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

Pericardial Disease in Patients with Cancer: Clinical Insights on Diagnosis and Treatment

Pericardial disease is increasingly recognized in cancer patients, including acute pericarditis, pericardial effusion, and constrictive pericarditis, often indicating a poor prognosis. Acute pericarditis arises from direct tumor involvement, cancer therapies, and radiotherapy. Immune checkpoint inhibitor (ICI)-related pericarditis, though rare, entails significant mortality risk. Treatment includes NSAIDs, colchicine, and corticosteroids or anti-IL1 drugs in refractory cases. Pericardial effusion is the most frequent manifestation, primarily caused by lung cancer, followed by breast cancer, lymphoma, leukemia, gastrointestinal tumors, and melanoma. Chemotherapy, immunotherapy, and radiotherapy may also cause fluid accumulation in the pericardial space. Symptomatic relief for pericardial effusion may require pericardiocentesis, prolonged catheter drainage, or a pericardial window. Instillation of intrapericardial cytostatic agents may reduce recurrence. Constrictive pericarditis, though less common, often develops from radiotherapy and requires multimodality imaging for diagnosis, with pericardiectomy as the definitive treatment. Primary pericardial tumors are rare, with metastases being more frequent. Patients with cancer and pericardial disease generally have poor survival, emphasizing the need for early detection. A multidisciplinary approach involving hematologists, oncologists, and cardiologists is crucial to tailoring pericardial disease treatment to a patient's clinical status, thereby improving the quality of life and prognosis.

Approach to cardiac masses: Thinking inside and outside the box

In this editorial we comment on the article by Huffaker et al, published in the current issue of the World Journal of Clinical Cases. Cardiac masses encompass a broad range of lesions, potentially involving any cardiac structure, and they can be either neoplastic or non-neoplastic. Primitive cardiac tumors are rare, while metastases and pseudotumors are relatively common. Cardiac masses frequently pose significant diagnostic and therapeutic challenges. Multimodality imaging is fundamental for differential diagnosis, treatment, and surgical planning. In particular cardiac magnetic resonance (CMR) is currently the gold standard for noninvasive tissue characterization. CMR allows evaluation of the relationship between the tumor and adjacent structures, detection of the degree of infiltration or expansion of the mass, and prediction of the possible malignancy of a mass with a high accuracy. Different flow charts of diagnostic work-up have been proposed, based on clinical, laboratory and imaging findings, with the aim of helping physicians approach the problem in a pragmatic way ("thinking inside the box"). However, the clinical complexity of cancer patients, in particular those with rare syndromes, requires a multidisciplinary approach and an open mind to go beyond flow charts and diagnostic algorithms, in other words the ability to "think outside the box".

Imaging Features Differentiating Between Cardiac Sarcomas and Hematologic Neoplasms

PURPOSE

The aim of the study is to assess the efficacy of computed tomography (CT) and positron emission tomography (PET)/CT findings in differentiating between cardiac sarcoma and cardiac hematologic neoplasms, which are rare but potentially lethal primary cardiac malignancies.

MATERIALS AND METHODS

We searched the electronic medical record for pathology-proven cases from 2012 to 2023, finding 69 patients (46 sarcomas, 23 cardiac hematologic neoplasms). Imaging features including tumor size, atrioventricular (AV) groove involvement, right coronary artery (RCA) encasement by 180°, pericardial effusion, lymphadenopathy, and metabolic activity on fluorodeoxyglucose PET were reviewed by a radiology fellow. Statistical analysis was performed using Fisher exact test and Wilcoxon test.

RESULTS

Cardiac sarcoma patients were younger (median age 49 years) compared to patients with cardiac hematologic malignancies (66 years, P = 0.006). While tumor size and chamber involvement were similar between the 2 categories, hematologic malignancies exhibited a notable predilection for AV groove involvement (70% vs 43%, P = 0.04) and RCA encasement (52% vs 26%, P = 0.02). Pulmonary metastases were more frequent in sarcoma cases (33% vs 4%, P = 0.006). There was no significant difference in fluorodeoxyglucose uptake. Lymphadenopathy was similar between the 2 disease groups. A decision tree constructed using AV groove involvement and patient age achieved 75% accuracy in predicting the diagnosis of the mass.

CONCLUSIONS

Overall, there is a substantial overlap in imaging features of cardiac sarcomas and hematologic malignancies involving the heart. Involvement of the AV groove and RCA encasement can allow a radiologist to favor hematologic malignancy. Ultimately, biopsy is required to establish a diagnosis.

Intracardiac echocardiography-guided biopsies for right-sided intracardiac tumors: An optimized diagnostic algorithm and case illustrations

Intracardiac tumors, though uncommon, necessitate a swift and accurate diagnosis for personalized treatment and prognosis estimation. While multi-modality imaging often determines the etiology of these cardiac masses, histological confirmation remains essential for definitive diagnosis and its specific treatment. Since cardiac tumors are often found in high-risk locations (ventricular free wall or atria), precision biopsy is paramount. The least invasive strategy would be to achieve this by means of endomyocardial biopsy (EMB); however real-time additional imaging is essential to reduce the risk of perforation/tamponade and to minimize sampling error. Intracardiac echocardiography (ICE) emerges as an excellent tool to achieve this goal preventing procedural complications and reducing the likelihood of sampling errors obtaining a definitive histopathological diagnosis in all cases. This paper outlines our diagnostic algorithm for optimal patient selection, details three illustrative cases, and elucidates the steps to acquire histopathology via percutaneous transvenous biopsy with ICE guidance in patients with right-sided cardiac tumors. Given the rarity of intracardiac tumors, we advocate these patients be managed by a dedicated multidisciplinary cardio-oncology team including an interventional cardiologist.

Case report: a non-invasive approach to diagnosis and management of pericardial haemangioma

Background

Pericardial haemangiomas represent a very rare subset of benign cardiac tumour in an unusual location, posing a diagnostic and clinical challenge. Historically, the definitive diagnosis was achieved through surgical resection or at biopsy. In recent years, multi-parametric cardiac magnetic resonance imaging (MRI) has proven to offer a non-invasive, biopsy-like approach to tumour characterization.

Case summary

In our case, multimodality imaging was used to characterize a pericardial mass as a haemangioma discovered coincidentally with a brain glioma. Diagnostic certainty was substantially improved through utilization of successive post-contrast bright-blood imaging at cardiac MRI, demonstrating a characteristic enhancement pattern of haemangiomas in direct comparison to the blood pool. Conservative management and mid-term follow-up showed an uneventful clinical course and partial regression of the presumed pericardial haemangioma.

Discussion

In the presence of typical features and application of individually tailored protocols, multimodality imaging can characterize cardiac tumours and guide patient management so that more invasive measures may be avoided. In our case of a suspected pericardial haemangioma, a conservative strategy was adopted with clinically uneventful course over a 2-year period. Whether this strategy can be applied to other patients with this rare tumour remains unclear, but the case report provides important information about the natural history of this entity and tissue characterization by cardiac MRI.

Cardiac metastatic melanoma presenting with ventricular tachycardia: a multimodality imaging evaluation case report

Background

Cardiac tumours are rare; secondary, metastatic cardiac tumours are 22-132 times more common than primary cardiac tumours. Multimodality imaging can elucidate the mass anatomy, composition, haemodynamic consequences, and guide management plan.

Case summary

We present a case of large left ventricular mass presenting with unstable ventricular tachycardia. We describe the cardiac magnetic resonance imaging, transthoracic echocardiography, and computed tomography findings used to assist in characterizing the left ventricular mass. We describe the multidisciplinary discussion involved in diagnosis, surgical biopsy, and treatment, and follow-up of cardiac metastatic melanoma.

Discussion

Metastatic melanoma should be within the differential for cardiac masses. Any patient presenting with a cardiac mass should be asked about history of skin malignancy. Multimodality imaging is crucial to diagnosis, staging, haemodynamic assessment, interventional and surgical planning, and assessment of response to therapy.

Ventricular cardiac hemangiosarcoma with brain metastases in a dog

An 11-year-old, female, spayed, soft-coated Wheaten terrier presented for acute onset of neurological signs. On presentation, neurological examination showed right thoracic and pelvic limb proprioceptive deficits, absent right menace reflex, and weak right nasal septum response. A left thalamocortical lesion was localized. On thoracic auscultation, an arrhythmia was noted, and electrocardiography showed frequent ventricular premature complexes and rare runs of ventricular tachycardia. Echocardiography identified an interventricular septal mass extending into the lumen of the left ventricle. Thalamocortical metastasis secondary to the cardiac mass was suspected to be the cause of the patient's neurological signs. Humane euthanasia was elected by the owner due to the patients clinical status and poor prognosis. A postmortem examination diagnosed hemangiosarcoma of the interventricular septum, the right ventricular free wall, and left ventricular free wall. The left ventricle adjacent to the paraconal groove showed myocardial necrosis and inflammation. Metastases to the brain and secondary intracranial hemorrhage were found which were suspected to be the cause of the antemortem neurological signs. Concurrent pulmonary and hepatic metastases were noted. This report describes a rare presentation of an intracardiac hemangiosarcoma of the interventricular septum, right ventricle, and left ventricle in a patient presenting with neurological signs.

Surgical planning aided with 3D technologies for management of complex paracardiac tumors

BACKGROUND

Accurate diagnosis and treatment of complex cardiac tumors poses challenges, particularly when surgical resection is considered. 3D reconstruction and printing appear as a novel approach to allow heart teams for optimal surgical and post operative care.

METHODS

We report two patients with uncommon masses including a cardiac angiosarcoma (CAS) and a IgG4-related disease (IgG4-RD) with exclusive cardiac involvement. In both cases, three-dimensional (3D) reconstruction and 3D-printed models were utilized to aid the surgical team achieve optimal pre-operative planning. Both patients underwent ECG-gated cardiac computed tomography angiography (CCTA) imaging and, due to the complex anatomy of the masses, their large dimensions, proximity to vital cardiac and vascular structures, and unclear etiology, computational and 3D-printed models were created for surgical planning. An exploratory literature review of studies using 3D-printed models in surgical planning was performed.

RESULTS

In case 1 (CAS), due to the size and extension of the mass to the right ventricular free wall, surgical intervention was not considered curative and, during thoracotomy, an open biopsy confirmed the imaging suspicion of CAS which guided the initiation of optimal medical treatment with chemotherapy and, after clear tumor retraction, the patient underwent a second surgical intervention, and during the 18 months of follow-up showed no signs of recurrence. In Case 2 (IgG4-RD), the patient underwent uncomplicated total surgical resection; this allowed directed treatment and, at 12 months follow-up, there are no signs of recurrence. Computational and 3D-printed models were used to plan the surgery and to confirm the findings. Limited studies have explored the use of 3D printing in the surgical planning of tumors.

CONCLUSIONS

We present two patients with uncommon cardiac tumors, highlighting the significant value of 3D models in the anatomical characterization and assessment of their extension. These models may be essential in surgical planning for complex cardiovascular cases and could provide more information than conventional imaging modalities. Further studies are needed to demonstrate the impact of 3D technologies in studying cardiac tumors.

Life-Threatening Conditions and Preoperative Complications Associated with Cardiac Neoplasm Do Not Affect Surgical Outcomes or Mortality

Background: Cardiac neoplasms may cause life-threatening symptoms associated with cerebral infarction, ventricular arrhythmias, and heart failure. Emergency surgery or preoperative treatment may be required for these patients. However, no study has reported the surgical outcomes in cases involving cardiac neoplasms with life-threatening complications. The current study investigated the mid- to long-term outcomes of surgery in patients with cardiac neoplasms in life-threatening conditions. Methods: This study retrospectively analyzed 36 consecutive patients who underwent resection for cardiac neoplasms with life-threatening cardiovascular, respiratory, and cerebral nervous system complications from January 2000 to December 2022. Their mean age at surgery was 54.9 years. In terms of fatal events, one patient who experienced a ventricular tachycardia storm caused by a left ventricular neoplasm was placed under deep sedation and managed with a ventilator preoperatively. Seven patients who presented with limb motor paralysis and visual defects had cerebral infarction. Two of the seven patients with cerebral infarction received cerebrovascular treatment before cardiac surgery. Results: During the follow-up period, cerebral- and cardiovascular-related deaths were not recorded. All postoperative cerebral and cardiovascular complications were new-onset cerebral infarction (n = 2) (with symptoms that improved during the long term). The mean follow-up period was 6.2 years. The 5- and 10-year survival rates of all patients were 89.8% and 78.7%, respectively. There were no significant differences in postoperative prognosis between patients with preoperative cerebral infarctions and those without. Conclusions: The long-term surgical outcome of patients with life-threatening symptomatic cardiac neoplasm was good. Thus, preoperative complications did not affect prognosis.

Case report: Cardiac neuroendocrine carcinoma and squamous cell carcinoma treated with MR-guided adaptive stereotactic radiation therapy

We present two cases of cardiac metastases adjacent to the right ventricle in a 55-year-old male and a 61-year-old female, both treated with magnetic resonance (MR)-guided adaptive stereotactic radiation therapy (SBRT). The prescribed regimen was 30Gy delivered in 3 fractions using a 1.5 Tesla magnetic resonance linear accelerator (MR-linac). Patients exhibited favorable tolerance to the treatment, with no observed acute toxicity.

Case Report: Lung cancer with rare cardiac and other multiple metastases

Metastasis to the left atrium is exceptionally uncommon, occurring at a rate of only 3.1%. The clinical manifestations of lung cancer metastasizing to the heart can vary widely. They range from paraneoplastic syndrome, dyspnea, and ST-segment elevation on an electrocardiogram to no clinically significant symptoms. Diverging from typical metastatic patterns observed in lung cancer, this case report presents a detailed description, from the perspective of the microenvironment, of a rare instance where lung cancer metastasized to the mediastinal lymph nodes, adrenal glands, brain, and notably, the left atrium, in a non-smoking female patient.

A Calcified Amorphous Tumor in the Left Atrium: A Case Report

Calcified amorphous tumors (CATs) of the heart are rare non-neoplastic cardiac masses primarily found in the mitral valve or annulus. However, their exact pathogenesis remains unknown. In this case report, we describe the CT and MRI findings and differentiating features of cardiac a CAT in the left atrium of a 79-year-old female.

Coronary artery thromboembolism as a cause of myocardial infarction with non-obstructive coronary arteries (MINOCA)

Acute myocardial infarction (AMI) usually represents the clinical manifestation of atherothrombotic coronary artery disease (CAD) resulting from atherosclerotic plaque rupture. However, there are cases in which coronary angiography or coronary computed tomography angiography reveals patients with acute coronary syndrome with non-obstructive CAD. This clinical entity is defined as myocardial infarction with non-obstructive coronary arteries (MINOCA) and often considered as a clinical dynamic working diagnosis that needs further investigations for the establishment of a final etiologic diagnosis. The main causes of a MINOCA working diagnosis include atherosclerotic, non-atherosclerotic (vessel-related and non-vessel-related), and thromboembolic causes This literature review aimed to investigate the major thromboembolic causes in patients presenting with MINOCA regarding their etiology and pathophysiologic mechanisms, as well as diagnostic and treatment methods.

Point-of-care Ultrasound in Infectious Diseases: Current Insights and Future Perspectives

Point-of-care ultrasound (POCUS) is a safe, noninvasive technique performed at the patient's bedside, providing immediate results to the operator. It complements physical examination and facilitates clinical decision-making. In infectious diseases, POCUS is particularly valuable, offering an initial assessment in cases of suspected infection. It often leads to an early tentative diagnosis enabling the prompt initiation of antimicrobial treatment without the delay associated with traditional radiology. POCUS provides direct visualization of affected organs, assists in evaluating fluid balance, and facilitates various interventions, all while reducing patient discomfort. For infectious disease specialists, becoming proficient in POCUS is a critical future challenge, requiring dedicated training for effective utilization.

Cardiac sarcoidosis manifesting with atrioventricular block and intracardiac masses: case report and literature review

Background

Cardiac sarcoidosis (CS) typically manifests with atrioventricular block (AVB), ventricular arrhythmias, or heart failure. Intracardiac masses due to CS are rare, and there is both a paucity of evidence and guidelines of how manage them.

Case summary

We describe a 45-year-old woman who presented with palpitations and dyspnoea on exertion found to have second-degree AVB. Further work-up noted two right atrial masses that, following excision and pathology, were identified as CS. Within several months of immunosuppressive treatment, imaging and device reports demonstrated mass resolution without arrhythmia recurrence.

Discussion

Intracardiac masses are a rare manifestation of CS. Immunosuppressive therapy remains the mainstay of treatment, with consideration of mass resection for diagnostic purposes.

Cardiac fibromas in adult patients: a case series focusing on rhythmology and radiographic features

Background

Fibromas are rare primary benign cardiac tumours that can become symptomatic due to expansive growth, ventricular rhythm disturbances, and sudden cardiac death. Distinguishing fibromas from other (malign) cardiac masses is essential for accurate diagnosis and treatment. While there is some experience in management of cardiac fibromas in children, management of adult patients is unknown.

Case summary

We present three cases of cardiac fibroma in adult patients diagnosed by echocardiography, cardiovascular magnetic resonance (CMR), and computed tomography (CT): (1) a 55-year-old male with a left ventricular fibroma leading to reduced left ventricular ejection fraction and mitral regurgitation. He had family history of sudden cardiac death, showed premature ventricular contractions (PVCs), and was treated with a primary preventive subcutaneous implantable cardiac defibrillator (S-ICD); (2) a 39-year-old male with right ventricular fibroma as an incidental finding. He complained of episodes of PVC. Due to a low PVC burden, decision was made against ablation and the patient was planned for follow-up; and (3) an 18-year-old female with left ventricular apex fibroma detected by CMR shortly after birth and confirmed by surgical biopsy. Being asymptomatic, conservative management was pursued and follow-up by CMR planned.

Discussion

Cardiac fibromas can show various clinical presentations and hence being detected late in life. Given potential complications of surgical biopsy, diagnosis of cardiac fibromas is primarily based on echocardiography, CT, and CMR. Rhythm disturbances as PVCs are common. Due to association with ventricular arrhythmias and sudden cardiac death, preventive ICD placement might be appropriate on an individual basis.

Caseous mitral annulus calcification: A forgotten benign condition mimicking cardiac mass, a case report

Key Clinical Message

Caseous mitral annulus calcification is a rare benign condition that can be misdiagnosed on echocardiography especially when it presents as a mass. This report highlights the contribution of cardiac MRI and computed tomography to the diagnosis through the case of a patient previously treated for breast cancer.

Abstract

We report the case of a patient, previously treated for breast cancer, in whom echocardiography suggested the diagnosis of a cardiac tumor due the presence of a mass on the posterior mitral annulus. Cardiac magnetic resonance was inconclusive. Computed tomography confirmed the diagnosis of caseous mitral annulus calcification.

Case report and literature review: cardiac hematic cyst

A 49-year-old female patient, asymptomatic, presented to the cardiology office for a right atrial mass, identified incidentally in a non-electrocardiogram (ECG)-gated contrast-enhanced computed tomography, performed for follow-up of pulmonary tuberculosis. Echocardiography, surprisingly, showed an anechogenic ovoid mass in the right atrium measuring 40 × 40 mm2, implanted in the interatrial septum without affecting the tricuspid valve. ECG-gated computed tomography angiography (CTA), confirmed the dimensions of the mass, which presented homogeneous content, calcified areas, and a 12-mm pedicle implanted near the ostium of the coronary sinus. Additionally, contrast uptake and infiltration of adjacent structures were ruled out. In the surgical field, an encapsulated mass with blood content was found, which pathology reported as a hematic endocardial cyst (HEC). These are rare cardiac masses, constituting 1.5% of all primary cardiac tumors. It is usually an incidental finding, and its clinical presentation will depend on its dimensions and the intracardiac hemodynamic impact. A highlighting feature is its anechogenic content on ultrasound, however, multimodality imaging allows for making diagnostic assumptions, discerning between primary cardiac tumors, and provides morphological and hemodynamic information useful for therapeutic decision making. The age of the patient, the large size of the HEC, and its location in the interatrial septum make up a completely atypical presentation of this rare disease, which motivated this report.

Cardiac Sarcoma Mimicking Libman-Sacks Endocarditis in a Patient with Systemic Lupus Erythematosus (SLE): A Case Report and Literature Review

We present the case of a 39-year-old woman who was diagnosed with SLE and antiphospholipid antibodies 8 years ago. The chief manifestations of her disease included low-grade fever and polyarthritis. Eight months before presentation, she experienced symptoms attributed to a flare of SLE, leading to an increase in immunomodulatory treatment with no improvement. She presented to the emergency room with acute onset of dyspnea. Clubbing of her fingers and toes was noted. When questioned, she reported the onset of clubbing 5 months earlier. A CTA was performed to rule out pulmonary embolism, which was excluded, although it revealed a severely damaged mitral valve with severe insufficiency and a large mass on the valve, protruding into the left atrium. Antibiotics were started, with a working diagnosis of infectious endocarditis; however, the severe mitral valve dysfunction lead to emergency mitral valve replacement, revealing an organized thrombus. She was treated with anticoagulation, with a working diagnosis of Libman-Sacks endocarditis, with no improvement. Additional immunosuppression failed to improve her symptoms. Enlargement of the thrombotic mass and an increased gradient across the prosthetic mitral valve led to repeat surgery, culminating in a diagnosis of high-grade sarcoma within the left atrial mass. We further discuss cardiac sarcoma and describe the occurrence of clubbing in patients with sarcoma. This case highlights the importance of interdisciplinary collaboration and the need for vigilant monitoring in refractory cases, particularly when atypical presentations arise.

Cardiac Tumors: Review

Cardiac tumors are rare and encompass a variety of presentations. Clinica symptoms are usually nonspecific, but they can present as obstructive, embolic, or constitutional symptoms. Treatment options and prognosis vary highly depending on the subtype, tumor size, and location. Surgical resection is usually the first-line therapy, except for cardiac lymphomas, and provides favorable long-term prognosis in most benign tumors. Cardiac sarcomas, however, are usually diagnosed in advanced stages, and the treatment relies on a multimodal approach with chemotherapy and radiotherapy. Metastatic cardiac tumors are usually related to advanced disease and carry an overall poor prognosis.

From dyspnea to diagnosis, unmasking undifferentiated cardiac sarcoma: a case report

BACKGROUND

Sarcomas are the most common type of cardiac malignancy, but they are extremely rare. Within this group, angiosarcomas have the highest frequency, followed by undifferentiated sarcomas. This type of tumor has a poor prognosis and a high recurrence rate. Information about these tumors is limited, relying mainly on case reports and autopsy series. The purpose of this case report is to detail the multifaceted approach to diagnosing and managing an undifferentiated cardiac sarcoma and contribute to the literature.

CASE PRESENTATION

A 28-year-old man presented with dyspnea and chest pain, which had developed progressively over several weeks. Physical examination revealed low blood pressure, elevated heart rate, and diminished heart sounds. Imaging, including a CT scan, identified a hypodense mass in the right ventricle. Further evaluation through echocardiograms and contrast angiotomography confirmed a mass causing right ventricular obstruction. Part of the tumor was surgically removed and diagnosed  as cardiac sarcoma.  Histopathological analysis of the mass showed an undifferentiated cardiac sarcoma.

CONCLUSION

This case underscores the significance of including cardiac tumors as a potential cause when diagnosing cardiac masses. It also demonstrates the poor prognosis and tendency for recurrence, while revealing the absence of established management guidelines.

Overall approaches to cardiac tumors: Still an unsolved enigma?

Cardiac tumors are neoplasms involving heart structures at any level, meaning the myocardium, valves, and cardiac chambers. When considering cardiac masses, it is not uncommon for surgeons to be surprised when they diagnose one. The real incidence of this complex group of diseases has been explored only after cardiac diagnostic tools became more appropriate. Despite differential diagnosis being relevant, surgical indication is usually requested for all malignant cardiac tumors and also for many types of benign tumors. The development of cardiac imaging techniques, therefore, has been the key point for a better understanding of the history of cardiac tumors and especially of the relevance of surgical indication in such conditions. Systematic and combined applications of echocardiography, cardiac computed tomography and magnetic resonance allow in the majority of case a clear definition of the nature of a newly discovered cardiac mass. The presence of a Li-Fraumeni syndrome seems to be the trigger aspect in accelerating the propensity of developing a cardiac tumor. Despite the revolutionary usefulness of the cardiac imaging techniques available, it is still considered a hazard to diagnose a malignant cardiac mass just with radiological imaging; the mainstay of the final diagnosis stands in surgical excision of the mass and histopathological report.

Mitral Annular Disease at Cardiac MRI: What to Know and Look For

Accurate evaluation of the mitral valve (MV) apparatus is essential for understanding the mechanisms of MV disease across various clinical scenarios. The mitral annulus (MA) is a complex and crucial structure that supports MV function; however, conventional imaging techniques have limitations in fully capturing the entirety of the MA. Moreover, recognizing annular changes might aid in identifying patients who may benefit from advanced cardiac imaging and interventions. Multimodality cardiovascular imaging plays a major role in the diagnosis, prognosis, and management of MV disease. Transthoracic echocardiography is the first-line modality for evaluation of the MA, but it has limitations. Cardiac MRI (CMR) has emerged as a robust imaging modality for assessing annular changes, with distinct advantages over other imaging techniques, including accurate flow and volumetric quantification and assessment of variations in the measurements and shape of the MA during the cardiac cycle. Mitral annular disjunction (MAD) is defined as atrial displacement of the hinge point of the MV annulus away from the ventricular myocardium, a condition that is now more frequently diagnosed and studied owing to recent technical advances in cardiac imaging. However, several unresolved issues regarding MAD, such as the functional significance of pathologic disjunction and how this disjunction advances in the clinical course, require further investigation. The authors review the role of CMR in the assessment of MA disease, with a focus on MAD and its functional implications in MV prolapse and mitral regurgitation. ©RSNA, 2024 Supplemental material is available for this article. See the invited commentary by Stojanovska and Fujikura in this issue.

Aortic valve fibroelastoma presenting with myocardial infarction with non-obstructive coronary arteries (MINOCA): A case report and review of the literature

Cardiac papillary fibroelastomas (CPFs) are rare benign cardiac tumors more often involving the left-sided valves and related with threatening embolic complications. We report the case of a 35-year-old woman presenting with relapsing-remitting chest pain and elevated cardiac troponins. After a negative coronary angiography, an integrated imaging assessment based on echocardiography and cardiac magnetic resonance showed a pedunculated mass on the aortic valve causing an intermittent obstructive engagement of the right coronary ostium. A tailored surgical treatment was performed and the histopathological examination of the specimen revealed mesenchymal tissue with the characteristics of CPF.

Treatment of primary cardiac diffuse large B-cell lymphoma involving the coronary sinus with R-EPOCH: a case report and literature review

Primary cardiac lymphomas (PCLs) are a rare clinical entity, in which treatment guidelines remain to be established. Rituximab, etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin (R-EPOCH) has been proposed, given that it involves a continuous infusion of anthracycline, reducing the risk of a cardiotoxicity and therefore the theoretical risk of perforation. However, the literature on this method of treatment is scarce. Herein, we present a unique case of a 75-year-old male, diagnosed with primary cardiac diffuse large B-cell lymphoma (DLBCL) with relatively unusual involvement of the coronary sinus, treated first with one cycle of R-EPOCH, followed by three cycles of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) to reduce said risk. To our knowledge, this is one of two cases, in which a patient with PCL was treated this way.

Is it a thrombus or a tumor? An imaging dilemma for clinicians

Atrial fibrillation, the most common cardiac arrhythmia in the Western world, confers a 5-fold increase in stroke, mainly due to thrombus formation in the left atrial appendage. Early rhythm control is often beneficial in reducing adverse cardiovascular events in higher-risk populations. Here, we present a patient who was found to have a 1 cm stalk-like lesion in the left atrial appendage on transesophageal echocardiogram prior to electrical cardioversion. Using multiple cardiac imaging modalities, including cardiac magnetic resonance imaging and computed tomography, the mass was eventually determined to be a chronic resolving thrombus.

A Rare Case of Stroke in a 76-Year-Old Woman: Left Atrial Papillary Fibroelastoma as the Culprit

BACKGROUND Papillary fibroelastoma is the most common type of benign primary cardiac tumor and is usually asymptomatic. However, tumor fragments or surface thrombus can embolize and cause transient ischemic attacks, strokes, or myocardial infarction. This report describes a 76-year-old woman who presented with dysarthria and right-sided weakness due to a stroke associated with a left atrial papillary fibroelastoma. CASE REPORT A 76-year-old woman visited the Emergency Department because she had right-sided weakness and dysarthria from 12 h ago. Brain magnetic resonance image was done at the Emergency Department, showing multiple small embolic, acute infarction in left basal ganglia and fronto-temporo-parietal lobes. Transthoracic and transesophageal echocardiogram showed a hypermobile echogenic mass (0.8×1.5 cm) with villous surface on the orifice of left atrial appendage. Twenty-four-hour Holter monitoring was performed to evaluate the cause of cerebral infarction, and there was no paroxysmal atrial fibrillation. Thoracic computed tomography angiography also showed a sea anemone-shaped mass around the left atrial appendage. Cardiac tumor excision was done via a lower partial sternotomy. Histopathologic analysis showed multiple delicate fronds, and the avascular fibroelastic cores were lined by a single layer of CD31-positive endothelial cells. Histopathologic findings were consistent with papillary fibroelastoma. The patient was discharged without any other complications on day 30 of hospitalization. CONCLUSIONS This case highlights the importance of cardiac imaging in patients with acute stroke, including transthoracic and transesophageal echocardiography, which can show the typical imaging features of papillary fibroelastoma and other intracardiac sources of embolus.

Intractable Ventricular Tachycardia Prior to an Overt Cardiac Tumor Mass of Metastatic Cardiac Rhabdomyosarcoma (Spindle-cell Type)

We herein report a 37-year-old man who experienced recurrence of metastatic cardiac rhabdomyosarcoma along with intractable ventricular tachycardia (VT) 7 years after resection of rhabdomyosarcoma in his right elbow. At 36 years old, he developed VT unresponsive to radiofrequency catheter ablation (RFCA). Initially, the cardiac tumor was not detected, but it gradually grew in size at the RFCA site. A surgical biopsy confirmed the diagnosis of metastatic cardiac rhabdomyosarcoma. Despite radiation therapy, cardiac tumor progression and VT instability could not be prevented. Ultimately, the patient died 27 months after the initial documentation of VT.

Radiologic-Pathologic Correlation of Cardiac Tumors: Updated 2021 WHO Tumor Classification

Cardiac tumors, although rare, carry high morbidity and mortality rates. They are commonly first identified either at echocardiography or incidentally at thoracoabdominal CT performed for noncardiac indications. Multimodality imaging often helps to determine the cause of these masses. Cardiac tumors comprise a distinct category in the World Health Organization (WHO) classification of tumors. The updated 2021 WHO classification of tumors of the heart incorporates new entities and reclassifies others. In the new classification system, papillary fibroelastoma is recognized as the most common primary cardiac neoplasm. Pseudotumors including thrombi and anatomic variants (eg, crista terminalis, accessory papillary muscles, or coumadin ridge) are the most common intracardiac masses identified at imaging. Cardiac metastases are substantially more common than primary cardiac tumors. Although echocardiography is usually the first examination, cardiac MRI is the modality of choice for the identification and characterization of cardiac masses. Cardiac CT serves as an alternative in patients who cannot tolerate MRI. PET performed with CT or MRI enables metabolic characterization of malignant cardiac masses. Imaging individualized to a particular tumor type and location is crucial for treatment planning. Tumor terminology changes as our understanding of tumor biology and behavior evolves. Familiarity with the updated classification system is important as a guide to radiologic investigation and medical or surgical management. ©RSNA, 2024 Supplemental material is available for this article.

Metastatic right atrial mass in the presence of atrial septal defect: A rare clinical coincidence

Key Clinical Message

The key takeaway from this clinical scenario is to choose the most appropriate and reasonable treatment plan when dealing with a patient who has atrial septal defect (ASD) and concurrent atrial and mediastinal masses. In such cases, a heart-oncology team should make the therapeutic decision.

Abstract

Right atrial masses are not pretty rare and might be a diagnostic challenge. Thrombosis, tumors, and vegetations are primary differential diagnoses. Workup for these masses usually includes multimodality imaging and biopsy in selected cases. We report a case of a 37-year-old lady who presented with cough, dyspnea, and head and neck swelling after a cesarean section. Echocardiography revealed a right atrial mass accompanied by a secundum type atrial septal defect (ASD). Pulmonary CT Angiography was performed, in which a lobulated mass in the anterior mediastinum was detected, and a heart-oncology team made the therapeutic decision. The patient was scheduled for surgical ASD closure and concomitant tissue biopsy. The pathology results were in favor of poorly differentiated germ cell tumors, and chemotherapy was started following the surgery. After two sessions of chemotherapy, the tumor did not respond to the primary regimen. Thus, an updated regimen was initiated. Compliance with the updated regimen was acceptable, and the patient is currently under treatment and follow-up.

Multimodality Imaging of Cardiac Myxomas

Cardiac myxomas are the most common benign cardiac neoplasms. Echocardiography is the first-line imaging modality used to analyze cardiac masses, allowing the detection of tumor location, size, and mobility. However, additional imaging techniques are required to confirm the diagnosis, evaluate tissue characteristics of the mass, and assess potential invasion of surrounding structures. Second-line imaging includes cardiac magnetic resonance imaging (MRI) and/or computed tomography (CT) depending on availability and the patient's characteristics and preferences. The advantages of CT include its wide availability and fast scanning, which allows good image quality even in patients who have difficulty cooperating. MRI has excellent soft-tissue resolution and is the gold standard technique for noninvasive tissue characterization. In some cases, evaluation of the tumor metabolism using 18F-fluorodeoxyglucose positron emission tomography with CT may be useful, mainly if the differential diagnosis includes primary or metastatic cardiac malignancies. A cardiac myxoma can be identified by its characteristic location within the atria, typically in the left atrium attached to the interatrial septum. The main differential diagnoses include physiological structures in the atria like crista terminalis in the right atrium and the coumadin ridge in the left atrium, intracardiac thrombi, as well as other benign and malignant cardiac tumors. In this review paper, we describe the characteristics of cardiac myxomas identified using multimodality imaging and provide tips on how to differentiate myxomas from other cardiac masses.

2024 CSANZ Position Statement on Indications, Assessment and Monitoring of Structural and Valvular Heart Disease With Transthoracic Echocardiography in Adults

Transthoracic echocardiography (TTE) is the most widely available and utilised imaging modality for the screening, diagnosis, and serial monitoring of all abnormalities related to cardiac structure or function. The primary objectives of this document are to provide (1) a guiding framework for treating clinicians of the acceptable indications for the initial and serial TTE assessments of the commonly encountered cardiovascular conditions in adults, and (2) the minimum required standard for TTE examinations and reporting for imaging service providers. The main areas covered within this Position Statement pertain to the TTE assessment of the left and right ventricles, valvular heart diseases, pericardial diseases, aortic diseases, infective endocarditis, cardiac masses, pulmonary hypertension, and cardiovascular diseases associated with cancer treatments or cardio-oncology. Facilitating the optimal use and performance of high quality TTEs will prevent the over or under-utilisation of this resource and unnecessary downstream testing due to suboptimal or incomplete studies.

Unusual Presentation of Cardiac Myxoma Mimicking Chronic Obstructive Pulmonary Disease (COPD) Exacerbation: A Report of a Rare Case

A cardiac myxoma is an authentic tumor that develops within the heart. Despite the typically benign histological characteristics, a cardiac myxoma may, on occasion, exhibit behavior reminiscent of malignant tumors. Most of these myxomas localize in the left atrium, often originating from a stalk near the foramen ovale region. The conventional presentation of cardiac myxomas includes a combination of obstruction, clot formation, and systemic symptoms, mirroring various other prevalent systemic diseases. They may manifest either spontaneously or through hereditary transmission. While familial myxomas are commonly linked to discernible genetic mutations, the precise molecular mechanisms underlying spontaneous myxomas remain somewhat enigmatic. Many individuals with myxomas may remain asymptomatic. However, should symptoms manifest, they can prove nonspecific and pose challenges in interpretation, particularly in instances of spontaneous heart myxomas. This report describes a 58-year-old female patient who presented with increasing severity of exertional dyspnea over a six-month duration. Initial differential diagnoses included common pulmonary and cardiac conditions, with a primary focus on chronic obstructive pulmonary disease and congestive heart failure. An echocardiogram revealed a large mass in the left atrium suggestive of a cardiac myxoma. Surgical resection confirmed the diagnosis. This case underscores the significance of including cardiac myxoma in differential diagnoses for progressive exertional dyspnea. Early detection and surgical intervention are crucial in mitigating potential complications like stroke, heart failure, or sudden cardiac death.

Primary cardiac angiosarcoma: Imaging characterization

This case report describes a 35-year-old female patient who presented with palpitations and shortness of breath. Imaging findings suggested a cardiac tumor, histopathology confirmed primary cardiac angiosarcoma. This tumor is highly aggressive, usually occurs in the right atrium, lacks specificity in clinical presentation, is prone to early metastasis, and has a poor prognosis. Echocardiography is the method of choice for early detection and is important in assessing tumor size, location, mode of attachment and whether cardiac function is impaired.

Isolated primary cardiac angiosarcoma

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

Right ventricular outflow tract obstruction by cardiac hemangioma in asymptomatic patient

Ventricular hemangiomas are rare benign tumors, pose diagnostic and therapeutic complexities. We report a case of a 52-year-old female with essential hypertension who developed a systolic ejection murmur during a hypertension clinic visit. The echocardiogram revealed a hyperechoic mass obstructing the right ventricular outflow tract, causing enlargement of the right atrium and ventricle, with a reduction in the right ventricular ejection fraction. Due to the risk of death, the patient underwent an emergency surgical resection along with tricuspid valve replacement. Postoperative recovery was uneventful, and subsequent cardiac magnetic resonance imaging showed an improvement in ejection fraction without residual tumor. This case highlights the diagnosis and therapeutic complexities of ventricular hemangiomas. With this report, we aim to provide a comprehensive review of ventricular hemangiomas and to enhance understanding of this condition for improved patient care.

Computer simulation-based nanothermal field and tissue damage analysis for cardiac tumor ablation

Radiofrequency ablation is a nominally invasive technique to eradicate cancerous or non-cancerous cells by heating. However, it is still hampered to acquire a successful cell destruction process due to inappropriate RF intensities that will not entirely obliterate tumorous tissues, causing in treatment failure. In this study, we are acquainted with a nanoassisted RF ablation procedure of cardiac tumor to provide better outcomes for long-term survival rate without any recurrences. A three-dimensional thermo-electric energy model is employed to investigate nanothermal field and ablation efficiency into the left atrium tumor. The cell death model is adopted to quantify the degree of tissue injury while injecting the Fe3O4 nanoparticles concentrations up to 20% into the target tissue. The results reveal that when nanothermal field extents as a function of tissue depth (10 mm) from the electrode tip, the increasing thermal rates were approximately 0.54362%, 3.17039%, and 7.27397% for the particle concentration levels of 7%, 10%, and 15% compared with no-particle case. In the 7% Fe3O4 nanoparticles, 100% fractional damage index is achieved after ablation time of 18 s whereas tissue annihilation approach proceeds longer to complete for no-particle case. The outcomes indicate that injecting nanoparticles may lessen ablation time in surgeries and prevent damage to adjacent healthy tissue.

STEMI or not STEMI? A multimodality imaging approach to a challenging intracardiac mass with a tricky presentation

Cardiac tumors, due to the various clinical scenarios and their histological subtypes, are still challenging for clinicians. They are differentiated into primary and secondary. The latest are more common and are usually lung and breast cancers, melanomas, and lymphoma metastasis. We present a case of a 73-year-old woman, with a history of breast cancer 10 years earlier, admitted to Cath lab for an elevation of the ST-segment of the electrocardiogram, myocardial infarction. Echocardiogram showed a curious abnormality in the myocardial wall. Thanks to a multimodality imaging strategy, including contrast-enhanced echocardiography and cardiac magnetic resonance, characterization of the underlying pathology was clear and, thus, the appropriate management and therapy.

Cardiac and Intramuscular Metastases Following Nephroureterectomy for Metachronous Urothelial Carcinoma

BACKGROUND We present a case of metachronous cardiac and intramuscular metastases in a patient with a known history of radical nephroureterectomy for upper-tract urothelial carcinoma (UTUC). CASE REPORT A 58-year-old man had a history of metachronous renal pelvis urothelial carcinoma with prior left radical nephroureterectomy. He was also diagnosed with malignancy-associated deep vein thrombosis (DVT) and was on rivaroxaban. He presented at an oncology follow-up consult with shortness of breath and right scapular lump. CT scan revealed a soft-tissue mass at the surgical bed suspicious for local recurrence, as well as intracardiac hypodensities and intramuscular nodules in the right latissimus dorsi and right adductor muscles. The intracardiac hypodensities were located in the left atrial appendage and inter-atrial septum. Given that the patient had a history of DVT and in a pro-thrombotic state, differentials for the intracardiac densities included intracardiac thrombi or metastases. The intramuscular hypodensities were rim-enhancing. Given that the patient was on rivaroxaban, differentials included hematomas or metastases. As there was no overlying bruising and the lesions remained unchanged in size clinically, they were treated as metastases. The patient was treated with clexane but re-presented with worsening of shortness of breath and palpitations. CT scan showed increased size of intracardiac lesions, suggesting no response to anticoagulation, and therefore were likely metastatic in nature. He completed a 2-year course of IV pembrolizumab and was in complete remission. CONCLUSIONS Our case highlights the importance of this clinically challenging scenario when patients with known malignancy and on anticoagulation present with cardiac or musculoskeletal symptoms. Though these patients are at risk of thrombus and haematoma, cardiac and intramuscular metastasis should be considered, as the prognosis is guarded.

Complete resection of a giant intrapericardial cardiac synovial sarcoma

Synovial sarcoma of the heart is a rare tumor. Herein we would like to report a case of giant intrapericardial cardiac synovial sarcoma that originated from the right ventricle and grew outward near the diaphragm. After making adequate preoperative preparation, we performed the surgery as quickly as possible and resected the tumor completely. Based on the identification of the translocation on chromosome 18 rearrangement, the tumor can be diagnosed as a primary cardiac synovial sarcoma. Through this study, we aim to afford more information about cardiac synovial sarcomas as well as a reference for similar cases.

Radiotherapy combined with anti-PD-1 and TKI for primary cardiac angiosarcoma considering the joint assessment of TLSs and PD-L1: a case report

BACKGROUND

Primary cardiac angiosarcoma(PCA) has a low incidence rate and poor prognosis. Currently, no unified clinical treatment standards are available.

CASE PRESENTATION

We report the case of a 48-year-old man presenting chest tightness, breathlessness, and dyspnea. Imaging and postoperative histopathologic studies confirmed PCA and that the tumor had invaded the entire right atrium. The patient developed progressive disease (PD) during postoperative radiotherapy. We used immunotherapy combined with targeted therapy based on the results of molecular profile and evaluation of tertiary lymphoid structures (TLSs) and programmed cell death-ligand 1 (PD-L1). After treatment, the metastatic lymph nodes of the patient were reduced to a certain extent, indicating that combination therapy was effective.

CONCLUSION

To the best of our knowledge, this is the first report of radiotherapy combined with anti-PD-1 and tyrosine kinase inhibitors(TKI) for PCA. In addition, this is the first report on immunotherapy for PCA based on new evaluation methods, including TLSs, PD-L1, and genomic profile.

A rare presentation of primary cardiac myxofibrosarcoma: Case report and literature review

BACKGROUND

Primary cardiac myxofibrosarcoma is a rare and aggressive malignancy, with the majority of approaching strategies relying on case reports. This article provides insights into its diagnosis and treatment.

CASE PRESENTATION

This paper presents the case of a 40-year-old man with sudden onset hemoptysis, leading to the diagnosis of primary cardiac myxofibrosarcoma. Treatment involved open-heart surgery to excise the left atrium tumor, followed by 6 cycles of adjuvant chemotherapy. Unfortunately, brain metastasis developed, leading to the patient's death 1 year after initial diagnosis.

CONCLUSION

Primary cardiac myxofibrosarcoma remains a clinical challenge with an unfavorable prognosis. Early diagnosis through advanced imaging is crucial, and research is needed to explore innovative treatments. This case underscores the complexities of managing this rare cardiac malignancy and highlights the necessity for ongoing investigations to enhance patient outcomes.

Epicardial Space: Comprehensive Anatomy and Spectrum of Disease

The epicardial space (ES) is the anatomic region located between the myocardium and the pericardium. This space includes the visceral pericardium and the epicardial fat that contains the epicardial coronary arteries, cardiac veins, lymphatic channels, and nerves. The epicardial fat represents the main component of the ES. This fat deposit has been a focus of research in recent years owing to its properties and relationship with coronary gossypiboma plaque and atrial fibrillation. Although this region is sometimes forgotten, a broad spectrum of lesions can be found in the ES and can be divided into neoplastic and nonneoplastic categories. Epicardial neoplastic lesions include lipoma, paraganglioma, metastases, angiosarcoma, and lymphoma. Epicardial nonneoplastic lesions encompass inflammatory infiltrative disorders, such as immunoglobulin G4-related disease and Erdheim-Chester disease, along with hydatidosis, abscesses, coronary abnormalities, pseudoaneurysms, hematoma, lipomatosis, and gossypiboma. Initial imaging of epicardial lesions may be performed with echocardiography, but CT and cardiac MRI are the best imaging modalities to help characterize epicardial lesions. Due to the nonspecific onset of signs and symptoms, the clinical history of a patient can play a crucial role in the diagnosis. A history of malignancy, multisystem diseases, prior trauma, myocardial infarction, or cardiac surgery can help narrow the differential diagnosis. The diagnostic approach to epicardial lesions should be made on the basis of the specific location, characteristic imaging features, and clinical background. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Perinatal Results and Long-Term Follow-Up of Fetal Cardiac Tumors: A 30-Year Historical Cohort Study

BACKGROUND

This was a 30-year retrospective cohort study that approximates closely to the natural history of cardiac tumors diagnosed in the fetus, since there was no case of pregnancy interruption.

OBJECTIVE

To assess morbidity and mortality in the perinatal period and at long term in fetuses diagnosed with cardiac tumor. Our secondary objective was to assess the evaluating factors of perinatal and postnatal results.

METHODS

This was a retrospective cohort study with 74 pregnant women with an echocardiographic diagnosis of fetal cardiac tumor at two referral centers between May 1991 and November 2021. A descriptive analysis was performed, and data were expressed as absolute (n) and relative (%) frequencies, median and interquartile range. Fisher's exact test was used to evaluate the association of echocardiographic characteristics and clinical manifestations with perinatal and postnatal results. Global survival was calculated using the Kaplan-Meier method and the curves were compared by the log-rank test. The time of follow-up, calculated in months, corresponded to the time elapsed from hospital discharge to current status (survived/ censoring or death). The level of significance was set at 5% (p<0.05).

RESULTS

Rhabdomyoma is the most common type of cardiac tumor (85%), with a high morbidity (79.3%) and overall mortality of 17.4%. The presence of fetal hydrops was a predictor of death.

CONCLUSION

The presence of fetal hydrops had an impact on mortality, and hence is an important factor in counselling and determining the prognosis. Most deaths occurred before hospital discharge.