Summary: A 50-year-old man presented with a 3-month history of a mild
cough with progressively increasing chest and low-back pain. He was
found to have multiple bilateral lung masses on a chest radiograph
(not shown). A computed tomography (CT) scan of the thorax (figure
1) and a positron-emission tomography (PET) scan (figures 2 and 3)
Metastatic lung carcinoma with malignant pericardial effusion
The CT scan of the lung bases demonstrates a small-to-moderate
pericardial effusion (figure 1). The PET scan reveals a halo of
increased uptake in the area of the pericardium (figure 2). There
are also metastases at the base of the heart and disseminated
disease. The patient subsequently developed cardiac tamponade. He
underwent an emergent pericardiocentesis. Malignant cells were
identified in the pericardial fluid cytology. Bronchoscopic biopsy
revealed poorly differentiated non-small cell lung cancer.
Metastatic involvement of the heart or pericardium commonly
leads to pericardial effusion and may be life threatening. When
pericardial effusion develops rapidly, as little as 250 mL may
cause tamponade, with subsequent impairment of right ventricular
diastolic filling, hypotension, syncope, and death. Emergency
pericardiocentesis is essential in this setting. Long-term
therapeutic options include creation of a pericardial window or
The PET scan revealed a band of increased activity encircling
the heart and extending superiorly beyond the upper border of the
left ventricle. The activity extends to the level of the great
vessels reflecting the anatomic border of the pericardium.
F-18-fluorodeoxyglucose (FDG) localizes in malignant tissues, in
inflammation or infection, and at other sites of high glucose
metabolism. Physiologic activity is seen in the myocardium, liver,
kidneys, and bladder regions. Intense foci consistent with
metastatic disease are noted adjacent to the cardiac margin (figure
2), and the pericardium appears nodular with moderate thickening
(figure 3). The presence of a pericardial effusion is suggested by
the separation of the pericardium from the inferior border of the
left ventricle. By contrast, the normal pericardium is rarely
visible on a PET study.
The CT scan (figure 1) revealed pericardial fluid both
posteriorly and encircling the heart. CT of the chest provides an
excellent means to detect pericardial effusions, pericardial
thickening, and masses invading the pericardium. Normally, the
pericardium is 1 to 2 mm thick, consisting of soft-tissue density
separated from the underlying myocardium by epicardial
fat.1 Small effusions collect posterior to the left
ventricle and lateral to the left atrium. With increasing size,
fluid accumulates anterior and lateral to the right ventricle.
Large effusions form an asymmetric halo around the heart. Simple
benign pericardial effusions often have water-density
attenuation.2 Hemorrhagic effusions usually have higher
attenuation, but the attenuation coefficient cannot be relied upon
to differentiate malignant from benign effusions.
Metastases to the heart and pericardium are common, discovered
at autopsy in 10% to 12% of all patients with
malignancies.3 Associated symptoms include dyspnea,
cough, and pleuritic chest pain. Unfortunately, these symptoms are
nonspecific and may also be seen in cancer patients without
pericardial disease. Tumors involve the heart and pericardium by
one of several pathways: antegrade or retrograde lymphatic
extension, hematogenous spread, transvenous extension, or direct
invasion. The most common path is through the mediastinal or hilar
lymphatics.4 Lung cancer involves the heart or
pericardium in as many as 30% of patients, 65% of whom have a
pericardial effusion.3,5 Pericardial effusions are also
frequently found in breast cancer, melanoma, and
lymphoma.6 Nonmalignant pericardial effusions are
associated with idiopathic, drug-induced, or radiation-induced
It is important to be aware of the frequent metastatic
involvement of the heart and pericardium in lung cancer and other
malignancies. Care should be taken to inspect the cardiac margins
and pericardium to detect the presence of potentially
life-threatening pericardial effusion.
1. Silverman PM, Harell GS, Korobkin M:
Computed tomography of the abnormal pericardium. AJR Am J
Roentgenol 140:1125-1129, 1983.
2. Lee JKT, Sagal S, Stanley RJ: Computed body
tomography with MRI correlation. 3rd ed. p 564. Baltimore:
Lippincott Williams and Wilkins, 1998.
3. Chiles C, Woodard PK, Gutierrez FR, Link KM:
Metastatic involvement of the heart and pericardium: CT and MR
imaging. RadioGraphics 21:439-49, 2001.
4. Tamura A, Matsubara O, Yoshimura N, et al:
Cardiac metastasis of lung cancer. A study of metastatic pathways
and clinical manifestations. Cancer 15:437-442, 1992.
5. Devita JR VT, Hellman S (eds): Cancer
Principles and Practice of Oncology. 6th ed., Vol 1. p 2737.
Baltimore: Lippincott Williams and Wilkins, 2001.
6. Decamp MM Jr., Mentzer SJ, Swanson SJ, Sugarbaker
DJ: Malignant effusive disease of the pleura and
pericardium. Chest 112(4 Suppl):291S-295S, 1997.