Positive and differential diagnosis in tumoral pericardial involvement focused on CT examinations

Transcription

1 Positive and differential diagnosis in tumoral pericardial involvement focused on CT examinations Poster No.: C-0989 Congress: ECR 2016 Type: Educational Exhibit Authors: A. Flintoaca-Filip, I. G. Lupescu, D. M. Tabac, M. Ichim, R. A. Capsa; Bucharest/RO Keywords: Metastases, Lymphoma, Acute, Contrast agent-intravenous, Computer Applications-Detection, diagnosis, CT, Oncology, Emergency, Cardiac DOI: /ecr2016/C-0989 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 45

2 Learning objectives To identify and describe the characteristics and morphologic features in metastatic pericardial involvement. To discuss the differential diagnosis of tumoral pericardial involvement. To list the CT findings of oncologic emergent condition in patients diagnosed with large mediastinal tumor. Page 2 of 45

3 Background ANATOMIC CONSIDERATION - The pericardium represents a fibrous bag that encloses the heart and the great vessels, anchoring the heart in the center of the thoracic cavity (1). - It is composed of two layers: visceral pericardium, adherent to the heart and great vessels (2), and parietal pericardium. - Between the two layers there is a space, which can contain approximately ml of serous fluid, distributed mostly over the atrioventricular and interventricular grooves (1, 3). - The pericardium extends cranially to cover the proximal great vessels (2, 4, 5), above level of the aortic root (6) and consecutively pericardial cavity forms the pericardial sinuses (1). Fig. 1 on page Page 3 of 45

4 Fig. 1: Anatomic drawing of pericardial recesses and sinuses. Oblique sinus (O), transverse sinus (T) and pulmonary vein recesses (arrow head). References: adapted from Netter's Atlas of Human Anatomy (5th Ed.) IMAGING OF NORMAL PERICARDIUM The normal pericardium can be visible at cross-sectional imaging as a thin curved structure, only if it is outlined by mediastinal or subepicardial fat (2,6). The normal values of the pericardial thickness is considered up to 2 mm (4). The pericardium is nearly avascular (3) and does not enhance post intravenous administration of contrast media (7). Fig. 2 on page 10 Page 4 of 45

5 Fig. 2: Axial CT scan shows normal pericardium lined between the epicardial (curved arrow) and mediastinal fat layers. References: Radiology, Medical Imaging and Interventional Radiology of Fundeni Clinical Institute, Bucharest, Romania IMAGING TECHNIQUES Echocardiography : - advantages : quick and simple test ;(1) - disadvantages : limited field of view ;(1) CT : - advantages : widely available, short acquisition time, large field of view, evaluation of tumoral extension throughout the thorax, assessment of complications-cardiac tamponade ;(1,6,12) - disadvantages : no functional informations ;(1,12) MRI : - advantages : tissue characterisation, excellent contrast resolution, functional informations ; (1,12) - disadvantages : long acquisition time.(1) CLASSIFICATION of pericardial masses General rule: pericardial mass= pericardial effusion+ nodular lesion (6) Primary pericardial tumors (Table 1 and Table 2) - extremely rare and frequently malignant (6) - benign tumors: fibroma, teratoma, hemangioma, lipoma (6) - malignant tumors: mesothelioma, angiosarcoma, liposarcoma, lymphoma (6) Page 5 of 45

6 Table 1 Primary pericardial tumors-age distribution Teratoma Lipoma Heman Fibroma Pericardial Sarcomas Lymphoma mesothelioma gioma Children + Adults Table 2 CT imaging findings in primary pericardial tumor Tumor Pericardial effusion Pericardial mass Teratoma +++ Multilocular cystic/ Fetal hydrops complex mass (8, Massive pleural and 10) pericardial effusions (9) Lipoma - Fat attenuation Fat attenuation mass, soft-tissue mass, no septa (10) enhancement (10) Fibroma +/- Heterogeneous mass (10) Calcification, enhancement (10) Hemangioma - Heterogeneous mass (10) Enhancement, vascular blush (10) Pericardial mesothelioma +/variable amount Irregular or diffuse Multiple coalescing pericardial masses that encase thickening (10) the heart (11) Sarcomas + Mass, broad base Heterogeneous tumor attachment enhancement (10) (10) Lymphoma + Nodular mass (10) Typical findings Heterogeneous enhancement (10) Secondary pericardial tumors - symptoms attributable to pericardial effusions and impairment of right cardiac filling (11) - occur in a late stage of a tumoral process (12) and are discovered at autopsy in 10-12% of all patients with malignancies (12) - most frequent tumoral involvement in: lung cancer, lymphoma, breast cancer, leukemia, gastric tumors, melanoma etc (13) - the lung- commonest primary site (14) Page 6 of 45

7 - pathways of secondary pericardial involvement: retrograde lymphatic extension-predominant route, direct invasion, hematologic spread, venous extension (11, 12) - tumoral involvement of epicardium in 75,5% of metastatic lesions (14) - extensive cardiac involvement in lymphoma (14) IMAGING ASPECTS 1) pericardial effusion: Most common manifestation of a malignant pericardial disease (7) Small to large with an imminent tamponade (15) Usually exudate (1) or hemorrhagic effusion (4, 12) In a patient with known cancer should prompt supplementary investigation (4,12) If there is no association with pericardial thickening a malignant pericardial disease is not exclude (7) Unexplained hematic pericardial effusion always rises suspicion of a malignant etiology (4,12) Associated with irregular thickening and mediastinal lymphadenopathy may suggest malignant pericardial effusion (7) May be seen in patients with voluminous mediastinal tumors, usually with regression post chemotherapy (16) in known cases of malignancy the differential diagnosis include: complication of antineoplastic therapies (17), radiation-induced pericarditis (12), opportunistic infections (15), idiopathic pericarditis (7) Analyses of pericardial fluid and pericardial or epicardial biopsies are essential for confirmation of malignant pericardial disease (15) Pericardiocentesis is indicated for suspicion of neoplastic and purulent pericarditis, clinical tamponade (7) 2) focal interruption of pericardial layers (6) 3) nodular or diffuse pericardial thickening (1) mean pericardial thickening greater in malignant than in benign pericardial disease (7) 4) discrete nodules (1) 5) tumoral obliteration of the superior pulmonary vein (5) 6) focal obliteration of the pericardial line (18, 21) Page 7 of 45

8 DIFFERENTIAL DIAGNOSIS any disease that can causes nodular thickening of pericardium can mimic a secondary pericardial involvement (12) cytology of pericardial fluid and biopsies are essential for differential diagnosis between malignant lesions and other causes of pericardial disease (15) 1. Radiation and chemotherapy -induced pericarditis (11,12) most often due to radiation therapy of Hodgkin' s lymphoma (15), dose dependent (15) CT findings: immediately post radiotherapy: acute pericarditis with or without effusion (15) delayed acute phase: large pericardial effusion +/-cardiac tamponade, serous or hemorrhagic effusion (15) late onset of pericardial disease generally occur after 2 years post radiotherapy: effusive-constrictive pericarditis or classical constrictive pericarditis (15) prior chest irradiation or chemotherapy=clue in differential diagnosis 2. Drug-related pericarditis CT findings: hyperdense pericardial effusion anticoagulant therapies represents risk factors for development of hemorrhagic pericardial effusion (15) 3. Infections of the pericardium -effusion and pericardial thickening (19) -may be found a loculated pericardial effusion (19) -always enhancement of pericardial layers (19) -tuberculosis may cause nodular or abnormal pericardial thickening (1, 7) 4. Idiopathic pericarditis pericardial thickening with or without effusion (1) pericardial enhancement during active inflammation (1) acute pericarditis -early enhancement of thickened pericardium (20) chronic pericarditis-irregular contour of thickened pericardium (20) 5. Pericardial hematoma usually occur following trauma or surgery (1) Page 8 of 45

9 CT aspects: hyperdense pericardial mass- density higher than skeletal muscles or myocardium, no enhancement post contrast media administration, the attenuation decreases in density with time (1) small calcification in chronic hematoma (1) 6. Pericardial cyst (11) -rare congenital abnormality (1, 6), no communication with pericardial cavity (15) -benign unilocular mass (6), -encapsulated fluid-filled mass (1), without nodules (6), no contrast enhancement (15) -usually localized in right cardio-phrenic angle (70% of cases) (6) COMPLICATIONS Pericardial tamponade bleeding from tumor implants, pericardial lymphatic obstruction by tumor cells determine accumulation of intrapericardial fluid (22) accumulation of fluid or blood increases intrapericardial pressure, leading to cardiac chambers compression and severe decline of diastolic filling (6) in almost 30% of all patients with known malignancy and pericardial effusion (22) clinical diagnosis (6): tachycardia, hypotension, jugular venous distension, peripheral cyanosis, pulsus paradoxus (23), dyspnea (22) CT findings: large pericardial effusion (23) distension of the superior and inferior vena cava (6, 23) compression or narrowing of the cardiac chambers (6, 22, 23) reflux of contrast media into the azygos vein or inferior vena cava (6, 23) Treatement - emergent pericardiocentesis (15, 22) Page 9 of 45

10 Images for this section: Fig. 1: Anatomic drawing of pericardial recesses and sinuses. Oblique sinus (O), transverse sinus (T) and pulmonary vein recesses (arrow head). adapted from Netter's Atlas of Human Anatomy (5th Ed.) Page 10 of 45

11 Fig. 2: Axial CT scan shows normal pericardium lined between the epicardial (curved arrow) and mediastinal fat layers. Radiology, Medical Imaging and Interventional Radiology of Fundeni Clinical Institute, Bucharest, Romania Page 11 of 45

12 Findings and procedure details We reviewed CT imaging findings of tumoral pericardial involvement, especially in patients diagnosed with mediastinal tumors, focusing on the differential diagnosis. TECHNIQUES (Fig. 2 on page 28) Fig. 2: Axial CT scan shows normal pericardium lined between the epicardial (curved arrow) and mediastinal fat layers. References: Radiology, Medical Imaging and Interventional Radiology of Fundeni Clinical Institute, Bucharest, Romania Unenhanced MSCT series were programmed to include the thorax. Enhanced MDCT was done in arterial and delayed phase. All patients received 1,5 ml/kg of a nonionic iodinated contrast (350 I mg/ml) with a monophasic injection using a power injector. The contrast material was administrated at a rate of 3,5-4 ml/s in all patients. CT acquisition was initiated at 25 seconds for the arterial phase and seconds for the delayed phase, after the injection of the contrast media began. CT scans were acquired without ECG gating IMAGING FINDINGS Secondary pericardial tumors 1. Hodgkin and non Hodgkin lymphoma Page 12 of 45

13 CT findings: exudate pericardial effusion Fig. 3 on page 28 Fig. 4 on page 29 pericardial effusion associated with nodular pericardial thickening and anterior cardiophrenic lymphadenopathy Fig. 4 on page 29 large mediastinal mass Fig. 3 on page 28 Fig. 4 on page 29 Fig. 5 on page 29 nodular pericardial thickening Fig. 3 on page 28 Fig. 4 on page 29 focal obliteration of the pericardial line Fig. 3 on page 28 compression of the right atrium Fig. 5 on page 29 focal interruption of pericardial layers Fig. 5 on page 29 nodular pericardial mass Fig. 5 on page 29 Fig. 3: Non Hodgkin lymphoma in a 26 year old woman. NECT (a) scan shows exudate pericardial effusion (11-14 HU). Contrast enhanced CT scan in axial (b), sagittal (c) and coronal (d) reconstruction shows a large anterior heterogeneous mediastinal mass (arrow) with obliteration of the normal tissue planes between the pericardium and the tumoral mass (curved arrow) and nodular pericardial (thin arrow) thickening (thin arrow). References: Radiology, Medical Imaging and Interventional Radiology of Fundeni Clinical Institute, Bucharest, Romania Page 13 of 45

14 Fig. 4: Voluminous anterior mediastinal tumor (star) in a 65 years old female patient diagnosed with non Hodgkin lymphoma. CT scan shows moderate pericardial effusion (arrow head), nodular pericardial thickening (notched arrow), anterior cardiophrenic lymphadenopathy (curved arrow). No clinical signs of cardiac tamponade. References: Radiology, Medical Imaging and Interventional Radiology of Fundeni Clinical Institute, Bucharest, Romania Page 14 of 45

15 Fig. 5: Heterogenous large mediastinal tumor (star), in a case of Hodgkin lymphoma, with focal interruption of pericardial layers (curved arrow), nodular mass (arrow) and compression of the right atrium. No clinical sign of cardiac tamponade. References: Radiology, Medical Imaging and Interventional Radiology of Fundeni Clinical Institute, Bucharest, Romania 2. Leukemia CT findings: obliteration of the pericardial line Fig. 6 on page 30 Fig. 7 on page 31 tumoral encasement of the superior pulmonary vein Fig. 6 on page 30 tumoral encasement of the cardio-pericardial structures Fig. 7 on page 31 Page 15 of 45

16 Fig. 6: Obliteration of the pericardial line (notched arrow) and tumoral encasement of the superior right pulmonary vein (arrow head) in a case of a 14 years old patient diagnosed with myeloid sarcoma. References: Radiology, Medical Imaging and Interventional Radiology of Fundeni Clinical Institute, Bucharest, Romania Page 16 of 45

17 Fig. 7: Lobulated large mediastinal tumor (star) with encasement of cardio-pericardic structures and obliteration of the pericardial line (notched arrow) in a 6 year old patient diagnosed with acute lymphoblastic leukemia. References: Radiology, Medical Imaging and Interventional Radiology of Fundeni Clinical Institute, Bucharest, Romania 3. Lung cancer CT findings: tumoral obstruction of superior pulmonary vein Fig. 8 on page 32 focal obliteration of pericardial line Fig. 8 on page 32 Fig. 9 on page 33 tumoral obliteration of inferior pulmonary vein Fig. 9 on page 33 Page 17 of 45

18 Fig. 8: Large mediastinal mass (star) and lung tumor (curved arrow), with tumoral obstruction of superior left pulmonary vein (black arrow), in a case of 66 year old male patient, diagnosed with small cell lung cancer. Note focal obliteration of pericardial line (arrow head). References: Radiology, Medical Imaging and Interventional Radiology of Fundeni Clinical Institute, Bucharest, Romania Page 18 of 45

19 Fig. 9: Large mediastinal and pulmonary mass, in a case of a 45 year old male patient diagnosed with squamous cell lung tumor. Focal obliteration of the pericardial line and compression of the left atrium (arrow head). Tumoral obliteration of inferior right pulmonary vein (curved arrow). References: Radiology, Medical Imaging and Interventional Radiology of Fundeni Clinical Institute, Bucharest, Romania 4.Esophageal cancer CT findings: -focal obliteration of pericardial line Fig. 10 on page 34 Page 19 of 45

20 Fig. 10: CT scan images of a 75 year old male patient, diagnosed with esophageal tumor, with esophageal stent placement. Focal obliteration of the pericardial line (curved arrow) by the posterior mediastinal mass. References: Radiology, Medical Imaging and Interventional Radiology of Fundeni Clinical Institute, Bucharest, Romania 5. Retroperitoneal tumor CT findings: tumor obliteration of the pericardial line Fig. 11 on page 35 compression and narrowing of the cardiac chambers Fig. 11 on page 35 Page 20 of 45

21 Fig. 11: Large voluminous retroperitoneal tumor (star), in a 48 year old male patient, with tumoral obliteration of the pericardial line, compression and narrowing of the left atrium (curved arrow). References: Radiology, Medical Imaging and Interventional Radiology of Fundeni Clinical Institute, Bucharest, Romania 6. Cardiac tumor CT findings: large pericardial effusion-exudate Fig. 12 on page 35 tumoral pericardial extension Fig. 12 on page 35 Fig. 12: Inoperable cardiac tumor (star) in a 29 year old female patient. CT scan shows large pericardial effusion (exudate) and tumoral pericardial extension. References: Radiology, Medical Imaging and Interventional Radiology of Fundeni Clinical Institute, Bucharest, Romania 7. Tymoma CT findings: Page 21 of 45

22 obliteration of pericardial line Fig. 13 on page 36 Fig. 13: Tymoma (star) in a 47 year old male. Obliteration of the fat plane between the tumoral mass and the pericardium (curved arrow). References: Radiology, Medical Imaging and Interventional Radiology of Fundeni Clinical Institute, Bucharest, Romania MIMICS 1. Radiation-induced pericarditis CT findings: pericardial effusion Fig. 14 on page 37 enhancement of pericardial layers Fig. 14 on page 37 irregular pericardial thickening Fig. 14 on page 37 Page 22 of 45

23 Fig. 14: Severe postradiotherapy pulmonary fibrosis (notched arrow) in a 69 year old male patient diagnosed with lung cancer. Irregular pericardial thickening (arrow) and moderate amount of pericardial effusion (arrow head). References: Radiology, Medical Imaging and Interventional Radiology of Fundeni Clinical Institute, Bucharest, Romania 2. Pericardial cyst CT findings: fluid fill encapsulated lesion Fig. 15 on page 38 Fig. 15: Unenhanced CT scan (a) and MR (b) image showing a fluid fill encapsulated lesion localized in the right anterior cardio-phrenic angle. References: Radiology, Medical Imaging and Interventional Radiology of Fundeni Clinical Institute, Bucharest, Romania Page 23 of 45

24 3. Pericardial hematoma CT findings: hyperdense pericardial mass, no enhacement post contrast media administration Fig. 16 on page 38 Fig. 16: NECT (a), CT+C (b) scan and coronal reconstruction (c) in a case of a 66 year old female patient with recent tricuspidian valvuloplasty. Hyperdense pericardial mass (a), with no enhancement post contrast media administration (b) and compression / narrowing of the right atrium (arrow) (c). References: Radiology, Medical Imaging and Interventional Radiology of Fundeni Clinical Institute, Bucharest, Romania 4. Hemoragic pericarditis CT findings: hyperdense pericardial effusion Fig. 17 on page 39 Page 24 of 45

25 irregular pericardial thickening Fig. 17 on page 39 Fig. 17: NECT (a), CT+C (b) scan and coronal (c) and sagittal (d) reconstruction in a 63 year old male patient with recent aortic-coronarian by pass. Hiperdense pericardial effusion (curved arrow) (a). Note irregular pericardial thickening (arrow-head) (b). References: Radiology, Medical Imaging and Interventional Radiology of Fundeni Clinical Institute, Bucharest, Romania 5. Infectious pericarditis CT findings pericardial thickening Fig. 18 on page 40 Page 25 of 45

26 enhancement of the pericardial layers Fig. 18 on page 40 Fig. 18: CT scan in a 75 year old male patient diagnosed with pulmonary empyema (Acinetobacter sp.)- split pleural sign (arrow head). Note pericardial thickened pericardium and mild enhacement of pericardial layers. References: Radiology, Medical Imaging and Interventional Radiology of Fundeni Clinical Institute, Bucharest, Romania WHAT TO REPORT? pericardial changes : - fluid/parafluid/hemorrhagic effusion, tamponade in a patient with known cancer - irregular/nodular pericardial thickening - calcifications mediastinal mass with focal obliteration of the pericardial line; tumoral obstruction of the superior pulmonary vein myocardial involvement signs of heart failure cardiac function extracardiac manifestations Page 26 of 45

27 Page 27 of 45

28 Images for this section: Fig. 2: Axial CT scan shows normal pericardium lined between the epicardial (curved arrow) and mediastinal fat layers. Radiology, Medical Imaging and Interventional Radiology of Fundeni Clinical Institute, Bucharest, Romania Fig. 3: Non Hodgkin lymphoma in a 26 year old woman. NECT (a) scan shows exudate pericardial effusion (11-14 HU). Contrast enhanced CT scan in axial (b), sagittal (c) and coronal (d) reconstruction shows a large anterior heterogeneous mediastinal mass (arrow) with obliteration of the normal tissue planes between the pericardium and the tumoral mass (curved arrow) and nodular pericardial (thin arrow) thickening (thin arrow). Page 28 of 45

29 Radiology, Medical Imaging and Interventional Radiology of Fundeni Clinical Institute, Bucharest, Romania Fig. 4: Voluminous anterior mediastinal tumor (star) in a 65 years old female patient diagnosed with non Hodgkin lymphoma. CT scan shows moderate pericardial effusion (arrow head), nodular pericardial thickening (notched arrow), anterior cardiophrenic lymphadenopathy (curved arrow). No clinical signs of cardiac tamponade. Radiology, Medical Imaging and Interventional Radiology of Fundeni Clinical Institute, Bucharest, Romania Page 29 of 45

30 Fig. 5: Heterogenous large mediastinal tumor (star), in a case of Hodgkin lymphoma, with focal interruption of pericardial layers (curved arrow), nodular mass (arrow) and compression of the right atrium. No clinical sign of cardiac tamponade. Radiology, Medical Imaging and Interventional Radiology of Fundeni Clinical Institute, Bucharest, Romania Page 30 of 45

31 Fig. 6: Obliteration of the pericardial line (notched arrow) and tumoral encasement of the superior right pulmonary vein (arrow head) in a case of a 14 years old patient diagnosed with myeloid sarcoma. Radiology, Medical Imaging and Interventional Radiology of Fundeni Clinical Institute, Bucharest, Romania Page 31 of 45

32 Fig. 7: Lobulated large mediastinal tumor (star) with encasement of cardio-pericardic structures and obliteration of the pericardial line (notched arrow) in a 6 year old patient diagnosed with acute lymphoblastic leukemia. Radiology, Medical Imaging and Interventional Radiology of Fundeni Clinical Institute, Bucharest, Romania Page 32 of 45

33 Fig. 8: Large mediastinal mass (star) and lung tumor (curved arrow), with tumoral obstruction of superior left pulmonary vein (black arrow), in a case of 66 year old male patient, diagnosed with small cell lung cancer. Note focal obliteration of pericardial line (arrow head). Radiology, Medical Imaging and Interventional Radiology of Fundeni Clinical Institute, Bucharest, Romania Page 33 of 45

34 Fig. 9: Large mediastinal and pulmonary mass, in a case of a 45 year old male patient diagnosed with squamous cell lung tumor. Focal obliteration of the pericardial line and compression of the left atrium (arrow head). Tumoral obliteration of inferior right pulmonary vein (curved arrow). Radiology, Medical Imaging and Interventional Radiology of Fundeni Clinical Institute, Bucharest, Romania Page 34 of 45

35 Fig. 10: CT scan images of a 75 year old male patient, diagnosed with esophageal tumor, with esophageal stent placement. Focal obliteration of the pericardial line (curved arrow) by the posterior mediastinal mass. Radiology, Medical Imaging and Interventional Radiology of Fundeni Clinical Institute, Bucharest, Romania Fig. 11: Large voluminous retroperitoneal tumor (star), in a 48 year old male patient, with tumoral obliteration of the pericardial line, compression and narrowing of the left atrium (curved arrow). Radiology, Medical Imaging and Interventional Radiology of Fundeni Clinical Institute, Bucharest, Romania Page 35 of 45

36 Fig. 12: Inoperable cardiac tumor (star) in a 29 year old female patient. CT scan shows large pericardial effusion (exudate) and tumoral pericardial extension. Radiology, Medical Imaging and Interventional Radiology of Fundeni Clinical Institute, Bucharest, Romania Page 36 of 45

37 Fig. 13: Tymoma (star) in a 47 year old male. Obliteration of the fat plane between the tumoral mass and the pericardium (curved arrow). Radiology, Medical Imaging and Interventional Radiology of Fundeni Clinical Institute, Bucharest, Romania Fig. 14: Severe postradiotherapy pulmonary fibrosis (notched arrow) in a 69 year old male patient diagnosed with lung cancer. Irregular pericardial thickening (arrow) and moderate amount of pericardial effusion (arrow head). Page 37 of 45

38 Radiology, Medical Imaging and Interventional Radiology of Fundeni Clinical Institute, Bucharest, Romania Fig. 15: Unenhanced CT scan (a) and MR (b) image showing a fluid fill encapsulated lesion localized in the right anterior cardio-phrenic angle. Radiology, Medical Imaging and Interventional Radiology of Fundeni Clinical Institute, Bucharest, Romania Page 38 of 45

39 Fig. 16: NECT (a), CT+C (b) scan and coronal reconstruction (c) in a case of a 66 year old female patient with recent tricuspidian valvuloplasty. Hyperdense pericardial mass (a), with no enhancement post contrast media administration (b) and compression / narrowing of the right atrium (arrow) (c). Radiology, Medical Imaging and Interventional Radiology of Fundeni Clinical Institute, Bucharest, Romania Page 39 of 45

40 Fig. 17: NECT (a), CT+C (b) scan and coronal (c) and sagittal (d) reconstruction in a 63 year old male patient with recent aortic-coronarian by pass. Hiperdense pericardial effusion (curved arrow) (a). Note irregular pericardial thickening (arrow-head) (b). Radiology, Medical Imaging and Interventional Radiology of Fundeni Clinical Institute, Bucharest, Romania Page 40 of 45

41 Fig. 18: CT scan in a 75 year old male patient diagnosed with pulmonary empyema (Acinetobacter sp.)- split pleural sign (arrow head). Note pericardial thickened pericardium and mild enhacement of pericardial layers. Radiology, Medical Imaging and Interventional Radiology of Fundeni Clinical Institute, Bucharest, Romania Page 41 of 45

42 Conclusion Familiarity of the radiologist with the spectrum of imaging findings in metastatic pericardial involvement is essential for an accurate and early diagnosis. The radiologist should be aware of different oncologic emergent conditions in patients diagnosed with large mediastinal tumor and their corresponding imaging. The thickened pericardium is suitable for the differential diagnosis between various etiologies: neoplastic, infectious, immunologic, post-radiation, postinfarct, idiopathic, Page 42 of 45

43 Personal information Prof.Dr.Ioana Lupescu Radiology, Medical Imaging and Interventional Radiology of Fundeni Clinical Institute, Bucharest, Romania University of Medicine and Pharmacy "Carol Davila", Bucharest Dr. Anca Filip Flintoaca Radiology, Medical Imaging and Interventional Radiology of Fundeni Clinical Institute, Bucharest, Romania Page 43 of 45

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