Sarcomas related to the heart and vasculature

Primary Cardiac Sarcoma: Clinical Characteristics and Prognostic Factors over the Past 2 Decades

BACKGROUND

Primary cardiac sarcomas (PCS) are extremely rare malignant tumors involving the heart. Only isolated case reports have been described in the literature over different periods of time. This pathology has been associated with a dismal prognosis and given its rarity; treatment options are very limited. Furthermore, there are contrasting data about the effectiveness of current treatment modalities in improving the survival of patients with PCS, including surgical resection which is the mainstay of therapy. There is a paucity of data on the epidemiological characteristics of PCS. This study has the objective of investigating the epidemiologic characteristics, survival outcomes, and independent prognostic factors of PCS.

METHODS

A total of 362 patients were ultimately registered in our study from the Surveillance, Epidemiology, and End Results (SEER) database. The study period was from 2000 to 2017. Demographics such as clinical characteristics, overall mortality (OM), and PCS-specific mortality (CSM) were taken into account. A p value of <0.1 in the univariate analysis leads to the incorporation of the variable into multivariate analysis adjusting for covariates. Adverse prognostic factors were represented by a Hazard Ratio (HR) greater than one. The five-year survival analysis was carried out using the Kaplan-Meier method and the log-rank test was used to compare survival curves.

RESULTS

Crude analysis revealed a high OM in age 80+ (HR = 5.958, 95% CI 3.357-10.575, p < 0.001), followed by age 60-79 (HR = 1.429, 95% CI 1.028-1.986, p = 0.033); and PCS with distant metastases (HR = 1.888, 95% CI 1.389-2.566, p < 0.001). Patients that underwent surgical resection of the primary tumor and patients with malignant fibrous histiocytomas (HR = 0.657, 95% CI 0.455-0.95, p = 0.025) had a better OM (HR = 0.606, 95% CI 0.465-0.791, p < 0.001). The highest cancer-specific mortality was observed in age 80+ (HR = 5.037, 95% CI 2.606-9.736, p < 0.001) and patients with distant metastases (HR = 1.953, 95% CI 1.396-2.733, p < 0.001). Patients with malignant fibrous histiocytomas (HR = 0.572, 95% CI 0.378-0.865, p = 0.008) and those who underwent surgery (HR = 0.581, 95% CI 0.436-0.774, p < 0.001) had a lower CSM. Patients in the age range 80+ (HR = 13.261, 95% CI 5.839-30.119, p < 0.001) and advanced disease with distant metastases (HR = 2.013, 95% CI 1.355-2.99, p = 0.001) were found to have a higher OM in the multivariate analyses adjusting for covariates). Lower OM was found in patients with rhabdomyosarcoma (HR = 0.364, 95% CI 0.154-0.86, p = 0.021) and widowed patients (HR = 0.506, 95% CI 0.263-0.977, p = 0.042). Multivariate cox proportional hazard regression analyses of CSM also revealed higher mortality of the same groups, and lower mortality in patients with Rhabdomyosarcoma.

CONCLUSION

In this United States population-based retrospective cohort study using the SEER database, we found that cardiac rhabdomyosarcoma was associated with the lowest CSM and OM. Furthermore, as expected, age and advanced disease at diagnosis were independent factors predicting poor prognosis. Surgical resection of the primary tumor showed lower CSM and OM in the crude analysis but when adjusted for covariates in the multivariate analysis, it did not significantly impact the overall mortality or the cancer-specific mortality. These findings allow for treating clinicians to recognize patients that should be referred to palliative/hospice care at the time of diagnosis and avoid any surgical interventions as they did not show any differences in mortality. Surgical resection, adjuvant chemotherapy, and/or radiation in patients with poor prognoses should be reserved as palliative measures rather than an attempt to cure the disease.

Cardiac angiosarcoma with multiple pulmonary metastases: A case report and literature review

In this report, we describe a 42-year-old man with dyspnea and recurrent hemoptysis who was diagnosed with cardiac angiosarcoma and multiple pulmonary metastases. Before visiting our hospital, he had been misdiagnosed with a lung infection. Bronchoscopy, multiple imaging methods, and extensive laboratory studies failed to identify a clear etiology. Cardiac magnetic resonance imaging and percutaneous lung biopsy revealed cardiac angiosarcoma with multiple pulmonary metastases. Cardiac angiosarcoma is extremely rare and diagnosis is difficult. Diffuse alveolar hemorrhage is not a common manifestation of pulmonary metastases of angiosarcoma and in patients with hemoptysis, clinicians should consider a malignant etiology that is not restricted to the lungs.

Small Bowel Intussusception Due to Rare Cardiac Intimal Sarcoma Metastasis: A Case Report

Background: Intimal sarcomas are rare malignant mesenchymal tumors arising from the heart and large blood vessels. Their intraluminal growth leads to vascular obstructive symptoms and peripheral neoplastic embolization. Direct infiltration of the lungs or metastases to the pulmonary system, occur in 40% of cases and extrathoracic spread is frequent, also in presentation. Intussusception is an unusual event in adults, accounting for <5% of bowel obstructions. In most cases it is caused by a malignancy and requires surgical resection. Case Presentation: We describe a rare case of a 50-year-old man suffering of bowel obstruction due to intussusception sustained by a small bowel metastasis of a primary cardiac intimal sarcoma. One year and a half before the onset of abdominal symptoms, a grade II intimal sarcoma was removed from his left atrium and consequently he followed a chemotherapy protocol. Four months later a CT scan revealed local recurrence. Eighteen months after heart surgery he referred to the ER with abdominal pain. CT scan showed an ileal intussusception and the patient was scheduled for surgery. A tract of 10 cm ileus was removed containing an intramural polypoid solid mass. Histological analyses revealed a grade II intimal sarcoma consistent with his first diagnosis. Conclusion: Primary heart tumors are late found and often partially resected, therefore metastatic pathways are to be expected. Adult small bowel intussusception is a rare event and caused by a malignancy in one third of cases. Therefore, our recommendation is to always resect the tract involved in order to perform a proper diagnosis.

Primary Soft Tissue Sarcoma of the Heart: An Emerging Chapter in Cardio-Oncology

Primary malignant cardiac tumors are rare, with a prevalence of about 0.01% among all cancer histotypes. At least 60% of them are primary soft tissue sarcomas of the heart (pSTS-h) that represent almost 1% of all STSs. The cardiac site of origin is the best way to classify pSTS-h as it is directly linked to the surgical approach for cancer removal. Indeed, histological differentiation should integrate the classification to provide insights into prognosis and survival expectancy of the patients. The prognosis of pSTS-h is severe and mostly influenced by the primary localization of the tumor, the difficulty in achieving complete surgical and pharmacological eradication, and the aggressive biological features of malignant cells. This review aims to provide a detailed literature overview of the most relevant issues on primary soft tissue sarcoma of the heart and highlight potential diagnostic and therapeutic future perspectives.

A case of sudden infant death due to a primary cardiac sarcoma

The case reported herein concerns the unexpected death of a 3-month-old female newborn who suddenly collapsed in her mother's arms and was dead on arrival at the hospital. The clinical histories of the baby and her parents were negative for symptoms or signs of illness, even those of cardiovascular origin. Furthermore, no clinical appearance of a pathologic status was noted by pediatricians after the birth until the last emergency recovery. The autopsy excluded external and internal signs of violence but revealed a large primary cardiac tumor arising from the free wall of the left ventricle, which had totally invaded the heart causing mitral valve deformation. Histological examination showed a low-grade sarcoma that completely infiltrated the myocardial tissue. The pathogenesis of this sudden infant death was postulated as being owing to a fatal ventricular fibrillation combined with a tumor-related restrictive cardiomyopathy obstructing left ventricular filling.

Cardiac tumors in a tertiary care cancer hospital: clinical features, echocardiographic findings, treatment and outcomes

Cardiac tumors are a rare entity, comprised of tumors with diverse histology and natural history. We report the clinical characteristics, echocardiograhic findings, therapy and outcome of 59 patients with primary and metastatic cardiac tumors. Our institutional echocardiogram data base from 1993 through 2005 was reviewed to identify patients diagnosed with intra-cardiac tumor. A total of 59 patients with cardiac tumors were identified and included in the study. The patients' characteristics, presenting symptoms, diagnostic tests, location, histology of the tumor, treatment and the one year survival rate of this population was collected from the medical records. Of the 59 cardiac tumor cases, 16 (27%) were primary cardiac tumors and 43 (73%) were secondary cardiac tumors. The most common primary tumor was sarcoma affecting 13 (81%) of the 16 cases. Of these, 5 patients were angiosarcoma, 5 unclassified sarcoma, one myxoid sarcoma and 2 malignant fibrous histiocytoma. The mean age at presentation was 41.1 years, and the most common location was right atrium affecting 6 cases (37.5%). The most common symptom of dyspnea was present in 10 (62.5%) cases. Eleven (25.6%) of the 43 secondary cardiac tumors were metastasis from renal cell carcinoma. The mean age at presentation was 55.4 years. Right atrium was the most frequent location affecting 18 (42%) of the 43 patients. The most common presenting symptom was dyspnea in 15 (35%) cases. For both primary and secondary tumors, dyspnea was the most common symptom and right atrium was most frequently involved. Sarcoma was the most common primary cardiac tumor while metastasis from renal cell carcinoma was the most common secondary tumor.

Outcomes after right-side heart sarcoma resection

BACKGROUND

In patients with primary cardiac sarcoma, the tumor's location is more important than cell type in determining patient presentation, therapy options, and outcomes. The purpose of the current study was to investigate the outcomes after right-side heart sarcoma resection.

METHODS

Clinicopathologic data from patients who underwent right-side heart sarcoma resection at our institution and patients identified in a literature search were examined. Morbidity and the 30-day mortality rate and survival were determined. We used univariate and multivariate analyses to identify independent predictors of overall survival.

RESULTS

We identified 57 patients who underwent right-side heart sarcoma resection. Right-side heart failure was the most common complication (4 patients, 19%), and the 30-day mortality was 14% (3 patients). The overall 5-year survival rate was 17%, and the median overall survival duration was 9 months. Multivariate analyses revealed that surgical margin status was the only independent predictor of survival. Patients with negative surgical margins had a longer median overall survival duration (27 months versus 4 months) and a significantly higher overall 5-year survival rate (36% versus 0%; p = 0.0003) than patients with positive surgical margins.

CONCLUSIONS

The patients with right-side heart sarcoma resection had worse survival after resection than that reported for our patients who underwent resection for left-side heart sarcoma or pulmonary artery sarcoma. Because positive surgical margin status is an independent predictor of reduced survival, induction chemotherapy should considered to enhance resectability in right-side heart sarcoma patients, thus maximizing the possibility of obtaining negative surgical margins.

Outcomes after surgical resection of cardiac sarcoma in the multimodality treatment era

OBJECTIVE

Primary cardiac sarcomas are rare tumors carrying poor prognosis. Resection remains the primary therapy. Especially in recent years, chemotherapy and radiation have been used adjunctively.

METHODS

All patients (n = 27) surgically treated for primary cardiac sarcoma at two tertiary referral centers from January 1990 to January 2006 were retrospectively reviewed.

RESULTS

There were 13 women and 14 men, with 26 resections and 1 palliative debulking performed. Cardiac explantation was necessary in 8 cases because of tumor location. Concomitant valve surgery (repair or replacement) or coronary artery bypass grafting was performed in 9 and 3 patients, respectively. Synchronous or staged resections of associated pulmonary metastases were performed in 6 and 2 patients, respectively. Operative mortality was 7.4% (2/27). Preoperative or postoperative chemotherapy was administered to 16 and 19 patients, respectively. At follow-up (median 22 months, range, 2-119 months), 12 patients were alive, with 7 tumor free. Among patients who underwent resection with curative intent and survived surgery (n = 24), median survival was 23.5 months (range 4-119 months). Patients who underwent surgical resection, radiofrequency ablation, or radiation treatment for tumor recurrence (local or metastatic, n = 7) had median survival of 47 months (range 16-119 months), whereas patients with no further intervention for recurrent disease (n = 7) had median survival of 25 months (range 8-34 months).

CONCLUSIONS

Multimodal therapy can achieve reasonable survival for patients with resected cardiac sarcomas. Patients with local tumor recurrence or metastatic disease may still benefit from aggressive treatment.

Primary cardiac sarcomas: a clinicopathologic analysis of a series with follow-up information in 17 patients and emphasis on long-term survival

Although cardiac sarcomas are rare in comparison to their soft tissue counterparts, they are the second most common type of primary cardiac neoplasm. Of the few hundred cases reported, most has been based on autopsy series. A series of 27 cardiac sarcomas removed at surgery for curative and diagnostic intent were reviewed for clinicopathologic features with correlation to available postoperative follow-up data in 17 patients. There were 6 angiosarcomas, 6 myxofibrosarcomas, 3 malignant peripheral nerve sheath tumors, 3 leiomyosarcomas, 2 synovial sarcomas, 1 epithelioid hemangioendothelioma, 1 chondrosarcoma, 1 osteosarcoma, and 4 poorly differentiated sarcomas. There was a wide age and size range with slight female predilection. There were 20 cases that arose in the atria/pulmonary vessels, 4 in the ventricles, 1 in mitral valve, and 2 in epi/pericardium. There was a slight left predilection. The histologic grade was low in 4, moderate in 3, and high in 20 cases. Six high-grade and 1 low-grade tumors were also treated with adjuvant chemotherapy and/or radiation. In 17 patients with follow-up data, 6 of 12 patients with high-grade tumor died (4 within 5 days of the initial surgery, 1 in 21 months, and 1 in 131 months), and 1 patient with moderate-grade tumor and all 4 patients with low-grade tumor were alive without evidence of disease at the end of follow-up. Tumor grade appeared to be prognostically important in cardiac sarcoma. Long survival was achieved in patients who survived the initial surgery well.

Metastatic pulmonary intimal sarcoma presenting as cauda equina syndrome: first report of a case

STUDY DESIGN

Case report and clinical discussion.

OBJECTIVE

To describe a rare case of metastatic pulmonary intimal sarcoma presenting as cauda equine syndrome.

SUMMARY OF BACKGROUND DATA

Pulmonary artery sarcoma is a rare tumor, frequently misdiagnosed as pulmonary embolism, and although it is highly aggressive, metastasis to bone is very rare. In our case, the tumor metastasised to the vertebral column, which lead the patient to present with cauda equine-type symptoms.

METHODS

We report the clinical and imaging features in a 38-year-old female presenting with back pain and weakness of the legs. Although initially misdiagnosed as a primary bone tumor of the vertebral column and a concurrent pulmonary embolism, the final diagnosis of pulmonary artery sarcoma with spinal metastasis, presenting as cauda equina syndrome was made.

RESULTS

At surgery, the mass was excised with the pulmonary valve and replaced with a homograft. The histology demonstrated an undifferentiated intimal sarcoma of the pulmonary artery. When stable enough the patient underwent a posterior L4-S1 decompression laminectomy after which she regained the power in the legs. The histology also showed a metastatic undifferentiated intimal sarcoma likely to have come from the pulmonary artery. The patient went on to receive a more formal vertebrectomy, front and back repair, and radiotherapy. Her 1-year follow-up computed tomography (CT) chest showed evidence of further metastases.

CONCLUSION

To our knowledge, this is the first case of metastatic pulmonary intimal sarcoma presenting as cauda equine syndrome described in the literature.

Tumor cell cycle arrest induced by shear stress: Roles of integrins and Smad

Interstitial flow in and around tumor tissue affects the mechanical microenvironment to modulate tumor cell growth and metastasis. We investigated the roles of flow-induced shear stress in modulating cell cycle distribution in four tumor cell lines and the underlying mechanisms. In all four cell lines, incubation under static conditions for 24 or 48 h led to G(0)/G(1) arrest; in contrast, shear stress (12 dynes/cm(2)) induced G(2)/M arrest. The molecular basis of the shear effect was analyzed, and the presentation on molecular mechanism is focused on human MG63 osteosarcoma cells. Shear stress induced increased expressions of cyclin B1 and p21(CIP1) and decreased expressions of cyclins A, D1, and E, cyclin-dependent protein kinases (Cdk)-1, -2, -4, and -6, and p27(KIP1) as well as a decrease in Cdk1 activity. Using specific antibodies and small interfering RNA, we found that the shear-induced G(2)/M arrest and corresponding changes in G(2)/M regulatory protein expression and activity were mediated by alpha(v)beta(3) and beta(1) integrins through bone morphogenetic protein receptor type IA-specific Smad1 and Smad5. Shear stress also down-regulated runt-related transcription factor 2 (Runx2) binding activity and osteocalcin and alkaline phosphatase expressions in MG63 cells; these responses were mediated by alpha(v)beta(3) and beta(1) integrins through Smad5. Our findings provide insights into the mechanism by which shear stress induces G(2)/M arrest in tumor cells and inhibits cell differentiation and demonstrate the importance of mechanical microenvironment in modulating molecular signaling, gene expression, cell cycle, and functions in tumor cells.

Primary malignant sarcomas of the heart and great vessels in adult patients--a single-center experience

BACKGROUND

Sarcomas arising in the heart or the great vessels are rare entities. The prognosis of the patients is dismal.

METHODS

Between January 1993 and September 2006, of 1,429 patients registered to the Sarcoma Center, 14 had a primary sarcoma of the heart or large vessels.

RESULTS

Tumors were located in the left ventricle (n = 3), left/right atrium (n = 2/3), pulmonary artery (n = 2), and ventricular septum, aorta, pericardium, and inferior vena cava (n = 1 each). The most frequently encountered histologic subtypes were leiomyosarcoma and angiosarcoma. Six patients presented with distant metastases to the lungs (n = 5), lymph nodes (n = 2), and liver (n = 1). Eight patients had localized disease. Six of them underwent resection with curative intent. Of those, two developed local recurrence within 2 and 10 months from surgery. Eleven patients received palliative chemotherapy, seven of those as initial treatment. Eight patients attained a response to treatment, two had disease stabilization for 6 and 12 months. After a median follow-up of 14.5 months (range, 2-156), three patients were alive with no evidence of disease 11, 52, and 156 months after diagnosis. Two patients were alive with disease and nine patients had died.

CONCLUSIONS

Patients with primary sarcomas of the heart and the large vessels were of a young age, and more than half of them presented with advanced disease. Given the promising response to chemotherapy, an optimized treatment approach including neoadjuvant chemo-/radiotherapy in patients with locally advanced disease should be pursued.

Intimal pulmonary artery sarcoma presenting as dyspnea: case report

BACKGROUND

We report a case of pulmonary sarcoma which is a rare cause of the common symptom of dyspnea.

CASE PRESENTATION

A fifty-one year old previously healthy male presented to the emergency room with complaints of dyspnea on exertion. A cardiac workup including an exercise stress test was negative but an echocardiography showed pulmonary stenosis. Cardiac MRI showed a large mass extending from the pulmonic valve to both the right and left pulmonary arteries suggestive of sarcoma. A complete resection and repair of the pulmonary artery was done and adjuvant chemotherapy with doxorubicin and ifosfamide was recommended. The patient is currently disease free after eighteen months.

CONCLUSION

Pulmonary artery sarcomas are a difficult diagnosis. The diagnosis may remain elusive for some time until the proper imaging techniques are utilized to make a diagnosis. Earlier and accurate diagnosis may lead to earlier interventions and improve survival.

Low-grade myofibroblastic sarcoma of the heart causing sudden death

A 5-year-old Asian girl collapsed at school and was dead on arrival to the hospital. At autopsy, she had a tumor arising from her aortic valve. Histology revealed a low-grade myofibroblastic sarcoma, which we believe occluded a coronary artery ostium, leading to sudden death. Primary cardiac neoplasms are rare. The most common primary cardiac neoplasm is the cardiac myxoma. Although uncommon, the most prevalent primary malignant tumors of the heart are sarcomas, and regardless of the subtype, the prognosis is typically poor. We present a case of a primary cardiac sarcoma presenting as sudden death in a 5-year-old Asian girl. Pathologic examination of the lesion confirmed that this was an atypical myofibroblastic neoplasm, consistent with a low-grade sarcoma. Pediatric cardiac sarcomas are rare in general, and this is the first reported case of a valvular low-grade myofibroblastic sarcoma presenting in a child.

[Intimal sarcoma of the inferior vena cava]

INTRODUCTION

Primary sarcomas of the great vessels, that is, the aorta, pulmonary artery, and inferior vena cava, are rare. They can be classified according to the location of the sarcoma in the vessel wall and by their gross appearance. Most often they are leiomyosarcomas or fibrosarcomas.

CASE

We report here a case of an intimal sarcoma of the inferior vena cava. Histological and immunohistochemical findings confirmed the diagnosis for this 17-year-old girl and distinguished it from leiomyosarcoma and angiosarcoma, both of which have better prognoses.

DISCUSSION

Intimal sarcoma of the inferior vena cava is rare and difficult to diagnose before surgery or biopsy. Histologically, it is a poorly differentiated tumor with the worst prognosis among the primary vascular sarcomas. Pathologic findings and immunohistochemical staining are useful for a positive diagnosis.

Combined heart and lung transplantation for unresectable primary cardiac sarcoma

OBJECTIVE

The prognosis for patients with primary cardiac sarcoma is poor. Median survival is less than 10 months, especially when complete surgical excision is not feasible. Removal of all cardiopulmonary structures involved by tumor followed by orthotopic allotransplantation has been proposed to improve long-term survival.

METHODS

From 1996 through 1999, we performed combined heart and lung resection followed by en bloc heart and bilateral lung transplantation in 4 patients (2 men and 2 women): 2 with inoperable pulmonary arterial sarcoma and 2 with left atrial sarcoma extending into the pulmonary vein.

RESULTS

Median age at diagnosis was 39 years (range 37-45 years). All 4 patients were given chemotherapy before transplantation: doxorubicin and ifosfamide in 2 cases, and doxorubicin, ifosfamide, mesna, and dacarbazine in 2 cases. There were no operative deaths. Median survival after transplantation was 31 months (range 5-49 months). All patients had tumor recurrence: local recurrence in the chest (n = 1) and distant metastases in the brain (n = 2) and abdomen (n = 1). One patient remains alive 49 months after disease progression with cerebral metastasis as the only site of recurrence treated with whole-brain irradiation, resection, and stereotactic radiosurgery.

CONCLUSIONS

Combined heart and lung transplantation is a technically feasible treatment for highly selected patients with localized advanced primary cardiac sarcomas. The high incidence of metastatic disease, however, limits its utility.

Extracutaneous angiosarcomas metastatic to the lungs: clinical and pathologic features of twenty-one cases

Angiosarcomas are rare malignant vascular tumors with a high rate of metastasis involving lungs (most commonly), liver, regional lymph nodes, bone, and other sites. In this study, we have reviewed the clinical presentation and histopathology of 21 cases of extracutaneous angiosarcoma metastatic to the lungs. Tumors with exclusively pleural involvement were excluded. Patients presented with dyspnea, chest pain, and/or hemoptysis lasting a few weeks to months. Radiologically, the most common finding comprised multiple peripheral lung nodules (57%), often accompanied by infiltrates. For 11 cases (52%), the primary tumor was not identified at the time of presentation. Vasoformative areas were identified in 15 cases (71%). Nine cases comprised spindle cells (43%), two contained epithelioid cells (9.5%), and 10 consisted of both spindle and epithelioid cells (48%). Nuclear pleomorphism was at least moderate in all cases. However, five tumors contained regions of minimal nuclear atypia. Hemorrhage, siderophages, and fibrosis were commonly present. Immunohistochemical staining (IHS) was performed on 14 cases. Thirteen tumors showed reactivity for vascular markers. Tumor cells reacted for Von Willebrand factor in 13 of 14 cases, and CD31 and CD34 were each positive in 2/2 cases. Two cases (of nine examined) also expressed cytokeratins. Because the tumor often first presented in the lungs before the primary sarcoma was identified, the clinical impression included both benign and malignant entities. For patients with primary cardiac tumors, symptoms referable to the primary tumor complicated the clinical presentation, and radiologic evaluation supported a clinical diagnostic impression of non-neoplastic pericarditis. Thus, angiosarcoma in the lung may elude diagnosis until histopathologic evaluation of the lung biopsy.

Leiomyosarcomas of great vessels

Sarcomas of the great vessels are rare. Altogether 400 such cases have been described in the aorta, the pulmonary artery, and inferior vena cava. The clinical symptoms are generally related to embolic phenomena, aneurysm formation, and widespread metastases, especially to bones. With improved diagnostic modalities more cases are diagnosed and treated surgically. Resection of the tumor may prolong the patient s life. In this paper authors present two cases of such rare sarcomas. In our first case a tumor has developed in the thoracic aorta with symptoms of imminent aortic dissection. The tumorous nature of the lesion was revealed only histologically, since neither the operation, nor macroscopic picture gave any clue to its tumorous nature. The second case was a male patient with a huge retroperitoneal tumor arising from the inferior vena cava, which was clinically suspected to be a carcinomaarising in the adrenal gland.

Pulmonary tumor embolism as a presenting feature of cavoatrial hepatocellular carcinoma

Pulmonary tumor embolism as a presenting feature of hepatocellular carcinoma is rare. It has been reported only once previously. In that case, other signs and symptoms of liver disease were present. We report the case of a patient with cavoatrial hepatocellular carcinoma presenting with isolated pulmonary tumor embolism, without any clinical or laboratory evidence of liver disease. Hepatocellular carcinoma should be included in the differential diagnosis as a rare cause of pulmonary tumor embolism.

Unusual primary tumors of the heart

Primary tumors of the heart, with the exception of atrial myxomas, occur rarely; tumors metastatic to or directly invasive of the heart are far more common. About 75% of primary tumors are benign, and 75% of these are atrial myxomas. The benign tumors include rhabdomyomas, fibromas, papillary fibroelastomas, hemangiomas, pericardial cysts, lipomas, hamartomas, teratomas, mesotheliomas, and paragangliomas or pheochromocytomas. The last 3 may also be malignant. The malignant tumors consist of various sarcomas: myxosarcoma, liposarcoma, angiosarcoma, fibrosarcoma, leiomyosarcoma, osteosarcoma, synovial sarcoma, rhabdomyosarcoma, undifferentiated sarcoma, reticulum cell sarcoma, neurofibrosarcoma, and malignant fibrous histiocytoma. Cardiac tumors produce a large variety of symptoms through any of 4 mechanisms. Their mass can obstruct intracardiac blood flow or interfere with valve function. Local invasion can lead to arrhythmias or pericardial effusions with tamponade. Bits of tumor can embolize, causing systemic deficits when the tumors are on the left side of the heart. Finally, the tumors may cause systemic or constitutional symptoms. Some tumors, of course, produce no symptoms and become evident as incidental findings. The most useful diagnostic tool is the echocardiogram, which in almost all cases precisely locates the tumor and defines its extent. The echocardiographic appearance may also allow quite accurate prediction of the tumor type and whether it is malignant or benign. Magnetic resonance imaging serves as the next most important test where the density of T1 and T2 images may allow tumor cell type identification. With few exceptions, these tumors require operative excision. Most benign tumors can be resected completely; a few, because of their large size, cannot be, and only tumor debulking may be possible. Heart transplantation should be considered for these patients. Many of the malignant tumors cannot be resected completely, either because of the extent of local spread and invasion or because of the frequent distant metastases. Transplantation may also be an option for those with extensive local disease. The long-term results for resected benign tumors are excellent; the long-term results for sarcomas are very poor, and there are few survivors. For patients with unresectable sarcomas, radiation and chemotherapy may be used, but without great expectation of successful results.

CT and MR imaging of primary cardiac malignancies

Primary cardiac malignancies are rare tumors that are difficult to diagnose clinically. Different primary cardiac malignancies may have different clinical, morphologic, and radiologic features and intracardiac locations. Angiosarcoma is the most common primary cardiac malignancy. It tends to occur in the right atrium and involve the pericardium. Because of its tendency to hemorrhage, angiosarcoma often demonstrates areas of increased signal intensity with T1-weighted sequences. Undifferentiated sarcomas typically occur in the left atrium and have variable epidemiologic and radiologic features. Rhabdomyosarcoma is the most common primary cardiac malignancy in children and is more likely than other primary cardiac sarcomas to involve the valves. Primary cardiac osteogenic sarcoma almost always occurs in the left atrium and frequently demonstrates calcification. Certain features (eg, broad base of attachment, origin at a site other than the atrial septum) help differentiate this tumor from left atrial myxoma. Leiomyosarcoma favors the left atrium and tends to invade the pulmonary veins and mitral valve. Fibrosarcoma also tends to occur in the left atrium and is often necrotic. Liposarcoma is very rare and usually manifests as a large, infiltrating mass. Foci of macroscopic fat are occasionally seen. Primary cardiac lymphoma occurs more commonly in immunocompromised patients, frequently involves the pericardium, and, unlike other primary cardiac malignancies, may respond to chemotherapy. The advent of cross-sectional imaging has allowed earlier detection of primary cardiac malignancies as well as more accurate diagnosis and characterization.

Cardiac Neoplasms

Surgical resection is usually the only form of curative therapy available for primary cardiac neoplasms. Benign tumors can often be completely removed with few complications and a low mortality rate, but complete resection is possible for fewer than half of primary malignant tumors. Radiation therapy plays an adjunct and palliative role in treatment. The outcome of chemotherapy, the dominant treatment method, is poor. Sarcomas are inherently chemoresistant and show a response rate of less than 50%. Lymphomas present late and respond poorly. Cardiectomy and cardiac transplantation may cure unresectable benign cardiac tumors or, rarely, malignant ones.

Left atrial leiomyosarcoma: double occurrence and double recurrence--report of one case

In October 1996 a 67-year-old man underwent transthoracic and transesophageal echocardiography (TEE) because of dyspnea on exertion and was found to have 2 left atrial cardiac masses. The 2 masses were surgically removed from the atrium and showed histopathologic and ultrastructural features of a leiomyosarcoma. Seven months later a double recurrence of left atrial masses was found with TEE; the patient refused surgery and decided instead to receive chemotherapy. In May 1998 he was in stable condition (New York Heart Association class III), but a further growth of the 2 left atrial masses was observed at TEE. We describe the echocardiographic features of the 2 cardiac masses and the clinical and prognostic implications.

Unusual "Polycystic" Appearance of a Right Atrial Angiosarcoma Described by Transesophageal Echocardiography

Angiosarcoma is the most common primary sarcoma of the heart and the most frequent location of the tumor is the right atrium. In the few published cases of right atrial angiosarcoma studied by transesophageal echocardiography, the features described greatly differ from one to another. We describe the transesophageal images of a prolapsing mass type angiosarcoma with polycystic appearance previously misinterpreted as a right atrial myxoma in two consecutives transthoracic echocardiograms.

Pericardial angiosarcoma after mediastinal irradiation for seminoma. A case report and a review of the literature

BACKGROUND

Second malignancies are a well recognized complication of radiation therapy.

METHODS

We performed a computer search of the literature using the Medline Database for Pericardial Tumors and Post-Irradiation Sarcomas.

RESULTS

The case history of a patient who developed a radiation-induced pericardial angiosarcoma is described. We present a detailed review of pericardial sarcomas.

CONCLUSIONS

We believe this to be the first report of a radiation-induced pericardial sarcoma. The importance of continued long-term observation for patients who receive mediastinal irradiation is stressed.

Successful treatment of a primary cardiac leiomyosarcoma with ifosfamide and etoposide

PURPOSE

Primary cardiac leiomyosarcoma is a rare malignant tumor in childhood. Patients with unresectable or partially resected cardiac leiomyosarcoma typically have a poor prognosis. The role of chemotherapy in the treatment of these patients has not been well defined.

PATIENT AND METHODS

A 6-week-old infant with an incompletely resected cardiac leiomyosarcoma was treated postoperatively with ifosfamide and etoposide.

RESULTS

The patient is disease-free and without apparent late effects 5 years following the completion of therapy.

CONCLUSION

The combination of ifosfamide and etoposide warrants further evaluation in patients with leiomyosarcoma.

Leiomyosarcoma of the pulmonary veins with extension to the left atrium

A leiomyosarcoma of the right pulmonary vein in a 43-year-old woman extended to the right atrial wall and compromised the posterior mitral leaflet. Successful surgical treatment was accomplished with a right pneumonectomy, partial resection of the left atrial wall, and mitral valve replacement under cardiopulmonary bypass. Six months later a mediastinal recurrence with extension to the left hemithorax was treated with resection and postoperative radiotherapy.