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Ann Thorac Surg 1996;61:208-210
© 1996 The Society of Thoracic Surgeons

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Case Report

Giant Pericardial Cysts

Department of Cardiothoracic Surgery, Guy's Hospital, London, United Kingdom

Accepted for publication July 7, 1995.

	Abstract

Top Footnotes Abstract Introduction Case Reports Comment References

 
Pericardial cysts are most commonly incidental radiologic findings of little clinical consequence. We present the unusual history of 2 patients in whom pericardial cysts were of massive sizes and caused significant symptoms; in 1, progression of the cyst size had been documented over 25 years. Diagnostic difficulties encountered and the utility of video-assisted thoracoscopy are described.

	Introduction

Top Footnotes Abstract Introduction Case Reports Comment References

 
Pericardial cysts are uncommon congenital abnormalities. Most are asymptomatic and are found incidentally on chest roentgenograms [1]. Giant cysts are an even more uncommon finding, and reports of their natural history, presentation, and management are few [2, 3]. In this report we describe the case histories of 2 patients that have allowed these subjects to be addressed.

	Case Reports

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Patient 1
A 47-year-old man presented with exertional dyspnea and a dry cough. Clinical examination revealed signs of a right-sided pleural effusion: chest wall expansion and basal air entry was reduced, and percussion over the lower chest produced a dull note. Posteroanterior and lateral chest roentgenograms demonstrated opacification of the full extent the right lower hemithorax, which was confluent with the diaphragm and the lower mediastinum, and possessed a dome-shaped upper border. Elevated right hemidiaphragm and subpulmonary effusion were considered likely diagnoses, but the latter was ``confirmed'' by demonstration of the content of fluid with an ultrasound examination. Percutaneous aspiration yielded 800 mL of straw-colored fluid and caused complete resolution of the symptoms and the radiologic abnormality. The effusate was found to be a transudate containing 6 g/L of protein.

The problem recurred twice in the subsequent 4 years; thus a video-assisted thoracoscopy was performed to aid in identifying the cause of the ``effusion.'' A large, smooth-walled cyst containing 2 L of clear fluid, free from adjacent lung and diaphragm, with a base arising from the pericardium anterior to the phrenic nerve and the inferior vena cava, was identified: a pericardial cyst. It was excised with an Endoscopic Linear Cutter ETC 60 (Ethicon Ltd, Maidstone, UK), which simultaneously divides and staples tissue adjacent to the line of division. The patient was discharged from the hospital on the third postoperative day, and no recurrence was noted at early follow-up.

Histopathologic examination demonstrated that the cyst was lined by a single layer of cuboidal/columnar cells, some of which were ciliated. Between the cells there was laminated fibrous tissue, fat, vessels, and patchy lymphocytic infiltrate. The features were consistent with those of a simple pericardial cyst.

Patient 2
A 58-year-old man had a chest roentgenogram performed as part of a mass screening program, which revealed the presence of a 7-cm spherical shadow situated in the right costophrenic angle. A presumptive diagnosis of pericardial cyst was made and subsequently confirmed by thoracoscopy. The patient was offered, but refused, surgical excision through a thoracotomy.

Regular review in the outpatient department demonstrated that the cyst had enlarged progressively (Fig 1). The patient remained asymptomatic until 1 year ago, when he noticed increasing exertional dyspnea. A chest roentgenogram revealed that the lower two thirds of the right hemithorax was filled by a mass, the upper border of which was concave (Fig 2A). Computed tomography was performed and demonstrated a large, thin-walled cystic structure in the lower anterior right hemithorax abutting the right border of the heart (Fig 2B). The Hounsfield number recorded was -4 and was consistent with waterlike contents and a pericardial cyst (see Fig 2). Video-assisted thoracoscopy demonstrated that the giant cyst contained 2.5 L of fluid and confirmed its origin from the pericardium. The cyst was resected with the endoscopic linear cutter ETC. The patient was discharged on the fourth postoperative day. Chest roentgenography performed 6 weeks postoperatively demonstrated the presence of a small residual stump. Complete resolution of symptoms was reported by the patient.

View larger version (78K): [in this window] [in a new window]   Fig 1. . Posteroanterior (A) and lateral (B) chest roentgenograms of patient 2 obtained more than 19 years ago showing the originally small size of the pericardial cyst.

View larger version (96K): [in this window] [in a new window]   Fig 2. . Posteroanterior chest roentgenogram (A) and computed tomographic scan (B) obtained recently when patient 2 presented with breathlessness. They show the enlarged cyst and demonstrate that it is smooth-walled and arises anteriorly in the cardiophrenic angle from the pericardium.

	Comment

Top Footnotes Abstract Introduction Case Reports Comment References

 
Pericardial cysts are caused by an incomplete coalescence of fetal lacunae forming the pericardium. The estimated incidence of pericardial cysts is 1:100,000 [3]. They are typically unilocular, are lined by endothelium or mesothelium, contain clear serous fluid, and do not communicate with the pericardial space. Most pericardial cysts are asymptomatic and are an incidental finding on roentgenograms, presenting as a round homogeneous radiodense lesion at the cardiophrenic angle, two thirds being found on the right. These findings are usually diagnostic but confirmation of the diagnosis may be obtained by two-dimensional echocardiography or computed tomography [4, 5].

The first of the 2 cases presented has demonstrated the diagnostic dilemma that may arise when a previously undiagnosed pericardial cyst presents as a giant lesion causing symptoms. Distinguishing radiologic features of a large pericardial cyst include a convex upper border and the absence of fluid within the interlobar fissures of the lung. Although pericardial cysts most commonly occur on the right they may be also found on the left, and arise more superior area pericardium than the costophrenic angle [5].

The second case has demonstrated the potential for progression of this pathology. It has also allowed the demonstration of the progress in surgical methodology over 25 years. The thoracoscope was, at the time of initial presentation, largely a diagnostic tool, and definitive treatment would have required a thoracotomy. As the size of the lesion has progressed, so has the technology associated with thoracoscopy, increasing the armamentarium of the thoracoscopist and thus enabling minimally invasive resection [6].

In summary, we have reported 2 cases of giant symptomatic pericardial cyst that were amenable to diagnosis and treatment with modern video-assisted thoracoscopic methods. They have demonstrated that large pericardial cysts should be considered in the differential diagnosis of a pleural effusion and raise the question whether minor or moderate-sized cysts merit routine long-term review to exclude progressive enlargement.

	Footnotes

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Address reprint requests to Dr Satur, Department of Cardiothoracic Surgery, Guy's Hospital, New Guy's House, St. Thomas St, London SE1 9RT, United Kingdom.

	References

Top Footnotes Abstract Introduction Case Reports Comment References

 

1. Ferguson MK. Thoracoscopic management of pericardial disease. Semin Thorac Cardiovasc Surg 1993;5:310–5.[Medline]
2. Szinicz G, Taxer F, Reidlinger J, Erhart K. Thoracoscopic resection of a pericardial cyst. Thorac Cardiovasc Surg 1992;40:190–1.[Medline]
3. Le Roux BT. Pericardial coelomic cysts. Thorax 1959;14:27–34.[Medline]
4. Hynes JK, Tajik AJ, Osborn MJ, Orszulak TA, Seward JB. Two-dimensional echocardiographic diagnosis of pericardial cyst. Mayo Clin Proc 1983;58:60–3.[Medline]
5. Tung KT, Chan O. Case report: misdiagnosis of an atypical pericardial cyst presenting in a patient with chest trauma. Clin Radiol 1991;43:272–3.[Medline]
6. Hazelrigg SR, Landreneau SJ, Mack KJ, Acuff TE. Thoracoscopic resection of mediastinal cysts. Ann Thorac Surg 1993;56:659–60.[Abstract]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Christopher M. R. Satur Jules E. Dussek Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Satur, C. M. R. Articles by Dussek, J. E. Search for Related Content PubMed PubMed Citation Articles by Satur, C. M. R. Articles by Dussek, J. E.