A Pericardial Mass in a Patient With Recurrent Liposarcoma

Abstract

Pericardial and cardiac masses in patients with established malignant neoplasms represent a diagnostic and therapeutic challenge. We present the case of a 66-year-old woman with history of myxoid liposarcoma of the left thigh who had an unexpected recurrence in the pericardium 12 years later.

Graphical Abstract

Cardiac and pericardial metastases are more common than primary malignant tumors. Although multimodality cardiac imaging is fundamental in this setting, definite histopathologic diagnosis is crucial for therapeutic considerations in patients with malignant tumors.¹ Pericardial metastases of liposarcomas are rare, and diagnosis is not always possible with cardiac imaging because fat areas may not be visualized with cardiac computed tomography (CT) or cardiac magnetic resonance (CMR).² The prognosis of patients with liposarcomas is related to the histologic subtype. Myxoid liposarcomas have been reported to be chemotherapy sensitive, with a 10% to 20% rate of metastatic disease at 5 years. Systemic treatment options include anthracycline combination chemotherapy and trabectedin.³ In this clinical vignette, we describe the case of a woman with pericardial recurrence of liposarcoma.

Take-Home Messages

• •Multimodality cardiac imaging is crucial for the assessment of cardiac and pericardial masses.
• •Definite histopathologic diagnosis in patients with pericardial masses who have a previous history of cancer is important for therapeutic decision making.

A 66-year-old woman was referred to the cardio-oncology clinic in our hospital because of an incidental finding on thoracic CT of a pericardial effusion. She had a past medical history of hypothyroidism, as well as myxoid liposarcoma in her left thigh 12 years earlier. She had been treated with resection surgery and radiotherapy with 60 Gy. She had presented with a retroperitoneal recurrence of myxoid liposarcoma 11 years later and underwent resection of the retroperitoneal mass. Follow-up CT showed possible recurrence in the quadratus lumborum muscle 9 months later; a resection of this mass was performed, confirming the diagnosis of myxoid liposarcoma. She underwent further treatment with 30 fractions of radiotherapy. Her last CT showed a new pericardial effusion (Figure 1A). She had been experiencing chest pain that increased with inspiration. An initial electrocardiogram in our clinic showed T-wave inversion from leads V₃ to V₆. An echocardiogram showed a pericardial mass adjacent to the apex (Figure 1B), and CMR was requested. CMR confirmed a complex pericardial mass infiltrating the left ventricular apex with pericardial thickening and effusion (dimensions 72 mm × 88 mm × 65 mm) (Figures 1C to 1E); normal biventricular function was described (Video 1). Given the patientś previous oncologic history and the high suspicion of a malignant pericardial mass, it was decided to perform resection through left thoracoscopy. During the procedure, dissection of a mucous-like encapsulated pericardial tumor was accomplished; however, because of the size of the mass, an anterolateral thoracotomy was performed. The mass was found to be infiltrating the apical portion of the heart. Pathologic analysis confirmed metastatic myxoid liposarcoma of the pericardium (Figure 1F). The patient had a successful recovery from the procedure and will be evaluated for systemic therapy with the oncology team.

Figure 1.

Cardiac Imaging and Pathology Findings of the Pericardial Mass

(A) Axial axis computed tomography showing a heterogeneous pericardial mass with areas of higher attenuation (arrowhead). (B) Transthoracic echocardiogram, 4-chamber view, showing a pericardial heterogeneous mass adjacent to the apical and lateral regions of the left ventricle (LV) (asterisk). (C) Cardiac magnetic resonance image steady-state free precession cinema in the 4-chamber view shows a pericardial mass attached to the parietal layer of the serous pericardium. The mass appears septated (arrowheads), associated with pericardial thickening (arrow) and mild effusion (asterisk). (D) In the short-tau inversion recovery sequence (T2-weighted) short-axis view, a hyperintense mass can be observed (asterisk), which is characteristic of cystic lesions or malignant neoplasms in the presence of edema. An increase in signal intensity is noted at the pericardial layers (arrow), indicating ongoing inflammation. (E) Late gadolinium enhancement sequence in the 4-chamber view shows diffuse and heterogeneous uptake by the pericardial mass (asterisk), which is characteristic of malignant lesions because of the extensive fibrosis and edema typical of this type of neoplasm. Pericardial uptake is observed as well (arrow), and in addition to the hyperintensity seen in short-tau inversion recovery sequences, it is consistent with the presence of an acute inflammatory process. It is also noticeable that the mass infiltrates the myocardium at the apex (arrowhead), thus raising suspicion of malignancy. (F) Pathologic findings consistent with myxoid liposarcoma. There is prominent myxoid stroma with the characteristic branching vasculature, so called “chicken wire vasculature” (arrowheads), necrotic foci, scattered lipoblasts, and round cells. RV = right ventricle.

Funding Support and Author Disclosures

The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Appendix

Video 1

CMR Sequences in SSFP Cinema 4C and 2C, Showing a Complex Septated Pericardial Mass Infiltrating the LV Apex

2C= 2-chamber; 4C= 4-chamber; CMR = cardiac magnetic resonance; LV= left ventricular; SSFP = steady-state free precession1