Pediatric heart tumors

Primary malignant tumors of the heart: Outcomes of the surgical treatment

Background

Malignant cardiac tumors are rare and have an extremely poor prognosis even when complete resection is attempted. The aim of this study was to review the experience of primary malignant cardiac tumors in 2 Italian academic hospitals.

Methods

The hospital records were searched to identify patients with primary malignant cardiac tumors who underwent surgery between January 1979 and December 2012. Secondary cardiac tumors, whether metastatic or invasive, were excluded as were primary sarcomas of the great arteries. Fourteen patients selected from our institution’s surgical series were identified. Eleven (78.6%) were men and 3 (21.4%) were women, and the mean age at surgery was 47.4 years.

Results

The most common histological type was angiosarcoma (28.6%). The mean survival was 28.8 ± 28 months and it was better in men than in women (30.5 ± 8.7 vs. 21.1 ± 3.2 months). Patients with a radical resection at the first surgery had a longer survival compared to patients with a partial resection (39.9 ± 23.2 vs. 24 ± 4 months).

Conclusions

The treatment outcome for patients affected by primary malignant heart tumors remains poor. Aggressive surgery alone does not provide good results in terms of survival rate. A new multidisciplinary approach is mandatory to improve long-term survival.

Cardioverter-defibrillator implantation to treat cardiac fibroma-induced ventricular tachycardia in a 70-year-old woman

Benign cardiac fibroma is rarely reported in adults. Its clinical symptoms are related to outflow obstruction or dysrhythmias. We present the case of a 70-year-old woman who had a syncopal episode from ventricular tachycardia caused by cardiac fibroma. Because of unfavorable tumor anatomy, the patient was not a candidate for surgical excision, and she declined orthotopic heart transplantation. To prevent sudden cardiac death, we placed an implantable cardioverter-defibrillator, and the patient remained well throughout the 2-year follow-up period. To our knowledge, this is the first report of implantable cardioverter-defibrillator therapy to treat an adult patient's unresectable cardiac fibroma.

Rhabdomyomas and tuberous sclerosis complex: our experience in 33 cases

Background

Rhabdomyomas are the most common type of cardiac tumors in children. Anatomically, they can be considered as hamartomas. They are usually randomly diagnosed antenatally or postnatally sometimes presenting in the neonatal period with haemodynamic compromise or severe arrhythmias although most neonatal cases remain asymptomatic. Typically rhabdomyomas are multiple lesions and usually regress spontaneously but are often associated with tuberous sclerosis complex (TSC), an autosomal dominant multisystem disorder caused by mutations in either of the two genes, TSC1 or TSC2. Diagnosis of tuberous sclerosis is usually made on clinical grounds and eventually confirmed by a genetic test by searching for TSC genes mutations.

Methods

We report our experience on 33 cases affected with rhabdomyomas and diagnosed from January 1989 to December 2012, focusing on the cardiac outcome and on association with the signs of tuberous sclerosis complex. We performed echocardiography using initially a Philips Sonos 2500 with a 7,5/5 probe and in the last 4 years a Philips IE33 with a S12-4 probe. We investigated the family history, brain, skin, kidney and retinal lesions, development of seizures, and neuropsychiatric disorders.

Results

At diagnosis we detected 205 masses, mostly localized in interventricular septum, right ventricle and left ventricle. Only in 4 babies (12%) the presence of a mass caused a significant obstruction. A baby, with an enormous septal rhabdomyoma associated to multiple rhabdomyomas in both right and left ventricular walls died just after birth due to severe heart failure. During follow-up we observed a reduction of rhabdomyomas in terms of both number and size in all 32 surviving patients except in one child. Eight patients (24,2%) had an arrhythmia and in 2 of these cases rhabdomyomas led to Wolf-Parkinson-White Syndrome. For all patients the arrhythmia spontaneously totally disappeared or was reduced gradually. With regarding to association with tuberous sclerosis, we diagnosed tuberous sclerosis clinically in 31 babies (93,9%).

Conclusion

Rhabdobyomas are tumors with favorable prognosis because they frequently do not cause symptoms and they often regress in numbers and size. Nevertheless, due to frequent association with tuberous sclerosis complex and the resulting neurological impairment, the prognosis can result unfavorable.

Inflammatory myofibroblastic tumor of the aortic valves causing sudden cardiac death: a case report and review of the literature

Cardiac inflammatory myofibroblastic tumor (IMT) is a rare entity affecting predominantly infants, children, and young adults. Although most tumors have a benign clinical course after complete surgical resection, some have significant clinical effects. We report the case of a 9-year-old girl who had sudden cardiac death as a result of occlusion of the left circumflex coronary artery. A review of 57 cases of cardiac IMTs reported in the literature in terms of epidemiology, clinical presentation, histologic and immunohistologic features, and outcome is presented. Recognition of this rare abnormality is important in order to initiate prompt surgical intervention.

Medical and surgical management of primary cardiac tumours in infants and children

Primary cardiac tumours in infants and children are extremely rare, with an estimated incidence of 0.2% according to echocardiographic studies. Owing to their rarity, there is very little literature available, and most knowledge is based on collections of case reports. Therefore, we reviewed retrospectively our 27 years of clinical experience on the overall management of cardiac tumours among children in order to improve not only our knowledge but also to provide others with information about the incidence, clinical presentation, management, and long-term outcome of this rare disease. Between April, 1982 and April, 2009, 52 children were diagnosed with cardiac tumours at our Institution. Medical records and follow-up echocardiographic evaluations were studied. The diagnosis was prenatal in 35% of the patients. The most frequent tumour types were rhabdomyomas (61.5%), fibromas (15.4%), and myxomas (5.8%). There were no cases of primary malignant tumours. All diagnoses were achieved using two-dimensional echocardiography, and for 12 patients a pathological analysis was carried out. A total of 41 patients (79%) were managed medically, whereas 11 (21%) patients underwent surgical treatment. At a mean follow-up of 7.2 ± 5.4 years, two patients died of complications related to cardiac transplantation; all the remaining patients are in excellent clinical condition. In conclusion, cardiac tumours in paediatric practice are usually clinically and histologically benign. Only a few cases need surgery. Up to one-third of the cardiac masses are detectable prenatally. Rhabdomyoma is the most common histotype, followed by fibroma and myxoma. The long-term prognosis is generally good.

Anesthesia for the child with cancer

Children with cancer undergo a host of surgeries and procedures that require anesthesia during the various phases of the disease. A safe anesthetic plan includes consideration of the direct effects of tumor, toxic effects of chemotherapy and radiation therapy, the specifics of the surgical procedure, drug-drug interactions with chemotherapy agents, pain syndromes, and psychological status of the child. This article provides a comprehensive overview of the anesthetic management of the child with cancer, focuses on a systems-based approach to the impact from both tumor and its treatment in children, and presents a discussion of the relevant anesthetic considerations.

Cardiac myxoma with prenatal diagnosis

The presentation of myxoma in the neonatal period is quite rare. We report the case of a female patient in whom two cardiac tumors were diagnosed prenatally. Surgery was performed at eight days of age, using cardiopulmonary bypass and circulatory arrest to facilitate excision of two polypoid tumors from within the right atrium. Pathology studies were consistent with myxoma. The postoperative course was satisfactory and the patient was discharged 14 days after surgery, at 22 days old.

Primary pediatric cardiac malignancies: the SEER experience

PURPOSE

Pediatric cardiac malignancies are exceedingly rare. We sought to examine demographics, presentation, and outcomes for this pathology.

METHODS

The SEER registry from 1973 to 2008 was queried for all patients <20 years of age with cardiac malignancies.

RESULTS

A total of 25 pediatric patients were identified with primary cardiac malignancies, with age-adjusted incidence of 0.00686 per 100,000 United States population. Median age at diagnosis was 10 years. The majority of patients were adolescent (n = 13, 52 %), Caucasian (n = 17, 68 %) and males (n = 14, 56 %). The most common histology was soft tissue sarcoma (n = 10, 40%), followed by non-Hodgkin lymphoma and teratoma (both n = 3, 12 %). Six patients presented with distant disease. More than half of patients (n = 16, 64 %) underwent surgical resection, while four patients (16 %) underwent radiation. The mean survival time for the cohort was 47 ± 67 months, with 14 (56 %) patients dying over the study period. Lymphomas had significantly longer survival than other malignancies (108 ± 66 vs. 36 ± 66, p = 0.03), while lack of surgical treatment was associated with worse survival (p = 0.016).

CONCLUSIONS

Primary malignant cardiac tumors are exceedingly rare in pediatric patients. They are most commonly soft tissue sarcomas and lymphomas demonstrated longer survival.

Sudden death as presenting symptom caused by cardiac primary multicentric left ventricle rhabdomyoma, in an 11-month-old baby. An immunohistochemical study

This case report describes a sudden cardiac death in an apparent healthy 11-month-old infant caused by a multifocal cardiac rhabdomyoma. Parents reported that a few days before the child had fallen to the ground getting a little superficial injury to the scalp. The authors hypothesize that it may have been a transient loss of consciousness episode caused by the cardiac tumour. After the gross examination, histological investigation supported by immunohistochemical analysis using antibody anti- Myoglobin, Actin, Vimentin, Desmin, CD34, S-100, Ki-67 was carried out for the diagnosis. Death was attributed to a multifocal cardiac rhabdomyoma, a benign tumour of striated muscle, which has been completely asymptomatic. In particular, one mass filled the entire posterior wall of the left ventricle. The insidious development of benign cardiac tumours also in infants and children is outlined, focusing on the responsible mechanisms of sudden death in such cases and providing a reference for additional study on these subjects.

Cardiac tumours in infancy

Cardiac tumours in infancy are rare and are mostly benign with rhabdomyomas, fibromas and teratomas accounting for the majority. The presentation depends on size and location of the mass as they tend to cause cavity obstruction or arrhythmias. Most rhabdomyomas tend to regress spontaneously but fibromas and teratomas generally require surgical intervention for severe haemodynamic or arrhythmic complications. Other relatively rare cardiac tumours too are discussed along with an Indian perspective.

Cardiac rhabdomyoma with LVOT obstruction and anorectal malformation in a neonate: a rare association

Cardiac rhabdomyomas are described as sporadic as well as associated with tuberous sclerosis. Association with LVOT obstruction with anorectal malformation or imperforate anus has not been reported so far in published literature. In this case report we describe one such case.

Myogenic tumors in children and adolescents

Neoplasms of striated and smooth muscle in children are a diverse group of neoplasms that have some unique aspects in contrast to these tumors in adults. Rhabdomyosarcoma is the most common soft tissue sarcoma of infancy and childhood and is relatively common in adolescents. In contrast, smooth muscle tumors are relatively rare, and the various types of rhabdomyoma and smooth and skeletal muscle hamartomas are very uncommon. In recent years, the understanding of the pathologic and genetic aspects of rhabdomyosarcoma has been enhanced by adjunct techniques, such as immunohistochemistry and cytogenetic or molecular genetic analysis. The current classification of rhabdomyosarcoma emphasizes the histologic-prognostic correlations. This article reviews the clinicopathologic features of striated and smooth muscle tumors with an emphasis on the unique aspects of these neoplasms in children and adolescents and the differential diagnosis.

Imaging sarcomas of the great vessels and heart

Primary sarcomas of the aorta, pulmonary artery, superior vena cava, inferior vena cava, and the heart are rare neoplasms. Aortic sarcomas are broadly categorized as either primarily luminal or primarily mural, with luminal sarcomas more likely to be misdiagnosed as thrombus. Pulmonary artery sarcomas are often mistaken for pulmonary embolism both clinically and at imaging. Vena caval sarcomas appear as intraluminal or extraluminal masses connecting to or filling the veins. The most common are leiomyosarcomas of the inferior vena cava. Primary sarcomas of the heart are rare and usually appear as heterogeneous aggressive masses.

Primary benign cardiac tumours: long-term results

OBJECTIVES

Primary heart tumours are rare lesions with variegated histological types. We reviewed our 35 years experience with a significant number of primary benign cardiac tumour cases.

METHODS

The patient database at University of Bologna was searched to identify patients with primary cardiac tumours between 1974 and 2009. Benign tumours were classified as myxomas and non-myxomas. Ninety-four were myxomas (mean age of 59.1 ± 15.6), and 13 were benign non-myxomas tumours (mean age of 39.7 ± 24.9; P = 0.0001). Complete resection of the masses was performed in all cases except in one.

RESULTS

In-hospital mortality was 3% in the myxoma group and 8% in the non-myxoma group. The mean follow-up was 15.1 and 7.4 years for the myxoma and non-myxoma groups, respectively. The long-term survival of discharged patients was 68 ± 7% for the myxoma group and 100% for the non-myxoma group at 20 years, respectively. Recurrence of a tumour occurred only in the myxoma group (four cases) after 1, 3, 5 and 8 years, respectively. Twenty patients had an extracardiac tumour that was diagnosed before operation in 12 (11 in the myxoma group) and during the follow-up in 8 patients (only in the myxoma group).

CONCLUSIONS

Primary cardiac tumours can be surgically treated with good short- and long-term results. Mortality and morbidity are mainly due to the status of preoperative patients'. An accurate follow-up is mandatory in order to detect the recurrence of a cardiac tumour such as to exclude the presence or the development of extracardiac tumours that we found frequently associated with the myxoma.

2011 consensus statement on endomyocardial biopsy from the Association for European Cardiovascular Pathology and the Society for Cardiovascular Pathology

The Association for European Cardiovascular Pathology and the Society for Cardiovascular Pathology have produced this position paper concerning the current role of endomyocardial biopsy (EMB) for the diagnosis of cardiac diseases and its contribution to patient management, focusing on pathological issues, with these aims: • Determining appropriate EMB use in the context of current diagnostic strategies for cardiac diseases and providing recommendations for its rational utilization • Providing standard criteria and guidance for appropriate tissue triage and pathological analysis • Promoting a team approach to EMB use, integrating the competences of pathologists, clinicians, and imagers.

Successful surgical excision of a large left ventricular fibroma in a child

Primary cardiac tumours in children are rare. Despite the majority of these tumours being benign, they may cause blood flow obstruction, ventricular dysfunction, and life-threatening arrhythmias. We present a case of a 4-year-old boy with repeated presyncope episodes in whom we found a large left ventricular fibroma. Our case emphasises that surgical resection is safely feasible even with large fibromas, avoiding cardiac transplantation in childhood.

Anesthetic considerations for the pediatric oncology patient--part 2: systems-based approach to anesthesia

One of the prices paid for chemo- and radiotherapy of cancer in children is damage to the vulnerable and developing healthy tissues of the body. Such damage can exist clinically or subclinically and can become apparent during active antineoplastic treatment or during remission decades later. Furthermore, effects of the tumor itself can significantly impact the physiologic state of the child. The anesthesiologist who cares for children with cancer or for survivors of childhood cancer should understand what effects cancer and its therapy can have on various organ systems. In part two of this three-part review, we review the anesthetic issues associated with childhood cancer. Specifically, this review presents a systems-based approach to the impact from both tumor and its treatment in children, followed by a discussion of the relevant anesthetic considerations.

Benign cardiac tumours, malignant arrhythmias

Four cases of pediatric cardiac tumours (PCTs) associated with ventricular arrhythmias are reported. Sudden cardiac death attributable to the tumour occurred in two children. A third child received an implantable cardioverter defibrillator and the fourth had persistent ventricular arrhythmia despite medical therapy. Most PCTs are considered benign; however, the development of malignant arrhythmias may complicate the management of these tumours in some patients. The literature regarding the arrhythmogenic potential of PCTs and the use of implantable cardioverter defibrillators in these patients is reviewed. The series highlights the deficiency of prognostic information for this cohort.

Prenatal diagnsis of intracardiac hamartoma and Turner syndrome

Turner syndrome is associated with a higher frequency of heart defects detected prenatally when compared to postnatal reports. The most common heart defects detected prenatally are hypoplastic left heart syndrome and coarctation of the aorta. We report a case involving a fetus at 16 gestational weeks with a septated cystic hygroma located on the neck and head, an interventricular septal mass, a hypoplastic left ventricle due to aortic stenosis, mitral stenosis, and a hypoplastic aortic arch with a karyotype of mos 45, X, [47 cells]/47, XXX [3 cells]. The autopsy findings confirmed our prenatal diagnosis with a final diagnosis of Turner syndrome and congenital cardiac vascular malformation.