Ann Thorac Surg 2001;72:2137-2139
© 2001 The Society of Thoracic Surgeons
Case report
Atypically located pericardial cysts
Hakan Kutlay, MDa,
ínasí Yavuzer, MD*a,
Serdar Han, MDa,
Ayten Kayi Cangir, MDa
a Department of Thoracic Surgery, Ankara University School of Medicine, Ankara, Turkey
Accepted for publication March 2, 2001.
* Address reprint requests to Dr Yavuzer, Ankara Üniversitesi Tip Fakültesi, 
bn-i Sina Hastanesi, Gö
üs Cerrahisi Anabilim Dali, 06100, Sihhiye, Ankara, Turkey
e-mail: eshakan{at}hotmail.com
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Abstract
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Pericardial cysts are uncommon benign abnormalities and are most often found in either cardiophrenic angle. We present the cases of 3 patients with a cyst in the mediastinum and review the literature. Pathological examination confirmed the diagnosis of pericardial cyst. Clinicians should include pericardial cyst in the differential diagnosis of mediastinal masses.
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Introduction
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Primary cysts of the mediastinum make up 19% to 25% of all mediastinal masses [1, 2]. Among primary cysts, pericardial cysts are the second most common type after bronchial cysts and constitute 7% of all lesions [1, 2]. Most pericardial cysts are asymptomatic and usually are found incidentally on routine chest roentgenograms. Pericardial cysts are typically located in the mediastinum; involvement of the cardiophrenic angle on the right side is more common than involvement on the left. Three of the patients with pericardial cyst seen in our department had an atypical location, that is, in the right paratracheal area of the superior mediastinum. This unusual location for a pericardial cyst has previously been reported [3].
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Case reports
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Patient 1
A 53-year-old man was admitted to our hospital in March 1989 with the complaint of retrosternal pain, which he had had for 1 year. Results of physical examination were normal. Laboratory examinations included an electrocardiogram, blood analysis, and spirometry, the results of which were within normal limits. A chest roentgenogram revealed a smooth-bordered mass in the superior mediastinum. A computed tomographic scan showed a homogeneous cystic mass in the right paratracheal area (Fig 1). A right thoracotomy with total cyst excision was performed. Pathological examination of the lesion revealed a pericardial cyst. The patient was discharged on the ninth postoperative day.
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Fig 1. (Patient 1.) Computed tomographic scan showing pericardial cyst (indicated by arrow) in right paratracheal area.
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Patient 2
A 67-year-old woman was admitted to our hospital in February 1997 with a 1-year history of coughing and dyspnea. Results of the physical examination and routine laboratory tests were normal. A chest roentgenogram revealed a mediastinal widening. A round, unilocular mass 4 cm in diameter in the right paratracheal area was detected on the computed tomographic scans. A right thoracotomy was performed. A thin-walled cystic lesion compressing both the superior vena cava and the azygos vein and communicating with the pericardial cavity was found. The lesion was completely excised. Pathological examination confirmed the diagnosis of a pericardial cyst. The patient was discharged on the fifth postoperative day.
Patient 3
A 47-year-old asymptomatic man was referred to our clinic after the detection of a superior mediastinal enlargement on the chest roentgenogram during a routine physical examination in February 1997. Results of physical examination, blood analysis, electrocardiogram, and spirometric studies were all normal. A right paratracheal cystic mass was seen on the computed tomographic scans (Fig 2). During a right thoracotomy, a thin-walled cystic lesion was found among the trachea, the superior vena cava, and the azygos vein. The cyst extended on a pedicle toward the pericardium. Total excision was performed. Histopathological examination of the lesion revealed a pericardial cyst. The patient was discharged on the fourth postoperative day.
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Fig 2. (Patient 3.) Computed tomographic scan showing pericardial cyst (indicated by arrow) in right paratracheal area.
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Comment
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Pericardial cysts are uncommon benign congenital mediastinal lesions. Their incidence is 1 per 100,000 population. These lesions do not present clinical symptoms unless they reach large size. In general, they are detected on routine radiological examinations [3, 4]. Mediastinal cysts are thin-walled, sharply defined, oval homogeneous masses; their attenuation is near water density (0 to 20 HU) and fails to enhance with intravenous administration contrast of material. However, not all cysts have a water density. Pericardial cysts can have a density higher than water (30 to 40 HU) [5].
Pericardial cysts are most commonly found at the cardiophrenic angle. The incidence at the right and left cardiophrenic angles is 70% and 22%, respectively. In 8% to 11% of patients, the cysts are found elsewhere, such as in the posterior mediastinum, the right or left hilar region, the right paratracheal area, or in the neighborhood of the aortic arch [3]. In 1986, Stoller and colleagues [3] reviewed the reports of atypically located pericardial cysts identified between 1929 and 1985. Three cases mentioned in their study were found in the right paratracheal region of the superior mediastinum, a location recognized as rare. Such cases should be kept in mind when making the differential diagnosis of other mediastinal cysts and tumors, particularly bronchial cysts.
Pericardial cysts are usually solitary cysts adjacent to the pericardium, but 20% of them communicate with the pericardium. Although they are considered to be developmental, most are detected in adult life. They consist of a fibrous wall with a thin mesothelial lining in histopathological evaluation (Fig 3). Bronchial cysts, on the other hand, are covered by bronchial-type epithelium and are usually filled with mucous secretions or air.
Between 1981 and 1997, a total of 18 patients with pericardial cysts (11 women and 7 men ranging from 32 to 81 years old) were treated surgically in our clinic. The cysts were located in the right cardiophrenic angle in 11 patients and in the left cardiophrenic angle in 4. In the other 3 patients, the cysts were found in an atypical location, that is, in the right paratracheal region of the superior mediastinum. A thoracotomy and a total excision were performed in all patients. A wound infection occurred in 1 patient. Three patients had dyspnea early postoperatively as a result of chronic obstructive pulmonary disease and were treated with bronchodilator therapy. No other complications or deaths occurred in our series of 18 patients.
Considering the complications in nonsurgically treated patients, such as rupture of the cyst, cardiac compression and the consequent hemodynamic disturbances, compression of the main bronchus, right ventricular wall erosion [6], and superior vena cava erosion [7], a conservative treatment approach does not appear to be the best option. We believe that thoracotomy should be the treatment of choice. It provides a radical therapy with excision of the mediastinal mass, produces a dramatic improvement in symptoms, and allows histopathological examination of the lesion. In select patients, a video-assisted thoracic surgical procedure should be considered as an alternative method of treatment [8].
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References
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Davis R.D., Jr, Oldham H.N., Jr, Sabiston D.C., Jr Primary cysts and neoplasms of the mediastinum: recent changes in clinical presentation, methods of diagnosis, management, and results. Ann Thorac Surg 1987;44:229-237.[Abstract]
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Cohen A.J., Thompson L.N., Edwards F.H., Bellamy R.F. Primary cysts and tumors of the mediastinum. Ann Thorac Surg 1991;51:378-386.[Abstract]
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Stoller J.K., Shaw C., Matthay R.A. Enlarging, atypically located pericardial cyst. Recent experience and literature review. Chest 1986;89:402-406.[Abstract/Free Full Text]
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Satur C.M.R., Hsin M.K.Y., Dussek J.E. Giant pericardial cysts. Ann Thorac Surg 1996;61:208-210.[Abstract/Free Full Text]
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Demos T.C., Budorick N.E., Posniak H.V. Benign mediastinal cysts: pointed appearance on CT. J Comput Assist Tomogr 1989;13:132-133.[Medline]
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Chopra P.S., Duke D.J., Pellett J.R., Rahko P.S. Pericardial cyst with partial erosion of the right ventricular wall. Ann Thorac Surg 1991;51:840-841.[Abstract]
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Mastroroberto P., Chello M., Bevacqua E., Marchese A.R. Pericardial cyst with partial erosion of the superior vena cava. An unusual case. J Cardiovasc Surg (Torino) 1996;37:323-324.[Medline]
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Hazelrigg S.R., Landreneau R.J., Mack M.J., Acuff T.E. Thoracoscopic resection of mediastinal cysts. Ann Thorac Surg 1993;56:659-660.[Abstract]
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Abstract
Introduction
