대한흉부영상의학회 Weekly Chest Cases

Case No : 968 Date 2016-05-16

Courtesy of Min Jeong Kim, Sung Shine Shim, Kim Yoo Kyung / Ewha Womans University Mokdong hospital
Age/Sex 61 / M
Chief ComplaintDyspnea for 2 months

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Diagnosis With Brief Discussion

Diagnosis: Localized pericardial malignant mesothelioma
Radiologic Findings: Chest PA shows enlarged heart that is suggestive of pericardial effusion with bilateral pleural effusions, especially in the right hemithorax.
Initial axial contrast enhanced CT scan shows a well-circumscribed, heterogeneously enhancing soft tissue mass that is located between the left atrium and the esophagus. PET-CT shows corresponding area of increased FDG uptake (SUV 4.8). After 5 months, the mass had increased in size, compressing the posterior aspect of the left atrium and the pulmonary vein.
This patient underwent excision of the intrapericardial mass with right video assisted thoracoscopic surgery (VATS). Although analysis of the pericardial fluid was negative for malignancy, the pericardial mass was confirmed as malignant mesothelioma, biphasic type.
Brief Review: Primary malignant mesothelioma of the pericardium accounts for less than 5% of all mesotheliomas. The etiology of primary malignant pericardial mesothelioma remains unclear. The role of asbestos exposure as a causative factor in the development of pericardial mesothelioma is not well established. Asbestos exposure has been documented only in 14% of the patients. Typically it appears as either multiple pericardial-based nodules with or without a dominant mass, or as a diffuse tumor that encases some portions of the heart. Localized (solitary) pericardial mesothelioma is considered a rare variant of malignant mesothelioma. Three histopathologic types of pericardial mesothelioma have been defined: pure epithelial, sarcomatoid, and mixed (biphasic).
As the extent of the disease can be evaluated with CT and MR imaging, these modalities offer more advantage over echocardiography. On both CT and MR images, pericardial mesothelioma appears as a heterogeneously enhancing mass that involves both the parietal and visceral layers of the pericardium. The possibility of invasion of the adjacent vascular and anatomic structures should be kept in mind. Localized malignant mesothelioma needs to be differentiated from solitary fibrous tumor of the pericardium, lymphoma, hemangioma, sarcoma, and metastasis.
Localized malignant mesothelioma is capable of aggressive behavior and carries a poor prognosis, with the length of survival ranging between 6 weeks and 15 months, regardless of therapy. However, in contrast to the diffuse type, complete surgical excision may be curative. Radiation therapy and chemotherapy have a limited role in cases of non-resectable disease.
References: 1. Patel J, Sheppard MN. Primary malignant mesothelioma of the pericardium. Cardiovascular pathology : the official journal of the Society for Cardiovascular Pathology. 2011;20(2):107-9.
2. Restrepo CS, Vargas D, Ocazionez D, Martinez-Jimenez S, Betancourt Cuellar SL, Gutierrez FR. Primary pericardial tumors. Radiographics : a review publication of the Radiological Society of North America, Inc. 2013;33(6):1613-30.
3. Val-Bernal JF, Figols J, Gomez-Roman JJ. Incidental localized (solitary) epithelial mesothelioma of the pericardium: case report and literature review. Cardiovascular pathology : the official journal of the Society for Cardiovascular Pathology. 2002;11(3):181-5.
Keywords: Pericardium, Malignant tumor,

No. of Applicants : 89

▶ Correct Answer : 15/89, 16.9%

- Seoul National University Hospital , Korea (South) Hyoung-In Choi
- SAISEIKAI KURIHASHI HOSPITAL , Japan YASUO OOKUBO
- Okayama University Hospital , Japan Toshiyuki Komaki
- Samsung Medical Center , Korea (South) Boda Nam
- Red Cross Society Himeji Hospital , Japan Soichiro Okamoto
- GHICL , France manuel toledano
- Fortis hospital , Mohali , India Shaleen Rana
- Chonnam National University Hospital , Korea (South) So yeon Ki
- The University of Tokyo Hospital , Japan Kaoru Sumida
- The Jikei university , Japan Taku Gomi
- Les cedres St malo , France nicolas gautier
- Centre Imagerie de Fribourg , Switzerland Benoit RIZK
- CLINIQUE STE CLOTILDE , Reunion patrick MASCAREL
- Kizawa Memorial Hospital , Japan Shoji Okuda
- Himeji Red Cross Hospital , Japan Mayu Uka

▶ Correct Answer as Differential Diagnosis : 21/89, 23.6%

- Oita University, Faculty of Medicine , Japan Fumito Okada
- The University of Tokyo Hospital , Japan Toshihiro Furuta
- Yokohama-asahi-chuo-general hospital , Japan Kyoko Nagai
- iran university , Iran Mohammad reza Ayoubpour
- McGill University Health Center , Canada Alexandre Semionov
- Maternity & child hospital , Saudi Arabia Sania ALBlushi
- Asan Medical Center , Korea (South) Hyung Jung Koo
- Kyoto University , Japan Akihiko Sakata
- Department of Radiology, Seoul National University Bundang Hospital , Korea (South) Sung Hyun Yoon
- Niigata University , Japan Atsushi Uehara
- Kizawa Memorial Hospital , Japan Yo Kaneko
- Saint Malo , France jean-baptiste Noel
- NASA SCANS , India RAKESH BHATIA
- Private sector , Greece Vasilios Tzilas
- Shiga University of Medical Science , Japan Akitoshi Inoue
- Kanto Rosai Hospital , Japan Taku Tajima
- Otsu Municipal Hospital , Japan Noriatsu Ichiba
- ZIGONG TCM HOSPITAL OF CHINA , China Cao Cunyou
- Seirei Hamamatsu General Hospital , Japan Kenichi Mizuki
- Nasaret Hospital , Korea (South) Hee Seok Choi
- Medicheck health care , Korea (South) Chae Lim

▶ Semi-Correct Answer : 1/89, 1.1%

- Kyungpook national university hospital , Korea (South) Nari Jung

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 968 Date 2016-05-16

Discussion

No. of Applicants : 89