Pericardial malignant mesothelioma: case report and discussion of immunohistochemical and histochemical findings

Pericardial Disease in Cancer Patients

PURPOSE OF REVIEW

To understand the variety of conditions in which the pericardium may be affected in cancer patients.

RECENT FINDINGS

Cancer may affect the pericardium directly (primary cancer; uncommon) or through metastases (commoner). Cancer treatment (chemotherapy and radiotherapy) may affect the pericardium leading to pericarditis and myopericarditis. Pericardial effusions, tamponade and constrictive pericarditis are complications that can also occur. A variety of techniques (predominantly cardiac imaging related) are used to make the diagnosis with the treatment strategy dependent on whether the pericardial disease is due to cancer or as a result of cancer treatment. A variety of pericardial diseases may be caused by cancer and cancer treatment. Determining the aetiology and providing effective treatment can often be challenging.

Malignant Pericardial Mesothelioma. Report of two Cases, Review of the Literature and Differential Diagnosis

Malignant pericardial mesothelioma is an uncommon variety of a primary malignant cardio-pericardial tumor and it is a highly lethal and fortunately rare cardiac neoplasm. The presentation of pericardial mesothelioma is aspecific and pathologically mesothelioma is not the most common among primary tumors of the pericardium. It is characterized by atypical solid growth of mesothelium with formation of atypical cavities surrounded by fibrous stroma. Antemortem diagnosis is difficult and distant metastases are extremely rare. Radical surgery can be used to treat localized mesothelioma. The treatment for advanced primary pericardial mesothelioma is usually palliative because the tumor is resistant to radiotherapy and chemotherapy. The prognosis is unfavorable. The median survival from the onset of symptoms is six months. In this paper we report two cases of patients with primary mesothelioma of the pericardium without a definite history of asbestos exposure.

Epidemiology of mesothelioma of the pericardium and tunica vaginalis testis

PURPOSE

Malignant mesothelioma most commonly arises in the pleura and peritoneum but also occurs rarely at other anatomical sites with mesothelial tissue, namely, the pericardium and tunica vaginalis testis (TVT). This review provides a better understanding of the epidemiology of mesothelioma of these extrapleural sites.

METHODS

We conducted a systematic review of the epidemiologic and clinical literature on pericardial mesothelioma and mesothelioma of the TVT. We also analyzed U.S. Surveillance, Epidemiology, and End Results cancer registry data to describe incidence patterns of these malignancies.

RESULTS

An etiologic role of asbestos exposure has been hypothesized for pericardial and TVT mesotheliomas, but no analytical case-control epidemiologic studies exist to test this relationship. A substantial proportion of cases with these malignancies report no known asbestos exposure. In large occupational cohorts with heavy asbestos exposures, no cases of pericardial or TVT mesothelioma have been reported. Trends in the incidence of these malignancies do not match those of pleural mesothelioma, which correspond to historical trends of commercial asbestos use. A male preponderance of pericardial mesothelioma is not evident.

CONCLUSIONS

In the absence of analytic epidemiologic studies, the etiologic role of environmental risk factors for mesothelioma of the pericardium and TVT remains elusive.

Malignant pericardial mesothelioma : A systematic review of current practice

BACKGROUND

Malignant mesothelioma is a rare but aggressive tumor, with a high misdiagnosis rate and overall bleak prognosis. In 0.7% of all cases, the origin is the pericardium.

METHODS

The present study is a review of the literature published in recent decades focusing on the advances in clinical manifestations, radiological findings, diagnosis, differential diagnosis, and treatment of malignant pericardial mesothelioma (MPM).

RESULTS

No clear relationship has been established between the etiologies and the development of MPM. Clinical symptoms and signs are nonspecific when present. The main presentations are chest pain and dyspnea. Imaging plays an important role in the detection, characterization, staging, and posttreatment follow-up. The definitive diagnosis is made on the basis of pathological findings. Chest radiography and echocardiography are common techniques used initially, but their roles are limited. Computed tomography and magnetic resonance imaging have an advantage in depicting the thickened pericardium, mediastinal lymph node, tumor, and the extension of adjacent structures. Surgery is the most important treatment modality and remains palliative in most cases, while the roles of chemo- and radiotherapy are unsatisfactory.

CONCLUSION

Clinical trials of malignant pleural and peritoneal mesothelioma remain important for MPM management. Multimodality treatment of surgery, chemotherapy, radiotherapy, and immunotherapy is expected to have a role in the treatment of MPM.

Primary pericardial malignant mesothelioma and response to radiation therapy

We report a case of a primary pericardial malignant mesothelioma. A 59-year-old male presented with episodic chest pain and dyspnea on exertion. Cardiac magnetic resonance imaging revealed a large mass in the pericardium attached to the right ventricle. Partial resection of the mass was undertaken revealing malignant mesothelioma, byphasic type. The patient was treated with chemotherapy intermittently over a period of 3 years, but his disease continued to progress. The patient was then treated with definitive radiation therapy to 64 Gy to the primary tumor using a six field 3D conformal technique. The patient remains free of progressive disease 86 months from the time of diagnosis and 50 months from the completion of his radiotherapy.

Recurrent pericardial effusion as initial manifestation of primary diffuse pericardial malignant mesothelioma

The case of a 61-year-old woman who presented a recurrent symptomatic pericardial effusion and a malignant cardiac tamponade six months prior to the detection of a mediastinal anterior mass is described. Diffuse malignant pericardial mesothelioma was diagnosed after mediastinal mass biopsy. The patient underwent further oncological evaluation followed by chemotherapy.

Unusual primary tumors of the heart

Primary tumors of the heart, with the exception of atrial myxomas, occur rarely; tumors metastatic to or directly invasive of the heart are far more common. About 75% of primary tumors are benign, and 75% of these are atrial myxomas. The benign tumors include rhabdomyomas, fibromas, papillary fibroelastomas, hemangiomas, pericardial cysts, lipomas, hamartomas, teratomas, mesotheliomas, and paragangliomas or pheochromocytomas. The last 3 may also be malignant. The malignant tumors consist of various sarcomas: myxosarcoma, liposarcoma, angiosarcoma, fibrosarcoma, leiomyosarcoma, osteosarcoma, synovial sarcoma, rhabdomyosarcoma, undifferentiated sarcoma, reticulum cell sarcoma, neurofibrosarcoma, and malignant fibrous histiocytoma. Cardiac tumors produce a large variety of symptoms through any of 4 mechanisms. Their mass can obstruct intracardiac blood flow or interfere with valve function. Local invasion can lead to arrhythmias or pericardial effusions with tamponade. Bits of tumor can embolize, causing systemic deficits when the tumors are on the left side of the heart. Finally, the tumors may cause systemic or constitutional symptoms. Some tumors, of course, produce no symptoms and become evident as incidental findings. The most useful diagnostic tool is the echocardiogram, which in almost all cases precisely locates the tumor and defines its extent. The echocardiographic appearance may also allow quite accurate prediction of the tumor type and whether it is malignant or benign. Magnetic resonance imaging serves as the next most important test where the density of T1 and T2 images may allow tumor cell type identification. With few exceptions, these tumors require operative excision. Most benign tumors can be resected completely; a few, because of their large size, cannot be, and only tumor debulking may be possible. Heart transplantation should be considered for these patients. Many of the malignant tumors cannot be resected completely, either because of the extent of local spread and invasion or because of the frequent distant metastases. Transplantation may also be an option for those with extensive local disease. The long-term results for resected benign tumors are excellent; the long-term results for sarcomas are very poor, and there are few survivors. For patients with unresectable sarcomas, radiation and chemotherapy may be used, but without great expectation of successful results.

An autopsy case of a malignant pericardial mesothelioma in a Japanese young man

An autopsy case of a malignant pericardial mesothelioma in a 27-year-old man with no history of exposure to asbestos is reported. He was admitted for heart failure due to pericardial effusion of unknown origin and surgically drained, but later died. The diagnosis of a malignant pericardial mesothelioma was made on the basis of histologic, immunohistochemical and ultrastructural findings. The tumor was located on the pericardium, but autopsy revealed that it had spread extensively in the mediastinum and the lungs. Microscopically, the tumor cells were epithelial like and contained histochemically demonstrable glycogen and hyaluronic acid. Immunohistochemical studies of the tumor demonstrated positive immunoreactivity for cytokeratin 19, muscle actin HHF35, epithelial membrane antigen, CA125, p53 and p21WAF1/CIP1 whereas the tumor was negative for cytokeratins 10 and 17, carcinoembryonic antigen, vimentin, epithelial antigen BerEP4, S-100, c-erbB2 and bcl-2. A high MIB-1 labeling index was noted. Under the electron microscope the tumor cells exhibited long, thin villi. The operation and autopsy findings thus revealed this to be a very rare case of malignant pericardial mesothelioma in a young man.