (Table 3). Discussion We conducted this study to determine whether CT findings are useful for differentiating malignant and benign pericardial disease in patients with pericardial effusion. Most cases of pericardial effusion can be managed safely with an echocardiographically guided percutaneous approach if there is a need for pericardiocentesis [16]. Pericardiocentesis is indicated for clinical tamponade, suspicion of purulent or neoplastic pericarditis, and treatment of patients who have symptoms despite medical treatment for more than 1 week [5]. Management of pericardial effusion should be aimed at the underlying cause. Although the definitive man-

C
W492

Fig. 4 Examples of pericardial effusion with irregular pericardial thickening. A , 50-year-old man with underlying nonsmall cell lung cancer. Contrast-enhanced axial CT scan shows metastatic lymph nodes in right hilar and subcarinal space. B, Contrast-enhanced axial CT scan of patient in A shows irregular (uneven) pericardial thickening (arrows ). Arrowheads indicate pleural effusion. C, 32-year-old man with tuberculous pericarditis. Contrast-enhanced axial CT scan shows irregular (nodular) pericardial thickening (arrow ) with pleural effusion (arrowhead ). D, Photomicrograph of pericardium of patient in C shows caseous necrosis (white arrows ), multinucleated giant cells (black arrows ), and surrounding granulation tissue (arrowheads ).

AJR:194, June 2010

CT of Pericardial Effusion TABLE 3: Diagnostic Value of the Findings of Abnormal (Smooth or Irregular) Pericardial Thickening and Mediastinal Lymph Node Enlargement
Abnormal Pericardial Thickening Characteristic Sensitivity Specificity Positive predictive value Negative predictive value Accuracy > 3 mm 46.4 (13/28) 76.1 (35/46) 54.2 (13/24) 70.0 (35/50) 64.9 (48/74) > 4 mm 42.9 (12/28) 91.3 (42/46) 75.0 (12/16) 72.4 (42/58) 77.0 (57/74) Irregular Pericardial Thickening 35.7 (10/28) 97.8 (45/46) 90.9 (10/11) 71.4 (45/63) 74.3 (55/74) Mediastinal Lymph Node Enlargement 60.7 (17/28) 93.5 (43/46) 85.0 (17/20) 79.6 (43/54) 81.1 (60/74)

NoteValues are percentages with raw numbers in parentheses.

agement of malignant pericardial effusion has not yet been established [17, 18], identification and prompt control of malignant pericardial effusion can dramatically alleviate symptoms, allowing continued systemic therapy and improvement of survival from an otherwise controllable disease [19]. The differential diagnosis of pericardial effusion in patients with malignant disease includes malignant pericardial effusion, radiation-induced pericarditis, drug-induced pericarditis, and idiopathic pericarditis [20]. Metastatic pathways to the pericardium can be lymphatic or direct extension [21]. The presence of effusion and an irregularly thickened pericardium or pericardial mass suggest metastatic involvement of the pericardium, and effusion is the most common manifestation of metastatic pericardial disease [10, 22, 23]. Metastatic involvement of the pericardium has been frequently found in autopsy series; however, visualization of metastatic deposits with any imaging method is unusual [24]. In addition, nonmalignant pericardial effusion is found at postmortem examination of as many as 6% of patients with cancer [22, 25]. In this study, irregular pericardial thickening ( p < 0.05) and mediastinal lymph node enlargement ( p < 0.001) were significant CT findings of malignant pericardial effusion. Although irregular pericardial thickening and mediastinal lymph node enlargement were significant findings of malignant pericardial effusion, the sensitivity of these findings was low at 37.9% and 62.1%, respectively. The sensitivities of cytologic examination of pericardial fluid and pericardial biopsy for malignant pericardial effusion are approximately 7587% and 2776%, respectively [26]. Pericardial biopsy guided by pericardioscopy has a sensitivity of 93.397% [3, 27]. Even though abnormal (smooth or irregular) pericardial thickening was a significant finding of malignant pericardial effusion, the sensitivity, spec-

ificity, positive predictive value, and negative predictive value were 48.3%, 76.1%, 56%, and 70%. Therefore, abnormal pericardial thickening is not a suitable finding in screening for malignant pericardial effusion. However, irregular pericardial thickening (not smooth thickening) had high specificity (97.8%) and positive predictive value (91.7%) and has the potential to be a reliably specific finding suggesting the presence of malignant pericardial effusion (Table 3), although the sensitivity was low (37.9%). Although mediastinal lymph node enlargement was a significant finding of malignant pericardial effusion, the number of cases was too small for assessment of the value of the location of the mediastinal lymph nodes for differentiating benign from malignant disease. Not surprisingly, mediastinal lymph node enlargement was the other significant CT finding of malignant pericardial effusion. The sensitivity, specificity, positive predictive value, and negative predictive value were 60.7%, 93.5%, 85%, and 79.6%. More important, mediastinal lymph node enlargement also was a significant finding of malignant pericardial effusion in patients with malignant disease. In the literature [28, 29], mediastinal lymph node enlargement has been associated with tuberculous pericarditis. However, among nine cases of tuberculous pericarditis in our study, only two cases (22.2%) manifested mediastinal lymph enlargement. Although the frequency of mediastinal lymph node enlargement of tuberculous pericarditis was low, the number of cases of tuberculous pericarditis was small. Further study with a large sample is needed. All seven patients who had both irregular pericardial thickening and mediastinal lymph node enlargement were found to have malignant pericardial effusion. A finding of irregular pericardial thickening or mediastinal lymph node enlargement

in patients with pericardial effusion may be highly suggestive of malignant pericardial effusion, especially in patients with underlying malignant disease. Furthermore, coexistence of irregular pericardial thickening and mediastinal lymph node enlargement may strongly suggest the presence of malignant pericardial effusion; therefore, therapeutic intervention, such as use of a percutaneous technique for window formation in the pericardium, is necessary at the time of initial pericardiocentesis [3032]. Tuberculous pericarditis can be lethal because of the difficulty of early diagnosis and ready progression to constrictive pericarditis [33]. As described in previous reports [9, 11, 34], tuberculous pericardial effusion can manifest as abnormal pericardial thickening. Seven of 11 cases (63.6%) of benign pericardial thickening in our study were associated with tuberculous pericarditis (six cases of smooth and one case of irregular thickening). The incidence of tuberculous pericarditis ranges from 8% to 17% among HIV-negative persons [33, 35, 36] but from 17% to 34% among HIV-positive persons [37]. Antituberculosis chemotherapy dramatically improves survival among patients with tuberculosis pericarditis. The immediate goal of treatment is to manage the acute symptoms of tamponade; the ultimate goal is to prevent constrictive pericarditis. Therefore, an early suggestion of tuberculous pericarditis can be helpful in an aggressive effort to diagnose tuberculous pericarditis, especially in a tuberculosisendemic area or among HIV-positive persons. Nevertheless, in most cases of tuberculous pericarditis, the lung fields exhibit no associated pulmonary tuberculosis [38]; therefore, an early suggestion of tuberculous pericarditis based on the presence of a pulmonary abnormality is difficult to discern. Among nine cases of tuberculous pericarditis in this study, associated pulmonary tuberculosis was found in only one case. Therefore, the presence of less than 4 mm of smooth pericardial thickening is more likely to suggest the presence of benign pericardial thickening; however, irregular pericardial thickening should be noted in benign pericardial effusion, especially in cases of tuberculous pericarditis. Careful evaluation with full consideration of the clinical information is mandatory. There were limitations to our study. First, the number of cases was relatively small; therefore, further studies with more patients are needed. Second, there was possible bias due to the different CT methods used (i.e., use

AJR:194, June 2010

W493

Sun et al. of conventional helical CT and 16-MDCT and no use of cardiac gating). Further study with well-controlled conditions is needed. Third, CT was performed after a procedure such as pericardiocentesis, catheterization, or pericardiectomy in 24 cases, and possible changes related to the procedure can affect image interpretation. Finally, owing to the moderate sensitivity of cytologic examination [26], the reference standard for malignant pericardial effusion might have been controversial in cases in which pericardial effusion in patients with malignant disease (n = 43) was proved benign (n = 14) with the initial negative cytologic finding (n = 11) or after tissue biopsy (n = 3) with more than 1 year of clinical and radiologic follow-up. Although it is possible that the cytologic (or tissue biopsy) result was false-negative and subsequent complete response to chemotherapy occurred, this situation is difficult to verify. The CT findings of irregular pericardial thickening and mediastinal lymphadenopathy have the potential to be reliable specific findings suggesting the presence of malignant pericardial effusion. The sensitivity is low, however, and irregular pericardial thickening can be associated with tuberculous pericardial thickening. Therefore, it would be useful to obtain pericardial fluid or tissue for cause-based management of pericardial effusion, especially in patients with malignant disease and in areas where tuberculosis is endemic. References
1. Gibbs CR, Watson RD, Singh SP, Lip GY. Management of pericardial effusion by drainage: a survey of 10 years experience in a city centre general hospital serving a multiracial population. Postgrad Med J 2000; 76:809813 2. Merce J, Sagrista-Sauleda J, Permanyer-Miralda G, Soler-Soler J. Should pericardial drainage be performed routinely in patients who have a large pericardial effusion without tamponade? Am J Med 1998; 105:106109 3. Seferovic PM, Ristic AD, Maksimovic R, Tatic V, Ostojic M, Kanjuh V. Diagnostic value of pericardial biopsy: improvement with extensive sampling enabled by pericardioscopy. Circulation 2003; 107:978983 4. Maisch B, Ristic AD. Practical aspects of the management of pericardial disease. Heart 2003; 89:10961103 5. Maisch B, Seferovi PM, Risti AD, et al. Guidelines on the diagnosis and management of pericardial diseases executive summary. The Task Force on the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology. Eur Heart J 2004; 25:587610 6. Rienmller R, Grll R, Lipton MJ. CT and MR imaging of pericardial disease. Radiol Clin North Am 2004; 42:587601 7. Silverman PM, Harell GS, Korobkin M. Computed tomography of the abnormal pericardium. AJR 1983; 140:11251129 8. Axel L. Assessment of pericardial disease by magnetic resonance and computed tomography. J Magn Reson Imaging 2004; 19:816826 9. Suchet IB, Horwitz TA. CT in tuberculous constrictive pericarditis. J Comput Assist Tomogr 1992; 16:391400 10. Olson MC, Posniak HV, McDonald V, Wisniew ski R, Moncada R. Computed tomography and magnetic resonance imaging of the pericardium. RadioGraphics 1989; 9:633649 11. Mayosi BM, Burgess LJ, Doubell AF. Tuberculous pericarditis. Circulation 2005; 112:36083616 12. Bull RK, Edwards PD, Dixon AK. CT dimensions of the normal pericardium. Br J Radiol 1998; 71:923925 13. Ling LH, Oh JK, Tei C, et al. Pericardial thickness measured with transesophageal echocardiography: feasibility and potential clinical usefulness. J Am Coll Cardiol 1997; 29:13171323 14. Silverman PM, Harell GS. Computed tomography of the normal pericardium. Invest Radiol 1983; 18:141144 15. Greiner M, Pfeiffer D, Smith RD. Principles and practical application of the receiver-operating characteristic analysis for diagnostic tests. Prev Vet Med 2000; 45:2341 16. Troughton RW, Asher CR, Klein AL. Pericarditis. Lancet 2004; 363:717727 17. Kilic D, Akay H, Kavukcu S, et al. Management of recurrent malignant pleural effusion with chemical pleurodesis. Surg Today 2005; 35:634638 18. Laham RJ, Cohen DJ, Kuntz RE, Baim DS, Lorell BH, Simons M. Pericardial effusion in patients with cancer: outcome with contemporary management strategies. Heart 1996; 75:6771 19. Swanepoel E, Apffelstaedt JP. Malignant pericardial effusion in breast cancer: terminal event or treatable complication? J Surg Oncol 1997; 64:308311 20. Chiles C, Woodard PK, Gutierrez FR, Link KM. Metastatic involvement of the heart and pericardium: CT and MR imaging. RadioGraphics 2001; 21:439449 21. Reynen K, Kockeritz U, Strasser RH. Metastases to the heart. Ann Oncol 2004; 15:375381 22. Posner MR, Cohen GI, Skarin AT. Pericardial disease in patients with cancer: the differentiation of malignant from idiopathic and radiation-induced pericarditis. Am J Med 1981; 71:407413 23. Cham WC, Freiman AH, Carstens PH, Chu FC. Radiation therapy of cardiac and pericardial metastases. Radiology 1975; 114:701704 24. Breen JF. Imaging of the pericardium. J Thorac Imaging 2001; 16:4754 25. Agner RC, Gallis HA. Pericarditis: differential diagnostic considerations. Arch Intern Med 1979; 139:407412 26. Porte HL, Janecki-Delebecq TJ, Finzi L, Metois DG, Millaire A, Wurtz AJ. Pericardoscopy for primary management of pericardial effusion in cancer patients. Eur J Cardiothorac Surg 1999; 16:287291 27. Nugue O, Millaire A, Porte H, et al. Pericardioscopy in the etiologic diagnosis of pericardial effusion in 141 consecutive patients. Circulation 1996; 94:16351641 28. Cherian G, Uthaman B, Salama A, Habashy AG, Khan NA, Cherian JM. Tuberculous pericardial effusion: features, tamponade, and computed tomography. Angiology 2004; 55:431440 29. Cherian G, Habashy AG, Uthaman B, Cherian JM, Salama A, Anim JT. Detection and follow-up of mediastinal lymph node enlargement in tuberculous pericardial effusions using computed tomography. Am J Med 2003; 114:319322 30. Ziskind AA, Pearce AC, Lemmon CC, et al. Percutaneous balloon pericardiotomy for the treatment of cardiac tamponade and large pericardial effusions: description of technique and report of the first 50 cases. J Am Coll Cardiol 1993; 21:15 31. Jackson G, Keane D, Mishra B. Percutaneous balloon pericardiotomy in the management of recurrent malignant pericardial effusions. Br Heart J 1992; 68:613615 32. Palacios IF, Tuzcu EM, Ziskind AA, Younger J, Block PC. Percutaneous balloon pericardial window for patients with malignant pericardial effusion and tamponade. Cathet Cardiovasc Diagn 1991; 22:244249 33. Desai HN. Tuberculous pericarditis: a review of 100 cases. S Afr Med J 1979; 55:877880 34. Hayashi H, Kawamata H, Machida M, Kumazaki T. Tuberculous pericarditis: MRI features with contrast enhancement. Br J Radiol 1998; 71:680 682 35. Bhan GL. Tuberculous pericarditis. J Infect 1980; 2:360364 36. Gooi HC, Smith JM. Tuberculous pericarditis in Birmingham. Thorax 1978; 33:9496 37. Hakim JG, Ternouth I, Mushangi E, Siziya S, Robertson V, Malin A. Double blind randomised placebo controlled trial of adjunctive prednisolone in the treatment of effusive tuberculous pericarditis in HIV seropositive patients. Heart 2000; 84:183188 38. Strang JIG. Tuberculous pericarditis. J Infect 1997; 35:215219

W494

AJR:194, June 2010

S-ar putea să vă placă și