Evaluation and Management of Cardiac Tumors. Curr Treat Options Cardiovasc Med. 2018;20:29. [PMID: 29556752 DOI: 10.1007/s11936-018-0625-z]

Case Report: Assessment of primary myxofibrosarcoma in the left atrium using multimodal ultrasonography

Primary myxofibrosarcoma of the heart, a rare cardiac malignancy, was diagnosed in a middle-aged female patient exhibiting progressive dyspnea following transthoracic echocardiography and pathological analysis. Postoperatively, the patient underwent chemotherapy and Lenvatinib mesylate therapy, with regular check-ups confirming her survival. After 10 months the patient is still alive and well.

Isolated primary cardiac angiosarcoma

Cardiac angiosarcoma (CAS) is the most prevalent malignant primary cardiac tumor in adults, often affecting young males. We present a case of this rare entity in a young female, highlighting the multidisciplinary team's role and multimodality imaging in the diagnosis and management.

Primary Cardiac Intimal Sarcoma: Multi-Layered Strategy and Core Role of MDM2 Amplification/Co-Amplification and MDM2 Immunostaining

Primary cardiac tumours are relatively uncommon (75% are benign). Across the other 25%, representing malignant neoplasia, sarcomas account for 75-95%, and primary cardiac intimal sarcoma (PCIS) is one of the rarest findings. We aimed to present a comprehensive review and practical considerations from a multidisciplinary perspective with regard to the most recent published data in the specific domain of PCIS. We covered the issues of awareness amid daily practice clinical presentation to ultra-qualified management in order to achieve an adequate diagnosis and prompt intervention, also emphasizing the core role of MDM2 immunostaining and MDM2 genetic analysis. An additional base for practical points was provided by a novel on-point clinical vignette with MDM2-positive status. According to our methods (PubMed database search of full-length, English publications from January 2021 to March 2023), we identified three studies and 23 single case reports represented by 22 adults (male-to-female ratio of 1.2; male population with an average age of 53.75 years, range: 35-81; woman mean age of 55.5 years, range: 34-70) and a 4-year-old child. The tumour-related clinical picture was recognized in a matter of one day to ten months on first admission. These non-specific data (with a very low index of suspicion) included heart failure at least NYHA class II, mitral regurgitation and pulmonary hypertension, acute myocardial infarction, ischemic stroke, obstructive shock, and paroxysmal atrial fibrillation. Awareness might come from other complaints such as (most common) dyspnoea, palpitation, chest pressure, cough, asthenia, sudden fatigue, weakness, malaise, anorexia, weight loss, headache, hyperhidrosis, night sweats, and epigastric pain. Two individuals were initially misdiagnosed as having endocarditis. A history of prior treated non-cardiac malignancy was registered in 3/23 subjects. Distant metastasis as the first step of detection (n = 2/23; specifically, brain and intestinal) or during follow-up (n = 6/23; namely, intestinal, brain and bone, in two cases for each, and adrenal) required additional imagery tools (26% of the patients had distant metastasis). Transoesophageal echocardiography, computed tomography (CT), magnetic resonance imagery, and even 18F-FDG positronic emission tomography-CT (which shows hypermetabolic lesions in PCIS) represent the basis of multimodal tools of investigation. Tumour size varied from 3 cm to ≥9 cm (average largest diameter of 5.5 cm). The most frequent sites were the left atrium followed by the right ventricle and the right atrium. Post-operatory histological confirmation was provided in 20/23 cases and, upon tumour biopsy, in 3/23 of them. The post-surgery maximum free-disease interval was 8 years, the fatal outcome was at the earliest two weeks since initial admission. MDM2 analysis was provided in 7/23 subjects in terms of MDM2-positive status (two out of three subjects) at immunohistochemistry and MDM2 amplification (four out of five subjects) at genetic analysis. Additionally, another three studies addressed PCISs, and two of them offered specific MDM2/MDM2 assays (n = 35 patients with PCISs); among the provided data, we mention that one cohort (n = 20) identified a rate of 55% with regard to MDM2 amplification in intimal sarcomas, and this correlated with a myxoid pattern; another cohort (n = 15) showed that MDM2-positive had a better prognostic than MDM2-negative immunostaining. To summarize, MDM2 amplification and co-amplification, for example, with MDM4, CDK4, HMGA3, CCND3, PDGFRA, TERT, KIT, CCND3, and HDAC9, might improve the diagnosis of PCIS in addition to MDM2 immunostaining since 10-20% of these tumours are MDM2-negative. Further studies are necessary to highlight MDM2 applicability as a prognostic factor and as an element to be taken into account amid multi-layered management in an otherwise very aggressive malignancy.

Echocardiographic Findings of Malignant Lymphoma with Cardiac Involvement: A Single-center Retrospective Observational Study

Objective Although malignant lymphoma (ML) can occur in every organ, diagnosing cardiac involvement without cardiac manifestations is difficult. We therefore investigated the incidence of cardiac involvement in ML in our hospital and clarified the transthoracic echocardiography (TTE) findings of cardiac involvement. Methods Patients with ML referred to our hospital between January 2013 and December 2019 were retrospectively reviewed. Patients During the study period, 453 patients were identified. The mean age was 64.9 years old, and 54% of the patients were men. Results Diffuse large B-cell lymphoma (DLBCL) was the most common lymphoma, followed by follicular lymphoma. Of the 453 patients, 394 (87.0%) underwent TTE at the initial diagnosis or during the clinical course. The performance rates of TTE in DLBCL, Hodgkin lymphoma, and mantle cell lymphoma were above 90%. Cardiac involvement was detected in 6 (five with DLBCL and one with B-cell lymphoma) (1.5%) of the 394 patients who underwent TTE. The involved lesions of the heart varied, and five patients had pericardial effusion. Five patients had a preserved left ventricular ejection fraction. All patients were treated with chemotherapy, and some were treated with radiation and surgery. Conclusion Cardiac involvement was observed in six (1.5%) of the patients with ML who underwent TTE. B-cell lymphoma, especially DLBCL, is a common ML with cardiac involvement. Although five patients had pericardial effusion, the involved lesions of the heart were not uniform. TTE is a useful imaging modality to noninvasively and repeatedly evaluate the tumor characteristics, response to ML treatment, and cardiac function.

Multimodality Imaging in the Evaluation and Management of a Right Atrial Mass

•Primary cardiac tumors are mostly cardiac myxomas but rarely present in the RA. •Multimodality imaging can help characterize cardiac masses and guide management. •CMR with a comprehensive protocol provides valuable diagnostic information.

Case Report: A long-term survival case of diffuse large B-cell lymphoma with left ventricular infiltration and spinal cord compression

Background

Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin lymphoma and may occur with lymph node and/or extranodal involvement. However, DLBCL with intracardiac mass is exceedingly rare. In the reported literature, the intracardiac infiltration of DLBCL mostly involves the right ventricle. Lymphoma that invades the heart has an aggressive nature, with symptoms that are easily ignored initially and can lead to multiple complications in severe cases, resulting in a poor prognosis. Early screening and diagnosis may significantly improve the survival rate. Early diagnosis may significantly improve outcomes.

Case summary

We presented a 68-year-old woman with back pain. PET/CT suggested increased FDG metabolism in the left ventricle, right adrenal gland, right erector spinae intramuscularis, multiple bones and multiple lymph nodes. Contrast-enhanced ultrasound showed a left ventricular apical mass with ventricular septum thickening. Cardiac MRI suggested a 1.6*1.1*2.1 cm mass in the apical-central portion of the left ventricle. Biopsy of the right neck mass confirmed the pathologic diagnosis of diffuse large B-cell lymphoma. However, before the pathologic diagnosis was confirmed, the patient was paralyzed due to spinal cord compression caused by the progression of bone metastases. Subsequently, pathology confirmed the diagnosis of diffuse large B-cell lymphoma, and rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) was treated immediately as first-line therapy. In addition, glucocorticoids and mannitol dehydration were administered to relieve the symptoms of spinal cord compression. After 8 cycles of R-CHOP, the tumor at all sites had almost complete regression. The patient was able to walk normally and had no tumor-related symptoms.

Conclusions

We present a case of DLBCL with a very high tumor load that involved multiple organs, including the left ventricle, but exhibited no cardiac-related symptoms. The combination of various imaging modalities is valuable for the diagnosis of cardiac infiltration. The mass in the left ventricle almost completely regressed after R-CHOP treatment, and no recurrence has occurred in the 5 years of follow-up so far.

Imaging of pediatric cardiac tumors: A COG Diagnostic Imaging Committee/SPR Oncology Committee White Paper

Cardiac tumors in children are rare and the majority are benign. The most common cardiac tumor in children is rhabdomyoma, usually associated with tuberous sclerosis complex. Other benign cardiac masses include fibromas, myxomas, hemangiomas, and teratomas. Primary malignant cardiac tumors are exceedingly rare, with the most common pathology being soft tissue sarcomas. This paper provides consensus-based imaging recommendations for the evaluation of patients with cardiac tumors at diagnosis and follow-up, including during and after therapy.

Cardiac computed tomographic imaging in cardio-oncology: An expert consensus document of the Society of Cardiovascular Computed Tomography (SCCT). Endorsed by the International Cardio-Oncology Society (ICOS)

Cardio-Oncology is a rapidly growing sub-specialty of medicine, however, there is very limited guidance on the use of cardiac CT (CCT) in the care of Cardio-Oncology patients. In order to fill in the existing gaps, this Expert Consensus statement comprised of a multidisciplinary collaboration of experts in Cardiology, Radiology, Cardiovascular Multimodality Imaging, Cardio-Oncology, Oncology and Radiation Oncology aims to summarize current evidence for CCT applications in Cardio-Oncology and provide practice recommendations for clinicians.

Lipomatous Atrial Septal Hypertrophy, an Unexpected Giant Interatrial Mass: A Case Report and Literature Review

Lipomatous atrial septal hypertrophy (LASH) is a histological cardiac benign lesion finding with high prevalence in healthy population, usually detected during imaging procedures for other indications. Nevertheless, it could become clinically significant if it compromises venous return and diastolic left ventricular filling, up to becoming an anatomical substrate for atrial tachyarrhythmias. We present a case of LASH diagnosed in a 54-year-old female patient admitted to our emergency department after ground fall and collateral finding of positive blood cultures leading to transesophageal echocardiography. A giant mass involving the interatrial septum was observed, in the absence of primitive neoplasia evidence after performing a total-body computed tomography scan and abdominal echography. No signs or symptoms of pulmonary venous congestion were observed, and no relevant tachyarrhythmias were detected at continuous electrocardiogram monitoring during the hospitalization period.

Cardiac lymphoma with early response to chemotherapy: A case report and review of the literature

Cardiac tumors are rare and benign masses account for the most part of the diagnosis. When malignant cancer is detected, primary or secondary cardiac lymphoma are quite frequent. Cardiac lymphoma may present as an intra or peri-cardiac mass or, rarely, it may diffusely infiltrate the myocardium. Although often asymptomatic, patients can have non-specific symptoms. Acute presentations with cardiogenic shock, unstable angina, or acute myocardial infarction are also described. Modern imaging techniques can help the clinicians not only in the diagnostic phase but also during administration of chemotherapy. A multidisciplinary counseling and serial multi-parametric assessment (echocardiography, cardiac troponin) seem to be the most effective approach to prevent possible fatal complications (i.e., cardiac rupture). Currently, only chemo- and radiotherapy are available options for treatment, but the prognosis remains poor. This is a case of secondary cardiac lymphoma presenting as a mediastinal mass with large infiltration of the heart and the great vessels with a good improvement after only one cycle of chemotherapy. It demonstrates the importance of an early diagnosis to modify the natural history of the disease.

Advances in Multimodality Imaging in Cardio-Oncology: JACC State-of-the-Art Review

The population of patients with cancer is rapidly expanding, and the diagnosis and monitoring of cardiovascular complications greatly rely on imaging. Numerous advances in the field of cardio-oncology and imaging have occurred in recent years. This review presents updated and practical approaches for multimodality cardiovascular imaging in the cardio-oncology patient and provides recommendations for imaging to detect the myriad of adverse cardiovascular effects associated with antineoplastic therapy, such as cardiomyopathy, atherosclerosis, vascular toxicity, myocarditis, valve disease, and cardiac masses. Uniquely, we address the role of cardiovascular imaging in patients with pre-existing cardiomyopathy, pregnant patients, long-term survivors, and populations with limited resources. We also address future avenues of investigation and opportunities for artificial intelligence applications in cardio-oncology imaging. This review provides a uniform practical approach to cardiovascular imaging for patients with cancer.

Primary cardiac sarcoma presenting with easy bruising: a case report

Background

Primary cardiac sarcomas are rare, aggressive types of malignancies with poor prognoses and can rarely present with thrombocytopenia. Sarcomas account for 65% of primary malignant cardiac tumours. Clinical symptoms often present with constitutional symptoms such as shortness of breath, weight loss, and fatigue. In addition, the tumour’s location determines treatment options and prognosis. Multimodal imaging facilitates the detection and assessment of cardiovascular tumours. This case study presents a rare primary right heart cardiac sarcoma presenting with thrombocytopenia.

Case summary

An 80-year-old male presented to the emergency department with complaints of worsening dyspnoea, ease of bruising, and chest pain. An extensive investigation into the cause of thrombocytopenia was performed. A transthoracic echocardiogram, computed tomography scan, and cardiac magnetic resonance (CMR) image revealed a large mass affecting the right atrium and right ventricle. Myocardial biopsy showed high-grade angiosarcoma. Due to his advanced age and intraventricular septal involvement of the mass, the multidisciplinary team decided to proceed with palliative chemotherapy.

Discussion

Many cardiac tumours remain asymptomatic, and the diagnosis is made at an advanced stage of the disease. Differential diagnoses of the intramural masses include haemangiomas, lipomas, rhabdomyomas, lymphomas, and sarcomas. Multiple treatment options should be considered to address thrombocytopenia. Tumour diagnosis and identification consist of laboratory tests and multimodal imaging. Complete surgical resection with neoadjuvant and adjuvant purposes is the mainstay of cardiac sarcoma therapy. A multidisciplinary, individualized care approach should be performed.

Genetic insights into cardiac tumors: a comprehensive review

Cardiac neoplasms are rare, however, also a curable form of the disease once detected early. In recent years the viscus tumors have gained their highlights, due to the advancement in techniques like echocardiography both 2D and 3D, MRI, etc. These cardiac tumors are divided based on their benign and malignant nature and also as well as primary and secondary cardiac tumors. Largely the primary cardiac tumors are often than secondary cardiac tumors. The secondary tumor happens anywhere in the body involving the heart. The most common malignant tumors are sarcoma, some are angiosarcomas, fibromas, rhabdosarcoma, and leiomyosarcoma. The primary sarcoma affects both men and women at an equal rate with non-specific symptoms. These conditions led to high demand in genomic testing that helps in spot the mutation that leads to the particular type of cardiac neoplasm and it additionally helps to screen the mutated sequence and stop it from being inherited. Recent studies on cardiac tumors have revealed many genes that are involved in tumorigenesis and technologies have enabled the right screening of the tumor location within the heart and their histopathological studies were also studied. This review principally focuses on the understanding of the various forms of cardiac tumors, genetic variants involved and their influence, genetic testing, and different diagnostic approaches in cardiac tumors.

Percutaneous ultrasound-guided core needle biopsy for the diagnosis of cardiac tumors: Optimizing the treatment strategy for patients with intermural and pericardial cardiac tumors

Objective

The aims of this study are to investigate the clinical value and practical safety of ultrasound-guided percutaneous core needle biopsy on diagnosing cardiac tumor and to discuss the treatment strategy for cardiac intermural and pericardial tumors.

Methods

The clinical data were retrospectively collected for patients with intermural and pericardial cardiac tumors. The patients were divided into groups of surgical resection, surgical resection after obtaining pathological tissue by PUS-CNB, and/or radiotherapy according to the treatment modality. Ultrasound-guided aspiration biopsy was divided into cardiac tumor biopsy and extracardiac lesion biopsy according to patient conditions. The surgical time was recorded, and the safety and clinical application value of PUS-CNB for the diagnosis of cardiac tumors were evaluated in terms of complications and satisfaction with pathological sampling.

Results

A total of 18 patient cases were collected, and PUS-CNB of cardiac tumors was performed in 8 cases, with sampling times averaging 15.6 ± 3.0 min. Four cases of cardiac tumors combined with extracardiac tumors were biopsied, with puncture times averaging 13.0 ± 2.9 min. All 12 biopsied patients had no postoperative complications. Except for 1 failed biopsy, the biopsies were successful and the pathological results were consistent with the clinical diagnosis with a satisfaction rate of 91.7%. Except for two cases of surgical resection, the rest were considered for conservative treatment. Surgical resection and/or biopsy were performed in six cases, and two cases were aggravated after surgery. The final pathology of all 17 cardiac tumors was malignant.

Conclusion

PUS-CNB is safe and effective, providing a simple and undemanding method for accurate diagnosis of cardiac intermural and pericardial tumors while avoiding unnecessary open-heart surgery.

Cardiac Rhabdoid Tumor—A Rare Foe—Case Report and Literature Review

Intracardiac masses are unusual findings in infants, and most of them are benign. Nevertheless, they may be associated with a significant degree of hemodynamic instability and/or arrhythmias. Malignant tumors of the heart rarely occur in children. Rhabdoid tumors are aggressive tumors with a dismal prognosis even when diagnosed early. Although rhabdomyomas are common cardiac tumors in infants, they are mostly benign. The most common sites of involvement are the kidneys and central nervous system, but soft tissues, lungs, and ovaries may also be affected. The diagnosis can be challenging, particularly in sites where they do not usually occur. In the present paper, we report the case of a 2-year-old boy diagnosed with cardiac rhabdoid tumor highlighting the importance of molecular studies and recent genetic discoveries with the purpose of improving the management of such cases. The aim of this educational case report and literature review is to raise awareness of cardiac masses in children and to point out diagnostic hints toward a cardiac tumor on various imaging modalities. Given the rarity of all tumors involving the heart and the lack of symptom specificity, a high degree of suspicion is needed to arrive at the correct diagnosis.

A riddle yet unsolved: two case reports of primary cardiac sarcoma

Primary malignant cardiac tumors are exceedingly rare and dangerous, often leading to very early death after initial symptom presentation. Each case poses a unique challenge, as no standardized practice guidelines have been developed due to their sheer rarity. Surgical excision and adjuvant therapy remain the mainstays of treatment. However, resection is impeded by the unique challenges of cardiac surgery and growth characteristics of the tumors, both contributing to high rates of recurrence. We present two cases of successfully treated primary cardiac sarcoma with survival rates exceeding expectations.

Diagnosis of cardiac occupancy as metachronous carcinoma using multimodal imaging: a case report

Background

Metachronous carcinoma presenting as a cardiac malignancy is rare, and timely diagnosis is critical. We report a patient with a primary cardiac tumor who eventually died and performed an imaging-related literature review.

Case presentation

A 68-year-old Chinese male patient, who had suffered from multiple malignancies, was suddenly found to have severely reduced platelets and symptoms of decreased cardiac function. After undergoing a series of imaging examinations such as transthoracic echocardiography and positron emission tomography-computed tomography, he was found to have a large occupancy within the right heart and was finally diagnosed with a primary cardiac malignancy. Combined with the patient's previous medical history, it was judged that this time it was a metachronous carcinoma. The patient was unable to accept the risk of surgery and eventually died.

Conclusion

This is a case report reporting a cardiac malignancy. This case highlights the importance of using multiple imaging modalities to make a common diagnosis and the need for more detailed evaluation in patients with metachronous carcinoma.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-022-02645-2.

Cardiac Computed Tomography in Cardio-Oncology: JACC: CardioOncology Primer

Cancer patients and survivors have elevated cardiovascular risk when compared with noncancer patients. Cardio-oncology has emerged as a new subspecialty to comanage and address cardiovascular complications in cancer patients such as heart failure, atherosclerotic cardiovascular disease (ASCVD), valvular heart disease, pericardial disease, and arrhythmias. Cardiac computed tomography (CT) can be helpful in identifying both clinical and subclinical ASCVD in cancer patients and survivors. Radiation therapy treatment planning CT scans and cancer staging/re-staging imaging studies can quantify calcium scores which can identify pre-existing subclinical ASCVD. Cardiac CT can be helpful in the evaluation of cardiac tumors and pericardial diseases, especially in patients who cannot tolerate or have a contraindication to cardiac magnetic resonance. In this review, we describe the optimal utilization of cardiac CT in cancer patients, including risk assessment for ASCVD and identification of cancer treatment-related cardiovascular toxicity.

Multimodal echocardiography in the diagnosis of masses localized to the proximal portions of pulmonary arteries

Proximal pulmonary artery masses are exceedingly rare, and their diagnosis and therapy are important and challenging for clinicians. This study reviews our experience exploring the value of a combination of transthoracic echocardiography and contrast echocardiography for the differential diagnosis of proximal pulmonary artery masses. Between January 2018 and June 2021, 44 patients diagnosed with a mass attached to the major pulmonary artery and straddling the bilateral pulmonary arteries or pulmonary valve on transthoracic echocardiography were referred to this study. Contrast echocardiography was performed in 17 patients. Masses were diagnosed based on their site of attachment, shape, size, mobility, hemodynamic consequences on transthoracic echocardiography, and tissue perfusion on contrast echocardiographic perfusion imaging. Pathological data were collected from medical records and analyzed. The most frequent location of proximal pulmonary artery masses was the major pulmonary artery trunk. Twelve patients underwent complete mass resection, whereas nine patients underwent percutaneous pulmonary artery biopsy puncture and had a pathological diagnosis. Another 24 patients were confirmed with the validation methods. Contrast echocardiography has good sensitivity and specificity for differentiating thrombi from pulmonary artery sarcomas (PAS). The mass types were distributed as follows: thrombi (19, 43%), PAS (15, 34%), metastatic tumors (6, 14%), vegetations (3, 7%), and primary benign lesions (1, 2%). The majority of proximal pulmonary artery masses were thrombi or PAS. A combination of transthoracic echocardiography and contrast echocardiography offers advantages in the early identification of proximal pulmonary masses and provides clinically important information about the characteristics of masses, especially for differentiating thrombi from PAS.

Concurrent Primary Cardiac Tumors in a High-Risk Patient Presenting With Tamponade

Primary cardiac tumors are rare, particularly in the elderly population. The patient described in this report presented with symptoms of dyspnea on exertion, leg swelling, and weight gain and was found to have two histologically distinct cardiac masses: atrial myxoma with concurrent aortic fibroelastoma. Given her history of cirrhosis and end-stage renal disease, the patient was a poor surgical candidate but opted for excision of both masses. The patient eventually succumbed to her cirrhosis six weeks after presentation. In this report, we advocate for further research into medical management for the unique presentation of concurrent primary cardiac tumors in high-operative-risk patients, particularly those whose symptoms are mostly due to tamponade.

Discovery of Tricuspid Fibroelastoma on Echocardiography

Papillary fibroelastoma (PFE) is a benign cardiac tumor usually incidentally found on cardiac imaging. They are typically located on the left-sided heart valves and are concerning primarily due to their risk for embolization into the periphery. Right-sided PFE, however, is very rare and their management is not well known. We present a 66-year-old male with a past medical history of HIV on antiretroviral therapy presenting with new exertional dyspnea. Upon workup, he was found to have a mass on the tricuspid valve seen on echocardiography which was ultimately resected and found to be a tricuspid fibroelastoma. The clinical management of right-sided PFE is poorly documented. Treatment of PFE in an asymptomatic is dependent on characteristics such as location, mobility, and risk of embolization. Echocardiography has made the incidental diagnosis of PFE a common issue in asymptomatic patients such as ours.

Characteristics, management, and outcomes among admissions for primary cardiac tumors: Results from the National Inpatient Sample

INTRODUCTION

Primary cardiac tumors (PCT) are rare, and their contemporary outcomes are not well characterized in the literature. We assessed temporal trends in patient characteristics and management of admissions for PCT in US hospitals.

METHODS

Admissions with the principal diagnoses of a PCT (benign neoplasm of heart: ICD-9 212.7, ICD-10 D15.1; malignant neoplasm of heart: ICD-9 164.1, ICD-10 C38.0) between 2006 and 2017 were extracted from the National Inpatient Sample. Trends in demographics and clinical profiles were evaluated. We conducted descriptive analyses on the cohort and compared outcomes between those managed medically and surgically.

RESULTS

Between 2006 and 2017, 19,111 admissions had the primary diagnosis of a PCT. Of these, 91.1% were benign. Admissions were mostly female (65.0%), caucasian (72.0%), and aged more than 50 years (76.0%). The annual admission rate for PCT was similar from 2006 to 2017 (p trend > .05) and associated with congestive heart failure, diabetes, renal failure, and valvular lesions. PCTs were managed surgically in 12,811 (67.0%) of overall cases, 70.8% for benign and 28.3% for malignant tumors. Overall, the in-hospital mortality rate was 2.3%. Medically managed cases reported a 2.5% higher mortality (p < .001) than those surgically managed. Admissions with malignant tumors were more likely to expire during hospitalization than those with benign tumors (odds ratio, 9.75; 95% confidence interval 6.34-14.99; p < .001).

CONCLUSION

Admissions for primary cardiac tumors were primarily women or in their fifth or sixth decade of life. Surgical intervention is more commonly practiced and is associated with better in-hospital survival.

[Non-Hodgkin cardiac lymphomas]

Cardiac non-Hodgkin lymphoma (CNHL) is a rare extranodal lymphoma with a poor prognosis. Secondary cardiac lymphoma is more frequent than primary cardiac lymphoma. CNHL often involves the right side of the heart. Diagnosis of CNHL can be suggested by echocardiography and magnetic resonance imaging. Cytological examination of pericardial fluid or histological of cardiac tissue is essential. The majority of cases are diffuse B-cell lymphoma. A prompt immediate diagnosis and early treatment are essential for better outcome. Management should be individualized and the most effective treatment is chemotherapy containing anthracycline variably combined with radiotherapy. A multidisciplinary approach is essential to the successful treatment of CNHL.

Society for Cardiovascular Magnetic Resonance 2019 Case of the Week series

The Society for Cardiovascular Magnetic Resonance (SCMR) is an international society focused on the research, education, and clinical application of cardiovascular magnetic resonance (CMR). The SCMR web site ( https://www.scmr.org ) hosts a case series designed to present case reports demonstrating the unique attributes of CMR in the diagnosis or management of cardiovascular disease. Each clinical presentation is followed by a brief discussion of the disease and unique role of CMR in disease diagnosis or management guidance. By nature, some of these are somewhat esoteric, but all are instructive. In this publication, we provide a digital archive of the 2019 Case of the Week series as a means of further enhancing the education of those interested in CMR and as a means of more readily identifying these cases using a PubMed or similar search engine.

Cardiac Masses: The Role of Cardiovascular Imaging in the Differential Diagnosis

Cardiac masses are space occupying lesions within the cardiac cavities or adjacent to the pericardium. They include frequently diagnosed clinical entities such as clots and vegetations, common benign tumors such as myxomas and papillary fibroelastomas and uncommon benign or malignant primary or metastatic tumors. Given their diversity, there are no guidelines or consensus statements regarding the best diagnostic or therapeutic approach. In the past, diagnosis used to be made by the histological specimens after surgery or during the post-mortem examination. Nevertheless, evolution and increased availability of cardiovascular imaging modalities has enabled better characterization of the masses and the surrounding tissue. Transthoracic echocardiography using contrast agents can evaluate the location, the morphology and the perfusion of the mass as well as its hemodynamic effect. Transesophageal echocardiography has increased spatial and temporal resolution; hence it is superior in depicting small highly mobile masses. Cardiac magnetic resonance and cardiac computed tomography are complementary providing tissue characterization. The scope of this review is to present the role of cardiovascular imaging in the differential diagnosis of cardiac masses and to propose a step-wise diagnostic algorithm, taking into account the epidemiology and clinical presentation of the cardiac masses, as well as the availability and the incremental value of each imaging modality.

How to diagnose heart failure with preserved ejection fraction: the HFA-PEFF diagnostic algorithm: a consensus recommendation from the Heart Failure Association (HFA) of the European Society of Cardiology (ESC)

Making a firm diagnosis of chronic heart failure with preserved ejection fraction (HFpEF) remains a challenge. We recommend a new stepwise diagnostic process, the 'HFA-PEFF diagnostic algorithm'. Step 1 (P=Pre-test assessment) is typically performed in the ambulatory setting and includes assessment for HF symptoms and signs, typical clinical demographics (obesity, hypertension, diabetes mellitus, elderly, atrial fibrillation), and diagnostic laboratory tests, electrocardiogram, and echocardiography. In the absence of overt non-cardiac causes of breathlessness, HFpEF can be suspected if there is a normal left ventricular ejection fraction, no significant heart valve disease or cardiac ischaemia, and at least one typical risk factor. Elevated natriuretic peptides support, but normal levels do not exclude a diagnosis of HFpEF. The second step (E: Echocardiography and Natriuretic Peptide Score) requires comprehensive echocardiography and is typically performed by a cardiologist. Measures include mitral annular early diastolic velocity (e'), left ventricular (LV) filling pressure estimated using E/e', left atrial volume index, LV mass index, LV relative wall thickness, tricuspid regurgitation velocity, LV global longitudinal systolic strain, and serum natriuretic peptide levels. Major (2 points) and Minor (1 point) criteria were defined from these measures. A score ≥5 points implies definite HFpEF; ≤1 point makes HFpEF unlikely. An intermediate score (2-4 points) implies diagnostic uncertainty, in which case Step 3 (F1: Functional testing) is recommended with echocardiographic or invasive haemodynamic exercise stress tests. Step 4 (F2: Final aetiology) is recommended to establish a possible specific cause of HFpEF or alternative explanations. Further research is needed for a better classification of HFpEF.

MR-guided stereotactic body radiation therapy for intracardiac and pericardial metastases

•

Radiation is not typical in the standard of care for cardiac metastases.

•

MR-guided radiation uses real-time imaging and offers better soft tissue contrast.

•

Real-time MR-guidance allows for safe high dose radiation to cardiac metastases.

•

MR-guided stereotactic radiation can improve symptoms without acute toxicity.

Aims

To assess the safety and efficacy of MR-guided stereotactic body radiation therapy (MRgSBRT) for cardiac metastases.

Materials/methods

This single institution retrospective analysis evaluated our experience with MRgSBRT for cardiac metastases. Response rate was compared between pre-RT and post-RT imaging. Symptomatic changes were also tracked and documented.

Results

Between 4/2019 and 3/2020, five patients with cardiac metastases (4 intracardiac and 1 pericardial) were treated with MRgSBRT. Median age at treatment was 73 years (range 64–80) and two patients had pre-existing cardiac disease. Histologies included melanoma and breast adenocarcinoma. Median lesion diameter was 2 cm (range 1.96–5.8 cm). Three patients were symptomatic, one of whom had pulmonary hypertension and RV enlargement. Another patient had an asymptomatic arrythmia. Median PTV prescribed dose was 40 Gy (range 40–50 Gy) and delivered in five fractions on nonconsecutive days. Median PTV volume was 53.4 cc (range 8.7–116.6 cc) and median coverage was 95% (range 84.1–100%). A uniform 3 mm margin was used for real-time gating, allowing a median 7% (range 5–10%) pixel excursion tolerance. Median follow-up was 4.7 months (range 0.9–12.3). Two patients exhibited stable disease, two had a partial response and one exhibited a complete response. All symptomatic patients experienced some relief. There were no acute adverse events, however, one patient without prior cardiac disease developed atrial fibrillation 6 months after treatment. Two patients died of causes unrelated to cardiac MRgSBRT.

Conclusion

In this largest known series of cardiac metastasis MRgSBRT, real-time image guidance enables safe treatment resulting in good response with improving presenting symptoms without acute adverse events.

The challenge in diagnosing cardiac tumors to avoid unnecessary cardiac surgery

Cardiac magnetic resonance in cardiac mass: Cardiac magnetic resonance (CMR) should be considered in the evaluation of patients with cardiac mass. Especially, when the diagnosis is not certain, CMR could provide paramount information that could be helpful for the decision on cardiac surgery.

Cardiac Tumors: JACC CardioOncology State-of-the-Art Review

Cardiac masses are rare, but remain an important component of cardio-oncology practice. These include benign tumors, malignant tumors (primary and secondary) and tumor-like conditions (e.g., thrombus, Lambl’s excrescences, and pericardial cyst). The advent of multimodality imaging has enabled identification of the etiology of cardiac masses in many cases, especially in conjunction with information from clinical settings. This paper provides a comprehensive review of the epidemiology, clinical presentation, imaging, diagnosis, management, and outcomes of cardiac masses.

•

Cardiac tumors are rare and should be considered as part of the differential diagnosis of any space-occupying mass noted on cardiovascular and/or thoracic imaging modalities.

•

It may be possible to get close to a diagnosis without biopsy using a structured imaging approach.

•

The prognosis and treatment of each tumor is different, although early diagnosis is usually associated with a better outcome.

Cardiac tumors invading the right ventricle; Aggressive Surgical Management with backup mechanical circulatory support if necessary

BACKGROUND

Primary cardiac tumors are exceedingly rare. Amongst the malignant types, sarcomas are the most frequently encountered. Treatment includes attempted aggressive surgical resection as the only curative option. We report our experience.

METHODS

During the last five years, six patients presented at our institution with complex cardiac tumors with different underlying diagnoses and were at different stages of their disease.

RESULTS

6 patients with median age of 30-years-old underwent surgery in our centre. 3 patients had undergone debulking prior to surgery at our institution. In all patients, the tumor involved the right ventricle. One patient had biventricular involvement, the septum was involved in 4 patients, 2 patients had extracardiac growth, one invading both great vessels, one involving the pericardium and the hilar structures on the right side. Complete resection was achieved in 4 cases, 3 with successful resection-reconstruction, one with cardiectomy and implantation of a total artificial heart. 5 patients are currently alive, 4 free of recurrence.

CONCLUSIONS

Complete radical surgery is the only curative treatment for patients suffering from cardiac tumors. The availability of mechanical circulatory support allows for a more radical surgical approach even including total cardiectomy, possibly resulting in a significant increase in R0 resections.

Cardiac tumors prevalence and mortality: A systematic review and meta-analysis

OBJECTIVES

Cardiac tumors and their associated outcomes are poorly characterized. This study sought to comprehensively assess the epidemiology and natural history of primary and secondary malignant cardiac tumors (PMCT and SMCT), a well as establish predictors of mortality.

METHODS

A comprehensive literature review was performed to identify articles reporting on PMCTs and SMCTs. The prevalence of important cardiac tumor (CT) subtypes was evaluated and further stratified based on the continental region. Outcomes of interest included short- and long-term mortality and utilization of heart transplantation (HTX). A random effect model was adopted, and a meta-regression was performed to determine predictors of the prevalence of CTs as well as predictors of operative mortality.

RESULTS

Of the 1,226 retrieved articles, 74 were included in our study (n = 8,849 patients). The mean follow-up was 2.27 years, mean age was 42.9 years, and 55% of the patients were females. There was a total number of 7,484 benign primary cardiac tumors (PCTs) (5,140 were myxoma), 862 (9.7%) malignant PCTs, and 355 secondary cardiac tumors. The prevalence of PMCTs among PCTs was 10.83% [95%CI = 09.11; 12.83%] with a trend towards being lower in South America compared to other continents (Prevalence = 5.80%). The prevalence of HTX among all patients was 2.45% [1.36; 4.38%]. The pooled short-term mortality was 5.90% [4.70; 7.39%] and the incidence of late mortality in all CTs, benign CT and PMCTs was 2.55% [1.76; 3.72%], 0.79% [0.46; 1.37%] and 14.77% [9.32; 23.40%], respectively. On meta-regression, the annual volume of cardiac tumor cases per center was the only predictor of lower early mortality (Beta = -0.14 ± 0.03, P < 0.0001).

CONCLUSIONS

PMCTs represent the minority of PCT (~10%) and have a higher prevalence in Europe and North America. Survival is higher in benign pathology and is significantly improved by treatment in specialized high-volume centers. Approximately 2% of patients with CTs undergo heart transplantation.

How to diagnose heart failure with preserved ejection fraction: the HFA-PEFF diagnostic algorithm: a consensus recommendation from the Heart Failure Association (HFA) of the European Society of Cardiology (ESC)

Making a firm diagnosis of chronic heart failure with preserved ejection fraction (HFpEF) remains a challenge. We recommend a new stepwise diagnostic process, the 'HFA-PEFF diagnostic algorithm'. Step 1 (P=Pre-test assessment) is typically performed in the ambulatory setting and includes assessment for heart failure symptoms and signs, typical clinical demographics (obesity, hypertension, diabetes mellitus, elderly, atrial fibrillation), and diagnostic laboratory tests, electrocardiogram, and echocardiography. In the absence of overt non-cardiac causes of breathlessness, HFpEF can be suspected if there is a normal left ventricular (LV) ejection fraction, no significant heart valve disease or cardiac ischaemia, and at least one typical risk factor. Elevated natriuretic peptides support, but normal levels do not exclude a diagnosis of HFpEF. The second step (E: Echocardiography and Natriuretic Peptide Score) requires comprehensive echocardiography and is typically performed by a cardiologist. Measures include mitral annular early diastolic velocity (e'), LV filling pressure estimated using E/e', left atrial volume index, LV mass index, LV relative wall thickness, tricuspid regurgitation velocity, LV global longitudinal systolic strain, and serum natriuretic peptide levels. Major (2 points) and Minor (1 point) criteria were defined from these measures. A score ≥5 points implies definite HFpEF; ≤1 point makes HFpEF unlikely. An intermediate score (2-4 points) implies diagnostic uncertainty, in which case Step 3 (F₁ : Functional testing) is recommended with echocardiographic or invasive haemodynamic exercise stress tests. Step 4 (F₂ : Final aetiology) is recommended to establish a possible specific cause of HFpEF or alternative explanations. Further research is needed for a better classification of HFpEF.

Cardiac Interventional Procedures in Cardio-Oncology Patients

Comorbidities specific to the cardio-oncology population contribute to the challenges in the interventional management of patients with cancer and cardiovascular disease (CVD). Patients with cancer have generally been excluded from cardiovascular randomized clinical trials. Endovascular procedures may represent a valid option in patients with cancer with a range of CVDs because of their minimally invasive nature. Patients with cancer are less likely to be treated according to societal guidelines because of perceived high risk. This article presents the specific challenges that interventional cardiologists face when caring for patients with cancer and the modern tools to optimize care.

Video-assisted minimally invasive resection of papillary fibroelastoma

Cardiac papillary fibroelastoma is a rare cause of embolic events, especially seen in young patients. A 38-year-old woman with a transient ischemic attack underwent cardiac diagnostic workup. Transesophageal echocardiography and magnetic resonance imaging identified a tumor on the anterior leaflet of the mitral valve as the only potential source of embolization. Video-assisted minimally invasive resection of the tumor and reconstruction of the mitral valve were performed. Postoperative transthoracic echocardiography showed no residual tumor or mitral valve insufficiency. Histology identified a papillary fibroelastoma. The patient was discharged on the 9th postoperative day in good physical condition and without any postoperative limitations.

Incidental finding of an asymptomatic pulmonary valve papillary fibroelastoma: A case report

Primary cardiac tumors are rare, but papillary fibroelastoma (PFE) is reportedly the most common form, which usually occurs on the left-side valves of the heart. However, PFE involving the tricuspid and pulmonary valves has also been documented. Although PFE is benign and seldom associated with valvular dysfunction, the associated embolic complications may lead to serious consequences. Most patients with PFE lack specific clinical symptoms and the diagnosis is incidental. Surgical resection is the mainstay treatment for PFE in order to prevent the occurrence of embolic complications. In this report, we present a case of a rare asymptomatic PFE of the pulmonary valve, which was incidentally noted during a routine examination with transthoracic echocardiography (TEE). There was neither valvular dysfunction nor hemodynamic change. The PFE was surgically removed, and the diagnosis was further confirmed with histopathology.

Multimodality Imaging in the Evaluation of Intracardiac Masses

Intracardiac masses are classified as neoplastic or non-neoplastic. Prognosis varies based on the diagnosis of the mass since treatment options differ greatly. As novel imaging techniques emerge, a multimodality approach to the evaluation of intracardiac masses becomes an important part of non-invasive evaluation prior to potential surgical planning or oncological treatment. The purpose of this article is to compare the available imaging modalities-echocardiography, cardiovascular magnetic resonance, cardiac computed tomography, nuclear imaging, and emerging novel hybrid imaging techniques for future clinical applications-and to review the characteristic features seen on those modalities for the most common intracardiac masses.

The Heart of the Matter: A Unique Convergence of Cardiac Neoplasm, Hereditary Nonpolyposis Colorectal Cancer, and Spindle Cell Sarcoma

Primary cardiac tumours are exceedingly unusual and aggressive; they often develop in younger patients and present with advanced disease. The rarity and heterogeneity of primary cardiac tumours challenge the standardisation of therapeutic guidelines. Undifferentiated primary cardiac spindle cell sarcomas, a distinct subset of primary cardiac sarcomas, are especially unique with <20 cases reported worldwide, the majority of which are of left atrial origin. This article presents a review of the aetiology, pathophysiology, and therapy of undifferentiated primary cardiac spindle cell sarcomas. In conjunction, the authors present a unique case of a woman with hereditary nonpolyposis colorectal cancer (Lynch syndrome) who presented with a primary cardiac spindle cell sarcoma of left ventricular origin; this is the first case of this type and location of cardiac tumour reported in a patient with Lynch syndrome.

Multidisciplinary approach to rare primary cardiac sarcoma: a case report and review

Background

Undifferentiated pleomorphic sarcoma is a very rare and aggressive type of primary cardiac tumors. Most cardiac sarcomas result in rapid growth and quick death. According to different sources the median survival is typically 6 to 12 months. We are presenting a case of primary cardiac sarcoma with 26 months disease free survival following cytoreductive surgery and chemotherapy.

Case presentation

A 48-year-old woman with progressing symptoms of dyspnea and palpitations for over 2 months was referred to a cardiologist. With the help of echocardiography and cardiovascular magnetic resonance cardiac sarcoma was suspected. Open biopsy and cytoreductive surgery were performed, complete resection of the tumor was not possible. Histology revealed undifferentiated pleomorphic sarcoma. Seven cycles of chemotherapy with Doxorubicine and Ifosfamide were completed. Cardiovascular magnetic resonance revealed a complete response – only signs of fibrosis without any signs of tumor were visible. Follow ups with echocardiography, cardiovascular magnetic resonance and chest, abdomen and pelvic computed tomography is performed every 3 months. Twenty-six months from initial diagnosis the patient is still free of recurrence of tumor with no compromises of the quality of life.

Conclusion

Standard chemotherapy together with cytoreductive surgery can have a complete response effect in undifferentiated pleomorphic sarcoma with unusual long-term survival.

Cardiac involvement in disseminated diffuse large B-cell lymphoma, successful management with chemotherapy dose reduction guided by cardiac imaging: A case report and review of literature

BACKGROUND

Secondary cardiac involvement by lymphoma has received limited attention in the medical literature, despite its grave prognosis. Although chemotherapy improves patients’ survival, a subgroup of treated patients dies suddenly due to myocardial rupture following chemotherapy initiation. Reducing the initial chemotherapy dose with dose escalation to standard doses may be effective in minimizing this risk but the data are limited. We report on the successful management of a patient with disseminated diffuse large B-cell lymphoma (DLBCL) involving the heart using such approach.

CASE SUMMARY

An 18-year-old male presented to our hospital with six months history of progressive dyspnea, orthopnea and cough. On physical examination, the patient was found to have a plethoric and mildly edematous face, fixed elevation of the right internal jugular vein, suggestive of superior vena cava obstruction, and a pelvic mass. Investigations during admission including a thoracoabdominal computed tomography (CT) scan with CT guided biopsy of the pelvic mass, echocardiography and cardiac magnetic resonance imaging led to the diagnosis of disseminated DLBCL with cardiac involvement. The patients were successfully treated with chemotherapy dose reduction followed by dose escalation to standard doses, under the guidance of cardiac imaging. The patient completed chemotherapy and underwent a successful bone marrow transplant. He is currently in remission and has a normal left ventricular function.

CONCLUSION

Imaging-guided chemotherapy dosing may minimize the risk of myocardial rupture in cardiac lymphoma. Data are limited. Management should be individualized.

A case report of left atrial myxoma-induced acute myocardial infarction and successive stroke

RATIONALE

Left atrial myxoma is a common primary cardiac tumor, however, due to poor image quality or atypical myxoma images, it is often misdiagnosed by echocardiograph. A case of left atrial myxoma being misdiagnosed as a thrombus, which successively caused acute myocardial infarction (AMI) and stroke, is very rare. Contrast-enhanced echocardiography can play an important role in definitive diagnosis.

PATIENT CONCERNS

A 44-year-old woman was diagnosed AMI because of chest pain with no significant stenosis in the coronary arteries. One month later, the patient was suddenly found unconscious, magnetic resonance imaging (MRI) showed acute multiple cerebral infarctions in the left cerebral hemisphere.

DIAGNOSES

Left atrial myxoma, acute myocardial infarction, and stroke.

INTERVENTIONS

The patient was given a cardiac surgery for tumor resection, the mass was surgically removed and histopathologic findings showed myxoma.

OUTCOMES

After several weeks of rehabilitation, the patient was able to resume daily activities without chest discomfort or dyspnea. One year later, echocardiography showed no recurrence of left atrial myxoma. The patient generally was in good condition.

LESSONS

Although myxoma is mostly benign, this patient occurred AMI and stroke because of misdiagnosis. Comprehensive assessments should be performed with multiple imaging methods for cardiac masses. If necessary, contrast-enhanced echocardiography should be used to clarify, so as not to delay the timing of surgery and bring potential risk of death to patients.