Anesth Analg 2006;102:1363-1364
© 2006 International Anesthesia Research Society
doi: 10.1213/01.ane.0000205753.59524.21
CARDIOVASCULAR ANESTHESIA
A Primary High-Grade Pleomorphic Pericardial Liposarcoma Presenting as Syncope and Angina
Thomas F. Kindl, MD*,
Ali M. Hassan, MD*,
Robert L. Booth, Jr, MD ,
Samuel J. Durham, MD , and
Thomas J. Papadimos, MD, MPH*
Department of *Anesthesiology, Pathology, and Surgery, Medical University of Ohio, Toledo, Ohio
Address correspondence to Thomas J. Papadimos, MD, MPH, Associate Professor, Medical University of Ohio, Department of Anesthesiology, 3000 Arlington Avenue, Toledo, OH 43614. Address e-mail to tpapadimos{at}meduohio.edu.
The incidence of liposarcoma has been estimated to be one in 2.5 million people, and pleomorphic sarcoma represents approximately 10%–15% of all liposarcomas (1). Liposarcomas develop later in adulthood and are usually located in the retroperitoneum or deep soft tissues of extremities. Primary liposarcoma of the pericardium is, however, exceedingly rare (1). A 74-yr-old male, with a history of aortic valve replacement and three-vessel coronary artery bypass grafting (CABG), left carotid endarterectomy, and abdominal aortic aneurysm repair was admitted with complaints of syncope, diaphoresis, and angina. Cardiac catheterization demonstrated a >80% occlusion of the left anterior descending artery. Transesophageal echocardiography (TEE) showed a large posterior, cystic mass impinging on the left and right atria, increased left atrial pressure, and diminished left ventricular filling pressure. The patient was scheduled for an elective CABG of the left anterior descending artery and possible excision of the pericardial mass. Intraoperative TEE confirmed a 7 x 7 cm cystic intrapericardial mass, posterior to the left and right atria (Figs. 1, 2) (please see video clip at www.anesthesia-analgesia.org). The mass obstructed left ventricular inflow, invaginated the right atrium posteriorly, and encircled the descending thoracic aorta. Frozen section biopsy revealed a poorly differentiated, aggressive liposarcoma. Because of the extent of the mass and its aggressive nature, the CABG surgery was aborted. Cardiac function dramatically improved after surgical evacuation of the cystic fluid. The resultant flaccid mass was excised, but a large adherent, invasive intracardiac portion of the mass could not be resected. The final pathology diagnosis was a primary high-grade pleomorphic pericardial liposarcoma. The patient made an otherwise uneventful recovery. He was subsequently discharged home where he died 2 mo later.
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Figure 1. A mid-esophageal bicaval view demonstrates tumor compression of the inferior vena cava (IVC), superior vena cava (SVC), and the right and left atria (RA, LA).
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Figure 2. A midesophageal four-chamber view demonstrates compression of the left atrium (LA) by the mass, suggesting that flow is impeded through the mitral valve (MV). The relationship of the right atrium (RA), right ventricle (RV), and left ventricle (LV) to the tumor is also shown.
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The clinical presentation of cardiac tumors is variable and dependent on their size and location. Included are benign lesions such as simple pericardial cysts, lipomas, hemangiomas, lymphangiomas, and bronchogenic cysts. Cystic malignancies, in addition to liposarcoma, include other sarcomas, teratomas, and malignant fibrous hystiocytomas. A pericardial liposarcoma may increase in size substantially before clinical symptoms are manifest and may produce valvular or outflow/inflow tract obstruction, arrhythmias, congestive heart failure, or cardiac tamponade. Large pericardial/mediastinal masses compressing pulmonary veins may produce aliased flow signals. High peak velocities with minimal phase variation may be evident with use of high-pulse-repetition-frequency Doppler studies (2). Moreover, obstructed intramyocardial coronary arteries with high flow velocity may be demonstrated with color flow Doppler (2). We report an exceedingly rare tumor causing substantial cardiac compression. Intraoperative TEE confirmed the extent of the intrapericardial tumor and facilitated assessment of hemodynamic changes after drainage of the cystic fluid.
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Footnotes
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Video images for this case can be accessed at www.anesthesia-analgesia.org. Click on Cardiovascular Anesthesia in the Contents page and then the Data Supplement link located below the title of the article.
Accepted for publication January 12, 2006.
No reprints will be available.
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References
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- Kindblom LG, Anervall L, Svendsen P. Liposarcoma: a clinicopathologic, radiographic, and prognostic study. Acta Pathol Microbiol Scand 1975;253:1–71.
- Nanda NC, Domoanski MJ. Atlas of transesophageal echocardiography, 1st ed. Baltimore: Williams and Wilkins, 1998.
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