No large controlled, randomized, prospective clinical trials demonstrate the optimal management of malignant pericardial effusions or tamponade. Treatment should therefore be individualized to maximize symptom relief with minimal impact on quality of life. Treatment options include percutaneous pericardiocentesis, pericardial sclerosis, subxiphoid pericardial window, pericardiectomy, or pericardotomy by thoracotomy or video-assisted thoracoscopy. Considerations in the choice of therapeutic option should include relief of tamponade, minimal invasiveness, cost, morbidity, safety, shortened hospitalization for patients with advanced disease, and patient's prognosis.[Level of evidence: III]
Large symptomatic malignant pericardial effusions are managed by draining the fluid, unless the goals of therapy dictate a less invasive, conservative approach with concomitant shorter survival that should be balanced against quality-of-life concerns. If treatment is indicated for management of tamponade, percutaneous subxiphoid pericardiocentesis is the treatment of choice in the acute setting. Echocardiography is recommended for catheter guidance.[6,34] Catheter drainage is recommended for large effusions to prevent rapid reaccumulation of fluid and subsequent tamponade and for the anticipated survival of the patient.
Recurrent pericardial effusion occurs in 21%  to 50% [33,34] of patients following pericardiocentesis. Limited case series suggest rates of pericardial fluid reaccumulation at 30 days ranging from 5% to 33% after pericardial drainage followed by intrapericardial treatment with sclerosing agents or phosphorus-colloid versus more than 50% of those treated with pericardial drainage alone.[33,34] Treatment options to prevent reaccumulation include intrapericardial sclerosis to obliterate the space within the pericardial sac, or pericardotomy to increase the quantity of fluid drained from the pericardium. The most effective sclerosing agent for malignant pericardial effusions had been tetracycline, with success rates of up to 80%; however, this agent is no longer available as an intravenous drug in the United States. Alternative sclerosants that have been used include doxycycline, bleomycin, thiotepa,;[Level of evidence: II] carboplatin,[Level of evidence: II] mitoxantrone, docetaxel, and radionuclide chromic phosphate. Most cases may require 3 or more treatments to achieve adequate sclerosis. Significant pain is reported by 16% of patients undergoing pericardial sclerosis. Consideration must be given to the side effects of various sclerosing agents, e.g., chest pain and arrhythmias. Of patients undergoing pericardial sclerotherapy, 70% to 80% have no fluid reaccumulation within 30 days of the procedure.
A retrospective comparison of pericardiocentesis with sclerotherapy to open surgical drainage among 60 patients showed similar rates for treatment complications, incidence of recurrent effusion, and survival following treatment in both treatment groups. A retrospective review of 59 patients also found similar success rates, whether patients were managed with surgical subxiphoid pericardial window or by pericardiocentesis with or without sclerosis. Patients who underwent pericardiocentesis followed by pericardial window had the longest survival, with a median of 6 months; however, selection bias toward patients with better performance status undergoing more aggressive surgical techniques may contribute to the reported survival advantage. The surgical procedure group had significantly higher average costs of $4,830 compared with $1,625 for patients managed with pericardiocentesis. Other studies have reported mortality, recurrence, and survival rates for sclerosis that are similar to or slightly lower than those for subxiphoid window or video-assisted thoracoscopy.[40,41];[Level of evidence: II][Level of evidence: III] Pericardiocentesis with or without sclerotherapy should be considered over more invasive procedures in patients with advanced disease or poor functional status.