When cardiac surgery comes to its limits: a case report of pericardial mesothelioma invading the myocardium

Our plain-English summary of When cardiac surgery comes to its limits: a case report of pericardial mesothelioma invading the myocardium, by L. Pölzl, J. Hirsch, A. Mayr, et al (European Heart Journal. Case Reports, 2021).

The study

• Authors: L. Pölzl, J. Hirsch, A. Mayr, C. Uprimny, G. Oberhuber, H.J. Zwick, L. Müller, G. Pölzl
• Journal: European Heart Journal. Case Reports
• Published: 2021;5(7):ytab237
• Type of article: Case report
• Cited by: 1 article, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Primary pericardial mesothelioma (PPM) is a rare form of highly aggressive cancer. Many patients are diagnosed only at an advanced stage. Therefore, the overall survival rate is poor with a median survival of 3 months. In some rare cases, the PPM infiltrates the myocardium causing lethal myocardial dysfunction.

Case Summary: A 66-year-old patient was transferred to our centre with the provisional diagnose of pericarditis of unknown origin. Using extensive cardiac imaging [echocardiography, computed tomography (CT), positron emission tomography-CT, cardiac magnetic resonance imaging, left and right heart catheterization, coronary angiography], PPM was finally diagnosed. After consultation with the oncologists, the heart team decided to resect the tumour first due to impaired haemodynamics and then initiate adjuvant chemotherapy. Intraoperatively, myocardial infiltration of the tumour became apparent, which was not detected preoperatively despite intensive imaging. Complete resection of the PPM was not possible and effective decompression of the ventricle could not be achieved. The patient died on the first postoperative day.

Discussion: Surgical therapy is indicated in many forms of cardiac tumours. However, when a tumour invades the myocardium, surgery often comes to its limits. In this case, myocardial invasion of PPM could not be detected despite extensive imaging. We therefore suggest that possible myocardial infiltration by PPM, and thus potential limitations of cardiac surgery, should be considered independently of imaging results when therapeutic options are discussed.

© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.

In plain English

This was a case report from the Medical University of Innsbruck, Austria, describing one patient with primary pericardial mesothelioma, a cancer of the lining around the heart. The patient, a 66-year-old man, had shortness of breath and weight loss beginning in March 2020. The authors stated that the patient had no previous asbestos exposure. Fluid drained from around the heart at another hospital showed no cancer cells. At the authors' centre, extensive imaging, including echocardiography, CT, PET-CT, cardiac MRI and heart catheterization, showed a tumour arising from the pericardium and pressing on the heart. Cardiac output was markedly reduced, at 1.8 L/min, but the imaging showed no sign that the tumour had grown into the heart muscle. The team operated in August 2020 to remove the tumour, with chemotherapy planned afterwards. During surgery the tumour was found to have penetrated the heart muscle. It could not be completely removed, and the pressure on the heart could not be relieved. ECMO, a heart-lung support machine, was not used. The patient died the day after surgery from multiorgan failure. The authors concluded that tumour invasion of the heart muscle should be considered even when imaging does not show it.

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 report (single patient)
• Who was studied: One 66-year-old Caucasian man treated at the Medical University of Innsbruck, Austria; first symptoms March 2020, presented 14 July 2020, surgery 3 August 2020
• Exposure: No previous asbestos exposure was reported for this patient
• Main results:
  • Earlier drainage of fluid from around the heart at another hospital produced 500 mL of serous exudate, with no malignant cells found
  • Before surgery, the patient's cardiac output was decreased at 1.8 L/min
  • Histology showed a spindle-shaped, partly tubular malignant tumour, with calretinin positivity
  • Tumour penetration into the heart muscle was diagnosed during surgery, not on preoperative imaging
  • Complete removal of the tumour, and with it stabilization of the circulation, was not possible
  • ECMO was not used because there was no prospect of weaning the patient off it
  • The patient died on the first day after surgery from multiorgan failure
• The authors' conclusion: The authors concluded that tumour infiltration of the heart muscle must be considered even when cardiac imaging shows no evidence of it

Topics

Medical terms in this study, explained in our Lexicon: Pericardial Mesothelioma, Overall Survival, Median Overall Survival, Chemotherapy.

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