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Cardiac tamponade from a giant thymoma: case report
© Fazlıoğulları et al; licensee BioMed Central Ltd. 2012
Received: 25 September 2011
Accepted: 6 February 2012
Published: 6 February 2012
Thymoma, the most common neoplasm of the anterior mediastinum especially in adults, accounts for 20-25% of all mediastinal tumors and 50% of anterior mediastinal masses. These tumors are routinely asymptomatic for prolonged periods of time. Pericardial tamponade is a very rare initial manifestation of a thymoma. This report presents a patient who had hemorrhagic pericardial tamponade that likely resulted from the largest symptomatic mixed type (type AB) thymoma described in the literature.
The thymus gland usually is found overlying the pericardium and great vessels in the anterior mediastinum. Tumors of the thymus, namely thymomas, may be of the benign or malignant variety. Of patients with a thymoma, one third to one half are asymptomatic, and one third of patients present with local symptoms related to the tumor encroaching on surrounding structures. Most tumors of the mediastinum are diagnosed accidentally by the routin chest x-rays. Chest pain, cough, dyspnea, myasthenia gravis, and weight loss are observed frequently in symptomatic patients. Pericardial effusion may be present in approximately 20% of cases. However, spontaneous hemorrhagic pericardial effusion is an unexpected clinical feature [1–3]. Tumors that have invaded the cardiac or vascular structures indicate a poor prognosis due to the therapeutic limitations . Here we report a case of giant thymoma with pericardial effusion which has treated by surgery and radiotherapy.
Hyperplasia, thymoma and hematopoietic neoplasms are the most common causes of thymic enlargement. The overall incidence of thymoma is rare, 0.15 cases per 100.000 . Histologically, 70-80% of thymomas are benign, but 2-6% of the tumors are thymic carcinomas with high degrees of malignancy. According to the recently-developed WHO classification, type A, AB and B tumors are not categorized as malignant, but type C tumors are considered to be malignant. The size, resectability and invasion of the surrounding structure are the most reliable prognostic factors for Masaoka staging [2, 4, 5]. Suspected malignancy and the presence of myasthenia gravis are surgical indications . Total resection should be verified with frozen sections during surgery for the removal cysts, hyperplasia and thymic tumors, except for lymphomas, seminomas and malignant germ cell tumors [4–7].
Thymomas account for approximately 20-25% of all mediastinal masses in people of all ages and 47% of all mediastinal masses in adults. These tumors are frequently asymptomatic [1–3]. Although only one-third of patients with localized disease are symptomatic, most patients with disseminated disease have significant complaints, such as chest pain, chest discomfort, dyspnea, and superior vena cava syndrome [1–5]. However, hemorrhagic pericardial tamponade is an uncommon initial manifestation.
Because complete resection and the type of the tumor are the most important factors determining prognosis, the resection should be performed with regard to pathological evaluation for thymic enlargements as much as possible. In this case, because of the size and the dissemination characteristics that were revealed by the CT scans, pericardiectomy and resection were unavoidable. Other diagnostic techniques, such as needle biopsies or VATS, were not used. Because of the pathological similarities between lymphoma and thymoma, we resected the tumor as much as possible, but according to the frozen sections, we did not achieve total resection. Additionally, lymphoma is more likely in this patient because of his age.
The presence of hemorrhagic pericardial tamponade without any history of chest trauma or any coagulation abnormality, thymic pathologies should definitly be suggested at first sight. Also, to the best of our knowledge, this thymoma is the largest one reported that has been diagnosed based on the sudden onset hemorrhagic pericardial tamponade as an initial symptom. We believe that CT scanning should definitely be performed for all pericardial effusions with unknown ethiology. If thymoma is a possible diagnosis, the first aim in surgical therapy should be total resection since the heterogenity of thymomas pathologic structure. Histological heterogenity of thymomas may cause misdiagnosis since some parts involve lymphocitic and some parts thymic dominancy as in our case.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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