Recurrent malignant fibrous histiocytoma of the left atrium with extracardiac extension

Society for Cardiovascular Magnetic Resonance 2022 Cases of SCMR case series

"Cases of SCMR" is a case series on the SCMR website (https://www.scmr.org) for the purpose of education. The cases reflect the clinical presentation, and the use of cardiovascular magnetic resonance (CMR) in the diagnosis and management of cardiovascular disease. The 2022 digital collection of cases are presented in this manuscript.

Primary spindle cell sarcoma of the heart treated with carbon-ion radiotherapy: Case report

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Primary cardiac tumors are rare. Seventy-five percent of the tumors are benign and 25 % are malignant.

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Primary cardiac sarcoma is a rare malignant cardiac neoplasm with a poor prognosis.

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No evidence-based guidelines exist regarding optimal surgical treatment of primary cardiac sarcomas.

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Systemic chemotherapy is indicated for patients with widespread or unresectable malignancies.

Introduction

Primary cardiac sarcoma is a rare malignant cardiac neoplasm with a poor prognosis. No evidence-based guidelines exist regarding surgical treatment management, although some case reports have been published. We report the outcome of a patient with spindle cell sarcoma of the heart treated postoperatively with carbon-ion radiotherapy and chemotherapy.

Presentation of case

A 16-year-old female patient was noted to have abnormal electrocardiogram results for 2 consecutive years at a high school medical check. She was referred to our hospital and a cardiac tumor in the left atrium was suspected. The preoperative diagnosis was myxoma, but abnormalities were also observed macroscopically during surgery, and a diagnosis of spindle cell sarcoma was made by rapid intraoperative pathological analysis. We resected the tumor as much as possible with surgery, but the tumor in the left lower pulmonary vein could not be respected. We performed carbon-ion radiotherapy postoperatively. She experienced recurrence 1 year later and tumor growth 2 years later. We considered additional surgical treatment, but eventually selected chemotherapy. She died 4 years and 7 months after initial surgery.

Conclusion

Spindle cell sarcoma is a rare disease with a poor prognosis. Although no optimal treatment method has been established, in the present case, incomplete surgical resection and postoperative carbon-ion radiotherapy were performed, yielding a relatively long survival period.

Radiation therapy for recurrent cardiac undifferentiated pleomorphic sarcoma after three operations

We report the case of a 57-year-old female suffering from recurrent malignant undifferentiated pleomorphic sarcoma of the left atrium. Metastasis to the posterior mediastinum was detected upon first presentation. Incomplete resections were carried out twice before mitral valve replacement was finally performed. The tumor recurred 16 months later and was treated with radiation therapy, which has proved to be effective in bringing about tumor regression for 2 years, to date. The patient has survived for 7 years since the first surgery.

Surgery for massive malignant tumors of the left atrium - one center's experience

Introduction

Surgery for primary non-resectable malignant tumors of the left atrium is controversial. Today heart autotransplantation as a method of surgical treatment for patients suffering primary massive malignant tumors of the left atrium is still not sufficiently studied.

Material and methods

We provide information on our single-center 5-year experience in performing surgical interventions for massive malignant tumors of the left atrium and including cases of 5 patients (3 males – 60%, 2 females – 40%). One case (1/5, 20%) involved debulking surgery with partial resection of the left atrial (LA) wall and its reconstruction using a xenopericardium patch. Orthotopic heart transplantation was performed in 1 patient (1/5, 20%) and heart autotransplantation (HA) in the 3 other cases (3/5, 60%).

Results

Mean myocardial ischemia duration was 165.6 ±12.0 minutes (range: 137–198), cardiopulmonary bypass (CPB) duration was 248.6 ±36.6 minutes (range: 188–392), and intervention duration was 498.0 ±77.4 minutes (range: 330–780). Mean total blood loss was estimated to be 2432 ±616.5 ml (range: 1610–4880). Major in-hospital complications were registered in 4 patients (4/5, 80%). In-hospital mortality was registered in 3 patients (3/5, 60%). Survival time in 2 (2/5, 40%) patients discharged from the hospital was 29 and 9 months, respectively. Both died because of disease progression.

Conclusions

Surgery in patients with massive resectable primary malignant tumor of the left atrium is associated with high incidence of major hospital complications and mortality. Heart autotransplantation with radical tumor resection is the treatment of choice for these cases. The surgical approach implies thorough primary hemostasis and selection of a proper surgical approach, allowing revision of all the regions of intervention during each step. The possibility of excessive tension and bleeding in the area of bicaval anastomosis should be considered when performing heart autotransplantation, and appropriate preventive measures should be applied.

A case of recurrent malignant fibrous histiocytoma of the mesentery

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MFH of the mesentery is a highly malignant tumor with early recurrence.

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The prognosis for MFH is poor.

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The surgery of recurrent MFH of the mesentery might provide good prognosis.

Primary malignant fibrous histiocytoma (MFH) mainly occurs in the extremities, trunk and retroperitoneum. However, MFH of the mesentery is very rare, and locally recurred MFH is even rarer. MFH is severely malignant and invasive regionally. The neoplasm can spread quickly. This report is about a case of a recurred MFH in the mesentery, which locally recurred within 3 years from the original operation. The patient (female, age 71) underwent a resection of the small bowl and mesentery of the recurrent MFH with negative resection margins. In the 24 months that followed, there has not been any evidence of recurrence or other metastasis in the patient. Although the prognosis of recurred MFH in mesentery was poor, a clear resection might provide a good opportunity for long-term survival, suggesting that surgery might be an effective treatment. This is the first report on the surgical treatment of recurrent MFH of the mesentery.

Unusual presentation of multiple recurrent cardiac sarcomas as acute acalculous cholecystitis caused by rapid expansion into the right cardiac chamber: report of a case

Sarcomas are rare malignant cardiac tumors and their prognosis is extremely poor, with a high recurrence rate despite extensive initial surgical resection. The development of therapeutic alternatives looks bleak for recurrent sarcomas, however, and complete surgical resection is crucial for any hope of survival even for the recurrent patients. We herein report the case of a 38-year-old male patient with multiple recurrent cardiac sarcomas causing acute acalculous cholecystitis 20 months after the resection of the primary tumor.

Large obstructive cardiac myxofibrosarcoma is nearly invisible on transthoracic echocardiogram

Malignant primary cardiac tumors are exceptionally rare, and the most common of these are sarcomas. We present a case of a patient who was found to have a large mass in the left atrium causing obstruction of mitral inflow. Only selected views on a transthoracic echocardiogram reveal the mass and its hemodynamic effect. Although the mass was sizeable, it could be easily overlooked on cursory review of the echocardiogram. After surgical resection, the mass was proven to be a myxofibrosarcoma. We review the etiologies and possible solutions for the imperfect sensitivity of transthoracic echocardiography for cardiac masses.

Cardiac autotransplantation for removal of left atrial hemangioma and a review of the literature

We describe the management of a patient who presented with symptoms of severe congestive heart failure. A 48-year-old man was initially seen in the emergency room, admitted to the hospital, and worked up with a transthoracic echocardiogram, a transesophageal echocardiogram, and a computer tomography scan of the chest. All cardiac valves were normal, as was the left ventricular ejection fraction. A mobile left atrial tumor measuring 6 x 4 x 5 cm was found attached to the left atrial dome, left atrial cuff, and left pulmonary veins. With each systolic atrial contraction, the mass prolapsed into the left ventricle across the mitral valve annulus, inducing a gradient of 19 mm Hg. The workup of the patient was negative for malignancy. The only feasible therapy for this patient was to excise the mass on cardiopulmonary bypass and cardioplegic arrest. At the time of surgery, the findings confirmed that the mass was attached broadly to the left atrial dome wall-epicardium, and the attachments were similar to those of the transesophageal echocardiographic findings. Atrial attachments extended from the base of the heart, along the atrioventricular groove, the left dome of the left atrium, the left atrial cuff, and the anterior aspect of both left pulmonary veins. The tumor could not be adequately excised, and reconstruction of the defect was not feasible with the heart in situ. We therefore decided to explant the heart and excise the tumor with a 0.5-cm margin of healthy tissue. The broad left atrial defect was reconstructed with bovine pericardium. The reconstruction encompassed the dome of the left atrium, the left atrial cuff, and the pulmonary veins. The heart was reimplanted back into the pericardial cavity. The superior vena cava with the retained sinus node was also anastomosed. The pathology diagnosis was a benign cavernous hemangioma. The sinus rhythm recovered following removal of the aortic cross-clamp and reperfusion of the heart. The patient had a rapid recovery and was discharged home on the 12th postoperative day. Placement of a pacemaker was not required because the patient retained the sinus rhythm. A review of the literature on cardiac autotransplantation revealed that this type of surgery has been performed frequently in centers that have a cardiac transplantation program or a surgeon who has cardiac transplantation experience. To our knowledge, this report is the first of cardiac autotransplantation for benign hemangioma.

Management of primary cardiac sarcomas

Cardiac sarcomas are rare entities. The biological behavior of cardiac sarcomas is similar to all soft-tissue sarcomas. Aggressive local growth and metastatic spread are common. Although histologic type affects behavior, survival is dependent on the histologic grade. Chemotherapy and radiation therapy are not adequate for long-term survival. Although surgery provides the best modality for local control it is limited by its inability to control distant metastatic disease. Right heart sarcomas tend to be bulky, infiltrative, cause heart failure late and metastasize early. Based on the surgical approach and clinical behavior, cardiac sarcomas can be classified as right heart sarcomas, left heart sarcomas and pulmonary artery sarcomas. Our limited - albeit the most extensive - experience with cardiac sarcomas has helped improve survival compared with chemotherapy alone. They are usually treated with chemotherapy prior to extensive resection. Left heart sarcomas tend to be more circumscribed, less infiltrative, cause heart failure early and metastasize later. They are usually treated with surgery first, given the possibility of cardiac failure. Pulmonary artery sarcomas tend to be confined to the pulmonary artery, often causing severe right heart failure and metastasize later than right heart sarcomas. They are usually treated with complete resection. Adjuvant therapy is recommended for all patients given that excellent local control is often achieved with surgery, yet long-term survival is often poor due to metastatic recurrence. Cardiac autotransplantation is an excellent technique for resection of posterior or left heart cardiac sarcomas. Surgical outcomes with cardiac autotransplantation are excellent in patients who do not require concurrent pneumonectomy. Pulmonary artery sarcomas allow for radiation therapy in addition to chemotherapy for neoadjuvant control, as the myocardium can be avoided. However, overall, long-term survival after cardiac sarcoma requires improved systemic control. This progress awaits the development of novel chemotherapeutics.

Primary malignant fibrous histiocytoma of the heart

We describe a case of a primary cardiac malignant fibrous histiocytoma in the left atrium of a 72-year-old man. Local recurrences appeared twice, at 2 and 14 months after initial tumor resection, and were managed surgically. The patient died of pancreatic metastasis 22 months after the initial diagnosis. The prognosis for MFH of the heart is poor despite aggressive surgical treatment.

Therapy insight: malignant primary cardiac tumors

Benign cardiac tumors are resected with a high degree of success with modern cardiac surgical techniques. Malignant cardiac tumors, however, continue to pose a therapeutic challenge to cardiac surgeons and oncologists because of the technical difficulty involved in extensive cardiac resections and the aggressive biological nature of the tumors. The majority of malignant cardiac tumors are sarcomas and can be categorized as right heart sarcoma, left heart sarcoma or pulmonary artery sarcoma. Right heart sarcomas are generally angiosarcomas, which infiltrate widely and metastasize early. A combination of chemotherapy and surgical resection is the preferred therapy. Left heart sarcomas, although large, are often less infiltrative and metastasize later than right heart sarcomas, but a similar approach to treatment is usually employed. Surgical resection is more-frequently necessary for left heart sarcomas because of intracardiac blood flow obstruction and congestive heart failure, although the anatomic position and relation of these tumors to cardiac structures can complicate surgery. We have developed and employed the technique of cardiac autotransplantation, which involves cardiac excision, ex vivo tumor resection with cardiac reconstruction, and cardiac reimplantation, to lessen these technical difficulties. Pulmonary artery sarcomas can be treated by radiotherapy, as well as by the other therapies, because the myocardium can be avoided by the radiation fields. Surgical resection of this sarcoma type often requires pneumonectomy and can require pulmonary root replacement.

Cardiac Autotransplantation for Primary Cardiac Tumors

BACKGROUND

Complete tumor resection is the optimal treatment of cardiac tumors. Anatomic accessibility and proximity to vital structures complicates resection of tumors involving the left heart. The results of standard resection and resection with orthotopic heart transplantation are dismal. We, therefore, reviewed our series of patients with complex left-sided primary cardiac tumors who underwent tumor resection with cardiac autotransplantation.

METHODS

Since April 1998, 11 consecutive patients with complex left atrial or left ventricular intracavitary cardiac tumors underwent 12 resections using cardiac autotransplantation-cardiac explantation, ex vivo tumor resection with cardiac reconstruction, and cardiac reimplantation. Demographics, tumor histology, operative data, and mortality were analyzed. Follow-up was complete in all patients.

RESULTS

Complete resection by cardiac autotransplantation was used in 7 patients with left atrial sarcoma, 1 patient with left ventricular sarcoma, 2 patients with left atrial paraganglioma, and 1 patient with a complex giant left atrial myxoma. Eight patients had previous resection of their cardiac tumor, and 1 patient had a repeat autotransplantation for recurrent disease. There were no operative deaths. Median overall survival was 18.5 months in patients with sarcomas. All patients with benign tumors are alive without evidence of recurrence.

CONCLUSIONS

Cardiac autotransplantation is a feasible technique for resection of complex left-sided cardiac tumors. Recurrent disease after previous resections can be safely treated with this technique. Operative mortality and overall survival seems favorable in this series of patients. Benefits of this technique include improved accessibility and ability to perform a complete tumor resection with reliable cardiac reconstruction.

Surgical outcome in 85 patients with primary cardiac tumors

BACKGROUND

We present a large, single institution experience with adult cardiac tumors and address factors affecting outcome.

METHODS

A retrospective review was made of all patients who underwent surgery for primary cardiac tumors from April 1975 through August 2002.

RESULTS

Eighty-five patients (33 male and 52 female) with a mean age of 54 years were identified with follow-up available for 80 (94%) patients. There were 68 (80%) benign tumors and 17 (20%) malignant tumors. Three tumors recurred and were resected giving a total of 88 surgeries. All benign tumors were grossly resected and the extent of resection for malignant disease ranged from 14 (78%) gross resections and 3 (17%) debulkings to 1 (5%) biopsy. There were 4 (5%) early hospital deaths. Median survival was 9.6 months and 322 months for patients with malignant and benign diseases, respectively. Significant predictors of long-term mortality were malignant disease (P <0.0001) and New York Heart Association class (P <0.03).

CONCLUSIONS

Surgical resection provides excellent outcome in patients with benign cardiac tumors. Malignant tumors continue to pose a challenge with good local tumor control but limited survival owing to metastatic disease.

Combined heart and lung transplantation for unresectable primary cardiac sarcoma

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A case of interleukin-6-producing malignant fibrous histiocytoma originating in the heart

Primary cardiac malignant fibrous histiocytoma is extremely rare and its pathophysiological characteristics remain largely unknown. We treated a female patient with persistent fever and disseminated intravascular coagulation. Since ultrasonic echocardiography revealed the presence of a cardiac tumor and her serum interleukin-6 level was elevated, we speculated she had a cardiac myxoma. Histological examination of the surgically resected specimen, however, revealed that the tumor was malignant fibrous histiocytoma. Although her disseminated intravascular coagulation and heart failure were transiently improved after operation, local recurrence and systemic metastasis occurred and she died 7 weeks after operation. Using the autopsied specimen, we examined whether the malignant fibrous histiocytoma constitutively synthesized interleukin-6. The interleukin-6 content in the tumor was high, consistent with interleukin-6 production by the tumor. This was confirmed by immunohistochemical analysis. To our knowledge, this is the first report demonstrating interleukin-6 production by a cardiac malignant fibrous histiocytoma.

Cardiac explantation and autotransplantation

Cardiac explantation and autotransplantation is a procedure by which the heart is removed from the chest and replaced. Explantation of the heart for tumor removal has been documented six times in the literature; however, with this aggressive approach, the median patient survival rate is only eight months. This article presents a case study in which this procedure was used to treat a patient with malignant fibrous histiocytoma.

Cardiac autotransplant for surgical treatment of a malignant neoplasm

Because of their anatomic location, cardiac sarcomas often interfere with cardiac function. Excision is considered to palliate the cardiac defect, but complete excision is often difficult owing to access, particularly in left atrial tumors. Incomplete resection results in tumor recurrence. To achieve complete resection of a large left atrial sarcoma, we used the technique of cardiac explantation, extracorporeal resection of the tumor with cardiac reconstruction, and cardiac autotransplantation.