SPC365

Masson’s Lesion: a very rare cardiac mass

Session: Sessão de casos clínicos
Speaker: Francisco Albuquerque

Congress: CPC 2021
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Session Type: Sessão de Casos Clínicos
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Authors: Francisco Albuquerque; João Presume; Sérgio Maltês; Pedro Freitas; António Ferreira; Marisa Trabulo; João Abecassis; Carla Saraiva; Ana Santos; Catarina Albuquerque; Sância Ramos; Márcio Madeira; José Pedro Neves
<p style="text-align:center"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><span style="font-size:11.0pt"><span style="color:#0e101a">A 66 years-old woman presented to her attending physician due to a pathological EKG (deep inverted T waves in the anterior and inferior leads) and echocardiogram (ill-defined mass adjacent to the RV). A fall with thoracic trauma one year ago was reported. Past medical record was notable for hypertension, type 2 DM, multinodular goiter, glaucoma, and left peripheral facial palsy. After the initial investigation:</span></span></span></span></p>

<ul>
	<li style="text-align:justify"><span style="font-size:12pt"><span style="color:#0e101a"><span style="font-family:Calibri,sans-serif"><strong><span style="font-size:11.0pt">Laboratory workup:</span></strong><span style="font-size:11.0pt">&nbsp;unremarkable.</span></span></span></span></li>
	<li style="text-align:justify"><span style="font-size:12pt"><span style="color:#0e101a"><span style="font-family:Calibri,sans-serif"><strong><span style="font-size:11.0pt">Contrast transthoracic echocardiography:&nbsp;</span></strong><span style="font-size:11.0pt">heterogenous mass adjacent to the RV with delayed contrast uptake (we were not able to detect any communication/flow between the RV and the mass)</span></span></span></span></li>
	<li style="text-align:justify"><span style="font-size:12pt"><span style="color:#0e101a"><span style="font-family:Calibri,sans-serif"><strong><span style="font-size:11.0pt">Cardiac MRI:</span></strong><span style="font-size:11.0pt">&nbsp;pericardial mass adjacent to the apical portions of the heart (8x4x7 cm) without a clear surgical cleavage plane; hyperintense in T1 and isointense in T2 with overall delayed gadolinium enhancement; perfusion study &ndash; contrast appears to disseminate to the mass from the apical portion of the RV.</span></span></span></span></li>
	<li style="text-align:justify"><span style="font-size:12pt"><span style="color:#0e101a"><span style="font-family:Calibri,sans-serif"><strong><span style="font-size:11.0pt">Angiography CT&nbsp;</span></strong><span style="font-size:11.0pt">(cardiac, thoracic, abdomen, and pelvis): no clear evidence of a narrow neck (typical in pseudoaneurysms); no evidence of distant neoplasia.</span></span></span></span></li>
</ul>

<p style="text-align:justify">&nbsp;</p>

<p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><span style="font-size:11.0pt"><span style="color:#0e101a">The differential diagnosis included primary pericardial sarcoma (especially, angiosarcoma), RV pseudoaneurysm (previous history of thoracic trauma), and pericardial inflammatory pseudotumor.</span></span></span></span></p>

<p style="text-align:justify">&nbsp;</p>

<p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><span style="font-size:11.0pt"><span style="color:#0e101a">The patient undergone a diagnostic biopsy through a mini left thoracotomy as per Heart Team&#39;s decision. A cystic mass was found, and the pericardial echocardiogram showed a communication between RV and the mass - the most probable diagnose at this point was a false aneurism. Due to the nature of the mass, a full tissue biopsy from a mini left thoracotomy approach was considered unsafe.</span></span></span></span></p>

<p style="text-align:justify">&nbsp;</p>

<p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><span style="font-size:11.0pt"><span style="color:#0e101a">Subsequently, cardiac surgery was performed through a median sternotomy and cardiopulmonary bypass. The mass was adjacent to the RV and filled with blood, thrombi, and fibrosis. It was partially excised, given the absence of a surgical cleavage plane and proximity to the LAD artery. The ventricle was closed with a double mattress suture supported by Teflon felts.</span></span></span></span></p>

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<p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><span style="font-size:11.0pt"><span style="color:#0e101a">The histopathological diagnosis was consistent with intravascular papillary endothelial hyperplasia also known as Masson&rsquo;s Lesion. This is a benign vascular non-neoplastic lesion characterized by reactive endothelial proliferation occurring usually in the skin and subcutaneous tissues. Current literature recommends total excision to avoid recurrence. Initial follow-up cardiac MRI revealed residual flow from the RV to the pericardial residual cavity delimited by the double mattress suture supported by Teflon felts. The case was debated in a second Heart Team meeting and clinical follow-up was proposed. 4 months after surgery, follow-up MRI showed the same pericardial residual cavity with similar size.&nbsp;</span></span></span></span></p>

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<p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif"><strong><span style="font-size:11.0pt"><span style="color:#0e101a">Conclusion:</span></span></strong><span style="font-size:11.0pt"><span style="color:#0e101a">&nbsp;Several challenges were faced during diagnosis and treatment of this very rare cause of pericardial tumor. The patient remains asymptomatic.</span></span></span></span></p>