Tetracycline sclerosis in the management of malignant pericardial effusion

Our plain-English summary of Tetracycline sclerosis in the management of malignant pericardial effusion, by F.A. Shepherd, J.S. Ginsberg, W.K. Evans, et al (Journal of Clinical Oncology, 1985).

The study

• Authors: F.A. Shepherd, J.S. Ginsberg, W.K. Evans, J.G. Scott, F. Oleksiuk
• Journal: Journal of Clinical Oncology
• Published: 1985;3(12):1678-82
• Cited by: 45 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Twenty-two patients with malignant pericardial effusion were seen at the Toronto General Hospital between 1979 and 1984. Under ECG monitoring, an indwelling Kifa catheter was inserted into the pericardial sac and then connected to a Hemovac system and allowed to drain for 12 to 24 hours. Xylocaine hydrochloride, 100 mg, was first instilled intrapericardially, followed by tetracycline hydrochloride, 500 to 1,000 mg, dissolved in 20 mL normal saline. The catheter was clamped for one to two hours and then allowed to drain into the Hemovac. This procedure was repeated every 24 to 48 hours until the net drainage was less than 25 mL/24 hours. Nine men and 13 women were treated (median age, 55 years). The primary malignancy included lung in 15 patients, breast in two patients, and carcinoma of the stomach, ovary, pleural mesothelioma, chronic granulocytic leukemia, and adenocarcinoma of unknown primary in one patient each. Twenty patients received one to five instillations of tetracycline. In one patient the catheter could not be inserted into the pericardial sac, and in one patient the catheter clotted before tetracycline instillation. Minor complications included transient arrhythmia in two patients, postinjection pain in four patients, and self-limited temperature elevation greater than 38.5 degrees C in two patients. fifteen patients had good control of their malignant pericardial effusion for more than 30 days (median survival, 160 days; range, 38 to 275 days). Three patients died before 30 days without evidence of effusion, and no patient surviving longer than 30 days developed recurrent effusion or pericardial constriction. Intrapericardial tetracycline instillation is a safe and efficacious treatment for malignant pericardial effusion and should be considered the first treatment modality in this situation.

In plain English

This was a review of hospital records for patients with malignant pericardial effusion, meaning cancer-related fluid around the heart, treated at the Toronto General Hospital from 1979 to 1984. Of 22 patients (13 women, 9 men, median age 55), 15 had lung cancer and one had pleural mesothelioma. The article does not discuss asbestos. Doctors drained the fluid through a catheter and then put tetracycline into the sac around the heart, repeating this until drainage fell below 25 mL in 24 hours. In two patients the procedure failed for technical reasons, and 20 received one to five doses. There were no major complications. Two patients had brief irregular heart rhythms, four had pain needing intravenous narcotics, and two had fever. By the Smith criteria, 15 of 22 patients (68%) had successful control. These 15 lived a median of 160 days (range 38 to 275), and none had the fluid return. The authors judged the effusion controlled in 18 of the 20 patients who received tetracycline. The authors concluded the treatment was safe and should be considered first.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Retrospective review of hospital records (case series) of patients treated with intrapericardial tetracycline
• Who was studied: 22 patients with malignant pericardial effusion at the Toronto General Hospital, Ontario, January 1, 1979 to December 31, 1984 (records of 24 were reviewed; treatment was attempted in 22). There were 13 women and 9 men, median age 55 (range 40 to 68). Primary tumors were lung in 15, breast in 2, and one each of stomach, chronic granulocytic leukemia, pleural mesothelioma, ovary, and adenocarcinoma of unknown primary.
• Exposure: No asbestos exposure is reported. The treatment studied was tetracycline hydrochloride, 500 to 1,000 mg in 10 mL normal saline, instilled through an indwelling pericardial catheter. Most patients first received 100 mg xylocaine. The procedure was repeated every 24 to 48 hours until net drainage was below 25 mL in 24 hours.
• Main results:
  • In 2 of 22 patients the procedure failed for technical reasons (catheter could not be inserted in one; catheter clotted before instillation in the other). The remaining 20 patients received one to five doses of tetracycline.
  • There were no major complications. Two patients had transient atrial arrhythmias, four had post-injection pain requiring intravenous narcotics, and two had temperature elevation.
  • Using the Smith criteria, 15 of 22 patients (68%) had successful control of their pericardial effusions.
  • Of the 20 treated patients, five survived less than 30 days. Three of these had evidence of effusion resolution, one died three days after instillation, and one had continued drainage despite three instillations.
  • The remaining 15 patients had a median survival of 160 days (range 38 to 275 days). None of the 15 who survived longer than 30 days had clinical or echocardiographic evidence of recurrent effusion.
  • Six patients had autopsy examination. None had residual pericardial fluid; four showed obliterative fibrinous pericarditis and two had dense pericardial fibrosis, which the pathologist attributed to prior radiotherapy. No patient developed signs of pericardial constriction.
  • Two patients required surgery to create a pericardial window: one because the catheter could not be inserted, and one because of continued drainage despite tetracycline.
  • The first two patients treated without xylocaine had very severe burning retrosternal chest pain.
  • The authors judged that the effusion was successfully controlled in 18 of the 20 patients who received tetracycline.
• The authors' conclusion: The authors concluded that intrapericardial tetracycline instillation is a safe treatment for malignant pericardial effusions of many tumor types and should be considered as the first treatment modality in this situation.
• Limitations the authors state:
  • The authors noted that the 68.2% success figure includes two patients in whom tetracycline could not be instilled for technical reasons, and three who died before 30 days from progressive metastatic disease without evidence of recurrent effusion.

Topics

Medical terms in this study, explained in our Lexicon: Pericardial Effusion, Pericardial, Carcinoma, Pleural Mesothelioma, Adenocarcinoma, Median Overall Survival.

Related studies

• Pericardial mesothelioma masquerading as a benign pericardial effusion — N.L. Coplan, A.J. Kennish, et al. (1984)
• Pericardial Mesothelioma in a 35-Year-Old Male With Ulcerative Colitis — J. Iliff, N.K. Bart, et al. (2019)
• Asbestos induced pericardial effusion and constrictive pericarditis — D. Davies, M.I. Andrews, et al. (1991)
• Pericardial effusion associated with asbestos exposure — S. Trogrlic, P.A. Gevenois, et al. (1997)
• Recurrent pericardial effusion with pericardial amyloid deposition: a case report and literature review — H. Itagaki, T. Yamamoto, et al. (2020)
• Sarcomatoid Type Primary Pericardial Mesothelioma with a Long-term Survival after the Onset of Cardiac Tamponade — C. Saisho, H. Ishii, et al. (2016)

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