Malignant invasion of the pericardium is always serious and, unfortunately, increasingly detected. Once the cell type is identified, physicians have an array of therapeutic options (condensed in Table 1
).1– In this issue of CHEST (see page 1412), Dr. Martinoni and colleagues have very carefully followed up their series of patients with various malignancies who were treated successfully with intrapericardial thiotepa. There were no complications from either the therapy or from the pericardiocentesis, which was necessary in every case. Absence of complicated taps may be ascribed both to echocardiographic monitoring and the very large size (749 ± 230 mL [± SD]) of the effusions.4 Before pericardiocentesis all patients were quite ill, mainly due to weakness and dyspnea; 56% were in New York Heart Association heart failure class III and 28% in class IV owing to cardiac tamponade in the majority of patients.