Differential diagnosis of right cardiophrenic angle masses.

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The right cardiophrenic angle is not an uncommon site for tumefactive lesions. Many of these are asymptomatic. Fortunately, most are benign, but occasionally a mass in this location is malignant. It is important, therefore, to make a definitive diagnosis when possible. Since most masses in the cardiophrenic angle are unsuspected clinically and are found only on roentgenographic examination of the chest, it behooves the radiologist to be familiar with the lesions that may occur in this location. His decision will many times serve to guide the clinician in the proper handling of the patient. In the last several years, we have had the opportunity of studying 16 patients with right cardiophrenic angle masses, the nature of which was established either by roentgenologic procedures or by operation. We have seen an equal number of cases in which the diagnosis was not proved. At the present time, we feel some confidence in the accuracy of a preoperative diagnosis based on the roentgenologic findings. In the roentgen study of these masses, we have found the following procedures useful. Rarely, however, do we find it necessary to perform all of them in an individual case. (1) Routine postero-anterior and right lateral chest films for identificacation of the lesion. (2) Fluoroscopy to determine the position of the mass in relation to adjacent structures, variations in size and shape with respiration, and the presence of transmitted or intrinsic pulsations. (3) Tomograms of the right cardiophrenic angle in frontal and lateral projections for better delineation of the mass and its relation to adjacent structures. (4) An abdominal film or barium enema study for localization of the transverse colon. (5) Upright chest films following pneumoperitoneum. (6) Upright and decubitus films following pneumothorax. (7) Occasionally an angiocardiogram or bronchogram. For the purposes of description and simplicity, we classify right cardiophrenic angle masses as follows: (A) congenital pericardial celomic cysts and diverticula; (B) omental herniations through the right foramen of Morgagni; (C) all other masses arising from the structures bordering the right cardiophrenic angle. Of our 16 proved cases, 6 were in class A, 6 in Class B, and 4 in Class C. A. Congenital Pericardial Celomic Cysts and Diverticula Lambert (14) described congenital pericardial celomic cysts and diverticula in detail in 1940, and since that time nearly a hundred cases have appeared in the literature (1–4, 13, 15–18, 22). According to Lambert, the pericardium is formed by the fusion of several mesenchymal lacunae. Failure of fusion of one or more of these results in the formation of a congenital pericardial celomic cyst, and an incomplete fusion results in a pericardial diverticulum, which communicates with the pericardium. Celomic cysts and diverticula may occur in any location adjacent to the pericardium but the majority are in the right cardiophrenic angle; all of them are within the mediastinum.