A Case of Malignant Pericardial Effusion

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A Case of Malignant Pericardial Effusion

  1. 1. Prof. Dr. Magesh kumar Unit M 1 unit Dr. Priya Kubendiran
  2. 2. Case History
  3. 3. <ul><li>H/o loss of weight/ appetite + </li></ul><ul><li>No h/o chest pain , palpitation , syncope </li></ul><ul><li>No H/o skin rash , joint pains, joint swelling </li></ul><ul><li>Past history : </li></ul><ul><li>No h/o similar complaints in the past </li></ul><ul><li>No H/o TB or contact with TB patient </li></ul><ul><li>No h/o jaundice in past </li></ul><ul><li>Not a k/c/o SHT , DM , TB , IHD , </li></ul><ul><li>Personal History : </li></ul><ul><li>Married with 2 children </li></ul><ul><li>No H/o bad obstetric history </li></ul><ul><li>Mixed diet </li></ul>
  4. 4. <ul><li>Family History - nil significant </li></ul><ul><li>Treatment history – </li></ul><ul><li>Had been receiving treatment from a local practitioner in the form of oral medications for the above complaints </li></ul><ul><li>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. </li></ul>
  5. 5. O/E : <ul><li>She is conscious, oriented </li></ul><ul><li>thin built , fairly hydrated , dyspneic </li></ul><ul><li>Pale , no cyanosis , clubbing,icterus, </li></ul><ul><li>B/L pitting pedal oedema + </li></ul><ul><li>Facial puffiness present </li></ul><ul><li>No lymph node palpable </li></ul><ul><li>Neck veins distended </li></ul><ul><li>JVP – elevated upto 8 cm. ( CVP – 13 cm of blood column ) </li></ul><ul><li>Vitals : T – 99F , </li></ul><ul><li>PR – 120 /min </li></ul><ul><li>RR – 26 / min </li></ul><ul><li>BP – 100/70 mm of Hg </li></ul>
  6. 6. <ul><li>RS – trachea shift to Right </li></ul><ul><li>use of accessory muscles present </li></ul><ul><li>spine , shoulder ,scapulae – normal </li></ul><ul><li>dull note on percussion </li></ul><ul><li>reduced VF / VR </li></ul><ul><li>absent breath sound </li></ul><ul><li>b/l fine crepitations present </li></ul><ul><li>CVS – apical impulse not visualised/ localised </li></ul><ul><li>muffled heart sounds </li></ul>In left infra scapular,infra axillary , infra mammary region. And right infra scapular regions as compared to the rest of the lung areas.
  7. 7. <ul><li>P/A </li></ul><ul><li>distended , umbilicus – normal </li></ul><ul><li>flank fullness present </li></ul><ul><li>Liver – palpable 4 cm below right costal margin, firm , tender , </li></ul><ul><li>Spleen – tip just palpable </li></ul><ul><li>Shifting dullness present </li></ul><ul><li>CNS :- no fnd </li></ul>
  8. 8. Problems <ul><li>Fever – low grade 15 days </li></ul><ul><li>B/L pleural effusion more on Left side </li></ul><ul><li>Pericardial Effusion </li></ul><ul><li>Ascites </li></ul><ul><li>Hepatomegaly </li></ul><ul><li>On ATT. </li></ul>
  9. 9. Provisional diagnosis <ul><li>Poly serositis for evaluation </li></ul><ul><li>Pericardial effusion causing right heart failure and then secondary ascites and pleural effusion </li></ul>
  10. 10. Investigations <ul><li>Hb – 10.4 gm % </li></ul><ul><li>TC – 9500 cells </li></ul><ul><li>DC – P68 , L30, E-1, </li></ul><ul><li>Platelet – 2.5 lac </li></ul><ul><li>PCV – 31 % </li></ul><ul><li>ESR – 42 mm / hr </li></ul><ul><li>RBS – 70 mg % </li></ul><ul><li>Urea- 22 mg % </li></ul><ul><li>Cr- 0.8 mg % </li></ul>
  11. 11. <ul><li>Urine examination: </li></ul><ul><li>Sugar – nil </li></ul><ul><li>Protein – + </li></ul><ul><li>Pus cell – nil </li></ul><ul><li>RBC – nil </li></ul><ul><li>Epi cel – 2-3 / hpf </li></ul><ul><li>24 hrs urine protein – 150 mg/day </li></ul><ul><li>Urine C/S – E. coli growth </li></ul>
  12. 12. <ul><li>ECG </li></ul><ul><ul><ul><li>Sinus tachycardia </li></ul></ul></ul><ul><ul><ul><li>Normal axis </li></ul></ul></ul><ul><ul><ul><li>Low voltage complexes </li></ul></ul></ul><ul><ul><ul><li>No electrical alternans </li></ul></ul></ul><ul><ul><ul><li>No ST –T changes </li></ul></ul></ul>
  13. 13. Radiography CXR AP VIEW
  14. 14. Cardiologist opinion <ul><li>Large pericardial effusion </li></ul><ul><li>Thickened pericardium </li></ul><ul><li>Few calcific spots seen </li></ul><ul><li>No pericardial strands seen </li></ul><ul><li>No e/o diastolic collapse of RV / RA </li></ul><ul><li>No tamponade </li></ul><ul><li>Normal LV systolic function </li></ul><ul><li>No regional wall abnormality </li></ul><ul><li>Trivial TR </li></ul><ul><li>No PHT. </li></ul><ul><li>No current need for pericardiocentesis </li></ul><ul><li>Patient to be managed conservatively </li></ul>
  15. 15. 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
  16. 17. Investigations ……. <ul><li>LFT : </li></ul><ul><li>Bilirubin (T) – 0.8mg % </li></ul><ul><li>SGOT – 34 IU/L </li></ul><ul><li>SGPT – 26 IU/L </li></ul><ul><li>Protein – 5.5 gm/L </li></ul><ul><li>Albumin 3.5 gm/L </li></ul><ul><li>HIV – non reactive </li></ul><ul><li>HBs Ag - neg </li></ul><ul><li>HCV – neg </li></ul>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
  17. 18. <ul><li>USG Abdomen : </li></ul><ul><li>Liver enlarged – 17 cm , altered echotexture , </li></ul><ul><li>GB , Pancreas , Spleen – normal study </li></ul><ul><li>Kidney - both kidney are of normal size , echoes and CMD maintained with PCS - normal </li></ul><ul><li>Uterus , Ovaries ,Bladder - normal study </li></ul><ul><li>Ascites present </li></ul><ul><li>Para aortic area – obscured </li></ul><ul><li>B/L pleural effusion present </li></ul><ul><li>Impression : Hepatomegaly with serous effusion </li></ul><ul><li>to be co-related clinically. </li></ul>
  18. 19. Course in ward <ul><li>As the patient had a pericardial effusion with thickened pericardium, a provisional diagnosis of subeffusive constrictive pericarditis probably tuberculous etiology was entertained </li></ul><ul><li>Treatment given : </li></ul><ul><li>ATT Cat 1 </li></ul><ul><li>Oral Predisolone </li></ul>
  19. 20. <ul><li>Accordingly , CTS opinion was sought for favour of surgical management </li></ul><ul><li>CTS opinion : </li></ul><ul><li>To get anaesthesia fitness for pericardiotomy/pericardectomy (to avoid future tamponade/ constriction) </li></ul><ul><li>Anaesthesia fitness was obtained and consent taken </li></ul><ul><li>Surgery was done on 13/12/10 </li></ul>
  20. 21. Operative notes summary <ul><li>Left anterio-lateral thoracotomy </li></ul><ul><li>500 ml of blood stained fluid was evacuated </li></ul><ul><li>Large bosselated tumor was present at the root of the main pulmonary trunk </li></ul><ul><li>Mass was adherent to great vessels </li></ul><ul><li>In view of inoperability of the tumor , incisional biopsy was taken </li></ul><ul><li>Pericardium anterior to the left phrenic nerve was excised </li></ul><ul><li>Left pleural space drained </li></ul><ul><li>Pericardial drain was inserted </li></ul>
  21. 22. Intraop photograph
  22. 25. POST OP CXR
  23. 26. Postop CT Scan Chest
  24. 30. POST OP DIAGNOSIS <ul><li>MALIGNANT PERICARDIAL EFFUSION </li></ul>
  25. 31. Biopsy report <ul><li>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. </li></ul><ul><li>Areas of Haemorrhage and haemosederin laden macrophages seen. Focal ares of hyalinisation seen. </li></ul><ul><li>No giant cells, mitosis, necrosis or inflammatory infiltrate seen </li></ul><ul><li>IMP : f/s/o Haemangiopericytoma </li></ul><ul><li>DD - Benign fibrous histiocytoma </li></ul><ul><li>Suggested IHC </li></ul>
  26. 34. <ul><li>Immuno histo chemistry results : </li></ul><ul><li>AWAITED </li></ul>
  27. 35. FINAL DIAGNOSIS <ul><li>PRIMARY MEDIASTINAL HAEMANGIOPERICYTOMA </li></ul><ul><li>With Local invasion </li></ul><ul><li>& Malignant pericardial effusion </li></ul>
  28. 36. Further Course…. <ul><li>Patient improved symptomatically after the procedure </li></ul><ul><li>She was referred to Medical Oncology department </li></ul><ul><li>Advised to review with IHC reports </li></ul>
  29. 38. 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.
  30. 40. HEMANGIOPERICYTOMA <ul><li>Hemangiopericytoma is one type of soft tissue sarcoma arising from the pericytes of Zimmerman in the walls of capillaries. </li></ul><ul><li>Intrathoracic hemangiopericytoma usually arises from pericytes that surround the basement membrane of capillaries and small venules within the lung parenchyma. </li></ul><ul><li>Most common sites : limbs, pelvis, head and neck </li></ul><ul><li>Primary mediastinal hemangiopericytoma represents 6% of primary mediastinum tumors. </li></ul>
  31. 41. <ul><li>TYPES : Infantile or Adult type; </li></ul><ul><li>Benign or malignant, </li></ul><ul><li>low grade or high grade </li></ul><ul><li>Histologically : tightly packed spindle cells around ramifying thin walled and endothelial lined vascular channels ranging from small capillaries to large gaping sinusoidal spaces. </li></ul><ul><li>Malignant hemangiopericytoma is recognized by its increased mitotic rate, tumor size and foci of hemorrhage and necrosis </li></ul>
  32. 42. <ul><li>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. </li></ul><ul><li>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 ]. </li></ul>
  33. 43. <ul><li>Differential diagnosis : solitary fibrous tumor </li></ul><ul><li>mesenchymal chondrosarcoma </li></ul><ul><li>synovial sarcoma </li></ul><ul><li>fibrous histiocytoma. </li></ul><ul><li>Treatment : surgery, </li></ul><ul><li>chemotherapy </li></ul><ul><li>(vincristin, cyclophosphamide, doxorubicin, </li></ul><ul><li>dactinomycen, methotrexate and metoxantrone) </li></ul>
  34. 44. <ul><li>Spontaneous bleeding into pleura/pericardium leads to haemorragic pleural/pericardial effusion </li></ul><ul><li>Infiltration of major vessels makes the tumor inoperable-(complete curable resection made impossible) </li></ul><ul><li>Attempt to partially resect this highly vascular tumor will cause heavy blood loss </li></ul><ul><li>Prognosis of malignant disease is poor. Recurrence rate is high in the first 2 years. Hence , careful follow up is advised. </li></ul>
  35. 45. <ul><li>We thank </li></ul><ul><li>Dept of Cardio-Thoracic Surgery </li></ul><ul><li>Dept of Cardiology </li></ul><ul><li>Dept of Pathology </li></ul><ul><li>GSH , Chennai. </li></ul>

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