Approach to Surgery for Cardiac Tumors: Primary Simple, Primary Complex, and Secondary

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

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

Differential diagnosis of cardiac tumors: General consideration and echocardiographic approach

Cardiac tumors may be primary (either benign or malignant) or secondary (malignant) and are first detected by echocardiography in most cases. The cardiologist often challenges their identification, the differential diagnosis and the best therapeutic approach. Malignant tumors have usually a poor prognosis, which may be significantly improved by appropriate and timely therapies. The echocardiographic aspects of benign and malignant cardiac tumors described in this article, along with a clinical evaluation may orient the differential diagnosis and aid in choosing the further steps useful to define the nature of the mass.

A rare cause of dyspnea: Primary large B cell lymphoma causes giant cardiac mass

Cardiac lymphoma (CL) is a rare and life-threatening clinical condition. Most cases are diagnosed late period. Although the definitive diagnosis is made by biopsy, a biopsy could not be performed in most cardiac masses due to the high mortality rate and therefore the exact incidence is not known. In this case report, we present a case of giant CL filling both the pericardial area and right heart cavities and treated with surgical resection in a previously healthy male patient who presented with symptoms of heart failure.

Papillary Fibroelastoma Incidentally Found on Left Atrial Wall During Minimally Invasive Aortic Valve Replacement

A 60-year-old man was about to undergo minimally invasive aortic valve replacement when transesophageal echocardiography revealed an intracardiac mass on the left atrial free wall. Multimodal images from 5 months earlier had shown no mass. We converted the procedure to open surgery. The excised mass resembled a cardiac myxoma but was determined to be a papillary fibroelastoma. This case illustrates that papillary fibroelastomas can form and grow rapidly, warranting alertness for their unexpected discovery before and during cardiac surgical procedures.

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.

Benign Cardiac Neoplasms in the United States: A Thirteen-Year Review

Cardiac neoplasms are uncommon tumors. For epidemiological purposes, they can be divided into benign and malignant subtypes, with the former occurring at a significantly higher rate than the latter. Due to their uncommon nature, there are few data-driven studies examining the characteristics and trends of benign cardiac neoplasms. Our retrospective HCUP-NIS data review purports to illuminate some of the trends surrounding benign cardiac neoplasms and their associated co-occurrences. The data consisted of 482,872,274 weighted discharges. There were 45,568 weighted discharges that included a benign cardiac neoplasm. Benign cardiac neoplasms were more often observed in women (64.33%), and the average age was 63.8 years. The most common cardiovascular co-occurrences in patients with benign cardiac neoplasm were atrial tachyarrhythmias (28.93%), heart failure (19.61%), and embolic events such as stroke, myocardial infarct, or pulmonary embolism (19.82%). Other co-occurrences included pulmonary hypertension (7.55%), ventricular arrhythmias (3.23%), and other EKG abnormalities (3.70%). Procedures were numerous in patients with benign cardiac neoplasms. 43% of patients with this diagnosis had some form of cardiac surgery during their hospitalization. Overall, this study found low incidence of benign cardiac neoplasms in the USA during this 13-year study period. However, in the presence of benign cardiac neoplasms, our study showed that cardiovascular co-occurrences are not uncommon and may help to illuminate this otherwise rare diagnosis.

Eustachian valve myxoma: a rare cause of Budd-Chiari syndrome

Budd-Chiari syndrome caused by right atrial myxomas are extremely rare. We report the case of a patient who presented with chronic liver disease who upon consequent investigation was found to have a mass occupying the right atrium and ventricle consistent with cardiac tumour. Intraoperatively, a giant mass was removed from the right atrium with the tumour stalk originating from the Eustachian valve. Histologic findings were consistent with myxoma.

Primary Cardiac Angiosarcoma

In this study, we present the case of a 34-year-old man who was diagnosed with primary cardiac angiosarcoma 1 month after hospital admission. Cardiac angiosarcoma is a relatively rare disease that can be easily misdiagnosed as pneumonia or other diseases. Although surgery is the preferred treatment to prolong survival time, highly malignant tumors with local infiltration and systemic metastasis can lead to poor prognosis.

Minimally invasive resection of benign cardiac tumors

Primary cardiac tumours for which surgical resection is the main stay of treatment are rare and present both diagnostic and management challenges. The majority of patients are asymptomatic and one third of those who have symptoms present with vague constitutional symptoms which further complicates the process of early diagnosis. The current state-of-the art multi-modality imaging, routine use of intra-operative transoesophageal echocardiogram (TOE) in most cardiac centres and the tremendous advances of endoscopic adjuncts greatly enhances both the diagnosis and management of those group of patients. The surgical burden of median sternotomy and the contemporary trend towards less invasive surgery urged the necessity for adopting minimally invasive surgery in general and cardiac tumours are no exception. Despite the rarity of theses tumours, minimally invasive resection is successful in the hands of experienced minimally invasive surgeons who employ the same minimal access valve surgery platform to access the tumours in various cardiac chambers and valves with no compromise to the oncological clearance and hence achieve the benefits of minimally invasive surgery without compromising long term outcomes.

Mature Teratoma in the Right Ventricle

We present an exceedingly rare case of right ventricular outflow tract obstructing mass in an adult patient who presented with dyspnea and dizziness. Transthoracic echocardiography and computed tomography angiogram of the chest showed a large mass in the right ventricle obstructing the outflow tract. A dual right ventriculotomy and right atriotomy surgical approach was taken to completely resect the mass from the interventricular septum, which subsequently confirmed histopathologically the mass as a mature cystic teratoma.

Left atrial spindle cell sarcoma: A case report and literature review

RATIONALE

Cardiac primary spindle cell sarcoma is 1 of the rarest cardiac malignancies, with only a few cases reported so far. Herein, we reported a case of left atrial spindle cell sarcoma diagnosed and treated by a multidisciplinary approach, and retrospectively reviewed other reported cases.

PATIENT CONCERNS

A 49-year-old woman presented to our hospital with 2 weeks of gradual onset of dyspnea on exertion, dry cough and subacute fever.

DIAGNOSIS

The patient was initially revealed a left atrium mass by 2-dimensional transthoracic echocardiography. Based on the contrast-enhanced echocardiography and cardiac magnetic resonance imaging, she was subsequently suggested to have a cardiac malignant tumor. And the post-operative histopathology confirmed the tumor to be a cardiac primary spindle cell sarcoma.

INTERVENTIONS

The tumor was completely resected using autotransplantation. The patient was referred for polychemotherapy afterwards.

OUTCOMES

Our patient underwent the tumor resection, with subsequent adjuvant polychemotherapy, and the tumor has not recurred during 12 months of follow-up.

LESSONS

Due to the rarity of these tumors and nonspecific symptoms, they are often difficult to diagnose preoperatively and missed occasionally. Thus, improving our understanding of the disease and facilitating its early diagnosis are essential.

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.

Primary cardiac sarcoma: a case report of a therapeutic challenge

BACKGROUND

Primary cardiac sarcomas are very rare and the prognosis is poor both because the diagnosis is typically made at an advanced stage of the disease and because data are insufficient to identify a standard treatment. Surgical resection is the cornerstone of therapy with the need to develop new therapeutic strategies.

CASE SUMMARY

We present a case of a young man admitted to the emergency department due to worsening dyspnoea. A left-sided sarcoma was diagnosed and treated with surgery, chemo- and radiation therapy, and subsequently with heart transplant for local recurrence of the disease. Endomyocardial biopsy made during the routine follow-up period was complicated by pericardial tamponade and cardiogenic shock and the patient was managed with veno-arterial extracorporeal membrane oxygenation, until recovery of left ventricular function (left ventricular ejection fraction of 55%). After 1 year a kidney transplant was performed. After 42 months from diagnosis, the patient is in good general condition.

DISCUSSION

Primary cardiac sarcomas are treated with surgery to reach R0 (free resection margins) and with chemo- and radiation therapy with adjuvant purposes. Auto-transplantation is also performed, while conventional heart transplant must be customized on an individual basis, after excluding metastases. A multidisciplinary assessment should be performed and the single patient treated with a personalized approach, in relation to his performance status, location of the mass, and stage of the disease.

Long-term follow-up of resection of primary benign right ventricular tumours: a 10-year surgical experience

INTRODUCTION

Primary benign right ventricular tumours are rare. They can cause significant mortality without appropriate and timely treatment. We investigated surgical treatment and survival characteristics for right ventricular tumours.

MATERIALS AND METHODS

From 2007 to 2017, 21 patients with primary benign right ventricular tumours who underwent tumour resection were retrospectively reviewed. Clinical findings and follow-up results were analysed.

RESULTS

Thirteen men and eight women were enrolled, with a mean age of 42.3 ± 15.3 years. The most frequent histotypes were myxoma, haemangioma and papillary fibroelastoma. Eight patients underwent concomitant tricuspid valvuloplasty and one had tricuspid valve replacement. No major adverse events or death occurred during the perioperative period. One patient with haemangioma underwent partial tumour resection; however, the tumour regressed gradually during follow-up. Within the 10-year follow-up period (mean 4.8 ± 2.6 years), the recurrence-free and overall survival rates were 81.0% and 85.7%, respectively.

CONCLUSIONS

Tumour resection for primary benign right ventricular tumours is safe and effective, and has a good prognosis. Tricuspid valvuloplasty or tricuspid valve replacement may be necessary for the resection of right ventricular tumours to improve the haemodynamics. Haemangiomas naturally undergo spontaneous regression.

Bronchogenic cyst of the interatrial septum

Although bronchogenic cysts are the most common primary mediastinal cysts, intracardiac bronchogenic cysts are extremely rare. We report a case of a bronchogenic cyst of the interatrial septum in a 42-year-old woman who presented with recent onset of dyspnea on exertion. Cardiac investigations including transthoracic echocardiography and computed tomography revealed a cystic homogeneous mass in the interatrial septum. The patient underwent surgical resection, and the resultant atrial septal defect was repaired using an autologous pericardial patch. Histopathological examination of the resected specimen revealed findings consistent with a benign bronchogenic cyst. Although bronchogenic cysts are extremely rare, they should be considered in the differential diagnoses of intracardiac tumors. Complete resection of bronchogenic cysts is recommended primarily for diagnostic and potentially therapeutic purposes.

Concomitant Resection of Left Ventricular Hemangioma and Lung Cancer With Ground-Glass Opacity

We report a case of concomitant left ventricular tumor and lung lesion with ground-glass opacity without preoperative confirmation of malignancy. To obtain definitive diagnosis, a wedge lung resection was performed through a median sternotomy. After confirmation of a negative margin by frozen section, the cardiac tumor was resected through a left anterior ventriculotomy. Histopathologic analysis identified a rare cardiac hemangioma and an adenocarcinoma with pTis, N0, M0, stage 0. Postoperative recovery was uneventful with intact cardiopulmonary functions despite the risk of low cardiac output attributable to ventriculotomy.