Cardiac masses and tumours

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”.

Safety and Outcomes of Mechanical Thrombectomy in Acute Ischemic Stroke Attributable to Cardiological Diseases: A Scoping Review

There is limited evidence on the outcomes and safety of mechanical thrombectomy (MT) among patients with acute ischemic stroke (AIS) in the context of cardiac diseases. Our study reviews MT in AIS within the context of cardiac diseases, aiming to identify existing and emerging needs and gaps. PubMed and Scopus were searched until December 31, 2023, using a combination of cardiological diseases and "mechanical thrombectomy" or "endovascular treatment" as keywords. Study design included case reports/series, observational studies, randomized clinical trials, and meta-analyses/systematic reviews. We identified 943 articles, of which 130 were included in the review. Results were categorized according to the cardiac conditions. MT shows significant benefits in patients with atrial fibrillation (n=139) but lacks data for stroke occurring after percutaneous coronary intervention (n=2) or transcatheter aortic valve implantation (n=5). MT is beneficial in AIS attributable to infective endocarditis (n=34), although functional benefit may be limited. Controversy surrounds the functional outcomes and mortality of patients with AIS with heart failure undergoing MT (n=11). Despite technical challenges, MT appears feasible in aortic dissection cases (n=4), and in patients with left ventricular assist device or total artificial heart (n=10). Data on AIS attributable to congenital heart disease (n=4) primarily focus on pediatric cases requiring technical modifications. Treatment outcomes of MT in patients with cardiac tumors (n=8) vary because of clot consistency differences. After cardiac surgery stroke, MT may improve outcomes with early intervention (n=13). Available data outline the feasibility of MT in patients with AIS attributable to large-vessel occlusion in the context of cardiac diseases.

Prominent crista terminalis mimicking a right atrial mass: a systematic literature review and meta-analysis

The crista terminalis is an anatomical structure localized on the posterolateral wall of the right atrium (RA). We performed a systematic review of the literature and meta-analysis concerning cases of unusual prominent crista terminalis mimicking RA mass. Moreover, we described the differential diagnosis of cardiac masses with the use of echocardiography, computed tomography, and cardiac magnetic resonance (CMR). We also emphasize the potential importance of this structure in electrophysiological procedures, including its role in exaggerated arrhythmias. Prominent crista terminalis may be a potential obstacle during invasive cardiac procedures or catheter ablation target. In analyzed cases, the crista terminalis was often erroneously interpreted as pathologic and at first confused with a thrombus or tumor during transthoracic echocardiography examination. The correct final diagnoses were mostly made with used transesophageal echocardiography or CMR. The most important imaging findings suggestive of prominent crista terminalis rather than tumor were a similar echogenicity/intensity with adjacent myocardium, the location on posterolateral wall of the RA, the phasic change in size, and no enhancement after contrast injection. We describe up to date and detailed imaging features for the differential diagnostics of selected intracardiac masses using various imaging techniques, including multimodality cardiac imaging. Familiarity with the anatomy and the imaging findings of the prominent crista terminalis will reduce misdiagnosis and avoid additional tests and unwarranted clinical interventions, while in patients considered for invasive cardiac procedures it might increase their efficacy and safety.

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.

Rheumatic heart disease of the mitral valve alongside the papillary fibroelastoma of the aortic valve: A case report

Key Clinical Message

Besides thromboses, it's crucial to also consider the rare possibility of tumors like papillary fibroelastomas when evaluating worsening cardiopulmonary symptoms in patients with severe rheumatic mitral stenosis and atrial fibrillation.

Abstract

Cardiac papillary fibroelastoma is a rare and benign endocardial tumor typically found on the aortic valve. The simultaneous occurrence of rheumatic heart disease affecting the mitral valve and papillary fibroelastoma on the aortic valve is infrequent, with limited documented instances. This unique case can enhance our understanding of the clinical presentation, diagnostic approaches, management options, and implications for patient outcomes in these two conditions. We present the case of a 47-year-old woman who was admitted to the hospital due to worsening dyspnea and fatigue, during which time she discovered an aortic valve papillary fibroelastoma. Further investigations revealed two thrombi in her left atrium and left atrial appendage, along with significant rheumatic mitral valve stenosis. The patient underwent thrombectomy, mitral valve replacement, and valve-sparing aortic valve tumor resection. Following surgery, the patient's recovery was unremarkable. This case report emphasizes the need for a comprehensive evaluation in patients with rheumatic mitral stenosis, considering all possible etiologies. While thrombi are typical in mitral stenosis and atrial fibrillation, the rare presence of tumors like papillary fibroelastomas should be recognized, underscoring the importance of further assessment when suspicion arises. Importantly, individuals with asymptomatic cardiac papillary fibroelastomas should undergo surgical treatment to minimize the potential risk of tumoral embolization.

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.

A Rare Case of Undifferentiated Pleomorphic Cardiac Sarcoma

We present a case of a patient with a four-month history of gradual-onset dyspnea and generalized body weakness. During the clinical evaluation, a mass was found in the left atrium. Coronary angiography was performed and showed normal coronary arteries. We proceeded with a complete surgical excision of the tumoral mass, and histopathology confirmed it as undifferentiated cardiac sarcoma. Six months after the surgical intervention and adjuvant chemotherapy, the patient is in complete remission, with no evidence of a recurrence of the malignant pathology. Cardiac sarcoma is a rare clinical finding and a diagnostic and therapeutic challenge due to its numerous non-specific clinical presentations.

Clinical presentation, diagnostic evaluation, and management of undifferentiated/unclassified cardiac sarcoma: A case report and literature review

This case report details a challenging instance of undifferentiated/unclassified cardiac sarcoma in a 28-year-old female, presenting with diverse symptoms like muscle weakness, shortness of breath, and hemoptysis. Diagnostic hurdles led to an initial misdiagnosis of granulomatosis with polyangiitis before discovering a sizable left atrial mass, ultimately diagnosed as high-grade undifferentiated/unclassified sarcoma. Despite initial surgical intervention, the patient's condition worsened, underscoring the complexities in managing such cases involving cardiac sarcomas. This case emphasizes the diagnostic complexities associated with primary cardiac sarcomas, particularly the challenges in achieving accurate diagnoses and formulating effective treatment strategies.

Cardiac Magnetic Resonance to Predict Cardiac Mass Malignancy: The CMR Mass Score

BACKGROUND

Multimodality imaging is currently suggested for the noninvasive diagnosis of cardiac masses. The identification of cardiac masses' malignant nature is essential to guide proper treatment. We aimed to develop a cardiac magnetic resonance (CMR)-derived model including mass localization, morphology, and tissue characterization to predict malignancy (with histology as gold standard), to compare its accuracy versus the diagnostic echocardiographic mass score, and to evaluate its prognostic ability.

METHODS

Observational cohort study of 167 consecutive patients undergoing comprehensive echocardiogram and CMR within 1-month time interval for suspected cardiac mass. A definitive diagnosis was achieved by histological examination or, in the case of cardiac thrombi, by histology or radiological resolution after adequate anticoagulation treatment. Logistic regression was performed to assess CMR-derived independent predictors of malignancy, which were included in a predictive model to derive the CMR mass score. Kaplan-Meier curves and Cox regression were used to investigate the prognostic ability of predictors.

RESULTS

In CMR, mass morphological features (non-left localization, sessile, polylobate, inhomogeneity, infiltration, and pericardial effusion) and mass tissue characterization features (first-pass perfusion and heterogeneity enhancement) were independent predictors of malignancy. The CMR mass score (range, 0-8 and cutoff, ≥5), including sessile appearance, polylobate shape, infiltration, pericardial effusion, first-pass contrast perfusion, and heterogeneity enhancement, showed excellent accuracy in predicting malignancy (areas under the curve, 0.976 [95% CI, 0.96-0.99]), significantly higher than diagnostic echocardiographic mass score (areas under the curve, 0.932; P=0.040). The agreement between the diagnostic echocardiographic mass and CMR mass scores was good (κ=0.66). A CMR mass score of ≥5 predicted a higher risk of all-cause death (P<0.001; hazard ratio, 5.70) at follow-up.

CONCLUSIONS

A CMR-derived model, including mass morphology and tissue characterization, showed excellent accuracy, superior to echocardiography, in predicting cardiac masses malignancy, with prognostic implications.

The challenging approach of a young patient with a primary intimal sarcoma of the heart: a case report

Background

Primary intimal sarcomas of the heart are extremely rare and have a dismal prognosis. Their management represents a complex clinical challenge since complete surgical resection is the only reliable possibility of cure but is only possible in 50% of patients. In non-resectable disease, anthracycline-based therapy is the most effective treatment, but pazopanib may be used in patients unfit to receive anthracyclines.

Case summary

A 38-year-old man presented with acute right heart failure symptoms due to a primary intimal sarcoma of the heart. A definite diagnosis was made after cardiac surgery. Multi-modality cardiac imaging showed early recurrence of disease with mitral valve and pulmonary veins' invasion, and the patient was deemed inoperable. Due to chronic kidney disease and previous heart failure symptoms, he was started on first-line pazopanib palliative treatment. After 11 months of chemotherapy, there was good clinical tolerance and no evidence of disease progression, which occurred after 13 months.

Discussion

This case highlights the value of a multi-modality imaging approach for cardiac masses. Most importantly, it reports the successful treatment of a young patient with a primary intimal sarcoma of the heart who was started on palliative pazopanib, with a significantly higher progression-free survival than is reported in the literature. This finding may support pazopanib as a good alternative as first-line treatment when there is contraindication for anthracycline-based chemotherapy.

The usefulness of contrast echocardiography in the evaluation of cardiac masses: a multicenter study

BACKGROUND

Cardiac masses can encompass a variety of conditions, such as tumors, thrombi, vegetations, calcific lesions, and other rare diseases. Treatment and management of these types of cardiac masses differ considerably. Thus, accurately distinguishing among thrombi, benign tumors, and malignant tumors in the heart is of great importance. Contrast echocardiography (CE) has emerged as a promising technology. Although published guidelines suggest that CE can enhance image quality and assist in differentiating between benign and malignant lesions, most studies on CE diagnosis of cardiac masses are limited to case reports or retrospective/small-sample-sized prospective cohorts. This study aims to evaluate the diagnostic accuracy of CE in patients with suspected cardiac masses and address the insufficient evidence for differential diagnosis using CE.

METHODS

Between April 2018 and July 2022, a prospective multicenter study was conducted, which included 145 consecutive patients suspected to have cardiac masses based on transthoracic echocardiography. All patients underwent CE examinations. The echocardiographic diagnosis relied on qualitative factors such as echogenicity, boundary, morphology of the base, mass perfusion, pericardial effusion, and motility as well as quantitative factors such as the area of the masses and the peak intensity ratio of the masses to adjacent myocardium (A1/A2).

RESULTS

The final confirmed diagnoses were as follows: 2 patients had no cardiac mass, 4 patients had pseudomass, 43 patients had thrombus, 66 patients had benign tumors, and 30 patients had malignant tumors. The receiver operating characteristic (ROC) analysis indicated that an optimal A1/A2 cutoff value of 0.499 distinguished a cardiac tumor from a thrombus, with AUC, sensitivity, specificity, PPV, and NPV of 0.977, 97.9%, 90.7%, 95.9%, and 95.1%, respectively. The optimal A1/A2 cutoff value of 1.583 distinguished a cardiac tumor from a thrombus, with AUC, sensitivity, specificity, PPV, and NPV of 0.950, 93.3%, 93.9%, 87.5%, and 96.9%, respectively.

CONCLUSIONS

Combined with qualitative and quantitative analyses, CE has the potential to accurately differentiate among different types of cardiac masses.

Primary cardiac lymphoma presenting with cardiac tamponade and complete heart block: case report

Background

Primary cardiac lymphoma (PCL) is rare and its presentation can be variable. Thorough workup of suspected PCL or other cardiac tumours typically incorporates a range of imaging techniques and laboratory investigations but ultimately diagnosis is confirmed by histological analysis of myocardial tissue.

Case Summary

An 80-year-old Caucasian female presented with complete heart block and symptomatic cardiac tamponade. A pericardiocentesis was performed and a dual-chamber permanent pacemaker was implanted for the management of her complete heart block. Subsequently, a right atrial mass was discovered on imaging and the patient underwent endomyocardial biopsy of the mass. Histological analysis of the sample confirmed a primary cardiac lymphoma. The patient opted to forgo treatment with chemotherapy and died from her disease 1 month later.

Discussion

Cardiac arrhythmias can occur in PCL due to infiltration of conduction pathways. Characterization of cardiac masses on various imaging modalities and laboratory tests guides diagnosis. Tissue diagnosis is required to confirm PCL. The location of a cardiac mass may present technical challenges when undertaking a biopsy, so the best approach to tissue sampling should be considered on an individual basis. Without treatment survival is less than one month but with modern chemoimmunotherapy five-year survival may exceed 50%.

Case Report: A long-term survival case of diffuse large B-cell lymphoma with left ventricular infiltration and spinal cord compression

Background

Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin lymphoma and may occur with lymph node and/or extranodal involvement. However, DLBCL with intracardiac mass is exceedingly rare. In the reported literature, the intracardiac infiltration of DLBCL mostly involves the right ventricle. Lymphoma that invades the heart has an aggressive nature, with symptoms that are easily ignored initially and can lead to multiple complications in severe cases, resulting in a poor prognosis. Early screening and diagnosis may significantly improve the survival rate. Early diagnosis may significantly improve outcomes.

Case summary

We presented a 68-year-old woman with back pain. PET/CT suggested increased FDG metabolism in the left ventricle, right adrenal gland, right erector spinae intramuscularis, multiple bones and multiple lymph nodes. Contrast-enhanced ultrasound showed a left ventricular apical mass with ventricular septum thickening. Cardiac MRI suggested a 1.6*1.1*2.1 cm mass in the apical-central portion of the left ventricle. Biopsy of the right neck mass confirmed the pathologic diagnosis of diffuse large B-cell lymphoma. However, before the pathologic diagnosis was confirmed, the patient was paralyzed due to spinal cord compression caused by the progression of bone metastases. Subsequently, pathology confirmed the diagnosis of diffuse large B-cell lymphoma, and rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) was treated immediately as first-line therapy. In addition, glucocorticoids and mannitol dehydration were administered to relieve the symptoms of spinal cord compression. After 8 cycles of R-CHOP, the tumor at all sites had almost complete regression. The patient was able to walk normally and had no tumor-related symptoms.

Conclusions

We present a case of DLBCL with a very high tumor load that involved multiple organs, including the left ventricle, but exhibited no cardiac-related symptoms. The combination of various imaging modalities is valuable for the diagnosis of cardiac infiltration. The mass in the left ventricle almost completely regressed after R-CHOP treatment, and no recurrence has occurred in the 5 years of follow-up so far.

Transient ischemic attack and minor stroke as "surgeons affairs": a narrative review

OBJECTIVE

The scope of this paper is to review the subtypes of transient ischemic attack (TIA) and minor stroke (mS) in which a surgical treatment is needed, discussing the importance and the timing of a multidisciplinary approach, in order to achieve an optimized management and prevent major strokes or other critical complications.

MATERIALS AND METHODS

The keywords "transient ischemic attack," "minor stroke," "surgical treatment," "vascular surgery," "heart surgery," "neurosurgery," and "multidisciplinary" were searched using MEDLINE, EMBASE, and Scopus. Relevant search results were discussed by the authors for references inclusion.

RESULTS

Notwithstanding that best medical therapy is usually the first choice for the most part of cases, there are specific but recurrent etiologies that must be properly recognized because of a potential surgical approach, even in urgency. In fact, symptomatic carotid stenosis, or particular cases of hemodynamic cerebrovascular events, should be promptly referred to vascular surgeon, since increasing evidences highlighted a benefit from an early artery revascularization. In addition, beyond arrhythmic causes, cardioembolic events due to bacterial endocarditis and atrial myxoma should be quickly diagnosed, possibly in emergency department, because they are a presumptive urgency for heart surgery. In addition to the above-mentioned conditions, in patients suffering from vertebrobasilar TIA or mS, clinicians should keep in mind the Bow Hunter disease, because surgical artery decompression can represent the only suitable treatment in selected cases.

CONCLUSIONS

TIA and mS require a multidisciplinary in order to discuss therapeutic options, comparing risks and benefits and determining the best timing for an optimized management.

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.

Percutaneous Intracardiac Mass Extraction in High Surgical-Risk Patients

Large intracardiac masses including tumors, thrombi, and vegetations result in detrimental embolic or obstructive sequelae and present a management dilemma. Open heart surgery, the traditional approach, may not be an option for many patients with a prohibitive surgical risk due to multiple comorbidities. Recently, percutaneous options have emerged with reported success in extracting such intracardiac masses. A 42-year-old female with history of advanced primary sclerosing cholangitis with decompensated liver cirrhosis causing ascites and variceal bleed presented to the emergency department with fatigue, subjective fevers, chills and melena. Laboratory results revealed neutrophil-predominant leukocytosis and normocytic anemia, and blood cultures were positive for Candida albicans. Electrocardiography showed sinus tachycardia. Chest X-ray was unremarkable. She underwent packed red blood cell transfusion and esophageal banding for variceal bleeding. Transthoracic echocardiogram revealed normal left ventricular ejection fraction and no wall motion abnormalities. A right atrial mobile mass measuring approximately 1.0 × 3.0 cm was noted. Multidisciplinary heart team discussion concluded that while the mass posed a high embolic risk, the patient had a prohibitive risk for surgical intervention. Successful percutaneous removal of the mass using Penumbra system device (Penumbra Incorporated, Alameda, CA) was accomplished. This case report details the procedure and outcomes, as well as presents a literature review.

Percutaneous Removal of Left Atrial Myxoma: The FLORIDA Procedure

Surgical resection has been the treatment of choice for cardiac myxomas, but older age and comorbidities relegate many patients to observation. Pure percutaneous removal of left atrial myxomas is both intriguing and challenging. We report a successful percutaneous technique for removal of left atrial cardiac myxoma in a nonsurgical candidate. (Level of Difficulty: Advanced.).

Gastroenteropancreatic Neuroendocrine Tumor Metastasis to the Heart: Evaluation of Imaging Manifestations

Neuroendocrine tumors (NET) may affect the heart by cardiac metastasis or carcinoid heart disease. NET metastasis to the heart is rare, with limited data characterizing it. We sought to evaluate 68Ga-DOTATATE PET scan imaging features and associated cardiac imaging characteristics where available in those with NET cardiac metastases. 68Ga-DOTATATE positron emission tomography (PET)/CT scans performed on patients with gastroenteropancreatic (GEP) NET at our institution were reviewed for cardiac involvement. Those identified with cardiac metastases had their electronic medical record, transthoracic echocardiogram (TTE) and cardiac magnetic resonance imaging (MRI) reviewed for characterization. From a total of 1426 68Ga-DOTATATE PET/CT scans performed on patients with GEP-NET, 25 (1.75%) had cardiac uptake consistent with metastasis. Of these, 22 had myocardial metastases (29 distinct myocardial lesions: left ventricle - 16, right ventricle - 6, and ventricular septum -7) and 3 had periradial lymph node involvement only. NET patients with cardiac metastases as identified by DOTATATE scan did not appear to have any hemodynamically significant TTE features, aside from those (2/25) who had concomitant carcinoid heart disease. Of the 14 patients who had available TTE for review, only one with high metastatic cardiac tumor burden had detectable cardiac mass. Of the 6 cases who had available MRI, all had metastatic cardiac lesions seen with excellent correlation with tumor localization on 68Ga-DOTATATE PET scan. 68Ga-DOTATATE PET has excellent capability for the diagnosis of cardiac NET metastasis. Cardiac MRI may provide further anatomic and tissue characterization evaluation. Those with myocardial NET metastases without carcinoid heart disease did not have significant hemodynamic effect based on echocardiographic criteria.

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.

A primary multiple pleomorphic rhabdomyosarcoma of the heart in an adult dog

BACKGROUND

Heart tumors are rare in dogs. They can be benign or malignant. Clinical signs depend primarily on the location of the tumor and its effect on blood flow.

CASE PRESENTATION

An eleven-year-old crossbreed male dog lethargic and anorectic for previous 3 days was presented to the veterinary clinic. The focused ultrasound assessment with sonograms in trauma (FAST) revealed multiple tumors in the heart which were then confirmed in echocardiographic examination performed by a veterinary cardiologist. Due to the poor general condition and grave prognosis, the dog was humanely euthanized. The autopsy revealed numerous intracardiac tumors in all four heart chambers. No proliferative changes were found in other organs either in thoracic or abdominal cavity. Immunohistochemical examination was performed using formalin-fixed, paraffin-embedded tissue from heart masses. The antibodies against myoglobin, desmin, smooth muscle actin, vimentin, CD34, S100, and pan-cytokeratin (AE1/AE3) were used. Microscopically, the tumor was composed of fascicles of spindle-shaped cells with pale eosinophilic cytoplasm with round, oval, and focally elongated nuclei and one or two prominent nucleoli. The tumor cells showed strong diffuse cytoplasmic immunopositivity for myoglobin and vimentin and focal staining for desmin. Immunostainings for smooth muscle actin-SMA, CD34, pan-cytokeratin, S-100 protein were negative. The immunohistochemical staining pattern confirmed rhabdomyosarcoma.

CONCLUSIONS

This is the first description of the primary multiple heart rhabdomyosarcoma in a dog.

Myxoma Mimic in a Patient With Acute Myeloid Leukemia

Cardiac masses are rare conditions that, depending on their size and location, can cause several cardiac and systemic symptoms. We describe a case of a 21-year-old male with a history of syphilis, pulmonary tuberculosis, and acute myeloid leukemia (AML), in whom a transthoracic echocardiogram assessment was solicited before the initiation of induction chemotherapy. The study revealed a pedunculated, highly mobile mass in the right atrium that protruded to the right ventricle. Surgical resection was performed. During surgery, tricuspid valve perforation was noted and was associated with severe tricuspid valve regurgitation. Histopathological analysis of the resected mass determined that the lesion was a cardiac thrombus.

Cardiac Masses Discovered by Echocardiogram; What to Do Next?

Cardiac tumors are rare conditions, typically diagnosed on autopsy, but with the advancement of imaging techniques they are now encountered more frequently in clinical practice. Echocardiography is often the initial method of investigation for cardiac masses and provides a quick and valuable springboard for their characterization. While some cardiac masses can be readily identified by echocardiography alone, several require incorporation of multiple data points to reach diagnostic certainty. Herein, we will provide an overview of the main clinical, diagnostic, and therapeutic characteristics of cardiac masses within the framework of their location.

Postoperative radiotherapy for high-grade primary cardiac spindle cell sarcoma: a rare entity

A patient in her early 20s presented with blood-stained sputum and shortness of breath. Initially, she was treated for pneumonia. Later, upon exacerbation of symptoms, further investigations were done which exhibited a left atrial mass causing compression of contralateral atrium. She underwent surgical resection of the mass, which was initially mistaken as myxoma. However, histopathological correlation revealed spindle cell sarcoma with focal myogenic differentiation. This case report highlights the role of Radiation Therapy in adjuvant setting with promising impact on improving local control after R2 resection. Cardiac spindle cell sarcoma, being one of the rarest cardiac tumours reported to date, warrants establishment of a Rare Tumour Multidisciplinary Team for management of such malignancies.

Practical Guide to Interpreting Cardiac Magnetic Resonance in Patients with Cardiac Masses

It is common for a cardiac mass to be discovered accidentally during an echocardiographic examination. Following the relief of a cardiac mass, being able to evaluate and characterize it using non-invasive imaging methods is critical. Echocardiography, computed tomography (CT), cardiac magnetic resonance imaging (CMR), and positron emission tomography (PET) are the main imaging modalities used to evaluate cardiac masses. Although multimodal imaging often allows for a better assessment, CMR is the best technique for the non-invasive characterization of tissues, as the different MR sequences help in the diagnosis of cardiac masses. This article provides detailed descriptions of each CMR sequence employed in the evaluation of cardiac masses, underlining the potential information it can provide. The description in the individual sequences provides useful guidance to the radiologist in performing the examination.

Sex-Related Disparities in Cardiac Masses: Clinical Features and Outcomes

BACKGROUND

Cardiac masses (CM) represent a heterogeneous clinical scenario, and sex-related differences of these patients remain to be established.

PURPOSE

To evaluate sex-related disparities in CMs regarding clinical presentation and outcomes.

MATERIAL AND METHODS

The study cohort included 321 consecutive patients with CM enrolled in our Centre between 2004 and 2022. A definitive diagnosis was achieved by histological examination or, in the case of cardiac thrombi, with radiological evidence of thrombus resolution after anticoagulant treatment. All-cause mortality at follow-up was evaluated. Multivariable regression analysis assessed the potential prognostic disparities between men and women.

RESULTS

Out of 321 patients with CM, 172 (54%) were female. Women were more frequently younger (p = 0.02) than men. Regarding CM histotypes, females were affected by benign masses more frequently (with cardiac myxoma above all), while metastatic tumours were more common in men (p < 0.001). At presentation, peripheral embolism occurred predominantly in women (p = 0.03). Echocardiographic features such as greater dimension, irregular margin, infiltration, sessile mass and immobility were far more common in men. Despite a better overall survival in women, no sex-related differences were observed in the prognosis of benign or malignant masses. In fact, in multivariate analyses, sex was not independently associated with all-cause death. Conversely, age, smoking habit, malignant tumours and peripheral embolism were independent predictors of mortality.

CONCLUSIONS

In a large cohort of cardiac masses, a significant sex-related difference in histotype prevalence was found: Benign CMs affected female patients more frequently, while malignant tumours affected predominantly men. Despite better overall survival in women, sex did not influence prognosis in benign and malignant masses.

Magnetic Resonance Imaging in the Study of Cardiac Masses: A Case Series

Cardiac masses are currently studied using multimodality imaging. For diagnosis, different imaging techniques that can provide complementary information are used. Cardiac magnetic resonance imaging (MRI) has become a fundamental tool for this type of pathology owing to its ability to provide tissue characterization, spatial accuracy, and the anatomic relationships of the different structures. This study presents a series of four clinical cases with an initial diagnosis of a cardiac mass. All cases were evaluated at a single center, and patients were aged 57 to 72 years. An etiological study was conducted on all patients using different imaging techniques, including MRI. This study describes the diagnostic and therapeutic procedures of the four cases, which included two intracardiac metastases and two benign tumors. Cardiac MRI was decisive in the diagnostic process, determining the clinical decision-making in all four cases. Cardiac MRI has emerged as a pivotal technique in the diagnosis of cardiac masses. It can provide a highly accurate histological diagnosis without the need for invasive techniques.

Echocardiographic Markers in the Diagnosis of Cardiac Masses

BACKGROUND

The echocardiographic parameters required for a comprehensive assessment of cardiac masses (CMs) are still largely unknown. The aim of this study was to identify and integrate the echocardiographic features of CMs that can accurately predict malignancy.

METHODS

An observational cohort study was conducted among 286 consecutive patients who underwent standard echocardiographic assessment for suspected CM at Bologna University Hospital between 2004 and 2022. A definitive diagnosis was achieved by histologic examination or, in the case of cardiac thrombi, with radiologic evidence of thrombus resolution after appropriate anticoagulant treatment. Logistic and multivariable regression analysis was performed to confirm the ability of six echocardiographic parameters to discriminate malignant from benign masses. The unweighted count of these parameters was used as a numeric score, ranging from 0 to 6, with a cutoff of ≥3 balancing sensitivity and specificity with respect to the histologic diagnosis of malignancy. Classification tree analysis was used to determine the ability of echocardiographic parameters to discriminate subgroups of patients with differential risk for malignancy.

RESULTS

Benign masses were more frequently pedunculated, mobile, and adherent to the interatrial septum (P < .001). Malignant masses showed a greater diameter and exhibited a higher frequency of irregular margins, an inhomogeneous appearance, sessile implantation, polylobate shape, and pericardial effusion (P < .001). Infiltration, moderate to severe pericardial effusion, nonleft localization, sessile implantation, polylobate shape, and inhomogeneity were confirmed to be independent predictors of malignancy in both univariate and multivariable models. The predictive ability of the unweighted score of ≥3 was very high (>0.90) and similar to that of the previously published weighted score. Classification tree analysis generated an algorithm in which infiltration was the best discriminator of malignancy, followed by nonleft localization and sessile implantation. The percentage correctly classified by classification tree analysis as malignant was 87.5%. Agreement between observer readings and CM histology ranged between 85.1% and 91.5%. The presence of at least three echocardiographic parameters was associated with lower survival.

CONCLUSIONS

In the approach to CMs, some echocardiographic parameters can serve as markers to accurately predict malignancy, thereby informing the need for second-level investigations and minimizing the diagnostic delay in such a complex clinical scenario.

Pathological Correlation of a Cardiac Mass with Multimodality Imaging

Cardiac masses are rarely encountered in clinical practice and can lead to severe hemodynamic consequences. In addition to clinical cues, noninvasive modalities can play an important role in characterization of these masses and therefore their diagnosis and management planning. Here in this case report, we describe the use of various forms of noninvasive imaging techniques to narrow the differential diagnosis and form an operative plan for a cardiac mass later identified as a benign myxoma originating from the right ventricle on histological examination.

Diagnostic challenge presented by right atrial mass: A report of two cases

Right atrial masses raised pose 3 major possibilities including tumors, thrombi, or vegetations. We present 2 cases: first, a 34-year-old male with no medical history, who presented with dyspnea, pleuritic pain, and fever; and the second, 65-year-old male with similar symptoms and a history of a left renal carcinoma. Both patients had right atrial masses found on a transthoracic echocardiogram. Cardiac magnetic resonance imaging and an 18 FDG-PET were necessary finding thrombi in the first patient; and tumoral thrombi in the second one. A multimodality imaging approach to right atrial masses is essential for proper diagnosis and therapeutic decision-making.

The diagnostic accuracy of contrast echocardiography in patients with suspected cardiac masses: A preliminary multicenter, cross-sectional study

Background

To evaluate the diagnostic accuracy of contrast echocardiography (CE) in patients with suspected cardiac masses.

Methods

A multicenter, prospective study involving 108 consecutive patients with suspected cardiac masses based on transthoracic echocardiography performed between November 2019 and December 2020 was carried out. CE examinations were performed in all patients. The echocardiographic diagnosis was established according to the qualitative (echogenicity, boundary, morphology of the base, mass perfusion, pericardial effusion, and motility) and quantitative (area of the masses and peak intensity ratio of the masses and adjacent myocardium A1/A2) evaluations.

Results

Final confirmed diagnoses were as follows: no cardiac mass (n = 3), pseudomass (n = 3), thrombus (n = 36), benign tumor (n = 30), and malignant tumor (n = 36). ROC analysis revealed the optimal A1/A2 with cutoff value of 0.295 for a cardiac tumor from a thrombus, with AUC, sensitivity, specificity, PPV, and NPV of 0.958 (95% confidence interval (CI): 0.899–0.988), 100, 91.7, 95.7, and 100%, respectively. CE was able to distinguish malignant from benign tumors with an AUC of 0.953 (95% CI: 0.870–0.990). Multivariate logistic regression analysis revealed that tumor area, base, and A1/A2 were associated with the risk of malignant tumor (OR = 1.003, 95% CI: 1.00003–1.005; OR = 22.64, 95% CI: 1.30–395.21; OR = 165.39, 95% CI: 4.68–5,850.94, respectively). When using A1/A2 > 1.28 as the only diagnostic criterion to identify the malignant tumor, AUC, sensitivity, specificity, PPV, and NPV were 0.886 (95% CI: 0.784–0.951), 80.6, 96.7, 96.7, and 80.7%, respectively.

Conclusion

CE has the potential to accurately differentiate cardiac masses by combining qualitative and quantitative analyses. However, more studies with a large sample size should be conducted to further confirm these findings.

Clinical trial registration

http://www.chictr.org.cn/, identifier: ChiCTR1900026809.

Primary cardiac sarcoma presenting with easy bruising: a case report

Background

Primary cardiac sarcomas are rare, aggressive types of malignancies with poor prognoses and can rarely present with thrombocytopenia. Sarcomas account for 65% of primary malignant cardiac tumours. Clinical symptoms often present with constitutional symptoms such as shortness of breath, weight loss, and fatigue. In addition, the tumour’s location determines treatment options and prognosis. Multimodal imaging facilitates the detection and assessment of cardiovascular tumours. This case study presents a rare primary right heart cardiac sarcoma presenting with thrombocytopenia.

Case summary

An 80-year-old male presented to the emergency department with complaints of worsening dyspnoea, ease of bruising, and chest pain. An extensive investigation into the cause of thrombocytopenia was performed. A transthoracic echocardiogram, computed tomography scan, and cardiac magnetic resonance (CMR) image revealed a large mass affecting the right atrium and right ventricle. Myocardial biopsy showed high-grade angiosarcoma. Due to his advanced age and intraventricular septal involvement of the mass, the multidisciplinary team decided to proceed with palliative chemotherapy.

Discussion

Many cardiac tumours remain asymptomatic, and the diagnosis is made at an advanced stage of the disease. Differential diagnoses of the intramural masses include haemangiomas, lipomas, rhabdomyomas, lymphomas, and sarcomas. Multiple treatment options should be considered to address thrombocytopenia. Tumour diagnosis and identification consist of laboratory tests and multimodal imaging. Complete surgical resection with neoadjuvant and adjuvant purposes is the mainstay of cardiac sarcoma therapy. A multidisciplinary, individualized care approach should be performed.

Diagnosis of cardiac occupancy as metachronous carcinoma using multimodal imaging: a case report

Background

Metachronous carcinoma presenting as a cardiac malignancy is rare, and timely diagnosis is critical. We report a patient with a primary cardiac tumor who eventually died and performed an imaging-related literature review.

Case presentation

A 68-year-old Chinese male patient, who had suffered from multiple malignancies, was suddenly found to have severely reduced platelets and symptoms of decreased cardiac function. After undergoing a series of imaging examinations such as transthoracic echocardiography and positron emission tomography-computed tomography, he was found to have a large occupancy within the right heart and was finally diagnosed with a primary cardiac malignancy. Combined with the patient's previous medical history, it was judged that this time it was a metachronous carcinoma. The patient was unable to accept the risk of surgery and eventually died.

Conclusion

This is a case report reporting a cardiac malignancy. This case highlights the importance of using multiple imaging modalities to make a common diagnosis and the need for more detailed evaluation in patients with metachronous carcinoma.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-022-02645-2.

Cardiac tumors: imaging findings, clinical correlations and surgical treatment in a 15 years single-center experience

BACKGROUND

The aims of this study were: to present the clinical and pathological characteristics of cardiac tumors in a single-center series of patients; to describe the association of imaging characteristics, clinical presentation and surgical treatment; to analyze if second level imaging tests, computed tomography (CT) and cardiac magnetic resonance (CMR); and to improve the diagnostic accuracy when compared to first-line imaging technique (transthoracic echocardiography [TTE]).

METHODS

We reviewed the medical and surgical records, TTE, CT and CMR examinations of 86 patients with a histological diagnosis of cardiac tumors between 2004 and 2019.

RESULTS

The majority were benign tumors (81%) with myxoma accounting for 66% of cases. Among malignancies, metastasis (8%) and primary tumors (10%) were equally recognized. Symptoms at presentation (45% of patients) were associated to larger diameters at TTE. Malignancies were larger (mean diameter 37±14 mm vs. 27±13 mm, P<0.01), more frequently exhibited irregular shape (67% vs. 17%, P<0.01), frayed or polylobulated surface (73% vs. 38%, P=0.035), heterogeneous aspect (67% vs. 32%, P=0.012). A maximum diameter >28 mm and a minimum diameter >19.5 mm emerged as possible cut-off values for the differentiation of benign and malignant tumors. The ability of TTE, CT and CMR features in identifying malignancies was moderate (diagnostic accuracy of 84%, 81%, 76% respectively). The mean survival time after surgery was 1.6±1.4 years in malignancies and 6.8±4.7 years in benign tumors.

CONCLUSIONS

Cardiac tumors are rare and mostly benign; their nature and clinics related to TTE appearance. CT and CMR may be used synergically with TTE. Surgery is curative in benign tumors, survival remains scarce in malignancies.

Left Ventricular Metastases from Penile Squamous Cell Carcinoma

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Cancer of the penis is rare in developed countries.

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Left ventricular metastases are very rare and not well documented.

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Complications of myocardial infiltration are tamponade, arrythmias, and myocardial rupture.

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Multimodal imaging is often necessary in the workup of cardiac masses.

An enormous right atrial myxoma highlights the role of echocardiography in heart failure pathways: a case report

BACKGROUND

Myxomata are rare, benign, primary tumours of the heart which can present with a variety of symptoms depending on size, location, and mobility. Here, we report a case of enormous right atrial myxoma, obliterating the right atrial and right ventricular cavities presenting with symptoms of heart failure.

CASE SUMMARY

A 66-year-old Caucasian female presented to primary care with symptoms of right heart failure and was found to have elevated N-terminal pro B-type natriuretic peptide of 2829 ng/L (normal value <125 ng/L). The patient was referred for urgent evaluation to the integrated heart failure service at our institution. Echocardiography revealed an enormous mobile mass attached to the right atrial septum, extending into the right ventricle and inferior vena cava measuring 90 × 42 mm. The patient underwent urgent surgical resection. Perioperative transoesophageal echocardiography demonstrated severe tricuspid regurgitation, which was treated with tricuspid annuloplasty ring. The patient made an uneventful recovery and was discharged. Subsequent imaging showed a reduction in right ventricular dimensions and improved systolic function.

DISCUSSION

This case serves to remind us of the critical role of echocardiography in the diagnosis and management of people with breathlessness and raised natriuretic peptides. Therapies for heart failure are guided by ejection fraction, therefore timely and accurate diagnosis is critical. Moreover, as in this case, echocardiography can also identify other features of critical relevance to patient care.

Unusual non-valvular left ventricular endocarditis presenting as multiple brain embolism

INTRODUCTION

Masses inside the heart can cause serious and life-threatening effects to the cardiovascular system, mainly because of hemodynamic obstruction of the blood flow, either in the heart cavities themselves or remotely due to embolization. In this paper, we report a case of left ventricular tumor mass which presented with neurological symptoms due to multiple brain embolism.

CASE REPORT

A 35-year-old female patient presented with right hemiparesis and dysarthria. Seven days prior to admission she had elevated body temperature and started taking antibiotics. Inflammatory markers were not elevated, and blood cultures were negative. Computerized tomography (CT) and magnetic resonance imaging (MRI) of the brain revealed multiple acute ischemic lesions. Echocardiography showed the presence of a lobular mass inside the left ventricle, which was attached to the basal segment of the lateral left ventricular wall. Based on the laboratory results and additional heart imaging (CT and MRI) the mass was primarily suspected to be a tumor. It was surgically removed. Microscopic analysis of the removed tissue revealed a non-specific endocardial inflammation with formed fresh fibrin thrombi on the surface. During the postoperative recovery intense physical rehabilitation was being performed, so the initial neurological deficit was completely withdrawn.

CONCLUSION

Intracardiac masses can cause serious and potentially fatal complications that often present with dramatic clinical symptoms. Despite the comprehensive clinical, laboratory, and imaging investigations, intracardiac masses can be hard to distinguish until the definite microscopic analysis. However, with the right approach and multidisciplinary collaboration, they can be successfully managed.

Cardiovascular magnetic resonance of cardiac tumors and masses

Cardiac masses diagnosis and treatment are a true challenge, although they are infrequently encountered in clinical practice. They encompass a broad set of lesions that include neoplastic (primary and secondary), non-neoplastic masses and pseudomasses. The clinical presentation of cardiac tumors is highly variable and depends on several factors such as size, location, relation with other structures and mobility. The presumptive diagnosis is made based on a preliminary non-invasive diagnostic work-up due to technical difficulties and risks associated with biopsy, which is still the diagnostic gold standard. The findings should always be interpreted in the clinical context to avoid misdiagnosis, particularly in specific conditions (e.g., infective endocarditis or thrombi). The modern multi-modality imaging techniques has a key role not only for the initial assessment and differential diagnosis but also for management and surveillance of the cardiac masses. Cardiovascular magnetic resonance (CMR) allows an optimal non-invasive localization of the lesion, providing multiplanar information on its relation to surrounding structures. Moreover, with the additional feature of tissue characterization, CMR can be highly effective to distinguish pseudomasses from masses, as well as benign from malignant lesions, with further differential diagnosis of the latter. Although histopathological assessment is important to make a definitive diagnosis, CMR plays a key role in the diagnosis of suspected cardiac masses with a great impact on patient management. This literature review aims to provide a comprehensive overview of cardiac masses, from clinical and imaging protocol to pathological findings.

Cardiac mass evaluation with cardiac computed tomography: A review

Cardiac masses are rare and include both benign and malignant neoplasms as well as pseudo-tumors. The goal of imaging in patients with suspected cardiac mass is to: (1) confirm presence of a mass; (2) determine the mass' location in the heart; (3) characterize the mass to determine if it is benign or malignant; and (4) evaluate its relationship and effect on adjacent structures. Echocardiography is often the first to detect and assess cardiac structures as it is widely available, non-invasive, and can be done bedside. Echo can also determine if the myocardium or pericardium is involved. Cardiac Magnetic Resonance Imaging (MRI) is often the second modality of choice to evaluate a cardiac mass. Cardiac Computed Tomography (CCT) is an excellent alternative modality with high spatial and temporal resolution, which is widely available, fast, and can be performed in patients with cardiac hardware. We will discuss the role of computed tomography (CT) in the evaluation of various cardiac masses.

Primary cardiac lymphoma in HIV infected patients: A clinicopathological report of two cases

INTRODUCTION AND IMPORTANCE

Due to advances in diagnostic methods and human immunodeficiency virus, there has been a recent increase in cardiac involvement by lymphoma.

CASE PRESENTATION CASE 1

15-year-old HIV infected male patient presented with features of heart failure and cardiac tamponade. The transthoracic echocardiogram showed pericardial effusion and a right atrioventricular mass. The resected tumour was confirmed to be diffuse large b-cell lymphoma on histopathology. Unfortunately, the patient died few hours after surgery. Case 2: 30-year-old HIV infected pregnant female presented with features of cardiac tamponade. The transthoracic echocardiogram showed pericardial effusion with right atrial mass. The resected tumour was confirmed to be Burkitt's lymphoma on histopathology. She was successfully treated with chemotherapy.

CLINICAL DISCUSSION

Cardiac lymphomas are rare with most cases diagnosed on autopsy. However, advances in diagnostic methods has increased antemortem diagnosis with subsequent optimal management. Majority of the cases are of B-cell lineage, although T-cell origin has been reported.

CONCLUSION

A high index of suspicion of cardiac lymphoma should be maintained in the right clinical setting in order to receive adequate attention and management.

The curious case of a massive right heart thrombosis: a case report

Background

Intraventricular masses are a relatively rare condition ranging from asymptomatic to potentially life-threatening situations.

Case summary

Herein, we report a case of a 49-year-old woman under investigation for a massive right ventricular (RV) mass who underwent complete investigation for possible differential diagnosis, in the suspect of RV tumour. Multimodality imaging with cardiac computed tomography and magnetic resonance imaging showed the presence of a massive thrombus partially obliterating the right ventricle. Surgical removal of the mass showed a large area of stratified thrombosis with an underlying area of endocardial fibrosis. The patient has been then discharged in good clinical condition and with lifetime oral anticoagulation.

Discussion 

Massive RV thrombosis is a rare yet potentially fatal condition. Invasive management is preferable and lifetime anticoagulation is required to reduce possible downstream thrombotic complications.

Tumoral Phenocopies of Hypertrophic Cardiomyopathy: The Role of Cardiac Magnetic Resonance

Hypertrophic cardiomyopathy (HCM) is a genetic cardiac disease that presents with cardiac hypertrophy. HCM phenocopies are clinical conditions that are phenotypically undistinguishable from HCM, but with a different underlying etiology. Cardiac tumors are rare entities that can sometimes mimic HCM in their echocardiographic appearance, thus representing an example of HCM phenocopy. At present, only case reports of tumoral HCM phenocopies can be found in literature. In this systematic review, we analyzed all the published cases in which a cardiac tumor mimicked HCM to the point of misleading the diagnosis, providing a structured overview of the currently available evidence on this topic.

A Right Atrial Mass as Initial Presentation of a Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is recognized to have a strong tendency for vascular invasion. However, right atrial (RA) involvement is uncommon. It has been principally described as a fortuitous discovery during oncology follow-up or as an autopsy finding of patients with known HCC. We present a case of a patient whose initial HCC presentation was an RA mass found during a dyspnea investigation. Thereby, on the basis of this new finding, clinicians should consider HCC in their differential diagnosis when discovering an RA mass.

Echocardiographic Features of Cardiac Echinococcal Infection

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Cardiac masses are a rare but important finding requiring detailed investigation.

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Echocardiography is a first-line imaging modality.

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CT and MRI together allow precise structural and tissue characterization.

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Surgical removal is a potentially curative treatment for cardiac hydatid cysts.