Bilocular pericardial cyst in an aberrant location - Interactive ...

doi:10.1510/icvts.2008.180729
Abstract
2009 Published by European Association for Cardio-Thoracic Surgery
ARTICLE IN PRESS
Interactive CardioVascular and Thoracic Surgery 8 (2009) 160–161
Case report - Thoracic general
Bilocular pericardial cyst in an aberrant location
a, a a b
Federico Raveglia *, Alessandro Baisi , Angelo Maria Calati , Larry R. Kaiser
aDivision
of Thoracic Surgery, Università degli Studi di Milano, Azienda Ospedaliera San Paolo, Milano, Italy
bDivision
of Thoracic Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
Received 31 March 2008; received in revised form 26 May 2008; accepted 21 July 2008
www.icvts.org
Pericardial cysts classically are found in the right or left cardiophrenic angle and rarely are located outside of this location. An 82-yearold
man presented with an asymptomatic cystic mass on chest CT-scan located in the upper right mediastinum and measuring 7=6=4 cm.
A follow-up chest CT-scan 12 months later showed that the cyst had increased in size to where it now measured 10=9=8 cm and was
noted to be dislocating and compressing the superior vena cava. The patient underwent surgical excision because of the uncertain diagnosis
and the compression of contiguous organs. Two cystic masses were able to be completely excised intact. A definitive diagnosis of double
pericardial cyst was histopathologically confirmed. Radiological findings of a pericardial cyst in the upper mediastinum are extremely rare.
In particular there have been no reports of bilocular or double pericardial cysts.
2009 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.
Keywords: Pericardial cyst; Mediastinum
1. Clinical summary
An 82-year-old man with a history of systemic vasculopathy
presented with an asymptomatic cystic mass on chest
CT-scan measuring 7=6=4 cm. CT-scan had been performed
on the base of an X-ray previously done during
preoperative evaluation for inguinal hernia repair. A followup
chest CT-scan 12 months later showed that the cyst had
increased in size to where it now measured 10=9=8 cm
and was noted to be dislocating and compressing the
superior vena cava and the azygos vein (Fig. 1). A transesophageal
echocardiogram confirmed a large fluid-filled
mediastinal mass. It was recommended to the patient that
he undergo surgical excision because of the uncertain
diagnosis and the compression of contiguous organs.
The surgical procedure was begun by introducing two
trocars with the intent to perform the procedure via a
thoracoscopic technique. Dense pleural adhesions were
encountered and a 6-cm muscle sparing right thoracotomy
incision was performed. Upon entering the chest, a thinwalled
cystic mass was noted in the paratracheal location
compressing both the superior vena cava and the azygos
vein (Fig. 2). The cystic mass was able to be completely
excised intact. A second smaller cyst, not seen on the CTscan,
was found posterior to the larger cystic mass in the
medial aspect of the mediastinum, adjacent to the aortic
arch. This smaller cystic mass was also excised. Histologic
examination revealed a mesothelial-lined cystic lesion and
the diagnosis of double pericardial cyst was confirmed. The
*Corresponding author. Piazza L. da Vinci 7, 20133, Milan, Italy. Tel.: q39-
3381336071; fax: q39-022666185.
E-mail address: ravegliafederico@tiscali.it (F. Raveglia).
patient was discharged from the hospital on the fourth
postoperative day.
2. Discussion
Pericardial cysts classically are found in the right or left
cardiophrenic angle and rarely are located outside of this
location w1x. In reviewing the literature from 1929 to 1985,
Stoller et al. noted only 34 cases of pericardial cysts in
aberrant locations w2x. From 1985 to the present only
occasional cases of atypically located pericardial cysts have
been reported. However, to our knowledge, there have
been no reports of bilocular or double pericardial cysts. In
our patient, the diagnosis of bilocular cyst was made only
Fig. 1. CT-scan. Giant cyst in upper right mediastinum.

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F. Raveglia et al. / Interactive CardioVascular and Thoracic Surgery 8 (2009) 160–161
Fig. 2. Open view of the cyst wall dislocating the azygos vein.
at the time of operation because the membrane between
the cystic lesions was thin and not identifiable on the CTscan
or on the transesophageal echocardiogram.
3. Conclusion
Surgical resection is widely accepted as the treatment of
choice when a patient has symptoms related to a mediastinal
mass or the diagnosis is uncertain w2x. We agree with
Mouroux et al.’s contention that asymptomatic cysts should
be considered for resection when the lesion is large and
there is compression of adjacent structures, and particularly
when the CT-scan demonstrates progressive enlargement.
If feasible, it is our opinion that these lesions should
be resected using minimally invasive thoracoscopic techniques
w3, 4x.
References
w1x Davis RD Jr, Oldham HN Jr, Sabiston DC. Primary cysts and neoplasms
of the mediastinum: recent changes in clinical presentation, methods
of diagnosis, management and results. Ann Thorac Surg 1987;44:229–
237.
w2x Stoller JK, Shaw C, Matthay RA. Enlarging atypically located pericardial
cyst. Chest 1986;89:402–406.
w3x Mouroux J, Vennissac N, Leo F, Guillot F, Padovani B, Hofman P. Usual
and unusual locations of intrathoracic mesothelial cysts. Is endoscopic
resection always possible? Eur J Cardiothorac Surg 2003;24:684–688.
w4x Umemori Y, Kotani K, Makihara S. Video-assisted thoracoscopical surgery
for pericardial cyst: report of two cases. Kyobu Geka 2001;54:1125–
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