a case of malignant pericardial effusion
TRANSCRIPT
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Prof. Dr. Magesh kumar UnitM 1 unit
Dr. Priya Kubendiran
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Case History
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H/o loss of weight/ appetite +No h/o chest pain , palpitation , syncopeNo 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 patientNo h/o jaundice in pastNot a k/c/o SHT , DM , TB , IHD ,
Personal History :Married with 2 childrenNo H/o bad obstetric historyMixed diet
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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.
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O/E :She is conscious, oriented thin built , fairly hydrated , dyspneicPale , no cyanosis , clubbing,icterus,B/L pitting pedal oedema +Facial puffiness presentNo lymph node palpableNeck 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
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RS – trachea shift to Rightuse of accessory muscles presentspine , shoulder ,scapulae – normaldull note on percussionreduced VF / VRabsent 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.
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P/A distended , umbilicus – normalflank fullness present
Liver – palpable 4 cm below right costal margin, firm , tender ,
Spleen – tip just palpable Shifting dullness present
CNS:- no fnd
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ProblemsFever – low grade 15 daysB/L pleural effusion more on Left sidePericardial EffusionAscitesHepatomegaly On ATT.
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Provisional diagnosis
Poly serositis for evaluation
Pericardial effusion causing right heart failure and then secondary ascites and pleural effusion
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InvestigationsHb – 10.4 gm %TC – 9500 cellsDC – P68 , L30, E-
1,Platelet – 2.5 lacPCV – 31 %ESR – 42 mm / hr
RBS – 70 mg %Urea- 22 mg %Cr- 0.8 mg %
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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
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ECG
Sinus tachycardia Normal axis Low voltage complexes No electrical alternans No ST –T changes
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Radiography
CXR AP VIEW
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Cardiologist opinionLarge pericardial effusionThickened pericardiumFew calcific spots seenNo pericardial strands seenNo e/o diastolic collapse of RV / RANo tamponadeNormal LV systolic functionNo regional wall abnormalityTrivial TRNo PHT.
No current need for pericardiocentesisPatient to be managed conservatively
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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
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Cell count Few lymphocytes seenNo atypical cells
Few lymphocytes seenNo atyical cells
Acellular smear
Impression Transudative Exudative Transudative
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Investigations …….
LFT :Bilirubin (T) – 0.8mg %SGOT – 34 IU/LSGPT – 26 IU/LProtein – 5.5 gm/LAlbumin 3.5 gm/L
HIV – non reactiveHBs Ag - negHCV – neg
CRP – 57.14 mg/L
TSH – 0.33 mic/dlTotal T3 – 96 mic/dlTotal T4 – 7.8 mic/dl
ANA – negativeRA – negative
Pleural fluid ADA – 10 U/L
Sputum AFB – negMantoux - neg
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USG Abdomen:
Liver enlarged – 17 cm , altered echotexture ,GB , Pancreas , Spleen – normal studyKidney - both kidney are of normal size , echoes
and CMD maintained with PCS - normalUterus , Ovaries ,Bladder - normal studyAscites presentPara aortic area – obscuredB/L pleural effusion present
Impression : Hepatomegaly with serous effusionto be co-related clinically.
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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 1Oral Predisolone
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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
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Operative notes summaryLeft anterio-lateral thoracotomy500 ml of blood stained fluid was evacuatedLarge bosselated tumor was present at the
root of the main pulmonary trunkMass was adherent to great vesselsIn view of inoperability of the tumor , incisional
biopsy was taken Pericardium anterior to the left phrenic nerve was
excisedLeft pleural space drainedPericardial drain was inserted
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Intraop photograph
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POST OP CXR
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Postop CT Scan Chest
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POST OP DIAGNOSIS
MALIGNANT PERICARDIAL EFFUSION
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Biopsy reportSection 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 histiocytomaSuggested IHC
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Immuno histo chemistry results :
AWAITED
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FINAL DIAGNOSIS
PRIMARY MEDIASTINAL HAEMANGIOPERICYTOMA
With Local invasion & Malignant pericardial effusion
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Further Course….
Patient improved symptomatically after the procedure
She was referred to Medical Oncology department
Advised to review with IHC reports
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A 53-year-old woman complained of cough and dyspnea for months before consultation. The chest X-rays and computedtomography revealed a well-defined mass in the left middle mediastinum with necrotic changes and calcification withinit. The patient underwent left thoracotomy with tumor resection, and a final diagnosis of primary mediastinal hemangiopericytoma was made.
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HEMANGIOPERICYTOMAHemangiopericytoma 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.
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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
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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].
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Differential diagnosis: solitary fibrous tumor
mesenchymal chondrosarcoma
synovial sarcoma fibrous histiocytoma.
Treatment : surgery, chemotherapy (vincristin, cyclophosphamide, doxorubicin, dactinomycen, methotrexate and
metoxantrone)
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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.
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We thank Dept of Cardio-Thoracic
SurgeryDept of CardiologyDept of Pathology GSH , Chennai.