Cushing's syndrome due to primary pigmented nodular adrenocortical disease with cardiac myxomas and mucocutaneous lentigines

The Variations in the Immunologic Features and Interleukin-6 Levels for the Surgical Treatment of Cardiac Myxomas

PURPOSE

In this study, we propose the existence of a relationship between cardiac myxomas and the immunologic features or interleukin-6 (IL-6), while also considering the optimal treatment of cardiac myxoma, especially "familial myxoma."

METHODS

In a 19-year period at our hospital, 20 patients underwent 21 operations for cardiac myxomas. The immunologic features and the IL-6 levels were measured pre-operatively in 13 cases and post-operatively in 10 cases. A case of "familial myxoma" was diagnosed based on molecular genetic analyses.

RESULTS

No patients died in the hospital. The tumor size correlated with the preoperative IL-6 and/or alpha1-globulin values (P < 0.05). In addition, all of the immunologic features and IL-6 levels normalized by 4 weeks after surgery. "Familial myxoma" demonstrated recurrence without showing increases in either the immunologic features, inflammatory signs, or serum IL-6 levels.

CONCLUSIONS

Patients with cardiac myxoma should therefore be operated on immediately because the possibility that the tumor size might be large when IL-6 and/or alpha1-globulin values are high. In addition, cases of "familial myxoma" require careful observation and periodic echocardiography after surgery to identify any possible recurrence. Recently, molecular genetic analyses are therefore considered to be an important diagnostic tool for cardiac myxoma, especially "familial myxoma." Our "familial myxoma" case demonstrated a C769T PRKAR1a mutation, which has also been observed in other cases of "familial myxoma."

Surgery for cardiac myxomas

Myxomas, particularly left-atrial myxomas, are the most common primary tumors of the heart that cardiac surgeons will be called upon to remove. Although some tumors are discovered incidentally during echocardiographic examination, many produce symptoms caused by the release of inflammatory cytokines, obstruction to intracardiac blood flow, and/or embolization. With rare exception, cardiac myxomas are benign, and excision is safe and curative in most patients. In a 38-year experience at the Mayo Clinic, 100 patients have had 106 operations for myxoma, and there has been only 1 perioperative death. During follow-up extending to 25 years, postoperative survival is similar to that of an age- and sex-matched population, and at 20 years postoperatively, 94% of patients were free of recurrent myxomas. Recognition of familial and syndrome myxomas (eg, Carney's complex) is important in guiding surgical approach, planning follow-up, and predicting recurrence of these unusual neoplasms.

Carney complex, a familial multiple neoplasia and lentiginosis syndrome. Analysis of 11 kindreds and linkage to the short arm of chromosome 2

Carney complex is an autosomal dominant syndrome characterized by multiple neoplasias, including myxomas at various sites and endocrine tumors, and lentiginosis. The genetic defect(s) responsible for the complex remain(s) unknown. We studied 101 subjects, including 51 affected members, from 11 North American kindreds with Carney complex. Blood samples were collected from patients and their family members. Hospital records, photographs, and tissue specimens of deceased individuals were reviewed. DNA was extracted from blood samples, patient-derived cell lines, and/or paraffin-embedded tissues. Linkage analysis was performed with highly polymorphic microsatellite markers, distributed over areas of the human genome harboring the most likely candidate genes. The most prevalent clinical manifestation in patients with Carney complex was spotty skin pigmentation, similar to that observed in Peutz-Jeghers and other lentiginosis syndromes. Skin and cardiac myxomas, Cushing syndrome, and acromegaly were present in 62, 30, 31 and 8 percent of the patients, respectively. Linkage was obtained for three markers on the short arm of chromosome 2 (2p16), with a maximum two-point lod score of 5.97 at theta = 0.03 for the marker CA-2 (odds in favor of linkage 10(6):1. The flanking markers CA7 and D2S378 defined a region of approximately 6.4 cM that is likely to contain the gene(s) associated with Carney complex. Candidate genes in the proximity, including the propiomelanocortin and the DNA-mismatch repair hMSH2 genes, were excluded. We conclude that the genetic defect(s) responsible for Carney complex map(s) to the short arm of chromosome 2 (2p16). This region has exhibited cytogenetic aberrations in atrial myxomas associated with the complex, and has been characterized by microsatellite instability in human neoplasias.