Interact CardioVasc Thorac Surg 2009;8:160-161. doi:10.1510/icvts.2008.180729
© 2009 European Association of Cardio-Thoracic Surgery
Case report - Thoracic general |
Bilocular pericardial cyst in an aberrant location
Federico Ravegliaa,*,
Alessandro Baisia,
Angelo Maria Calatia and
Larry R. Kaiserb
a Division of Thoracic Surgery, Università degli Studi di Milano, Azienda Ospedaliera San Paolo, Milano, Italy
b Division of Thoracic Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
Received 31 March 2008;
received in revised form 26 May 2008;
accepted 21 July 2008
*Corresponding author. Piazza L. da Vinci 7, 20133, Milan, Italy. Tel.: +39-3381336071; fax: +39-022666185.
E-mail address: ravegliafederico{at}tiscali.it (F. Raveglia).
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Abstract
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Pericardial cysts classically are found in the right or left cardiophrenic angle and rarely are located outside of this location. An 82-year-old man presented with an asymptomatic cystic mass on chest CT-scan located in the upper right mediastinum and measuring 7x6x4 cm. A follow-up chest CT-scan 12 months later showed that the cyst had increased in size to where it now measured 10x9x8 cm and was noted to be dislocating and compressing the superior vena cava. The patient underwent surgical excision because of the uncertain diagnosis and the compression of contiguous organs. Two cystic masses were able to be completely excised intact. A definitive diagnosis of double pericardial cyst was histopathologically confirmed. Radiological findings of a pericardial cyst in the upper mediastinum are extremely rare. In particular there have been no reports of bilocular or double pericardial cysts.
Key Words: Pericardial cyst; Mediastinum
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1. Clinical summary
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An 82-year-old man with a history of systemic vasculopathy presented with an asymptomatic cystic mass on chest CT-scan measuring 7x6x4 cm. CT-scan had been performed on the base of an X-ray previously done during preoperative evaluation for inguinal hernia repair. A follow-up chest CT-scan 12 months later showed that the cyst had increased in size to where it now measured 10x9x8 cm and was noted to be dislocating and compressing the superior vena cava and the azygos vein (Fig. 1). A transesophageal echocardiogram confirmed a large fluid-filled mediastinal mass. It was recommended to the patient that he undergo surgical excision because of the uncertain diagnosis and the compression of contiguous organs.
The surgical procedure was begun by introducing two trocars with the intent to perform the procedure via a thoracoscopic technique. Dense pleural adhesions were encountered and a 6-cm muscle sparing right thoracotomy incision was performed. Upon entering the chest, a thin-walled cystic mass was noted in the paratracheal location compressing both the superior vena cava and the azygos vein (Fig. 2). The cystic mass was able to be completely excised intact. A second smaller cyst, not seen on the CT-scan, was found posterior to the larger cystic mass in the medial aspect of the mediastinum, adjacent to the aortic arch. This smaller cystic mass was also excised. Histologic examination revealed a mesothelial-lined cystic lesion and the diagnosis of double pericardial cyst was confirmed. The patient was discharged from the hospital on the fourth postoperative day.
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2. Discussion
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Pericardial cysts classically are found in the right or left cardiophrenic angle and rarely are located outside of this location [1]. In reviewing the literature from 1929 to 1985, Stoller et al. noted only 34 cases of pericardial cysts in aberrant locations [2]. From 1985 to the present only occasional cases of atypically located pericardial cysts have been reported. However, to our knowledge, there have been no reports of bilocular or double pericardial cysts. In our patient, the diagnosis of bilocular cyst was made only at the time of operation because the membrane between the cystic lesions was thin and not identifiable on the CT-scan or on the transesophageal echocardiogram.
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3. Conclusion
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Surgical resection is widely accepted as the treatment of choice when a patient has symptoms related to a mediastinal mass or the diagnosis is uncertain [2]. We agree with Mouroux et al.'s contention that asymptomatic cysts should be considered for resection when the lesion is large and there is compression of adjacent structures, and particularly when the CT-scan demonstrates progressive enlargement. If feasible, it is our opinion that these lesions should be resected using minimally invasive thoracoscopic techniques [3, 4].
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References
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- Davis RD Jr, Oldham HN Jr, Sabiston DC. Primary cysts and neoplasms of the mediastinum: recent changes in clinical presentation, methods of diagnosis, management and results. Ann Thorac Surg 1987;44:229–237.[Abstract]
- Stoller JK, Shaw C, Matthay RA. Enlarging atypically located pericardial cyst. Chest 1986;89:402–406.[CrossRef][Medline]
- Mouroux J, Vennissac N, Leo F, Guillot F, Padovani B, Hofman P. Usual and unusual locations of intrathoracic mesothelial cysts. Is endoscopic resection always possible? Eur J Cardiothorac Surg 2003;24:684–688.[Abstract/Free Full Text]
- Umemori Y, Kotani K, Makihara S. Video-assisted thoracoscopical surgery for pericardial cyst: report of two cases. Kyobu Geka 2001;54:1125–1127.[Medline]
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Abstract
1. Clinical summary
