A 69-year-old male with diabetes mellitus presented with epigastric pain and weight loss for 3 months. Examination revealed low grade fever and markedly raised jugular venous pressure. Chest radiograph demonstrated cardiomegaly and small bilateral pleural effusions. Transthoracic echocardiography demonstrated large pericardial effusion with cardiac tamponade. He underwent emergency pericardiocentesis and 1060 ml of hemorrhagic fluid was aspirated.
Percutaneous pericardial biopsy was done to look for specific etiology. After pericardial biopsy, a 4-F pigtail catheter was left in the pericardial cavity for further aspiration. Exactly 5600 ml of hemorrhagic pericardial fluid was aspirated during the following 2 weeks. Pericardial fluid Gram stain and culture were negative for pyogenic or tuberculosis infection. Cytology did not reveal any malignant etiology. Repeat echocardiographic imaging revealed a large solid mass (7 x 10 x 8 cm) involving the right ventricular inflow, the body of the right ventricle and right ventricular outflow tract postero-medially. The mass appeared relatively fixed with possible myocardial infiltration [Figure 1a-c]. Cardiac catheterization and hemodynamic assessment showed biventricular heart failure. Right ventricular angiogram demonstrated a filling defect in the postero-inferior aspect of the right ventricle. Biopsy taken from that area using a bioptome revealed primary cardiac sarcoma of the malignant fibrous histiocytoma sub-group. He was offered tumor resection with chemotherapy but he did not accept. Initial computed tomography (CT) scan did not reveal any extracardiac tumor or metastasis. Echocardiographic evaluation at 6 and 8 months interval revealed enlarging tumor mass. The last echocardiogram demonstrated a huge right ventricular tumor measuring 20 x 10 cm, filling the entire right ventricular cavity and infiltrating through the right ventricular wall into the liver [Figure 2a and b]. He also had small pericardial effusion, bilateral pleural effusions, ascites as well as hepatic and splenic metastasis. He continued to refuse any treatment and expired at home 16.5 months after the initial presentation.