The 2021 WHO Classification of Tumors of the Heart

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.

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.

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.

Epicardial cavernous haemangioma; A case report of a unique incidental finding

Background

Primary cardiac tumours are rare, accounting for only 0.002-0.03% at autopsy. Cardiac haemangiomas are benign vascular tumours and constitute for 0.28% of all primary cardiac tumours. Cavernous haemangiomas, capillary haemangiomas, and arteriovenous haemangiomas are three distinct types. Cardiac haemangiomas are often misdiagnosed as myxomas and must be differentiated from malignant angiosarcomas.

Case summary

We present a 44-year-old Mediterranean male patient with a cavernous haemangioma in the inferior vena cava and right atrium, detected on transthoracic echocardiography. The patient experienced palpitations and dyspnoea on exertion. Computed tomography (CT) angiography revealed a 7.5 × 6 × 5 cm mass suspected to be perfused by the distal right coronary artery. A watch-and-wait approach was suggested, leading to a cardiac magnetic resonance imaging (MRI) with contrast 6 months later. T1 mapping exhibited a prolonged relaxation time and isointensity to the myocardium. T2 mapping revealed a homogenous hyperintense mass with heterogenous late enhancement. Surgical excision was performed using a bicaval cannulation technique on cardiopulmonary bypass. Intraoperatively, no connection to the coronaries was noted. At 1 year follow-up, the patient reported restored physical resilience, with no evidence of tumour recurrence.

Discussion

Clinical symptoms of cardiac cavernous haemangiomas are unspecific and become evident once the tumour grows. To investigate the nature and vascular involvement of the tumour, a contrast-enhanced CT angiography or MRI can be performed. Cardiac haemangiomas are often misdiagnosed and must be differentiated from malignant angiosarcomas. Clear guidelines for the treatment of cardiac haemangiomas in adult patients are lacking. Primary cardiac tumours require thorough investigation, and surgical intervention should be tailored to the individual's case.

Surgical resection of primary intracardiac sarcomas and outcomes: A review of case reports over 20 years

Objective

A quarter of all cardiac tumors are malignant, and most (~ 95%) are sarcomas. It is the most aggressive malignant cardiac tumor carrying the worst prognosis. Tumor involvement with the vital intracardiac structures makes it difficult for complete surgical resection. We aimed to study the role of complete surgical resection and its importance in long-term outcomes.

Methods

We analyzed published literature from 2002 to 2022 using PubMed. Cases reported adult, intracardiac sarcomas, and received surgical resections were included. We reviewed 132 published case reports, including and analyzed the following variables: demographics, clinical presentations, diagnostic imaging modality, the extent of surgical resection, pathological diagnosis, tumor location, postoperative chemo-radiation therapy, and follow-up (including re-operation, local and distant recurrence).

Results

A total of 135 patients are included from 132 articles. The mean age was 46.69 (18-86) and 76 patients were females. The main complaints were dyspnea (70%) and chest pain (32%). Performed investigations were transthoracic echocardiography (TTE) in 114/135 (84%), computer tomography (CT) scan 89/135 (66%), trans-esophageal echocardiography (TOE) 22%, and cardiac magnetic resonance imaging (MRI) 29%. The most common location was the atrium (left 46%, right 30%). Complete surgical resection was performed in 91 cases (67%), and frozen section was performed in 62 patients (43 positives). Incomplete resections were in 42 cases. Patients who underwent complete surgical resection had mean survival of 14.58 months and median of 10.5 months, compared to incomplete resection patients with 9.12 months and 6.5 months respectively.

Conclusion

Our review shows complete surgical resection results in better short- and long-term outcomes in intracardiac sarcoma patients. Furthermore, combining chemo-radiotherapy has additional benefits towards long-term survival.

Cardiac Hemangioma in the Left Ventricular Septum

Background  Primary cardiac tumors are an exceedingly rare benign group of tumors that may remain asymptomatic for a prolonged duration or could lead to significant clinical events. Case Presentation  A 64-year-old female patient underwent echocardiography prior to elective knee surgery due to the presence of palpitations and dyspnea. This revealed the existence of a mass located on the left side of the interventricular septum, which was resected successfully. Conclusion  Surgical resection represents the primary therapeutic approach for the management of cardiac hemangiomas. Failure to perform timely resection may elevate the risk of developing total atrioventricular block and experiencing sudden death.

Cardiac Masses and Pseudomasses: An Overview about Diagnostic Imaging and Clinical Background

A cardiac lesion detected at ultrasonography might turn out to be a normal structure, a benign tumor or rarely a malignancy, and lesion characterization is very important to appropriately manage the lesion itself. The exact relationship of the mass with coronary arteries and the knowledge of possible concomitant coronary artery disease are necessary preoperative information. Moreover, the increasingly performed coronary CT angiography to evaluate non-invasively coronary artery disease leads to a rising number of incidental findings. Therefore, CT and MRI are frequently performed imaging modalities when echocardiography is deemed insufficient to evaluate a lesion. A brief comprehensive overview about diagnostic radiological imaging and the clinical background of cardiac masses and pseudomasses is reported.

Case series: cardiac sarcoma

Background

Cardiac masses encompass a wide differential including primary and secondary malignancies and can present with a variety of symptoms, many of which are non-specific. Early identification and classification are important, particularly for cardiac malignancies such as sarcomas as these are aggressive tumours with exceptionally poor prognoses when metastases are present at diagnosis.

Case summary

We report two cases of patients who presented with dyspnoea and were diagnosed with cardiac sarcomas; the former a primary sarcoma (undifferentiated pleomorphic subtype) and the latter a secondary sarcoma (round cell myxoid liposarcoma) that serve as comparisons for presentation and management of different types of this disease. Computed Tomography (CT) and echocardiography imaging findings are demonstrated showing the typical location and morphology of each subtype.

Discussion

Cardiac sarcomas are the most common primary cardiac malignancy, of which undifferentiated pleomorphic sarcoma is a common subtype. Undifferentiated pleomorphic sarcomas are aggressive, have a tendency to arise in the left atrium, and can appear similar to benign cardiac masses. Round cell myxoid liposarcomas by contrast are rare causes of secondary cardiac malignancies, metastasizing to the heart from soft tissues. Both diagnoses carry poor prognoses and although rare, are important to recognize as timely intervention with surgery, radiotherapy, and consideration of chemotherapy is key to maximizing survival.

Surgical experience in cardiac myxomas at a tertiary hospital

INTRODUCTION

Cardiac myxomas account for 50% of all benign cardiac tumors. Their clinical presentation varies from embolisms to fever. Our objective was to describe the surgical experience in the resection of cardiac myxomas during an 8-year period.

METHODS

This is a retrospective, descriptive study of a series of cases with cardiac myxomas diagnosed from 2014 to 2022 at a tertiary care center. Descriptive statistics were used to define the populational and surgical characteristics. We used Pearson's correlation to study the relationship between postoperative complications and age, tumor size and affected cardiac chamber.

RESULTS

31 patients were included, with a predominance of females (1:2 ratio). The prevalence was 0.44%, which was calculated based on the number of cardiac surgeries performed in our unit over the 8-year period. The main clinical manifestation was dyspnea (85%, n = 23), followed by cerebrovascular event (CVE) (18%, n = 5). Atriotomy and resection of the pedicle were performed with preservation of the interatrial septum. Mortality was 3.2%. The postoperative evolution was uneventful in 77%. Tumor recurrence occurred in 2 patients (7%), both debuting with embolic phenomena. No association was observed between postoperative complications or recurrence and tumor size, nor aortic clamping and extracorporeal circulation times with regard to age.

CONCLUSIONS

Four atrial myxoma resections are performed in our unit per year, with an estimated prevalence of 0.44%. The tumor characteristics described coincide with the previous literature. A relationship between embolisms and recurrences cannot be ruled out. Wide surgical resection of the pedicle and base of tumor implantation may influence tumor recurrence, although further studies are needed.

MR imaging of primary benign cardiac tumors in the pediatric population

Primary cardiac tumors are rare in all ages, especially in children, with a reported prevalence range of 0.0017-0.28% in autopsy series. Due to their rarity, the diagnostic and therapeutic pathways reserved to them are usually described by single case reports, leading to the point where a common diagnostic protocol is imperative to obtain a differential diagnosis. The first diagnostic approach is done with transthoracic echocardiogram (TTE), due to its wide availability, low cost, absence of ionizing radiations and non-invasiveness. Several tumors are discovered incidentally and, in many cases, TTE is helpful to determine location, size and anatomical features, playing a key role in the differential diagnosis. In the last few years, cardiac magnetic resonance imaging (CMR) has had an increased role in the diagnostic pathway of pediatric cardiac masses, due to its high accuracy in characterizing mass tissue properties (especially for soft tissue), and in detecting tumor size, extent, pericardial/pleural effusion, leading to the correct diagnosis, treatment and follow-up. Therefore, nowadays, several consensus statements consider CMR as a leading imaging technique, thanks to its non-invasive tissue characterization, without the use of ionizing radiation, in an unrestricted field of view. As suggested by the most recent literature, the pediatric protocol is not so different from the adult one, adapted to the size and cardiac frequency of the patient, sometimes requiring special conditions such as free-breathing sequences and/or sedation or general anesthesia in non-cooperating patients.

Multimodality imaging assessment of primary pericardial rhabdomyosarcoma: a case report

Primary pericardial sarcomas are rare and lethal diseases. To date, only a few cases of primary pericardial sarcomas, such as rhabdomyosarcoma (RMS), have been reported. Since the unusual location of RMS in the pericardium makes it challenging to diagnose, precise diagnostic procedures are required. In this study, we present the case of a 23-year-old man who experienced postprandial obstruction and atypical precordial pain that lasted for a week. Echocardiography revealed a heterogeneous isoechoic pericardial mass with a significant pericardial effusion. Contrast-enhanced CT revealed a massive pericardial effusion along with an irregular, defined, heterogeneously enhancing mass that was located between the pericardium and diaphragm. PET-CT imaging showed an intense FDG uptake in the pericardial mass. Furthermore, cardiac MRI demonstrated malignant characteristics of the pericardial mass and provided a detailed visualization of its exact anatomical connection with both cardiac and extracardiac structures. Finally, a pathologic examination of a puncture biopsy specimen confirmed the diagnosis of primary pericardial RMS. Our case emphasizes the importance of multimodal imaging for the differential diagnosis and evaluation of cardiac involvement, while providing clinicians with crucial information for clinical treatment and decision-making.

Morphological characteristics of cardiac myxoma causing embolism: a series of 40 years of experience at a single institute

Systemic and cerebral embolisms are serious complications of associated with cardiac myxoma. Embolism risk reportedly depends on the gross and histological morphology. This study is aimed at analyzing the morphologic pattern of excised cardiac myxoma as a high-risk embolic cause. Between 1978 and April 2022, 116 surgical specimens of cardiac myxomas were recorded at the pathology department of our hospital. The tumors were classified into three types based on their macroscopic shapes and external morphology-round-smooth, irregular, and villous-to investigate the embolic complications. Of the 116 specimens, 106 macroscopic images of cardiac myxoma (89% were located in the left atrium) were prepared. Round-smooth types were found in 36 (34.0%) patients, irregular types in 32 (30.2%) patients, and the villous types in 38 (35.8%) patients. Multivariable analysis revealed that a villous external appearance was an independent predictor of embolic events (odds ratio: 8.7; 95% confidence interval: 2.4-42.1; p < 0.001). Villous external appearance of cardiac myxoma was associated with the highest risk of distal embolism.

A “Ping-Pong” left atrial thrombus mimicking left atrial myxoma: A case report

Introduction

Valvular heart disease is highly prevalent, especially in developing countries. Mitral Stenosis (MS) is a condition where there is narrowing of mitral heart valve. Left atrial (LA) thrombus is often seen in severe MS patients.

Case presentation

A 47-year-old woman complained of palpitation and shortness of breath. The heart sounded irregularly irregular, with grade III/IV diastolic murmurs at the apex. Her electrocardiogram showed atrial fibrillation (AF) with rapid ventricular response Transthoracal echocardiography (TTE) showed severe MS, mild tricuspid regurgitation, and LA thrombus. Mitral valve replacement surgery, tricuspid valve repair, and evacuation of the LA thrombus were immediately done. We evacuated a spherical mass with a size of 4 × 3x2.2 cm, layered and easily separated. Microscopic examination showed extensive fibrin and bleeding with mononuclear inflammatory cells and macrophages, corresponding to a thrombus conclusion.

Clinical discussion

Atrial thrombus is common in MS patients. The incidence will increase by about two times in patients with AF. TTE is a reliable tool in diagnosing large mobile atrial thrombus and differentiated it from other cardiac masses. However, histopathological examination is still the gold standard to distinguish between LA thrombus and myxoma. Immediate thrombus evacuation and valve replacement, if needed, will give good results and reduce systemic thromboembolism.

Conclusion

LA thrombus is often seen in a patient with severe MS. Optimal preoperative preparation involves assessing preoperative risk stratification will give good results.

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Left atrial thrombus is often seen in a patient with severe mitral stenosis with atrial fibrillation.

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Transthoracal echocardiography is an essential and simple modality to diagnose cardiac masses such as large mobile atrial thrombus or myxoma.

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Histopathological examination is the gold standard to distinguish between atrial thrombus and myxoma.

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Several scoring systems can help to assess preoperative preparation such as EuroSCORE and STS score.