心タンポナーデ，血性胸水を合併した心膜嚢胞に対して胸腔鏡下嚢胞切除術を行った1例

Thoracoscopic Resection of a Pericardial Cyst with Cardiac Tamponade and Pleural Bloody Effusion

要旨　患者は55歳，女性．労作時息切れの精査目的で紹介入院となる．家族歴，既往歴に特記歴なし．現症では血圧98/60mmHg，脈拍92/分・不整，頸静脈怒張，肝腫大あり．血液検査にてCRPの軽度上昇と肝障害，胸部X線像で右二弓の突出と心肥大，心電図で心房細動，心エコー図で心嚢水貯留と右房外側の腫瘤像を認めた．また胸部CT，MRIでも右房外縁に計3cmの円形の腫瘤を認め，嚢胞性疾患を疑つた．Ga scanでは前縦隔と後縦隔に集積を認め心膜集積が疑われた．入院後数日間経過をみるも，症状は徐々に増悪し，胸部X線像上で大量胸水貯留も出現したため，胸水穿刺，心嚢水穿刺を行つたところ，いずれも血性を呈しており，悪性疾患も否定できず，全麻下胸腔鏡下にて腫瘤切除術を行つた．腫瘤は心膜嚢胞で，病理組織所見上，リンパ球の浸潤を認めた．心膜嚢胞は稀な疾患で，多くは無症状であるが，重症化する危険性もあり注意を要する．本例の診断および治療には全麻下胸腔鏡下切除術が極めて有効であった．

　A 55-year-old female with no significant previoushistory was admitted to our hospital because of dyspneaon exercise. Physical findings, demonstrated right-sided heart failure with dilated neck vein, hepatomegaly andperipheral edema. Her temperature was 37.0℃, bloodpressure was 98/60mmHg, pulse was 92/min (irreg.) andheart sounds were distant. On laboratory data, it wasshown that transaminase and ductal enzyme were elevated. Chest radiograph showed cardiomegaly with adilated right atrium. Echocardiography revealed moderate pericardial effusion and a pericardial mass. Computed tomographic scan showed a well defined cyst in theright cardiophrenic angle which was in contact with thepericardium and parietal pleura. In MRI and Ga scan,we suspected the mass was an inflammatory cysticlesion. In the clinical course, the patients symptomswere progressive with massive pleural effusion. Todetermine diagnosis, we tried puncture of both pleuraland pericardial effusions. Both effusions were bloodyand CAl25 in the tumor marker was elevated, so wecould not ignore the possibility of a malignant cysticlesion and carried out thoracoscopic surgical resectionof the cyst as a minimally invasive procedure. The cystwith adhesion of parietal pleura was completelyremoved and cardiac tamponade lessened. In histopathological findings, the cyst size was 3.6×2.0×0.8cm andthe cyst wall was composed of lined mesothelium, collagen with adipose tissue and accumulations oflympocytes. These data confurined our preoperativededuction that cardiac tamponade and pleural effusionwere induced by a inflammatory pericardial cyst. Weconsider thoracoscopic surgical resection to be themethod of choice, when a pericardial cyst is identifiableas such or when differential diagnosis is difficult, as wasthe case in this instance.