Which of the following is/are acceptable alternatives in the management of malignant pericardial effusion?

A. Pericardiocentesis.

B. Subxiphoid pericardiotomy (“pericardial window”).

C. Thoracotomy with pericardiectomy.

D. Instillation of tetracycline or bleomycin into the pericardial space.

E. Treatment of the underlying malignancy. 

DISCUSSION: In patients with symptomatic malignant pericardial effusions, management options may be designed to establish a diagnosis, relieve symptoms, or prevent recurrence. Pericardiocentesis is very successful in removing fluid for diagnosis and alleviating symptoms; however recurrence rates are greater than 50%. This rate can be reduced to around 20% with instillation of sclerosing agents such as tetracycline or bleomycin. Surgical techniques, including subxiphoid pericardiotomy and thoracotomy with pericardiectomy, offer the highest success rates (approximately 90%) but are more invasive and usually require general anesthesia. Systemic antitumor therapy with chemotherapy or radiation therapy can be effective in controlling malignant effusions in cases of sensitive tumors such as lymphomas, leukemias, and breast cancer.