Massive benign pericardial cyst presenting with simultaneous superior vena cava and middle lobe syndromes
Journal of Cardiothoracic Surgery
Massive benign pericardial cyst presenting with simultaneous superior vena cava and middle lobe syndromes
Pankaj Kaul 0
Kalyana Javangula 0
Shahme A Farook 0
0 Address: Yorkshire Heart Centre, Leeds General Infirmary , Great George Street, Leeds, LS1 3EX , UK
A 66 year old woman presented in extremis with symptoms and clinical and radiological signs of simultaneous obstruction of superior vena cava and middle lobe of right lung secondary to compression by a massive benign anterior mediastinal cyst. Excision of the cyst at median sternotomy resulted in complete resolution of all symptoms. This report is unusual on account of a) the concomitant presence of superior vena cava and middle lobe syndromes caused by a benign cyst because of its sheer size producing obstruction of these structures and b) the complete resolution of all symptoms and signs after removal of the cyst. Benign anterior mediastinal cysts are unknown to cause either of the two syndromes. To our knowledge, it is the first report of a benign anterior mediastinal cyst causing either superior vena cava syndrome or middle lobe syndrome or both simultaneously. Etiologies of both superior vena cava and middle lobe syndromes are discussed in detail.
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Case presentation
A 66 year old hypertensive and asthmatic chronic smoker
presented with 8 month history of progressively
increasing shortness of breath. Examination revealed an anxious,
tachycardic woman, breathless at rest with engorged neck
veins, purple discolouration of face, swelling of face and
neck and wheeze over whole of right chest. A
posteroanterior chest X ray showed a large mediastinal mass
occupying right middle and lower zones of chest with an
atelectatic middle lobe (fig 1). Lateral chest x ray
confirmed the anterior location of the mediastinal mass (fig
2). Spirometry demonstrated FEV1 0.84 L (47%
predicted), FVC 2 L (92% predicted), VC 2 L (92% predicted),
FEV1/FVC 42%, PEF120 L/min. Flexible bronchoscopy
showed normal appearances of the tracheobronchial tree.
CT Thorax showed a smooth ovoid mass in the right
anterior lower chest abutting the chest wall, diaphragm and
the right pericardium, and which showed a thin slightly
higher density wall and low density contents with average
CT number of 10, consistent with fluid (fig 3). There was
no mediastinal lymphadenopathy. An MR scan showed a
large cystic mass 11 × 11 × 8 cm in the right anterior
hemithorax, having the signal characteristics of neither a
vascular lesion nor a lipoma, in direct contact with
pericardium and, therefore, quite likely to be a pericardial
cyst, and causing external compression of right hilum,
right atrium and SVC (figs 4 and 5). Blood examination
revealed normal FBC, U&E, LFTs, calcium and glucose and
a slightly increased ESR at 25 mm/hr. Echocardiography
revealed an extracardiac mass abutting the right atrium
and ventricle and TOE, on operation table, confirmed the
presence of a huge anterior mediastinal mass (Fig 6).
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Chest X ray (PA) view showing a large mediastinal mass
occupying middle and lower zones of right chest and causing
compressive atelectasis of middle lobe.
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CT scan of chest showing a smooth ovoid low density mass
abutting the right anterior chest wall, diaphragm and the right
atrium and ventricle.
At median sternotomy, there was a 15 × 10 × 8 cm cyst,
adherent to the pericardium loosely, overlying SVC, right
atrium, right pulmonary hilum, the middle lobe and the
anterior basal segment of the lower lobe of lung and
compressing all the above structures (Fig 7). The large cyst was
dissected off intact from the above structures without
opening the pericardium while preserving the right
tFCioihgneusortfeXt2hreaym(erdigiahsttilnatael rmalavsisew) confirms the anterior
locaChest X ray (right lateral view) confirms the anterior
location of the mediastinal mass.
hFMeiRgmusitrcheaon4rdaxemonstrating a large cystic mass in right anterior
MR scan demonstrating a large cystic mass in right anterior
hemithorax.
aFMniRgdusrrcigeahnt5svheonwtriincgleexternal compression of SVC, right atrium
MR scan showing external compression of SVC, right atrium
and right ventricle.
phrenic nerve (Fig 8). The middle lobe and the anterior
basal segment of lower lobe expanded completely. The
cyst was opened on table (Fig 9). It had a thin 2 mm wall,
was filled with 600 mls of haemorrhagic fluid with strands
of fibrin and the inner wall did not have any suspicious
masses although there were a few small clots attached to
TFmriegadunisaresestio6npahlaflgueidalfeillcehdomcaarsdsiogram shows a huge anterior
Transesophageal echocardiogram shows a huge anterior
mediastinal fluid filled mass.
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