Clinical Radiology (1989) 40, 307 308
External Radiotherapy in the Management of Malignant Pericardial Effusion D. J. F A I R L A M B Radiotherapy Department, The Royal Hospital, Wolverhampton W V 2 1BT, U K Malignant pericardial effusions that are not causing tamponade can be effectively treated by external beam irradiat i o n - a readily available non-invasive treatment. In a consecutive series six out of eight patients achieved good palliation of their effusions as a result of this treatment.
METHOD Over a 4-year period eight patients with a known preexisting carcinoma were clinically diagnosed as suffering from malignant pericardial effusions. All patients had the diagnosis confirmed by echocardiography. Three patients required pericardiocentesis before starting radiotherapy and one needed a repeat aspiration during treatment. Positive cytology was obtained in two cases_ Radiotherapy was planned on an X-ray simulator and the field sizes included the whole pericardial sac. Resimulation was undertaken twice weekly allowing whenever possible field size reductions to be made. Treatment was delivered using equally weighted parallel opposed fields with 4MV X-rays and the midline dose was 30 Gy in 10 daily fractions over 12 to 14 days_
sites usually being breast, bronchus or malignant melanoma (Hill and Cohen, 1970). Treatment of the underlying malignancy is essential. However, the effusion frequently occurs in the terminal stages and only palliation is possible. Multiple needle pericardiocentesis, percutaneous insertion of a pericardial drain, subxiphoid pericardiotomy and radical pericardiectomy have been recommended (Horgan, 1987). If pericardiocentesis is required then tetracycline should be instilled doxorubitin, 5fluorouracil, Thiotepa or nitrogen mustard are alternative drugs. Sudden death may occur after such procedures and the fluid may reaccummulate after 24-48 h (Theoglides, 1981). Instillation of radio isotopes (32-phosphorus, 90-yttrium and 198-gold) has been largely abandoned because of problems with radiation protection, administration and availability at short notice. External radiotherapy has been used formerly (Lokich, 1973; Cham et al., 1975). However, its use declined with the increase in intrapericardial and/or systemic chemo-
RESULTS These are summarised in Table l_ Two patients died of cardiac tamponade before the radiotherapy was completed - ' o n e despite repeat pericardiocentesis. All six patients who received the full therapy achieved good palliation though not always complete abolition of the effusion or its consequent symptoms. In none of these patients was recurrent effusion a problem. The prognosis was that of the underlying malignancy.
DISCUSSION Malignant pericardial effusions are an uncommon finding in patients with advanced c a n c e r - t h e primary
Fig. 1- Before radiotherapy and pericardiocentesis.
Table 1 Age~sex
48 57 42 70 65 70 42 48
Lung Lung Breast Breast Lung Lung Breast Adenocarcinoma
No Yes Yes No Yes Yes Yes Yes
F* M F* F M M F F*
* Required pericardiocentesis before or during radiotherapy. t Radiographs, Figs 1 and 2.
Recurrence qlctamponade No No No No No No
O~tlcoDte and survival
Died after first Rx Died after 9 months Died aftcr 11 months Died during radiotherapy Died after 9 months Died after 6 months Died after 2 months Alive at 10 monthst
CLINICAL RADIOLOGY pulsus paradoxus becomes established. If this latter o c c u r s p e r i c a r d i o c e n t e s i s is e s s e n t i a l t o p r o v i d e r a p i d r e l i e f a n d t e t r a c y c l i n e s h o u l d b e i n s t i l l e d ( D a v i s et al., 1984). W h e n t h e d i a g n o s i s is m a d e b e f o r e c a r d i a c e m b a r rassment occurs then external radiotherapy should be g i v e n as it is a n e f f e c t i v e , r e a d i l y a v a i l a b l e n o n - i n v a s i v e treatment.
Fig. 2 Five months after radiotherapy.
Chain, WC, Freiman, AH, Carstens, PB & Cbu, FCH (1975). Radiation therapy o f cardiac and pericardial metastases. Radiology, 114, 701 704. Davis, S, Rambotti, P & Grignani, F (1984). Intrapericardial tetracycline sclero:is in the treatment of malignant pericardial effusion. Journal of Clinical Oneology, 2, 631-636. Hill, GJ & Cohen, BI (1970). Pleural pericardial window for palliation of cardiac tamponade due to cancer. Cancer, 26, 81 93. Horgan, JH (1987). Cardiac tamponade. British Medical Journal, 295, 563. Lokich, JJ (1973). The management of malignant pericardial effusions Journal of the American Medical Association, 224, 1401 1404. Malden, LT (1987). Malignant effusions. Cancer Topics, 6, 82 83. Theoglides, A (1981). In Oncologic Emergencies, ed: Yarbro, JW & Bornstein, RS pp. 1 21. Grune and Stratton, New York.
t h e r a p y . M a l i g n a n t p e r i c a r d i a l e f f u s i o n is a l i f e - t h r e a t e n i n g c o m p l i c a t i o n . T h e d i a g n o s i s , h o w e v e r , is o f t e n e s t a b lished before tamponade and low ventricular output with
Book Reviews Diseases of the Esophagus - Pathophysiology, Diagnosis, Conservative and Surgical Treatment. Edited by J. R. Siewert and A. H. Holscher,
Atlas of Nuclear Medicine. Edited by D. V. Nostrand and S. Baum, J. B.
Lippincott & Co., Philadelphia, 1988, 413 pp., £55.
Springer-Verlag, Berlin, 1988, 1400 pp., 600 figs, DM 398. This volume is a summary of the proceedings of the third triennial congress of the International Society for Diseases of the Oesophagus held in Munich during September 1986. Some 380 papers were given and the majority are published here. It is to the Editors' and Publishers' great credit that they have performed such a feat in a very short space of time and they make the justifiable claim that this book 'reproduces for 1987 the topical state of the art about pathology, pathophysiology, diagnostic and therapy of benign and malignant disease of the oesophagus'. All aspects of oesophageal disease have been considered with slightly more emphasis being placed on the cancer section than the benign section; each of these sections is subdivided into chapters on epidemiology, pathology, diagnosis and management. This encyclopaedic coverage obviously means that only a comparatively small proportion of the book relates to diagnostic techniques, and even here pride of place is given to endoscopy. In fact, there is very little discussion of conventional contrast radiology with only two papers being devoted to it. One of these is on the early detection of superficial oesophageal cancer and the other is on cost benefit aspects of investigation for reflux disease. The latter paper makes the interesting observation that fibreoptic oesophagoscopy costs twice as much as any other diagnostic method, be it radiology, nuclear medicine or pH monitoring. The only other aspects of diagnostic radiology are centred on the roles of CT and endoluminal ultrasound in the staging of oesophageal cancer. It can therefore be seen that this book will be of limited value to the diagnostic radiologist as only approximately 20 ou t of the 380 papers are on 'his' topic. Although there is a vast amount of useful information here most of it relates to alternative forms of diagnosis as well as management. For this reason alone the book cannot be recommended for purchase by individual radiologists or indeed the majority of X-ray department libraries. Where it will find a very useful niche is on the library shelves of specialist thoracic units where it can be consulted by surgeons, endoscopists and radiotherapists as well as radiologists. There is no doubt that it presents a comprehensive review of all aspects of oesophageal disease and provides a ready reference for further reading. A. Freeman
Atlases of nuclear medicine tend to be of two types, either comprehensive or selecting an organ or system and giving a more detailed covering of the subject. The reviewed book chooses to steer a path between these two approaches and aims to present 'a more extensive atlas either of nuclear medicine procedures or of specific aspects of nuclear medicine procedures that have been presented only superficially in previous atlases and/or do not warrant a separate book'. Thus a more precise title of the edition would be A Highly Selective Atlas o[ Nuclear Medicine. l have no idea why the editors selected the 16 topics chosen. These range from the mundane (hepatobiliary imaging in patients without prior surgery, indium white cell scanning) to the esoteric (paediatric radionuclide lymphography, fluorescent thyroid scanning) with those whose inclusion in a nuclear medicine atlas must be questioned fine needle aspiration of the thyroid seems particularly out of place. Aside from the reservation of the selection of topics, how well does the book fulfil its role as an in-depth atlas? Unfortunately the reader is likely to be disappointed as many chapters are not comprehensive. Thus the chapter on hepatobiliary imaging in patients without prior surgery contains no examples of ectopic gall bladders, choledochal cysts, biliary fistulae or of biliary-gastric reflux. The chapter on leucocyte scanning makes scant reference to enteric communication of abscesses, nor does it give examples of 'cold' bone abscesses--both are met frequently in clinical practice. It implies that a pancreatic abscess can be distinguished from pancreatitis by intensity of tracer accumulation over the organ which is misleading. Quality of images is generally satisfactory although some (e.g. the parathyroid acquisition and subtraction sequences, and some of the renal transplant studies) are so small as to be valueless. Inevitably comparison will be made between this book and the recently published atlas edited by Fogelman and Maisey. The British text is more comprehensive, better illustrated and of much greater value to the individual or department and, apart from titles, you are not comparing like with like. The highly selective nature of the topics in a text such as this makes their identification obscure for someone researching a subject, and I think the book will be little used for reference purposes. It has few redeeming features and I do not recommend it. A. J. Coakley