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Ann Thorac Surg 2006;81:374
© 2006 The Society of Thoracic Surgeons

Images in cardiothoracic surgery

Intrapericardial Teratoma Presenting With Circulatory Compromise

Karen M. Brown, FRCS * , Saswata Banerjee, MRCS, Pauline A. Kane, MRCP, MRCR, Michael T. Marrinan, FRCS

Department of Cardiothoracic Surgery, King's College Hospital, London, United Kingdom

* Address correspondence to Dr Brown, King's College, Department of Cardiac Surgery, London SE5 9RS, UK (Email: kbrown{at}doctors.net.uk).

A 44-year-old man presented with severe chest pain and dyspnea after 2 years of fatigue, weight loss, and cough. His pulse and blood pressure were 100 and 100/60 mm Hg, respectively; his jugular venous pressure was raised and air entry was reduced on the left. On air, his pO2 was 61 mm Hg with pCO2 of 33 mm Hg. Chest roentgenogram showed a large mass filling the aortopulmonary window, inseparable from the left heart border with a raised left hemidiaphragm (Fig 1).



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  		Fig 1.
 
Magnetic resonance imaging (MRI) showed a huge mediastinal mass of mixed signal with a fat-fluid level that compressed the heart and airway (Fig 2; [A], the axial spin-echo sequence; [B], the axial proton density fat suppression sequence; Fig 3).



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  		Fig 2.
 


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  		Fig 3.
 
Figure 2 contains the T2 MRI coronal section at the level of T4 showing ascending aorta, pulmonary artery (PA) bifurcation with marked compression of the left PA. Note the central high intensity signal (T2) nodule, which loses signal on the fat suppression sequence confirming its fatty nature. The layering of complex fluid in the remaining mass is characteristic of a dermoid.

Figure 3 contains the T1 MRI sagittal section showing a large mass compressing the left ventricle containing cystic and solid elements and abutting the transverse aorta. Some residual pericardial fluid is still present after percutaneous drainage.

A pericardial effusion was seen and drained percutaneously with the release of purulent fluid. At sternotomy the tumor was compressing the heart significantly from its mass effect and had breached the pericardium. Complete excision was achieved although inflammatory reaction increased the difficulty of the dissection. The patient recovered well and histology confirmed the presence of a mature cystic teratoma (dermoid cyst) containing skin, respiratory epithelium, and cartilage with foci of salivary and intestinal epithelium.

Intrapericardial teratomas are rare in neonates and children but are virtually unheard of in adults [1, 2]. In our case it is likely the tumor arose outside the pericardium and provoked an intense inflammatory reaction that led to intrapericardial tumor invasion with a large effusion.

Although MRI gives unrivaled views of tumor proximity and spread around the mediastinal structures, there is a paucity of its use in case reports of patients with teratoma. We submit this case report not only for the striking appearance on MRI but also for its rare involvement of the pericardium.


   References
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 References
 

  1. Lewis BD, Hurt RD, Farrow GM, Knapp RH, Muhm JR. Benign teratomas of the mediastinum J Thorac Cardiovasc Surg 1983;86:727-731.[Abstract]
  2. Saabye J, Elbkirk A, Andersen K. Teratomas of the mediastinum Scand J Thorac Cardiovasc Surg 1987;21:271-272.[Medline]



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