Giant Thymoma and Cardiac Tamponade

Abstract

SESSION TITLE: Student/Resident Case Report Poster - Cardiac and Thoracic Surgery SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: The thymus is a gland overlying the pericardium and great vessels in the anterior mediastinum that typically involutes after puberty. Thymomas are rare tumors of the thymus gland in which associated pericardial effusions are found in a minority while hemorrhagic pericardial effusion causing tamponade physiology is extremely rare (1). We present a case of a patient who had hemorrhagic pericardial effusion with cardiac tamponade due to a malignant Type B2 Thymoma. CASE PRESENTATION: A 51-year-old previously healthy male presented to the hospital with a four-week history of progressive dyspnea on exertion, orthopnea, and pleuritic chest pain, as well as, six months of 40-pound weight loss. On examination, he was found to be tachycardic with normal heart sounds, distended neck veins, and bilateral basal lung rales. Pulsus paradoxus was 24 mm Hg. Electrocardiogram showed sinus arrhythmia with tachycardia, diffuse low voltage QRS complexes and T-wave flattening in the inferior leads, without electrical alternans. His CBC showed leukocytosis with lymphocytic predominance. Other labs, including ESR, CRP, TSH, ANA, HIV, Rheumatoid Factor, syphilis and myasthenia gravis antibodies, were within normal limits. A Chest X-ray demonstrated an enlarged Cardiac silhouette and a large anterior mediastinal mass. Transthoracic echocardiogram showed a large pericardial effusion with tamponade physiology, as well as, a mass anterior to the right heart. An urgent pericardiocentesis was performed draining 640 ml of bloody fluid with the resolution of tamponade. Chest CT confirmed a large anterior mediastinal mass (16.3 x 19.5 x 20.6 cm) with central areas of necrosis and significant mass effect on the heart, trachea, and the bilateral main stem bronchi. Subsequently, the patient underwent mediastinoscopy with biopsy and flow cytometry demonstrating malignant Type B2 Thymoma. The patient was treated with neoadjuvant chemotherapy with cisplatin, doxorubicin, cyclophosphamide, and prednisone. He then underwent surgical debulking with plans for radiation therapy. DISCUSSION: The overall incidence of thymoma is 0.15 cases per 100,000 (2). Hemorrhagic pericardial effusion with cardiac tamponade represents a rare initial presentation of Malignant Thymoma. CONCLUSIONS: Thymic pathologies should be included as a rare etiology in the differential diagnosis of hemorrhagic pericardial effusion and cardiac tamponade. To the best of our knowledge, this case represents the largest malignant thymoma that has been diagnosed with a presentation of hemorrhagic pericardial effusion and cardiac tamponade Reference #1: Takanami I, Takeuchi K, Naruke M. Noninvasive large thymoma with a natural history of twenty-one years. J Thorac Cardiovasc Surg. 1999;118:1134-1135. doi: 10.1016/S0022-5223(99)70120-0. Reference #2: Engels EA, Pfeiffer RM: Malignant thymoma in the United States: demographic patterns in incidence and associations with subsequent malignancies. Int J Cancer 105(4):546-51, 2003 DISCLOSURE: The following authors have nothing to disclose: Irfan Ahsan, Wisam Alfay, Jenna Jarriel, Gregary Marhefka No Product/Research Disclosure Information