A case of pericardial cyst with an atypical location (paratracheal) which was removed by mediastinoscopy / Mediastinoskopi ile cikarilan atipik yerlesimli (paratrakeal) perikardiyal kist olgusu.
Authors: Yazici, Ulku
Ege, Taner
Gulhan, Erkmen
Tastepe, Irfan
Pub Date: 12/01/2010
Publication: Name: Turkish Thoracic Journal Publisher: Aves Yayincilik Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 Aves Yayincilik ISSN: 1302-7808
Issue: Date: Dec, 2010 Source Volume: 11 Source Issue: 4
Accession Number: 305563067
Full Text: ABSTRACT

The incidence rate of pericardial cysts accounts for nearly 7% of all mediastinal cysts. They occur in one in 100.000 people. They may either be of congenital origin or acquired. Their most common location is the right anterior cardiophrenic angle. This is a report of a case who underwent mediastinoscopy for a 3x4 cm coelomic pericardial cyst with an atypical location in the paratracheal area. A paratracheal cyst was incidentally detected in a 41 year old male patient. The cyst was in the upper right mediastinum with a paratracheal location. The patient underwent mediastinoscopy and the cyst was completely removed. Postoperative pathology reported a coelomic pericardial cyst. The patient was discharged on the 3rd postoperative day. Mediastinoscopy is a less invasive method compared to median sternotomy, thoracotomy and VATS in a mediastinal cyst. (Tur Toraks Der 2010; 11: 184-6)

Key words: Pericardial cyst, mediastinoscopy, paratracheal cyst

Received: 16.04.2008

Accepted: 21.072008

OZET

Perikardiyal kist insidansi tum mediastinal kistlerin yaklasik %7'sini olusturur. Bu kistler, 100.000 kiside bir gorulur. Kistler konjenital veya edinsel olabilir. En sik sag on kardiofrenik acida yerlesim gosterirler. Bu, atipik olarak paratrakeal alanda yerle-sim gosteren, 3x4 cm'lik bir colemik perikardiyal kist icin medi-astinoskopi yapilmis bir olgunun sunumudur. Paratrakeal kist 41 yasindaki erkek bir hastada tesadufen tespit edildi. Kist, sag ust mediastende paratrakeal yerlesimli idi. Hastaya mediastinoskopi uygulandi ve kist tamamen alindi. Ameliyat sonrasi patolojide, bu kistin colemik perikardiyal bir kist oldugu raporlandi. Hasta, ameliyat sonrasi 3. gun taburcu edildi. Mediastinoskopi, median sternotomi, torakotomi ve VATS'a kiyasla daha az invaziv bir metottur. (Tur Toraks Der 2010; 11: 184-6)

Anahtar sozcukler: Perikardiyal kist, mediastinoskopi, paratra-keal kist

Gelis Tarihi: 16.04.2008

Kabul Tarihi: 21.07.2008

INTRODUCTION

Nonneoplastic mediastinal cysts comprise 20% of all primary mediastinal lesions. Of these lesions, 50-60% are bronchogenic; 20-30% pericardial, and 7-15% enteric or duplication cysts (1). Congenital pericardiac cysts are usually asymptomatic and are detected incidentally on routine pulmonary graphs (2). The incidence rate of pericardial cysts accounts for nearly 7% of all mediastinal cysts (3), (4). The diagnosis is established in the light of the results of pulmonary graph, fluoroscopy, echography, and computer tomography. MRI may be required for differential diagnosis. Treatment is provided by complete surgical excision of the cyst.

CASE

A 41-year-old male patient was followed-up for uveitis when a paratracheal cyst was incidentally detected. The patient was referred to our clinic with this initial diagnosis for surgical treatment.

The patient had no complaints, and his familial and personal history was non-specific. The findings of the physical examination and laboratory studies were normal. The pulmonary graph of the patient revealed a minimal enlargement in the upper right mediastinal region. The thoracic CT obtained upon initial diagnosis of sarcodiosis at the previous center showed a cystic lesion of 3x4cm in the paratracheal area with liquid content and smooth contours (Figure 1).

[FIGURE 1 OMITTED]

The patient had undergone an MRI evaluation, which indicated a cyst of 3x4cm in size in the upper right mediastinum with a paratracheal location. The cyst was thin-walled, showed liquid density on all the secants, and thus was thought to be a benign bronchogenic cyst. (Figure 2).

[FIGURE 2 OMITTED]

In the light of the results of the thoracic CT and MRI evaluations, surgical excision through mediastinoscopy was decided for the treatment of the cystic lesion located in the right paratracheal area.

The patient underwent mediastinoscopy while under general anesthesia. A cystic lesion of nearly 3x4cm in size was observed in the right paratracheal area. The cyst was partially dissected and freed from the adjacent tissues. The cyst was then punctured. The transparent yellowish fluid of nearly 30cc was aspirated. The cystic cavity which was emptied was drawn with forceps and its peduncle was observed. The peduncle of the cyst was held with forceps and its walls were excised (Figure 3).

[FIGURE 3 OMITTED]

The postoperative pathology report, based on the sections of 0.1 cm wall thickness, was compatible with a coelomic pericardial cyst 4x3cm in size, layered with a single layer of cubic epithelium and involving lymphocytes and congested, vascular structures. The patient was discharged on the 3rd postoperative day with no complications. The clinical and radiological evaluations of the patient in the monthly follow-up were normal (Figure 4).

[FIGURE 4 OMITTED]

DISCUSSION

Coelomic pericardial cysts are rare entities, affecting one in every 100.000 person (5). Coelomic pericardial cysts or diverticula are detected incidentally in middle age. They may be congenital or acquired.

They are usually located at the cardiophrenic angle, particularly on the right side (6). The left costophrenic angle, hilus, and upper mediastinum at the level of the arcus may be listed as some other rare locations. They are observed as asymptomatic cystic lesions on routine pulmonary roentgenograms. The right cardiophrenic angle (70%) and the left cardophrenic angle (22%) in the mediastinum have been reported to be the most common locations (7). However, they also have an atypical location at a rate of 8-10%. Similarly, the cystic lesion in our patient was located in the paratracheal area, which is an atypical location for these cysts.

As was defined by Lambert, the pericardial coelom is formed by a series of uncombined lacunes. The pericardial space is formed by the fusion of these lacunes (8). The cysts termed coelomic pericardial cysts have thin walls and are layered with unilocular and endothelium or mesothelium and contain clear liquid. These cysts do not originate from the pericardium but are loosely connected to it and thus can easily be removed during the operation. In our patient, the cystic content was clear liquid and the cyst was easily dissected away from the adjacent tissues.

Only 20% of pericardial cysts produce symptoms such as dyspnea or chest wall complaints. Although most cases are asymptomatic, the most common symptom is atypical chest pain (9). Patients may rarely suffer chest pain associated with torsion of the cyst. On the other hand, there have been reports of fatal complications such as acute right cardiac failure and tamponade due to rupture of the cyst into the pericardial space (10).

No definitive physical examination finding is detected. Pulmonary graphs, echocardiography, computer tomography, and magnetic resonance imaging are the most commonly used diagnostic tools for pericardial cysts. MRI should be the method of choice of diagnosis and monitoring particularly for the pericardial cysts of atypical location (11).

Surgery should be performed upon diagnosis of the cyst. Otherwise, the cyst may reach large dimensions and the risk of rupture and complications increase, leading to morbidity or mortality (12).

Median sternotomy, thoracotomy or VATS (video assisted thorascopic surgery) may be applied as the surgical techniques. Pericardial cysts are nearly avascular and smooth-contoured structures. Therefore, they are vulnerable to extirpation with minimally invasive techniques (13). In our patient, we used another minimally invasive technique, mediastinoscopy for the first time and initially vacated the cystic content through a mediastinoscope and then totally excised the resultant cystic cavity.

Through surgical extirpation, radical treatment is provided and symptoms regress. Malignancy may then be ruled out by histochemical analysis of the lesion (14). Accordingly, even for asymptomatic patients, surgery should be performed in order to prevent potential complications and establish definite diagnosis (15). Spontaneous resolutions of pericardial cysts have been reported rarely (16).

The mortality risk of surgical treatment is very low and the prognosis is excellent due to total excision of the cyst (17).

In conclusion, desired outcome was obtained after mediastinoscopy, a less invasive method compared to median sternotomy, thoracotomy, and VATS recommended for the treatment of mediastinal cysts, applied on a patient with a pericardial cyst of paratracheal location. Mediastinoscopy may be considered an alternative to median sternotomy, thoracotomy, and VATS for the treatment of patients with cysts of the atypical location described above because it is a less invasive method.

Address for Correspondence/ Yazisma Adresi: Taner Ege, Ataturk Gogus Hastaliklari ve Gogus Cerrahisi Egitim ve Arastirma Hastanesi, Gogus Cerrahisi Klinigi, Ankara, Turkey Phone: +90 312 381 94 02 E-mail: drtaners@hotmail.com

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Ulku Yazici, Taner Ege, Erkmen Gulhan, Irfan Tastepe

Ataturk Gogus Hastaliklari ve Gogus Cerrahisi Egitim ve Arastirma Hastanesi, Gogus Cerrahisi Klinigi, Ankara, Turkey

doi:10.5152/ttd.2010.30
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