Clinical classification of cardiovascular tumors and tumor-like lesions, and its incidences

Ultrasound, Histomorphologic, and Immunohistochemical Analysis of a Cardiac Tumor with Increased Purkinje Cells Detected in a Canine Fetus 42 Days into Pregnancy

A seven-year-old healthy female Chow Chow was referred for pregnancy monitoring. Ultrasonography was used to evaluate all pregnancy and fetus parameters, and they were found to be normal. During the examination of the 42 day pregnant bitch, an unusual mass was seen in a fetus's heart. This fetus had a cardiac frequency of 273-300 beats, while the others had heart rates of 220-240 beats. Natural vaginal birth occurred at 63 days pregnant: the first two puppies were stillborn but perfectly formed, and the other three were alive and had optimal APGAR. In one of two deceased puppies, an unusual, reddish, smooth mass occupying the space in the heart was found through necroscopy. The organ was submitted for histological examination. Histopathology, immunohistochemical, and histochemical analyses all indicated a cardiac tumor with increased Purkinje cells. This type of tumor has been described in infants, swine, bearded seals, and deer but never in fetuses and neonates of dogs. To our knowledge, this is the first such case reported in veterinary medicine.

Renal Embolism Associated with the Atrial Myxoma: A Case Report and Literature Review

Renal embolisms due to cardiac myxomas are extremely rare; the clinical course, treatment, and prognosis of this disease are not established. A 69-year-old Japanese woman who underwent a nephrectomy for renal cell carcinoma 3 years earlier was hospitalized with a right occipital lobe cerebral infarction. Her renal function suddenly worsened 3 days post-admission: her serum creatinine rose from 1.46 mg/dL to 6.57 mg/dL and then to 8.03 mg/dL the next day, and hemodialysis therapy was started. Abdominal computed tomography (CT) scans showed patchy non-contrasted low-density areas in the right kidney, and chest CT scans and transesophageal ultrasonography revealed a left atrial tumor. We diagnosed renal infarction due to a left atrial myxoma. Hemodialysis and anticoagulant therapy (heparin) were continued, followed by the cardiac myxoma's resection. The patient's renal function gradually improved post-surgery, and the hemodialysis was discontinued. Considering our patient and 19 other case reports of renal infarction associated with cardiac myxoma, the treatment for such a renal infarction and the outcomes differ depending on the embolus site. The poor outcome of abdominal aortic embolism requires a prompt embolectomy, whereas a branch renal artery embolism requires anticoagulation therapy to prevent thrombosis formation around the myxoma.

Multimodality imaging of a rare intracardiac bronchogenic cyst

The authors report a case of pathologically proven intracardiac bronchogenic cyst embedded within the interatrial septum of a 30-year-old woman presenting with chest pain and first-degree AV block. Multimodality imaging played an essential role in the discovery, investigation, and diagnosis of this extremely rare entity.

MRI and CT Appearances in Various Cardiac Tumours

While primary cardiac malignancies are infrequent, the heart often serves as a site for metastases. Myxomas are recognized as among the most prevalent primary benign tumours globally, while sarcomas represent the most common malignant primary tumours. The diverse range of potential clinical presentations depends on factors such as location, size, and the aggressiveness of the disease. The majority of diagnoses rely on medical imaging, making it crucial to familiarize oneself with their distinctive characteristics. When a cardiac mass is suspected, MRI of the heart has emerged as the preferred diagnostic method, surpassing previous techniques. CT is a valuable tool for assessing cardiac morphology and improving electrocardiography gating by providing enhanced details. This article conducts a comprehensive review of the MRI and CT characteristics of both primary and secondary cardiac malignancies, emphasizing crucial distinctions and common diagnostic pitfalls. Despite their rarity, cardiac masses continue to hold significance in the realm of cardio-oncology. Furthermore, this article explores conditions such as thrombus, Lambl's excrescences, and pericardial cysts, which can mimic tumours. Multimodal imaging has played a pivotal role in identifying the origin of cardiac masses in numerous cases, particularly when combined with the clinical context. This article offers an in-depth examination of the frequency, clinical indicators, imaging, diagnostic procedures, available treatments, and prognoses related to cardiac masses.

The characteristics of invasive cardiac lipoma: case report and literature review

Invasive cardiac lipoma is a rare type of primary cardiac tumor that is composed of adipose tissue but infiltrating the adjacent structures. It is a benign tumor that can cause significant morbidity and mortality due to its size and location within the heart. We describe a giant invasive intracardiac lipoma across atrial wall extending to the ascending aorta and the superior vena cava. This review will provide an overview of invasive cardiac lipoma, including its clinical presentation, diagnosis, and management.

Sex-Related Disparities in Cardiac Masses: Clinical Features and Outcomes

BACKGROUND

Cardiac masses (CM) represent a heterogeneous clinical scenario, and sex-related differences of these patients remain to be established.

PURPOSE

To evaluate sex-related disparities in CMs regarding clinical presentation and outcomes.

MATERIAL AND METHODS

The study cohort included 321 consecutive patients with CM enrolled in our Centre between 2004 and 2022. A definitive diagnosis was achieved by histological examination or, in the case of cardiac thrombi, with radiological evidence of thrombus resolution after anticoagulant treatment. All-cause mortality at follow-up was evaluated. Multivariable regression analysis assessed the potential prognostic disparities between men and women.

RESULTS

Out of 321 patients with CM, 172 (54%) were female. Women were more frequently younger (p = 0.02) than men. Regarding CM histotypes, females were affected by benign masses more frequently (with cardiac myxoma above all), while metastatic tumours were more common in men (p < 0.001). At presentation, peripheral embolism occurred predominantly in women (p = 0.03). Echocardiographic features such as greater dimension, irregular margin, infiltration, sessile mass and immobility were far more common in men. Despite a better overall survival in women, no sex-related differences were observed in the prognosis of benign or malignant masses. In fact, in multivariate analyses, sex was not independently associated with all-cause death. Conversely, age, smoking habit, malignant tumours and peripheral embolism were independent predictors of mortality.

CONCLUSIONS

In a large cohort of cardiac masses, a significant sex-related difference in histotype prevalence was found: Benign CMs affected female patients more frequently, while malignant tumours affected predominantly men. Despite better overall survival in women, sex did not influence prognosis in benign and malignant masses.

Nonbacterial Thrombotic Endocarditis of the Mitral Valve With Echocardiographic Appearances Mimicking a Papillary Fibroelastoma in a Middle-Aged Female Patient

Papillary fibroelastoma (PFE) and nonbacterial thrombotic endocarditis (NBTE) account for <1% of all cardioembolic strokes. When there is no evidence of infection, and an exophytic valve lesion is seen on echocardiography, PFE may be an initial imaging diagnosis. NBTE, or Libman-Sacks endocarditis, is a rare entity and can present with varied imaging findings. This report presents a case of embolic stroke and NBTE mimicking a PFE. We discuss a 49-year-old female with a past medical history of diabetes mellitus who presented with headache and right-hand numbness. The initial CT head was negative and the MRI brain showed multiple infarcts in the watershed areas where anterior and posterior brain circulation meet and overlap. A transesophageal echocardiogram (TEE) showed a left ventricle (LV) mass initially diagnosed as PFE. The patient was started on aspirin only with no anticoagulation since we thought the stroke was related to an embolus from a tumor, not a thrombus. The patient underwent surgery but the pathology report revealed a diagnosis of organizing thrombus with abundant neutrophilic infiltration and no neoplastic proliferation. This case report highlights the importance of a comprehensive evaluation of valvular masses and the diagnostic approaches currently available to help clinicians differentiate between various causes of embolic stroke like PFE, bacterial endocarditis, and NBTE. Early differentiation is critical because it can affect the treatment and outcome. This report shows that echocardiography of endocardial and valvular lesions may provide a differential diagnosis, but a definitive diagnosis requires microbiology and histopathology. Advanced imaging techniques such as cardiac CT or cardiac MRI may assist in identifying select cases that are at lower risk for subsequent embolic events, in which surgical intervention may safely be avoided.

Cardiac Vascular Hamartoma: Adult Diagnosis and Cardiac Reconstruction

Cardiac hamartoma is a rare benign tumor of the heart, and the vascular type is an extremely rare histologic diagnosis. A small number of cases have previously been described in childhood. We report the case of a 63-year-old woman with an incidentally detected cardiac mass that was finally diagnosed as vascular hamartoma. Approval for publication was obtained from the patient.

Case report: Metastatic myxoid liposarcoma arising from the right atrium extends as cardiac tamponade-A rare case of atrial oncology

The reported incidence of liposarcomas in ~2,000 cases annually results in about 30% of myxoid liposarcomas. Cardiac myoxid liposarcomas are very rare; their presentation could be cardiac tamponade, due to direct compression of the tumor and/or pericardial effusion. In this report, we describe a patient who presented with pericardial effusion secondary to myoxid liposarcomas from the right atrium, an extremely rare presentation of liposarcomas in the heart. We also present non-invasive imaging through echocardiography, CECT thorax and FDG PET scans, followed by a CT-guided mass biopsy. Histopathology of the right atrial mass demonstrated myxoid liposarcoma positive for the S100 tumor marker.

Echocardiographic Markers in the Diagnosis of Cardiac Masses

BACKGROUND

The echocardiographic parameters required for a comprehensive assessment of cardiac masses (CMs) are still largely unknown. The aim of this study was to identify and integrate the echocardiographic features of CMs that can accurately predict malignancy.

METHODS

An observational cohort study was conducted among 286 consecutive patients who underwent standard echocardiographic assessment for suspected CM at Bologna University Hospital between 2004 and 2022. A definitive diagnosis was achieved by histologic examination or, in the case of cardiac thrombi, with radiologic evidence of thrombus resolution after appropriate anticoagulant treatment. Logistic and multivariable regression analysis was performed to confirm the ability of six echocardiographic parameters to discriminate malignant from benign masses. The unweighted count of these parameters was used as a numeric score, ranging from 0 to 6, with a cutoff of ≥3 balancing sensitivity and specificity with respect to the histologic diagnosis of malignancy. Classification tree analysis was used to determine the ability of echocardiographic parameters to discriminate subgroups of patients with differential risk for malignancy.

RESULTS

Benign masses were more frequently pedunculated, mobile, and adherent to the interatrial septum (P < .001). Malignant masses showed a greater diameter and exhibited a higher frequency of irregular margins, an inhomogeneous appearance, sessile implantation, polylobate shape, and pericardial effusion (P < .001). Infiltration, moderate to severe pericardial effusion, nonleft localization, sessile implantation, polylobate shape, and inhomogeneity were confirmed to be independent predictors of malignancy in both univariate and multivariable models. The predictive ability of the unweighted score of ≥3 was very high (>0.90) and similar to that of the previously published weighted score. Classification tree analysis generated an algorithm in which infiltration was the best discriminator of malignancy, followed by nonleft localization and sessile implantation. The percentage correctly classified by classification tree analysis as malignant was 87.5%. Agreement between observer readings and CM histology ranged between 85.1% and 91.5%. The presence of at least three echocardiographic parameters was associated with lower survival.

CONCLUSIONS

In the approach to CMs, some echocardiographic parameters can serve as markers to accurately predict malignancy, thereby informing the need for second-level investigations and minimizing the diagnostic delay in such a complex clinical scenario.

Diagnostic test accuracies of F-18 FDG PET for characterisation of cardiac masses compared to conventional imaging techniques: systematic review and meta-analysis

OBJECTIVE

The present systematic review and meta-analysis compared the diagnostic performance of F-18 fludeoxyglucose positron emission tomography (18F-FDG PET) and conventional imaging, including MRI, echocardiography, and CT, in characterising cardiac masses.

METHODS

A literature search of the PubMed, Cochrane, and EMBASE databases for studies comparing the diagnostic accuracies of 18F-FDG PET and conventional imaging in characterising cardiac masses, from inception of indexing to 31 July 2020, was performed. The Quality Assessment of Diagnostic Accuracy Studies-2 tool was used to assess study quality. Sensitivity and specificity across the studies were determined, positive and negative likelihood ratios (LR+ and LR-, respectively) were calculated, and summary receiver operating characteristic curves were constructed.

RESULTS

Of six included studies (n = 212 patients), 18F-FDG PET demonstrated a pooled sensitivity of 0.89 (95% confidence interval [CI] 0.81-0.94) and a pooled specificity of 0.89 (95% CI 0.80-0.94). LR syntheses yielded an overall LR+ of 7.9 (95% CI 4.3-14.6) and LR- of 0.12 (95% CI 0.07-0.22). The calculated pooled diagnostic odds ratio (DOR) was 64 (95% CI 23-181). For conventional imaging, the pooled sensitivity was 0.70 (95% CI 0.57-0.81) and the pooled specificity was 0.96 (95% CI 0.88-0.98). LR syntheses yielded an overall LR+ of 16.1 (95% CI 5.8-44.5) and LR- of 0.31 (95% CI 0.21-0.46). The evaluated pooled DOR was 52 (95% CI 17-155).

CONCLUSION

18F-FDG PET and conventional imaging demonstrated comparable diagnostic accuracies for the characterisation of cardiac masses. Further large multicentre studies are, however, required to corroborate the diagnostic performances of 18F-FDG PET and conventional imaging for the characterisation of cardiac masses.

ADVANCES IN KNOWLEDGE

No previous studies have comprehensively analysed the diagnostic performance of 18F-FDG PET/CT compared with conventional imaging techniques including echocardiography, CT, and MRI. According to the current study, 18F-FDG PET/CT yielded a pooled DOR of 64, whereas other conventional imaging techniques demonstrated a DOR of 52. As such, 18F-FDG PET/CT demonstrated sensitivity and specificity, with a high pooled DOR comparable with other conventional imaging modalities.

Giant lipoma in superior vena cava: A case report and literature review

INTRODUCTION

Intravascular lipomas are rare occurrences, especially in major vessels. This tumour is composed of adipocytes in a fibrous capsule that has a slow growth rate and usually shows no symptoms. There were only eight reports in the literature regarding intravascular lipoma located in the superior vena cava.

CASE PRESENTATION

A 54-year-old man had episodes of supraventricular tachycardia and atrial flutter for over a year. Preoperative radiological findings showed a giant mass that arose from the superior vena cava to the right atrium and a biopsy catheter showed that there were no signs of malignancy. The patient then underwent surgery through median sternotomy and the mass was extirpated on the highest part of the stalk that could be reached. The patient was stable and remained to show no symptoms or evidence of residual mass or stalk in 2 years follow-up.

CONCLUSION

The surgical approach in excising lipoma in SVC should be considered wisely with the support of adequate preoperative diagnosis. Since lipoma is a very slow-growing tumour, extensive manipulation that could increase surgical technique difficulty or postoperative morbidity and mortality is not necessary.

Atrial invasion from primary lung adenocarcinoma extension via the pulmonary vein

Intravascular extension of lung adenocarcinoma is one of the four defined routes of metastasis to the heart but is rarely described in the literature. This is a rare case of primary lung adenocarcinoma with intravenous extension to the left atrium via the pulmonary vein. A 56-year-old female presented to the hospital with chest tightness and dyspnea. Chest computed tomography revealed a right hilar mass extending through the right superior pulmonary vein into the left atrium. Transthoracic echocardiography revealed a large, partially mobile left atrial mass occupying the entire atrial cavity and affecting mitral valve closure. Endobronchial ultrasound with transbronchial biopsy of the right middle lobe of the lung histologically showed a poorly differentiated adenocarcinoma compatible with the primary lung cancer. The patient was deemed a poor surgical candidate by cardiothoracic surgery due to the extent of metastasis and was started on chemoradiation. The patient's left atrial tumor mass started shrinking in size after starting the treatment. This unique case displaying intravascular extension of lung cancer to the left atrium has rarely been described in the literature.

A Fatal Cause of Rapidly Progressive Heart Failure in a Middle-Aged Woman

Primary cardiac neoplasms are rare, with 3/4 cases being benign. Most malignant neoplasms are sarcomas. Clinically, they present as pseudovalvular obstruction or remote embolism and rarely as a paraneoplastic syndrome. Median survival depends on complete resection rather than histologic type. We describe the case of a 65-year-old woman who presented to the hospital with a three-month history of asthenia, anorexia, weight loss, and progressive worsening of exertional dyspnea. Transthoracic echocardiogram showed a bulky mass in the auricles with significant transvalvular obstruction of the mitral valve. The CT scan showed a voluminous mass in the interauricular septum with the invasion of both atria and restriction of flow in both pulmonary veins. A transvenous biopsy was performed and histology revealed a primary intimal sarcoma. The patient was not eligible for surgery and was proposed for palliative chemotherapy, but she succumbed to her illness in less than two weeks. This report describes this rare and rapidly fatal disease and reviews the literature.

A case of a small-sized cavernous hemangioma in the right ventricle - an incidental finding

A cardiac cavernous hemangioma is a rare, primary, benign tumor that is usually diagnosed in young or middle-aged patients. In this article, we report the case of a 71-year-old male patient whose doctors incidentally discovered a heart tumor on his transthoracic echocardiography. Triple-phase computed tomography (CT) (pre-contrast, arterial and portal venous) missed the lesion, and magnetic resonance imaging (MRI) revealed a small, oval tumor attached to the wall of the right ventricle. The tumor was successfully removed surgically, and the patient recovered after 2 weeks. A histopathological examination resulted in the diagnosis of a benign cavernous hemangioma.

Dysphonia as a Presenting Symptom of a Giant Left Atrial Sarcoma Developing within Five Years

An 83-year-old woman presented with a new onset of dyspnea and dysphonia. Physical examination revealed no abnormalities. Computerized tomography, bidimensional echocardiography, and cardiac magnetic resonance confirmed the presence of a cardiac mass in the left atrium. Surgical resection was uneventful and showed the origin of the mass in the ostium of the left inferior pulmonary vein. Histological evaluation revealed undifferentiated pleomorphic sarcoma with myxoid features. This case highlights the importance of considering cardiac neoplasms as a rare differential diagnosis, including rare and misleading clinical presentations.

Mediastinal tumours and pseudo-tumours: a comprehensive review with emphasis on multidisciplinary approach

The diagnosis of a mediastinal mass may be challenging for clinicians, since lesions arising within the mediastinum include a variety of disease entities, frequently requiring a multidisciplinary approach. Age and sex represent important information, which need to be integrated with imaging and laboratory findings. In addition, the location of the mediastinal lesion is fundamental; indeed, we propose to illustrate mediastinal diseases based on the compartment of origin. We consider that this structured approach may serve as hint to the diagnostic modalities and management of mediastinal diseases. In this review, we present primary mediastinal tumours in the evolving context of new diagnostic and therapeutic tools, with recently described entities, based on our own experience with >900 cases encountered in the past 10 years.

Given the mediastinal anatomical heterogeneity, the correct positioning of mediastinal lesions becomes primal, in order to first establish a clinical suspicion and then to assist in planning biopsy and surgical procedurehttps://bit.ly/3p0gsk3

Unusual presentation of atrial Myxoma in a young Malawian male: Case report and review of literature

We report a 30-year-old male who presented with signs and symptoms of right heart failure who was later diagnosed with right-sided atrial myxoma. This patient, unfortunately, died while waiting for cardiac surgery outside Malawi and postmortem was not done to ascertain the cause of death.

Staged surgery for advanced cardiac intimal sarcoma involving the right atrium and the inferior vena cava

Intimal sarcomas simultaneously involving the right atrium and the inferior vena cava (IVC) are rare. We report an advanced cardiac intimal sarcoma in the right atrium of a 19-year-old man that was complicated by tumor-related IVC thrombosis. We initially performed partial tumor resection and vena cava thrombectomy to resolve the circulatory obstruction, because complete resection was difficult due to the invading malignancy and an unclear margin. The patient received adjuvant chemo- and radiotherapy along with anticoagulant therapy. After 3 months, the border of the residual sarcoma was clear, and the patient underwent a secondary complete sarcoma excision (including that of the right atrium) and a suprahepatic vena cava reconstruction. At the 2-year follow-up, there was no tumor recurrence. We conclude that aggressive treatment and a staged complete resection can lead to improved outcomes for advanced cardiac intimal sarcoma with poor prognosis.

A case report of a massive cardiac intimal sarcoma manifesting as syncope during a stress test

Background

Syncope has many aetiologies but from a cardiac standpoint, if arrhythmogenic and ischaemic causes are not present, obstructive lesions should be considered. Cardiac spindle cell sarcomas are incredibly rare and difficult to cure.

Case summary

A 62-year-old man presented for exercise stress test and had a syncopal episode on the treadmill. He was found to have a massive mass obstructing the transmitral flow. Patient was taken to the operating room and the mass was resected successfully. Histopathological confirmation revealed the mass to be a cardiac intimal sarcoma. Patient was initiated on a trial regimen of doxorubin, ifosfamide, and mesna.

Discussion

Cardiac intimal sarcomas are aggressive cancers and are difficult to treat; there are no established treatment guidelines. They can lead to obstruction of blood flow through the cardiac chambers. From a cardiac perspective, without arrhythmogenic and ischaemic causes of syncope, obstructive lesions should be considered.

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.

An MRI Image Analysis of Primary Cardiac Neoplasms

Objective

This study aimed to examine the magnetic resonance imaging (MRI) characteristics of primary cardiac neoplastic lesions.

Methods

A retrospective investigation was conducted on 24 cases of primary cardiac neoplastic lesions as confirmed by surgery and pathology results. All the cases in this study received MRI multi-sequence and multi-dimension scanning, including the cardiac long-axis and short-axis cine sequences, parameter sequences of the cardiac long axis and short axis (T1WI, T2WI), first-pass perfusion sequence, and delayed enhancement sequence of the cardiac long axis and short axis. The age and gender of the patients and the location, size, signal characteristics, and relationship with the neighboring tissues of all the lesions were examined.

Results

Twenty-four cases of primary neoplastic lesions were examined in this study, the onset age was 11–72 years old, the median age was 53 years old, and the mean age was 46 years old. Among these cases, there were 8 cases including males and 16 cases including females, 19 cases were benign lesions; including 11 cases of myxoma, 4 cases of hemangioma, 1 case of paraganglioma, 1 case of PEcoma, 1 case of hamartoma, and 1 case of lipoma. The malignant lesions included 3 sarcomas and 2 lymphomas in 5 patients.

Conclusion

MRI imaging provides a great value in the preoperative classification of primary cardiac neoplastic lesions.

Primary neuroendocrine tumours of the heart: case report and literature review

Neuroendocrine tumours occur most frequently in the gastrointestinal tract, lungs, and pancreas. Primary malignant cardiac tumours are uncommon and are usually sarcomas, lymphomas, or, infrequently, mesotheliomas. Primary cardiac neuroendocrine carcinomas are exceedingly rare; only nine have been reported in the literature to date. We report the tenth case of this disorder in a 44-year-old man with a well-differentiated low-grade primary cardiac neuroendocrine carcinoma treated with surgery who remains in remission more than a year later. Our case and review of the literature demonstrate that surgical treatment for well-differentiated primary cardiac neuroendocrine carcinomas can be effective.

Diagnostic pitfalls: intramyocardial lymphoma metastasis mimics acute coronary syndrome in a diffuse large B cell lymphoma patient-case report

Background

Cardiac tumors are very uncommon compared to other cardiac diseases. Their clinical symptoms can vary from absent to non-specific. The most common symptoms are arrhythmias, blood flow obstruction due to valvular dysfunction, shortness of breath, systemic embolization, and accumulation of pericardial fluid. Hereby, we describe a very rare case of a diffuse large B cell lymphoma patient who presented with the symptoms and signs of acute coronary syndrome (ACS) but the patient’s complaints were caused by his intramyocardial lymphoma metastasis.

Case presentation

Forty-eight-year-old diffuse large B cell lymphoma patient was admitted to our emergency department with chest pain, effort dyspnea, and fever. The patient had normal blood pressure, blood oxygen saturation, sinus tachycardia, fever, crackles over the left lower lobe, novum incomplete right bundle branch block with Q waves and minor ST alterations, elevated C-reactive protein, high-sensitivity troponin-T, and d-dimer levels. Chest X-ray revealed consolidation on the left side and enlarged heart. Bed side transthoracic echocardiography showed inferior akinesis with pericardial fluid. Coronary angiography showed no occlusion or significant stenosis. Chest computed tomography demonstrated the progression of his lymphoma in the myocardium. He was admitted to the Department of Hematology for immediate chemotherapy and he reached complete metabolic remission, followed by allogeneic hematopoietic stem cell transplantation. Unfortunately, about 9 months later, he developed bone marrow deficiency consequently severe sepsis, septic shock, and multiple organ failure what he did not survive.

Conclusions

Our case demonstrates a very rare manifestation of a heart metastasis. ACS is an unusual symptom of cardiac tumors. But our patient’s intramyocardial lymphoma in the right atrium and ventricle externally compressed the right coronary artery and damaged the heart tissue, causing the patient’s symptoms which imitated ACS. Fortunately, the quick diagnostics and immediate aggressive chemotherapy provided the patient’s remission and suitability to further treatment.

Multiple small tumor formation on both surfaces of the aortic valve cusps in Epstein-Barr virus-associated T/NK-cell lymphoproliferative disease: a case report

A 41-year-old woman presented acute cerebral infarction. Transesophageal echocardiography revealed multiple masses only on both surfaces of the aortic valve cusps. There was no primary lesion outside the heart according to various examinations. After treatment for cerebral infarction, we replaced the aortic valve instead of preservation because the intraoperative histological examination reported that malignancy was highly suspected. Contrary to the rapid frozen section diagnosis, histological and immunohistochemical examinations failed to exhibit malignancy. The tumors were composed of atypical large lymphoid cells and they were assessed to be related to T-/natural killer-cells. Furthermore, Epstein–Barr virus related markers were also positive. Her three-year postoperative course was uneventful without chemotherapy. We report an extremely rare case of Epstein–Barr virus-associated T-/natural killer-cell lymphoproliferative disease which formed multiple small tumors on both surfaces of the aortic valve.

A rare case of a right atrial lipoma originating from the superior vena cava: review, diagnosis and management

Primary cardiac tumors are usually found incidentally on imaging and are much less common than tumors that metastasize to the heart. Cardiac lipomas are benign cardiac tumors that are usually found in the right atrium or left ventricle. Primary intravascular venous lipomas of the great cardiac vessels are extremely rare and there are few reported cases of a lipoma originating from the superior vena cava causing direct compressive intracardiac effects. Here we describe a case of a symptomatic right atrial lipoma originating from the superior vena cava.

A rare diagnostic challenge in a female patient with a rapid recurrent pleural effusion: Autopsy revealed cardiac angiosarcoma with bilateral pleural and pulmonary metastases. A case report

INTRODUCTION

We present a very rare case with diffuse cardiac angiosarcoma. Because all symptoms are often non-specific, this diagnosis is difficult to establish. To our knowledge this is the first clinical description of this rare disease.

PRESENTATION OF CASE

A 47-year-old female presented with bilateral pulmonary infiltrates and non-specific symptoms as fever, chest pain and dyspnoea on exertion. She was treated with antibiotics for suspected lung infection but deteriorated developing rapid recurrent pleural effusion. Her transthoracic- and transoesophageal-echocardiography as well as the thoracentesis and endobronchial ultrasound findings were normal. A minimally invasive pulmonary wedge resection, partial pleurectomy and pericardial fenestration was performed. The pathologic interpretation of these specimen was very difficult and a correct diagnosis could be made only by the second reference pathologist. While awaiting reference histology report she was administered high-flow oxygen therapy for hypoxia, antibiotics, catecholamines and corticosteroids. The patient deteriorated very rapidly and died in the ICU.

DISCUSSION

As in earlier studies, misdiagnosis delayed the actual diagnosis, especially because there was no clinical suspicion for angiosarcoma. Pathologic evaluation may be difficult because different growth patterns may be present in the same tumour and pleural or lung specimen may show only very tiny tumour formations within a fibrosing tissue changes.

CONCLUSION

This case report highlights the difficulties to establish a diagnosis of diffuse angiosarcoma in time. An early diagnosis, to initiate oncologic treatment, require a high level of clinical suspicion and a histological proof from pericardial or myocardial biopsy.

Rapidly growing papillary fibroelastoma complicated by myxoma

Rapidly growing papillary fibroelastoma complicated by myxoma is extremely rare. An 80-year-old male was transported to our hospital because of cerebral hemorrhage. Echocardiogram revealed a massive pedunculated tumor in the septum of the left atrium. The tumor extended to the mitral valve orifice and posed a risk of strangulation, yet removing it immediately would have required cardiopulmonary bypass with anticoagulant, which would have posed a serious risk of rebleeding. Magnetic resonance imaging showed that the tumor stalk was sufficiently thick for us to perform a standby surgery 1 month after cerebral hemorrhage. Follow-up echocardiogram prior to this surgery revealed a new, high-mobility tumor in the right ventricular septum. We resected these two tumors together. Histopathological examination showed that the tumor of the left atrium was a myxoma and the tumor of the right ventricle was a papillary fibroelastoma. The patient had a good postoperative course and was discharged without complications.

Diagnostic Accuracy of Cardiac Computed Tomography and 18-F Fluorodeoxyglucose Positron Emission Tomography in Cardiac Masses

OBJECTIVES

This study sought to assess the diagnostic accuracy of cardiac computed tomography (CT) and ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) with positron emission tomography/computed tomography (PET/CT) in defining the nature of cardiac masses.

BACKGROUND

The diagnostic accuracy of cardiac CT and ¹⁸F-FDG PET/CT in identifying the nature of cardiac masses has been analyzed to date only in small samples.

METHODS

Of 223 patients with echocardiographically diagnosed cardiac masses, a cohort of 60 cases who underwent cardiac CT and ¹⁸F-FDG PET/CT was selected. All masses had histological confirmation, except for a minority of thrombotic formations. For each mass, 8 morphological CT signs, standardized uptake value (SUV_max, SUV_mean), metabolic tumor volume, and total lesion glycolysis in ¹⁸F-FDG PET were used as diagnostic markers.

RESULTS

Irregular tumor margins, pericardial effusion, invasion, solid nature, mass diameter, CT contrast uptake, and pre-contrast characteristics were strongly associated with the malignant nature of masses. The coexistence of at least 5 CT signs perfectly identified malignant masses, whereas the detection of 3 or 4 CT signs did not accurately discriminate the masses' nature. The mean SUV_max, SUV_mean, metabolic tumor volume, and total lesion glycolysis values were significantly higher in malignant than in benign masses. The diagnostic accuracy of SUV, metabolic tumor volume, and total lesion glycolysis ¹⁸F-FDG PET/CT parameters was excellent in detecting malignant masses. Among patients with 3 or 4 pathological CT signs, the presence of at least 1 abnormal ¹⁸F-FDG PET/CT parameter significantly increased the identification of malignancies.

CONCLUSIONS

Cardiac CT is a powerful tool to diagnose cardiac masses as the number of abnormal signs was found to correlate with the lesions' nature. Similarly, ¹⁸F-FDG PET/CT accurately identified malignant masses and contributed with additional valuable information in diagnostic uncertainties after cardiac CT. These imaging tools should be performed in specific clinical settings such as involvement of great vessels or for disease-staging purposes.

Primary pericardial angiosarcoma: case report and review of treatment options

A primary cardiac angiosarcoma is a rare type of soft-tissue sarcoma with a high mortality rate. This report describes a young woman who presented with chest pain and worsening shortness of breath over the course of a year. She was diagnosed with and treated for latent tuberculosis and autoimmune pericarditis over the last year, however, her condition kept worsening. Further workup revealed a large pericardial and right atrial mass associated with multiple lung nodules. The biopsy from the lung mass showed angiosarcoma, and she was diagnosed with primary metastatic angiosarcoma of the pericardium. She was treated with doxorubicin and Ifosfamide (AIM-75 regimen), which led to a partial response. However, soon after completion of six cycles, the tumour progressed rapidly, leading to cardio-respiratory failure. In this report, we will discuss the clinical challenges and treatment options (surgical and medical) that are available for treating patients with angiosarcoma of the heart.

Prominent right ventricular mass in a young patient with a history of classic testicular seminoma: a case report

Background

The incidence of intracardiac masses is generally low. In most cases, the formation of a thrombus represents the principal diagnosis in clinical practice. The differential diagnosis mainly includes primary tumours of the heart as well as intracardiac metastases. Testicular cancer is a rare malignancy, accounting for approximately 1% of all male tumours. Cardiac metastasis of a seminoma is extremely rare.

Case summary

A 30-year-old man with a history of a classic seminoma of the right testis was referred to our university hospital from an outside clinic. Transthoracic echocardiography showed a large space-occupying mass in the right ventricle (4.0 cm × 4.5 cm × 5.5 cm) attached to the apex and septum. Cardiac magnetic resonance imaging confirmed the finding of a 5.5 cm × 3.5 cm lesion without freely movable appendage or obstruction of the right ventricular outflow tract. Tissue characterization by T1- and T2-weighted black blood imaging revealed a signal behaviour comparable to pulmonary metastases. Additionally, positron emission tomography (PET) with 250 MBq induced 18-fluorodeoxyglucose (¹⁸F-FDG) as part of a re-staging showed significant FDG-uptake. Thus, the final diagnosis of an intracardiac metastasis of the testicular seminoma was made, and the patient was treated with cisplatin, etoposide, and bleomycin chemotherapy according to the current guidelines. A repeat trans-thoracic echocardiogram (TTE) performed 2 weeks later already demonstrated a significant reduction of the metastasis with a diameter of 3.3 cm × 3.0 cm.

Discussion

In the past few years, multimodality imaging has become essential in the diagnostic evaluation of cardiac disease. In order to improve the diagnostic accuracy, a modern approach should preferably contain the integration of different imaging modalities. Cardiac magnetic resonance imaging as well as ¹⁸F-FDG-PET/computed tomography helped us reach the aetiological diagnosis of an intracardiac metastasis and to initiate prompt treatment.

An unusual tumour: Hamartoma of mature cardiac myocytes

Heart neoplasms are uncommon and usually benign. Hamartoma of mature cardiac myocytes is an unusual lesion with only a few reported cases. It is a heterogeneous mixture of well-differentiated myocytes, fibroblasts, adipocytes and blood vessels. We present a case of hamartoma of mature cardiac myocytes and a concise review of the pertinent literature. A multi-lobulated polypoid tumour attached to the wall of the right atrium was found during an autopsy of a young woman. Microscopy revealed cardiomyocytes, fibrous connective tissue and well-differentiated adipocytes. The immunohistochemical study had a positive immunoreactivity for desmin, muscle-specific actin (HHF-35) and CD34 markers, showing the different types of mesenchymal cells involved. This combination of markers has not been previously used. Other tumours, such as cardiac rhabdomyoma and cardiac myxoma were ruled out due to the differences in histological characteristics and clinical presentation.

A rare case of primary cardiac lymphoma and the role of early surgical debulking: a case report

BACKGROUND

Primary cardiac lymphoma (PCL) is a very rare disease and is most commonly found among immunocompromised patients. Its cardiac manifestations are non-specific, leading to delayed diagnosis and poor prognosis. However, chemotherapy could improve survival, which makes early and prompt diagnosis very crucial. This is a report of a rare case of PCL found on a 73-year-old man who benefit from early debulking surgery.

CASE SUMMARY

A 73-year-old man presented with worsening dyspnoea over the last 2 months. A 7.2 × 10.2 cm intramural tumour was found extending from the right atrium to the right ventricle. It was considered that the tumour could cause sudden death due to its size and extension. Therefore, surgical debulking with biopsy and valve repair was done. Cytology examination from the resected specimen demonstrated diffuse large B-cell lymphoma non-germinal centre B-cell like type. He was discharged 2 weeks after the surgery in stable condition and referred to internal medicine department for chemotherapy. However, he chose palliative home care and died 44 days after surgery.

DISCUSSION

In cases of PCL with concerning tumour size and symptoms due to cardiac obstruction, early surgical debulking could improve haemodynamics, prevent sudden death, and confirm immunopathological diagnosis needed in determining further chemotherapy, which is proven to improve survival.

[Robotic surgery versus conventional open chest surgery for heart tumor: a propensity score matching analysis]

OBJECTIVE

To compare conventional open chest surgery and robotic surgery for their efficacy, short?term outcomes and patient selection in the treatment of heart tumors. Method The clinical data were collected from 225 patients (a total of 228 operations) who underwent cardiac neoplasm resection in our hospital between January, 1993 and April, 2016. A propensity score matching (PSM) was established according to the vital baseline data of the patients receiving conventional open chest surgery (n=125) and robotic surgery (n=60) after screening. The patients were matched for propensity into 60 pairs, and the efficacy, short?term outcomes and patient selection were compared between the two groups.

RESULTS

Before PSM, the patients in conventional surgery group had significantly greater tumor size (P<0.001) and a higher proportion of patients with New York Heart Association functional class III and IV (P<0.001). The patients' baseline data were nearly balanced (P=0.982) between the two groups after matching. No significant differences were found between the two groups in cardiopulmonary bypass time (P=0.256), crossclamp time (P=0.862), in?hospital mortality (P=1.000), arrhythmia (P=1.000), delayed mechanical ventilation (>24 h; P=0.209), thoracic complications (P=0.611) or systemic embolism (P=1.000). The survival rates were 100% in both groups in the 6?month follow?up after the operation, and no significant difference was found between the two groups in the incidence of major adverse cardiac and cerebrovascular events within 6 months (P=0.438).

CONCLUSION

Robotic heart tumor resection has a favorable efficacy with a good short?term prognosis, and can serve as an alternative for treatment of solitary lesions in low?risk patients receiving operations for the first time.

Primary cardiac diffuse large B-cell lymphoma with concurrent high MYC and BCL2 expression in an immunocompetent Chinese elderly woman

Primary cardiac lymphoma is a rare type of extranodal lymphoma that involves only heart and/or pericardium. It is usually observed in immunodeficient people. However, immunocompetent patients may also suffer from this disease. Most primary cardiac lymphomas are of B-cell lineage, and they usually present as diffuse large B-cell lymphoma (DLBCL). Diffuse large B-cell lymphoma with concurrently high MYC and BCL2 expression, which is named as double-expressor lymphoma (DEL), is a rare subtype of DLBCL. Here we report a rare case of a primary cardiac DEL in an immunocompetent 65-year old Chinese woman. Echocardiography and magnetic resonance imaging revealed a mass of 6.6 cm×5.6 cm in the right atrium. No tumor formations were observed in other organs. Histopathologic examination showed that the cardiac tumor was diffuse large B-cell lymphoma, non-germinal center B-cell type by Hans algorithm. The tumor cells showed high MYC and BCL2 protein expression by immunohistochemistry, with high proliferative index.

Cardiac and pericardial tumors: A potential application of positron emission tomography-magnetic resonance imaging

Cardiac and pericardial masses may be neoplastic, benign and malignant, non-neoplastic such as thrombus or simple pericardial cysts, or normal variants cardiac structure can also be a diagnostic challenge. Currently, there are several imaging modalities for diagnosis of cardiac masses; each technique has its inherent advantages and disadvantages. Echocardiography, is typically the initial test utilizes in such cases, Echocardiography is considered the test of choice for evaluation and detection of cardiac mass, it is widely available, portable, with no ionizing radiation and provides comprehensive evaluation of cardiac function and valves, however, echocardiography is not very helpful in many cases such as evaluation of extracardiac extension of mass, poor tissue characterization, and it is non diagnostic in some cases. Cross sectional imaging with cardiac computed tomography provides a three dimensional data set with excellent spatial resolution but utilizes ionizing radiation, intravenous iodinated contrast and relatively limited functional evaluation of the heart. Cardiac magnetic resonance imaging (CMR) has excellent contrast resolution that allows superior soft tissue characterization. CMR offers comprehensive evaluation of morphology, function, tissue characterization. The great benefits of CMR make CMR a highly useful tool in the assessment of cardiac masses. (Fluorine 18) fluorodeoxygluocse (FDG) positron emission tomography (PET) has become a corner stone in several oncological application such as tumor staging, restaging, treatment efficiency, FDG is a very useful imaging modality in evaluation of cardiac masses. A recent advance in the imaging technology has been the development of integrated PET-MRI system that utilizes the advantages of PET and MRI in a single examination. FDG PET-MRI provides complementary information on evaluation of cardiac masses. The purpose of this review is to provide several clinical scenarios on the incremental value of PET and MRI in the evaluation of cardiac masses.

Primary intimal sarcoma of the left atrium presenting with constitutional symptoms

Intimal (spindle-cell) sarcomas are exceptionally rare and are highly aggressive cardiac tumors. The authors describe a case of a 43-year-old female, presenting with a 3-month history of constitutional symptoms with fever, night sweats, anorexia and weight loss, associated with productive cough and pleural effusion that was admitted with clinical suspicion of pulmonary tuberculosis. The patient developed sudden acute heart failure symptoms during hospitalization, leading to mechanical ventilation. Computed tomography scan with contrast showed a cardiac tumor filling the left atrium causing compression of pulmonary veins. Surgical resection was performed and histologic examination revealed an intimal sarcoma. Although commenced on adjuvant chemotherapy, local tumor recurrence occurred with pericardium invasion. The patient died within 4 months of initial diagnosis. This report aims to describe an unusual presentation of this rare disease entity, and to discuss its highly aggressive clinical course.

Surgical Experience of Primary Cardiac Tumor: Single-Institution 23-Year Report

Background

Primary cardiac tumors are rare but have favorable surgical prognosis. Previous studies have been small series studies with limited surgical approaches. To date, few studies have examined the clinical features associated with different surgical procedures.

Material/Methods

In a search of the cardiovascular surgery database of our institution, we retrospectively identified 225 patients who had cardiac tumor resection from January 1993 to May 2016. The patients’ clinical characteristics and operation information were reviewed, and the operation parameters, postoperative complications, and short-term prognosis among robotic, mini-thoracotomy, and conventional procedures in our center were compared.

Results

A total of 228 operations were performed, including 156 traditional open surgeries (68.4%), 60 robotically assisted neoplasm resections (26.3%), and 12 mini-thoracotomy procedures (5.3%). Among 232 lesions, myxoma (94.8%) was the most common neoplasm, and the remainders were fibroma (1.3%) and lipoma (0.9%). Operative complications occurred in 36 patients (15.8%). Arrhythmia (8.8%) was the first common complication, and delayed mechanical ventilation (4.8%) ranked second. The overall risk of recurrence of myxoma was 2.7%. The cardiopulmonary bypass (CPB) time in the mini-thoracotomy group was longer than in the robotic group (p=0.034) and the conventional group (p=0.002). There were no significant differences in cross clamp time (p=0.266) or complications (p=0.835) among the three groups. The in-hospital survival rate was 100% in all patients. There were no significant differences in main adverse events among the three groups at six-month follow-up (p=0.285).

Conclusions

Prognosis for cardiac neoplasm surgical resection is favorable for primary cardiac tumors. The minimally invasive surgery of cardiac tumor resection can be an alternative to conventional operations in selected patients.

Complete Resolution of Tumor Burden of Primary Cardiac Non-Hodgkin's Lymphoma

Primary cardiac tumors are a rare set of benign and malignant neoplasms found in the heart or pericardium. We describe a patient presenting with nonspecific symptoms and ultimately diagnosed with primary cardiac non-Hodgkin's lymphoma (PCL). Our patient had extensive tumor in the right ventricle, which extended into the right atrium and right ventricular outflow tract. The tumor also encased the right coronary artery, which manifested as ischemic changes on EKG and cardiac MRI. The patient was treated with chemotherapy and achieved complete remission, with dramatic and full resolution of the mass on repeat echocardiography in nine weeks. More studies are needed to understand the optimal management and prognosis of patients with PCL.

A potential concomitance of papillary fibroelastoma in the case with cardiac myxoma

An 84-year-old woman was referred to our hospital with a suspected cardiac tumor detected by transthoracic echocardiography performed as a preoperative examination of gastric cancer. In addition to a tumor in the left atrium, we found on cardiac ultrasound a 15-mm mobile tumor that adhered to the aortic valve. Gross findings and histological examination confirmed that the tumor in the left atrium was a cardiac myxoma, and that the tumor adhered to the aortic valve was a papillary fibroelastoma. We experienced a rare case where preoperative examination before gastrectomy accidentally revealed concomitant cardiac tumors.

Primary cardiac diffuse large B-cell lymphoma in immunocompetent patients: clinical, histologic, immunophenotypic, and genotypic features of 3 cases

Primary cardiac lymphoma (PCL) is a rare extranodal lymphoma that involves only the heart and/or pericardium. Primary cardiac lymphoma is much less common in immunocompetent patients compared with those who are immunosuppressed. Patients with PCL have variable clinical manifestations that may lead to misdiagnosis and delay in treatment. Modern radiologic imaging now allows for earlier detection of these tumors. This study describes the clinical, histologic/cytologic, immunophenotypic, and molecular genetic findings for 3 immunocompetent patients with primary cardiac diffuse large B-cell lymphoma. All 3 patients had different initial clinical presentations. The neoplastic cells in all 3 cases were large in size, morphologically resembling diffuse large B-cell lymphoma. Neoplastic cells in 2 cases had non-germinal center (GC)-like (non-GC-like) and 1 case had GC-like immunophenotype. Neoplastic cells in all 3 cases showed C-MYC and BCL2 immunohistochemical protein coexpression. Neoplastic cells in 1 case showed double-hit MYC and BCL2 gene rearrangements, whereas another 1 case showed MYC gene rearrangement without BCL2 gene rearrangement. Epstein-Barr virus-encoded RNA was negative in the neoplastic cells in all 3 cases. All 3 patients received rituximab-based chemotherapy. Two patients subsequently had disease relapse at other extranodal sites at 10 and 24 months, respectively, whereas 1 patient was alive without disease at 9 months after diagnosis. If there is sufficient diagnostic tissue in these rare tumors, molecular studies should ideally be performed for prognostication and further patient management.

Factors affecting in-hospital mortality and likelihood of undergoing surgical resection in patients with primary cardiac tumors

BACKGROUND

Previous studies on primary cardiac tumors were mainly based on small case series collected from a limited number of institutions. Contemporary data of patients with primary cardiac tumors treated with or without surgery in a nationwide clinical setting are limited.

METHODS

Using the Diagnosis Procedure Combination database, we retrospectively identified 1317 patients hospitalized with a primary cardiac tumor (1023 myxomas, 63 non-myxomas, 72 sarcomas, 41 malignant lymphoma, 118 unspecified tumors) at 486 hospitals in Japan from July 2010 to March 2013. The outcome was overall in-hospital mortality, defined as in-hospital death occurring during the initial hospitalization or during rehospitalization. We examined the associations of baseline factors with overall in-hospital mortality and undergoing surgical resection using multivariable logistic regression analyses.

RESULTS

Overall, 914 (69.4%) patients underwent surgery and 403 (30.6%) did not. The surgery group was younger (median age, 67 years vs. 71 years, p<0.001) and was more likely to be treated at an academic hospital (38.9% vs. 27.8%, p<0.001) than the no-surgery group. The surgery group also had a higher Barthel index and a higher conscious level and showed a lower frequency of extracardiac malignancies than the no-surgery group. The likelihood of undergoing surgery was associated with coexisting cerebral infarction [adjusted odds ratio (95% confidence interval), 1.96 (1.23-3.12)] and academic hospital [1.58 (1.20-2.09)]. Patients with lower Barthel index and coexisting extracardiac malignancies were less likely to undergo surgery. Overall in-hospital mortality was 2.1% and 13.4% in the surgery and non-surgery groups, respectively. Older age, lower Barthel index, lower consciousness level, coexisting metastatic extracardiac malignancy [2.95 (1.24-7.01)], and sarcoma [21.04 (8.28-53.42)] were associated with higher overall in-hospital mortality, while academic hospital [0.41 (0.20-0.84)] and surgical resection [0.39 (0.20-0.74)] were associated with lower mortality.

CONCLUSIONS

Several background factors were associated with prognosis and surgery in patients hospitalized with primary cardiac tumors.