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\begin{document}

\title{Timely diagnosis of primary pericardial mesothelioma}



\author[1]{Hsiao Chun Chen}%
\author[1]{Ming-Chon Hsiung}%
\author[2]{Shihi Chang}%
\author[1]{Wei-Kang Kwang}%
\author[1]{Tien-Ping Tsao}%
\author[1]{Yung-Nien Yang}%
\affil[1]{Cheng Hsin General Hospital}%
\affil[2]{Peking Union Medical College Hospital}%


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  \date{June 04, 2024}


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\begin{abstract}
A 66-year-old male referred to our hospital with dyspnea and bilateral
lower-extremity edema. Chest radiography (CXR) showed pleural effusions
and cardiomegaly. Transthoracic echocardiography revealed large
pericardial effusion with a heterogeneous hyperechoic mass in the right
ventricular pericardial wall. Histopathological examination confirmed
the diagnosis of epithelioid mesothelioma. Primary pericardial
mesothelioma is an extremely rare and poorly diagnosed malignancy with a
historically poor prognosis. Thus, a timely diagnosis and treatment are
crucial for the management of primary pericardial mesothelioma.%
\end{abstract}%



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Timely diagnosis of primary pericardial mesothelioma

Hsiao-Chun Chen \textsuperscript{1} \textbar{} Ming-Chon
Hsiung\textsuperscript{1}* \textbar{} Shihi
Chang\textsuperscript{2}\textbar{}

Wei-Kang Kwang \textsuperscript{3} \textbar{} Tien-Ping
Tsao\textsuperscript{1} \textbar{} Yung-Nien Yang
\textsuperscript{1}\textbar{}

\textsuperscript{1} Heart center, Cheng Hsin General Hospital, Taipei
Taiwan.

\textsuperscript{2} Plastic surgery hospital, Chinese Academy of Medical
Sciences and Peking Union Medical College, Beijing China

\textsuperscript{3} Pathology, Cheng Hsin General Hospital, Taipei
Taiwan.

*Corresponding author. Tel:(886)2-28264000-2508.
E-mail:mhsiung0007@gmail.com

Timely diagnosis of primary pericardial mesothelioma

We present a case of a 66-year-old male with dyspnea and bilateral
lower-extremity edema. The patient was a nonsmoker and denied history of
prior asbestos exposure. Chest radiography (CXR) revealed bilateral
pleural effusions and moderate cardiomegaly. Transthoracic
echocardiography demonstrated an irregular, thickened pericardium with
heterogeneous echogenicity tumor mass concomitant with large
circumferential pericardial effusion, thus ruling out infiltration
pericardium. (Fig 1); upon hospitalization, Non-contrast Computed
tomography (CT) scan of the chest and abdomen showed pericardial
effusion encasing the heart with small bilateral pleural effusions.
Pericardiocentesis with pigtail drainage was immediately performed and
sent for cytology testing, and the report suspected malignant.
Consequently, pericardiotomy and biopsy were performed and reported
malignant mesothelioma. The micro showed pericardial tissue with
epithelioid type mesothelioma. The tumor cells revealed positivity for
Calretinin, GATA-3 and CK, and focal positivity for D2-40.The
immunostatin for BAP-1 showed loss of nuclear positivity in the tumor
cells that, coupled with morphology, accord with a primary pericardial
mesothelioma diagnosis. (Fig 2) We continued with PET for further
evaluation which showed increased FDG uptake of the entire pericardium,
confirming the diagnosis of previous examinations. (Fig 3) Primary
pericardial mesothelioma is poorly diagnosed, has unfavorable prognosis,
and is extremely rare, even among heart tumors, with an incidence of
\textless{}0.002\% and accounting for less than 5\% of all
mesotheliomas. {[}1{]} Patients often show nonspecific but typical
symptoms like constrictive pericarditis, cardiac tamponade, and heart
failure. {[}2{]} From the limited literature, up to 75 percent of cases
were diagnosed postmortem {[}3{]} and cytologic analysis of pericardial
fluid were often negative {[}4{]}. Echocardiography is the most commonly
used investigative tool but is low in the identification of pericardial
mesotheliomas. In our case, despite the large amount of pericardial
effusion of the first echocardiography, the infiltrated like pericardium
was still detected. In addition, cytology after pericardiocentesis
reported suspicion of malignancy, which followed by pericardiotomy and
biopsy, lead to our timely diagnosis. Echocardiography after the
drainage of pericardial effusion displayed a notable heterogenous
echogenicity mass (Fig 4). Surgical resection could be curative for
localized cases, but our patient refused surgical treatment and is
currently receiving chemotherapy.

References:

{[}1{]} Tajjiou M, Wild W, Sayed N, et al. Primary Pericardial
Mesothelioma, Which Was Veiled by a Pleural Empyema: A Case Report and
Review. \emph{Case Rep Surg.} 2019;2019:2896810. Published 2019 Sep 11.
doi: 10.1155/2019/2896810

{[}2{]} Dipak P, Tiffany W, Deborah R, et al. Echocardiographic
Diagnosis of Malignant Mesothelioma Involving the
Pericardium.\emph{Echocardiography.} 2005;Vol 22, No6:538-39.

{[}3{]} Takeda K, Ohba H, Hyodo H, et al. Pericardial mesothelioma:
hyaluronic acid in pericardial fluid. \emph{American Heart
Journal.}1985;110:486-88.

{[}4{]} Elizabeth, McGehee, David, et al. Treatment and Outcomes of
Primary Pericardial Mesothelioma: A Contemporary Review of 103 Published
Cases. \emph{Clinical Lung Cancer.} 2018 Mar 20(2):e152-e157.\selectlanguage{english}
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