A case report of malignant primary pericardial mesothelioma with atypical imaging appearance: multimodality imaging with histopathological correlation

Our plain-English summary of A case report of malignant primary pericardial mesothelioma with atypical imaging appearance: multimodality imaging with histopathological correlation, by A. Banišauskaitė, A. Jankauskas, V. Šarauskas, et al (European Heart Journal. Case Reports, 2020).

The study

• Authors: A. Banišauskaitė, A. Jankauskas, V. Šarauskas, M. Aržanauskaitė
• Journal: European Heart Journal. Case Reports
• Published: 2020;4(2):1-5
• Cited by: 8 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Primary pericardial mesothelioma is a rare primary cardiac malignancy, with three main histopathological types, sarcomatoid histotype being the rarest. The imaging features were atypical due to concomitant extensive calcification, which resulted in aggravated differential diagnosis.

Case Summary: A 45-year-old man presented to our hospital with non-specific clinical symptoms. According to clinical history, a mediastinal tumour had been suspected with a previous unsuccessful attempt of transthoracic computed tomography-guided biopsy at an overseas hospital with limited data of performed imaging procedures. Multimodality imaging at our centre revealed extensively calcified solid masses in the pericardium, invading the left atrium. As the imaging features suggested an atypical primary pericardial malignancy, a diagnostic thoracoscopy was performed. Histopathological analysis of specimen revealed sarcomatoid type of pericardial mesothelioma with areas of necrosis and foci of osteogenic differentiation. Despite planned treatment, 2 weeks after histological diagnosis, the patient passed away due to perforated peptic ulcer-related sepsis.

Discussion: The presence of extensive calcification in the lesion resulted in a challenging imaging workup and diagnosis. Initial differential diagnosis included primary or metastatic calcification-prone tumour, secondary calcification due to haemorrhage after previous interventional procedure and other pathologies, such as tuberculous pericarditis, calcified amorphous tumour, among others. Calcification may be part of the histological tumour characteristics; however, proper history taking is crucial as concomitant diseases, previous treatment, and interventional procedures may alter the imaging pattern.

© The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology.

In plain English

This was a case report about one patient, a 45-year-old man. He came to the authors' hospital with a 1-year history of breathlessness, palpitations, chest pain and other symptoms. A CT-guided biopsy of a suspected mediastinal tumour at another hospital had been complicated by pericardial tamponade and gave uninformative tissue. At the authors' centre, echocardiography, CT and cardiovascular magnetic resonance showed a large, extensively calcified solid mass in the pericardium (the sac around the heart). The mass invaded the left atrium and had satellite nodules. A nodule was removed by thoracoscopy. Tissue analysis showed sarcomatoid primary pericardial mesothelioma with necrosis and foci of osteogenic (bone-forming) differentiation. The tumour was too advanced for surgery, and chemotherapy was scheduled. Two weeks after diagnosis, he died of sepsis related to a perforated peptic ulcer, which the authors said may have followed long-term dexamethasone treatment. The authors suggested the calcification may partly have come from a haematoma (blood collection) after the first biopsy. The report did not describe any asbestos exposure for this patient. The authors concluded that knowing the imaging features helps narrow the possible diagnoses.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: case report (single patient)
• Who was studied: One 45-year-old man seen at the authors' hospital, who had previously had an unsuccessful CT-guided biopsy at an overseas hospital
• Main results:
  • Six months before admission, a CT-guided biopsy of the suspected mediastinal tumour at another hospital was complicated by pericardial tamponade.
  • ECG-gated CT showed a large (14 by 8 by 12 cm), heterogeneous, contrast-enhancing, markedly calcified pericardial lesion extending into the left atrial walls.
  • Cardiovascular magnetic resonance confirmed a large solid pericardial mass (14 by 7 by 14 cm) along the left ventricular walls, invading the left atrium.
  • Tissue from thoracoscopy showed sarcomatoid pericardial mesothelioma with necrosis and foci of osteogenic differentiation.
  • Immunohistochemistry was positive for cytokeratin and epithelial membrane antigen (EMA).
  • The tumour was too advanced for surgical removal, and an oncology appointment for chemotherapy was scheduled.
  • The patient died 2 weeks after histological diagnosis from sepsis related to a perforated peptic ulcer.
  • The authors said the peptic ulcer may have developed after long-term dexamethasone treatment.
  • The authors suggested that a possible reason for the calcification was a chronic haematoma caused by the first biopsy.
• The authors' conclusion: The authors concluded that, although malignant primary pericardial mesothelioma is very rare, knowledge of its imaging features and multimodality imaging help narrow the possible diagnoses.

Topics

Medical terms in this study, explained in our Lexicon: Pericardial Mesothelioma, Sarcomatoid, Differential Diagnosis, Biopsy, Pericardium, Pericardial, Thoracoscopy, Necrosis.

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