Surgical implications in malignant cardiac disease

A monster into the heart: an unusual presentation of cardiac leiomyosarcoma

BACKGROUND

Malignant primary cardiac tumors are infrequent and can lead to an unfavorable prognosis if not identified and treated promptly. Early detection and prompt treatment of malignant primary cardiac tumors are crucial for a better prognosis. This article presents a case of primary cardiac leiomyosarcoma and reviews the literature on this topic.

CASE PRESENTATION

Female patient that developed recurrent pericardial effusion and hemodynamic instability caused by a cardiac tumor, later identified as leiomyosarcoma. Multidisciplinary treatment was administered to the patient.

CONCLUSIONS

The initial approach to this type of pathology should include multimodality imaging to establish a prompt diagnosis leading to complete standard treatment, to minimize risks to the patient's heart function which may include resection with complete margins of the neoplasm, otherwise the prognosis may be poor.

New curative approach using embolization followed by moderate-dose radiotherapy after surgical failure for large right heart metastasis

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Rapid improvement observed in a patient with a large cardiac metastasis.

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There is today no curative therapeutic option when the tumor is inoperable.

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Transcoronary tumor embolization plus moderate targeted radiotherapy should be a new option for tumor control.

Purpose

Cardiac metastasis is a rare fatal event. An intracavitary right tumor mainly in the ventricle is difficult to manage. Literature reports suggest that cardiac surgery in oligometastatic patients could offer median survival of 1 year. We investigated salvage treatment comprising transcoronary tumor embolization followed 15 days later by cardiac radiotherapy (40.5 Gy/15 fractions).

Cases

We report two cases of severe right cardiac metastasis with a history of abdominal cancer managed by this salvage treatment following residual cardiac mass after previous cardiac surgery.

Conclusion

Both symptomatic patients improved progressively and were locally controlled for at least 1 year without toxicity.

Left atrial high-grade rhabdomyosarcoma; an unusual location

A 63-year-old diabetic and hypertensive lady presented in New York Heart Association class III-IV dyspnea on exertion. Echocardiography showed a large mass attached to the anterior mitral leaflet and the base of the interatrial septum. After removal of the mass and excision of the anterior and posterior mitral leaflets, a bioprosthetic valve was deployed. The postoperative course was uneventful. Histopathology showed that the tumor was a high-grade rhabdomyosarcoma. Although it is a highly lethal tumor, surgical removal was indicated to relieve dyspnea, clarify the diagnosis, and improve short-term survival. Our patient survived for 8 months after surgical excision.

Postoperative chemotherapy and radiation improve survival following cardiac sarcoma resection

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Two Decades of Contemporary Surgery of Primary Cardiac Tumors

Objective  The decision to operate cardiac tumors is an issue of balancing surgical outcome and survival with quality of life (QOL). We report our single-center experience in managing primary cardiac tumors between 1994 and 2014.

Methods and Results  In this study, 269 patients were subjected to our standardized operative protocols, preoperative preparations, postoperative follow-up, and consents of participation. Demographic and preoperative/intraoperative/postoperative variables were collected with focus on long-term follow-up and survival. A total of 72,000 cardiac procedures were performed within 20 years at our institution. Two hundred sixty-nine patients were diagnosed with primary cardiac tumors (0.37%), with a male:female ratio of 1:1.68, mean age of 57.4 ± 19.5 years, and body mass index of 25.49 ± 6.5. The most presenting symptoms were dyspnea ( n  = 94), arrhythmias ( n  = 53), embolic event ( n  = 36), and chest pain ( n  = 29), and 33 patients were accidentally discovered. Isolated tumor excision and concomitant ablation were performed on 181 patients, while the rest needed additional procedures such as coronary artery bypass grafting ( n  = 27) or valve surgery ( n  = 61). Focus on pathology, tumor location was done reporting the commonest pathology such as myxoma ( n  = 177) and fibroelastoma ( n  = 56). The frequent site was the left atrium ( n  = 162). Our primary results showed incidence of bleeding in 9 patients (3.3%), arrhythmias in 76 patients (28.25%), and mortality in 49 patients (18.2%). Five patients (1.8%) showed recurrence and 220 patients (81.8%) showed complaint-free survival.

Conclusion  Complete excision of primary cardiac tumors is the golden rule in management as it improves survival and decreases morbidity expected from the progressing tumors process. The progression of minimally invasive techniques improves QOL and should be performed whenever possible.

Huge right ventricular mass lesion associated with genital malignant tumor: a case report

Background

Primary heart tumors are rare, whereas metastatic heart tumors occur more frequently.

Case presentation

We report a case of a 75-year-old Japanese woman who had metastatic heart tumors of the right ventricle. Although she initially received antibiotic therapy following a diagnosis of pneumonia and pleuritis, her symptoms worsened, and she developed dyspnea and bilateral lower limb edema. Echocardiography showed a huge mass lesion occupying the entire right ventricle. Because the patient’s tumor markers were elevated, we used computed tomography to search for the primary lesion, which was located in the vagina or the uterus. Histology demonstrated the presence of basaloid squamous cell carcinoma in the vaginal tissue. Chemotherapy with paclitaxel and carboplatin was initiated.

Conclusions

These data suggest that the tumor in the right ventricle metastasized from the genital organs.

Primary Cardiac Leiomyosarcoma: A 27-Month Survival with Surgery and Chemotherapy

The patient was a 39-year-old man hospitalized due to the presence of a cardiac mass and heart failure. Emergency tumor resection and mitral valve replacement were performed. The pathological findings of the tumor led to a diagnosis of cardiac leiomyosarcoma. After the operation, multiple metastases were found. The patient underwent three courses of chemotherapies: adriamycin, ifosfamide, dacarbazine, and mesna (MAID therapy), gemcitabine plus docetaxel, and sunitinib. During MAID therapy, the patient underwent resection of gastrointestinal metastases twice due to gastrointestinal hemorrhaging. Although he died 27 months after the initial treatment, use of multimodal therapy was effective in achieving a longer survival for the patient.

Cardiac metastasis in cervical cancer

Metastasis of cervical carcinoma to the heart is uncommon. Most cases are found during autopsy. These type of metastasis occur mostly in epicardium and myocardium. We present a case report of a patient with carcinoma cervix stage IIIB who presented to the hospital with pitting edema of right lower limb, post 1 year of completion of treatment. PET-CT scan showed FDG avid inguinal, iliac and retroperitoneal lymph nodes, which were bulky on right side causing pedal edema. There was FDG avid uptake seen in right atrial wall and in the atrioventricular groove indicative of metastasis to the heart. Patient refused biopsy or further treatment and hence received best supportive care only. She had a disease free survival of 12 months, and survived for 11 months after being diagnosed with recurrence. Overall survival was 23 months.

Surgical treatment of primary cardiac valve tumor: early and late results in eight patients

Background

To report early and late outcomes of patients with the primary cardiac valve tumor undergoing surgical treatment over a 30-year period in our cardiovascular center.

Methods

From January 1980 to December 2014, a total of 211 patients with primary cardiac tumors accepted surgical treatments, of which only 8 (3.8 %) were primary cardiac valve tumor patients in our surgical center of cardiovascular.

Results

The diagnosis was identified by echocardiography preoperatively and pathological analysis postoperatively. All patients underwent intracardiac procedures with extracorporeal circulation. Intracardiac procedures included resection of tumor on leaflet in 2 patients (25 %), resection of tumor and native valvuloplasty in 2 patients (25 %), resection of neoplasm and replacement of native valve with prosthetic valve in 4 patients (50 %). One man was performed a resection of tumor on aortic noncoronary leaflet and a coronary artery bypass graft. Eight cases of primary valve tumor occured in all of four cardiac valves. The majority of valvular tumor was myxoma in 3 cases (37.5 %), followed by the papillary fibroelastomas in 2 cases (25 %). There were one rhabdomyoma (12.5 %), one lipoma (12.5 %) and one mild malignant sarcoma (12.5 %). The mitral valve was the most commonly original valve (62.5 %). There was pulmonic (12.5 %), aortic (12.5 %) and tricuspid (12.5 %) valve tumor each one patient. There was no death and recrudescence in the series. Follow-up of all patients ranged from 1 to 16 years (mean 7.06±4.24 years). There was no recrudesce and cardiac valve dysfunction. 

Conclusion

The incidence of primary valve tumor was very low. More understanding of the rare disease and widespread use of echocardiography would greatly improve the diagnosis of primary valve tumor in the early stage. Echocardiography could detect millimeters in diameter neoplasms on cardiac valve. The diagnoses were based on imaging findings and the classical triad symptoms associated with the hemodynamic abnormalities, the organ embolism and the systemic symptoms directly from tumors. The intraoperative frozen sections and postoperative pathology analysis provided accurate diagnosis and supported the treatment strategies. Early diagnosis and intervention were keys to reserve the normal original valve function. Prompt surgical resection is necessary to prevent potential critical events.

Role of palliative radiotherapy in the management of mural cardiac metastases: who, when and how to treat? A case series of 10 patients

Cardiac metastases (CM), although a rare manifestation of metastatic cancer, are increasing in incidence with the improved prognosis and increased longevity of many patients with cancer. This condition may be life‐threatening, especially for bulky rapidly growing tumors. Such cancer presentations may be amenable to palliative radiotherapy to improve symptoms and to prevent further cardiac function decline. Here, we report on our experience with 10 patients with mural CM who received radiotherapy (RT) to the heart with palliative intent. The radiation treatment was given in different clinical situations using different dose and fractionation, and with a variety of outcomes. Palliative RT was a reasonably effective treatment, leading to good radiographic response in five patients who were evaluable for radiologic response. The mean duration of response in responding patients was 6.3 months (range: 3–11 months). This report describing clinical dilemmas around CM radiation therapy summarizes the previous experiences with radiation in treatment of CM and may assist in the considerations of palliative treatment for these patients.

Prognostic analysis for survival after resections of localized primary cardiac sarcomas: a single-institution experience

BACKGROUND

Primary cardiac sarcomas are rare diseases with a poor prognosis. This study aims to provide a prognostic analysis after different levels of resections of cardiac sarcomas.

METHODS

Twenty-nine patients undergoing resections of primary cardiac sarcomas at the Zhongshan Hospital from September 1995 to July 2012 were retrospectively reviewed.

RESULTS

There were 15 women and 14 men. The mean age was 41.0 years. The most common histologic type was angiosarcoma (28%). The median survival for the entire cohort was 17 months (range, 5 to 216 months). Patients with microscopically negative margin (R0) resections had a better median survival than those with microscopically positive margin (R1) resections (58 months versus 11 months; p<0.001). The median survival after an R1 resection was not different from that after a partial resection (12 months; p=0.81). The median local recurrence-free survival after an R0 resection was longer than that after an R1 resection (36 months versus 6 months; p<0.001). Five patients who underwent R0 resections and repeated resections of local recurrences or metastases had the longest median survival of 72 months. None of the patients with R0 resections received adjuvant therapy. Multimodality treatment after R1 and partial resections slightly increased the survival.

CONCLUSIONS

For nonmetastatic and localized primary cardiac sarcoma, an R0 surgical resection of cardiac sarcomas should be performed. Aggressive surgical treatment or radiation therapy for local recurrence or metastasis prolongs the survival. Multimodality treatment is recommended after incomplete resections of cardiac sarcomas. The role of adjuvant chemotherapy after R0 resections is unclear.

Round cell liposarcoma metastatic to the heart

Myxoid liposarcoma is a soft tissue tumor in adults with rare cardiac involvement. We report a 50-year-old female with high grade round cell liposarcoma of the left knee with metastases to the right heart chambers. The tumor was located in the right atrium with extension to right ventricle. The Patient underwent radiotherapy after surgical resection and 12-month follow-up revealed no recurrent cardiac disease.

Metastatic liposarcoma of the heart. Case series and brief literature review

Secondary cardiac tumors are 20-40 times more frequent than primary lesions. Primary cardiac lesions are represented by myxomas when related to benign tumors, and by sarcomas in terms of malignant disease. Metastases to the heart from liposarcomas are very rare. We present three cases of secondary liposarcomas involving the left atrium, the right atrium, and the pericardium.

Symptomatic cardiac metastases of breast cancer 27 years after mastectomy: a case report with literature review--pathophysiology of molecular mechanisms and metastatic pathways, clinical aspects, diagnostic procedures and treatment modalities

Metastases to the heart and pericardium are rare but more common than primary cardiac tumours and are generally associated with a rather poor prognosis. Most cases are clinically silent and are undiagnosed in vivo until the autopsy. We present a female patient with a 27-year-old history of an operated primary breast cancer who was presented with dyspnoea, paroxysmal nocturnal dyspnoea and orthopnoea. The clinical signs and symptoms aroused suspicion of congestive heart failure. However, the cardiac metastases were detected during a routine cardiologic evaluation and confirmed with computed tomography imaging. Additionally, this paper outlines the pathophysiology of molecular and clinical mechanisms involved in the metastatic spreading, clinical presentation, diagnostic procedures and treatment of heart metastases. The present case demonstrates that a complete surgical resection and systemic chemotherapy may result in a favourable outcome for many years. However, a lifelong medical follow-up, with the purpose of a detection of metastases, is highly recommended. We strongly call the attention of clinicians to the fact that during the follow-up of all cancer patients, such heart failure may be a harbinger of the secondary heart involvement.

Tachyarrhythmia secondary to cardiac metastasis as first presentation of non-small-cell lung cancer

We describe a man who presented at our institution with tachyarrhythmia and dyspnea. Echocardiography, magnetic resonance imaging (MRI) and computed tomography (CT) of the chest performed during hospitalization revealed a mass within the left atrium. A biopsy of the mass showed a non-small-cell lung cancer, adenocarcinoma G3. Metastatic involvement of the heart is rare; most cases are asymptomatic and diagnosed only during autopsies. Echocardiography, CT scan and MRI are complementary investigations in the evaluation of cardiac lesions. In the setting of cardiac metastatic cancer, all management is palliative.

Outcomes after right-side heart sarcoma resection

BACKGROUND

In patients with primary cardiac sarcoma, the tumor's location is more important than cell type in determining patient presentation, therapy options, and outcomes. The purpose of the current study was to investigate the outcomes after right-side heart sarcoma resection.

METHODS

Clinicopathologic data from patients who underwent right-side heart sarcoma resection at our institution and patients identified in a literature search were examined. Morbidity and the 30-day mortality rate and survival were determined. We used univariate and multivariate analyses to identify independent predictors of overall survival.

RESULTS

We identified 57 patients who underwent right-side heart sarcoma resection. Right-side heart failure was the most common complication (4 patients, 19%), and the 30-day mortality was 14% (3 patients). The overall 5-year survival rate was 17%, and the median overall survival duration was 9 months. Multivariate analyses revealed that surgical margin status was the only independent predictor of survival. Patients with negative surgical margins had a longer median overall survival duration (27 months versus 4 months) and a significantly higher overall 5-year survival rate (36% versus 0%; p = 0.0003) than patients with positive surgical margins.

CONCLUSIONS

The patients with right-side heart sarcoma resection had worse survival after resection than that reported for our patients who underwent resection for left-side heart sarcoma or pulmonary artery sarcoma. Because positive surgical margin status is an independent predictor of reduced survival, induction chemotherapy should considered to enhance resectability in right-side heart sarcoma patients, thus maximizing the possibility of obtaining negative surgical margins.

Primary Cardiac Angiosarcoma in a Young Woman

A 30-year-old woman was admitted to our hospital with severe shortness of breath. A transthoracic echocardiogram showed moderate pericardial effusion with a lesion in the right atrium, confirmed by chest CT scan and cardiac RMN. Pleural and middle lobe involvement occurred within one month. Middle lobe biopsy was performed and pathological examination confirmed the diagnosis of metastatic angiosarcoma. After two months, because of recurrent pleural effusions, chemical pleurodesis was performed. Chemotherapy was started but the patient died four months after the diagnosis. This case highlights the misdiagnosis at initial clinical presentation, available diagnostic approaches and therapeutic options for cardiac angiosarcoma.

Reconstruction of two independent neo-atria after resection of recurrent leiomyosarcoma

We describe a case of a patient with recurrent leiomyosarcoma involving both atria after a previous right pneumonectomy. The patient was treated with wide resection of the mass and separate reconstruction of the cardiac cavities with prosthetic material.

Outcomes after surgical resection of cardiac sarcoma in the multimodality treatment era

OBJECTIVE

Primary cardiac sarcomas are rare tumors carrying poor prognosis. Resection remains the primary therapy. Especially in recent years, chemotherapy and radiation have been used adjunctively.

METHODS

All patients (n = 27) surgically treated for primary cardiac sarcoma at two tertiary referral centers from January 1990 to January 2006 were retrospectively reviewed.

RESULTS

There were 13 women and 14 men, with 26 resections and 1 palliative debulking performed. Cardiac explantation was necessary in 8 cases because of tumor location. Concomitant valve surgery (repair or replacement) or coronary artery bypass grafting was performed in 9 and 3 patients, respectively. Synchronous or staged resections of associated pulmonary metastases were performed in 6 and 2 patients, respectively. Operative mortality was 7.4% (2/27). Preoperative or postoperative chemotherapy was administered to 16 and 19 patients, respectively. At follow-up (median 22 months, range, 2-119 months), 12 patients were alive, with 7 tumor free. Among patients who underwent resection with curative intent and survived surgery (n = 24), median survival was 23.5 months (range 4-119 months). Patients who underwent surgical resection, radiofrequency ablation, or radiation treatment for tumor recurrence (local or metastatic, n = 7) had median survival of 47 months (range 16-119 months), whereas patients with no further intervention for recurrent disease (n = 7) had median survival of 25 months (range 8-34 months).

CONCLUSIONS

Multimodal therapy can achieve reasonable survival for patients with resected cardiac sarcomas. Patients with local tumor recurrence or metastatic disease may still benefit from aggressive treatment.

Malignant primary cardiac tumors: review of a single institution experience

BACKGROUND

Primary cardiac sarcomas are uncommon. The authors undertook to review the Mayo Clinic's experience with primary cardiac sarcomas consisting of 34 patients seen over a 32-year period.

METHODS

The patient database at the Mayo Clinic was searched to identify patients with malignant tumors of the heart seen during the 32-year period between 1975 and 2007. Thirty-four patients with primary cardiac sarcomas were identified and their medical records reviewed for details pertaining to presenting symptoms, staging modalities, treatment approaches, and outcomes.

RESULTS

Of the 34 patients, 17 were men and 17 were women. The median age was 44 years. The mean duration of symptoms at the time of diagnosis was 3.6 months. The most common histologic type was angiosarcoma (41%). The median follow-up for the entire group was 12 months (range, 0-61 months). The median survival for those who underwent a complete surgical excision was 17 months compared with 6 months for those in whom a surgical complete remission could not be achieved (P = .01). Patients with angiosarcoma had a lower survival compared with patients with other histologies (5 months vs 17 months; P = .01). The median survival of patients with metastatic disease was 5 months versus 15 months in patients without metastatic disease (P = .03 by the log-rank test).

CONCLUSIONS

Cardiac sarcomas remain a rare but lethal disease. Compared with extracardiac sarcomas, the prognosis for patients with cardiac sarcomas remains very poor. A complete surgical excision should be performed if possible. Innovative treatment strategies are required.

[Cardiac metastases and colorectal cancer: a case study]

We report the case of a patient with asymptomatic and fortuitously detected right ventricular colorectal cancer metastasis. These metastatic lesions are uncommon and after a description of the index case we provide a review of the most recently published cases.

Right atrial mass presenting as cardiac tamponade

Intracavitary tumors such as angiosarcomas are prone to embolize, and occlude valves and vessels. Intramyocardial tumors cause cardiac failure and arrhythmias. Pericardial tumors cause effusions which result in tamponade. It is very rare that an intracavitary tumor presents itself with a cardiac tamponade. A 32-year old woman presented to the emergency room with palpitation and shortness of breath. Her physical examination revealed pulsus paradoxus and jugular venous distention. The transthoracic echocardiography showed normal left ventricular function, and an intracavitary right atrial mass. As the patients clinical status deteriorated an emergency operation was performed. The hemorrhagic pericardial fluid was cytologically positive for malignant cells. Histopathological findings were indicative of an angiosarcoma.

Successful resection of cardiac metastatic liposarcoma extending into the SVC, right atrium, and right ventricle

Cardiac metastatic liposarcoma is a rare tumor. We report a case of successful resection of a cardiac metastatic liposarcoma extending into the superior vena cava (SVC), right atrium, and right ventricle. Using cardiopulmonary bypass (CPB) by venous cannulation of the upper portion of the SVC and inferior vena cava (IVC), the intracardiac tumor was completely resected. Surgical resection with the addition of radiotherapy prolonged the patient's life.

Ventricular septal hamartoma mimicking hypertrophic cardiomyopathy in a 41-year-old woman presenting with paroxysmal supraventricular tachycardia

We report an unusual case of cardiac hamartoma involving the ventricular septum. The patient presented with palpitations and exertional chest pain. Echocardiography indicated a large homogeneous mass occupying the superior two-thirds of the ventricular septum. This report confirms the use of transthoracic echocardiography as a screening tool in the diagnosis and management of an uncommon case of a benign cardiac tumor.

Cardiac encasement by metastatic myxoid liposarcoma

Isolated cardiac metastasis from a primary liposarcoma of noncardiac origin is a rare occurrence. A patient who presented with biventricular failure and constrictive hemodynamics years after successful resection of a primary liposarcoma of the thigh is described. Extensive cardiac encasement by tumor was suspected on diagnostic imaging. Hemodynamic instability and multiorgan failure necessitated urgent exploratory sternotomy. The patient died intraoperatively. Extensive metastatic sarcoma limited to the heart was confirmed during surgical procedure. This case suggests that in clinical and pathological investigation of a cardiac mass, knowledge of previous extracardiac involvement with soft tissue sarcoma is essential.

Cardiomyoplasty: ventricular reconstruction after tumor resection

OBJECTIVE

Although cardiac transplantation has been performed for complete removal of ventricular tumors, complete surgical resection with ventricular reconstruction is desirable. Thus patients with benign tumors would probably be cured, and those with malignant tumors would have a better prognosis. In this study extensive and complete surgical resection of ventricular tumors is followed by anatomic and functional ventricular reconstruction with a dynamic cardiomyoplasty procedure.

METHODS

Seven patients (mean age, 32.7 years) underwent complete resection of ventricular tumors. Histologic types were distributed as follows: fibroma in 2 patients and sarcoma, lymphosarcoma, hemangioma, lipoma, and metastatic angiosarcoma, respectively, in the remaining 5 patients. Six of the patients were considered candidates for heart transplantation because of the extent of tumor invasion. Surgery consisted of 4 steps: (1) tumor resection; (2) coronary artery resection (when invaded by the tumor) and coronary artery bypass grafting; (3) valvular reconstruction (when possible) or replacement; and (4) ventricular wall reconstruction with a pericardial patch for closure of the ventricular defect (neoendocardium) covered by the electrostimulated latissimus dorsi muscle flap (neomyocardium).

RESULTS

All patients survived surgical intervention, but 2 late postoperative deaths are reported. Among the surviving patients, early complications played a major role in their postoperative course and consisted of arrhythmias, atrioventricular block necessitating a dual-chamber pulse generator, respiratory insufficiency, and heart failure. Two patients were assisted postoperatively with an intra-aortic balloon pump. On postoperative follow-up (mean, 72.4 +/- 8.5 months), an improvement in the patients' functional status was observed. Patients moved from a mean New York Heart Association functional class of 2.8 to a mean functional class of 1.2.

CONCLUSIONS

The excellent long-term evolution without recurrence, ventricular dysfunction, and/or thromboembolic complications implies that cardiomyoplasty could be recommended as an alternative to heart transplantation for the therapy of large ventricular tumors.

Cardiac metastasis from a myxoid liposarcoma

Intracardiac metastases due to solid tumours are rare. We describe a patient with a myxoid liposarcoma of the thigh and a secondary lesion in the interventricular septum, which was treated with radiotherapy.

Primary left atrial fibrosarcoma

An elderly female with refractory cardiovascular symptoms due to functional mitral stenosis secondary to a primary left atrial fibrosarcoma is described. The symptoms are often nonspecific and most of the patients present first time with hemodynamic compromise. A high index of suspicion is essential for the early diagnosis of these highly malignant cardiac tumors because of their rarity, a wide spectrum of nonspecific symptoms and poor survival.

Metastatic synovial sarcoma of the left ventricle

A metastatic synovial sarcoma of the left ventricle is described. A 26-year-old Japanese woman underwent resection of a synovial sarcoma of the right thigh 8 years prior to admission, which was followed by multiple surgical procedures for pulmonary metastasectomy. Echocardiography demonstrated obstruction of the outflow tract of the left ventricle caused by a metastatic tumor, which was surgically resected on the day of admission. The histologic characteristics of the cardiac tumor were identical to those of the pulmonary metastases. Additional cardiac metastasectomy was performed 9 months later. She complained of dyspnea on exertion 8 months after the second cardiac metastasectomy due to recurrence in the heart. Radiotherapy with LINAC (a total dose: 50 Gy) diminished the size of the tumor temporarily. The patient died 20 months after the initial cardiac metastasectomy.

Cardiac sarcoma originating from the tricuspid valve

Primary cardiac sarcomas are uncommon. We report an unusual presentation of a cardiac sarcoma that originated from the posterior leaflet of the tricuspid valve. This tumor, which provided a working diagnosis of tricuspid valve myxoma before and during surgery, should be considered in the differential diagnosis of right atrial and ventricular masses.

Symptomatic intracavitary (noninvasive) cardiac metastasis from low grade endometrial stromal sarcoma of the uterus

We report a 49-year-old woman who was operated upon 33 years ago for uterine endometrial stromal sarcoma of low-grade malignancy. The patient showed obstruction of the right ventricular outflow tract. An echocardiogram and MRI showed that a mass emanating from the inferior vena cava filled the right atrium, the right ventricle, and part of the pulmonary artery. The entire intracavitary neoplasm was successfully removed and diagnosed as low-grade endometrial stromal sarcoma. To our knowledge, this is the second report of a low-grade endometrial stromal sarcoma reaching the heart via the inferior vena cava. In this case an intracavitary metastasis may be a feature indicating the progression of the endometrial stromal sarcoma. Therefore, this neoplasm should be included in the differential diagnosis of cardiac intracavitary neoplasms. Patients affected by this tumor may benefit from early identification and resection of the obstructing neoplasm.

Primary cardiac sarcoma in pregnancy: a case report and review of the literature

Primary cardiac sarcoma (PCS) is a rare disease with a poor prognosis, because of diagnostic delay, therapeutic difficulties, and high metastatic potential. Surgery is the standard treatment. A case of PCS in pregnancy is reported, with a review of published surgical series of PCSs, focusing on the role of surgery and adjuvant therapy. Prompt surgery improved cardiac function and patients' outcome in comparison with untreated cases. The role of adjuvant treatment was analyzed only in a few series, mainly without distinction between postoperative chemotherapy and radiotherapy; adjuvant therapy improved survival in the larger series of resected PCSs. Only three other cases of PCS in pregnancy were reported. In the present case, resection was performed with no major complication for the mother and the infant. Even if the patient's survival was short, cardiac surgery allowed prolonging of pregnancy until an acceptable possibility of fetal survival was reached. Although resection is not curative in most cases, surgery remains the treatment of choice for PCS and has a definite palliative significance. The role of postoperative chemotherapy and radiotherapy is difficult to ascertain; however, adjuvant chemotherapy seems advisable in high-grade tumors.

Cardiac Neoplasms

Surgical resection is usually the only form of curative therapy available for primary cardiac neoplasms. Benign tumors can often be completely removed with few complications and a low mortality rate, but complete resection is possible for fewer than half of primary malignant tumors. Radiation therapy plays an adjunct and palliative role in treatment. The outcome of chemotherapy, the dominant treatment method, is poor. Sarcomas are inherently chemoresistant and show a response rate of less than 50%. Lymphomas present late and respond poorly. Cardiectomy and cardiac transplantation may cure unresectable benign cardiac tumors or, rarely, malignant ones.

Primary cardiac tumors: early and late results of surgical treatment in 91 patients

BACKGROUND

Between March 1980 and September 1997, 91 patients underwent evaluation and treatment for primary cardiac neoplasms.

METHODS

Tumors were grouped into three categories: atrial myxomas, benign nonmyxomas, and malignant tumors. Survivors were contacted; no one was lost to follow-up. The mean follow-up for this series is 7 +/- 5 years.

RESULTS

Eighty-three patients were diagnosed with atrial myxomas (Male/Female: 29/54), average age 55 +/- 13 years. The hospital mortality was 3.6% (3/83), the late mortality was 6.5% (5/80). No recurrent myxomas have been identified clinically or by echocardiography in any patient. Three patients were diagnosed with benign nonmyxoma tumors. (Male/Female: 2/1), average age 64 +/- 8 years. There were no perioperative deaths and 1 patient died 4 years postoperatively from fibroma, with no linked causes. No recurrent tumors have been identified. Five patients were diagnosed with malignant tumors. (M/F: 1/4), average age 53 +/- 16 years. The hospital mortality was 20% (1/5); in 3 patients a redo-operation was necessary after 8, 11, and 12 months because of tumor recurrence. All patients died within 3 years of the first operation (mean 13 +/- 14 months).

CONCLUSIONS

Surgical resection, when possible, is the treatment of choice for all primary cardiac tumors. Patients with benign tumors are probably cured by resection and in our experience there was no known tumor recurrence. Effective palliation is possible with resection of malignant tumors, but more effective adjuvant therapy will be necessary to improve long-term prognosis.

Primary cardiac sarcomas: an immunohistochemical and grading study with long-term follow-up of 24 cases

AIMS

Primary cardiac sarcomas are rare and aggressive tumours. The aims of this study were to precisely classify cardiac sarcomas according to their pathology, and to determine their clinicopathological features and prognosis.

METHODS AND RESULTS

Twenty-four primary cardiac sarcomas were studied. Clinical features and follow-up of all patients were collected. Histological diagnoses were obtained by combining both morphological features as described in soft tissue counterparts and the immunoprofile of the tumours. The 24 cases were classified as undifferentiated sarcoma (nine cases), angiosarcoma (six cases all located in the right atrium), leiomyosarcoma (six cases), malignant fibrous histiocytoma (one pleomorphic and one giant cell type) and synovial sarcoma (one case). Patients included 14 men and 10 women, with a mean age of 46 years. Clinical manifestations were protean, often delaying the diagnosis. Dyspnoea resulting from obstruction of the cardiac chambers was the most common symptom. Echocardiography and magnetic resonance imaging were useful respectively to detect and to evaluate tumour extension. Complete macroscopic resection was possible in only 33% of patients. The most common cause of death was local recurrence of the tumours (50%), even in the cases of complete macroscopic resection. Whatever the treatment, the prognosis was poor with a mean survival of 16.5 months after diagnosis.

CONCLUSIONS

All types of sarcomas may be observed in the heart with a predominance of undifferentiated sarcomas. Histological grading, unlike histological type, seems to correlate with survival which remains extremely poor.

Acute vascular embolus resulting from metastatic endocardial involvement with synovial sarcoma: report of a case and review of the literature

A rare case of metastatic soft tissue sarcoma (STS) involving the endocardium of the left ventricle of the heart is described. A 57-year-old man with a previously resected synovial sarcoma of the anterior abdominal wall presented 5 years later with an acute ischaemic arm resulting from tumour embolus. The treatment and outcome of the patient are outlined. Metastatic STS cardiac involvement and management of this complication are reviewed.

Cardiac metastasis of liposarcoma

The authors describe a retroperitoneal liposarcoma with secondary involvement of the left ventricle. Therapy has been disappointing, and is guided by the nature of the primary tumor, previous therapy, extent of metastatic spread, and feasibility of cardiac resection. In selected patients whose primary tumor is well-controlled and progressing slowly, with no evidence of widespread disease, resection of the cardiac metastases can be performed when technically feasible.

Primary sarcomas of the heart

Seventy-five primary sarcomas of the heart were classified by histologic appearance as angiosarcoma (26 cases), undifferentiated sarcoma (18 cases), osteosarcoma (9 cases), fibrosarcoma (6 cases), malignant fibrous histiocytoma (6 cases), leiomyosarcoma (4 cases), myxosarcoma (3 cases), synovial sarcoma (2 cases), and neurofibrosarcoma (1 case). The ages of the patients ranged from 1 to 75 years at the time of presentation (mean, 39 years). Angiosarcomas were predominantly right-sided and osteosarcomas left-sided. Forty patients treated surgically were examined, and survival correlated with clinical and histologic parameters. the survival rate was poor, with a mean of 11 months and median of 6 months. By univariate analysis, the survival rate was more favorable for patients with tumors located on the left side of the heart, without necrosis, with a low mitotic count, and without metastasis at diagnosis. Survival rates were better in patients receiving chemotherapy and radiation therapy. Age, gender, presence of differentiation, and histologic type did not affect prognosis. By multivariate analysis, a low level of mitotic activity and any therapy were the only significant factors affecting survival rate. Immunostaining with commercially available antisera was useful in the diagnosis of sarcoma but not in subclassification of 19 tumors so tested. Although the prognosis for patients with cardiac sarcomas is dismal, histologic grading is useful in predicting outcome, as has been shown for soft tissue sarcomas of other sites.

Primary cardiac leiomyosarcomas

Two patients with primary cardiac leiomyosarcoma, one of the rarest malignant tumors of the heart, are described. The first patient had a tumor of the pulmonary trunk and was admitted with symptoms suggestive of pulmonary thromboembolism. The second had a tumor of the left atrium and had signs and symptoms of mitral valve obstruction and regurgitation. The 2 patients were operated on and later underwent adjuvant chemotherapy. Both died more than 22 months after operation, having required multiple hospital admissions for treatment of complications related to the pathology or the treatment of the primary cardiac leiomyosarcoma. Nonetheless, aggressive surgical excision followed by chemotherapy appears to have improved survival in these patients with primary cardiac leiomyosarcoma, as they are among the longest survivors reported.

Cardiac metastases. Case report on an isolated cardiac metastasis of a myxoid liposarcoma

This report describes an isolated case of cardiac metastasis of a myxoid liposarcoma that was successfully resected by surgery after clinical and ultrasound diagnosis. Although cardiac metastases are rarely diagnosed during patients' lifetimes, a search should be made for such lesions whenever cardiac disorders appear suddenly in cancer patients. Echocardiography appears to be one of the best investigative techniques for such purposes. Despite generally poor therapeutic results, surgical resection occasionally permits long periods of survival.