Case Report
Large Pericardial Cyst in an Asymptomatic Child: A Case Report
World Journal for Pediatric and Congenital Heart Surgery 4(3) 315-317 ª The Author(s) 2012 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/2150135112471351 pch.sagepub.com
S. Loggos1, F. Mitropoulos1, K. Kondrafouris1, M. Milonakis1, M. Kanakis1, A. Chantzis1, D. Bobos1, N. Giannopoulos1, and P. Azariadis1
Abstract We present a case report of a nine-year-old asymptomatic girl with a large cystic lesion of the left hemithorax, occupying almost 80% of the left hemithorax, first believed to be a parasitic cyst that was operated and proved to be of parietal pericardial origin. Mediastinal cysts and pericardial cysts in particular are mostly discovered accidentally and so was the case with our patient. The diagnosis included not only clinical examination but also the utilization of computed tomography and magnetic resonance imaging. The only treatment for pericardial cysts is surgical excision and patients recover fully with no complication. Keywords Pericardial cyst, diagnosis, surgical treatment, asymptomatic, size Submitted July 7, 2012; Accepted November 1, 2012. Presented as a poster at the National Cardiothoracic Meeting, Thessaloniki Greece; November 23, 2012.
Introduction We present a case of a nine-year-old girl with no previous medical history that was referred to our unit with a large cystic lesion on the left hemithorax. Mediastinal cysts and pericardial cysts in particular are rare in the young population and the overall incidence of pericardial cyst is 1:1,000,000 in all age groups and very few cases below the age of 18 years.1 These constitute only 6% of all mediastinal masses and up to 11% of all mediastinal cysts.2-4 In most of the cases, these cysts are asymptomatic and are found incidentally during routine chest radiography or echocardiography.
Case Report The patient is a nine-year-old girl with no past medical history and normal development. She was first seen by a pediatrician, because of a viral infection, without accompanying chest pain or shortness of breath. The examination revealed decreased breath sounds over the left chest. The chest x-ray and chest and abdominal computed tomography (CT) revealed a large 12 7 cm, fluid to viscous filled cyst, on the left hemithorax (Figure 1A and B), with no clear point of origin. There was evidence of various compartments within the cyst but no signs of any parasitic organisms. The patient was tested for possible Hydatid infection and although the first set of tests were just above the normal values the second consecutive set of tests were within normal limits. The full blood count revealed no eosinophilia and both C-reactive protein and erythrocyte sedimentation rate were only mildly elevated. To complete the diagnosis an
magnetic resonance imaging (MRI) was performed (Figure 1C) which was in accordance with the findings of the CT. Echocardiogram, although routinely done in all patients in our department, was not used in this case as the MRI and CT were sufficient to support the decision to proceed with surgery and investigate the cyst by direct vision. She was transferred to our unit and after discussing the treatment options with her parents she was prepared for surgery. A left anterolateral thoracotomy was performed, through the 6th intercostal space. We chose open thoracotomy to videoassisted thoracic surgery (VATS), taking into account the unclear point of origin and the possibility that the cyst could have been a parasitic hydatid cyst with possible contamination of the thoracic cavity if wrongly manipulated. Upon entering the left hemithorax, a large mass filled with dark fluid was apparent with no visible point of origin, occupying almost 80% of the left hemithorax. Due to the size, and the indefinable borders to the left lung, which was compressed and atelectatic, we were unable to safely manipulate the lesion (Figure 2A). We then proceeded to aspirate and evacuate the cyst, so as to facilitate excision. As much as, 540 mL of bloody chocolate-
1
Department of Pediatric and Congenital Cardiac Surgery, Onassis Heart Center, Kalithea, Athens, Greece Corresponding Author: Spiros Loggos, Department of Pediatric and Congenital Cardiac Surgery, Onassis Heart Center, 356 Syggrou Avenue, Kalithea, 17674 Athens, Greece. Email: [email protected]
Downloaded from pch.sagepub.com at NORTH DAKOTA STATE UNIV LIB on June 30, 2015
316
World Journal for Pediatric and Congenital Heart Surgery 4(3)
Figure 1. A, B, The chest x-ray and chest and abdominal computed tomography (CT) performed both revealed a large 12 7 cm, fluid to viscous-filled cyst, on the left hemi thorax. C, To complete the diagnosis an magnetic resonance imaging (MRI) was performed.
Abbreviations and Acronyms CT MRI PICU VATS
computed tomography magnetic resonance imaging pediatric intensive care unit video-assisted thoracic surgery
colored viscous fluid were aspirated, with no spill of contents in the hemithorax and was sent to the laboratory for further investigations, including Gram stain and cytology. The lesion was now easier to manipulate and we were able to identify some attachments to the diaphragm, posterior mediastinum, and proceeded with dissection. The point of origin was in fact the parietal pericardium (Figure 2B). The cyst appeared to be lined with a thick capsule and there was no indication of a parasitic infection. The phrenic nerve was also trapped within the cyst and we were able to mobilize and conserve it (Figure 2C). We then proceeded in ligating the point of origin in the pericardium. Subsequently, the left lung expanded fully. The excised cyst was send for further tests. The histology report identified the cyst as a pericardial cyst with areas of inflammation and calcification, with no signs of malignancy. The girl was transferred to the pediatric intensive care unit (PICU) and was extubated two hours after the end of the procedure. She was transferred to the normal ward the following day and was discharged on the 5th postoperative day following a satisfactory echocardiogram and chest x-ray. She had a follow-up, with chest x-rays at 30 days, 6 months, and 12 months, and an echocardiogram at 6 months, with no findings.
Discussion Mediastinal cystic lesions can have their origin anywhere in the thoracic cavity. They vary in size, age of presentation, and type, and can either be benign or be malignant and their presenting symptoms can be specific or nonspecific. In the anterior and superior mediastinum the presented cysts include, thymic cysts, thyroid, and parathyroid, in the middle pericardial cysts, bronchogenic cysts, parathyroid cysts, parasitic or of infective
origin, and finally in the posterior mediastinum meningocele, esophageal cysts, thoracic duct cysts, and cystic hygroma. Finally, it is essential to include tumors, including, Hodgkin disease, germ cell tumors, mediastinal carcinomas, metastases to lymph nodes, among other types that are prone to undergo cystic degeneration, but are rare in the pediatric population.4 Regarding pericardial cysts, they are not common and are usually detected by chance. They are usually silent; nevertheless, symptoms and serious complications may occur including bleeding and hemorrhagic shock or tamponade,5 unspecific symptoms such as syncope or collapse due to compression of the heart chambers,5 respiratory distress,6 and chest pain. Echocardiography7 is the imaging modality most often used for the initial evaluation of pericardial disease, especially in patients suspected of having pericardial effusion or tamponade. Both CT and MRI offer distinct advantages in the imaging of the thoracic cavity. Both modalities provide a larger field of view than echocardiography, thus allowing the examination of the entire chest and detection of associated abnormalities in the mediastinum and lungs as well as providing excellent anatomic delineation and enable precise localization of the lesion in question. It is widely accepted that surgical exploration and treatment is the method of choice for these lesions once they grow in significant size or cause symptoms, although both conservative and invasive procedures have been used with success. They can be safely performed through a median sternotomy or a left lateral thoracotomy and also with the use of VATS.1
Conclusion Mediastinal and in particular pericardial cysts, although rare, present a significant challenge for the several specialties involved. The use of MRI, CT, and echocardiogram has made diagnosis and follow-up easier, as it is common for certain types of cysts, mainly pericardial cysts to be observed for a certain period of time for change is size, change in the radiological appearance, or change in presenting symptoms. The progress of VATS and minimal invasive procedures has improved surgical results, as surgery is the
Downloaded from pch.sagepub.com at NORTH DAKOTA STATE UNIV LIB on June 30, 2015
Loggos et al
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Figure 2. A, Due to the size, and the indefinable borders to the left lung, which was compressed and atelectatic, we were unable to safely manipulate the lesion. B, The point of origin was in fact the parietal pericardium. C, The phrenic nerve was also trapped within the cyst and we were able to mobilize and conserve it.
only treatment, in all cases, especially in view of acute hemodynamic or respiratory compromise. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Eto A, Arima T, Nagashima A. Pericardial cyst in a child treated with video-assisted thoracoscopic surgery. Eur J Pediatr. 2000; 159: 889-891. 2. Kumar S, Jain P, Sen R, et al. Giant pericardial cyst in a 5-yearold child: a rare anomaly. Ann Pediatr Cardiol. 2011;4(1): 68-70.
3. Noyes BE, Weber T, Vogler C. Pericardial cysts in children: surgical or conservative approach? J Pediat Surg. 2003;38: 1263-1265. 4. Zambudio AR, Lanzas JT, Calvo MJ, et al Non-neoplastic mediastinal cysts. Eur J Cardiothorac Surg. 2002;22(5): 712-716. 5. Debus V, Krasemann T, Semik M. An epicardial cyst in a child. Department of Pediatric Cardiology, Westfaelische WilhelmsUniversity Muenster, Germany. Cardiol Young. 2001;11(6): 660-662. 6. Upadhyaya M, Jaffer M. Life-threatening respiratory distress in a neonate with a pericardial cyst. Pediatr Surg Int. 2003;19(9-10): 680-682. 7. Wang ZJ, Reddy GP, Gotway MB, et al. CT and MR imaging of pericardial disease. Department of Radiology, University of California, San Francisco, CA, USA Radiographics. 2003 Oct;23 Spec No: S167-80. 8. Tanoue Y, Fujita S, Kanaya Y, et al. Acute cardiac tamponade due to a bleeding pericardial cyst in a 3-year-old child. Department of Cardiovascular Surgery, Kyushu University, Fukuoka, Japan. Ann Thorac Surg. 2007;84(1): 282-284.
Downloaded from pch.sagepub.com at NORTH DAKOTA STATE UNIV LIB on June 30, 2015
Large Pericardial Cyst in an Asymptomatic Child: A Case Report
World Journal for Pediatric and Congenital Heart Surgery 4(3) 315-317 ª The Author(s) 2012 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/2150135112471351 pch.sagepub.com
S. Loggos1, F. Mitropoulos1, K. Kondrafouris1, M. Milonakis1, M. Kanakis1, A. Chantzis1, D. Bobos1, N. Giannopoulos1, and P. Azariadis1
Abstract We present a case report of a nine-year-old asymptomatic girl with a large cystic lesion of the left hemithorax, occupying almost 80% of the left hemithorax, first believed to be a parasitic cyst that was operated and proved to be of parietal pericardial origin. Mediastinal cysts and pericardial cysts in particular are mostly discovered accidentally and so was the case with our patient. The diagnosis included not only clinical examination but also the utilization of computed tomography and magnetic resonance imaging. The only treatment for pericardial cysts is surgical excision and patients recover fully with no complication. Keywords Pericardial cyst, diagnosis, surgical treatment, asymptomatic, size Submitted July 7, 2012; Accepted November 1, 2012. Presented as a poster at the National Cardiothoracic Meeting, Thessaloniki Greece; November 23, 2012.
Introduction We present a case of a nine-year-old girl with no previous medical history that was referred to our unit with a large cystic lesion on the left hemithorax. Mediastinal cysts and pericardial cysts in particular are rare in the young population and the overall incidence of pericardial cyst is 1:1,000,000 in all age groups and very few cases below the age of 18 years.1 These constitute only 6% of all mediastinal masses and up to 11% of all mediastinal cysts.2-4 In most of the cases, these cysts are asymptomatic and are found incidentally during routine chest radiography or echocardiography.
Case Report The patient is a nine-year-old girl with no past medical history and normal development. She was first seen by a pediatrician, because of a viral infection, without accompanying chest pain or shortness of breath. The examination revealed decreased breath sounds over the left chest. The chest x-ray and chest and abdominal computed tomography (CT) revealed a large 12 7 cm, fluid to viscous filled cyst, on the left hemithorax (Figure 1A and B), with no clear point of origin. There was evidence of various compartments within the cyst but no signs of any parasitic organisms. The patient was tested for possible Hydatid infection and although the first set of tests were just above the normal values the second consecutive set of tests were within normal limits. The full blood count revealed no eosinophilia and both C-reactive protein and erythrocyte sedimentation rate were only mildly elevated. To complete the diagnosis an
magnetic resonance imaging (MRI) was performed (Figure 1C) which was in accordance with the findings of the CT. Echocardiogram, although routinely done in all patients in our department, was not used in this case as the MRI and CT were sufficient to support the decision to proceed with surgery and investigate the cyst by direct vision. She was transferred to our unit and after discussing the treatment options with her parents she was prepared for surgery. A left anterolateral thoracotomy was performed, through the 6th intercostal space. We chose open thoracotomy to videoassisted thoracic surgery (VATS), taking into account the unclear point of origin and the possibility that the cyst could have been a parasitic hydatid cyst with possible contamination of the thoracic cavity if wrongly manipulated. Upon entering the left hemithorax, a large mass filled with dark fluid was apparent with no visible point of origin, occupying almost 80% of the left hemithorax. Due to the size, and the indefinable borders to the left lung, which was compressed and atelectatic, we were unable to safely manipulate the lesion (Figure 2A). We then proceeded to aspirate and evacuate the cyst, so as to facilitate excision. As much as, 540 mL of bloody chocolate-
1
Department of Pediatric and Congenital Cardiac Surgery, Onassis Heart Center, Kalithea, Athens, Greece Corresponding Author: Spiros Loggos, Department of Pediatric and Congenital Cardiac Surgery, Onassis Heart Center, 356 Syggrou Avenue, Kalithea, 17674 Athens, Greece. Email: [email protected]
Downloaded from pch.sagepub.com at NORTH DAKOTA STATE UNIV LIB on June 30, 2015
316
World Journal for Pediatric and Congenital Heart Surgery 4(3)
Figure 1. A, B, The chest x-ray and chest and abdominal computed tomography (CT) performed both revealed a large 12 7 cm, fluid to viscous-filled cyst, on the left hemi thorax. C, To complete the diagnosis an magnetic resonance imaging (MRI) was performed.
Abbreviations and Acronyms CT MRI PICU VATS
computed tomography magnetic resonance imaging pediatric intensive care unit video-assisted thoracic surgery
colored viscous fluid were aspirated, with no spill of contents in the hemithorax and was sent to the laboratory for further investigations, including Gram stain and cytology. The lesion was now easier to manipulate and we were able to identify some attachments to the diaphragm, posterior mediastinum, and proceeded with dissection. The point of origin was in fact the parietal pericardium (Figure 2B). The cyst appeared to be lined with a thick capsule and there was no indication of a parasitic infection. The phrenic nerve was also trapped within the cyst and we were able to mobilize and conserve it (Figure 2C). We then proceeded in ligating the point of origin in the pericardium. Subsequently, the left lung expanded fully. The excised cyst was send for further tests. The histology report identified the cyst as a pericardial cyst with areas of inflammation and calcification, with no signs of malignancy. The girl was transferred to the pediatric intensive care unit (PICU) and was extubated two hours after the end of the procedure. She was transferred to the normal ward the following day and was discharged on the 5th postoperative day following a satisfactory echocardiogram and chest x-ray. She had a follow-up, with chest x-rays at 30 days, 6 months, and 12 months, and an echocardiogram at 6 months, with no findings.
Discussion Mediastinal cystic lesions can have their origin anywhere in the thoracic cavity. They vary in size, age of presentation, and type, and can either be benign or be malignant and their presenting symptoms can be specific or nonspecific. In the anterior and superior mediastinum the presented cysts include, thymic cysts, thyroid, and parathyroid, in the middle pericardial cysts, bronchogenic cysts, parathyroid cysts, parasitic or of infective
origin, and finally in the posterior mediastinum meningocele, esophageal cysts, thoracic duct cysts, and cystic hygroma. Finally, it is essential to include tumors, including, Hodgkin disease, germ cell tumors, mediastinal carcinomas, metastases to lymph nodes, among other types that are prone to undergo cystic degeneration, but are rare in the pediatric population.4 Regarding pericardial cysts, they are not common and are usually detected by chance. They are usually silent; nevertheless, symptoms and serious complications may occur including bleeding and hemorrhagic shock or tamponade,5 unspecific symptoms such as syncope or collapse due to compression of the heart chambers,5 respiratory distress,6 and chest pain. Echocardiography7 is the imaging modality most often used for the initial evaluation of pericardial disease, especially in patients suspected of having pericardial effusion or tamponade. Both CT and MRI offer distinct advantages in the imaging of the thoracic cavity. Both modalities provide a larger field of view than echocardiography, thus allowing the examination of the entire chest and detection of associated abnormalities in the mediastinum and lungs as well as providing excellent anatomic delineation and enable precise localization of the lesion in question. It is widely accepted that surgical exploration and treatment is the method of choice for these lesions once they grow in significant size or cause symptoms, although both conservative and invasive procedures have been used with success. They can be safely performed through a median sternotomy or a left lateral thoracotomy and also with the use of VATS.1
Conclusion Mediastinal and in particular pericardial cysts, although rare, present a significant challenge for the several specialties involved. The use of MRI, CT, and echocardiogram has made diagnosis and follow-up easier, as it is common for certain types of cysts, mainly pericardial cysts to be observed for a certain period of time for change is size, change in the radiological appearance, or change in presenting symptoms. The progress of VATS and minimal invasive procedures has improved surgical results, as surgery is the
Downloaded from pch.sagepub.com at NORTH DAKOTA STATE UNIV LIB on June 30, 2015
Loggos et al
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Figure 2. A, Due to the size, and the indefinable borders to the left lung, which was compressed and atelectatic, we were unable to safely manipulate the lesion. B, The point of origin was in fact the parietal pericardium. C, The phrenic nerve was also trapped within the cyst and we were able to mobilize and conserve it.
only treatment, in all cases, especially in view of acute hemodynamic or respiratory compromise. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References 1. Eto A, Arima T, Nagashima A. Pericardial cyst in a child treated with video-assisted thoracoscopic surgery. Eur J Pediatr. 2000; 159: 889-891. 2. Kumar S, Jain P, Sen R, et al. Giant pericardial cyst in a 5-yearold child: a rare anomaly. Ann Pediatr Cardiol. 2011;4(1): 68-70.
3. Noyes BE, Weber T, Vogler C. Pericardial cysts in children: surgical or conservative approach? J Pediat Surg. 2003;38: 1263-1265. 4. Zambudio AR, Lanzas JT, Calvo MJ, et al Non-neoplastic mediastinal cysts. Eur J Cardiothorac Surg. 2002;22(5): 712-716. 5. Debus V, Krasemann T, Semik M. An epicardial cyst in a child. Department of Pediatric Cardiology, Westfaelische WilhelmsUniversity Muenster, Germany. Cardiol Young. 2001;11(6): 660-662. 6. Upadhyaya M, Jaffer M. Life-threatening respiratory distress in a neonate with a pericardial cyst. Pediatr Surg Int. 2003;19(9-10): 680-682. 7. Wang ZJ, Reddy GP, Gotway MB, et al. CT and MR imaging of pericardial disease. Department of Radiology, University of California, San Francisco, CA, USA Radiographics. 2003 Oct;23 Spec No: S167-80. 8. Tanoue Y, Fujita S, Kanaya Y, et al. Acute cardiac tamponade due to a bleeding pericardial cyst in a 3-year-old child. Department of Cardiovascular Surgery, Kyushu University, Fukuoka, Japan. Ann Thorac Surg. 2007;84(1): 282-284.
Downloaded from pch.sagepub.com at NORTH DAKOTA STATE UNIV LIB on June 30, 2015
