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Number 07:16– Late Mediastinal malignancy treatment complications

Case from: Mark Westwood, Malcolm Walker, The Heart Hospital, University College Hospital, London, United Kingdom.

Clinical history: Increasing Breathlessness. Past medical history included a thymoma removal with subsequent mediastinal radiotherapy. Previous successful PCI to the LAD for radiation induced coronary artery disease.

Cine CMR:
1. Signal dropout from the old style proximal LAD stent noted (top left).
2. Dilated atria, evidence of heart failure despite normal systolic function.
3. A septal bounce suggesting ventricular coupling on the segmented SA cine a suggestion of constriction even without pericardial thickening (TSE, middle left). Unilateral pleural effusion with lung tethering (top right; clinically at an old chest drain site)
4. Real time cines, short axis, (bottom left) during inspiration/expiration:
Imaging for dynamic ventricular coupling is bizarre – septal flattening not clearly in inspiration.
4. Real time cine, coronal for the diaphragmn: (bottom right) during inspiration/expiration:
The left hemi-diaphragm is paralysed. This is the cause of the almost paradoxical ventricular coupling – the left phrenic nerve was excised at thymoma removal.

Perspective:
This case shows 3 post mediastinal radiotherapy/surgery features: radiation induced coronary artery disease, probable pericardial constriction, here without thickening and phrenic nerve palsy. Thoracotomy with mobilisation of the tethered lung and diaphragmatic plication was considered but he improved with diuretics and is now under regular review

Scanner: Siemens avanto.

References: References: here(full text) and here

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