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Abstract
PURPOSE OF REVIEW This is an in-depth review on the etiology, clinical manifestation, differential diagnosis, diagnostic modalities, complications, and management of pericardial cysts (PCs). RECENT FINDINGS PCs are the third most common type of mediastinal masses and are usually identified incidentally by chest x-ray (CXR) or transthoracic echocardiography (TTE). Although most PCs are asymptomatic, they might lead to serious complications such as cardiac tamponade. Diagnosis is confirmed by cardiac computed tomography or cardiac magnetic resonance. Cysts need to be followed by imaging every 1 to 2 years; however, a recent report suggested less frequent follow-up. Most cases resolve spontaneously, but if needed, aspiration or surgical resection can be done. PCs are rare entities and are usually detected incidentally after CXR or TTE. Providers should be aware of this condition since it could potentially lead to serious complications.
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Affiliation(s)
- Mohamed Khayata
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Saqer Alkharabsheh
- Center for the Diagnosis and Treatment of Pericardial Disease, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Nishant P Shah
- Center for the Diagnosis and Treatment of Pericardial Disease, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Allan L Klein
- Center for the Diagnosis and Treatment of Pericardial Disease, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA.
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Alkharabsheh S, Gentry Iii JL, Khayata M, Gupta N, Schoenhagen P, Flamm S, Murthy S, Klein AL. Clinical Features, Natural History, and Management of Pericardial Cysts. Am J Cardiol 2019; 123:159-163. [PMID: 30390989 DOI: 10.1016/j.amjcard.2018.09.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 09/18/2018] [Accepted: 09/21/2018] [Indexed: 11/20/2022]
Abstract
With the increased use of medical imaging, there has been an increase in the numbers of pericardial cysts identified. However, there is a paucity of data regarding the clinical course for pericardial cysts. Hence, we aimed to study the clinical features and natural history of pericardial cysts. We retrospectively studied all patients with the diagnosis of pericardial cysts based on computed tomography (CT) chest or cardiac magnetic resonance imaging (CMR) between 2008 and 2014. The maximum diameter of the cyst was measured at the initial study (CT/CMR) and was compared with the most recent follow-up imaging modality of the same type if available. A change in the maximum diameter more than 10% was considered significant. We included 103 patients in the study; 89% were asymptomatic and 67% were females. Twenty-nine asymptomatic patients had repeat imaging with the same modality (CT/CMR) with a mean follow-up of 23 months. The maximum cyst diameter decreased by a mean of 25% in 34% of the patients and increased by a mean of 13% in 17% of the patients. The remaining patients (48%) had no significant change. All 29 patients remained asymptomatic. In conclusion, most pericardial cyst cases were asymptomatic. On repeat imaging, approximately 1/3 of pericardial cysts were found to decrease in size, whereas interval enlargement was infrequent and unlikely to be clinically relevant. Therefore, within the limitations of our study, serial imaging in asymptomatic patients with CT or CMR does not appear to impact management decisions.
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Affiliation(s)
- Saqer Alkharabsheh
- Department of Cardiovascular Medicine, Center for the Diagnosis and Management of Pericardial Diseases, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - James L Gentry Iii
- Department of Cardiovascular Medicine, Center for the Diagnosis and Management of Pericardial Diseases, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Mohamed Khayata
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Neha Gupta
- Department of Cardiovascular Medicine, Center for the Diagnosis and Management of Pericardial Diseases, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Paul Schoenhagen
- Department of Radiology, The Cleveland Clinic Foundation, Cleveland, Ohio
| | - Scott Flamm
- Department of Cardiovascular Medicine, Center for the Diagnosis and Management of Pericardial Diseases, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sudish Murthy
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Allan L Klein
- Department of Cardiovascular Medicine, Center for the Diagnosis and Management of Pericardial Diseases, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
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Kar SK, Ganguly T. Current concepts of diagnosis and management of pericardial cysts. Indian Heart J 2017; 69:364-370. [PMID: 28648435 PMCID: PMC5485391 DOI: 10.1016/j.ihj.2017.02.021] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 02/28/2017] [Indexed: 10/29/2022] Open
Abstract
Pericardial cysts are rare with an incidence of about 1 in every 100,000 persons and one in 10 pericardial cysts may actually be a pericardial diverticulum. Pericardial cysts and diverticula share similar developmental origin and may appear as an incidental finding in chest roentgenogram in an asymptomatic patient. CT scan is considered as best modality for diagnosis and delineation of the surrounding anatomy. Cardiac MRI is recommended in the evaluation of the compressive effects caused by the pericardial cysts. The authors recommend echocardiography for serial follow up and image guided aspiration of the pericardial cyst in presence of compressive effects leading to cardiovascular and airway symptoms. A systematic approach is desirable for management of pericardial cysts depending on size, shape and compression effects, symptoms and easy access to serial Echocardiographic follow up. However, pericardial diverticulum may not be differentiated from cysts by the above testing, and only identified at surgery.
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Affiliation(s)
- Sandeep Kumar Kar
- Department of Cardiac Anesthesiology, Institute of Post Graduate Medical Education and Research, Kolkata, India.
| | - Tanmoy Ganguly
- Department of Cardiac Anesthesiology, Institute of Post Graduate Medical Education and Research, Kolkata, India
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Tower-Rader A, Kwon D. Pericardial Masses, Cysts and Diverticula: A Comprehensive Review Using Multimodality Imaging. Prog Cardiovasc Dis 2017; 59:389-397. [PMID: 28062266 DOI: 10.1016/j.pcad.2016.12.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 12/29/2016] [Indexed: 10/20/2022]
Abstract
Pericardial masses/tumors, cysts, and diverticula are quite rare. Presentation is variable and often patients may be asymptomatic with pericardial involvement initially only detected at time of autopsy. When patients do present with symptoms they are often non-specific and often mimic other conditions of the pericardium such as pericarditis, pericardial effusion, constriction or tamponade. Therefore, echocardiography and cross-sectional imaging are essential in identifying and characterizing pericardial disease. Imaging findings vary in specificity depending on the type of tumor. The purpose of this review is to describe the role of multi-modality imaging and characteristic findings in patients with pericardial masses/tumors, cysts, and diverticula.
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Kang DWW, Corpa MCE, Racy MDCJ, Baroni RH, Engel FC, Andrade Filho LDO, Bueno MAS. Pleuropericardial cyst torsion: case report. EINSTEIN-SAO PAULO 2016; 8:228-31. [PMID: 26760009 DOI: 10.1590/s1679-45082010rc937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Pericardial cysts account for 12-18% of all mediastinal masses. They are usually asymptomatic and incidentally detected. However, when large, they can cause symptoms. Most pericardial cysts are located in the right cardiophrenic angle, but they can be anywhere in the mediastinum. We reported a pleuropericardial cyst torsion after physical stress, a very rare complication of this condition. The diagnosis was made by computed tomography and confirmed by video-assisted thoracoscopy.
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Kandula M, Moole H, Cashman M, Volmar FH, Bechtold ML, Puli SR. Success of endoscopic ultrasound-guided ethanol ablation of pancreatic cysts: a meta-analysis and systematic review. Indian J Gastroenterol 2015; 34:193-9. [PMID: 26108653 DOI: 10.1007/s12664-015-0575-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Accepted: 05/14/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND Endoscopic ultrasound (EUS)-guided ethanol ablation has emerged as an efficacious and safe alternative management option for pancreatic cysts. We undertook a meta-analysis and systematic review to assess the overall safety and efficacy of EUS-guided ethanol ablation of pancreatic cysts. METHOD STUDY SELECTION CRITERIA EUS-guided ethanol ablation of pancreatic cysts. DATA COLLECTION EXTRACTION Articles were searched in Medline, Pubmed, and Ovid journals. STATISTICAL METHOD Fixed and random effects models were used to calculate the pooled proportions. RESULTS Initial search identified 1,319 reference articles, in which 120 relevant articles were selected and reviewed. Data was extracted from seven studies (n = 152) of EUS-guided ethanol ablation of pancreatic cysts, which met the inclusion criteria. With EUS-guided ethanol ablation, the pooled proportion of patients with complete cyst resolution was 56.20 % (95 % CI = 48.16 to 64.08) and partial cyst resolution was 23.72 % (95 % CI = 17.24 to 30.89). Postprocedural complications after ablation were significant for abdominal pain in 6.51 % (95 % CI = 3.12 to 11.04) and pancreatitis in 3.90 % (95 % CI = 1.39 to 7.60) of the pooled percentage of patients. Publication bias calculated using Harbord-Egger bias indicator gave a value of -1.09 (95 % CI = 10.21 to 8.03, p = 0.77). The Begg-Mazumdar indicator gave a Kendall's tau b value of 0.05 (p ≥ 0.99). CONCLUSIONS EUS-guided ethanol ablation may be a safe alternative treatment modality for pancreatic cysts, with acceptable intraprocedural and postprocedural complications. However, due to the limited data available, prospective randomized controlled trials with a long follow up period are required in this area.
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Affiliation(s)
- Manasa Kandula
- Division of Internal Medicine, University of Illinois College of Medicine at Peoria, Peoria, IL, USA,
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Atilgan R, Ozkan ZS, Kuloglu T, Kocaman N, Baspinar M, Can B, Şimşek M, Sapmaz E. Impact of intracystic ethanol instillation on ovarian cyst diameter and adjacent ovarian tissue. Eur J Obstet Gynecol Reprod Biol 2013; 174:133-6. [PMID: 24411950 DOI: 10.1016/j.ejogrb.2013.12.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 11/04/2013] [Accepted: 12/12/2013] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To investigate the regression level of simple ovarian cyst size after local ethanol application and the damage level of adjacent ovarian reserve in rats. STUDY DESIGN This study was conducted at Firat University Animal Laboratory with 18 mature (12-14 weeks old) female Wistar albino rats weighing 200-220g, with regular cycles. Ovarian cyst induction was performed with unilateral salpingectomy. Fourteen rats with ovarian cysts after a second laparotomy were divided into two groups as follows: Group 1 (n=7): cyst aspiration group, and Group 2 (n=7): intracystic 95% ethanol application group. One month after the cyst aspiration procedure a third laparotomy was performed. The cyst number and size were recorded for each rat. Right ovariectomy was performed and formalin-fixed/paraffin-embedded tissues were sectioned at 5μm thickness. Under light microscopy, ovarian total follicle reserve and fibrosis were evaluated with Masson trichrome staining and apoptosis was evaluated with TUNEL staining. The groups were compared with the Mann-Whitney U test and Wilcoxon Rank test. p<0.05 was considered significant. RESULTS Ovarian cyst formation was observed in 85% (15/18) of rats. The mean diameter of ovarian cysts in Groups 1 and 2 were, respectively, 10.3mm and 10.1mm. After aspiration, there was no significant reduction in the cyst diameter (10.3mm vs 8.1mm), but after ethanol application the diameter significantly reduced (10.1mm vs 3.4mm, p<0.05). Mean ovarian follicle count in Group 2 was significantly lower than in Group 1 (25 vs 42, p<0.05), and mean fibrosis and apoptosis scores in Group 2 were significantly higher than in Group 1 (2.5 vs 0.9, p<0.05). CONCLUSION Local ethanol application reduces cyst diameter but concomitantly decreases ovarian reserve due to increased fibrosis in rats. In humans, intracystic ethanol application should be performed cautiously.
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Affiliation(s)
- Remzi Atilgan
- Firat University School of Medicine, Department of Obstetrics and Gynecology, 23119 Elazig, Turkey
| | - Zehra Sema Ozkan
- Firat University School of Medicine, Department of Obstetrics and Gynecology, 23119 Elazig, Turkey.
| | - Tuncay Kuloglu
- Firat University School of Medicine, Department of Histology and Embryology, 23119 Elazig, Turkey
| | - Nevin Kocaman
- Firat University School of Medicine, Department of Histology and Embryology, 23119 Elazig, Turkey
| | - Melike Baspinar
- Firat University School of Medicine, Department of Obstetrics and Gynecology, 23119 Elazig, Turkey
| | - Behzat Can
- Firat University School of Medicine, Department of Obstetrics and Gynecology, 23119 Elazig, Turkey
| | - Mehmet Şimşek
- Firat University School of Medicine, Department of Obstetrics and Gynecology, 23119 Elazig, Turkey
| | - Ekrem Sapmaz
- Firat University School of Medicine, Department of Obstetrics and Gynecology, 23119 Elazig, Turkey
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Abstract
Pancreatic cystic neoplasms represent a wide spectrum of invariably benign to precancerous and malignant tumors. Endoscopic ultrasound-guided pancreatic cyst ablation with ethanol and/or paclitaxel offers a nonoperative treatment for patients refusing or not eligible for surgery. Histopathology after resection in these patients has shown variable degrees of cyst epithelial ablation ranging from 0% to 100%. Future research investigating the safety of this procedure, modifications of reported ablation techniques, choice and number of the lavage agents used, and criteria to optimize selection of the appropriate pancreatic cysts for treatment is needed.
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Affiliation(s)
- John DeWitt
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, 550 North University Boulevard, UH 4100, Indianapolis, IN 46202, USA.
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Ablation of pancreatic cystic lesions: the use of multiple endoscopic ultrasound-guided ethanol lavage sessions. Pancreas 2011; 40:664-8. [PMID: 21562447 DOI: 10.1097/mpa.0b013e3182128d06] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Determine the effectiveness of multiple endoscopic ultrasound-guided ethanol lavage (EUS-EL) sessions for attempted ablation of pancreatic cystic lesion (PCL). METHODS Retrospective review of patients who have undergone 2 or more EUS-EL treatments of a PCL. Eligible patients had asymptomatic, benign-appearing PCL, no previous pancreatitis, and were considered poor surgical candidates. RESULTS Final analysis was performed on 13 patients with suspected branch duct intraductal papillary mucinous neoplasms. The mean maximum cyst diameter at baseline and after 1 and 2 EUS-EL treatments was 20.1 ± 7.1, 17.0 ± 9.8 (P = 0.06), and 12.8 ± 9.6 mm (P = 0.0002), respectively. The mean surface area after 2 EUS-EL sessions: baseline, 5734 ± 6846 mm(2); 1 EUS-EL session, 4906 ± 9240 mm(2) (P = 0.52); and 2 EUS-EL sessions, 2311 ± 4093 mm(2) (P = 0.008). Complete resolution of the cystic lesion was not seen by computed tomography or magnetic resonance imaging in any patient after 1 EUS-EL but occurred in 5 (38%; P = 0.02) of 13 patients after 2 EUS-EL treatments. One patient had minor abdominal pain 1 day after the first EUS-EL session and 2 days after the second session. CONCLUSIONS Compared with only 1 EUS-EL, 2 EUS-EL treatment results in a significantly greater decrease in the size and surface area of PCL and is associated with a significantly higher rate of image-defined cyst resolution.
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DeWitt J, McGreevy K, Schmidt CM, Brugge WR. EUS-guided ethanol versus saline solution lavage for pancreatic cysts: a randomized, double-blind study. Gastrointest Endosc 2009; 70:710-23. [PMID: 19577745 DOI: 10.1016/j.gie.2009.03.1173] [Citation(s) in RCA: 187] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2008] [Accepted: 03/27/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND Surgery for pancreatic cysts is associated with significant morbidity. A pilot study previously demonstrated the safety of EUS-guided ethanol lavage of pancreatic cysts. OBJECTIVE To determine whether EUS-guided ethanol lavage would decrease pancreatic cyst size more than saline solution lavage. DESIGN Prospective, multicenter, randomized trial. SETTING Two tertiary referral hospitals in the United States. PATIENTS Patients referred for EUS with a 1- to 5-cm unilocular pancreatic cyst were randomized to blinded ethanol or saline solution lavage. Three months later, the cyst diameter was remeasured by EUS, and a second unblinded ethanol lavage was performed. INTERVENTIONS EUS-guided pancreatic cyst lavage. MAIN OUTCOME MEASUREMENTS Cyst ablation based on size changes from follow-up EUS, CT, and histology of resected specimens. RESULTS Of 58 patients randomized, 16 were excluded and 42 underwent initial ethanol (n = 25) or saline solution (n = 17) lavage. Ethanol lavage resulted in a greater mean percentage of decrease in cyst surface area (-42.9; 95% CI, -58.4 to -27.4) compared with saline solution alone (-11.4; 95% CI, -25.0 to 2.2; P = .009). Nineteen (76.0%) of 25 and 14 (82.3%) of 17 patients randomized to ethanol and saline solution, respectively, underwent a second ethanol lavage. A follow-up CT scan demonstrated resolution in 12 (33.3%) of 36 cysts. Histology of 4 resected cysts demonstrated epithelial ablation ranging from 0% (saline solution alone) to 50% to 100% (1 or 2 ethanol lavages). Complication rates were similar in all groups. LIMITATION Short-term follow-up. CONCLUSIONS EUS-guided ethanol lavage results in a greater decrease in pancreatic cyst size compared with saline solution lavage with a similar safety profile. Overall CT-defined complete pancreatic cyst ablation was 33.3%.
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Affiliation(s)
- John DeWitt
- Department of Gastroenterology and Hepatology, Massachusetts General Hospital, Boston, Massachusetts, USA.
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Modi S, Chenzbraun A, Fewins H, Binukrishnan S, Ramsdale DR. Giant asymptomatic pericardial cyst. J Cardiovasc Med (Hagerstown) 2009; 10:646-8. [PMID: 19584629 DOI: 10.2459/jcm.0b013e328329ea03] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Pericardial cysts are rare. We provide high-quality imagery demonstrating a giant cyst using plain radiography, ultrasound and magnetic resonance imaging (MRI).
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Affiliation(s)
- Simon Modi
- The Liverpool Heart and Chest Hospital, NHS Trust, Liverpool, UK.
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Maisch B, Seferović PM, Ristić AD, Erbel R, Rienmüller R, Adler Y, Tomkowski WZ, Thiene G, Yacoub MH. Guía de Práctica Clínica para el diagnóstico y tratamiento de las enfermedades del pericardio. Versión resumida. Rev Esp Cardiol 2004; 57:1090-114. [PMID: 15544758 DOI: 10.1016/s0300-8932(04)77245-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Abstract
Our case report details the clinical course and management of a neonate with acute life-threatening respiratory distress presenting soon after birth. She needed intubation and ventilation. A pericardial cyst was diagnosed after a CT scan and 2D echo investigation. As a temporizing procedure the fluid was tapped and the child was electively operated. Postoperatively she made an uneventful and complete recovery. We have reviewed the literature for this rare and often asymptomatic lesion.
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Affiliation(s)
- Manasvi Upadhyaya
- Department of Pediatric Surgery, Royal Hospital, PO Box 1331, 111 Seeb Muscat, Sultanate of Oman.
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Martín Díaz E, Montoro Martín T, Martín Rodríguez E. [A paratracheal pericardial diverticulum]. Arch Bronconeumol 2000; 36:58. [PMID: 10726187 DOI: 10.1016/s0300-2896(15)30235-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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