Pericardial masses





Key points





  • Pericardial tumors can be benign or malignant. Of the benign pericardial tumors, pericardial cysts are the most common. Other benign pericardial tumors include angiomas, lymphangiomas, fibromas, teratomas, and lipomas.



  • Primary malignant pericardial tumors include mesotheliomas, lymphomas, thymomas (may be benign or malignant), sarcomas, and liposarcomas.



  • Metastatic pericardial tumors occur 20 to 40 times more common than primary pericardial tumors and mostly result from the direct extension of tumors, principally the lung and the breast, producing a pericardial effusion that can progress to cardiac tamponade.



  • Echocardiography, computed tomography, and magnetic resonance imaging are diagnostic modalities for detecting pericardial masses ( Box 25.1 ).



    Box 25.1


    Primary pericardial tumors are rare and may be classified as benign or malignant. The most common benign lesions are pericardial cysts and lipomas. Mesothelioma is the most common primary malignant pericardial neoplasm. Other malignant tumors include a wide variety of sarcomas, lymphoma, and primitive neuroectodermal tumor. When present, signs, and symptoms are generally nonspecific. Patients often present with dyspnea, chest pain, palpitations, fever, or weight loss.


    The diagnostic workup often starts with transthoracic echocardiography (TTE), which usually identifies the mass. Further evaluation using transesophageal echocardiography (TEE) may be indicated to complement the TTE assessment. Often, investigation with other imaging modalities such as CT, CMR, or PET is warranted for more detailed assessment by visualization of the entire pericardium, tissue characterization, and evaluation of surrounding structures. Although imaging may help in the identification and characterization of the mass, a biopsy is often needed for definitive tissue diagnosis .


    Information on whether a mass is malignant or benign is important to direct surgical versus medical management. In addition, the extent of cardiac and extracardiac involvement is also important to determine the potential for complications such as pericardial effusion with or without cardiac tamponade, constrictive pericarditis . Large masses deemed to be benign based on imaging can often be completely surgically excised to not only provide tissue for pathologic analysis, which remains the gold standard for definitive identification but also to provide symptom relief .


    Small masses may be best assessed using CT given its high spatial resolution while larger masses may be better assessed using CMR due to its superior tissue characterization abilities . Progression of the disease can be assessed using TTE if there are optimal acoustic windows or using CT or CMR if not easily visualized by TTE while the metabolic response to treatment can be evaluated using PET .



Fig. 25.2


The images depict tuberculous pericarditis. (A and B) TTE in a 29-year-old man presenting with orthopnea, peripheral edema, and progressive dyspnea over the preceding 2 weeks after protracted low fever, arthralgia, and weight loss (16 kg) over the preceding 5 months shows a large pericardial effusion, thickened pericardium with surface irregularities, and 2 large intrapericardial masses with regular contours (white arrows) (5.5 cm × 2.0 cm and 4.3 cm × 2.3 cm). The masses are interconnected with a bridge of tissue and are attached to the visceral and parietal layers of the pericardium with fibrinous strands. The masses float inside the pericardial fluid and have not invaded the surrounding tissues. (C) The patient underwent urgent pericardiotomy, and the masses were completely excised. The masses were disk-shaped and macroscopically composed of a lobulated, yellowish soft tissue. The histopathology results revealed a pattern of chronic granulomatous inflammation with necrosis, consistent with tuberculosis. (D) Another patient is presented herein with tuberculous pericarditis with a thick fibrin strand in the pericardial space, mimicking an intrapericardial mass ( Supplementary Video 25.1 ). (E) The 4 stages of tuberculous pericarditis are presented herein.

The images depict tuberculous pericarditis. (A and B) TTE in a 29-year-old man presenting with orthopnea, peripheral edema, and progressive dyspnea over the preceding 2 weeks after protracted low fever, arthralgia, and weight loss (16 kg) over the preceding 5 months shows a large pericardial effusion, thickened pericardium with surface irregularities, and 2 large intrapericardial masses with regular contours (white arrows) (5.5 cm × 2.0 cm and 4.3 cm × 2.3 cm). The masses are interconnected with a bridge of tissue and are attached to the visceral and parietal layers of the pericardium with fibrinous strands. The masses float inside the pericardial fluid and have not invaded the surrounding tissues. (C) The patient underwent urgent pericardiotomy, and the masses were completely excised. The masses were disk-shaped and macroscopically composed of a lobulated, yellowish soft tissue. The histopathology results revealed a pattern of chronic granulomatous inflammation with necrosis, consistent with tuberculosis. (D) Another patient is presented herein with tuberculous pericarditis with a thick fibrin strand in the pericardial space, mimicking an intrapericardial mass (Supplementary Video 25.1 in the online version at https://doi.org/10.1016/B978-0-323-84906-7.00011-X ). (E) The 4 stages of tuberculous pericarditis are presented herein.





Pericardial masses are relatively rare and are mostly caused by malignancies. The metastatic involvement of the pericardium is more frequent than that by primary tumors and often carries a poor prognosis. Inflammatory and infectious diseases are very rarely reported as causes of pericardial masses in the literature, with a few reports of cardiac echinococcosis, rheumatoid arthritis, inflammatory pseudotumors, and tuberculous pericarditis. The presentation varies, and patients are often asymptomatic, with pericardial involvement detected only at the autopsy or as an incidental finding during thoracic imaging tests. Some patients, however, may develop progressive symptoms of venous congestion due to the evolution of pericardial effusion (diastolic restriction) or constriction, presenting with dyspnea, orthopnea, and peripheral edema .


Fig. 25.3


The images illustrate a pericardial cyst. (A) The chest X-ray shows a large density adjacent to the cardiac apex (white arrow) . (B) TTE reveals a large echo-free space (14 cm × 5.2 cm) anterior to the left and right ventricles without compressive effects (black arrow) . (C) Thoracic CT scan shows a large cystic lesion in the left hemithorax adjacent to the cardiac apex (white arrow) . The final diagnosis was a pericardial cyst.




Pericardial cysts are rare congenital anomalies located in the mediastinum. They are usually asymptomatic; nonetheless, they rarely produce symptoms based on their location and size. Commonly, they are located in the right cardiophrenic angle, followed by the left, anterosuperior, and posterior mediastinum. They are usually unilocular, well-marginated, spherical-shaped cysts lined with a single layer of mesothelial cells histologically. Most cysts are asymptomatic, but occasional complications include the obstruction of the right ventricular outflow tract, the obstruction of the main bronchi and atelectasis, cardiac tamponade, and sudden death. Imaging modalities include echocardiography, CT, and MRI. Usually, close follow-ups are sufficient in asymptomatic patients. Percutaneous drainage and surgical resection are the usual treatment modalities for symptomatic individuals .



Table 25.4

Differential diagnoses of isolated cystic shadows adjacent to the heart.

























Lesions Differentiating features
Bronchial cysts Lined with the bronchial epithelium
Localized pericardial effusions Fluid between the visceral and parietal pericardium
Teratomas Usually associated with some solid components along with cystic components
Neurenteric cysts Located in the right posterior chest and associated with vertebral anomalies
Lymphangiomas Multilocular or multiple cysts
Congenital cysts of primitive foregut origins (e.g., bronchogenic cysts, gastroenteric cysts, and esophageal duplication cysts) Usually located in the posterior mediastinum and lined by the epithelium


Table 25.5

Etiologies of pericardial cysts.













1. Congenital
2. Inflammatory (e.g., rheumatic pericarditis, bacterial infection, particularly tuberculosis, and echinococcosis)
3. Traumatic
4. Postcardiac surgery
5. Patients on chronic hemodialysis


Table 25.6

Echocardiography in pericardial cysts.

Reproduced with permission form Kumar Kar S, Ganguly T. Current concepts of diagnosis and management of pericardial cysts. Indian Heart J 2017; 69:364–70. https://doi.org/10.1016/j.ihj.2017.02.021 .












Characteristics A homogeneous echolucent mass with minor attenuation of the ultrasound through a low-density fluid-filled structure
An echo-free space, indicating its separation from the cardiac chambers
Advantages Safe
Low cost
May be performed on unstable patients
Diagnostic modality for follow-ups and image-guided percutaneous aspiration
Disadvantages Limited windows and narrow fields of view
Technical difficulties in patients with obesity or obstructive lung disease, as well as in patients immediately post cardiothoracic surgery
Difficulty in the localization of cysts at uncommon locations
Operator dependent

Algorithm 25.7


The image depicts the approach to pericardial cysts.



Fig. 25.8


The images illustrate a pericardial simple cyst in transthoracic echocardiography. The apical 4-chamber view of transthoracic echocardiography in a patient presenting with atypical chest pain shows an echolucent space adjacent to the right atrium without compressive effects (yellow arrow) . This finding is compatible with a pericardial simple cyst.



Fig. 25.9


Pericardial cyst on computed tomography (CT). High pitch prospective ECG-triggered CT angiography was performed for a patient suspicious of acute aortic dissection. Hypodense (densitometry: 10 HU) oval shape mass (white arrow) at right cardiophrenic angle and pericardial base. Intramural hematoma (red arrow) in descending aorta and bilateral pleural effusion (yellow arrows) .




Typically, pericardial cysts appear on CT images as well-defined, nonenhancing, homogeneous fluid-attenuation lesions that contain no internal septa. On CT, these thin-walled, homogeneous structures are nonenhancing with iodinated contrast and have an attenuation between − 10 and 20 HU. Occasionally, the cyst may contain proteinaceous fluid, in which case the lesion will demonstrate intermediate attenuation at CT. Pericardial cysts with hemorrhagic contents appear with hyperattenuation at CT .


Fig. 25.10


Pericardial cyst on CMR. (A and B): Large cystic lesion (white arrow) in right hemithorax and pericardial based has shown high T2 signal cystic lesion in SSFP sequences in axial and coronal view in order. (C) Iso to hyposignal T1 lesion in HASTE sequence. (D and E) Late gadolinium enhancement (LGE) sequence revealed no enhancement. (F) Asymmetric hypertrophy of septum (yellow arrows) and patchy LGE due to concomitant hypertrophic.

Nov 10, 2024 | Posted by in CARDIOLOGY | Comments Off on Pericardial masses

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