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Right Cardiophrenic Mass
__ I
ROENTGENOGRAM OF THE MONTH
Right Cardiophrenic Mass Thomas V. Thomas, M.D., F.C.C.P.·
tributed his inability to work and recent onset of symptoms to a mass in his right lower thorax, first seen on chest films approximately ten years ago. He had had a heart attack five years earlier.
This 59-year-old man complained of pain in the right chest, shortness of breath, and occasional epigastric discomfort relieved by antacids. He at°From the Department of Surgery, Veterans Administration Hospital, Kansas City, Missouri.
FIGURE
1
FIGURE
87
2
THOMAS V. THOMAS
88 Diagnosis: Pericardiocelomic Cyst Posteroanterior chest film shows an oblong density in the right lower chest, inseparable from the diaphragm inferiorly and the heart medially (Fig 1 ). In the lateral view the mass overlies the cardiac shadow (Fig 2). No gas-fluid pattern was visible. Barium studies were noncontributory. Exploratory thoracotomy revealed a thin-walled solitary cyst filled with clear fluid attached to the pericardium. It was easily shelled out. Pericardiocelomic cyst is also known as hydrocele of the mediastinum, spring water cyst, parapericardial cyst, pleuropericardial cyst, mesothelial mediastinal cyst, and pericardial cyst. In a mass chest roentgen survey of 300,000 people, only three such cases were encountered. It is more frequent in men and is usually asymptomatic. The right thorax is twice as common a site as the left. Usually the cyst is located in the cardiophrenic angle, but it may occasionally be found along any portion of the pericardium. Le ROUX,l in a review of the world literature, collected 120 cases of pericardiocelomic cysts. Approximately 10 percent were multiloculated. Only three communicated with the pericardial cavity and on fluoroscopy these showed decrease in size with inspiration. The cysts are thin-walled and filled with clear fluid. The fluid usually contains proteins (195-400 mg percent), chlorides (616-690 mg percent) and
urea nitrogen (28 mg percent). The cyst wall is lined by a single layer of flat cells having the appearance of mesothelium or endothelium. Diagnosis is usually established at the time of thoracotomy. Surgical intervention is indicated only to exclude other neoplastic lesions. Pericardiocelornic cyst may closely resemble retrosternal hernia, mediastinal or pericardial fat pad, and localized eventration of the diaphragm. Distinction from diaphragmatic pathology may be made by gastrointestinal barium studies and diagnostic pneumoperitoneum. 2 Bronchoscopy, bronchography, and angiography are usually of little value. The cyst usually shows little change on folJow-up roentgen examinations, although occasionally enlargement may be striking. The distinction between celomic cyst and cystic hygroma is usually difficult. Typical hygroma intimately incorporates the surrounding structures and receives a recognizable blood supply, in contradistinction to celomic cyst. REFERENCES
1 Le Roux BT: Pericardial coelomic cysts. Thorax 14:27, 1959 2 Thomas TV: Congenital eventration of the diaphragm. Ann Thoracic Surg 10: 180, 1970 Reprint requests: Dr. Thomas, Veterans Administration Hospital, 4801 Linwood Blvd., Kansas City, Missouri 64128.
International Symposium on Chronic Obstructive Lung Disease The Israel Organization of Chest Physicians, in cosponsorship with the American College of Chest Physicians, will present an International Symposium on Chronic Obstructive Lung Disease, in Tel-Aviv,
December 20-22, 1971. For further information, please write Dr. I. Bruderman, Secretary of the Symposium, Meir Hospital, Kfar Saba, Israel.
CHEST, VOL. 60, NO.1, JULY 1971
ROENTGENOGRAM OF THE MONTH
Right Cardiophrenic Mass Thomas V. Thomas, M.D., F.C.C.P.·
tributed his inability to work and recent onset of symptoms to a mass in his right lower thorax, first seen on chest films approximately ten years ago. He had had a heart attack five years earlier.
This 59-year-old man complained of pain in the right chest, shortness of breath, and occasional epigastric discomfort relieved by antacids. He at°From the Department of Surgery, Veterans Administration Hospital, Kansas City, Missouri.
FIGURE
1
FIGURE
87
2
THOMAS V. THOMAS
88 Diagnosis: Pericardiocelomic Cyst Posteroanterior chest film shows an oblong density in the right lower chest, inseparable from the diaphragm inferiorly and the heart medially (Fig 1 ). In the lateral view the mass overlies the cardiac shadow (Fig 2). No gas-fluid pattern was visible. Barium studies were noncontributory. Exploratory thoracotomy revealed a thin-walled solitary cyst filled with clear fluid attached to the pericardium. It was easily shelled out. Pericardiocelomic cyst is also known as hydrocele of the mediastinum, spring water cyst, parapericardial cyst, pleuropericardial cyst, mesothelial mediastinal cyst, and pericardial cyst. In a mass chest roentgen survey of 300,000 people, only three such cases were encountered. It is more frequent in men and is usually asymptomatic. The right thorax is twice as common a site as the left. Usually the cyst is located in the cardiophrenic angle, but it may occasionally be found along any portion of the pericardium. Le ROUX,l in a review of the world literature, collected 120 cases of pericardiocelomic cysts. Approximately 10 percent were multiloculated. Only three communicated with the pericardial cavity and on fluoroscopy these showed decrease in size with inspiration. The cysts are thin-walled and filled with clear fluid. The fluid usually contains proteins (195-400 mg percent), chlorides (616-690 mg percent) and
urea nitrogen (28 mg percent). The cyst wall is lined by a single layer of flat cells having the appearance of mesothelium or endothelium. Diagnosis is usually established at the time of thoracotomy. Surgical intervention is indicated only to exclude other neoplastic lesions. Pericardiocelornic cyst may closely resemble retrosternal hernia, mediastinal or pericardial fat pad, and localized eventration of the diaphragm. Distinction from diaphragmatic pathology may be made by gastrointestinal barium studies and diagnostic pneumoperitoneum. 2 Bronchoscopy, bronchography, and angiography are usually of little value. The cyst usually shows little change on folJow-up roentgen examinations, although occasionally enlargement may be striking. The distinction between celomic cyst and cystic hygroma is usually difficult. Typical hygroma intimately incorporates the surrounding structures and receives a recognizable blood supply, in contradistinction to celomic cyst. REFERENCES
1 Le Roux BT: Pericardial coelomic cysts. Thorax 14:27, 1959 2 Thomas TV: Congenital eventration of the diaphragm. Ann Thoracic Surg 10: 180, 1970 Reprint requests: Dr. Thomas, Veterans Administration Hospital, 4801 Linwood Blvd., Kansas City, Missouri 64128.
International Symposium on Chronic Obstructive Lung Disease The Israel Organization of Chest Physicians, in cosponsorship with the American College of Chest Physicians, will present an International Symposium on Chronic Obstructive Lung Disease, in Tel-Aviv,
December 20-22, 1971. For further information, please write Dr. I. Bruderman, Secretary of the Symposium, Meir Hospital, Kfar Saba, Israel.
CHEST, VOL. 60, NO.1, JULY 1971