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Year : 2004  |  Volume : 14  |  Issue : 1  |  Page : 21-23
Primary pericardial mesothelioma : Review of two cases


Dept. of Radiodiagnosis, Gujarat Cancer and Research Institute, Asarwa, Ahmedabad-380016, India

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Keywords: Pericardial Mesothelioma, Radiograph, CT, MR

How to cite this article:
Patel S B, Shah S R, Goswami K G, Ashok K R. Primary pericardial mesothelioma : Review of two cases. Indian J Radiol Imaging 2004;14:21-3

How to cite this URL:
Patel S B, Shah S R, Goswami K G, Ashok K R. Primary pericardial mesothelioma : Review of two cases. Indian J Radiol Imaging [serial online] 2004 [cited 2019 Jun 24];14:21-3. Available from: http://www.ijri.org/text.asp?2004/14/1/21/28548

   Introduction Top


Primary pericardial mesothelioma is a rare malignancy, with an estimated incidence of 0.0022% [1] in a large autopsy study. We report two cases of primary pericardial mesothelioma revealed by a large and recurrent pericardial effusion in one case and by a large soft tissue mass encasing the major mediastinal vessels and heart in the other case.


   Case Reports Top


A thirty-five year male patient presented with intermittent fever, cough with expectoration, pedal edema and engorged neck veins since one month. On Clinical examination patient had bilateral pedal edema and distended neck veins. His chest radiograph showed bilateral pleural effusion more on the left side with increase in transverse diameter of the heart - P/o Pericardial effusion [Figure - 1]. Ultrasonography of the thorax and abdomen was performed on Sonoline Elegra machine with 3.5 MHz probe which showed minimal right pleural effusion, gross left pleural effusion, large hypoechoic mass encasing the pericardium and major vessels in superior mediastinum. Abdominal viscera appeared normal. CT scan of thorax both Plain and IV Contrast enhanced study were performed on Hitachi W-2000 spiral CT scanner. CT images showed a large soft tissue density mass in the superior and middle mediastinum showing gross diffuse thickening of the pericardium and encasing the major vessels of the mediastinum and the heart circumferentially, which is very much constricted and compressed. No evidence of calcification was noted. Mass showed minimal enhancement on post-contrast studies. Bilateral pleural effusion was noted [Figure - 2],[Figure - 3]. A diagnosis of Primary Pericardial Mesothelioma was considered. CT guided biopsy of the mediastinal mass was performed. Cytology of biopsied material was equivocal and Histopathological examination showed atypical round, oval and spindle cells. Findings were suggestive of Small cell type of Mesothelioma. Chemotherapy was started. Patient did not respond well and expired due to heart failure.

Another patient aged fifty-five years presented with history of dyspnoea on and off which was relieved by repeated pericardial fluid tapping. His chest Radiograph showed moderate cardiac enlargement (pericardial effusion) with left side pleural effusion [Figure - 4]. CT scan of thorax performed on Hitachi Spiral scanner post contrast images showed gross pericardial effusion with Pericardial thickening on the right and left lateral margins which showed contrast enhancement [Figure - 5]. No evidence of calcification or nodularity within the pericardium was noted. There was no evidence of any lung or pleural pathology appreciated. A diagnosis of Effusive Pericarditis or focal Pericardial mesothelioma with pericardial effusion was considered. Post pericardial tapping MR T1 and T2-weighted axial Turbo spin echo images of the mediastinum showed the presence of Pericardial effusion with pericardial thickening which is hypointense on T1 and hyperintense signal intensity on T2-wtd image [Figure - 6],[Figure - 7]. Coronal T2-wtd image also shows hyperintense pericardial thickening [Figure - 8]. Patient underwent open biopsy of the pericardium. Post biopsy histopathological study revealed findings suggestive of mesothelial hyperplasia favouring mesothelioma. Patient is undergoing chemotherapy now with repeated pericardial tappings. Patient is symptomatically better.


   Discussion Top


Pericardial malignant mesothelioma (PMM) is extremely rare compared with pleural mesothelioma. The incidence of pericardial tumors are 0.0022% [1]. Malignant mesothelioma is the most common primary pericardial malignancy. A causal relationship between it and asbestosis is uncertain because of prevalence of this neoplasm even in patients without any history of exposure to asbestosis.

Pericardial Mesothelioma may occur in diffuse, multiple and localized forms. Most of the pericardial mesotheliomas are multiple or diffuse growths encasing the heart, localized forms being distinctly uncommon. Mesothelioma may present as a well defined single mass, multiple nodule or diffuse plaque involving the visceral and parietal pericardium and wrapping around the cardiac chambers and great vessels.

Echo-cardiography is usually the initial technique for evaluation of a suspected cardiac neoplasm. However, if the echo-cardiographic window is suboptimal CT or MR may provide valuable information. Chest computed tomography (CT) may reveal an irregularly enhancing mass occupying the entire pericardial space and surrounding the great vessels of the mediastinum. Irrespective of modality employed, pericardial effusion is the most common finding. Hemorrhagic effusion, frequently associated with primary malignant mesotheliomas has distinct features on both CT and MR. High attenuation on CT indicative of recent hemorrhage, which decreases with time. On MR imaging blood products in the pericardial space present as areas of high, low and medium signal intensities depending upon age of hemorrhage. Focal or generalized pericardial thickening is other frequent imaging finding of malignant involvement. Direct invasion can be inferred if the normally pencil thin pericardium appears thickened or interrupted in close proximity to the neoplasm. Despite its rarity, this diagnosis should be considered in cases with rapid evolution of constrictive or effusive-constrictive pericarditis [4]. Differential diagnosis includes solitary fibrous tumor, synovial sarcoma, epithelioid angiosarcoma and adenomatoid tumor of the pericardium [3].

The prognosis for pericardial mesothelioma is poor due to its late diagnosis, the difficulty of surgical excision and poor response to radiotherapy or chemotherapy [4]. No satisfactory treatment is available except for the cases with early presentation in which surgical resection may be curative [6].

 
   References Top

1.Akoudad H, Boubel K, Belmadani K, et al ; Pericardial mesothelioma. A case report; Ann Cardiol Angeiol (Paris) 1999 Jun;48(6):435-40   Back to cited text no. 1    
2.Hirano H, Maeda T, Tsuji M, et al ; Malignant mesothelioma of the pericardium: case reports and immunohistochemical studies including Ki-67 expression. Pathol Int 2002 Oct;52(10):669-76   Back to cited text no. 2    
3.Val-Bernal JF, Figols J, Gomez-Roman JJ. Incidental localized (solitary) epithelial mesothelioma of the pericardium: case report and literature review; Cardiovasc Pathol 2002 May-Jun;11(3):181-5   Back to cited text no. 3    
4.Anao AO, Gil V, Trabulo M, et al ; Primary mesothelioma of the pericardium: a clinical case; Rev Port Cardiol 2001 Nov;20(11):1125-30   Back to cited text no. 4    
5.Kobayashi Y, Murakami R, Ogura J, et al ; Primary pericardial mesothelioma: a case report; Eur Radiol 2001;11(11):2258-61   Back to cited text no. 5    
6.Eryilmaz S, Sirlak M, Inan MB, et al ; Primary pericardial mesothelioma. Cardiovasc Pathol 2001 May-Jun;10(3):147-9Primary Pericardial mesothelioma: Review of two cases   Back to cited text no. 6    

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Correspondence Address:
S B Patel
Dept. of Radiodiagnosis, Gujarat Cancer and Research Institute, Asarwa, Ahmedabad-380016
India
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Source of Support: None, Conflict of Interest: None


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    Figures

[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8]



 

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