Angiosarcoma of the Pericardium: A Diagnostic Challenge

Abstract

An 84-year-old woman with a history of recurrent pericardial effusion was admitted to our institution for further evaluation. We had the last four month patient history with us. That showed reduced general condition, tachycardia, dyspnea and recurrent vertigo and tinnitus. Echocardiograms on admission showed only large intra-pericardial fluid concentration without suspicious pericardial morphological disorders. Computed Tomography Angiography scan (CTA) showed no tumorous formations (Fig.1/Fig.2). Previous pericardiocentesis usually yielded 200-400ml bloody fluid. No malignant cells were detected at different episodes. Only reactively modified mesothelial cells were described. Cultures were negative for micro organisms. Signs of congestive heart failure and presumed diagnosis of dressler ́s pericardial effusion were diagnosed. Therefore, a combination of intra-venous diuretics, NSAIDs and corticosteroids therapy was initiated. However, no improvement could be achieved. Indication for video assisted thoracoscopy with pericardial fenestration and pericardial biopsy was made and employed for further diagnostics. Histological examinations yielded a fibrosing mesothel covered connective tissue, with low grade chronic inflammation. Immuno-histological staining showed no features of a malignancy. On arrival at our institution the patient was noted to be hemodynamically unstable, with dyspnea at rest. A transthoracal echocardiogram was performed, showing abundant pericardial effusion with severely compromised ventricular function. The patient was immediately transferred to the operating room. Percutaneously, intrapericardial insertion of a pigtail catheter using Seldinger technique was performed and 400ml bloody fluid was evacuated. No suspicious microbiological and cytological findings were observed. Abstract: Pericardial malignancies, including angiosarcomas, have a high tendency to cause recurrent pericardial effusion. This complication is associated with significant morbidity and mortality. Patient directed therapy is crucial and depends on multidisciplinary consultation after multimodal imaging diagnosis.