대한흉부영상의학회 Weekly Chest Cases

Case No : 881 Date 2014-09-15

Courtesy of Yun Jung Kim, Yoo Jin Hong / Severance Hospital, Yonsei University College of Medicine
Age/Sex 22 / M
Chief ComplaintRecurrent pericardial effusion for 4 months

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Diagnosis With Brief Discussion

Diagnosis: Malignant Pericardial Mesothelioma
Radiologic Findings: Chest PA shows cardiomegaly and small amount of left pleural effusion. Iniital chest CT scan shows small amount of pericardial effusion and left pleural effusion. The 2 months follow up chest CT scan shows increased amount of septated pericardial effusion with heterogeneous enhancing infiltrative soft tissue mass along the pericardium. PET-CT shows infiltrative mass lesions along the pericardium with intensely increased FDG uptake combining with loculated pericardial effusion.

This patient was complained of recurrent pericardial effusion and was diagnosed on pericardial biopsy as pericardial mesothelioma and treated by pericardiectomy with partial resection of the mass under mid-sternotomy and adjuvant chemotherapy.
Brief Review: Primary pericardial tumors are rare and can be benign (teratoma, fibroma, angioma, lipoma) or malignant (mesothelioma, sarcoma). Secondary tumors are more common, metastasizing mostly from the lung, breast, melanomas, lymphoma, or leukemia. The incidence of malignant pericardial involvement has been reported in the literature from 0.15−21% of all patients with an underlying malignancy. It is estimated that of all patients with malignant cardiac involvement, about 85% have pericardial involvement. Prognosis is poor with survival after diagnosis ranging from six weeks to 15 months.
Pericardial mesothelioma is extremely rare, although it is the most common primary malignant pericardial tumor. Pericardial mesothelioma can present as a localized or as a diffuse mass. Three histological types have been described: epithelial, spindle cell, and mixed. There is a possible relation to asbestos exposure but this is seen only in cases with coexistent asbestos related pleural disease.
The onset of symptoms is usually insidious. Common clinical manifestations of pericardial mesothelioma are constrictive pericarditis, pericardial effusion, cardiac tamponade, and heart failure caused by myocardial infiltration. Further symptoms may arise due to compression of coronary arteries and local spread into the surrounding great vessels. Primary mesothelioma can also mimic tuberculous pericarditis or intra-atrial myxomas. Distant metastasis, conduction block due to myocardial infiltration,5 and tumour embolism causing neurological deficits have also been reported.
Pericardial fluid in pericardial mesothelioma can be difficult to aspirate. A multimodal imaging approach, including echocardiography, computed tomography (CT), magnetic resonance imaging (MRI) and FDG-PET scans, is required. Chest radiography of patients reveals cardiomegaly, an irregular cardiac silhouette or diffuse mediastinal enlargement. Transthoracic echocardiography is the mainstay imaging technique for cardiac tumor detection. CT scan can demonstrate the extent of the cardiac tumor, the extent of pericardial thickening, the mediastinal lymph node and the extracardiac lesions. Cardiovascular MRI is the reference non-invasive imaging technique for assessment and characterization of a suspected cardiac mass. It allows accurate confirmation of the presence of a space occupying lesion, localization and assessment of the extent of involvement, evaluation of the functional impact of the lesions, as well as tissue characterization. However, in a recent report, PET-CT was useful in the staging and preoperative evaluation of pleural or pericardial mesothelioma, detection of unsuspected nodal and occult distant metastases (Ost et al., 2008). Other investigations such as immunohistochemistry, cytological examination, and high pericardial hyaluronic acid content of the pericardial aspirate can be diagnostic. The abnormal pericardium has also been known to take up gallium 67 extensively at scintigraphy.
Pericardial mesothelioma responds poorly to radiotherapy. Cyclical combination chemotherapy with doxorubicin, vincristine, and cyclophosphamide may reduce the tumor mass. Surgical resection can be curative in localized cases. Palliative treatment includes pericardiectomy, which prevents cardiac tamponade and relieves constriction. Alternatively, a pericardial window can be formed to introduce chemotherapeutic agents. Areas of ongoing research include intracavitary chemotherapy and irradiation. Photodynamic treatment, inhibition of growth factors, vaccines, and adenoviral molecular chemotherapy are also being expored.
Please refer to
References: 1.S Suman, P Schofield, and S Large, Heart. Jan 2004; 90(1): e4.
2.J Montesinos, S Catot, F Sant, et. Al., Mesotheliomas - Synonyms and Definition, Epidemiology, Etiology, Pathogenesis, Cyto-Histopathological Features, Clinic, Diagnosis, Treatment, Prognosis, In Tech, 2012: 40-42.
Keywords: Pericardium, Malignant tumor,

No. of Applicants : 83

▶ Correct Answer : 21/83, 25.3%

- The University of Tokyo Hospital , Japan Akifumi Hagiwara
- NIMS, HYDERABAD , India bhaskar kakarla
- Yokohama-asahi-chuo-general hospital , Japan Kyoko Nagai
- Kyoto University , Japan Akihiko Sakata
- McGill University Health Center , Canada Alexandre Semionov
- Kizawa Memorial Hospital , Japan Yo Kaneko
- Samsung medical center , Korea (South) Hyun Su Kim
- MBAL BURGAS , Bulgaria VLADISLAV RUSINOV
- The University of Tokyo Hospital , Japan Toshihiro Furuta
- jaslok hospital & research centre mumbai , India JAINENDRA JAIN
- Government Medical College, Nagpur, India , India Krishna Prasad Bellam
- The University of Tokyo Hospital , Japan Takeyuki Watadani
- Saint Malo , France jean-baptiste Noel
- CHU POITIERS , France SZTARK Guillaume
- National Center hospital of Neurology and Psychiatry , Japan Kaoru Sumida
- Teikyo University Mizonokuchi Hospital , Japan Noriko Kobayashi
- IRSA LA ROCHELLE , France, Metropolitan BIGOT
- CLCC Rennes , France nicolas gautier
- Northern Yokohama Showa university , Japan Kota Watanabe
- CLINIQUE STE CLOTILDE , Reunion patrick MASCAREL
- CNUH , Korea (South) Kim Soo Hyun

▶ Correct Answer as Differential Diagnosis : 25/83, 30.1%

- Oita University, Faculty of Medicine , Japan Fumito Okada
- Kyung Hee University Hospital at Gangdong , Korea (South) Seong Jong Yun
- Niigata City General Hospital , Japan Takao Kiguchi
- Seoul National University Hospital , Korea (South) Sang Min Lee
- Royal Perth Hospital , Australia Yuranga Weerakkody
- GHICL , France manuel toledano
- Ibaraki-gazou-shindan , Japan Shoichi Katoh
- Kmc chennai , India chellaraja c
- CHU Poitiers , France CHAN paul
- Seirei Hamamatsu General Hospital , Japan Kenichi Mizuki
- DAYA General Hospital,Thrissur,Kerala , India Raveendran TK
- National Hospital Organization Okinawa Hospital , Japan Yasuji Oshiro
- Asan Medical Center, Ulsan University , Korea (South) Mi Young Kim
- Shiga University of Medical Science , Japan Akitoshi Inoue
- chungbuk national university hospital , Korea (South) jeehye kim
- ZIGONG TCM HOSPITAL OF CHINA , China Cao Cunyou
- Hanyang universitiy, radiology department , Korea (South) HyunGyu Lee
- IRSA La Rochelle , France Denis Chabassiere
- Nagasaki University Hospital, Department of Pathology , Japan TOMONORI TANAKA
- Onomichi municipal hospital , Japan Hirofumi Mifune
- Fortis hospital , Mohali , India Shaleen Rana
- Gifu Central Hospital , Japan Haruo Watanabe
- Pneumologia Universitaria, Policlinico di Bari , Italy Mario Damiani
- Medicheck health care , Korea (South) Chae Lim
- Onomichi Municipal Hospital , Japan Yoshihisa Masaoka

▶ Semi-Correct Answer : 1/83, 1.2%

- Chonnam national university hospital , Korea (South) INSOO JANG

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 881 Date 2014-09-15

Discussion

No. of Applicants : 83