[Metastatic cardiac tamponade as initial manifestation of papillary thyroid carcinoma]

Papillary carcinoma, diffuse sclerosing variant corresponds to 2% of all papillary thyroid carcinomas. It is usually diffuse and bilateral, affecting the entire gland. At the time of diagnosis, patients present lymph node and lung metastasis. It affects mainly young women. This case report describes a cardiac tamponade as the initial manifestation of an unusual variant of papillary thyroid carcinoma. A 32 year-old woman was attended at the emergency room with epigastric pain and dry cough. Physical examination revealed hypotension, tachycardia and decreased heart sounds. An echocardiogram confirmed severe pericardial effusion. Pericardial fluid cytology was positive for malignancy. The patient evolved with recurrent pericardial effusion and a pleuropericardial window was performed. At this procedure, a subpleural nodular lesion was found, which histology corresponded to metastases of papillary carcinoma, probably from thyroid origin. Total thyroidectomy was performed. The final diagnosis was papillary carcinoma, diffuse sclerosing variant. This variant infiltrates the connective tissue of the interfollicular spaces, mimicking thyroiditis and it is associated with early vascular permeation. This tumor, compared to the classic variants of thyroid carcinoma, is more aggressive and it has higher risk of recurrence. Papillary thyroid carcinoma should be considered as differential diagnosis in our population, in all metastatic papillary lesions, and even more in young female patients.

Video-assisted thoracoscopic pericardiectomy for malignant pericardial effusion

BACKGROUND

A malignant thoracic tumour often causes malignant pericardial effusion with cardiac tamponade. However, no standard treatment has yet been established. The purpose of this study was to clarify the utility of performing video-assisted thoracoscopic (VATS) pericardiectomy in patients presenting malignant pericardial effusion.

PATIENTS AND METHODS

VATS pericardiectomy was performed for 11 patients with malignant pericardial effusion from 2000 to 2010. The clinical characteristics and outcome of these patients were retrospectively analysed. Pericardial windows were created under general anaesthesia and single lung ventilation was performed using three trocars.

RESULTS

All patients were successfully managed by thoracoscopic resections. There were no surgical difficulties and the postoperative periods were uneventful. The performance status and Hugh-Jones classification both improved after treatment in nine and eight out of eleven cases, respectively. The average duration of chest tube drainage was seven days. No recurrent pericardial effusion was noted during follow-up.

CONCLUSION

The thoracoscopic approach was able to safely resect a sufficient amount of the pericardium and to provide sufficient surgical visualisation while being minimally invasive for patients with malignant pericardial effusion.

Sudden and unexpected death in three cases of Ehlers-Danlos syndrome type IV

Ehlers-Danlos syndrome (EDS) type IV is a connective tissue disorder characterized by the inability to produce sufficient amounts of collagen or a defect in the structure of collagen. The most serious complications include a rupture of a viscus or vascular rupture with or without mural dissection. Death may result from internal hemorrhage. This report describes three cases of sudden and unexpected death caused by EDS type IV. Two cases involved hemothorax as a result of dissection of the subclavian artery and aorta, respectively. The third case represented spontaneous pulmonary rupture and hemorrhage. A detailed family history should be sought, and additional specimens collected to confirm the diagnosis, including skin fibroblasts for collagen testing and blood for DNA testing. The forensic pathologist should consider the possibility of EDS type IV upon discovery of spontaneous visceral or arterial rupture and should alert the family members of this hereditary and potentially fatal condition.

Importance of flow cytometric analysis of serous effusions in the diagnosis of hematopoietic neoplasms in patients with prior hematopoietic malignancies

OBJECTIVE

To determine the criteria for the use of immunophenotyping by flow cytometry (FCM) in the diagnosis of hematopoietic lesions.

STUDY DESIGN

A retrospective review of 89 consecutive body fluid specimens with concurrent FCM analysis during 2001 to 2006 was performed. The cytopathologic diagnosis was compared with the final diagnosis as modified by subsequent FCM.

RESULTS

The cytopathologic diagnosis was benign in 61 cases (69%), atypical in 20 cases (22%) and malignant in 8 cases (9%). In patients without any prior clinical history, FCM study was positive in 2 cases and negative in 49 cases. In these patients, the working cytopathologic diagnosis was modified from benign/atypical to malignant in 2 (11%) cases and atypical to benign in 11 (33%) cases. In patients with a prior clinical history, FCM was positive in 23 cases and negative in 15 cases.

CONCLUSION

FCM studies were helpful in the cytopathologic diagnosis in 35% of body fluid specimens, permitting appropriate cancer staging and management. In the absence of a prior clinical history, immunophenotyping by FCM in body fluid specimens should be ordered after adequacy studies when there is cytologic atypia or a strong suspicion of malignancy on the cytopathologic diagnosis.

Helical tomotherapy in the radiotherapy treatment of Hodgkin's disease - a feasibility study

Radiation therapy for advanced Hodgkin's disease often requires large fields and may result in significant exposure of normal tissues to ionizing radiation. In long-term survivors, this may increase the risk for late toxicity including secondary malignancies. 3DCRT has been successfully used to treat this disease but treatment delivery is often complex requiring matching of photon with electron beams, utilization of field-in-field techniques and of partial transmission blocks. HT is an arc-rotational intensity modulated radiation therapy technique proven to achieve superior target dose conformality and sharp dose gradients around critical normal tissues. HT however, has also been associated with higher volumes of low dose regions in normal tissues and therefore, higher integral dose. The present study was undertaken to compare the dosimetry of 3DCRT to HT in a pediatric patient with advanced HD. Clinical target volume (CTV) included bilateral lower cervical and supraclavicular areas, mediastinum, bilateral hili, left axilla and bilateral diaphragmatic lymph nodes. The planning target volume (PTV) was derived by circumferentially expanding the CTV by 1 cm. Whole lung and heart irradiation was also planned due to bilateral pleural and pericardial effusions. The prescribed radiation dose was 21 Gy to the PTV and 10.5 Gy to the whole lung and heart. Target coverage was comparable for both plans. The minimum, maximum and mean PTV doses were 18.61 Gy, 22.45 Gy and 21.52 Gy with 3DCRT and 19.85 Gy, 22.36 Gy and 21.39 Gy with HT, respectively. HT decreased mean normal tissue dose by 21.6% and 20.07% for right and left breast, 20.40% for lung, 30.78% for heart and 22.74% for the thyroid gland. Integral dose also decreased with HT by 46.50%. HT results in significant dosimetric gain related to normal tissue sparing compared to 3DCRT. Further studies are warranted to evaluate clinical applications of HT in patients with HD.

Primary cardiac B-cell lymphoma presented as heart tamponade and atrioventricular block: a case report

BACKGROUND

Primay cardiac lymphoma is rare, and its diagnosis is not determined until autopsy.

CASE

A 49-year-old man presented with heart tamponade and atrioventricular block. Bloody pericardiac effusion showed a monotonous proliferation of atypical large mononuclear cells, which demonstrated a lambda light-chain monoclonality by the fluorescence-activated cell-sorter method and clonal rearrangement bands by Southern blot analysis of the IgH gene. Transvenous biopsy excised from the right atrial tumor was diagnosed as diffuse large B-cell lymphoma. He underwent chemotherapy and permanent pacemaker implantation and is alive and well.

CONCLUSION

Liquid cytology of cardiac effusion was very useful for rapid diagnosis, leading to a better prognosis.

Efficacy of rituximab monotherapy for an elderly hemodialysis patient with primary cardiac lymphoma

We report a case of primary cardiac lymphoma (PCL) occurring in a 76-year-old man during maintenance hemodialysis. Chest computed tomography (CT) revealed a tumor with pericardial effusion in the left ventricular posterior wall. Cytological examination of the pericardial fluid revealed monotonous lymphoid cells positive for B-cell markers, and clonal immunoglobulin heavy chain gene rearrangement was detected, indicating B-cell lymphoma. Rituximab monotherapy was administered biweekly at the therapeutic level on hemodialysis. The follow-up chest CT showed tumor disappearance with pericardial fluid after two courses of therapy. Rituximab monotherapy was effective for an elderly hemodialysis patient with PCL.

Massive pericardial effusion as the primary manifestation of high-grade malignant lymphoma

Pericardial effusion might be the first presentation of various pathologies including malignant tumors. Massive pericardial effusion as the primary manifestation of high-grade malignant lymphoma is a very rare condition. A 53-year-old woman presented with progressive dyspnea of one-week history. Physical examination showed venous distention of the neck veins and diminished heart sounds. The chest X-ray demonstrated increased cardiothoracic index. Transthoracic and transesophageal echocardiographic examinations showed massive pericardial effusion without any other pathology. Hematologic and biochemical tests showed only anemia. The patient underwent pericardiocentesis. Pericardial adenosine deaminase test and cultures were negative. Cytopathologic examination of the fluid showed huge lymphocytes and highly atypical lymphoid cells consistent with high-grade malignant lymphoma (non-Hodgkin's lymphoma). Immunohistochemical analysis showed positivity for leukocyte common antigen. No other primary origin could be determined.

[Evaluation of immunohistochemistry staining and cytologic diagnosis by using cell block sections prepared with effusion fluid cytology specimens]

OBJECTIVE

To study the values of immunohistochemistry staining and cytological diagnosis by using cell block sections prepared with the effusion fluid cytology specimens.

METHODS

Ninety-nine effusion cytology specimens with the diagnoses of reactive mesothelial hyperplasia, atypical cells and metastatic carcinoma were enrolled into the study. The cytospin preparations/smears, cell block sections and immunohistochemical study were performed and correlated with the clinical findings and follow-up data.

RESULTS

Amongst the 99 cases studied, the percentage with positive diagnosis using cytospin preparations/smears was 68.7% (68/99). The percentages with negative and equivocal diagnoses were 16.2% (16/99) and 15.1% (15/99), respectively. As for cell block sections, the percentages were 71.7% (71/99), 16.2% (16/99) and 12.1% (12/99), respectively. On the other hands, the percentages became 76.8% (76/99), 20.2% (20/99) and 3.0% (3/99), respectively, when coupled with immunohistochemical findings. The overall percentages of positive, negative and equivocal diagnoses were 77.8% (77/99), 17.2% (17/99) and 5.0% (5/99), respectively, upon clinicopathologic correlation. The difference between cytospin preparations/smears and cell block sections was not statistically significant (P > 0.05). When coupled with immunohistochemical findings or clinicopathologic correlation, the difference in rates of equivocal diagnosis however carried statistical significance (P < 0.05). The false-negative rate of immunohistochemical study applied on cell block sections was 1.0% (1/99).

CONCLUSIONS

Immunohistochemistry, when applied on cell block sections, is useful in delineation of the primary origins of the tumor cells in effusion fluid cytology specimens. Combination of morphologic examination, immunohistochemical findings and clinicopathologic correlation can further improve the rate of positive diagnosis.

A case of Riedel's thyroiditis with pleural and pericardial effusions

Riedel's thyroiditis (RT) is a rare type of chronic thyroiditis of unproven etiology and definite treatment. It can be associated with retroperitoneal, mediastinal, orbital, and hepatic fibrosis. Symptoms arise mainly due to compression of neighboring structures. Surgery is usually required for a definite diagnosis and decompression to relieve the symptoms. Glucocorticoids and tamoxifen are commonly used agents for the pharmacotherapy. We hereby describe the development of pleural and pericardial effusions during the clinical course of an RT case. A 39-year-old woman suffering from neck compression symptoms was admitted to the hospital. After a decompression isthmectomy, RT was diagnosed. She responded well to glucocorticoid therapy after surgery. However, symptoms reoccurred shortly after glucocorticoid withdrawal and the disease process extended to the mediastinum. Tamoxifen was started and the neck and mediastinal mass regressed and her symptoms disappeared considerably for more than 6 months. However, she was readmitted with severe dyspnea and chest pain. Further investigation revealed an exudative pleural and pericardial effusion and mediastinal enlargement. A thorough evaluation of the patient's effusions did not disclose any specific etiological insult. The patient was symptom-free with a considerable reduction of the soft tissue mass and no effusions, and treated successfully with colchicine, azathioprine, and glucocorticoids. To the best of our knowledge, this is the first case reported in the literature as an RT presenting with pleuropericardial effusions.

Cytologic aspects of T-cell acute lymphoblastic leukemia presenting as a massive pericardial effusion: a case report

BACKGROUND

Acute lymphoblastic leukemia (ALL) with a clinical presentation of cardiac tamponade and the presence of blasts in the pericardial fluid is an uncommon event. A cytopathologist needs to adopt a cautious interpretive approach while dealing with a lymphoid-rich pericardial effusion in order to prevent a false negative diagnosis.

CASE

A 27-year-old male presented with breathlessness, ascites, bilateral pedal edema and fever. He had mild hepatomegaly. On detailed clinical examination, a diagnosis of anemia with cardiac tamponade was made. Cytology of pericardial fluid revealed a large number of lymphoid cells in a hemorrhagic background that, under low magnification, closely resembled mature lymphocytes. However, a careful examination of May-Grünwald-Giemsa-stained cytologic smears, under an oil immersion objective (x 1,000), showed atypical lymphoid cells having blastoid morphology. Rare lymphoid cells displayed a "hand mirror" appearance. A hematologic workup was carried out to exclude leukemia/lymphoma. Complete blood count revealed pancytopenia with abnormal lymphoid cells. Bone marrow showed replacement by 90% lymphoblasts exhibiting periodic acid-Schiff stain, CD3 and terminal deoxynucleotidyl transferase positivity. A diagnosis of T-cell acute lymphoblastic leukemia (FAB L1) was offered, and the patient was started on a remission and induction regimen. However, he had a rapid downhill course and died of cardiorespiratory arrest.

CONCLUSION

Both clinicians and cytopathologists need to be aware of rare instances in which ALL may present with a pericardial effusion as an initial manifestation. The abnormal lymphoid cells found in the pericardial fluid in such situations need to be interpreted cautiously, as their presence is of clinical significance.

Primary mediastinal synovial sarcoma with transdiaphragmatic extension presenting as a pericardial effusion

Synovial sarcoma is a distinctive soft tissue neoplasm, most commonly seen in the extremities of young adults. Mediastinal synovial sarcoma is a well-documented entity; however, in many cases, the differentiation between this and other spindle cell tumours may be difficult, especially in monophasic tumours. Unlike most pleuropulmonary synovial sarcomas which are well circumscribed, mediastinal tumours are often infiltrative and resection may not be adequate, leading to a high rate of recurrence. We present a 49-year-old man with a primary pericardial synovial sarcoma, with transdiaphragmatic intra-abdominal extension, which clinically, radiologically and grossly mimicked a tuberculous pericarditis.

Clinical and cytological correlations in pericardial effusions with cardiac tamponade

We studied 27 patients diagnosed with pericardial effusion with cardiac tamponade on which pericardiocentesis was performed. The purpose of the study was to evaluate the benefits and limits of the cytological examination of the pericardial liquid in the etiological diagnosis and the treatment of patients with cardiac tamponade. The pericardial liquid taken was examined macroscopically, biochemically (content of proteins, glucose, cholesterol, and LDH), cytologically (MGG stained smears from pericardial liquid) and bacteriologically. The obtained results were compared to the clinical data, the laboratory and paraclinical tests, to differentiate the cause and therapeutically procedure. The cardiac tamponade remitted after pericardiocentesis in all patients. The pericardial liquid was exudate (Ligth criteria) in 82% of all patients. The cytological examination of the pericardial liquid showed malignant smear in 40.74% of the patients, smear of the TBC specific inflammation type in 7.40% patients, smear of non-specific inflammation type in 25.94% of patients, reactive type smear in 25.9% of patients.

Accuracy and added value of triage beyond segregating potentially neoplastic effusions in immediate wet preparation

OBJECTIVE

To sudy the accuracy and value of immediate wet preparation (WP) procedure on effusion and washing cytologic specimens.

STUDY DESIGN

Two hundred specimens were identified over 3 months in our cytology laboratory, including 102 pleural effusion, 59 peritoneal effusion, 28 pelvic washing and 11 pericardial fluid specimens. WP slides were prepared, stained with toluidine blue (TB) and .. evaluated. Findings were reported as negative, suspicious or positive for malignant cells. For negative specimens, the remaining prepared slides were stained together. For suspicious or positive interpretation, slides were stained separately. Accuracy and additional benefits from this immediate triage step were studied.

RESULTS

Interpretation ofslides resulted in 152 negative, 34 positive and 14 suspicious for malignancy. Analysis for additional values resulted in immediate interpretation relayed to clinicians, additional fluid centrifuged for adequate sediment in samples with scant cellularity, selection of bloody specimens for acid washing procedures, selection of cases to optimize cell block preparation when pivotal histologic evaluation or immunohistochemistry was anticipated and selection of cases for potentially needed ancillary studies. Accuracy, sensitivity, specificity and positive and negative predictive values were high.

CONCLUSION

WP using the TB is accurate, sensitive and highly specific and has considerable value beyond segregating potential neoplastic cases.

Spontaneous hemopericardium in a patient with hemophilia B: a case report and review of the literature

Spontaneous hemopericardium is extremely rare in patients with hemophilia and has never been reported in hemophilia B-factor IX deficiency. We report a patient with hemophilia B who presented with spontaneous hemopericardium and tamponade requiring emergent pericardiocentesis. As advances in therapies improve the longevity and quality of life of patients with hemophilia, it is likely that adult interventional cardiologists will increasingly encounter these patients in the cardiac catheterization laboratory. We review the clinical challenges raised by this group of patients undergoing cardiac procedures and present a stepwise approach to optimal management during the periprocedural period.

Assessment of aortic stiffness and ventricular functions in familial Mediterranean fever

OBJECTIVE

To investigate systolic and diastolic ventricular functions, aortic elastic properties and the presence of pericardial effusion in familial Mediterranean fever (FMF) patients.

METHODS

A case-controlled, cross-sectional study was performed on 44 FMF patients and 27 controls. Subjects with hypertension, diabetes mellitus and hyperlipidemia were excluded. Left and right ventricular functions were measured using echocardiography including two-dimensional, M-mode, and conventional Doppler as well as pulsed wave tissue Doppler imaging (TDI). Aortic elasticity was analyzed using M-mode tracing guided by the two-dimensional echocardiography. Statistical analysis was performed using Mann Whitney U, Spearman rho correlation and Fisher's exact tests.

RESULTS

Age, sex, body mass index, smoking status and lipids were comparable in patients and controls (p>0.05). None of the subjects had pericarditis and/or pericardial effusion. Aortic wall properties were similar between groups (p>0.05). The TDI parameters of mitral lateral annulus revealed significantly lower Em/Am ratios in patients compared to controls [1.77 (0.6-3.4) vs. 1.79 (0.9-4.8), p=0.02]. Mitral flow propagation velocity was significantly lower in patients than healthy subjects [63 (39-100) vs. 74 (40-94) cm/s, p=0.008]. Tricuspid annular plane systolic excursion (TAPSE) was significantly reduced in FMF group than in controls [2 (1.3-2.5) vs. 2.5 (1.7-3.2) cm; p<0.001]. Eight of the patients and one control had impaired TAPSE (<2 cm; p=0.025). There was no difference regarding right ventricular diastolic dysfunction (RVDD) as assessed by using standard Doppler echocardiography (p>0.05). However, pronounced RVDD was observed in FMF patients documented by TDI (Em/Am<1; 19 patients vs. 0 controls, p<0.001).

CONCLUSION

Subclinical myocardial involvement is present in a cohort of relatively young FMF patients who were also free of classical cardiovascular risk factors. Pericardium and aorta seem to be spared during attack free periods of FMF.

Tuberculous effusive-constrictive pericarditis

Infection with Mycobacterium tuberculosis and the human immunodeficiency virus has reached epidemic proportions in South Africa. Cardiac involvement occurs in approximately one per cent of patients suffering from active tuberculosis. This concerns predominantly pericardial involvement, resulting in chronic pericardial effusions, cardiac tamponade and constrictive pericarditis. Effusive-constrictive pericarditis is a clinical haemodynamic syndrome in which constriction by the visceral pericardium occurs in the presence of a tense effusion in a free pericardial space. We present a patient who was diagnosed with this condition, and highlight the value of contrast-enhanced magnetic resonance imaging in demonstrating the underlying structural and functional abnormalities.

Percutaneous balloon pericardiotomy in a patient with advanced case of malignant pericardial effusion and tamponade

Surgical creation of a pericardial window has been a standard procedure for relieving symptoms of patients presenting with recurrent pericardial effusion. In this report we describe the application of Multitrack balloon catheter for creating a pericardial window in a patient who had recurrent pericardial effusion with tamponade as a result of advance malignant disease of breast.

CYP1A/regucalcin gene expression and edema formation in zebrafish embryos exposed to 2,3,7,8-Tetrachlorodibenzo-p-dioxin

In this study, zebrafish eggs were exposed to a relatively low concentration (50 pg/mL) of 2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD) for 72 h and then transferred to vehicle/TCDD-free water for the remainder of the experiments. Mortality, heart rates, edema severity, CYP1A, and regucalcin gene expressions were investigated to study TCDD-induced toxicity in zebrafish during the early life stage. Results indicated that the 50 pg/mL TCDD caused severe and visible developmental toxicity. Further research of the long term and low concentration of TCDD exposure is required.