Stuck Between a Rock and a Hard Place
An 82-year-old woman initially presented with left-sided chest and shoulder pain. She was noted to have a large mass on a chest radiograph, but surgical intervention was deemed inappropriate because of her age. Eighteen months later, she complained of increasing shortness of breath at rest and progressive weakness, and a pericardial effusion was discovered. However, it was not possible to determine with either CT or transthoracic echocardiography whether tumor infiltration of the pericardium and great vessels had occurred. Cardiovascular MR (CMR) demonstrated compression of the main pulmonary artery between the huge mass and the ascending aorta, resulting in an impressive slitlike stenotic deformation of the vessel (Figure 1). CMR also showed pericardial thickening of up to 11 mm and tumor infiltration in the lateral and anterolateral region of the heart in the presence of a small pericardial effusion (Figure 2). Subsequently, these CMR findings were confirmed at surgery where partial pericardectomy and total resection of the mass were performed, resulting in pulmonary artery decompression (Figure 3). The patient made an uneventful postoperative recovery. Histology revealed a malignant type IIIb thymoma (World Health Organization classification), an unusual finding in the elderly. In this patient, the ability of CMR to acquire images in any desired plane allowed full evaluation of tumor expansion and was useful in guiding the surgical approach.
We thank Prof Dr H.J. Heinze (Head of the Department of Neurology II, Otto-von-Guericke-University Magdeburg), who generously provided the MR scanning facility and Dr Kim Rajappan (London, UK) for the revision of the manuscript.
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
Circulation encourages readers to submit cardiovascular images to the Circulation Editorial Office, St Luke’s Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.