A Case of Malignant Pericardial Effusion
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A Case of Malignant Pericardial Effusion

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    A Case of Malignant Pericardial Effusion A Case of Malignant Pericardial Effusion Presentation Transcript

    • Prof. Dr. Magesh kumar Unit M 1 unit Dr. Priya Kubendiran
    • Case History
      • H/o loss of weight/ appetite +
      • No h/o chest pain , palpitation , syncope
      • No H/o skin rash , joint pains, joint swelling
      • Past history :
      • No h/o similar complaints in the past
      • No H/o TB or contact with TB patient
      • No h/o jaundice in past
      • Not a k/c/o SHT , DM , TB , IHD ,
      • Personal History :
      • Married with 2 children
      • No H/o bad obstetric history
      • Mixed diet
      • Family History - nil significant
      • Treatment history –
      • Had been receiving treatment from a local practitioner in the form of oral medications for the above complaints
      • Got admitted at Meenakshi Medical College and was started on ATT and was then referred to GSH as she didn’t show response to treatment.
    • O/E :
      • She is conscious, oriented
      • thin built , fairly hydrated , dyspneic
      • Pale , no cyanosis , clubbing,icterus,
      • B/L pitting pedal oedema +
      • Facial puffiness present
      • No lymph node palpable
      • Neck veins distended
      • JVP – elevated upto 8 cm. ( CVP – 13 cm of blood column )
      • Vitals : T – 99F ,
      • PR – 120 /min
      • RR – 26 / min
      • BP – 100/70 mm of Hg
      • RS – trachea shift to Right
      • use of accessory muscles present
      • spine , shoulder ,scapulae – normal
      • dull note on percussion
      • reduced VF / VR
      • absent breath sound
      • b/l fine crepitations present
      • CVS – apical impulse not visualised/ localised
      • muffled heart sounds
      In left infra scapular,infra axillary , infra mammary region. And right infra scapular regions as compared to the rest of the lung areas.
      • P/A
      • distended , umbilicus – normal
      • flank fullness present
      • Liver – palpable 4 cm below right costal margin, firm , tender ,
      • Spleen – tip just palpable
      • Shifting dullness present
      • CNS :- no fnd
    • Problems
      • Fever – low grade 15 days
      • B/L pleural effusion more on Left side
      • Pericardial Effusion
      • Ascites
      • Hepatomegaly
      • On ATT.
    • Provisional diagnosis
      • Poly serositis for evaluation
      • Pericardial effusion causing right heart failure and then secondary ascites and pleural effusion
    • Investigations
      • Hb – 10.4 gm %
      • TC – 9500 cells
      • DC – P68 , L30, E-1,
      • Platelet – 2.5 lac
      • PCV – 31 %
      • ESR – 42 mm / hr
      • RBS – 70 mg %
      • Urea- 22 mg %
      • Cr- 0.8 mg %
      • Urine examination:
      • Sugar – nil
      • Protein – +
      • Pus cell – nil
      • RBC – nil
      • Epi cel – 2-3 / hpf
      • 24 hrs urine protein – 150 mg/day
      • Urine C/S – E. coli growth
      • ECG
          • Sinus tachycardia
          • Normal axis
          • Low voltage complexes
          • No electrical alternans
          • No ST –T changes
    • Radiography CXR AP VIEW
    • Cardiologist opinion
      • Large pericardial effusion
      • Thickened pericardium
      • Few calcific spots seen
      • No pericardial strands seen
      • No e/o diastolic collapse of RV / RA
      • No tamponade
      • Normal LV systolic function
      • No regional wall abnormality
      • Trivial TR
      • No PHT.
      • No current need for pericardiocentesis
      • Patient to be managed conservatively
    • Serum levels Right Pleural Effusion Left Pleural Effusion Ascites Physical - Clear straw coloured Blood tinged Clear straw coloured Sugar – 100 mg% 81 96 101 Protein - 5.5 gm/dl 2.4 gm/dl 5.0 gm/dl 2.9 gm/dl Albumin – 3.5 gm --- --- 1.7 gm Grams stain AFB -- -- -- -- -- -- Cell count Few lymphocytes seen No atypical cells Few lymphocytes seen No atyical cells Acellular smear Impression Transudative Exudative Transudative
    •  
    • Investigations …….
      • LFT :
      • Bilirubin (T) – 0.8mg %
      • SGOT – 34 IU/L
      • SGPT – 26 IU/L
      • Protein – 5.5 gm/L
      • Albumin 3.5 gm/L
      • HIV – non reactive
      • HBs Ag - neg
      • HCV – neg
      CRP – 57.14 mg/L TSH – 0.33 mic/dl Total T3 – 96 mic/dl Total T4 – 7.8 mic/dl ANA – negative RA – negative Pleural fluid ADA – 10 U/L Sputum AFB – neg Mantoux - neg
      • USG Abdomen :
      • Liver enlarged – 17 cm , altered echotexture ,
      • GB , Pancreas , Spleen – normal study
      • Kidney - both kidney are of normal size , echoes and CMD maintained with PCS - normal
      • Uterus , Ovaries ,Bladder - normal study
      • Ascites present
      • Para aortic area – obscured
      • B/L pleural effusion present
      • Impression : Hepatomegaly with serous effusion
      • to be co-related clinically.
    • Course in ward
      • As the patient had a pericardial effusion with thickened pericardium, a provisional diagnosis of subeffusive constrictive pericarditis probably tuberculous etiology was entertained
      • Treatment given :
      • ATT Cat 1
      • Oral Predisolone
      • Accordingly , CTS opinion was sought for favour of surgical management
      • CTS opinion :
      • To get anaesthesia fitness for pericardiotomy/pericardectomy (to avoid future tamponade/ constriction)
      • Anaesthesia fitness was obtained and consent taken
      • Surgery was done on 13/12/10
    • Operative notes summary
      • Left anterio-lateral thoracotomy
      • 500 ml of blood stained fluid was evacuated
      • Large bosselated tumor was present at the root of the main pulmonary trunk
      • Mass was adherent to great vessels
      • In view of inoperability of the tumor , incisional biopsy was taken
      • Pericardium anterior to the left phrenic nerve was excised
      • Left pleural space drained
      • Pericardial drain was inserted
    • Intraop photograph
    •  
    •  
    • POST OP CXR
    • Postop CT Scan Chest
    •  
    •  
    •  
    • POST OP DIAGNOSIS
      • MALIGNANT PERICARDIAL EFFUSION
    • Biopsy report
      • Section studied shows a well circumscribed lesion composed of Spindles cells, arranged in intervening fascicles and bundles and small blood vessels of the size of capillaries.
      • Areas of Haemorrhage and haemosederin laden macrophages seen. Focal ares of hyalinisation seen.
      • No giant cells, mitosis, necrosis or inflammatory infiltrate seen
      • IMP : f/s/o Haemangiopericytoma
      • DD - Benign fibrous histiocytoma
      • Suggested IHC
    •  
    •  
      • Immuno histo chemistry results :
      • AWAITED
    • FINAL DIAGNOSIS
      • PRIMARY MEDIASTINAL HAEMANGIOPERICYTOMA
      • With Local invasion
      • & Malignant pericardial effusion
    • Further Course….
      • Patient improved symptomatically after the procedure
      • She was referred to Medical Oncology department
      • Advised to review with IHC reports
    •  
    • A 53-year-old woman complained of cough and dyspnea for months before consultation. The chest X-rays and computed tomography revealed a well-defined mass in the left middle mediastinum with necrotic changes and calcification within it. The patient underwent left thoracotomy with tumor resection, and a final diagnosis of primary mediastinal hemangiopericytoma was made.
    •  
    • HEMANGIOPERICYTOMA
      • Hemangiopericytoma is one type of soft tissue sarcoma arising from the pericytes of Zimmerman in the walls of capillaries.
      • Intrathoracic hemangiopericytoma usually arises from pericytes that surround the basement membrane of capillaries and small venules within the lung parenchyma.
      • Most common sites : limbs, pelvis, head and neck
      • Primary mediastinal hemangiopericytoma represents 6% of primary mediastinum tumors.
      • TYPES : Infantile or Adult type;
      • Benign or malignant,
      • low grade or high grade
      • Histologically : tightly packed spindle cells around ramifying thin walled and endothelial lined vascular channels ranging from small capillaries to large gaping sinusoidal spaces.
      • Malignant hemangiopericytoma is recognized by its increased mitotic rate, tumor size and foci of hemorrhage and necrosis
      • Hemangiopericytoma has no uniform clinical or radiographic features, usually affects older individuals, and mostly presents as an asymptomatic, non-calcified solitary mass on chest X-ray.
      • Immunohistochemically, hemangiopericytomas are known to show a positive response to antibodies against vimentin and type IV collagen and a negative response to VIII-related antigen, S-100 protein, neuron specific enolase, carcinoembryonic antigen, desmins, laminin and cytokeratins [ 9 ].
      • Differential diagnosis : solitary fibrous tumor
      • mesenchymal chondrosarcoma
      • synovial sarcoma
      • fibrous histiocytoma.
      • Treatment : surgery,
      • chemotherapy
      • (vincristin, cyclophosphamide, doxorubicin,
      • dactinomycen, methotrexate and metoxantrone)
      • Spontaneous bleeding into pleura/pericardium leads to haemorragic pleural/pericardial effusion
      • Infiltration of major vessels makes the tumor inoperable-(complete curable resection made impossible)
      • Attempt to partially resect this highly vascular tumor will cause heavy blood loss
      • Prognosis of malignant disease is poor. Recurrence rate is high in the first 2 years. Hence , careful follow up is advised.
      • We thank
      • Dept of Cardio-Thoracic Surgery
      • Dept of Cardiology
      • Dept of Pathology
      • GSH , Chennai.