Heart-breaking tumours: a case series of malignant pericardial effusion

Our plain-English summary of Heart-breaking tumours: a case series of malignant pericardial effusion, by S.S. Wan Muhamad Hatta, A.R. Mirza, N. Sunni, et al (European Heart Journal. Case Reports, 2025).

The study

• Authors: S.S. Wan Muhamad Hatta, A.R. Mirza, N. Sunni, A. Bashir
• Journal: European Heart Journal. Case Reports
• Published: 2025;9(3):ytaf009
• Type of article: Case report
• Cited by: 2 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Malignant pericardial effusions are often linked to metastases from solid tumours, such as those in the lung or breast, or haematological diseases. Primary cardiac tumours are rare, occurring in only 0.02% of cases, with pericardial tumours comprising 6.7%-12.8% of all primary cardiac tumours.

Case Summary: In Case 1, a 49-year-old Black African male presented with chest pain and breathlessness after a COVID-19 vaccine. Initially treated for pericarditis, he returned with worsening symptoms. Echocardiography revealed pericardial effusion and cardiac tamponade. Imaging confirmed a right atrial mass diagnosed as malignant biphasic mesothelioma. He died 4 months after diagnosis. In Case 2, a 43-year-old Caucasian male developed breathlessness and fever post-COVID-19 vaccine. Imaging identified a large posterior pericardial mass, later diagnosed as synovial sarcoma. Chemotherapy yielded minor tumour reduction, but he succumbed to his illness, spending his final days in a hospice.

Discussion: Initial clinical signs are critical in determining the origin of pericardial effusion. Malignancy should be suspected in cases with cardiac tamponade, unexplained haemorrhagic pericardial fluid, or recurrent symptoms. Negative cytology warrants further investigation with advanced imaging or biopsy to improve diagnostic sensitivity. Diagnosing rare tumours involves multiple imaging modalities, fluid analysis, biopsies, and an interdisciplinary approach, with pathological analysis being the gold standard. Treatment remains challenging due to the rapid progression of these tumours, with surgery often not feasible. A multi-pronged diagnostic approach is crucial, and clinicians must maintain suspicion for malignancy in persistent pericardial effusion cases, even in the context of other potential confounding factors.

© The Author(s) 2025. Published by Oxford University Press on behalf of the European Society of Cardiology.

In plain English

This case series described two men with tumours of the pericardium, the sac around the heart. The first was a 49-year-old Black African man who worked in a cardboard factory with no asbestos exposure. He was first treated for pericarditis after a COVID-19 vaccine. He returned with fluid pressing on the heart (cardiac tamponade). The fluid contained blood, but tests found no cancer cells. Scans showed a mass by the right atrium that later measured 6 cm by 3 cm. A biopsy indicated malignant biphasic mesothelioma, though undifferentiated sarcoma was also considered. He died 4 months after diagnosis. The second, a 43-year-old Caucasian man, had a 14 cm by 10 cm pericardial mass that an open biopsy confirmed as synovial sarcoma. Surgery was not feasible, and chemotherapy shrank the tumour only slightly. The authors described his survival as 24 months after first presentation, and he died in a hospice. Citing earlier literature, the authors wrote that there is no strong evidence linking asbestos to pericardial mesothelioma. They concluded that clinicians should keep suspecting cancer when pericardial effusion persists.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: case series (two patients)
• Who was studied: Two men seen at a UK hospital (authors from Walsall Healthcare NHS Trust): a 49-year-old Black African man (Case 1) and a 43-year-old Caucasian man with asthma (Case 2), both with recent COVID-19 vaccination; dates not given
• Exposure: No asbestos exposure was reported for Case 1, who worked in a cardboard factory; no occupational or asbestos exposure is described for Case 2
• Main results:
  • Case 1: cardiac tamponade with haemorrhagic pericardial fluid, but cytology was negative for malignancy
  • Case 1: repeat cardiac MRI showed the mass had grown to 6 cm by 3 cm
  • Case 1: VATS biopsy histology indicated malignant biphasic mesothelioma (epithelioid and spindled cells); the differential diagnosis included undifferentiated sarcoma with reactive mesothelial proliferation
  • Case 1: the patient died 4 months after diagnosis
  • Case 2: cardiac MRI showed a 14 cm by 10 cm pericardial mass; an open biopsy confirmed synovial pericardial sarcoma after surgical excision proved unfeasible
  • Case 2: six cycles of doxorubicin and ifosfamide gave some improvement and minor tumour reduction; the authors described a 24-month survival after presentation, and he died in a hospice
  • In the discussion, citing a prior report, the authors stated that asbestos is a key risk factor in other mesotheliomas but there is no strong evidence of a causal link for pericardial mesothelioma
• The authors' conclusion: The authors concluded that a multi-pronged diagnostic approach is needed, that clinicians must keep suspecting malignancy in persistent pericardial effusion, and that negative cytology should prompt further investigation such as pericardial biopsy

Topics

Medical terms in this study, explained in our Lexicon: Pericardial Effusion, Pericardial, Cardiac Tamponade, Biphasic Mesothelioma, Synovial Sarcoma, Chemotherapy, Hospice, Cytology.

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