Malignant tumors of the heart

Intracavitary cardiac metastasis of cervical squamous cell carcinoma with immune thrombocytopenia: a rare case report

Cervical cancer is a prevalent gynecological malignancy; however, intracavitary cardiac metastasis of cervical squamous cell carcinoma is exceptionally rare. In addition, the co-occurrence of cervical cancer and right ventricular cancer thrombus with autoimmune diseases is extremely uncommon. Furthermore, the role of immune checkpoint inhibitors in the treatment process of such cases remains controversial. Given the scarcity of reported cases, it is imperative to document and highlight this unique presentation, providing novel insights into diagnosis and management strategies. We present the case of an adult patient diagnosed with cervical cancer and concurrent right ventricular cancer thrombus, accompanied by immune thrombocytopenia (ITP). The patient exhibited resistance to conventional ITP drugs, with suboptimal platelet response. However, upon achieving initial control of the tumor, the patient's platelet counts returned to normal. Notably, the addition of immune checkpoint inhibitors targeting PD-L1 resulted in effective tumor control, accompanied by sustained high platelet levels. Unfortunately, during subsequent anti-tumor therapy, the patient experienced a prolonged platelet rise time, rendering continuous effective anti-tumor therapy and anticoagulant therapy unattainable. This led to a gradual increase in intraventricular thrombosis, ultimately resulting in the patient's demise due to circulatory failure. This rare case sheds light on the potential alleviation of ITP in patients with tumor complications through effective antitumor therapy. The successful control of ITP after tumor management highlights the importance of integrated treatment approaches. Furthermore, the inclusion of immune checkpoint inhibitors demonstrated their potential role in achieving tumor control and maintaining platelet levels. However, the prolonged platelet rise time observed during subsequent therapy underscores the challenges in maintaining both effective anti-tumor therapy and anticoagulant therapy, necessitating careful management strategies. This case report emphasizes the need for a comprehensive evaluation and tailored therapeutic interventions in similar complex scenarios. In summary, this case report offers valuable clinical insights into the management of intracavitary cardiac metastasis of cervical squamous cell carcinoma, the coexistence of immune thrombocytopenia, and the potential implications of immune checkpoint inhibitors in such cases. Understanding these rare occurrences and their clinical impact can contribute to improved diagnostic approaches, therapeutic decision-making, and patient outcomes.

Myxoma Mimic in a Patient With Acute Myeloid Leukemia

Cardiac masses are rare conditions that, depending on their size and location, can cause several cardiac and systemic symptoms. We describe a case of a 21-year-old male with a history of syphilis, pulmonary tuberculosis, and acute myeloid leukemia (AML), in whom a transthoracic echocardiogram assessment was solicited before the initiation of induction chemotherapy. The study revealed a pedunculated, highly mobile mass in the right atrium that protruded to the right ventricle. Surgical resection was performed. During surgery, tricuspid valve perforation was noted and was associated with severe tricuspid valve regurgitation. Histopathological analysis of the resected mass determined that the lesion was a cardiac thrombus.

Implications of IL-21 in solid tumor therapy

Cancer, the most deadly disease, is known as a recent dilemma worldwide. Presently different treatments are used for curing cancers, especially solid cancers. Because of the immune-enhancing functions of cytokine, IL-21 as a cytokine may have new possibilities to manipulate the immune system in disease conditions, as it stimulates NK and CTL functions and drives IgG antibody production. Indeed, IL-21 has been revealed to elicit antitumor-immune responses in several tumor models. Combining IL-21 with other agents, which target tumor cells, immune-regulatory circuits, or other immune-enhancing molecules enhances this activity. The exciting breakthrough in the results obtained in pre-clinical situations has led to the early outset of present developing clinical trials in cancer patients. In the paper, we have reviewed the function of IL-21 in solid tumor immunotherapy.

Long-term outcomes after minimal right lateral thoracotomy for the resection of cardiac tumors

OBJECTIVES

Cardiac tumors are a rare and heterogeneous entity, with a cumulative incidence of up to 0.02%. This study aimed to investigate one of the largest patient cohorts for long-term outcomes after minimally-invasive cardiac surgery using right-anterior thoracotomy and femoral cardiopulmonary bypass (CPB) cannulation.

METHODS

Between 2009 and 2021, patients who underwent minimally-invasive cardiac tumor removal at our department were included. The diagnosis was confirmed postoperatively by (immune-) histopathological analysis. Preoperative baseline characteristics, intraoperative data, and long-term survival were analyzed.

RESULTS

Between 2009 and 2021, 183 consecutive patients underwent surgery for a cardiac tumor at our department. Of these, n = 74 (40%) were operated on using a minimally-invasive approach. The majority, n = 73 (98.6%), had a benign cardiac tumor, and 1 (1.4%) had a malignant cardiac tumor. The mean age was 60 ± 14 years, and n = 45 (61%) of patients were female. The largest group of tumors was myxoma (n = 62; 84%). Tumors were predominantly located in the left atrium in 89% (n = 66). CPB-time was 97 ± 36min and aortic cross-clamp time 43 ± 24 min s. The mean hospital stay was 9.7 ± 4.5 days. The perioperative mortality was 0%, and all-cause mortality after ten years was 4.1%.

CONCLUSION

Minimally-invasive tumor excision is feasible and safe, predominantly in benign cardiac tumors, even in combination with concurrent procedures. Patients who require cardiac tumor removal should be evaluated for minimally-invasive cardiac surgery at a specialized center, as it is highly effective and associated with good long-term survival.

Stereotactic Magnetic Resonance-Guided Adaptive and Non-Adaptive Radiotherapy on Combination MR-Linear Accelerators: Current Practice and Future Directions

Stereotactic body radiotherapy (SBRT) is an effective radiation therapy technique that has allowed for shorter treatment courses, as compared to conventionally dosed radiation therapy. As its name implies, SBRT relies on daily image guidance to ensure that each fraction targets a tumor, instead of healthy tissue. Magnetic resonance imaging (MRI) offers improved soft-tissue visualization, allowing for better tumor and normal tissue delineation. MR-guided RT (MRgRT) has traditionally been defined by the use of offline MRI to aid in defining the RT volumes during the initial planning stages in order to ensure accurate tumor targeting while sparing critical normal tissues. However, the ViewRay MRIdian and Elekta Unity have improved upon and revolutionized the MRgRT by creating a combined MRI and linear accelerator (MRL), allowing MRgRT to incorporate online MRI in RT. MRL-based MR-guided SBRT (MRgSBRT) represents a novel solution to deliver higher doses to larger volumes of gross disease, regardless of the proximity of at-risk organs due to the (1) superior soft-tissue visualization for patient positioning, (2) real-time continuous intrafraction assessment of internal structures, and (3) daily online adaptive replanning. Stereotactic MR-guided adaptive radiation therapy (SMART) has enabled the safe delivery of ablative doses to tumors adjacent to radiosensitive tissues throughout the body. Although it is still a relatively new RT technique, SMART has demonstrated significant opportunities to improve disease control and reduce toxicity. In this review, we included the current clinical applications and the active prospective trials related to SMART. We highlighted the most impactful clinical studies at various tumor sites. In addition, we explored how MRL-based multiparametric MRI could potentially synergize with SMART to significantly change the current treatment paradigm and to improve personalized cancer care.

Gender-Related Outcomes after Surgical Resection and Level of Satisfaction in Patients with Left Atrial Tumors

BACKGROUND

Cardiac tumors are rare, with a low incidence of between 0.0017 and 0.19%. The majority of cardiac tumors are benign and predominantly occur in females. The aim of our study was to examine how outcomes differ between men and women.

METHODS

From 2015 to 2022, 80 patients diagnosed with suspected myxoma were operated on. In all patients, preoperative, perioperative, and postoperative data were recorded. Such patients were identified and included in a retrospective analysis focused on gender-related differences.

RESULTS

Patients were predominantly female (n = 64; 80%). The mean age was 62.76 ± 13.42 years in female patients and 59.65 ± 15.84 years in male patients (p = 0.438). The body mass index (BMI) was comparable in both groups: between 27.36 ± 6.16 in male and 27.09 ± 5.75 (p = 0.945) in female patients. Logistic EuroSCORE (LogES) (female: 5.89 ± 4.6; male: 3.95 ± 3.06; p = 0.017) and EuroSCORE II (ES II) (female: 2.07 ± 2.1; male: 0.94 ± 0.45; p = 0.043), both scores to predict the mortality in cardiac surgery, were significantly higher in female patients. Two patients died early, within 30 days after surgery: one male and one female patient. Late mortality was defined as the 5-year survival rate, which was 94.8%, and 15-year survival rate, which was 85.3% in our cohort. Causes of death were not related to the primary tumor operation. The follow up showed that satisfaction with surgery and long-term outcome was high.

CONCLUSION

Predominately female patients presented with left atrial tumors over a 17-year period. Relevant gender differences aside from that were not evident. Surgery could be performed with excellent early (within 30 days after surgery) and late results (follow up after discharge).

Primary Cardiac Epithelioid Angiosarcoma with Sustained Remission following Surgical Resection: A Case Report

Epithelioid angiosarcoma is an extremely rare subtype of cardiac angiosarcoma that is highly aggressive and associated with poor prognosis. Due to its rare nature, the epidemiology and pathogenesis of this disease are not well-known. Thus, effective diagnostic and treatment modalities are limited. Here, we report a case of a primary epithelioid angiosarcoma in a patient who was treated successfully with surgical resection. A 45-year-old woman who initially presented with chronic systemic symptoms and severe anemia and subsequently developed new-onset atrial fibrillation with rapid ventricular rate was found to have a right-sided cardiac mass with a large pericardial effusion. Several years prior to presentation, she was treated for localized papillary thyroid cancer with Gc protein-derived macrophage-activating factor (Gc-MAF) therapy after declining thyroidectomy. After initial workup of her cardiac mass, including a transthoracic echocardiogram and cardiac MRI, she was transferred to an outside hospital where her mass was surgically resected. She was found to have stage IIIA high-grade epithelioid angiosarcoma involving the inferior vena cava, right atrium, and pericardium. She subsequently had complete resolution of her pericardial effusion and anemia and continues to have good performance status 16 months after her excellent surgical outcome without evidence of recurrence. This unique case contributes to our knowledge of epithelioid cardiac angiosarcoma, of which limited number of cases has been reported. It highlights a favorable outcome following surgical resection of a rare, life-threatening primary cardiac tumor.

Metastatic patterns and prognosis of patients with primary malignant cardiac tumor

Background

Distant metastases are independent negative prognostic factors for patients with primary malignant cardiac tumors (PMCT). This study aims to further investigate metastatic patterns and their prognostic effects in patients with PMCT.

Materials and methods

This multicenter retrospective study included 218 patients with PMCT diagnosed between 2010 and 2017 from Surveillance, Epidemiology, and End Results (SEER) database. Logistic regression was utilized to identify metastatic risk factors. A Chi-square test was performed to assess the metastatic rate. Kaplan-Meier methods and Cox regression analysis were used to analyze the prognostic effects of metastatic patterns.

Results

Sarcoma (p = 0.002) and tumor size¿4 cm (p = 0.006) were independent risk factors of distant metastases in patients with PMCT. Single lung metastasis (about 34%) was the most common of all metastatic patterns, and lung metastases occurred more frequently (17.9%) than bone, liver, and brain. Brain metastases had worst overall survival (OS) and cancer-specific survival (CSS) among other metastases, like lung, bone, liver, and brain (OS: HR = 3.20, 95% CI: 1.02-10.00, p = 0.046; CSS: HR = 3.53, 95% CI: 1.09-11.47, p = 0.036).

Conclusion

Patients with PMCT who had sarcoma or a tumor larger than 4 cm had a higher risk of distant metastases. Lung was the most common metastatic site, and brain metastases had worst survival among others, such as lung, bone, liver, and brain. The results of this study provide insight for early detection, diagnosis, and treatment of distant metastases associated with PMCT.

An undifferentiated, pleomorphic cardiac sarcoma masquerading as myxoma

Cardiac sarcoma is a very rare cause of primary cardiac tumor. We present a case of an undifferentiated, pleomorphic cardiac sarcoma, masquerading as a cardiac myxoma on multimodal imaging evaluation, which was definitively diagnosed on intra-operative histopathologic examination followed by surgical resection.

Learning objective

Evaluate and diagnose a rare primary cardiac tumor via multimodal imaging and a multidisciplinary approach.

Benign and malignant cardiac masses: long-term outcomes after surgical resection

BACKGROUND

Cardiac tumors represent a rare and heterogenous pathologic entity, with a cumulative incidence of up to 0.02%. This study aimed to investigate one of the largest patient cohorts published for clinical presentation and long-term outcomes after surgical resection.

RESEARCH DESIGN

Between 2009 and 2021, 183 consecutive patients underwent surgery for tumor excision in our center. Preoperative baseline characteristics, intraoperative data, and long-term survival were analyzed. The diagnosis was confirmed postoperatively by histology and Immunohistochemical investigations. Kaplan-Meier curves assessed survival, and the Cox, proportional hazards model, was used to identify prognostic factors for overall survival.

RESULTS

This series included 183 consecutive patients; most (n=169, 92.3%) were diagnosed with benign cardiac masses. The mean age of patients was 60 ± 16 years, and 48% (n=88) were females. The largest group of tumors is represented by myxoma (n = 98; 54%). The most common malignant tumor was sarcomas (n = 5; 2.7%). The mean hospital stay was 11 ± 6.5 days, and all-cause mortality after ten years was 14%.

CONCLUSION

Surgery represents the gold standard in treating primary cardiac tumors; in benign tumors, it is highly effective and curative, whereas, in malignant tumors, it remains associated with more prolonged survival.

A Rare Case of Undifferentiated Pleomorphic Cardiac Sarcoma with Inflammatory Pattern

Cardiac undifferentiated pleomorphic sarcoma (UPS) associated with fever and inflammatory response is an extremely rare condition. Herein, we report a rare case of cardiac UPS with unusual clinical presentation and inflammatory response. A 67-year-old male complaining of progressive dyspnea and intermittent fever of unknown cause was referred to our hospital for surgical resection of a left atrial mass. Laboratory analysis showed leukocytosis (26 × 103/μL) and high C-reactive protein (CRP) levels (155.4 mg/L). Hemoculture tests and urine analysis were negative for infection. A contrast chest computed tomography revealed a mass measuring 5.5 × 4.5 cm, occupying the left atrium cavity. The patient underwent surgical excision of the mass, however, surgical margin of the resected tumor could not be evaluated, due to the multifragmented nature of the resection specimen. Postoperative CRP and leukocyte levels normalized, highlighting the relationship between the tumor and the inflammatory status. Early diagnosis is crucial for a proper management and favorable outcome, enabling patients to undergo chemotherapy and achieve complete surgical resection.

Towards Accurate and Precise Image-Guided Radiotherapy: Clinical Applications of the MR-Linac

Advances in image-guided radiotherapy have brought about improved oncologic outcomes and reduced toxicity. The next generation of image guidance in the form of magnetic resonance imaging (MRI) will improve visualization of tumors and make radiation treatment adaptation possible. In this review, we discuss the role that MRI plays in radiotherapy, with a focus on the integration of MRI with the linear accelerator. The MR linear accelerator (MR-Linac) will provide real-time imaging, help assess motion management, and provide online adaptive therapy. Potential advantages and the current state of these MR-Linacs are highlighted, with a discussion of six different clinical scenarios, leading into a discussion on the future role of these machines in clinical workflows.

Cardiac tumors-sex-related characteristics and outcomes after surgical resection

OBJECTIVES

Cardiac tumors represent a rare and heterogeneous pathological entity, with a cumulative incidence of up to 0.02%. Gender was previously reported to influence outcomes after tumor surgery. This study aimed to investigate for gender-related differences in outcomes after cardiac surgery.

METHODS

Between 2009 and 2021, 95 male and 88 female patients underwent surgery for tumor extirpation in our center. Preoperative baseline characteristics, intraoperative data, and long-term survival were analyzed. The diagnosis was confirmed postoperatively by (immune-)histopathological analysis.

RESULTS

There were no significant differences in baseline characteristics and survival. Myxoma was the most common tumor type overall and was more diagnosed in women (n = 36 vs. n = 62, p ≤ 0.001). Sarcoma was the most common malignant tumor type (n = 5). Tumor location at the atrial septum was more likely in women (n = 26 vs. n = 16, p = 0.041), whereas ventricular localization was more common in male patients (n = 20 vs. n = 7, p = 0.001). Minimally invasive tumor extirpation was significantly more often performed in women, and in-hospital stay was shorter in female patients.

CONCLUSION

The localization and dignity of cardiac tumors differ between genders, not affecting survival. Surgical tumor extirpation remains the gold standard of treatment for cardiac tumors in both genders as it is highly effective and associated with good long-term survivorship.

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.

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.

Intracardiac masses: Single center experience within 12 years: I-MASS Study

Objective

The aim of this cross-sectional, retrospective, descriptive study was to review and classify cardiac masses systematically and to determine their frequencies.

Methods

The medical records of 64,862 consecutive patients were investigated within 12 years. Every patient with a cardiac mass imaged by transthoracic echocardiography (TTE) and confirmed with an advanced imaging modality such as transesophageal echocardiography (TEE), computed tomography (CT) and/or cardiac magnetic resonance imaging (CMR) was included. Acute coronary syndromes triggering thrombus formation, vegetations, intracardiac device and catheter related thrombi were excluded.

Results

Data demonstrated 127 (0.195%) intracardiac masses consisting of 33 (0.050%) primary benign, 3 (0.004%) primary malignant, 20 (0.030%) secondary tumors, 3 (0.004%) hydatid cysts and 68 (0.104%) thrombi respectively. The majority of primary cardiac tumors were benign (91.67%), predominantly myxomas (78.79%), and the less malignant (8.33%). Secondary cardiac tumors were common than the primary malignant tumors (20:3), with male dominancy (55%), lymphoma and lung cancers were the most frequent. Intracardiac thrombi was the majority of the cardiac masses, thrombi accompanying malignancies were in the first range (n = 17, 25%), followed by autoimmune diseases (n = 13, 19.12%) and ischemic heart disease with low ejection fraction (n = 12, 17.65%).

Conclusions

This retrospective analysis identified 127 patients with cardiac masses. The majority of benign tumors were myxoma, the most common tumors that metastasized to the heart were lymphoma and lung cancers, and the thrombi associated with malignancies and autoimmune diseases were the most frequent.

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.

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.

Role of the HIPPO pathway as potential key player in the cross talk between oncology and cardiology

The HIPPO pathway (HP) is a highly conserved kinase cascade that affects organ size by regulating proliferation, cell survival and differentiation. Discovered in Drosophila melanogaster to early 2000, it immediately opened wide frontiers in the field of research. Over the last years the field of knowledge on HP is quickly expanding and it is thought will offer many answers on complex pathologies. Here, we summarized the results of several studies that have investigated HP signaling both in oncology than in cardiology field, with an overview on future perspectives in cardiology research.

Intimal Sarcoma: An Extremely Rare Case of a Left Atrial Tumor with Partial Obstruction of the Mitral Orifice

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Primary malignant cardiac tumors are very rare.

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This is the first case report of intimal sarcoma of left atrial origin.

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Echocardiographic diagnosis of malignant cardiac tumor is critical but challenging.

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The authors outline the differentiation of primary malignant cardiac tumors.

Extensive pulmonary metastases in young boy with primary cardiac angiosarcoma: a case report

BACKGROUND

Malignant primary cardiac neoplasms are rare and primary cardiac angiosarcoma is the most common and aggressive subtype. It most commonly presents in middle-aged males and due to its non-specific clinical presentation, the diagnosis is often delayed until advanced disease is already present. Clinical presentation is determined by manifestations of local infiltration or metastatic disease and making an early diagnosis is extremely challenging.

CASE SUMMARY

A 15-year-old previously healthy boy was admitted to the emergency department with a history of pathological weight loss and functional decline. The patient was found to have a left-sided pneumothorax as well as bilateral diffusely spread pulmonary nodules on plain chest radiograph. Computed tomography chest confirmed widespread pulmonary metastases and a right atrial filling defect. Echocardiography revealed a right atrial tumour and transvenous endomyocardial biopsy of the tumour was done under fluoroscopic and echocardiographic guidance. A diagnosis of primary cardiac angiosarcoma was made. The patient demised shortly after presentation.

DISCUSSION

Primary cardiac angiosarcoma is rare and even more so in patients as young as the case described. The diagnostic process poses several challenges to the clinician, of which the obtaining of a histological sample is one. This case report demonstrates aspects both unique and typical of this rare disease. It also describes an effective option for obtaining tissue for a histological diagnosis in patients whose clinical condition may not allow biopsy under general anaesthesia.

[Pathology of primary cardiac tumors]

Primary heart neoplasms are rare and poorly known by general pathologists. However, they are not exceptionally encountered in pathology laboratories having a recruitment of cardiac surgery specimens. About 80 % of them are benign tumors and 20 % are malignant tumors. Some tumors are specific to the heart or have characteristics when they grow in the heart, including myxoma and papillary fibroelastoma. The classification currently in use is the 4th edition of the WHO classification of heart tumors published in 2015, which takes into account the evolution of knowledge in the field of sarcomas, but which does not yet recognize cardiac intimal sarcoma. recently individualized in its intracardiac location.

Recurrent cardiac intimal sarcoma misdiagnosed as a myxoma or malignant transformation of a cardiac myxoma?

Cardiac intimal sarcoma is extremely rare and aggressive primary malignant cardiac tumors. Here, we reported the case of a young man initially operated for a tumor of the left atrium, causing a dynamic obstruction of the mitral valve and (mis-)diagnosed as a myxoma at the histopathological analysis. Patient presented a local recurrence at 3 months and was reoperated. Pathology revealed this time the presence of an intimal sarcoma. Patient received adjuvant chemotherapy. Despite a good local control, the 1-year follow-up positron emission tomography scan revealed the presence of a metastasis in the left adrenal gland that was surgically resected. This article aims to highlight the risk of misdiagnosis in case of cardiac tumors, the hypothetical concept of malignant transformation of a cardiac myxoma, the aggressive course of the extremely rare cardiac intimal sarcoma, and the therapeutic modalities available to treat this pathology.

Surgical Treatment of Atrial Myxomas: Outstanding Outcome of a Treacherous Tumor

Background

Primary cardiac tumors are quite rare and mostly benign in nature. Most of the benign heart tumors are myxomas. These might present with a wide range of symptoms from being completely asymptomatic to having life-threatening complications like stroke, heart failure, or even sudden death. This study summarizes our 6-year clinical experience with surgical resection of cardiac tumors at Chittagong Medical College and Hospital, Chattogram, Bangladesh.

Methods

Twenty patients who underwent surgical excision of primary intracardiac myxoma between February 2014 and February 2020 were included in the study. Seventeen (85%) of them were female and 3 (15%) were male. Mean age was 43.4 ± 14.1 years. The tumors were located in the left atrium in 19 patients and in 1 patient it was in the right atrium. The most common attachment site was the interatrial septum. Most of the patients presented with dyspnea. Preoperative diagnosis was established using transthoracic echocardiography with colour Doppler. Surgery for all patients was via median sternotomy.

Results

All 20 patients survived the surgery. Mean tumor dimension was 4.6 ± 3.5 cm in the longest diameter. Solid tumors were detected in 13 patients (65%) whereas papillary myxomas were found in 7 patients (35%). On follow-up of these 20 patients, there was no perioperative death. One patient presented with recurrence 28 months after the surgery.

Conclusions

Although cardiac myxomas carry the risk of serious systemic and cardiac symptoms, prompt surgical excision gives excellent outcome.

Primary Atrial Undifferentiated Sarcoma Found on FDG PET/CT Mimicking Cardiac Myxoma

A 52-year-old man had shortness of breath and chest discomfort for 2 months. Chest CT and MRI showed a mass in the left atrium attached to the mitral annulus without obvious enhancement. Initial diagnosis was suspected of myxoma. Preoperative FDG PET/CT demonstrated the corresponding lesion with abnormal FDG uptake, indicating a malignancy. Finally, histopathologic examination revealed primary undifferentiated sarcoma.

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

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

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

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

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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.

A rare disease of primary cardiac intimal sarcoma at the left atrium presented with mimicking mitral stenosis in a patient with polycystic kidney disease

A 55-year-old woman presented with a history of constitutional symptoms with exertional dyspnea, orthopnea, and cough for one month. She developed progressive heart failure symptoms. Initial computed tomography revealed a large left atrial mass with compression of pulmonary veins and mitral valve. Surgical resection was performed, and histologic examination revealed an intimal sarcoma. The most effective treatment has been found to be a surgical resection, with chemotherapy and radiotherapy. The objective of this report is to describe a common presentation of a rare disease, and to discuss the significance of appropriate diagnosis, pathological findings, and timely interventional management. <Learning objective: Cardiac intimal sarcomas are rare primary malignant tumors. It requires a clinical suspicion for timely diagnosis and intervention, which could result in a good prognosis.>.

Primary Cardiac Undifferentiated High-Grade Intimal Pleomorphic Sarcoma: A Case Series Report

We report two patients with primary cardiac sarcomas. The first patient was admitted for dyspnea on exertion secondary to congestive heart failure. She was later diagnosed with intimal pleomorphic sarcoma involving the right ventricular outflow tract extending into the pulmonary artery, which was further complicated by metastasis to the lung. The second patient was admitted for left-sided weakness secondary to a right frontal lobe ischemic stroke. The patient was later diagnosed with left atrial intimal pleomorphic sarcoma, which was further complicated by metastasis to the small bowel and right femur.

Postoperative chemotherapy and radiation improve survival following cardiac sarcoma resection

OBJECTIVE

Cardiac sarcoma represents a rare and aggressive form of cancer with a paucity of data to produce outcome-driven evidence-based guidelines. Current surgical management consists of resection with postoperative therapy (chemotherapy, radiation, or both) offered on a selective, individualized basis. This study was designed to determine whether postoperative therapy was associated with improved overall survival after resection.

METHODS

The National Cancer Database was used to identify patients with cardiac sarcoma between 2004 and 2015. Patient characteristics were stratified by treatment (surgical, nonsurgical, and none), and treatment was analyzed by stage. Overall survival, assessed with Kaplan-Meier methodology, was compared between patients who received postoperative therapy and those who did not following resection. Multivariable survival modeling using a Weibull model identified risk factors associated with survival while controlling for confounders.

RESULTS

The study included 617 patients diagnosed with cardiac sarcoma. Only 24% (149/617) of patients were diagnosed with early-stage disease. Angiosarcoma represented 48% (298/617) of cases and was the most commonly identified histologic subtype. 60% (372/617) underwent surgical resection and 58% (216/372) of those patients were treated with postoperative therapy. Following surgery, median survival was more than doubled for patients treated with postoperative therapy (19 months vs 8 months, P = .026). However, 5-year overall survival was similar between the groups. Multivariable analysis confirmed an improvement in survival with postoperative therapy (hazard ratio, 0.68; 95% confidence interval, 0.51-0.91, P = .009).

CONCLUSIONS

Postoperative therapy is associated with better median survival following resection of cardiac sarcoma. However, at 5 years, the difference in overall survival is not statistically significant.

Genomic Alterations In Primary Cardiac Diffuse Large B Cell Lymphoma: A Case Report And Literature Review

Primary cardiac diffuse large B cell lymphoma (PC-DLBCL) is a rare kind of hematological malignancy, and its clinical and pathologic characteristics, especially in Eastern countries, remain unclear. Moreover, genomic alterations in PC-DLBCL have not been studied previously. We describe a case of a 57-year-old man who presented with exertional dyspnoea due to a heart mass in April 2018 and was diagnosed with PC-DLBCL characterized by immunohistochemical markers of the activated B cell (ABC) subtype and double expression of c-MYC and Bcl-2. Mutations in a total of 11 genes—TBL1XR1, CD79B, IGLL5, ZMYM3, MYD88, TMSB4X, PIM1, BTK, NRXN3, CUX1, and CSMD1—were detected via next-generation sequencing (NGS), while 19 copy number variations (CNVs) such as 1q+, 3p+, 3q+(*2), 5p+, 6p−, 6q−, 7q+, +11, 12q−, 15q−, 17q+, 17p−, +18, 19q+, 19p−, 19q−, X q+, and −Y and 4 copy-neutral loss of heterozygosity (CN-LOH) lesions located at 1q21.1q44, 3p26.3q11.2, 3q13.11q29 and 6p22.2p21.32 were identified by single nucleotide polymorphism (SNP) array karyotyping. Some key gene alterations in lymphoma, such as PRDM1 deletion and Bcl-2 amplification, were identified using SNP array analysis. The patient received 6 courses of chemotherapy (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone, R-CHOP regimen) after surgery and is currently in remission. In summary, the present case was diagnosed as PC-DLBCL, ABC subtype by the Hans algorithm and double expression lymphoma, with co-occurrence of the MYD88^L265P and CD79B mutations (MCD) subtype by genetic alteration analysis. This study presents a unique PC-DLBCL case in which complex genomic alterations were revealed by NGS and SNP array analysis, which has never been reported in the literature, and these findings could provide new insight into the genomic characterization of PC-DLBCL.

Successful multidisciplinary clinical approach and molecular characterization by whole transcriptome sequencing of a cardiac myxofibrosarcoma: A case report

BACKGROUND

Cardiac tumors are rare and complex entities. Surgery represents the cornerstone of therapy, while the role of adjuvant treatment remains unclear and, in case of relapse or metastatic disease, the prognosis is very poor. Lack of prospective, randomized clinical trials hinders the generation of high level evidence for the optimal diagnostic workup and multimodal treatment of cardiac sarcomas. Herein, we describe the multidisciplinary clinical management and molecular characterization of a rare case of cardiac myxofibrosarcoma in an elderly woman.

CASE SUMMARY

A 73-year-old woman presented signs and symptoms of acute left-sided heart failure. Imaging examination revealed a large, left atrial mass. With suspicion of a myxoma, she underwent surgery, and symptoms were promptly relieved. Histology showed a cardiac myxofibrosarcoma, a rare histotype of cardiac sarcoma. Eight months later, disease unfortunately relapsed, and after a multidisciplinary discussion, a chemotherapy with doxorubicin and then gemcitabine was started, achieving partial radiologic and complete metabolic response, which was maintained up to 2 years and is still present. This report is focused on the entire clinical path of our patient from diagnosis to follow-up, through surgery and strategies adopted at relapse. Moreover, due to their rarity, very little is known about the molecular landscape of myxofibrosarcomas. Thus, we also performed and described preliminary genome analysis of the tumor tissue to get further insight on mechanisms involved in tumor growth, and to possibly unveil new clinically actionable targets.

CONCLUSION

We report a case of cardiac myxofibrosarcoma that achieved a very good prognosis due to an integrated surgical, cardiac and oncologic treatment strategy.

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.

Primary Cardiac Epithelioid Angiosarcoma in a Latin American Patient: Case Report and Literature Review

Cardiac angiosarcoma is a rare and clinically challenging pathology. It is a high-grade primary malignant tumor of the heart tissue that has many variants, of which the epithelioid variant is rarely present in the heart or the great vessels. As with many other cardiac tumors, it is mainly a diagnosis of exclusion and the initial diagnostic test is an echocardiogram followed by a biopsy with immunohistochemistry analysis to ascertain the type of tumor. The differential diagnosis of cardiac tumors is challenging due to the overlapping clinical manifestations with different cardiac tumors and systemic diseases. Cardiac angiosarcomas are often aggressive with a poor prognosis even with treatment. Herein, we present a case of the epithelioid variant of a cardiac angiosarcoma in addition to a thorough review of the recent literature on the clinical manifestation, diagnosis, and treatment of this type of tumors.

3D printing and coating to fabricate a hollow bullet-shaped implant with porous surface for controlled cytoxan release

Intratumoral implants have aroused great interests for local chemotherapy of cancer, however, how to efficiently control drug release from implants is still a great challenge. Herein, we designed and prepared a new hollow bullet-shaped implant with porous surface by 3D printing, loaded chemotherapeutic agent cytoxan (CTX) with tetradecyl alcohol or lecithin as matrix and coated it with poly (lactic acid) to obtain a CTX implant, which has a highly tuned drug release property with a drug release time from 4 h to more than 1 month. The drug release from the implant can be easily controlled by changing pore sizes, kinds of matrices, and coating thickness.

Pericardial Disease Associated with Malignancy

PURPOSE OF REVIEW

Pericardial effusion is commonly associated with malignancy. The goals of treatment should include optimizing symptom relief, minimizing repeat interventions, and restoring as much functional status as possible.

RECENT FINDINGS

Pericardiocentesis should be the first intervention but has high recurrence rates (30-60%). For patients with recurrence, repeat pericardiocentesis is indicated in those with limited expected lifespans. Extended pericardial drainage decreases recurrence to 10-20%. The addition of sclerosing agents decreases recurrence slightly but creates significant pain and can lead to pericardial constriction and therefore has fallen out of favor. Most patients with symptomatic pericardial disease have a short median survival time due to their underlying disease. In patients with a longer life expectancy, surgical drainage offers the lowest recurrence rate. Surgical approach is based on effusion location and clinical condition. Subxiphoid and thoracoscopic approaches lead to similar outcomes. Thoracotomy should be avoided as it increases morbidity without improving outcomes.

Primary cardiac sarcoma complicated with cerebral infarction and brain metastasis: A case report and literature review

In large autopsy series, the estimated frequency of primary tumors of the heart ranges from 0.0017% to 0.33%. Approximately 25% of primary cardiac tumors are malignant, and nearly 20% of these are sarcomas. To date, a completely feasible surgical resection remains the major treatment measure of cardiac sarcoma, especially for recurrent focal cardiac sarcoma and the recurrence of a restrictive metastasis. Although characteristically medical treatments are recommended, there is no consistent opinion for adjuvant radiotherapy and chemotherapy following an operation. Since these tumors usually undergo extensive spread by the time that the diagnosis is established, the prognosis of cardiac sarcoma remains poor. In this report, we described a case who underwent initial cardiac tumor resection, and was confirmed to be a pleomorphic undifferentiated sarcoma based on pathological findings. However, the patient complicated with cerebral infarction and subsequent brain metastasis sarcoma after the initial surgery, which was confirmed by brain tissue pathology. During the course of therapy, the patient underwent three surgical operations and refused to accept any chemotherapy and radiotherapy intervention. To the best of our knowledge, this is the first case report describing a primary cardiac sarcoma complicated with cerebral infarction and brain metastasis. The management of primary cardiac sarcoma is also discussed.

A Case of Severe Cardiac Sarcoidosis with Minimal Pulmonary Involvement: A Case Report with Literature Review

Sarcoidosis is a granulomatous disease of unknown etiology. Although sarcoidosis is a systemic disease, there appears to be a predilection for involvement of certain organs. The pulmonary system is the most commonly affected system among all racial groups. Cardiac and respiratory complications are the leading causes of death due to sarcoidosis and in certain patient populations about half of these deaths are attributed to cardiac sarcoidosis. There are few autopsy case reports of cardiac sarcoidosis with minimal respiratory involvement making this case report relevant to the importance of the recognition and awareness of this entity. Acad Forensic Pathol. 2018 8(2): 407-415.

Primary tumors of the heart

PURPOSE OF REVIEW

Primary cardiac tumors are a rare disease, which may have severe clinical consequences. Malignant tumors may be misdiagnosed as mixomas, with improper treatment. The aim of this review is to report how to make a differential diagnosis using old and modern tools, the latest trends in tumor classification and treatment, and their possible impact on prognosis.

RECENT FINDINGS

Papillary fibroelastomas seem to be more frequent than previously reported, and surgery is also suggested in asymptomatic patients. A genetic background has been identified for some myxomas and angiosarcomas. Malignant tumors are now classified as soft-tissue sarcomas of other organs. Immunohistochemistry and molecular diagnosis aid in recognizing several subtypes of sarcomas, leading to the possibility of targeted chemotherapy. The reports of single-center and multicenter experiences, collecting a large number of treated patients, analyzed the impact on prognosis of different approaches. The best results for survival and event-free survival are obtained with the multimodality approach.

SUMMARY

Before referring a patient with cardiac tumor to the cardiac surgeon, a presumptive diagnosis of benignity or malignancy should be obtained. Malignant tumors should be referred to a cardiac tumor team with special expertise, in order to plan the best therapeutic approach.

Evaluation and Management of Cardiac Tumors

PURPOSE OF REVIEW

Our purpose is to discuss the importance of multimodality imaging in the assessment of cardiac tumors and management. We have compiled a recent review of the scientific literature and embedded our clinical pathways and recommendations based on data and clinical experience.

RECENT FINDINGS

The use of contrast echocardiography in the assessment of cardiac masses has been shown to be helpful in distinguishing tumor from thrombus. Deformation imaging of cardiac tumors has been shown to differentiate better rhabdomyomas from fibromas in pediatric patients. Cardiac MRI (CMR) appears to be helpful in determining whether cardiac tumors are benign or malignant by identifying presence of infiltration, uptake of contrast in first pass perfusion and gadolinium enhancement. Patients with evidence of cardiac metastases by CMR show similar survival to stage IV cancer without cardiac metastases. In our institution, we use a standardized approach for the evaluation of cardiac masses, which includes multimodality imaging in the appropriate clinical context. The autotransplantation surgical technique has shown some promise in improving survival in patients with primary cardiac sarcomas. In our institution, we do not routinely recommend anticoagulation for "tumor-thrombus" in renal cell carcinoma due to risk of bleeding from primary tumor. Cardiac masses are often found incidentally, but sometimes can present with cardiovascular symptoms due to obstruction and valvular dysfunction, which may prompt imaging. It is important to determine whether the mass is a normal variant, imaging artifact, vegetation, thrombus, or tumor. Transthoracic echocardiography is ideally suited to be the initial imaging modality because of the portability, wide availability, lack of radiation, and relatively low cost. The gold standard cardiac imaging technique to distinguish tumor from thrombus is contrast enhanced CMR with prolonged inversion time. Advantages of CMR when compared to echocardiography regarding characterization of cardiac tumors are as follows: larger field of view, better spatial resolution, better tissue characterization, lack of attenuation, and ability to image at any prescribed plane. Primary and secondary cardiac tumors have particular characteristics in echocardiography and CMR. Imaging of cardiac tumors plays an important role in establishing a diagnosis and in planning management.

Surgical Treatment of Cardiac Tumors: Insights from an 18-Year Single-Center Analysis

Background

The aim of this study was to investigate the clinical presentation, operative data, and early and late outcomes of a large patient cohort undergoing surgical treatment for cardiac tumors in our institution.

Material/Methods

A total of 181 patients underwent surgery because of suspected cardiac tumor in our institution between 1998 and 2016. In 162 cases, the diagnosis was confirmed postoperatively and these patients were included in this study. Preoperative baseline characteristics, operative data, and postoperative early and long-term outcomes were analyzed.

Results

Mean age at presentation was 56.6±17.6 years, and 95 (58.6%) patients were female. There were 126 (77.8%) patients with benign cardiac tumors, while the remaining patients had malignant tumors (primary and metastasized). The mean follow-up time was 5.2±4.7 years. The most frequent histologically verified tumor type was myxoma (63%, n=102). In terms of malignant tumors, various types of sarcomas presented most primary malignant cardiac tumors (7.4%, n=12). The mean ICU length of stay was 1.7±2.2 days and overall in-hospital mortality was 3.1% (n=5). Frequent postoperative complications included mediastinal bleeding (5.8%, n=9), wound infection (1.3%, n=2), acute renal failure (5.6%, n=9), and major cerebrovascular events (n=7, 4.6%). The overall cumulative survival after cardiac tumor resection was 94% at 30 days, 85% at 1 year, 72% at 5 years, and 59% at 15 years.

Conclusions

Surgical treatment of cardiac tumors is a safe and highly effective strategy associated with good early and long-term outcomes.