Pericardial constriction caused by primary mesothelioma

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.

Non-Hodgkin's Lymphoma Presenting as Constrictive Pericarditis: A Rare Case Report

Constrictive pericarditis (CP) is an uncommon post inflammatory disorder. It is described as pericardial thickening, myocardial constriction, and impaired diastolic filling. The most common etiologies are idiopathy, mediastinal radiotherapy, and prior cardiac surgery. Less common etiologies include viral infections, collagen vascular disorders, renal failure, sarcoidosis, tuberculosis, and blunt chest trauma. CP can less commonly be caused by malignancy. We report a very rare case of non-Hodgkin's lymphoma (NHL) presenting twice with attacks of decompensated heart failure. Echocardiography revealed that CP was responsible for the patient's symptoms as the first manifestation of NHL. Chest computed tomography scan and biopsy findings were compatible with the diagnosis of NHL. The patient received R-CHOP (cyclophosphamide, hydroxydaunorubicin, Oncovin^®, and prednisone or prednisolone, combined with the monoclonal antibody rituximab) chemotherapy. Three months later, there was significant improvement in the patient's symptoms and considerable decrease in pericardial thickness.

Surgery for pericardial disease

The pericardium is an important structure, and there are many diseases that affect the pericardium and the heart. Often, surgery is required for drainage or removal of the pericardium, but techniques are not standardized, and there is controversy, especially with regard to treatment of constrictive pericarditis. This paper reviews surgical methods for the treatment of inflammatory and constrictive pericarditis and presents early and late outcome of operation.

Occult malignancy presenting as constrictive pericarditis

Metastatic tumour progression to the pericardium is generally characterised by an effusional pericarditis. It is extremely rare for tumour to metastasise to the pericardium and cause constrictive pericarditis in the absence of a pericardial effusion. We report the recent case of a patient who was referred to our centre with constrictive pericarditis. Following pericardectomy and histopathological analysis this was found to be secondary to an occult metastatic adenocarcinoma.

Primary pericardial mesothelioma

Primary pericardial mesothelioma is an extremely rare tumor. This case illustrates the typical late presentation of primary pericardial mesothelioma with symptoms and signs of constrictive pericarditis. An unusual feature was the complete encasement of the heart by the tumor. No satisfactory treatment was available.

A case of pleural mesothelioma with effusive-constrictive pericarditis

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Pericardial constriction due to malignant lymphoma

We experienced a case of T-cell lymphoma demonstrating diastolic heart failure as an initial manifestation. An 81-year-old Japanese male was admitted to the University of Tokyo Hospital because of progressive dyspnea and general fatigue. Clinical presentation was congestive heart failure and cervical lymphadenopathy. Right heart catheterization revealed "dip and plateau" waveforms in right ventricular pressure, which suggested a constrictive nature of heart failure. Gallium scintigram showed marked uptake in the heart. Biopsy from a cervical lymph node confirmed the diagnosis of malignant lymphoma of T-cell origin. Diastolic heart failure remained after successful chemotherapy. Autopsy revealed pericarditis with severe adhesion of the pericardium and the epicardium.

Constrictive pericarditis

The diagnosis of constrictive pericarditis remains a challenge because its physical findings and hemodynamics mimic restrictive cardiomyopathy. Various diagnostic advances over the years enable us to differentiate between these two conditions. This review begins with a case report of constrictive pericarditis, followed by a brief history and discussions of etiologies. Clinical features, radiologic, electrocardiographic, angiographic findings, and hemodynamics of constrictive pericarditis are reviewed. The echocardiographic findings are detailed and the recent advances in Doppler flow velocity patterns of pulmonary, mitral, tricuspid valves and hepatic veins are reported. Nuclear ventriculograms depict rapid ventricular filling in constrictive pericarditis and differentiate it from restrictive cardiomyopathy. Endomyocardial biopsy helps further in recognizing the various types of restrictive cardiomyopathies. Computed tomography and magnetic resonance imaging delineate abnormal pericardial thickness in constrictive pericarditis. Association of characteristic hemodynamic changes and abnormal pericardial thickness > 3 mm usually confirms the diagnosis of constrictive pericarditis. Effusive and occult varieties of constrictive pericarditis are briefly described. This review concludes with emphasizing the importance of pericardial resection.

Constrictive pericarditis: its history and current status

The diagnosis of constrictive pericarditis remains a challenge because it is often mimicked by restrictive cardiomyopathy. The last few years have seen numerous advances in our ability to differentiate between these two conditions which often have similar physical findings and hemodynamics. This review begins with a brief history of constrictive pericarditis; this is followed by an extensive discussion of newer etiologies, and then the classical clinical history and physical examination findings are described. Radiologic, electrocardiographic, and angiographic findings are discussed. The hemodynamics of constrictive pericarditis are reviewed. Recent results of echocardiographic and echo-Doppler investigations are presented. Emphasis is placed upon the limitations of M-mode echocardiography in the diagnosis of constrictive pericarditis. The value of echocardiographic Doppler studies of mitral and tricuspid flow velocity patterns, as well as of those in the pulmonary veins and hepatic veins, is described. Nuclear ventriculograms and angiocardiograms tend to show more rapid ventricular filling in constrictive pericarditis than in restrictive cardiomyopathy. Although only a small number of patients has been studied, these evaluations seem to have merit in separating restrictive cardiomyopathy from constrictive pericarditis. The role of computed tomography scanning and magnetic resonance imaging studies of pericardial thickness in confirming the presence of constrictive pericarditis is discussed. Abnormal pericardial thickening (> 3 mm) confirms the diagnosis of constrictive pericarditis, but only if the characteristic hemodynamic pattern is present. The usefulness of endomyocardial biopsy in recognizing specific varieties of restrictive cardiomyopathy is presented.(ABSTRACT TRUNCATED AT 250 WORDS)

Primary malignant mesothelioma of the pericardium. Case report and literature review

Pericardial mesothelioma is a highly lethal and fortunately rare cardiac neoplasm. We present the clinical and pathologic features of a primary sarcomatoid mesothelioma. To better understand the clinical, radiographic, and pathologic features of this entity, we reviewed 27 cases described in the English literature from 1972 through 1992, which, together with our case, provided a total of 28 cases. Findings of the review include a male-female ratio of 2:1, a wide age range (12 to 77 years; mean, 47 years), and documented asbestos exposure in 4 of 28 (14%) patients. Commonly used imaging studies do not appear to offer great sensitivity, for a mass was detected by echocardiography in only 2 of 16 (12%) patients and by computed tomography in 4 of 9 (44%). Pathologic findings revealed a diffuse growth pattern in most cases (18 of 25, or 72%), together with an equal distribution between the biphasic, epithelioid, and sarcomatoid variants. Effusion cytology revealed malignant cells in only 2 of 10 (20%) cases. With or without therapy, prognosis was uniformly poor, since 24 of 27 patients were dead of the disease at the time the reports were published.

Cardiac synovial sarcoma with translocation (X;18) associated with asbestos exposure

A primary cardiac spindle cell tumor with immunoreactivity for keratin proteins is reported. Cytogenetic analysis of the tumor demonstrated a translocation (X;18), an aberration almost exclusively reported in synovial sarcomas. Postmortem examination revealed amphibole asbestos within the lungs and diaphragmatic pleural plaques indicative of asbestos exposure. These findings raise questions about the possible causation of this tumor.

Cerebral metastases in pleural mesothelioma: case report and review of the literature

A case of malignant mesothelioma metastatic to the brain is described. A 52-year old woman, with no known exposure to asbestos, presented with a biphasic mesothelioma of the left parietal pleura. Following resection, the thorax was irradiated with 4000 cGy, and all symptoms subsided. Three months later, a left temporal lobe tumor was diagnosed and subsequently resected. Despite neurological improvement, she died 10 days post-operatively from constrictive pericardial disease. The authors have reviewed the 54 reported cases of brain metastases from mesothelioma and have noted that the histologic appearance of brain metastases from mesothelioma may be similar to glioblastoma multiforme. Because brain metastasis from mesothelioma is rare, procedures to clarify the nature of the tumor should be performed.

Primary pericardial mesothelioma presenting as tuberculous pericarditis

Ante-mortem diagnosis of primary pericardial mesothelioma is very rare. We report a case which presented clinically as tuberculous constrictive pericarditis. The patient underwent pericardial resection with an immediate haemodynamic benefit, although the malignant process progressed, and he died 14 weeks later.

Constrictive pericarditis versus restrictive cardiomyopathy: a reappraisal and update of diagnostic criteria

Distinguishing constrictive pericarditis from restrictive cardiomyopathy is a difficult clinical challenge. We review published reports in which hemodynamic criteria were used to differentiate these two diagnoses. There were 82 cases of constriction and 37 cases of restriction. The overall predictive accuracy of the difference between right and left ventricular end-diastolic pressures (RVEDP and LVEDP), RV systolic pressure, and the ratio of RVEDP to RV systolic pressure were 85%, 70%, and 76%, respectively. If all three criteria were concordant, the probability of having correctly classified the patient was greater than 90%. However, one fourth of patients could not be classified by hemodynamic criteria. There are few data to support the use of hemodynamic measurements after exercise or volume infusion to separate these two groups. Numerous recent studies have reported on the ability of left ventriculography, Doppler echocardiography, or radionuclide angiography to distinguish constriction from restriction. Many of the proposed indices appear promising, but these studies suffer from small sample size, potential selection bias, and complexity of the proposed criteria, which have limited their widespread application. New imaging technologies, such as CT scanning or MRI have been applied in a limited number of cases, but appear to be a sensitive means of detecting abnormal pericardium. Endomyocardial biopsy has proven useful in establishing the diagnosis of infiltrative cardiomyopathies, eliminating in those cases the need for surgical intervention. The finding of myocarditis must be considered a nonspecific finding that does not preclude thoracotomy. Since constrictive pericarditis is a surgically curable condition, the distinction between constrictive and restrictive disease is of critical importance. Taking into account the relative contribution of data derived from hemodynamic, imaging,and biopsy studies, we propose an algorithm for the selection of appropriate candidates for pericardial biopsy and stripping.

Common emergencies in cancer medicine: cardiovascular and neurologic syndromes

A myriad of multisystem disorders may result from primary malignant disease, metastasis, or treatment. Neoplastic pericardial disease in the form of malignant effusions, tamponade, and pericarditis are not uncommonly seen. Compromise of blood return to the right side of the heart due to the superior vena cava syndrome is a well known entity that is also still undergoing examination of the variety of treatment options available. The central and peripheral nervous systems also may be involved from both primary or secondary malignant disease. The recognition, diagnostic approach, natural history, and therapeutic options will be reviewed.

Primary malignant pericardial mesothelioma

Malignant primary tumors of the pericardium are rare. The authors present two male patients, aged 44 and 67 years, not exposed to asbestos, who died from pericardial mesothelioma. Repeated evacuation of fluid from the pericardium due to cardiac tamponade failed to reveal the cause of pericarditis. In one case, the diagnosis was made on surgical exploration, and in the other, at autopsy. A significant difference between benign and malignant pericardial effusion was observed. In cases of pericardial mesothelioma, symptoms of epicardial involvement cannot be attributed solely to the hindered inflow and cardiac tamponade, but also to congestive heart failure due to myocardial infiltration. In one patient, temporary improvement was achieved, first by pronisone therapy and then by radiotherapy.

Localized epicarditis mimicking cardiac tumor

A rare case of localized epicarditis mimicked a cardiac tumor. The diagnosis was confirmed at surgery. Epicardial peel with resection of the aneurysmal right atrial appendage resulted in complete recovery.