Massive benign pericardial cyst presenting with simultaneous superior vena cava and middle lobe syndromes

Journal of Cardiothoracic Surgery, May 2008

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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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. - 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). coFCocihgcmeuspprtryeeXins1sgriavmyei(daPtdAelel)ecavtnieadwsilsosowhfoemwrizdnodgnlaeslaoorbgfeerigmhetdcihasetsitnalnmdacsasusing 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. aFCtbiTrguiuutstmcrinaegna3ntohdfevcrehingehtsrticaslhneotewriongr cahsemstowotahll,odvioapidhrloagwmdaenndsithyemraigshst 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. ItsrFnheiigtegghrmuateornepeptnuietrl7mreoaofatintvht (...truncated)


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Pankaj Kaul, Kalyana Javangula, Shahme A Farook. Massive benign pericardial cyst presenting with simultaneous superior vena cava and middle lobe syndromes, Journal of Cardiothoracic Surgery, 2008, pp. 32, 3, DOI: 10.1186/1749-8090-3-32