Medical Image of the Month: Malignant Pleural and Pericardial Effusions

Figure 1. CTA chest axial view showing moderate pericardial effusion, bilateral pleural effusions and an anterior mediastinal mass.

Figure 2. Echocardiography subcostal four-chambered view showing a large pericardial effusion with right ventricular collapse during diastole.

A 67-year-old woman with a history of presumed thymoma presented to the emergency department with four weeks of progressive shortness of breath and wheezing. CT imaging of the chest on arrival demonstrated a 13.1 x 8.6 x 8.2 cm anterior mediastinal mass with compression of the SVC, pulmonary veins, and right pulmonary artery (Figure 1). A moderate pericardial effusion was also seen. A transthoracic echocardiogram was performed to further evaluate the pericardial effusion, which revealed diastolic collapse of the right ventricle consistent with cardiac tamponade (Figure 2). The patient was taken for urgent pericardiocentesis, which drained 450cc of sanguineous fluid. Percutaneous biopsy of the mass revealed poorly differentiated carcinoma suspicious for a primary breast malignancy. Cytology of the pericardial fluid did not demonstrate malignancy, however. Cytology of subsequent pleural effusion also was not positive for malignancy, although, both effusions are believed to be related to the malignancy even if no malignant cells were present on analysis.

Malignant pericardial effusions account for 18-23% of cases, and are one of the most common causes of hemorrhagic effusions. Multiple types of cancers can involve the pericardium; lung cancer is the most common but lymphoma, leukemia, melanoma, and breast cancer are other potentially causative malignancies. Presence of a symptomatic malignant effusion is a poor prognostic indicator with median survival on the order of 2-4 months after diagnosis, although certain malignancies (e.g. hematologic rather than solid) may have better results (1).

Nathan Coffman MD and Jessica Vondrak MD

Department of Internal Medicine

Banner University Medical Center

University of Arizona

Tucson, AZ USA

Reference

1. Dequanter D, Lothaire P, Berghmans T, Sculier JP. Severe pericardial effusion in patients with concurrent malignancy: a retrospective analysis of prognostic factors influencing survival. Ann Surg Oncol. 2008 Nov;15(11):3268-71. [CrossRef] [PubMed] 

Cite as: Coffman N, Vondrak J. Medical image of the month: Malignant pleural and pericardial effusions. Southwest J Pulm Crit Care. 2018;17(5): . doi: https://doi.org/10.13175/swjpcc107-18 PDF 

Medical Image of the Week: Fast-growing Primary Malignant Mediastinal Mixed Germ Cell Tumor

Figure 1. A: Chest radiograph taken 3 months prior to presentation. B: Chest radiograph showing large mediastinal mass (arrows). C: Coronal view of thoracic CT in soft tissue windows showing the large mediastinal mass (arrows). D: Lateral view of thoracic CT showing large mediastinal mass.

A 28-year-old man presented with progressive hemoptysis for two weeks. He had fever, cough, and night sweats for one month prior to admission that was treated as inflenza, bronchitis and/or pneumonia. He had started to experience anorexia, dysphagia, fatigue, a 30-pound weight loss, panic attacks, and the new onset of hypertension during the 3 months prior to admission. He also had intermittent middle chest pain that was aggravated by coughing for 5 months, but a cardiac catherization two months prior failed to show an abnormality. The chest x-ray and CT scan on this admission demonstrated a 15 cm large anterior mediastinal mass exerting a mass effect on the heart and medistial lymphadenopathy (Figure 1-B,C,D) which were absent on a chest x-ray performed 3 months prior to admission (Figure 1A). Core biopsy and immunohistochemical staining revealed a mixed germ cell tumor with components of seminoma and yolk-sac tumor. He was started on chemotherapy, to which he responded well. The malignant mediastinal germ cell tumor in this case is fast-growing and most likely of extragonadal origin. The majority of tumors occ in men between 20 and 35 years (1). The symptoms of these tumor and nonspecific as described in our case, which may lead to a low index of suspicion of malignant tumor with resultant delayed diagnosis.

Yufei Tian, Stella Pak, and Qiang Nai

Department of Medicine

University of Toledo Medical Center

Toledo, Ohio USA

Reference

1. Carter BW, Marom EM, Detterbeck FC. Approaching the patient with an anterior mediastinal mass: a guide for clinicians. J Thorac Oncol. 2014 Sep;9(9 Suppl 2):S102-9. [CrossRef] [PubMed]

Cite as: Tian Y, Pak S, Nai Q. Medical image of the week: fast-growing primary malignant mediastinal mixed germ cell tumor. Southwest J Pulm Crit Care. 2017;15(3):114-5. doi: https://doi.org/10.13175/swjpcc103-17 PDF