Management of intracavitary left atrium tumors during pregnancy - two case reports

OBJECTIVE

Authors documented an individual management of intracavitary left atrium tumors diagnosed during pregnancy.

SUBJECT

Two case reports were presented. Brain embolisation was supposed in the case one of intracavitary left atrium tumor. An urgent cardiosurgery at 24 weeks' gestation was performed on the cardiopulmonary bypass. In case two (multiple pregnancy - twins) cardiac tumor in left atrium was detected in third trimester of pregnancy. The mother was without any serious cardiac and systemic complications during the last trimester. Surgical approach was different - removal of tumor after delivery.

CONCLUSION

The surgical approach should be determined by clinical behavior of left atrial cardiac tumors.

Sonographic appearance of aggressive angiomyxoma of the scrotum

Aggressive angiomyxoma (AAM) is a rare, locally infiltrative tumor that occurs almost exclusively in the pelvic and perineal regions of women of childbearing age. We report the unusual case of a 26-year-old man with an AAM presenting as a slowly enlarging scrotal mass. Gray-scale scrotal sonography demonstrated a well-demarcated, hypoechoic, extratesticular, extraepididymal mass with multiple thin, echogenic internal septa. The mass arose inferior to the left testicle and displaced the testicle cephalad. Color Doppler sonography revealed surrounding vascularity but no Doppler signals within the mass. The testicles and epididymides demonstrated normal echogenicity and vascularity. Histologic examination of the excised mass revealed a well-demarcated, nonencapsulated lesion composed of spindle-shaped cells in a myxoid background with a prominent vascular component.

Mass confusion

A patient is reported who presented to the hospital with a benign arrhythmia and what was initially believed to be a benign intracardiac tumour as imaged by transthoracic echocardiography and a first transesophageal echocardiogram. Comprehensive assessment with a second transesophageal echocardiogram revealed extensive extra- and intracardiac involvement by masses with many malignant-appearing features, including compression of vascular structures in the mediastinum. Peripheral biopsy yielded a diagnosis of high-grade lymphoma. The clinical, echocardiographic and radiological findings are discussed, as are the expected features of myxomae, and by comparison, common features of malignancy. The ability of transesophageal echocardiography, when comprehensively performed, to define the location and extent of mass lesions, and their physiological impact, such as compression of the pulmonary vasculature, by two-dimensional imaging and spectral Doppler are emphasized.

Differential diagnosis of intracavitary tumors obstructing the right ventricular outflow tract

Three cases of right ventricular outflow tract obstruction caused by 3 distinct tumors-myxoma, sarcoma, and presumed metastatic tumor-diagnosed by transthoracic and transesophageal echocardiography are presented. The differences among these 3 types of tumors with similar clinical and echocardiographic findings are highlighted, and a review of the pertinent literature is discussed. By applying the approximate frequencies of cardiac tumors categorized by type and site, statistically, an intracavitary right ventricular outflow tract tumor is 70 to 140 times more likely to be malignant than benign; furthermore, if it is a primary cardiac tumor, it is approximately 2 times more likely to be a sarcoma than a myxoma.

Atrial myxoma presenting as isolated unilateral blindness: a case report and review of the literature

Myxomas are the most common primary cardiac tumours in adults. Systemic embolization is often the first presentation, with the central nervous system being the most common site. The present report reviews the literature and discusses a 29-year-old patient who presented with an isolated left retinal artery occlusion secondary to a previously undiagnosed left atrial myxoma.

More than just the "Q-tip sign"

In the early days of transesophageal echocardiography, the "Q-tip sign" was occasionally mistaken for a left atrial mass. This area is now well recognized as a normal anatomic landmark dividing the left atrial appendage from the left upper pulmonary vein. However, in this report we describe 2 patients in whom pathology was found in this area, which should not be overlooked.

Infected left atrial myxoma

Upon examination, a 40-year-old man was found to have fever, weight loss, and malaise. A blood culture was positive for Streptococcus mutans. Under the suspicion of endocarditis, he was treated with penicillin. Echocardiography revealed a large tumor in the left atrium. After 6 weeks of penicillin treatment, he was transferred to our hospital for excision of the tumor. Pathology revealed a myxoma with fibrin deposits, bacterial colonization, and massive infiltration with neutrophils.

Recurrent pulmonary embolism originating from right atrial myxoma

The use of transesophageal echocardiography is a useful adjunct to transthoracic echocardiography in the diagnosis and management of right atrial tumors in patients who are thought to have idiopathic recurrent pulmonary embolism, especially with suboptimal transthoracic echocardiography studies. We describe a 30-year-old woman with a history of recurrent pulmonary embolism who was admitted for investigation of pleuritic chest pain in whom transesophageal echocardiography played a critical role in the diagnosis and management.

Left ventricular myxoma: report of a case

Although recent advances in echocardiography have made it easier to detect cardiac tumors, left ventricular myxomas are still rare and often not found until the patient presents with a history of syncopal episodes or systemic embolization. Left ventricular myxomas are usually benign and curable; however, unreliable excision of the myxoma due to poor visualization of the left ventricular cavity can result in recurrence. To prevent recurrence, it is necessary to select the most appropriate surgical approach to excise the myxoma completely. We report herein the case of a patient in whom surgical excision of a left ventricular myxoma arising from the posterior wall of the left ventricle was successfully performed.

[Successful surgical removal of a cardiac myxoma from the left ventricular outflow tract]

The precondition for successful, exclusively surgical treatment in the extracorporeal circulation, is the precise diagnosis of heart myxoma, particularly in rare locations such as the left ventricle. We present a case of myxoma in the outflow tract of the left ventricle as the exceptionally rare location, successfully diagnosed and surgically treated at the Clinic for Cardiac and Thoracic Surgery of the Military Medical Academy. A female patient, aged 46 years, was sent from another hospital with misdiagnosis of idiopathic hypertrophic subaortic stenosis. The patient was successfully operated after transthoracic and transesophageal echocardiography as the main diagnostic procedures. Myxoma that completely obstructed the aortic opening if pulled, was completely removed through aortic valve in the extracorporeal circulation. Its pedicle was arising from the ventricular side of the great mitral cusp. Postoperative course was uneventful and the patient was released from the hospital on the tenth postoperative day.

Laryngeal myxoma

Myxoma is an uncommon neoplasm in the head and neck region. Laryngeal myxomas are rarer still. We report a case of a large myxoma in the supraglottis, that was excised endoscopically.

[Large myxoma of the right atrium]

We describe the case of a patient in whom two-dimensional echocardiography, performed due to dissociated cholestasis and jugular ingurgitation, demonstrated a huge mass in the right atrium which prolapsed in the right ventricle. Intraoperative transesophageal echocardiography was performed to further assess the dimension and characteristics of the mass and to discard the involvement of associated structures. The patient underwent a cardiopulmonary bypass surgery and the mass (12 * 5 cm) was removed without complications. Histologic examination confirmed the diagnosis of myxoma. This case is of interest because of the size of the mass, and is centered in the diagnosis following clinical suspicion due to the pattern of dissociated cholestasis and jugular ingurgitation leading to surgery to prevent the potential embolic complications.

The role of interleukin-6 in cases of cardiac myxoma. Clinical features, immunologic abnormalities, and a possible role in recurrence

We performed this prospective study to evaluate the correlation of interleukin-6 serum levels with preoperative constitutional symptoms and immunologic abnormalities, and the possible role played by this cytokine in tumor recurrence. Eight patients with atrial myxoma were evaluated at our institution from July 1993 to November 1998. We measured their interleukin-6 serum levels by enzyme-linked immunosorbent assay method preoperatively and 1 and 6 months after surgery. Two of the cases involved recurrent tumor, 1 patient had undergone his 1st surgery at a different institution and died during the 2nd procedure, so his data were incomplete. Preoperatively the whole group of patients had elevated interleukin-6 serum levels. Although patients with a 1st occurrence of tumor demonstrated a positive correlation between interleukin-6 serum level and tumor size, the 2 patients with recurrent tumors appeared to have higher interleukin-6 levels regardless of tumor size. Once the tumor was surgically removed, interleukin-6 levels returned to normal values, and this was associated with regression of clinical manifestations and immunologic features. According to our study, the overproduction of interleukin-6 by cardiac myxomas is responsible for the constitutional symptoms and immunologic abnormalities observed in patients with such tumors and might also play a role as a marker of recurrence. This study also suggests that recurrent cardiac myxomas form a subgroup of cardiac myxomas with a highly intrinsic aggressiveness, as implied by their greater interleukin-6 production despite their smaller size. Further studies are needed to confirm these results.

[Embolism at the iliac bifurcation secondary to an atrial myxoma]

A 73-year-old woman presented a clinical picture of bilateral acute ischemia of the lower limbs. After embolectomy, transthoracic echocardiography revealed left atrial tumor. The picture was complicated by the onset of compartment syndrome in the lower extremities requiring decompressive fasciotomy. The excised atrial tumor proved to be a cardiac myxoma. Atrial myxoma, the most common benign cardiac tumor, leads to systemic, cardiac and embolic sequelae. Transthoracic echocardiography is the main diagnostic technique available, proving more useful than transesophageal echocardiography for small tumors. Such techniques can also be used during surgery, particularly in cases where preoperative assessment has left doubts about tumor location. We also argue in favor of early use of transesophageal echocardiography when peripheral arterial embolism is the diagnosis, in order to locate a cardiac focus as the cause of the clinical picture.

Magnetic resonance imaging of myxoma in the mandible: a case report

The findings of conventional radiography, computed tomography, and magnetic resonance imaging (MRI) are reported for an odontogenic myxoma arising in the mandible of a 48-year-old Japanese man. The MRI characteristics of an intraosseous myxoma are described for only the third time. MRI showed a well-defined and smooth-walled mass lesion with high-signal intensity on T2-weighted images and low-intermediate-signal intensity on TI-weighted images. Soft tissue myxomas have been reported to show low-signal intensity on TI-weighted images and high-signal intensity on T2-weighted images. However, the first MRI report of an intraosseous myxoma showed a higher-signal intensity on TI-weighted images and lower-signal intensity on T2-weighted images. The MRI findings in this study thus correspond to those of soft tissue myxomas and do not agree with observations of the first MRI report of the intraosseous myxoma. Further studies are needed to clarify the reasons for this difference.