ARTICLE IN PRESS

doi:10.1510/icvts.2009.231456

Interactive CardioVascular and Thoracic Surgery 10 (2010) 1056–1058

www.icvts.org

Case report - Thoracic non-oncologic

Surgical resection of a giant pericardial cyst showing a rapidly
growing feature
Rumi Matono, Fumihiro Shoji*, Tokujiro Yano, Yoshihiko Maehara
Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan

Received 18 December 2009; received in revised form 16 February 2010; accepted 4 March 2010

Abstract

This report presents an extremely rare case of a rapidly growing giant pericardial cyst which was surgically removed 20 years after the
first detection. A 38-year-old asymptomatic male was referred because of rapidly growing mass on the right diaphragm. This lesion was
detected about 20 years earlier and checked by a chest roentgenogram once a year. However, this lesion showed rapid growth over the
last year, therefore surgical removal was performed. A pathological examination revealed this lesion as a giant pericardial cyst without
inflammatory, hemorrhage or malignant cells. Therefore, there was no pathological explanation for the rapid growth of this cyst. In
conclusion, general thoracic surgeons should be aware of the possibility of rapid growth, even if the diagnosis is a pericardial cyst.
䊚 2010 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.

Keywords: Giant pericardial cyst; Rapidly growing feature; Video-assisted thoracoscopic surgery

1. Introduction of the heart; however, the size showed no change. However,

Pericardial cysts are caused by an incomplete coalescence
of fetal lacunae during the development of the pericardi-
um. The estimated incidence of pericardial cyst is
1:100,000 and it represents 6–7% of all mediastinal masses
w1, 2x. These cysts are usually unilocular and have thin and
translucent wall lined by endothelium or mesothelium,
containing a clear serous fluid. In addition, the natural
history of the pericardial cyst is unknown.
Most cases are asymptomatic, however, some patients
complain of chest pain, dyspnea, or paroxysmal tachypnea,
due to the pressure of the surrounding organs w1–3x. Most
happen to be found by medical checkup, and a roentgeno-
gram shows a round homogeneous radiodense lesion at the
cardiophrenic angle, which is most likely to occur in the
right cavity. In principle, a pericardial cyst only requires
follow-up, however, growing cases or symptomatic cases
require surgical removal.
This report herein presents a rare case of rapidly growing
giant pericardial cyst 20 years following its detection.
2. Case
A 38-year-old asymptomatic male had a 20-year’s history
of chest roentgenogram abnormality (Fig. 1f). The patient
was found to have a giant pericardial cyst in the right side
*Corresponding author. Tel.: q81-92-642-5466; fax: q81-92-642-5482.
E-mail address: fumayuchan@yahoo.co.jp (F. Shoji).
䊚 2010 Published by European Association for Cardio-Thoracic Surgery
this lesion showed a rapid growth over the last year,
therefore, the patient was admitted for an investigation of
evidence of malignancy. Fig. 1 shows the time course of
the roentgenogram over 20 years. Chest roentgenogram
revealed a rounded mass in the right cardiophrenic angle.
From 1990 to 2006 (Fig. 1a–d), the size of this lesion
showed no change. However, this lesion showed sudden
growth in the roentgenogram of 2008 (Fig. 1e). Magnetic
resonance imaging (MRI) showed the presence of a giant
mass, measuring 12 cm in diameter and the internal density
of this lesion was equivalent to that of water. Although the
findings of the MRI showed this lesion to be a benign cystic
lesion, surgical removal was considered due to the rapidly
growing characteristics, which indicated the possibilities of
inflammation, hemorrhaging or malignant transformation.
The patient was referred to undergo surgical treatment of
this cyst, and this lesion was resected by video-assisted
thoracic surgery. The cyst, measuring 12=10 cm in diame-
ter, did not adhere to either the lung or diaphragm. The
cyst was connected to the inferior pericardial surface only
by a thin pedicle. After this pedicle was ligated and cut,
the cyst was completely removed. The lesion was a cystic
lesion with a thin wall and filled with about 200 ml of clear
serous fluid (Fig. 2a). An intraoperative examination
revealed this fluid to contain neither inflammatory, hem-
orrhage nor malignant cells. The cystic lesion (hematoxylin
and eosin stain, 40=) was composed of a single layer of
mesothelial cells and collagenous tissue without inflam-
matory, hemorrhage or malignant cells (Fig. 2b). These
features were compatible with a benign pericardial cyst.
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Fig. 1. The time course of the 20-year natural history of chest roentgenogram in the giant pericardial cyst. (a) 1990, (b) 1995, (c) 2005, (d) 2006, (e) 2008 and
(f) 2009.

The patient had an uneventful postoperative recovery with-

Negative
Results
out any complications.

3. Discussion

Follow-up
Paper
Pericardial cysts are uncommon congenital abnormalities
and they usually have a diameter ranging from 1 to 5 cm
w1, 4x. Pericardial cysts with a diameter over 10 cm are

State-of-the-art
known as ‘giant pericardial cysts’, and they are extremely
rare.
Most pericardial cysts are asymptomatic. Some patients
with giant pericardial cysts, including the present case, are
also asymptomatic w5x. However, some cases have demon-

Best Evidence
strated life-threatening complications w1–3x. Nina et al.
reported a case of a cyst measuring 13 cm in size with

Topic
symptom, such as progressive dyspnea, right-sided chest
pain and dry cough due to mediastinal compression w1x.
McMillan et al. presented a case complicated by a pericar-
Nomenclature
ditis w2x and Lesniak-Sobelga et al. also showed a case
compressing the right ventricle w3x.
The treatment of a symptomatic or growing giant pericar-
dial cyst is surgical removal w1–3, 5x. The cyst in the
present case also was successfully removed by video-assist-
ed thoracic surgery. This cyst was initially thought to either
Historical
Pages

be infected, hemorrhaged or to have transformed into a

neoplasm. However, there was neither evidence of inflam-
mation, hemorrhage, nor any malignancy in this cyst.
Therefore, no pathological explanation could be found for
Communication

Fig. 2. (a) The macroscopic appearance of the giant pericardial cyst filled the rapid growth of this cyst.
with clear serous fluid. (b) The cystic lesion (hematoxylin and eosin stain,
Brief

40=) consisted of a single layer of mesothelial cells and collagenous tissue.

The natural history of a giant pericardial cyst is unknown
The features are compatible with a pericardial cyst. There is no evidence of in detail. Therefore, the present case is the extremely rare
malignancy. case with a natural history of 20 years. Although the cyst
Case Report
 ARTICLE IN PRESS
1058 R. Matono et al. / Interactive CardioVascular and Thoracic Surgery 10 (2010) 1056–1058
in this case had shown no change over about 18 years, a
rapid growth was suddenly observed between the roentgen-
ogram obtained in 2008 and 2009. This was not proven
pathologically, however, careful observation is necessary
whenever a pericardial cyst is being followed up.
In conclusion, this report presented the case of a rapidly
growing giant pericardial cyst with a long natural history.
General thoracic surgeons should therefore be aware of
the possibility of a sudden rapid growth of such cysts
without any definite reason, even if the diagnosis is a
pericardial cyst.
Acknowledgements
We thank Brian Quinn for critical comments on the
manuscript.
References
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